BACKGROUND: Radioactive heavy metals, including uranium, strontium-90, caesium-137, radium, thorium, and plutonium, pose potential health risks to nursing infants through breast milk transfer. Understanding the extent of...BACKGROUND: Radioactive heavy metals, including uranium, strontium-90, caesium-137, radium, thorium, and plutonium, pose potential health risks to nursing infants through breast milk transfer. Understanding the extent of contamination, transfer mechanisms, and health implications is critical for public health policy. OBJECTIVE: This scoping review synthesises evidence on radioactive heavy metal contamination in breast milk, maternal-infant transfer mechanisms, and associated health impacts on early life development. METHODS: A comprehensive scoping literature search was conducted in December 2024 across multiple electronic databases. After deduplication, 161 unique papers remained. An AI-assisted relevance scoring approach (SciSpace biomedical agent) was used to prioritize screening; final eligibility decisions and data extraction were performed by the authors. Thirty studies were included for synthesis. RESULTS: Evidence demonstrates measurable concentrations of strontium-90, caesium-137, uranium, and radium in breast milk following environmental contamination events (Chernobyl, Techa River, nuclear weapons testing) and in regions with naturally elevated radioactivity. Transfer rates vary by radionuclide, with strontium-90 showing significant maternal-infant transfer. Biokinetic models indicate dose-dependent accumulation in infant tissues. Limited direct evidence exists for specific health outcomes, though theoretical risk assessments suggest potential impacts on hematopoietic development, bone metabolism, and long-term cancer risk. CONCLUSIONS: While breast milk contamination with radioactive heavy metals is documented in specific contexts, the health benefits of breastfeeding generally outweigh risks except in acute high-exposure scenarios. Gaps remain in understanding long-term neurodevelopmental and growth impacts. Enhanced biomonitoring and longitudinal studies are needed to inform evidence-based public health guidance.
OBJECTIVE: This study aimed to investigate the combined effects of dedicated lactation specialist roles and family-centered support to increase breastfeeding rate in very low birth weight infants. METHODS: A non-concurre...OBJECTIVE: This study aimed to investigate the combined effects of dedicated lactation specialist roles and family-centered support to increase breastfeeding rate in very low birth weight infants. METHODS: A non-concurrent controlled study was conducted. VLBWIs hospitalized at the Affiliated Hospital of Zunyi Medical University from November 2023 to November 2024 were selected as the intervention group. A dedicated team of breastfeeding nurses was established to implement the following interventions: early assessment and guidance for mothers within 12 h after neonatal NICU admission; regular communication with mothers and families to monitor maternal conditions; enhanced breast milk management via digital platforms; a nighttime breast milk reception green channel; material support; and the promotion of colostrum utilization. VLBWIs admitted between November 2022 and October 2023 were included as the conventional group for comparison. RESULTS: The any breastfeeding rate in the intervention group (62.4%, 118/189) was significantly higher than that in the conventional group (42.5%, 74/174). The colostrum feeding rate in the intervention group (36.5%, 69/189) was higher than that in the conventional group (19%, 33/174), and the breastfeeding rate at discharge was significantly greater in the intervention group (37%, 70/189) than in the conventional group (26.4%, 46/174) (P < 0.05). The initiation time of pumped breast milk feeding in the intervention group was significantly earlier than that in the control group (P < 0.05). CONCLUSION: The dual-track empowerment model, which integrates dedicated breastfeeding lactation specialists and family support, effectively improved breastfeeding rates and practices for VLBWIs. This model provides a valuable reference for clinical healthcare providers to promote breastfeeding.
Glenn T, Carroll J, Kimball A
… +12 more, Speziale M, Romanowski G, Chamankhah N, Helgeson H, Sim E, Kimmel J, Kang J, Wong A, Grimm P, Van Gorder M, Heath D, Moyer L
OBJECTIVE: Infants in the NICU often require prolonged sedation, increasing risk for iatrogenic withdrawal. We aimed to reduce mean opioid exposure by 20% (26 to 21 days) by May 2023, with sustained improvement through M...OBJECTIVE: Infants in the NICU often require prolonged sedation, increasing risk for iatrogenic withdrawal. We aimed to reduce mean opioid exposure by 20% (26 to 21 days) by May 2023, with sustained improvement through May 2024. STUDY DESIGN: A multidisciplinary team used the Model for Improvement with iterative Plan-Do-Study-Act cycles and EHR tools to implement a standardized sedation-weaning guideline. Applicable outcome, process, and balancing measures were analyzed using statistical process control charts. RESULTS: Among patients receiving >4 days of opioids, mean exposure decreased from 26 to 17 days, length of stay from 70 to 50 days; and overall dexmedetomidine exposure from 18 to 12 days. Adherence to individualized weaning plans improved and feedback indicated effective withdrawal management. CONCLUSIONS: Standardized weaning reduced opioid exposure, LOS, and sedative use, enhancing safety, care quality, and NICU capacity.
