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I can't. Hello, everyone. I'm Caroline Delahanty. I'm a consultant. Pediatrician. Um, I'm going to talk about prematurity. It's a big lecture set, but I've I've got to share. So I think we'll do a percentage of it today and then a percentage of it on Thursday. So I will not get through the 50 odd slides, and perhaps I should have separated them, but I haven't. But let's start thinking about prematurity, so we're gonna start with some definitions, so pregnancy is measured. I'm not an obstetrician is measured from the thirst day of the Mothers last menstrual period, and then it's confirmed in the UK at a 12 week ultrasound scam. And in fact, we think ultrasound dating is more accurate. So actually, the dates can be adjusted at that point in the UK, but usually they correlate within a few days, either side. Full term infant is defined at as 40 weeks, but there is a range of normal maturity of the newborn infant between 37 42 weeks of gestation. So a baby born at 37 weeks, we would actually say is normally is a mature knee and age, so preterm men is defined as less than 37 weeks. But obviously there's gonna be a huge range varying from an infant that we would potentially consider resuscitation. And it is consider 22 weeks, but certainly by 25 weeks. We are resuscitate in the majority of neonate that come through. There are gray areas, the moderate too late preterm is 32 to 37 weeks. Very preterm is defined in police station, but not weight as 28 to 31 weeks. An extreme preterm is the 22 to 27 week infants. So to give you an idea of the scale of the problem, there will be 50,000 moderate late preterm babies born in the U. K per year, which need a different level of care to a normal knee in age only slightly, um, very preterm. There'll be approximately 7000 births and extreme preterm. There will be about 4000 births. So obviously there's huge resources going into this which you can debate. But there are a lot of resources like go into it. So what causes prematurity? We don't understand it. I'm sorry. There's a dog barking in the background. I can run and shut it. I'm going to run and shut the door so we don't fully understand what causes prematurity. We know that there are risk factors. If a mum develops chorioamnionitis this, then the foetus is likely to trigger labor. So nature is trying to protect itself. The bed. The baby is better out getting antibiotics because if it stays in in an infected environment, it's likely to come to harm. Poor growth, Um, will be a obstetric indication for intervening if they think there is growth, arrest and the baby is not growing. And there is placental dysfunction because growth is a measure of placental function. Obviously, if you get central abruption, you need to get the babies losing oxygen, losing blood supply. You need to get the baby out, and then if you have, if you want to deliver to protect the mother's health because the mom is the most important person here, you do not want a maternal death. You accept a neonatal death. But if you need to protect the mom, so if the mom has uncontrolled preeclampsia and eclampsia, that pregnancy needs to be ended. If she has poorly controlled insulin diabetes, you may want to intervene and deliver the baby to facilitate regaining her control. Um, if there are congenital abnormalities, sometimes with the late preterm babies, if the mom is having a lot of anxiety, a lot of issues, you may choose to go in and accept that you have a late pred, um, infant, because the survival of the late preterm infant is very good. But we do need to always think about the embryology and what is happening in the room. So the all the fetal organs are present from 12 weeks, but they're underdeveloped. Last week I was showing you, uh, pictures of lung development as it goes through the bronch I developing and then the bronchioles developing when we have branching. And then eventually, in a mature the nature, we come up to mature Al Viola with type one and two. You're type two cells with cilia and with lamella bodies that are storing surfactant. But I'm going to concentrate very much today on thermogenic Cicis actually. So at 24 weeks, you've got to think about the skin being thin, very fragile, very easy to break down. Quite often, what determines whether a baby is of extreme prematurity is going to survive. Everyone thinks it's the lungs and the heart, which obviously it is. But equally it is that skin barrier, because if that skin barrier is sloughing in your hands every time you touch that baby, that baby doesn't have a protective barrier for infect to stop infection getting in, which is a killer but equally like. Although we can support thermogenic icis, how quickly we can get the skin to Claritin eyes to produce carrot in and to become stronger and thicker is so important. So if you've got a poor skin barrier, I've mentioned infection. But really, what we're concerned about is water losses and thermal regulation. Okay, so your skin prevents water losses. We'll talk a little bit