With millions of journal articles published yearly, it is impossible to keep up. This month, the team from NEOTrips give us a whistle-stop tour of some of their research and other articles that have inspired potential future studies.
Neonatal Trainee-led Research and Improvement Projects (NeoTRIPs) is a national neonatal study group which aims to improve neonatal care for patients and families through large-scale quality improvement projects. NeoTRIPs was founded in London in 2019 and has expanded nationally to continue developing collaborative projects across the UK. Learn more about past and future projects on their website www.neotrips.org . Join our mailing list by contacting info@neotrips.org and follow us on Twitter @NeoTRIPS1.
Happy Reading 🙂
If you or your team want to submit a review, please get in touch with Dr Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.
Article 1: National survey of Probiotic use in neonatal units in the UK
Patel N; NeoTRIPS Collaborative Group; Evans K, Berrington J, Szatkowski L, Costeloe K, Ojha S, Fleming P, Battersby C. How frequent is routine use of probiotics in UK neonatal units? BMJ Paediatrics Open 2023;7:e002012. doi: 10.1136/bmjpo-2023-002012
What’s it about?
The use of probiotics in preterms to prevent NEC varies widely across the UK, despite being supported by national bodies such as BAPM and ESPGHAN. The NeoTRIPS network was used to conduct a survey that would define practices across the nation’s Neonatal Units (all levels).
Why does it matter?
The existing literature on the efficacy of probiotics in reducing the risk of NEC, late-onset sepsis, and death is inconclusive and often conflicting. This is compounded by the variation in which probiotic strains are used. Further understanding of probiotics use in the UK will help to design future research into their efficacy and safety, which could be conducted using data routinely collected via existing national databases.
Check out Probiotics in review – Don’t Forget the Bubbles and Necrotising Enterocolitis – Don’t Forget the Bubbles.
Of the 86% of neonatal units that responded to the survey, 70 of 161 (44%) routinely give probiotics to preterm babies, with almost two-thirds using the brand Labinic™. The second most commonly used brand was ProPrems®. NICUS were more likely than LNUS and SCUS, respectively, to use probiotics. The majority had a guideline for probiotic use, which advised use in infants born ≤32 weeks’ gestation.
Around a quarter of the units not currently using probiotics at the time of the survey were planning to introduce them within the next year. Compared with previous surveys, this showed a significant increase in probiotic use over recent years, highlighting an opportunity to assess whether this increase impacts clinical outcomes. Uncertainty amongst responding clinicians regarding whether their local microbiology laboratory was aware of probiotic use in their neonatal unit also highlighted the importance of involving the microbiology department in implementing probiotic guidelines to facilitate post-implementation surveillance of adverse effects.
Clinically Relevant Bottom Line
Probiotic use in preterm neonates is increasing, and it is important to engage local microbiology teams in the implementation process.
Reviewed by Lauren Ferretti
Article 2: How common is early-onset sepsis in neonates?
Kimpton J, A, Verma A, Thakkar D, Teoh S, Verma A, Piyasena C, Battersby C: Comparison of NICE Guideline CG149 and the Sepsis Risk Calculator for the Management of Early-Onset Sepsis on the Postnatal Ward. Neonatology 2021;118:562-568. doi: 10.1159/000518059
What’s it about?
This was a prospective, multicentre, observational study to evaluate the incidence and current management of Early-Onset Sepsis (EOS) in newborns ≥34 weeks gestation on the postnatal ward against NICE guidelines and the theoretical application of the Kaiser Permanente Sepsis Risk Calculator (KP SRC) in 13 London neonatal units over a two-month period.
The KP SRC suggests either commencing empiric antibiotics, taking a blood culture and observing (without commencing antibiotics), or no culture and no antibiotics. It is not common practice in the UK to take a blood culture without commencing antibiotics. So, for this study, if the calculator suggested a blood culture only, it was assumed that antibiotics would be commenced.
Why does it matter?
Since NICE introduced its early-onset neonatal infection guideline in 2012, antibiotic use in this cohort has increased. This guideline described maternal intrapartum antibiotics for suspected infection as a red flag risk factor, whereas the KP SRC takes into account the protective effect of these antibiotics on EOS. This study aimed to establish the incidence of EOS in the area and which of these babies would have been started on antibiotics based on the NICE guidelines versus the SRC.