Magers J, Burton A, Prusakov P
… +6 more, White NO, Miller RR, Moraille R, Theile AR, Sánchez PJ, Nationwide Children’s Hospital Neonatal Antimicrobial Stewardship Program (NEO-ASP)
J Perinatol
· 2026 May · PMID 42056240
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OBJECTIVE: To determine adherence and safety of a diagnostic (culture, urinalysis) and therapeutic (5-day antibiotic course with a time-out) guideline for urinary tract infection (UTI) in the Neonatal Intensive Care Unit...OBJECTIVE: To determine adherence and safety of a diagnostic (culture, urinalysis) and therapeutic (5-day antibiotic course with a time-out) guideline for urinary tract infection (UTI) in the Neonatal Intensive Care Unit STUDY DESIGN: Prospective surveillance of non-bacteremic UTIs from 11/2020-12/2022. Safety outcomes were defined by re-initiation of antibiotics within 7 days for a subsequent UTI due to the same organism and overall and UTI-related mortality. RESULTS: 77 infants received treatment for 93 UTIs with 77% (72/93) adherence to diagnostic criteria; 90% (82/91) of infants received ≤6 days of definitive treatment (median [IQR] antibiotic duration 5 [5-6] days). Antibiotics were restarted within 7 days for a recurrent (same organism) UTI in 1/91 (1%) UTIs. Mortality was 4% (4/93); none were due to UTI. CONCLUSION: Adherence to diagnostic UTI criteria was 77%. 90% of infants received short course treatment that was associated with a 1% failure rate. No safety concern was identified.
OBJECTIVE: To characterize relationships between social determinants of health (SDoH) and mortality among infants receiving extracorporeal membrane oxygenation (ECMO). STUDY DESIGN: Retrospectively, we identified infants...OBJECTIVE: To characterize relationships between social determinants of health (SDoH) and mortality among infants receiving extracorporeal membrane oxygenation (ECMO). STUDY DESIGN: Retrospectively, we identified infants born >34weeks gestation and >1.8 kilograms who received ECMO from 2010-2022. The primary predictor was the child opportunity index (COI). The outcome was in-NICU mortality. Due to interactions between SDoH and diagnoses, the main analyses were performed within the diagnostic cohort using multilevel socioecological factors. RESULTS: Overall, 2254 neonates received ECMO [congenital diaphragmatic hernia (32%, CDH), meconium aspiration syndrome (27%, MAS), cardiac (13%) and other (28%, e.g., sepsis)]. Characteristics differed with MAS more common in lower COI and Black race, while CDH was more common in the White race. COI and maternal race/ethnicity were unrelated to in-NICU mortality. CONCLUSION: Despite epidemiological differences by SDoH, the primary outcome was consistent across groups, suggesting potential resilience to social risk factors and underscoring the importance of studying distinct cohorts separately.
OBJECTIVE: To determine the incidence of dysphagia and define the associated co-morbidities in infants born very preterm (VP) or very low birth weight (VLBW). STUDY DESIGN: This is a retrospective cohort study evaluating...OBJECTIVE: To determine the incidence of dysphagia and define the associated co-morbidities in infants born very preterm (VP) or very low birth weight (VLBW). STUDY DESIGN: This is a retrospective cohort study evaluating 158 VP or VLBW infants born over two years. Forty infants diagnosed with dysphagia confirmed by flexible endoscopic evaluation of swallowing were compared to 118 infants with no dysphagia. RESULTS: The incidence of dysphagia was 25%. After adjusting for gestational age and birth weight, dysphagia was associated with morbidities such as necrotizing enterocolitis, bronchopulmonary dysplasia, and intracranial hemorrhage. Regression analyses indicated that dysphagia was associated with higher central line days and longer hospital length of stay. Feeds were thickened in 38 infants (95%) before discharge and 3 infants (7.5%) needed gastrostomy tube. CONCLUSION: Dysphagia is an important morbidity affecting a quarter of the infants born VP or VLBW. Significant associations with other major morbidities were noted.
