Critically-ill Neonates Research Articles

Exploring the use of cluster analysis to assess antibiotic stewardship in critically-ill neonates in a low resource setting

BackgroundSepsis is the third leading cause of neonatal death in low and middle-income countries, accounting for one third of all deaths in Ethiopia. A concerning issue is the increasing number of multidrug-resistant microorganisms facilitated by suboptimal antibiotic stewardship. The study aims to identify clusters of newborns switching antibiotic lines for sepsis in a neonatal intensive care unit (NICU) in Ethiopia, and to explore their potential association with sepsis outcomes.MethodsA retrospective cohort study was conducted including all newborns discharged with a diagnosis of probable neonatal sepsis from the St. Luke Catholic Hospital NICU between April and July 2021. The antibiotic management protocol included two lines according to WHO guidelines and a third line based on internal hospital guidelines. In the cluster analysis, the Gower distance was estimated based on the antibiotics employed in the different lines and the duration of each line. Mortality and respiratory distress (RD) were the response variables.ResultsIn the study period, 456 newborns were admitted to the NICU and 196 (42.8%) had probable neonatal sepsis. Four antibiotic management clusters were identified. Cluster 1 (n = 145, 74.4%) had no antibiotic switches, using only the first line. Cluster 2 (n = 26, 13.3%) had one switch from the first to the second line. Cluster 4 (n = 9, 4.6%) had two switches: from first to second and then to third line. In cluster 3 (n = 15, 7.7%), newborns were switched from ceftriaxone/cloxacillin as second line to off-protocol antibiotics. There were no differences in sex, age, weight on admission or crude mortality between clusters. Cluster 3 included a higher frequency of infants who did not breathe at birth (53.3%, p = 0.011) and that necessitated bag ventilation (46.7%, p = 0.039) compared to the other clusters.ConclusionsThe first antibiotic line failed in one out of four newborns with probable sepsis while third-generation cephalosporins were insufficient in one in ten patients. Cluster analysis can provide valuable insights into antibiotic treatment patterns and their potential implications. This approach may support antibiotic stewardship and aid in contrasting antimicrobial resistance in limited resource settings.

Costs associated with acute kidney injury in critically Ill neonates with patent Ductus arteriosus: pediatric health information system(PHIS) analysis.

Compare costs of hospitalization between critically-illneonates with patent ductus arteriosus (PDA) who did and did not develop acute kidney injury (AKI). Using the Children's Hospital Association's Pediatric Health Information System (PHIS) database, we ascertained the marginal estimated total cost of hospitalization between those who did and did not develop AKI. Query of 49 PHIS centers yielded 14,217 neonates with PDA, 1697 with AKI and 12,520 without AKI. Predictors of cost included AKI, birth weight, ethnicity, race, length of stay (LOS), and Feudtner Complex Chronic Conditions Classification System. LOS was the strongest predictor (AKI: median 71 days [IQR 28-130]; No AKI: 28 days[10-76]; p < 0.01). Neonates with AKI had $48,416 greater costs (95% CI: $43,804-53,227) after adjusting for these predictors (AKI: $190,063, 95% CI $183,735-196,610; No AKI: $141,647, 95% CI $139,931-143,383 l; p < 0.01). AKI is independently associated with increased hospital costs in critically-illneonates with PDA.

An Evacuation Simulation in Multiple Neonatal Intensive Care Units Across a Single City: Lessons Learned.

Evacuations of neonatal intensive care units (NICUs) in emergency situations pose specialized challenges given their population of critically-ill neonates. Most of the literature on this topic describes planned evacuations and simulations due to natural disasters, usually involving only NICU staff. This study examines a unique emergent NICU evacuation simulation involving multiple responders occurring on a citywide scale. A simulated evacuation in response to a fire was conducted in 6 different NICUs in El Paso, Texas. The exercise utilized response from NICU staff and first responders. A standardized tool, by independent evaluators, was used to evaluate staff competencies while reactions were assessed using post-exercise surveys. This city-wide multidisciplinary simulation improved NICU personnel skills in evacuation and also introduced first responders to this specialized patient population. Areas of strength across all NICUs included teamwork, knowledge of evacuation equipment, and patient tracking. Areas for improvement included lack of adequate equipment for post-evacuation care, understanding implications of smoke exposure, alternative evacuation routes, incident command structure, and unified communication. This successful, citywide NICU evacuation simulation improved knowledge among participants, introduced first responders to a specialized patient population, and provided valuable lessons on neonate-specific themes that can be incorporated to improve citywide emergency preparedness.