about humidity and which nursing these babies in humidity at extreme prematurity to try to stop that trans epidermal, um, osmosis of water that's taken place. So also, the babies have no subcutaneous fat. They don't have white adipose. They luckily, the mammal. Mammalian newborns are very fortunate in that they have evolved to produce brown adipose tissue, which can give us non shivering thermogenesis because if you think about the musculature on a very preterm baby, um, they can't shiver. They don't shiver. They can't contract. They don't have strong enough muscles. They have to rely on brown adipose tissue for heat generation. So they've got poor heat ability, and they've got poor energy reserves as well. Um, I put a statement in to say the eyelids infused until 25 to 26 weeks. It's one of the things that we're not sure about the guest station. We'll look at the eyelids. Can that baby open? It's eyes. If they can open its size, it's probably more than 26 weeks. If it can't open its size, it's little. The brain doesn't and this works with us. Actually, the brain is immature and it's going to continue to develop. So if we can protect that brain, not cause bleeding, not causes, ski me a lock of our lack of oxygen and lack of blood supply and hemorrhage. That brain is going to mature with us, which is positive, and myelin ation comes in, um, at term and after term, you continue to myelin age and improve your brain for the first seven years of your life, remember, the lungs are underdeveloped and the gut is immature. So there's levels of care, and someone asked me last week about I'm working in a remote part of India. What can I do? I I I think what you're really doing is supporting the later preterm baby and getting a good outcome there. And really, you're going to hit the basics. You're going to hit, um, thermal care, and you're going to hit keeping the baby warm, keeping the baby pink with any oxygen that you can deliver and keeping the baby with appropriate sugar. We always say, If we've got pink warm, sugary baby, you've done well, and that's really what you have to focus on. Nutrition, heat and oxygen delivery If you can, infants less than 34 weeks would tend to calm to specialist care. After 34 weeks, we try to keep them with Mom because the aim is to not separate a mom and baby from maternal bonding wherever possible. Um, so there's there's levels of care that are important. Let's think about keeping the baby warm. So why is keeping warm so important? If you staying warm takes energy, Okay, so if we can support that, we'll get better growth if we do nothing, and that baby has to fight your fight for itself. It's more of a problem for the baby, so we would God nurse in an incubator at less than 1800 g. Sorry, these slightly old slides. I would I would at the beginning, but I would very quickly bring a 1600 grammar if it looks good, and I think it's quite mature. It's got nice lanugo hair. The skin is carotene eyes, and I would bring it out into a hot caught with a heated mattress, because it's much better. That incubator. Those walls are a barrier for that mum to pick her baby up. So in the very preterm we nursing humidity to reduce those water losses by osmosis, and we would actually nurse them in 80% humidity. That is our aim. Every time you open the door, you lose humidity, so we really try to drive this warm, humid sauna. They are lying in a sauna. Then we gradually wean the humidity after 10 days because naturally, in a preterm skin and I'm talking about babies of less than 30 weeks here, the skin should have started to carotene eyes great in the 30 weeks. There is already some Claritin in there. They don't have such fragile skin. They don't need humidity. We just heat them. We don't actually keep them moist as well. Um, and then once they get able to get into a court's and maintain temp, and normally we get a feel for that, so in a very small baby believe it's not. We can actually be heating a baby up to 37 degrees, so we're heating them to body temperature. And then as they get bigger, the temperature we need to heat comes down, and the nursing staff often know where they do know where to set the incubator temp. But once you're down to an incubator temp of 30 degrees, you can do that outside. Okay, so brown. Add a poise. I briefly mentioned it. It's very important in the neo nation. It's important in mammal, all the mammalian group, So what it's doing is it's allowing us to generate heat in the mitochondria from triglycerides. Okay, so triglycerides are broken down through a mitochondrial enzyme to release free fatty acids, and we get gin heat generation, so there's a U C. P I. I can't actually remember what it stands for which transportes proteins across the membrane and that dissipates the gradient. And then we get substrate oxidation, which then releases heat, and the substrate is actually the triglyceride and the free fatty acid. It's obviously depleting energy, so if that baby has to heat itself, it's using fat reserves, and it doesn't have much, and it will cause weight