OBJECTIVE: To evaluate the impact of routine 6-h transcutaneous bilirubin (TcB) surveillance on bilirubin rate-of-rise (ROR) values meeting American Academy of Pediatrics (AAP) age-specific cut-points. STUDY DESIGN: Retr...OBJECTIVE: To evaluate the impact of routine 6-h transcutaneous bilirubin (TcB) surveillance on bilirubin rate-of-rise (ROR) values meeting American Academy of Pediatrics (AAP) age-specific cut-points. STUDY DESIGN: Retrospective cohort study of healthy newborns ( ≥ 35 weeks' gestation, ≥2.0 kg) undergoing routine 6-h TcB monitoring during birth hospitalization. ROR was calculated from consecutive TcB pairs and assessed as a screening test for selected hemolytic hyperbilirubinemia neurotoxicity risk factors (HNRFs). RESULTS: Among 621 newborns (3787 TcB measurements), 71.8% had ≥1 AAP ROR cut-point. Nearly one-quarter of these events were preceded by a negative slope, indicating frequently variable TcB trajectories. Extending surveillance from 6 to 12 h reduced the odds of AAP ROR cut-points by ~60%. As a screening test for HNRFs, AAP ROR cut-points demonstrated moderate sensitivity (73%) but low specificity (28%). CONCLUSIONS: Routine 6-h TcB surveillance yields frequent AAP ROR cut-points with poor HNRF specificity, limiting short-interval ROR clinical utility.
OBJECTIVE: Describe the prevalence of oral care with human milk (OHM) for infants with critical congenital heart disease (CCHD) and estimate the effect of early OHM (1st postnatal week) on lactation outcomes. STUDY DESIG...OBJECTIVE: Describe the prevalence of oral care with human milk (OHM) for infants with critical congenital heart disease (CCHD) and estimate the effect of early OHM (1st postnatal week) on lactation outcomes. STUDY DESIGN: Retrospective cohort including infants with CCHD from 2014-2023. Adjusted regression estimated effects of early OHM frequency (quartiles (Q); Q1 = 0-1 OHM doses, Q2 = 2-6, Q3 = 7-13, Q4 ≥ 14) on human milk intake and breastfeeding (BF) at discharge. RESULT: For 297 infants ≤6 months old, OHM comprised 25.5% of oral care. Early OHM frequency was associated with 42.67-57.03 mL/kg/d higher human milk intake (p < 0.001 for Q2-4 compared to Q1), and 4.7-6.03 greater odds of BF (p < 0.01 for Q2-4) at discharge. CONCLUSION: Increased early OHM frequency was strongly associated with lactation outcomes for newborns with CCHD. OHM may support human milk/BF exposure in this vulnerable population.
McGowan EC, McGrath M, Law A
… +12 more, O'Shea TM, Blackwell CK, Aschner J, Ganiban JM, Higgins RD, Taylor GL, Spillane NT, Hudak ML, Camargo CA, Talavera-Barber MM, Lester BM, ECHO Cohort Consortium
J Perinatol
· 2026 Apr · PMID 42045667
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OBJECTIVE: To investigate positive health perceptions during the COVID-19 pandemic of adolescents born preterm (<37 weeks' gestation). STUDY DESIGN: The study population included 4093 mother-child dyads from 38 pediatric...OBJECTIVE: To investigate positive health perceptions during the COVID-19 pandemic of adolescents born preterm (<37 weeks' gestation). STUDY DESIGN: The study population included 4093 mother-child dyads from 38 pediatric cohort sites. The study used generalized estimating equations to evaluate positive health among adolescents born preterm versus term while controlling for age and date of questionnaire completion, child sex, maternal education, and site. RESULTS: 691 individuals born preterm were compared with 3402 individuals born term. In adjusted analyses, adolescents born <28 weeks' gestation (n = 359) had higher life satisfaction (β = 2.95, 95% CI: 2.46, 3.44) and meaning and purpose (β = 2.26, 95% CI 0.73, 3.79) scores than those born at term. CONCLUSION: During the pandemic, adolescents born <28 weeks had a more positive outlook on their well-being than their term-born peers. Confirming findings and uncovering supportive factors that augment positive health perceptions may optimize long-term health and resiliency.