1066 of the 8856 babies (12%) cared for on the postnatal ward during the study period were started on antibiotics. Seven cases had a positive blood culture. Thus, the incidence of EOS was 0.8/1000.
There were sufficient data for 601 patients to determine that 21.6% would have been started on antibiotics as per the KP SRC (when an incidence of 0.5/1000 was applied), versus 87.7% as per the NICE guidelines.
When the study’s incidence of 0.8/1000 was applied to the KP SRC, 29.7% of newborns would have been commenced on antibiotics. Six of the seven patients with positive blood cultures would have received antibiotics as per the NICE guidelines, and five as per the KP SRC when an incidence of 0.8/1000 was applied. Applying the SRC would significantly reduce antibiotic use on postnatal wards; however, the need to assess its safety led to the observational study summarised below.
Clinically Relevant Bottom Line
More research is needed to clarify if updated scoring systems can be used to rationalise antibiotic use in this patient cohort.
Reviewed by Lauren Ferretti
Article 3: Â Which scoring system is more effective in rationalising antibiotics?
Piyasena C, Galu S, Yoshida R Neonatal Trainee-Led Research and Improvement Projects (NeoTRIPs) group, et al. Comparison of diagnoses of early-onset sepsis associated with use of Sepsis Risk Calculator versus NICE CG1
What’s it about?
This prospective observational study utilised the NeoTRIPS network to compare rates of EOS diagnosed after 24 hours of life in babies born ≥34 weeks’ gestation between London units using the KP SRC and the NICE EOS guidelines. Over a 12-month period between September 2020 and August 2021, 10 units used the KP SRC, and 16 used the NICE guidelines.
Why does it matter?
Whilst the NICE guidelines were historically used widely throughout the UK, there were reservations that they may result in antibiotic overuse. The KP SRC has been shown to reduce antibiotic use and was widely adopted in the UK during the COVID-19 pandemic to manage resources and facilitate earlier discharges. However, there are concerns that the KP SRC may lead to delays in treatment or missed cases of EOS, and there is variation in how it is used and applied in different units.
Of 99,683 live births, the incidence of culture-positive early onset sepsis was 0.64/1000 live births. Before this study, the background incidence of EOS in Greater London was 0.8/1000 live births. Whilst there was no statistically significant difference in the incidence of EOS identified after 24 hours of life between KP SRC and NICE units, use of the KP SRC was associated with a 50% reduction in the number of babies receiving antibiotics within 24 hours of life.
Similar proportions of babies were started on antibiotics after 24 hours of life (but less than 7 days of life) in both types of hospital. Of 5 cases of EOS identified after 24 hours of life, 3 were readmissions to hospitals following NICE guidelines, suggesting that these events are rare and no more likely to occur with either approach. Group B Streptococcus was the most common organism isolated. The authors suggest that a randomised controlled trial should now be conducted to determine any difference in outcome between the two approaches.  Â
Clinically Relevant Bottom Line
Even though the incidence of neonatal sepsis is low, using the KP SRC resulted in fewer babies receiving antibiotics.
Reviewed by Lauren Ferretti
Publications that have inspired future NeoTRIPs projects.
Article 4: What can be done to reduce unplanned extubations on the neonatal unit?
Javed R, Mahadev K, Gowda H. Reducing unplanned extubation in tertiary NICU: a quality improvement project. Arch Dis Child Educ Pract Ed. 2025 Jan 17;110(1):36-39. doi: 10.1136/archdischild-2023-326753. PMID: 38697824.
What’s it about?
This Birmingham NICU had observed a high rate of unplanned extubations (UEs) on their unit. It thus aimed to identify the factors leading to this and introduce measures to reduce their occurrence over 2 years. They retrospectively collected data on UEs in their unit and introduced team education on the risk factors for UE, before re-evaluating UE rates. The reference standard used was <1 UE per 100 ventilation days.
Why does it matter?
Unplanned extubation and subsequent re-intubation can result in various complications for NICU patients, including cardiorespiratory deterioration requiring resuscitation and airway trauma. Neonates are at higher risk of UE due to multiple factors, including the size and type of endotracheal tubes (ETTs) used, subtle changes in ETT insertion length, fixation methods and routine cares/procedures performed.