loss. But it's also an energy dependent process. And actually, if you start to plead your energy, you then have less energy for cardiac function. You have less energy for respiratory function. You have less energy for surfactant production, which is an energy dependent process, and we're trying to deal with the lungs as well. So we do not want babies to get cold were measured on it. Okay, so there's not a lot of brown adipose around the body, so you always think of it as being subcutaneous. But actually it lies around the aorta. It lies between the scapula blades, and it lies around the kidneys and the adrenal glands. This brown adipose thermogenic icis is driven by nor adrenaline and a sympathetic nervous system, so the baby has to have mature receptor, so you can imagine a 26 week is just not going to do this is just going to get colder and colder and colder until it gets so more about hypothermia. It gets bradycardia, and you're going to get cardio arrest so you'll get cardio respiratory arrest. So you have to be mature enough as a neonate to be able to kick out your sympathetic nervous system and have no adrenaline release nor adrenaline, then drive the mitochondria to work. So there is a mature Embry, a logical foetal maturity factor going on here. So why do babies get cold? This picture says it all, but I want you to be thinking, What is the problem? Does anybody want to shout out? This is obviously a Termini and eight, but Termini and it's get cold. Thermal care is really important. It's taught it on all the resuscitation courses. What's the first thing you do? Okay, the first. The problem you've got, you've got a wet baby coming out okay, that's been nursed in the uterus, which is that maternal body temperature, so that new uterus is at 36.5 to 37.5, and it's so it's being nursed in a hot bath. Okay, so it comes out into a cold room and it's wet. It's also got a large surface area to volume ratio. That head, remember, the baby's head's are large in proportion to the rest of their body. Okay, so they have a large surface area volume ratio. So we're wet. We've got large surface area. We're going into an environment where you can get conduction, convection radiation, heat losses. Think about your physics. You have a baby that isn't very good at shivering because it's not got good musculature. And the brown adipose will generation only kicks in once that baby is already getting colds. You've already lost grounds. It kicks in below 36 degrees. And really, it's only a mature response after 36 weeks gestation. So we know if you get cold, you you increase mortalities so well, we always say to our trainees that for every one degree heat loss, you've raised that babies mortality by 5%. I am talking about babies less than 32 weeks. So what do we do? I've got this all wrong. Actually, I should have gone maybe with the first thing we should do is obviously in a term, baby. You want to dry and wrap with a warm towel, and you want to place a hat on the baby because of that large surface area to volume ratio. And there's no hair to keep the baby warm. And once we're dried and wrapped, we used to think, Oh, let's just wrap them in lots of blankets. But actually, the best way to keep them warm is maternal. Skin to skin is the best method. All right, hang on. So this is a mom and a baby having maternal skin to skin. Okay, so you can see that the baby's got a hat on. I specifically chose a picture with the baby with a hat on because I think that's better. We've got the baby in the nude against Mum in the nude, and then we've got the blankets wrapped around the mum and baby on the back. So there's no heat loss, uh, from the mom after that. But we are using maternal body temperature to keep our baby warm, and that's absolutely something you can do in the community. Ideally, you'd also want to close the windows to stop drafts you'd want to have the room as warm or the environment as warm as possible. But you use Mum to keep your baby warm. And that's what we tell our ambulance drivers. If the baby has been delivered at home or delivered in the ambulance, wrap the baby to mom. Don't think putting it in towels because Mum is hotter than a towel mom is. And immediately after labor that mum is running with a temperature of 37 degrees. She's hotter. Okay, I'm going to go back, right? What do we do in a hospital environment? So believe it or not, in babies of less than 32 weeks, we put them in a plastic bag, which I know sounds horrific, but and they're normal plastic bags. They're not anything special. They are plastic bags that we get in supermarkets. Um, but we have to put them under a radiant heat. Do not put a baby in a plastic bag to keep warm. If you're not heating that plastic bag, you're better with Mom, okay? And no plastic bag because plastic bag acts as a barrier. The reason we use a plastic bag is we're try happen in the baby's water so that we're heating the water. We're stopping those trans epidermal water losses. This is in prematurity. We know we've got thin skin, We've got high water losses