Probiotics And NEC

Treatment of necrotizing enterocolitis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic reviewJ.Peds Surg.

 

Objective

The optimal treatment of necrotizing enterocolitis (NEC) is a common challenge for pediatric surgeons. Although many studies have evaluated prevention and medical therapy for NEC, few guidelines for surgical care exist. The aim of this systematic review is to review and evaluate the currently available evidence for the surgical care of patients with NEC.

Methods

Data were compiled from a search of PubMed, OVID, the Cochrane Library database, and Web of Science from January 1985 until December 2011. Publications were screened, and their references were hand-searched to identify additional studies. Clinicaltrials.gov was also searched to identify ongoing or unpublished trials. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee proposed six questions deemed pertinent to the surgical treatment of NEC. Recent Cochrane Reviews examined three of these topics; a literature review was performed to address the additional three specific questions.

Results

The Cochrane Reviews support the use of prophylactic probiotics in preterm infants less than 2500 grams to reduce the incidence of NEC, as well as the use of human breast milk rather than formula when possible. There is no clear evidence to support delayed initiation or slow advancement of feeds. For surgical treatment of NEC with perforation, there is no clear support of peritoneal drainage versus laparotomy. Similarly, there is a lack of evidence comparing enterostomy versus primary anastomosis after resection at laparotomy. There are little data to determine the length of treatment with antibiotics to prevent recurrence of NEC.

Conclusion

Based on available evidence, probiotics are advised to decrease the incidence of NEC, and human milk should be used when possible. The other reviewed questions are clinically relevant, but there is a lack of evidence-based data to support definitive recommendations. These areas of NEC treatment would benefit from future investigation.

Using Elecare to fortify breast Milk

Breast milk of 30 ml
22 cal/oz-- add 0.4 grams of elecare--(-increases protein by 0.4 gr/30ml)
24 cal/oz-- 0.85grams of elecare------(-increases protein by 0.44gr/30ml)
27 cal/oz-- 1.5grams of elecare---------(-increases protein by0.54gr/30ml)

Gangnam Style- A new sensation music video

Price of A Surprise-Concluding

 “Are you interested in the dolphin encounters at Blue Lagoon which is $100 cheaper per person”, the lady at the concierge desk enquired. I was deeply disturbed by this auditory hallucination. Did the three leaves, that I ate last time cause this, I wondered. Or is it the heat exhaustion! How can I get $300 savings out of the blue? Is it because, the ocean is blue? I dismissed the ridiculous proposition and continued to nurse the sudden menacing malady that I was instantly enduring. “I am sorry; I thought savings will be savory to you. I will go ahead and confirm the tickets at Atlantis itself and it will be….”. Wait a minute, the facts were stranger than fiction sometimes, I figured. She appeared like an angel with mellifluous voice. Her melody cured my malady and felt like a millionaire in a minute. I profusely thanked her, and reflected that woes of my vows were waning!

The ride to the Blue Lagoon was brief and breezy and the cove looked cozy. The trainers gave us orientation to the sea life and dolphin behavior. The narration gave a sensation elation, which sparked ovation to the oration, kindling instant donation, and my asset migration. All happened in a short duration for animal conservation. The excitation however continued, “A marvelous chance to swim with these magnificent mammals is available to just a few mortal beings”, trainer announced. My family beings were the chosen ones. The temptation and titillation turned in to trepidation. The tokens were not free. Everything was transient. Unlike friends, neither fun nor funds are forever.

The dolphins were cute and we thoroughly enjoyed the encounter. The dolphins came to kiss us. I never let anyone touch my lips, except… so, I gave my cheek for its pleasure. It simply didn’t like it and began to snort. I just paid for its survival, but it acted like my rival. How can one kiss, who has not brushed for decades! However, my daughter in another area was having a great time. A baby dolphin was desperately vying for Srinidhi’s attention. It used to come in between her legs and come up to the surface asking Srinidhi to pet her. It would go back, only to return to her side tickling her soles seeking her attention. The trainers however cautioned people not to pet even though, the baby dolphins looked very cute. It was a very delightful distraction. The grand finale was the dolphin push. They literally propel you forward with sheer force whizzing you on the water. Everyone rejoiced. It was a ride with pride moment. “Did you catch it” (video) my wife asked me very eagerly. The camera was very safe in the locker. Her disappointment was distinctly discernible as joyous juncture was missed in a jiffy. There was never any dearth of surprises for me. To my dismay, Radha saw the display in the hallway about the dolphin push video. Her expression was priceless, her desire was guileless, my reaction was lifeless, and my wallet became weightless. The price of a surprise implies that you need good money supplies; that’s how I can surmise without any despise.