OBJECTIVE: To determine safety and efficacy of exclusive human milk diet (EHMD) for very low birth weight (VLBW, <1500 g) infants. DESIGN: Prospective, controlled, open trial of VLBW infants randomized to EHMD (mother's...OBJECTIVE: To determine safety and efficacy of exclusive human milk diet (EHMD) for very low birth weight (VLBW, <1500 g) infants. DESIGN: Prospective, controlled, open trial of VLBW infants randomized to EHMD (mother's own milk [MOM]/donor milk [DM] with human milk-based fortifiers) or Standard Diet (MOM/DM with cow milk-based fortifier/formula). Outcomes included superiority of weight gain velocity from birth to 34 weeks gestational age, time to full feeds, and safety. RESULT: In total, 147 infants received EHMD (n = 77) or Standard Diet (n = 70). The EHMD group had superior mean weight gain velocity versus the Standard Diet (13.44 vs 11.96 g/kg/day, p = 0.006) and earlier mean time to full feeds (20.0 vs 25.9 days, p = 0.03); adverse events were not significantly different (32.5% vs 21.4%, p = 0.13). CONCLUSION: EHMD is viable for management of VLBW infants, providing improved growth without reduced safety. TRIAL REGISTRATION AND ID: Japan Registry of Clinical Trials: jRCT2031210384.
BACKGROUND: Prematurity remains a leading cause of neonatal mortality and morbidity; with neurodevelopmental disorders among its most significant complications. Erythropoiesis-stimulating agents (ESAs) have been explored...BACKGROUND: Prematurity remains a leading cause of neonatal mortality and morbidity; with neurodevelopmental disorders among its most significant complications. Erythropoiesis-stimulating agents (ESAs) have been explored for their neuroprotective potential. OBJECTIVE: To evaluate whether early prophylactic administration of ESAs in preterm neonates ( < 37 weeks' gestation) improves neurodevelopmental outcomes up to 36 months of age. STUDY DESIGN: A systematic search of MEDLINE, Embase, Cochrane Library, and ICTRP identified 1142 studies, of which ten met the inclusion criteria. The meta-analysis included only randomized control trials (RCTs) reporting Bayley Scales of Infant Development scores or cerebral palsy diagnosis. RESULTS: Among the ten included studies (eight RCTs, two retrospective cohorts), comprising 2861 preterm infants, narrative synthesis was inconclusive. Meta-analysis showed reduced odds of adverse cognitive outcomes (OR: 0.55; 95% CI: 0.35-0.85), and cerebral palsy (OR: 0.66; 95% CI: 0.45-0.97) in ESA-treated group, with no evidence of publication bias. Sensitivity analyses indicated potential fragility of pooled estimates. CONCLUSION: Εarly ESAs administration may provide cognitive benefits. Standardized methodologies and longer-term studies are needed to confirm neurodevelopmental effects and clinical relevance.
Coccidioidomycosis is a dimorphic fungal infection endemic to the southwestern United States and parts of the Americas. Pregnant individuals have an increased risk of disseminated disease, yet the diagnosis and managemen...Coccidioidomycosis is a dimorphic fungal infection endemic to the southwestern United States and parts of the Americas. Pregnant individuals have an increased risk of disseminated disease, yet the diagnosis and management of neonatal coccidioidomycosis remain poorly defined. Neonatal coccidioidomycosis is rare but associated with significant morbidity and mortality. Transmission may occur via transplacental spread, aspiration of infected decidua at delivery, or early postnatal exposure. Diagnosis is challenging due to overlapping signs with prematurity and limitations of current serologic, antigen-based, and molecular assays. Placental pathology can provide insight, but does not reliably predict neonatal infection. Herein, we review the current literature on neonatal coccidioidomycosis and propose a risk-stratified, multidisciplinary approach to the evaluation and management of at-risk neonates, using illustrative cases to demonstrate the challenges of diagnosis and management. This practical approach includes maternal history, placental evaluation, targeted neonatal testing, and consideration of empiric antifungal therapy.