and we're heating them. So we're trying to create that sauna. We heat the room. We have constant battles over theater temperature. We like that. We would ideally want theater to be running at 32 degrees, but everyone says it's too hot to operate, so there's a battle. We use maternal skin to skin. As I've said, we can think about other things we can think about in a more mature infant. We if we if they we find they're getting cold, they're not very good at keeping warm. We can place them on a heated mattress, as opposed to in an ordinary court's. We can use incubator heat. We're aiming for a temperature of 36 5 to 37 5, and if you do nothing, they lose note 50.12 point 3 C a minute. So this is a baby in a plastic, uh, under a radiant heater on labor ward. Once we get them into the incubator with humidity, we take the plastic bag away, but we transfer them in the plastic bag. Plastic bag. It goes with them until we're happy. We've got the incubator temperature. Correct. This is an incubator. Unfortunately, there's no picture of what temperature that incubator is. He did juicer. To me. It looks like it's switched off, but there will be a temperature set on it, and you can see that the baby isn't dressed. The baby's lying just with the nappy on. Um, but as we cool the incubator, we'll start putting clothes on the baby and we'll ask Mum to bring in close. And they're always quite delighted at that. I may skip respiratory distress, actually, because we talked about it the other day. Okay. Oh, gosh, right. There's a lot of respiratory distress slides, but I'm just going to move on from them, okay? I'm going to move on to patent Artur EOC and cardiovascular problems that we see in the new board in the premature baby. Maybe I'm being being a bit illogical, not covering respiratory distress, but we did cover it the other day, so we we've we've kept the baby warm. We've sorted out the respiratory system and then we start to think about the cardiovascular system, And what problems are we likely to anticipate? And one of the problems that we have in prematurity. And I again, I'm talking at babies of less than 32 weeks in general here, remember, labor has given you a huge prostaglandin surge. Okay, So that maternal fetal access unfortunately, as driven prostaglandins into this baby. Now, prostaglandins inhibit the patent doctors closing okay. And the baby doesn't necessarily close its patent. Doctors are terrio, sis. The other problem these babies may have is hypotension. And we We struggled to find that, actually, but because of poor contractility of their muscles myocardial contractility, they may not sort out their BP. Okay, let's talk about Doctor. So the doctors are terrio. Sis, I'm going to take you back. Two in the room. Blood is coming in. Okay. Through the vein, oxygenated blood is coming in through the umbilical vein. It's the only vein that ever carries oxygenated blood. That's a good multiple choice question that we find. Okay, it goes through the liver, the doctors for gnosis, Um, and then up into the right atrium. Remember? In the room you would have, because you don't need to pick up oxygen from your lungs. You would have driven some blood down into the right ventricle. But the majority going across the intra-atrial forum in a valley into the left atrium, down into the left ventricle. Okay, down here then. Up into the pulmonary branches. Now. Oh, sorry. That's the wrong way round. Okay. Up around the aorta and then from the aorta. If that duct is open because the aortic pressure is higher than the pulmonary pressure, blood will come back across the into the pulmonary and keep feeding into the lungs. So when we've adapted our circulation, if we don't flows that dot we will continuously feed more blood into the lungs and create pulmonary edema because we're starting to flood. The lungs were overdrive in the parliamentary circulation into the lungs. So we want that duct to close. But the problem in prematurity and particularly in extreme prematurity, the duct doesn't close. And it's almost normal for the duck to stay open. The problem is, we don't know what to do about it and all the studies we've done. Really? Because what we're after, we're trying to show that we hypothesize that if we close the dot we would reduce chronic lung changes because we wouldn't be prolonging the need for ventilation from the pulmonary edema and the baby not able to cope as you stop ventilating and bring your pressure's down. The lungs flood because the pulmonary pressures are then able. You know you're not pushing that Dema back into the inter capillary space. So Peyton, Doc, Tris is when it's the Dutch will fail to close or it may reopen, it may close and then open. It doesn't maintain closure, which will increase blood flow to the lungs because you will get a left to right shunt from the high pressure aorta, which has a higher pressure than the pulmonary arteries, which will increase if the lungs to become a de Metis. The baby has more breathing difficulties. If an adult in cardiac failure, it increases the