With millions of journal articles published yearly, it is impossible to keep up.
In this edition, we’re taking it back to DFTB26, where in Bonnie Scotland we experienced a truly magical Bubble Wrap Live. This is the first of 3 instalments. Looking at 5 important papers in Neonates- by speaker Vix Monnelly.
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: Updated Resuscitation guidelines – a narrative review comparing three NLS guidelines.
Kuitunen I, Davis PG. How consistent are recent neonatal resuscitation guidelines? Resusc Plus. 2026 Apr 3;29:101314. doi: 10.1016/j.resplu.2026.101314. PMID: 42027799; PMCID: PMC13100290.
What’s it about?
In 2025, there was a guidelines update. The first paper was a narrative review comparing the three NLS guidelines: ILCOR, AAP, and ERC guidelines. This is a nice walk through the resuscitation guidelines to see, well, of course, they’ll be pretty much the same, right? They’re all derived from the same resuscitation science.
Why does it matter?
No, although there are similarities and we do agree on many fundamentals, there are quite a lot of differences between our guidelines. This paper breaks down the sections of the NLS guidelines into seven tables. In Europe, what do they do with oxygen? Well, what do they do in America now? What do we do in ILCOR?
The stat show some of the main areas of difference, namely resuscitation with an intact cord. There are differences in our approach to initiating oxygen in preterm infants; we vary quite significantly across the globe in how much oxygen we start our preemies on, and then there’s the age-old debate of two- to three-second inflation breaths that we do here in parts of Europe versus just getting straight on and doing PPV. Okay, who’s right? Who knows? The answer comes from the same evidence base.
Clinically Relevant Bottom Line
Although all our resuscitation guidelines come from the same evidence origin, we interpret the evidence differently and variation exists. That variation comes from pragmatism, differences in our healthcare systems or resources, but it also comes in because of paucity of evidence, and most of our resuscitation science evidence, particularly in babies, is very low certainty evidence, and that’s not because the trials aren’t very good, it’s just they’re so small in number, whenever there’s paucity of evidence, or indeed, no evidence. Expert opinion creeps in, and that also adds to variation.
This paper also highlights a really important point: that there is an extreme lack of data from extremely preterm infant babies when it comes to resuscitation, and therefore, it’s hard to extrapolate our NLS guidelines down to the tiniest, most fragile babies that we look after.
Reviewed by Vix Monnelly
Article 2: Should we start enteral fluids day 1 or gradually feed preterm infants?
Ojha S, Mitchell EJ, Johnson MJ, et al. Full exclusively enteral fluids from day 1 versus gradual feeding in preterm infants (FEED1): a open-label, parallel-group, multicentre, randomised, superiority trial. Lancet Child Adolesc Health. 2025 Dec;9(12):827-836. doi: 10.1016/S2352-4642(25)00271-8. Epub 2025 Oct 17. Erratum in: Lancet Child Adolesc Health. 2026 Jan;10(1):e3. doi: 10.1016/S2352-4642(25)00348-7. PMID: 41115446.
What’s it about?
The next paper impacts a huge number of babies, and this is the Feed1 trial that was published in The Lancet Child and Adolescent Journal earlier this year, It was a randomized superiority trial looking at over 2000 infants from 30 weeks up to 33 weeks gestation, with the aim to answer the question: Should we start full milk feeds from day one of life in these babies, or should we carry on with our gradual approach with a bit of background parenteral nutrition or IV fluids, and build up the milk over several days.
Now, why is this question important? Well, we are worried about feeding preterm babies because we’re worried about necrotising enterocolitis (NEC), but in this population of babies, the background risk of NEC is extremely low, less than 1%. So this seemed like a good population of babies to try a full milk strategy on.
Why does it matter?
Now, in this RCT, the primary outcome was length of hospital stay, but they also included important safety outcomes such as rates of NEC and hypoglycemia. Sensibly, they excluded babies who couldn’t safely enter a feed, and they also excluded babies small for gestational age with reversed end-diastolic flow on umbilical Doppler. So, what did this trial show? There was no difference in the length of hospital stay. There was also no statistically significant difference in the rates of IV cannulas, central lines, or late-onset sepsis. Importantly, there was no increase in hypoglycemia or NEC in these babies.