Price of A Surprise

 

 

Having enjoyed the beautiful wedding of my daughter, it was time to get back to the routine. Even so, the routine seemed so prosaic after a year of hysteria. I was itching for a vacation; however, my wife didn’t want to leave our location. I wished for a cruise, but she reminded me of our dues. I yearned for fun and she wanted none. I understood that concurrence is a rare occurrence, and discussions may have repercussions. When, I first uttered I Do, I did not realize that it would become my daily routine!
My goal was clear but means to the mission was menacingly mystifying. If pleasing agreement cannot be achieved, a pleasant amazement may do the trick, I thought! Surprise her! Bhama (wife) in Bahamas mission thus took shape. I started booking the flight tickets as they were becoming expensive by the hour, and we had only 72 hours to leave! I was still able to get a reasonable price with a business-class return for a deal. I was gloating that would give her a pleasant surprise. The next chore was booking a hotel. It is difficult to surprise someone with a cheap hotel. I was under pressure to look for a hotel with an expensive feel. The feel resulted in paradoxical perception-expensive feeling in the heart and empty feeling in the pocket! Maybe mutual agreement would have saved me from this predicament. Alas, I already bought non-refundable tickets. I have no choice but to proceed with the amazing choice-the Atlantis on Paradise Island.
I was in a quandary about when to inform her about the trip. She was under the impression that we were going to Virginia Beach and stay at one of our time-share properties, and thus save tons of money. I decided to inform her just before we reached the airport. The flight was in the morning. However, my plight started in the evening. Radha decided to make snacks on the morning of our departure day, so that we do not have to spend too much money on outside food. That tumbled all my plans. What man proposes, spouse disposes, I suppose! She left me with no choice but to reveal about the bewitching Bahamas the previous night. After careful scripting, I said, “Radha, it is our 25th marriage anniversary, a memorable moment that would never come again. I wanted to surprise you with a trip to Bahamas." Sensing her anxiety about the expenditure, I said, “you have done so much for all of us, you deserve to enjoy at least once. Do not worry about the expenses, I have planned and arranged the funds; Ask thy shall be given. Your wish will be my command on the trip." My emphatic statement earned an approving smile from her. I did not realize that the power of my speech would wipe out her anxiety and my assets in one sweep later!
Both my wife and my daughter felt extremely fortunate to have found such a doting person as myself, who was willing to keep them happy at any cost. As we proceeded to the check-in counter, the agent asked if we wanted the business-class upgrade. It seemed as if the agent was aware of my emphatic promises at home and decided to add woes to my vows. Before, I could think, I saw the blinding bright light emanating from their eyes, much before reaching the sunny paradise. So, I blindly said yes. The joy in their faces was priceless, but the agent figured out the price and charged my Master Card.
As we settled in the comfortable business-class seats, the flight attendant greeted us with light snacks. I hungrily opened one. Oh! My goodness, it really smelled like shi.. I was perturbed. I deal with a lot of meconium, but I certainly don’t want to eat one. I was about to call the attendant, when my wife pointed to the back seat. A young couple in the back seat felt pampered in the business class to change a dirty pamper. It was business casual in business class for them. At once, there was a silence and no one dared open their mouths as everyone experienced breath holding reaction. It taught us unity in action in a fraction. It was a bizarre situation, as we can neither open the windows nor hold the breaths for long. The couple later apologized.
Once we landed, we breathed fresh ocean breeze for a change. The lady at the hotel counter suggested that we could try the one and only Exumas excursion. I booked Atlantis for it had the vast number of acclaimed activities such as aquaventure, dolphin cay etc. I began to explain to the hotel registration lady about all the great things the resort was offering within its premises in an effort to preempt any request from my family. The lady was undeterred and pointed at the picture of a beautiful exclusive island with turquoise blue waters and declared that it was worthless leaving Bahamas without visiting it. How can a vow stricken doleful doting father and husband deny such an opportunity for his family?