Elberson V, Rao K, Chepuri S
… +1 more, Chandrasekharan P
J Perinatol
· 2026 May · PMID 42026155
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OBJECTIVE: Using a quality improvement (QI) framework, we aimed to reduce the number of transfusions of packed red blood cells (pRBC) through adoption of evidence based more restrictive transfusion thresholds. METHODS: A...OBJECTIVE: Using a quality improvement (QI) framework, we aimed to reduce the number of transfusions of packed red blood cells (pRBC) through adoption of evidence based more restrictive transfusion thresholds. METHODS: A SMART aim was developed to decrease pRBC transfusions in infants less than 35 weeks gestation at birth by approximately 25 percent from the baseline rate of 28/1000 patient days by 12/31/2024 through implementation of a transfusion protocol with more restrictive thresholds. Five sequential Plan-Do-Study-Act cycles incorporated guidelines to decrease transfusions. Statistical Process Control charts (QI Macros SPC Software for Microsoft Excel) were used to track time-ordered data. RESULTS: pRBC transfusions decreased from 28/1000 patient days to 18.3/1000 patient days below the target of 21/1000 patient days over a 16-month period. CONCLUSION: A transition to more restrictive transfusion thresholds was done successfully in our unit with a robust framework leading to fewer pRBC transfusions.
This systematic review and meta-analysis evaluated whether caffeine administration within the first 7 days after birth reduces neonatal AKI without increasing adverse events. Randomized and nonrandomized studies were ide...This systematic review and meta-analysis evaluated whether caffeine administration within the first 7 days after birth reduces neonatal AKI without increasing adverse events. Randomized and nonrandomized studies were identified through MEDLINE, CENTRAL, and EMBASE. Risk of bias was assessed using RoB2 and ROBINS-I, and the certainty of evidence was rated using GRADE. Twenty-five studies were included, six of which reported AKI outcomes. Three adjusted observational studies were eligible for meta-analysis. Early caffeine administration resulted in a large reduction in AKI (915 participants; aOR 0.16; 95% CI 0.09-0.31; low-certainty evidence). The evidence was very uncertain about early caffeine administration reducing maximum serum creatinine levels (one study; 50 participants; MD -0.42 mg/dL; 95% CI -0.58 to -0.26; very low-certainty evidence). No increase in adverse events was observed, although the pooled estimates of adverse events were unavailable. Early caffeine administration is associated with reduced neonatal AKI without evidence of increased adverse events.
BACKGROUND: Neonatal hypoglycemia is a common reason for neonatal intensive care unit (NICU) admission. Management variations may prolong intravenous (IV) dextrose use and NICU length of stay (LOS). METHODS: We aimed to...BACKGROUND: Neonatal hypoglycemia is a common reason for neonatal intensive care unit (NICU) admission. Management variations may prolong intravenous (IV) dextrose use and NICU length of stay (LOS). METHODS: We aimed to reduce IV dextrose duration for hypoglycemic neonates transferred to the NICU by 30%. Standardization efforts included multidisciplinary team formation, guideline development, Epic SmartPhrase creation, and education. Our primary outcome measure was IV dextrose infusion duration. Secondary outcomes were LOS, percentage of patients started on IV dextrose, and number of blood draws. The process measure was guideline utilization. Balancing measures were readmissions, second IV courses, and dextrose boluses. RESULTS: Mean IV dextrose administration decreased from 25 to 16 h and LOS from 59 to 27 h. The number of blood draws and boluses decreased without changes in readmissions or second IV dextrose courses. CONCLUSIONS: Our quality initiative safely reduced IV dextrose duration and NICU LOS, without significant rebound hypoglycemia.
OBJECTIVE: To identify novel risk factors associated with tracheostomy in preterm infants with Grade 3 bronchopulmonary dysplasia (BPD). STUDY DESIGN: Single-center retrospective cohort of infants with Grade 3 BPD (mecha...OBJECTIVE: To identify novel risk factors associated with tracheostomy in preterm infants with Grade 3 bronchopulmonary dysplasia (BPD). STUDY DESIGN: Single-center retrospective cohort of infants with Grade 3 BPD (mechanical ventilation at 36 weeks' postmenstrual age) from 2019 to 2025. Data included extubation attempts, corticosteroid and neuromuscular blockade use, mean airway pressure (MAP) and respiratory severity scores (RSS) at 36 and 40 weeks. Infants who received tracheostomy or died were compared to those successfully extubated. RESULTS: Of 60 infants, 37% underwent tracheostomy. Patients requiring tracheostomy had higher MAP (17 vs. 12 cm H₂O) and RSS (6 vs. 4) at 40 weeks, with no difference at 36 weeks. Patients requiring tracheostomy experienced more steroid courses, need for neuromuscular blockade, and failed extubations. CONCLUSIONS: Number of steroid courses, neuromuscular blockade, and ventilator settings at 40 weeks were associated with tracheostomy placement. These variables could inform future data collection strategies for infants with severe BPD.