Small babies, less than a kilo, and babies with reversed end diastolic flow, so abnormal Dopplers, were underrepresented in this trial, so you might hear people say the FEED1 trial says it’s safe to feed babies from 30 weeks gestation full milk, just be aware that it doesn’t apply to all babies in this gestation category, particularly those that may have a higher baseline risk of complications.
The authors state that babies were enrolled when the clinician was in equipoise regarding which feeding strategy was best. This does introduce a bit of selection bias because if they think this baby is too high-risk for NEC, they’re not going to approach them for enrollment.
And, of course, there was more donor breast milk and more formula used if we’re trying to feed from day one of life, we don’t know the longer term consequences of that, and I certainly am eagerly awaiting the neurodevelopmental outcomes from this trial, which will be published in due course, but the final thing about this trial was that it was designed, performed, and the results disseminated in partnership with parents, and all of those aspects on the slide, there were done with parental input, and I think this really sets the gold standard for how we should be performing neonatal trials going forward.
Clinically Relevant Bottom Line
There was no difference in the length of hospital stay. There was also no statistically significant difference in the rates of IV cannulas, central lines, or late-onset sepsis. Importantly, there was no increase in hypoglycemia or NEC in these babies that were commenced on full feeds from D1 of life.
Reviewed by Vix Monnelly
Article 3: Patent ductus arteriosus – to close or not to close?
Buvaneswarran S, Wong YL, Liang S, Quek SC, Lee J. Active Treatment vs Expectant Management of Patent Ductus Arteriosus in Preterm Infants: A Meta-Analysis. JAMA Pediatr. 2025 Aug 1;179(8):877-885. doi: 10.1001/jamapediatrics.2025.1025. PMID: 40423988; PMCID: PMC12117495.
What’s it about?
Now let’s talk about the duct, or the patent ductus arteriosus (PDA), and the question of whether to close or not to close, the age-old question that has been going round for decades. This meta-analysis, published earlier this year in JAMA Pediatrics, examined active management with pharmacological closure in the first two weeks of life among preterm infants born before 33 weeks. It pooled data from 10 trials. Big PDA trials were included with over 2000 babies, and the primary outcome was a composite of death or moderate and severe BPD (Bronchopulmonary dysplasia).
Why does it matter?
There was more death and more moderate to severe BPD in babies who had active management of their duct in the first two weeks; now death and BPD are not equal. If you ask parents, they’re not equal measures of outcome. So, we need to look at the individual components so death alone, there is a significantly higher rate of death in babies who had active management to try and close their duct in the first two weeks of life.
There are two hypotheses for why babies in the expectant management group did better: one is that the duct itself, its presence, is in some ways protective, and the other is that the drugs used to close it may be harmful. Okay, and so why might the duct itself be helpful to be there? We learn, don’t we, that the duct sends more blood to the lungs, and then you get pulmonary overcirculation, you go into heart failure, and that is bad.
But the authors propose that if you send more blood to the lungs, you actually get more blood coming back from the lungs to the left side of the heart, which then goes up to the brain, so you get better cerebral blood flow.
Maybe this is one of the reasons why they also say that if you’ve got pulmonary hypertension, which often babies with BPD have a bit of coexistent pulmonary hypertension, then the duct acts as a blow-off valve or a pop-off valve for the right side of the heart.
This might confer an advantage to the baby, and certainly they go on to talk about the deleterious side effects of the drugs that are used in the various treatment regimens. Importantly, it wasn’t possible for the authors to talk about the cause of deaths and why there might be more deaths in the active management group, which was mainly due to lack of reporting of cause of deaths in the trials that were included in this meta- analysis.
Clinically Relevant Bottom Line
In this study, babies had a worse outcome (BPD and death) when PDA was treated in the first few weeks with pharmacological management.