risk of pulmonary hemorrhage as well, actually, because of Visa dilatations of the capillary bed, and it increases the risk of chronic lung disease, so we know it drives chronic lung disease. But all our attempts at closing it have not shown that we reduce chronic lung disease, so we don't understand everything. You may have such a big ductal steal. Believe it or not, that so much blood is going back into the parliamentary system that you actually drop your BP. And you may get hyperperfusion to the gut through the celiac celiac access to the renal and cause a degree of renal insufficiency. And even for it is, it even felt to be a driving factor in intraventricular hemorrhage. Um, and obviously I've said you may go into heart failure, cardiac failure as well, so we don't like ducts, but we don't know what to do. It really know what to do about them. So the other problem about them is they can be clinically silent. So unless you do an echo, you may not realize it's a problem. So they're often clinically silent for the first few days of life because you don't hear the murmur because you have to wait for the pulmonary pressures to drop in the first few days of life for that murmur, too, to become evidence. And then we describe it as the continuous machine machinery murmur, and you have to listen just underneath the clavicle because remember the dumps. It's quite high near that aortic arch. So you're almost putting your stethoscope in a funny place. You go under the clavicle, okay, but you'll you'll start thinking about it. If you think all that baby's got a tachycardia, that heart rate is sitting at 1 70. And yet the baby looks well, doesn't look. Septic doesn't look shocked. You'll start to think, I think that ducts driving the heart rate, we get bounding pulse pressure because we've got what we call a wide pulse, pressure bound impulses. So you feel the pulses, and they're easy to feel because there's no fat. Um, the skin is thin. Neonatal pulses are so easy to feel. You can even feel the dorsalis pedis pulse. Um, and you may see on X ray that the heart is big. The investigation is an echo. Do an echocardiogram. Okay, but what do we do about it? And it's debated. There is no consensus around the world. A lot of people will just say, We'll just watch and wait, Baby, I'll close it at some point and let's just do supportive care. One of the problems about supportive care is that you would want to, just as in an adult, if you're in heart failure, you fluid restrict, but remember where counterbalance in giving extra fluid because of the skin losses, we we really want calories and nutrition's. We want big fluid in. We like to feed our babies 180 mils per kilo, even 200 mils per kilo. But of course, that's difficult if you're in heart failure when you want to cut down to 140. But it may not be enough because you won't meet the nutritional needs and you won't meet the skin losses. Medical treatments have been tried and continue to be used. Actually, ibuprofen is used because it's cheap. Okay, we given not given a non steroidal one of the problems we see. Unfortunately, because the gut wall is thin, the stomach wall is thin. In adults, you think about gastric irritation and bleeding. Unfortunately, we get perforations. We don't like that because it takes the baby to surgery drives catacholamines drive cytokines, all of which can damage the brain. So briefings used and parous Esmael are used. There's a little bit of debate out there where the paracetamol increases the risk of autistic spectrum disorder. Um, surgical ligation is obviously the gold standard, but they tend to want the babies to be 1.5 kg, which is often difficult. So Boof in is working. Obviously, by inhibiting the conversion of academic acid, prostaglandins are trying to bring that prostaglandin surge level down so that the doc then spontaneously closes. And it does work. But although it works, doesn't seem to reduce chronic lung disease. So it's been disappointing. So it's a mmm. So we get rid of the ducts, so we feel better. But we don't necessarily change the outcome of the baby. Okay, so that's a difficult. Do you think the presence of a doctor is a risk factor for necrotizing enterocolitis, which I'll come onto as well, Then? From a cardiovascular point of view, we always think about BP. We don't actually know what we're aiming for. We tend to use the BP mean to the gestational age, or add on five. So, in a 24 week er, I am looking for a BP of a mean BP of 24 in a 30 weaker. I'm looking for a mean BP of 30 in a term baby. I'm looking for a mean BP of 40. Okay, but really, what you want to know is are you perfusing all the organs? So some people would say Don't drive the BP. Because if you've got higher BP, you may actually drive your cerebral blood flow and increase your risks of intraventricular hemorrhage, and they're getting very debatable. Hear what you really want to know is are you perfusing all your organs? So you want to know that you're not generating lactic acidosis, Okay, From end organ perfusion limitations, you want