It was time to have some refreshing food after a prolonged breath holding journey. We asked the front desk for suggestions for a vegetarian restaurant. She gave directions for a popular restaurant nearby. After we were seated, we went through the menu. We didn’t find anything that remotely resembled vegetarian. At last, my daughter found bread and butter in the breakfast menu. We were excited as we were hungry. The waitress did not write down what we ordered nor did she move from our table. We were bit taken aback. We reiterated our order. It was now her turn to be surprised. She seriously thought we were discussing about grocery shopping, as she never had any customer order bread in a lobster specialty restaurant. She asked us “what do you want to order to eat here?” still in disbelief that someone would eat bread on a seafood abundant island. A colleague of her passing by said that the last time he served bread was about six months ago, and if we were keen he can find some! It was time for us to find a safer restaurant. The waitress as we were leaving, asked us where we are from. After learning that we came from USA, she exclaimed, “boy, I never knew American economy was so badly hurt."
We had no choice but to seek an upscale restaurant for at least salad serving. I ordered a salad for Radha and myself, and my daughter wanted pasta. The ambience was very elegant and music was soothing. After about half an hour, our salad was served on a beautiful peewee platter. It had three leaves arranged in a very artistic manner with dressing sprinkled on them with a medication dropper probably. The leaves were exactly the same as the weeds; I plucked in my lawn few days ago. I was surprised, how fast they came back to my plate across the ocean! Nevertheless, the waiter enthusiastically encouraged me to enjoy the artistic leaves. I was not sure how we were going to share the tiny third leaf with a dot of dressing on top. It was $27 with 15% surcharge and further unknown tax. I probably needed to add an additional 20% for the tip. I could have consumed the same in the comfort of my own lawn; I thought. Radha pacified me and said that she brought some home-made snacks that we could eat for tonight.

None of these dampened the enthusiasm of my family. After we came back from the beautiful island world adventure trip, we found a note from the hotel concierge that they were offering a 10% discount coupon for dolphin encounters. The ticket was $200 per person. As I was trying to hide it from the temptation prone souls, the dolphin images caught my daughter’s attention. She was ecstatic and screamed loudly “dolphin encounter is so cheap now." She didn’t stop dancing. My wife looked at me pleadingly for my daughter. Your wish is my command words were distinctly ringing in my ears as my lips bore mystic Mona Lisa’s smile with the poignant philosophy of surprise.

Coffee- Should We Start Taking It More Often?

A recent study published in NEJM on 17th May 2012 showed that-

¨Inverse associations were observed for deaths due to heart disease, respiratory disease, stroke, injuries and accidents, diabetes, and infections, but not for deaths due to cancer.

¨Similar associations were observed whether participants drank predominantly caffeinated or decaffeinated coffee. They studied the association of coffee drinking with subsequent total and cause-specific mortality among 229,119 men and 173,141 women in the National Institutes of Health–AARP Diet and Health Study who were 50 to 71 years of age at baseline. 

This is a large study by all means. If you are wondering how they could study so many individuals, it could be because, they could not find half a million rats in one place! Since there is no funding for multi center Rat trials, they proceeded to study the humans directly. It is actually good, since the results would be directly applicable to all of us. The Mice trials have been mystifying so far.

Pediatric Research journal Vol. 69, No. 4, 2011, discussed that postnatal mice exposed to hypoxia showed decreased ventriculomegaly and better myelination of the brain, when caffeine was administered compared to placebo. Chronic low-dose caffeine administration in an immature hypoxic-ischemic rat model was neuroprotective. However, other studies also showed decreased seizure threshold, sleep issues in these rat models.

As sleep deprivation is considered as equivalent to harsh CIA interrogation techniques, research began focus more on humans and disease prevention (just kidding). There is strong evidence to show that caffeine is very protective in the preterm animals exposed to hypoxia. Hypoxia, which releases adenosine, causes premature acceleration of maturation of oligodendrocyte precursor cells leading to decrease in the the number of mature oligodendrocytes that which leads to decreased myelination of neurons and white mater injury of the brain in the prematurely born animals and human beings. Adenosine inhibits oligodendrocyte proliferation, & caffeine inhibits A1AR receptor and prevents white matter injury and hence, cerebral palsy. 

  Caffeine also a role in the lungs and the brain in the premature beings. A2a adenosine receptor activation leads to neutrophil migration and A2b adenosine receptor activation leads to cytokine release, which lead to capillary leakage and inflammation, which in preterm infants can lead to lung damage and intraventricular bleeding. Caffeine being a non-specific adenosine inhibitor counters these effects and reduces the consequences.

Studies published in NEJM in 2006, J.Peds in 2010 confirmed that caffeine indeed protects the preterm infants from chronic lung disease and laso reduces the incidence of cerebral palsy. However, the 2012 JAMA article, which followed the same infants up to 5-6 years did not show sustained caffeine effect on survival without severe disability. On the other hand,

The gross motor impairment was less severe in caffeine-treated children than in controls. Odds ratio 0.64 (0.47-0.88) P=0.006.

Well, this caffeine is useful in adults as well. It is evident from a huge metanalysis involving about 500,000 men and women that type 2 diabetes risk decreases by 7% with each cup of coffee. Several mechanisms are proposed.

¨Adiponectin (regulates the catabolism of glucose and insulin sensitivity) is protective in diabetes is ↑ by coffee. (Nutr j. 2011 Sep 13;10:93.) 

¨Recent prospective study showed ↓ IL-18 (pro-inflammatory cytokine) with coffee.

¨Antioxidant effect on the beta cells of pancreas, chelating actions on iron preventing excessive accumulation are also noted. ¨It also decreases corticosteroid production.