Reviewed by Vix Monnelly
Article 4: Emergency laparotomy in NICU – is that even possible?
Sehdev S, O’Sullivan B, Blaise BJ, Lee G, Selman A, Yardley I. Emergency Laparotomy in the Neonatal Intensive Care Unit: A Systematic Review of Indications and Outcomes. Eur J Pediatr Surg. 2026 Feb;36(1):43-51. doi: 10.1055/a-2767-4700. Epub 2025 Dec 9. PMID: 41365380.
What’s it about?
This was also a systematic review looking at babies who needed a laparotomy, either for NEC, for spontaneous intestinal perforation (SIP), or congenital diaphragmatic hernia (CDH) repair. This systematic review looked at 849 neonates who had 871 laparotomies (453 in theatre and 418 cot side in NICU).
Why does it matter?
Regarding the laparotomies performed in the NICU, there were no increased adverse events, there was no increased mortality rate, and there was no increase in infections. When we look at the patient characteristics, these babies that had their laparotomies on the NICU were smaller, 1.3 kilos versus 2.9 and more immature, 29 weeks versus 34 weeks. So, you would expect the smaller, sicker, more immature babies to have more complications, a higher mortality rate, and that was not found.
Clinically Relevant Bottom Line
This systematic review concluded that current evidence suggests that cotside laparotomy is safe, feasible, and clinically justified for a well-defined population of babies.
If you work in a centre what does cot side operating, it’s really important that there’s appropriate guidelines and governance, because only a third of these of the places in the study that were doing it actually had any form of standard operating procedural guidelines, and if you’re not doing it, hopefully I’m starting to stir some things in your mind to think maybe we should.
Reviewed by Vix Monnelly
Article 5: Â Educational attainment of preterm-born children in England
Health and socioeconomic characteristics underlying educational attainment of children born preterm in England: a population cohort study using linked data. Sadia Haider, Athanasios Tsanas, G. David Batty et al. medRxiv 2025.11.13.25340148; doi: https://doi.org/10.1101/2025.11.13.25340148
What’s it about?
This is going beyond the NICU. This was a cohort study examining all babies born preterm in England, less than 32 weeks, over a five-year period. It took the neonatal record and linked that to the national database, so more than 15,000 kids. The aim was to describe school readiness at age five, to examine educational attainment in the early primary school years, and to look at any other factors that might be associated with educational attainment.
Why does it matter?
Over half of children born preterm were not school-ready at age 5, and these deficits persist into the early school years across all domains. As might be expected, there is a dose-response effect from gestational age. The rate of non-attainment is much higher at lower gestational ages, and this paper, aside from gestation, sought to outline other risk factors for poor educational attainment.
Things you can’t change are factors like the gestation you’re born at, the sex that you’re born at, and the season of birth. In England, summer is important because the school year runs from September to August. If you’re born in the summer, you’re young for your year.
There are some modifiable factors, such as socioeconomic status, and what the study found was that being eligible for free school meals (e.g. in lower socioeconomic status) gave similar outcomes to having severe IVH.
Clinically Relevant Bottom Line
As neonatologists, we are worried and focused on how we can reduce acquired brain injury in preterm babies, but free school meal eligibility, or this proxy for social deprivation, is far more prevalent than grade three or four IVH, and if you are eligible for free school meals, you have an almost doubling of your risk of poor school attainment.
Reviewed by Vix Monnelly
Take-home messages
We interpret resuscitation science differently, even though it all comes from the same origin, depending on where we are in the world. Be aware of these variations; they’ll open your mind.
It is safe to exclusively feed most babies from 30 weeks, but not all.
Leave the ducts alone for the first two weeks unless new data becomes available.
Until new data emerge, use of NSAIDS or paracetamol during the first two weeks of life for PDA closure should be undertaken with caution.
Operate in the NICU if you can, and if you already do, make sure you’ve got appropriate governance.
Let’s have a think as a pediatric community about modifying the modifiable risk factors for educational attainment, because that is probably going to be far more important for our preterm babies to optimise their outcomes.
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 all articles.