to know that you're perfusing your kidneys and urine output. Okay, remember, that can be very difficult. And a preterm baby, because they don't have a glamorous all a bud or a loop of Henley. Um, so they p too much they can't re absorb. So actually, you're chasing urine outputs of five mils per kilo per hour, where as an adult, you're working to two mils per kilo per hour. Aren't you 1 to 2 mils? So sometimes it's difficult to know, but we look at creatinine expecting creatinin's to be very low because there's no muscle mass and no muscle breakdown. Okay, I've got nerves there, actually, which is non invasive, um, red light, infra spectroscopy spectroscopy, which is basically a measure of cerebral fusion. So that's getting very technical. Just think. I just want to know the baby's peeing, and that is not acidotic from poor skin perfusion. And I want to look at the baby and check that they're refusing their skin. Um, as well as doing things like capillary refill and just looking generally at the baby we measure noninvasively are ideal in the first week of life in a very premature baby would be to put a number like an artery catheter in or a peripheral arterial line. So we've got continuous measurement. We're probably very cautious over volume replacement. We may try it if we think the baby has had a hemorrhage, but we'll probably go much quicker to some inotrope gentle inotrope management If we think that baby is low, we we don't really know what we're doing, actually. Okay, let's, uh, just a reminder as agreed that you're 20 minutes until the session, and just to remind you as you asked for it before, just, um, also in the chat. The link has been posted for feedback myself and Dr Sharon Raymond has also posted the link. So please do follow up on the link as well. Thank you. Ok, thank you. OK, I'm going to move on to the gut, so Okay, so feeding babies. Okay. And I think this is what you can everyone can do around the world. Okay. So if they can't suck, you're going to put a nasal gastric tube down or stringent it gently into their mouth. Just get them to lick it. Some some of the more mature babies, if they're not, if they're they're struggling to fix onto the nipple may feed very well just licking from a cup. So it's almost like a little cat licking, actually. But it's so beautiful to watch so you can express the mother's breastmilk. So our primary choice of milk is always maternal breast milk. OK, maternal breast milk. And I know you've had to talk from the breastfeeding sister right at the beginning. It's just one of the most beautiful things. It is made for the baby. It has all the nutrients in it. And it has all the phospho lipids required for brain myelin, a shin That is really what it has. But it also protects the gut, and we know we don't actually know what's in it. That's protecting the gut. But we certainly see less feed intolerance unless inflamed bowel with necrotizing enterocolitis if they are fed on breast milk. We do have donor breast milk banks in Britain. So if we can't use maternal breast milk, we will say to the parents were not in an extreme preterm in less than 32 weeks. We're not feeding your baby cows milk. We're not feeding your baby from Macau. We are going to use the breast milk bank and we really discourage cow's milk feeding until after 34 weeks of gestation. Okay, so we're going to talk about feed, intolerance and difficulties, and we're going to talk about necrotizing enterocolitis this. Okay, so feed intolerance. There's probably not much to say, actually, um, out with if the baby won't tolerate feeds heart sink because we have to feed them intravenously. So your option is if they won't tolerate having the nasogastric feeding. If they can't suck, then we have to feed intravenously to maintain sugar, titrate one up and titrate one down. But let's look at necrotizing enterocolitis. This carries a high mortality. We hate it. Okay, Unfortunately, it's quite common. It's 2 to 5%. A very low birth weight. Infants. Sometimes you get a cluster and your data will suddenly spike up to 8% and you end up having to deep dive into them. Was there anything we could have happened, but actually, we know that viral outbreaks can drive it. Unfortunately, it has a high mortality, so it's 20 to 30%. There is a gray area on that, because if you have mild necrotizing enterocolitis, you're not good, you're probably not going to die. You're going to respond to conservative management. But if you have advanced radiological any E. C, there is a high mortality. What do we think causes it? So obviously, if you had a baby delivered by abruption who has had a hypoxic insult and a hypotensive insult, they're more the higher risk of getting inflammation of the gut so that they could have had a profusion scheme, ick insult, which is going to lead to the necrosis that necrotizing enterocolitis. We don't fully understand it. The only thing we do know is that breast milk protects okay, and also it's associated prematurity and your risks increase, the more preterm you are. But breast milk