Thermoneutral Environment for Neonates: Back to the Basics.

Thermoregulation is an essential component to the stability and long-term outcomes of newborns and critically-ill neonates. A thermoneutral environment (TNE) is an environment in which a neonate maintains a normal body temperature while minimizing energy expenditure and oxygen consumption. Neonates who experience thermal stability within a TNE demonstrate enhanced growth, decreased respiratory support, decreased oxygen requirements, increased glucose stability, reduced mortality, and reduced morbidities associated with hyperthermia and hypothermia. Heat exchange occurs between the neonate and surrounding environment through four mechanisms: evaporation, conduction, convection, and radiation. By recognizing the methods by which heat is lost or gained, the neonatal provider can prevent adverse conditions related to abnormal thermal control and support a thermoneutral neonatal environment.

Comparative Performance of Four Established Neonatal Disease Scoring Systems in Predicting In-Hospital Mortality and the Potential Role of Thromboelastometry.

Background: To compare the prognostic accuracy of the most commonly used indexes of mortality over time and evaluate the potential of adding thromboelastometry (ROTEM) results to these well-established clinical scores. Methods: The study population consisted of 473 consecutive term and preterm critically-ill neonates. On the first day of critical illness, modified Neonatal Multiple Organ Dysfunction (NEOMOD) scoring system, Score for Neonatal Acute Physiology (SNAP II), Perinatal extension of SNAP (SNAPPE), and SNAPPE II, were calculated and ROTEM standard extrinsically activated (EXTEM) assay was performed simultaneously. Time-to-event methodology for competing-risks was used to assess the performance of the aforementioned indexes in predicting in-hospital mortality over time. Time-dependent receiver operator characteristics curves for censored observation were compared across indexes. The addition of EXTEM parameters to each index was tested in terms of discrimination capacity. Results: The modified NEOMOD score performed similarly to SNAPPE. Both scores performed significantly better than SNAP II and SNAPPE II. Amplitude recorded at 10 min (A10) was the EXTEM parameter most strongly associated with mortality (A10 < 37 mm vs. ≥37 mm; sHR = 5.52; p < 0.001). Adding A10 to each index apparently increased the prognostic accuracy in the case of SNAP II and SNAPPE II. However, these increases did not reach statistical significance. Conclusion: Although the four existing indexes considered showed good to excellent prognostic capacity, modified NEOMOD and SNAPPE scores performed significantly better. Though larger studies are needed, adding A10 to well-established neonatal severity scores not including biomarkers of coagulopathy might improve their prediction of in-hospital mortality.

Study of neonatal acute kidney injury based on KDIGO criteria

Significant advancement has occurred over the years in diagnosis, recognition, intervention and impact of acute kidney injury (AKI) on morbidity and mortality in critically-ill neonates. However an increased risk of chronic kidney disease (CKD) is still observed among neonates who survive an episode of AKI. Therefore, preventing and adequately managing AKI in neonates could help in controlling long-term renal morbidity in neonates who develop AKI. Thus, this study was undertaken with the aim of studying the incidence, contributing factors and outcomes of AKI in at-risk term neonates admitted to the neonatal intensive care unit (NICU). One hundred and ninety-six term neonates admitted to the NICU with sepsis, hypoxic ischemic encephalopathy (HIE), dehydration and respiratory distress were enrolled and evaluated over a period of one year. Detailed maternal history along with neonatal history, anthropometry, vitals and clinical signs of neonates were recorded in a pretested proforma. Urine output was measured in all at-risk neonates. Serum creatinine was estimated to categorize AKI into stages as per modified KDIGO criteria. Incidence of AKI was 21%, (n=107 out of 510 admissions) in the study. Mortality was significantly higher in AKI stage III neonates (88.9%) (p<0.001). Multivariate analysis revealed that hypoxic ischemic encephalopathy (HIE) had 35.293 (p<0.001) times higher risk, while sepsis had 35.701 (p<0.001), dehydration had 30.260 times (p<0.001) and respiratory distress had 10.366 times (p<0.001) higher risk of developing AKI. Our study recorded a high incidence of AKI among at-risk neonates. KDIGO criteria for diagnosing AKI is feasible to apply in the at-risk neonates and helps in its early identification. Early diagnosis and timely intervention in neonates with HIE, sepsis, dehydration and respiratory can prevent the progression of AKI and thus improve prognoses.

Validity of Random Triglyceride Levels in Infants Receiving Parenteral Nutrition.