The team identified a baseline UE rate of 2 per 100 ventilation days. They found that the most common risk factors for UE on their unit were physical examination, vomiting +/—suctioning, and procedures including X-ray. Their action plan included staff education on the risk factors for UE, a proforma for UEs, incident reporting of all UEs, and the introduction of a two-person holding technique for all procedures.
They completed three audit cycles, the second and third of which utilised prospective data collection. In the second PDSA (Plan-Do-Study-Act) cycle, an increase in UE of 3.19 per 100 ventilation days was observed, which was thought to be secondary to increased case identification via the incident reporting system. It also revealed slightly different risk factors, including baby movement, cuddles with parents, and ETT adjustment. This triggered further interventions, such as introducing 12-hourly documentation of ETT observations and using a 2-person technique for ETT adjustments.
By the third PDSA cycle, they observed a fall in the rate of UEs to 1.75 per 100 ventilation days, although the total number of ventilation days during this period was reduced. The authors concluded that thorough documentation and surveillance of UEs, as well as minimising the duration of invasive ventilation, are essential for reducing UE rates. Â
Clinically Relevant Bottom Line
Many factors can be identified and managed to reduce unplanned extubations in the neonatal unit.
Reviewed by Lauren Ferretti
Article 5: How is IVH related to survival and neurodevelopmental outcomes?
Rees P, Gale C, Battersby C, Williams C, Carter B, Sutcliffe A. Intraventricular Hemorrhage and Survival, Multimorbidity, and Neurodevelopment. JAMA Netw Open. 2025 Jan 2;8(1):e2452883. doi: 10.1001/jamanetworkopen.2024.52883. PMID: 39761048; PMCID: PMC11704976.
What’s it about?
This cohort study aimed to identify trends in rates of IVH, survival and neurodevelopmental outcomes at 2 years corrected age in infants born at <29 weeks’ gestation in England between 2013 and 2019. Cases were identified with any grade of IVH and matched with controls.
Why does it matter?
Many advances in neonatal intensive care have been made over recent years; however, it is not clear whether this has led to improvements in rates of IVH, survival and long-term neurodevelopmental outcomes. More specifically, whilst the neurodevelopmental impact of high-grade (grade 3-4) IVH has previously been well-defined, the consequences of low-grade (grade 1-2) IVH on neurodevelopmental outcomes remain unclear.
It was found that 26756 infants were born at <29 weeks’ gestation in England during the observation period, of which 8461 were diagnosed with IVH (5570 low-grade, 2891 high-grade). 98.4% of these survived beyond 24 hours and were included in the study. Primary outcome data on survival at 2 years’ correct age were available for 78.8% of infants. There was a statistically non-significant increase in the incidence of high-grade IVH over time, and a slight increase in the incidence of low-grade IVH, which was statistically significant even when 22-23 week gestation infants were excluded.
Survival without severe neurodevelopmental impairment (NDI) was 32.8% in the high-grade IVH group, compared with 59.8% in controls. Survival without severe NDI was slightly lower in the low-grade IVH group compared with controls, with approximately 52.2% of survivors having no NDI and 64.4% having no developmental delay. For both low- and high-grade IVH, survival without severe NDI was lower where there was bilateral compared with unilateral IVH. When looking at other major morbidities such as bronchopulmonary dysplasia and surgical necrotising enterocolitis, each significantly reduced survival without severe NDI, independent of co-morbidities and with no relationship between morbidity pairs.
Read more about IVH here: Intraventricular Haemorrhage – Don’t Forget the Bubbles.
Clinically Relevant Bottom Line
The lack of improvement in rates of IVH over time is reflected internationally, and the reason for this must be elucidated – is it because of changes in the underlying population, or changes in care? Neurodevelopmental assessment at 2 years corrected age is inadequate for understanding long-term outcomes for these patients.Â
Reviewed by Lauren Ferretti
If we missed something useful or you think other articles are worth sharing, please add them in the comments!
That’s it for this month—many thanks to our reviewers for scouring the literature so you don’t have to.
Vicki Currie, DFTB Bubble Wrap Lead, reviewed and edited all articles.