protects, but we do see it in 30 to 2 30 to 4 weekers and like, it's just devastating if your growth retarded again. And the theory behind that is you've had placental insufficiency and the baby will have been trying to preserve its brain. It's heart. It's lungs. It's kidneys before it protected. It's gut, unfortunately, so the celiac access to superior and inferior meeting Tarik Accies will vase a constrict to protect brain, heart and kidneys. Okay, so unfortunately, the gut is vulnerable. So we know formula feeding and Pao's milk protein. And some of this is felt to be cosmic. Protein is a large protein molecule, so we then thought, Well, we'll use a hydrolyzed feed and is that better? But it's still a problem. It's not as good as breast milk, so there is something in that. So we then tried even to be thinking, Oh, is it the lack of Vasilis in breast milk? So we've given Prebiotics. We've given probiotics, but none of it has helped. So there's been various protective factors that have been tried. Okay, we'll give them like a bacillus, and it just didn't work. What was interesting? So Britain did something called the Pips study, and it was probiotics. And prematurity is what it stands for. They used a single agent Lactobacillus, and didn't show a benefit, and they collected over 1000 babies. It was powered enough. That study Australia ran a study at the same time, but they used a multi strain probiotic and did show a benefit. But there is still a lack of consensus consensus consensus around the world, and I think you find in the developed countries it's still only 20% of units that are given a multi strain probiotic so that there's still a desire for more information of what is it that's protecting. But we certainly know breast milk protects one of the problems we do. Unfortunately, after time, we start to fortify breast MMA, and we use Cosmo to fortify um, cow's milk protein. Sorry to fortify and we see late surgeon next. So even some cow's milk protein seems to cause a problem. People were worried about the feed advancement. Could you go up quicker on the feed? There's something called this sift trial speed of increasing feed tolerance. I think it probably stands for which showed that we are allowed to advance. We can feed babies 30 mils, increase them by 30 mils peculiar per day, which means that within five days we can stop are intravenous nutrition, which then gets central lines out and stops infection risks. We know are you g are perinatal is fixed here that I've talked about P. D. A. Is a problem. Also, if a baby has cyanotic heart disease again, it's the oxygenation profusion of the God. There's been debate about central line insertions because if we go up that underlie kalar tary, are we causing steal from the superior, inferior renal and mesenteric arteries, and we try to avoid the positioning, so we're not having the tip end at the position, but we have to use them. Many babies get through without a you, uh, without any problems. So the the Epidiolex epidemiological data there's no RCT that's telling us not to use them anemia again. Red cell carriage of oxygen to avoid significant anemia. Let's talk about how it presents, Okay, it could be nonspecific is one of the problems, and then you get this insidious onset and then they suddenly collapse. So, uh, it's difficult. They may present with AM Nia's pausing of their breathing, they may present with temperature instability. These are all very vague, nonspecific, common, premature problems they can present with feeding tolerance. And if we see bile, we would actually think Let's do an abdominal X ray. So if you see a bilious aspirate, you have to do an abdominal x ray, right, Because you may have a mole rotation in there. You may have duodenal a treasure. You may have other congee, dental surgical problems. But actually, what you're doing is checking the position of the nasogastric tube as well. Make sure you haven't pushed it down too far through that pylori this. But you're also checking to see Do you have inflamed bowel? I'm going to show you an X ray of inflamed brow all but if you see a baby with abdominal distention, you'd be more suspicious. But again, if you're given CPAP to that baby continuous positive airway pressure, remember, all a lot of that is going into the gut. So we have our nasogastric tubes on free drainage, so you want to aspirated the air out of the gut as well. But abdominal distension could be a sign if the baby's tender. I think that is pathological. A baby should not have abdominal tenderness. Right? You've got a problem. If you've got tenderness, you've got a problem. Also, if you've got blood in the stool, you've got some colitic process going on you very rarely. In an older baby, you may have a fissure, but blood in the stool normally would suggest there is a inflammatory bowel condition going on. If you see abdominal wall erythema, obviously that can be coming from the necrotizing enterocolitis. The bowel is stick into the wall. The wall is so thin the skin. So you're seeing the erythema coming through. You're