Background: Intravenous lipid emulsions (IL) are an important part of parenteral nutrition (PN) to meet essential fatty acid (EFA) requirements and metabolic demands of neonates and preterm infants. Some critically-ill neonates may not metabolize IL effectively which can lead to hypertriglyceridemia. Risks associated with this include increased pulmonary vascular resistance, displaced bilirubins, and platelet or macrophage dysfunction. Serum triglyceride (TG) concentration is used as a marker for lipid tolerance and predictor of potential complications involved with IL administration, but the clinical significance of this is still debated. Management of TG levels with regard to timing of laboratory tests, the ideal goal range, and duration of infusion of IL varies across institutions and is not standardized.Methods: Single-center, retrospective study of newborn infants receiving parenteral nutrition (PN). Fasting and non-fasting TG levels were drawn during the same lipid infusion of 2–3g/kg/day. The primary outcome was the difference between fasting and non-fasting TG levels. Statistical assessment of continuous data was done with student t-test and nominal data was evaluated using X2-test and logistic regression.Results: Forty infants were included with mean gestational age at birth of 29.5 ± 3.4 weeks and mean birth weight of 1.3 ± 0.5 kg. Mean time between lab draws while on same IL dose was 11.6 ± 0.2 h with resulting mean fasting and non-fasting (random) TG levels 82 ± 40 mg/dL (95% CI 68.4, 97.6) and 101 ± 40 mg/dL (95% CI 88.5, 115.8), respectively. Mean difference between TG levels during lipid-free interval and during infusion was −18.6 ± 51.2 mg/dL (95% CI −35.0, −2.3; p = 0.03).Conclusion: We concluded there is no difference in the management of IL, when TG level was drawn randomly or as fasting sample. Obtaining TG level during routine lab draws is appropriate. We extrapolated that the administration of IL over 24 h will not interfere with TG level.

32 Web-based Camera (NICView) as a sense of proximity tool: a Quality-Improvement initiative for parents of neonates admitted in the NICU

Abstract Background Family-centered care (FCC) is an important approach and a vital component in healthcare. However, implementation of FCC model in a clinical setting presents a challenge. Effective parent-health care provider relationships are very essential in NICU especially when treatment is complex during the management of critically-ill neonates. Web-based camera (WBC) systems have been used in a few NICUs in the USA and the UK, allowing virtual visitation of the family members. However, to the best of our knowledge, there is no center in Canada that has utilized this WBC (NICView ®) service. NICView® is a WBC mounted to the baby’s bed, which is streaming ‘live’ video around-the-clock to parents and families. We report the perception of parents and their satisfaction after using NICView® facility in our NICU. Objectives Our goal was to see if the WBC system reduced the anxiety and stress level in parents by exploring NICView ® as a tool to enhance FCC model. This study was designed to explore the perception of parents and their satisfaction levels during their newborns stay within our NICU. Design/Methods A prospective, questionnaire-based study conducted over 6-month period. Determinants that may facilitate or disrupt the use of a commercially-available camera device were identified. After signing an informed consent form, the parents utilized the camera service continuously throughout the newborn stay within the NICU, except during the times of procedures, feedings and routine baby care. Demographic information of parents was collected in the questionnaire, along with along satisfaction questions. Parents filled out the questionnaires after 1-week of utilization of the camera or sooner if the baby was getting discharged. Results 94 respondents completed the questionnaire. Parental perception was consistent with earlier studies. Almost all parents used the service on a regular basis, twenty NICView cameras had more than 7000 logins by respondents during study period. Family members residing out of Saskatoon or out-of-SK and in some instances out-of-Canada used it the most, especially working fathers or distant grandparents. Seventy-five percent of the respondents were mothers. Almost 89% of parents reported having the WBC system helped reduce their anxiety and stress levels. All parents (100%) recommended this WBC system to other parents and strongly agreed that NICView was easy to use. Nearly 98% of parents agreed that they felt very connected with their baby using the WBC system. Frequently reported comments were on the positioning of camera like incorrect camera placement that did not offer a good view of the baby, the need to call nurses sometimes to turn on or adjust the camera after care, using the chat option to adjust the camera position when moved away. After we saw these frequent comments, we had to reiterate to bed-side nurses to re-position the camera if moved away and reminded parents to make use of the NICView® 24-hr customer support service available offered by the company. Conclusion

Placenta and perinatal brain injury: the gateway to individualized therapeutics and precision neonatal medicine.

