Evidence vs experience in neonatal medicine.

Tremendous progress has been made in the field of neonatal–perinatal medicine over the past two decades. However, the incidence of prematurity continues to increase in the United States. Care of infants born prematurely is evolving continuously based on evidence and experience. In 2004, a steering committee (Jatinder Bhatia, Rangasamy Ramanathan, Kris Sekar and Istvan Seri) was established to organize a scientific meeting to present results from randomized controlled trials or when there is no evidence from controlled trials; ‘experts’ in neonatal medicine were invited to discuss their ‘experience’. The 4th Annual Conference in Chicago focused on nutrition of extremely low birth weight (ELBW) infants, necrotizing enterocolitis (NEC), fetal inflammation and lung injury, resuscitation and stabilization of the preterm infant, strategies in protecting the preterm infant's lungs and newer therapeutic options for ELBW infants. National and international experts participated in the meeting to discuss these topics. As program chair, I began the meeting with a brief introduction about the specific aim of the meeting, which is to provide the updated information and take-home messages to clinicians caring for sick newborns based on evidence or experience. Henry Ford, pediatric surgeon from Children's Hospital Los Angeles (CHLA), whose research interest has been to study the role of gut immunity on NEC, elegantly presented data on the role of gut-associated lymphoid tissue, gut epithelial barrier function and pathophysiology of NEC. Following Dr Ford's presentation, Victoria Camerini, also from CHLA, discussed spontaneous intestinal perforation (SIP), which is being increasingly recognized as a different entity from NEC among ELBW infants. She also presented evidence from randomized trials on the medical and surgical management of NEC and SIP and discussed the role of primary peritoneal drainage vs laprotomy. Boris Kramer, from Academisch ziekenhuis Maastricht (the Netherlands), presented on the role of fetal inflammation in initiating lung injury. Use of room air or oxygen during resuscitation of the newborn, especially the preterm infant remains controversial. Professor Ola Saugstad of Oslo, Norway, an internationally known scientist for his work in this area, presented evidence for the optimal resuscitation of infants at birth. Marilyn Escobedo, from Oklahoma University Children's Hospital, a member of the neonatal resuscitation program steering committee, presented revised resuscitation guidelines and practical implications of changes in the guidelines. Bronchopulmonary dysplasia continues to be a major morbidity among preterm infants. Waldemar Carlo, from the University of Alabama, talked about the use of continuous positive airway pressure in the delivery room. I discussed evidence from controlled clinical trials on lung-protective ventilatory strategies in very low birth weight infants requiring positive pressure ventilation. Surfactant therapy is one of the few interventions that has been studied extensively in neonatology. Professor Henry Halliday, from Royal Maternity Hospital in Belfast, Ireland, was our keynote speaker, and he took us through the past, present and future of surfactant therapy. In the final session of our meeting, Roger Soll, from the University of Vermont, reviewed results from the meta-analysis on the prevention of heat loss in preterm infants. Hemodynamically significant patent ductus arteriosus (PDA) frequently complicates the clinical course in ELBW infants. Dr Sekar, from Oklahoma University Children's Hospital, discussed the pros and cons of treatment of PDA with indomethacin vs ibuprofen. Management of infants delivered at the threshold of viability continues to be a major ethical and moral challenge. Dr Seri, from CHLA, discussed the various approaches in the management of micropreemies and provided an algorithm for the management of these tiny infants.