Other benefits of coffee are-

¨Study suggests that caffeinated coffee consumption may be associated with lower endometrial cancer risk among obese postmenopausal women, but the association with decaffeinated coffee remains unclear. Nutrients. 2011 Nov;3(11). 45,696 women followed.

 

¨ Coffee ↓ lethal prostate cancer-J Natl Cancer Inst. 2011 Jun 8;103(11) 47,911 men prospectively followed.

¨European Prospective Investigation into Cancer and Nutrition (EPIC)-Germany study (Am J Clin Nutr. 2012 Apr)- coffee consumption does not increase the risk of chronic disease, but it may be linked to a lower risk of T2D. 42,659 participants and 8.9 year follow up.

 

¨Direct animal studies have shown that caffeine protects against Alzheimers.

¨AD mice given caffeine since young adulthood showed decreased cognitive impairment and low amyloid in the brains.

¨J.Alzheimers Disease in June 2012 published a study which showed direct link between high caffeine levels and decreased progression from mild cognitive impairment to dementia.¨ A critical level of 1200ng/ml and above was protective. 

With all the current evidence, it appears that coffee has quite a few health benefits. So, should we consume coffee more! You decide. 
The relationship of coffee intake to health benefits is direct. Higher the consumption, higher the benefits at least from the studies. Caffeinated or decaffeinated did not matter.

Impact of Caffeine on Outcomes of Small for Gestation (SGA) Infants of ≤29 Weeks of Gestation

This is an interesting observation by our team. We noted that caffeine specifically helps the small for gestation preterm infants more than the appropriate for gestational age infants. Ninety percent of the SGA infants in the late caffeine group (when caffeine was initiated by day 4 of life in preterm infants of
 Early caffeine was strongly associated with a decreased incidence of CLD and shorter LOS and DV in SGA infants. Initiating caffeine early may be more important in SGA than in AGA preterm infants. This is going to be presented at the upcoming American Academy of Pediatrics 2012 conference in New Orleans.

Bulb Syringes-Which One -It Matters!

http://www.sciencedirect.com/science/article/pii/S0300957211006770
This study focussed on the issue-which bulb syringe is ideal for neonatal resuscitation? In many resource scarce countries, bulb syringes are the only ones available for newborn resuscitation. The researchers asked a simple question-do these bulb syringes conform to the Neonatal Resuscitation's recommended negative pressures. American Academy of Pediatrics has a program called Helping Babies Breathe and they provide the bulb syringes to the primary care centers around the world.
This study should help caregivers to choose an appropriate bulb syringe to prevent inadvertent damge to the newborn.

Objective

To reduce airway injury secondary to high suction pressures, the American Academy of Pediatrics Neonatal Resuscitation Program (NPR) recommends that suction pressures be less than 100 mm Hg. This study was conducted to determine if suction bulbs conform to these recommendations.

Study design

In this prospective in vitro study, 25 personnel involved in neonatal resuscitation squeezed a new bulb three times for each of six commercially available bulbs using their delivery suite technique. A calibrated, pneumatic transducer measured the pressure of each squeeze.

Results

Only one bulb met the NRP guidelines with none of the participants exceeding 100 mm Hg (p < 0.001).

Conclusions

Only one bulb met the NRP guidelines of generating pressures less than 100 mm Hg. This bulb's large size (3 oz) may preclude its use in premature infants. Individuals involved in resuscitating newborns need to be aware of the pressures generated to avoid injuring the delicate oral airway.

Effect of increasing protein content of human milk fortifier

http://www.ajcn.org/content/early/2012/01/30/ajcn.111.026351.abstract

Design: This is a randomized controlled trial in 92 preterm infants born at <31 wk gestation who received maternal breast milk that was fortified with HMF containing 1.4 g protein/100 mL (higher-protein group) or 1.0 g protein/100 mL (current practice) until discharge or estimated due date, whichever came first. The HMFs used were isocaloric and differed only in the amount of protein or carbohydrate. Length, weight, and head-circumference gains were assessed over the study duration.

Results: Length gains did not differ between the higher- and standard-protein groups (mean difference: 0.06 cm/wk; 95% CI: −0.01, 0.12 cm/wk; P = 0.08). Infants in the higher-protein group achieved a greater weight at study end (mean difference: 220 g; 95% CI: 23, 419 g; P = 0.03). Secondary analyses showed a significant reduction in the proportion of infants who were less than the 10th percentile for length at the study end in the higher-protein group (risk difference: 0.186; 95% CI: 0.370, 0.003; P = 0.047).

Conclusions: A higher protein intake results in less growth faltering in human milk–fed preterm infants. It is possible that a higher-protein fortifier than used in this study is needed.