Wu and colleagues analyzed the placental pathology from a subset of the neonates in the NEATO trial who had reports available and correlated the placental pathology findings with outcomes. This study highlights the importance of placental pathology, and its potential to bring precision medicine to critically-ill neonates. Placental pathology will likely aid stratification of neonates for clinical trials and accelerate progress for neurorepair.

Drug Disposition and Pharmacotherapy in Neonatal ECMO: From Fragmented Data to Integrated Knowledge.

Extracorporeal membrane oxygenation (ECMO) is a lifesaving support technology for potentially reversible neonatal cardiac and/or respiratory failure. As the survival and the overall outcome of patients rely on the treatment and reversal of the underlying disease, effective and preferentially evidence-based pharmacotherapy is crucial to target recovery. Currently limited data exist to support the clinicians in their every-day intensive care prescribing practice with the contemporary ECMO technology. Indeed, drug dosing to optimize pharmacotherapy during neonatal ECMO is a major challenge. The impact of the maturational changes of the organ function on both pharmacokinetics (PK) and pharmacodynamics (PD) has been widely established over the last decades. Next to the developmental pharmacology, additional non-maturational factors have been recognized as key-determinants of PK/PD variability. The dynamically changing state of critical illness during the ECMO course impairs the achievement of optimal drug exposure, as a result of single or multi-organ failure, capillary leak, altered protein binding, and sometimes a hyperdynamic state, with a variable effect on both the volume of distribution (Vd) and the clearance (Cl) of drugs. Extracorporeal membrane oxygenation introduces further PK/PD perturbation due to drug sequestration and hemodilution, thus increasing the Vd and clearance (sequestration). Drug disposition depends on the characteristics of the compounds (hydrophilic vs. lipophilic, protein binding), patients (age, comorbidities, surgery, co-medications, genetic variations), and circuits (roller vs. centrifugal-based systems; silicone vs. hollow-fiber oxygenators; renal replacement therapy). Based on the potential combination of the above-mentioned drug PK/PD determinants, an integrated approach in clinical drug prescription is pivotal to limit the risks of over- and under-dosing. The understanding of the dose-exposure-response relationship in critically-ill neonates on ECMO will enable the optimization of dosing strategies to ensure safety and efficacy for the individual patient. Next to in vitro and clinical PK data collection, physiologically-based pharmacokinetic modeling (PBPK) are emerging as alternative approaches to provide bedside dosing guidance. This article provides an overview of the available evidence in the field of neonatal pharmacology during ECMO. We will identify the main determinants of altered PK and PD, elaborate on evidence-based recommendations on pharmacotherapy and highlight areas for further research.

Inter-facility transports of critically ill neonates

Purpose: Interfacility transports (IFTs) of critically ill neonates (CINs) for a higher level of care are fraught with risk. Data on outcomes of IFTs of CINs requiring intensive monitoring and therapeutic interventions are scant. Our purpose was to compare IFTs of CINs and matched controls to a quarternary center by a specialized pediatric transport team. Specifically, we compared a) clinical characteristics and pre-transport status, b) unplanned events (UEs) and therapeutic interventions (TIs) during IFT and c) status on arrival, using the validated Transport risk index of physiologic stability …

Gasping for air

In this volume of The Journal, Steinhorn et al report the results of a multicenter randomized placebo-controlled trial of the effects of the endothelium receptor antagonist bosentan in neonates with persistent pulmonary hypertension (PPHN) and incomplete responses to inhaled nitric oxide. The primary outcome was treatment failure, defined as the need for extracorporeal membrane oxygenation or initiation of an alternative pulmonary vasodilator. The trial also evaluated time to complete weaning from mechanical ventilation. There were no significant differences in any of these outcomes. The bosentan was well-tolerated and there were no notable adverse effects. This report highlights some of the important difficulties in conduct of clinical trials in critically-ill neonates with this enigmatic disorder. Enrollment was slow due to several factors. Thankfully, the incidence of moderate to severe PPHN may be decreasing due to improvements in obstetric care. The incidence of incomplete response to inhaled nitric oxide has fallen in recent years due to improvements in management of infants with PPHN. This has been accompanied by a decrease in rates of extracorporeal membrane oxygenation reported by the Extracorporeal Life Support Organization. The study mandated an early enrollment. Failure to recruit adequate patient numbers has been reported in other trials of neonates with PPHN evaluating the use of inhaled prostaglandins (Trials 2014;15:486). Thus, we are faced with some good news—improved outcomes for infants with PPHN due to multifactorial contributions. We are, nonetheless, still challenged by infants with incomplete responses to mechanical ventilatory support and pharmacologic therapy, the confounding effects of different etiologies and the difficulty in accumulating enough patients to address the relationship between the clinical phenotype and pharmacodynamic responses. Article page 90 ▶ Bosentan as Adjunctive Therapy for Persistent Pulmonary Hypertension of the Newborn: Results of the Randomized Multicenter Placebo-Controlled Exploratory TrialThe Journal of PediatricsVol. 177PreviewTo evaluate the efficacy, safety, and pharmacokinetics of the endothelin receptor antagonist bosentan as adjunctive therapy for neonates with persistent pulmonary hypertension of the newborn (PPHN). Full-Text PDF