obviously a differential. There would be a skin infection and cellulitis. But think with abdominal wall erythema. Or if you think the baby looks ill and you've got bacteria, me a floating where are those bacteria trans locating from? Are they coming across that thin bowel or immature bowel wall that can't keep the bacteria in the looming? Okay, we stage it. It's important to stage it for reporting, but also for outcome data plus research so milder when you've got the clinical features and you show an abdomen with distended loops and evidence of an alias. I'm going to minimize this a minute. OK, Stage two is when you've got gastric bleeding. So you've got blood in the stool or blood coming up in your nasal gastric aspirants. You've got marked abdominal distention and you've got bowel loops that you can feel because you shouldn't be able to feel the bowel loops. Really an abdominal discoloration. When you look at that x ray, there is no doubt that you have a necrotizing enterocolitis process going on your distended. You're seeing bowel wall edema and you're seeing pneumatosis ISS and loops. Stage three is when you're probably at the point of no return. Actually, that baby has developed hypertension hemorrhage and you have perforated the bowel. And also we always say that if you see portal venous gas, you've got a 90% mortality. I'll show you an X ray. I hope this comes across okay. What I'm showing you is the diaphragm here. So when I'm looking at this, the first place I look, believe it or not, is remember the baby's lying flat. The baby's not standing up so we will see any free air track up to the diaphragm. So I'm looking to see if I can lift the diaphragm with a bubble of air sitting there, the other place that we see it and I'm not seeing it here. You have a fancy power. Um, ligament leftover embryologically, and we see almost looks like a football sitting in front there and you'll see a strap going across it when you see it. You won't forget it, but what I'm seeing here as I come down, I'm seeing gas in the portal tract. I hope you can see that, but I'm seeing the branching of the portal tract. So I've got portal gas. Okay, I'm seeing a nasogastric tube in the stomach. And then when I look at the bowel wall, they just don't look healthy, do they? They're dilated. So if I took an intervertebral space and use that as my thumbnail measurement, multiply that space by 2.5 cent 2.5 times that intervertebral space, your bowels should not be any more dilated than that. I'm not a radiologist, though, but that's what we think about as clinicians and then looking at the bowel itself. It looks as if you've almost got soap bubbles over it, doesn't it? It looks like foam. That is pneumatosis iss. So I've got bubbling in the wall. Okay, so my wall is not crisp and clear. My wall has got fermentation and bubbling. Take place. It looks like a fermentation process. When you're looking at that bubbling, you want to see Is it in the wall or is it intraluminal here? It's everywhere. But this is bowel wall. This is bowel wall because sometimes you'll see stool down here, but the rest will look okay. And the stool can look a bit bubbly. But that's just the nature of stool. That stool can look mottled, but this is radiological advanced neck. What are we going to do? And I'll be finishing after this. We're going to. So the first thing you need to do it stopped feeding. Okay, you put the mill by mouth for 10 to 14 days. If you've got confirmed neck and you start your intravenous total parenteral nutrition and then when you restart feeds, you start back at the beginning again. You start them on 15 mils per kilos. Maybe one mil or half a mil every two hours, and you gradually advance. You don't go back to full feeds. You must have your nasogastric tube on free drainage, and you want this to be as large bore as possible. You give antibiotics because although it's not always infective driven because that gut is now leaky, you're going to get transportation of bacteria, so you use anaerobic cover as well. Um, so we tend to use a grand positive gram negative and an anaerobic cover. You give them analgesia for pain, and you support them in a multi system cardiovascular and respiratory support. A true any C we would intubate and ventilate You need to think about. Do you need the surgeon to go in and resect bowel and give them a stoma? But at least you rescue their life. So severe Neck not responded to medical management or perforation of the bowel goes to a surgeon where they will resect the necrotic bowel. And they'll either try if they think the rest is very healthy to a primary, an ostomy Asus, or they'll go for a stoma, a colostomy, and then they and an ileostomy wherever it is, and they'll close the stoma is three months later. Sometimes it is palliation and death. Okay, how much time have I got left? So we just got about four minutes left, right? I'm going to stop there. I think on Thursday what we'll do is we'll talk about intraventricular hemorrhage and brains, but I'm going to stop there for questions.