OBJECTIVE: We investigated the impact of leaders' interprofessional teamwork behaviors on NICU staff perceptions of teamwork processes, trust, psychological safety, and voice behavior. STUDY DESIGN: To develop a measure...OBJECTIVE: We investigated the impact of leaders' interprofessional teamwork behaviors on NICU staff perceptions of teamwork processes, trust, psychological safety, and voice behavior. STUDY DESIGN: To develop a measure of leaders' interprofessional teamwork behaviors, we observed 199 rounding events at a NICU in the Southeastern United States. We evaluated the effect of leaders' teamwork behaviors on teamwork by observing 931 interprofessional rounds and collecting 115 staff surveys. RESULTS: We identified three categories of leaders' interprofessional teamwork behaviors during rounds: sharing information, inviting input, and maintaining positive rapport. Results indicated a small, positive effect on staff ratings of psychological safety and voice behavior. Leader behaviors did not significantly predict staff ratings of teamwork processes or trust. CONCLUSION: Results indicate that NICU leaders' interprofessional teamwork behaviors can improve NICU staff perceptions of psychological safety and voice behavior during rounds, but did not indicate that these behaviors significantly affect teamwork processes or trust.
OBJECTIVE: Characterize variation of macronutrient and bioactive composition between levels of human milk-derived human milk fortifier (HM-HMF), and between donor human milk (DHM) from commercial vs non-profit banks. STU...OBJECTIVE: Characterize variation of macronutrient and bioactive composition between levels of human milk-derived human milk fortifier (HM-HMF), and between donor human milk (DHM) from commercial vs non-profit banks. STUDY DESIGN: Macronutrients, Immunoglobulin A (IgA), and cortisol levels were measured in 10 lots of each HM-HMF product (20, 24, 26, 28, and 30 (n = 5) kcal/oz), including both "ready to feed" products and fortifiers reconstituted in donor milk. RESULTS: Caloric density, protein, fat, carbohydrate, and total IgA concentration generally increased with the level of HM-HMF labeled caloric density, while cortisol concentration did not. Protein concentration of DHM did not differ between commercial and non-profit milk banks. Carbohydrates, fat, calories, and cortisol were higher, and IgA was lower in DHM from a commercial milk bank. Lot-to-lot variability of all components, besides cortisol, was lower in commercial DHM. CONCLUSION: Macronutrient composition and variability differ in DHM from commercial vs non-profit milk banks.
OBJECTIVE: To evaluate the feasibility and early physiologic effects of postoperative invasive neurally-adjusted ventilatory assist (NAVA) in neonates with severe congenital diaphragmatic hernia (CDH). STUDY DESIGN: Retr...OBJECTIVE: To evaluate the feasibility and early physiologic effects of postoperative invasive neurally-adjusted ventilatory assist (NAVA) in neonates with severe congenital diaphragmatic hernia (CDH). STUDY DESIGN: Retrospective observational study of inborn neonates with CDH who received invasive NAVA during the post-repair ventilator weaning phase. Ventilator parameters, blood gas variables, respiratory indices, and diaphragm-based efficiency measures were evaluated serially within infants at 0, 12, 24, and 48 hours after NAVA initiation. RESULTS: Of 123 inborn infants with CDH, 19 with high disease severity received postoperative invasive NAVA. Oxygen requirements decreased over time, with favorable changes in gas exchange by 48 hours. The oxygenation index declined without increased ventilator pressures. Neuroventilatory and neuromechanical efficiency remained stable, including in infants with type D defects. All infants were successfully weaned from invasive mechanical ventilation. CONCLUSIONS: Postoperative invasive NAVA was feasible and well tolerated in neonates with severe CDH, including those with type D defects and prior extracorporeal membrane oxygenation support.