27. Natural History of Iatrogenic Pediatric Femoral Artery Injury

Iatrogenic femoral artery trauma complicates the course of critically-ill neonates and children. Complications from persistent arterial occlusion include claudication and limb length discrepancies. Data supporting risk factors for such and need for revascularization are lacking.

Long Term Renal Outcomes in Survivors of Acute Kidney Injury in Critically-Ill Children and Neonates

The epidemiology of pediatric acute kidney injury (pAKI) has transformed in the last decades with a shift from primary kidney disease to AKI associated with systemic illnesses or their treatments in critically-ill children and neonates. Even though pAKI has been shown to be associated with poor short-term outcomes including mortality in multiple studies, the long-term renal outcomes in survivors of pAKI in the pediatric and neonatal intensive care unit (PICU/NICU) settings have been understudied. The purpose of this article was to explore the burden of chronic kidney disease (CKD) in survivors of pAKI in critically-ill children and neonates through a review of the literature. We identified 10 observational studies from PICU (n=7) and NICU (n=3) survivors revealing a high prevalence of CKD following AKI (PICU:10-69%, NICU:63-85%). The wide range of CKD prevalence is likely related to multiple sources of heterogeneity between studies including definitions of AKI and CKD, varying lengths of follow-up, and large attrition rates. In light of the large number of patients identified with CKD following pAKI, we suggest that all critically-ill children and neonates should have ongoing surveillance after an AKI episode.

Serum Neutrophil Gelatinase-associated Lipocalin as a Predictor of Acute Kidney Injury in Critically-ill Neonates

Early detection of evolving Acute Kidney Injury (AKI) in critically ill neonates can lead to better preventive and therapeutic interventions. Neutrophil Gelatinase-associated Lipocalin (NGAL) is a promising biomarker of AKI, which was also shown to increase in inflammation. The objective of this study was to assess the utility of serum NGAL (sNGAL) as an early marker of evolving AKI in critically-ill neonates with and without sepsis. sNGAL levels were estimated in 60 critically-ill neonates at the time of admission to Neonatal Intensive Care Unit (NICU), in comparison to 20 healthy matched control. Patients were categorized as sepsis (n = 35) and no-sepsis (n = 25) subgroups on basis of clinical and laboratory criteria. They were subsequently discriminated according to creatinine and urine output criteria of the Acute Kidney Injury Network (AKIN), into AKI (n = 34) and no-AKI (n = 26) subgroups, sNGAL levels were significantly higher in the patient group as compared to control (132.7 +/- 67.8 vs. 55 +/- 10.3 ng mL(-1), p = 0.0001). Elevated levels were comparable between sepsis and no-sepsis groups (130.1 +/- 69.4 vs. 136.5 +/- 66.6 ng mL(-1), p = 0.7) and they positively correlated with 48-hour post-admission serum creatinine (p = 0.0001). Patients of AKI group had significantly higher sNGAL than those of no-AKI group (176.2 +/- 55.9 vs. 75.9 +/- 28.3 ng mL(-1), p = 0.0001). A cut-off value for sNGAL of 117.5 ng mL(-1), was predictive of AKI with a sensitivity of 82% and a specificity of 88.5%. It could be speculated that measurement of serum NGAL can serve as a clinically useful marker for early prediction of evolving AKI in critically-ill neonates with and without sepsis.

Hospitalización neonatal desde el servicio de urgencias en un centro hospitalario de Uruguay

To determine the prevalence of neonatal admissions through a pediatric emergency department (PED), and to evaluate the characteristics of patients who present vital risk on arrival. We performed a descriptive, retrospective review of neonates aged 2-28 days arriving from home who presented to the pediatric emergency department between 01/01/03 and 31/12/03. Of a total of 943 neonatal consultations, 277 (29.3 %) required admission. The most common diseases were respiratory (42.6 %) and fever without source (17 %). Among the 943 patients attended, 42 (4,5 %) showed vital risk, and in this group, 81 % were full term neonates, with a P50 of age of 19 days, and a P50 of weight of 3200 g. Among these, there was a predominance of infectious diseases (74 %), especially respiratory tract infections (50 %). Respiratory syncytial virus (RSV) was identified in 14 of the 42 patients. Thirty-six percent required mechanical ventilation and 71.5 % were transferred to the pediatric intensive care unit. Sixty percent of the critically-ill neonates were admitted in the 3 winter months (p < 0.001). A high percentage of the neonates arriving from home required admission, and vital risk was more frequent in this age group than in other ages (p < 0.001). This does not correspond to risk related to perinatal pathology, or to nutritional reasons, but to community-acquired infections, particularly those of the respiratory tract, the most frequent cause of which is RSV.

Common problems and their solutions in paediatric cardiac intensive care

There are many daunting challenges that need to be met by any seeking to achieve leadership in the area of cardiac intensive care. Paediatric cardiac intensive care has now emerged as a specialized clinical area, focusing on the unique needs of critically-ill neonates, children, and adults with congenital and acquired heart disease.1 Although an increasing number of centres dealing with paediatric cardiology have either started, or are considering starting, a dedicated cardiac intensive care unit and programme, there are no published primers regarding the logistical aspects of such a challenging endeavour. While there may be an ongoing debate about the preferred strategy in the clinical ownership of the patients treated in intensive care, most authorities agree that it is beneficial to have a dedicated team devoted to the needs of critically-ill children and adults with congenital and acquired cardiac disease.

Chemical Diagnosis of Congenital Metabolic Disorders by Gas Chromatography / Mass Spectrometry (GC/MS) in India

The present study reports the chemical diagnosis of 254 high-risk children by GC/MS using MILS method, which detects biochemical marker compounds specific for congenital metabolic disorders. Air-dried urine filter paper allows simple bedside collection, transportation and a link with other hospitals. Simulta- neous analysis of 101 metabolic disorders has the advan- tage of a wide range of detection to the attending doctor having limited health infrastructure in small towns and rural areas. The definite diagnosis was done in 44 samples (17.3%), reflecting the vast unexplored population of varied genetic etiology. This higher incidence in com- parison with the earlier reports (4-5%) from India, based on conventional methods indicated the urgency of lat- est technology. In critically-ill neonates, the metabolic abnormality was 24.3%. This emphasizes the crucial role of GC/MS in preventing mortality and morbidity. The high-risk genetic factors were consanguinity (13%), fam- ily history of mental retardation (13%), and stillbirth and deaths (33%), indicating the racial and ethnic diver- sity, as well as cultural and traditional impact. The 3 interesting cases among many are discussed where suc- cessful management and therapy was done. Accuracy of GC/MS analysis made genetic counselling more effective in evaluating the risk of Inborn Errors of Metabolism (IEM) in future pregnancy.

Importance of Postnatal Age(PNA) in Vancomycin Pharmacokinetics in the Critically-ill Neonate. 317

Dosing recommendations for vancomycin, which has primarily renal elimination, are derived from studies demonstrating that renal function in the human neonate increases significantly at approximately 34 wks postconceptional age(PCA, where PCA = gestational age[GA] + PNA). To examine the independent role of PNA, we calculated vancomycin pharmacokinetics (104 studies) in 79 critically-ill neonates. Elimination rate constant (Kel) and volume of distribution (Vd) were determined. As shown in the Table(mean±SD), infants were divided into three GA groups: ≤30, 31-35, and >35 wks(PCA 31.3±3.2, 35.9±3.9, and 42.8±2.0 wks, respectively). Although Kel was greater in the more mature infants, a significant correlation between PNA and Kel was observed within each gestational age group. Furthermore, for all infants with PCA 29-36 wks, the correlation between PNA and Kel was r=.49, p 35 wks)

The training of a neonatologist

A neonatologist must acquire the basic knowledge of a perinatologist through training in a perinatal centre with close obstetric collaboration. As a clinician, he/she must acquire competence in the medical care of critically-ill neonates through 3 years of neonatal experience following general paediatric training. As an administrator, skills are required in nursery management, regional planning, audit and follow-up of high-risk survivors. Skills are required as an educator for medical/nursing staff and the community. Training as a researcher enables appreciation of perinatal research, and appropriate application of scientific advances to clinical practice. He/she must become a person who cares, able to understand psychosocial and ethical issues in neonatology.