ACE inhibitors-Are they safe in newborns?

http://link.springer.com/article/10.1007%2Fs00246-013-0813-2
Pediatric Cardiology March 2014, Volume 35, Issue 3, pp 499-506

The age range of neonates at ACEi initiation was 15.9–18.1 days. The inclusion criteria was met by 206 neonates: 168 term (82 %) and 38 preterm (18 %) newborns. The mean dose of captopril was 0.07 ± 0.009 mg/kg for the preterm neonates and 0.13 ± 0.019 mg/kg for the term neonates.

Nearly 42 % of all the patients showed renal risk, with approximately 30 % demonstrating renal failure by modified pRIFLE (pediatric risk, injury, failure, loss, and end-stage renal disease) criteria. Despite the lack of significantly different CrCl, the premature neonates were more likely to experience ACEi-related renal failure by pRIFLE (55 %) than their term counterparts (23 %; p < 0.001). Despite its common use for term neonates with cardiac disease, ACEi should be used cautiously and only when indications are clear. These results also raise the question whether ACEi should be used at all for preterm neonates.

Closed Captioning-Altered Version.

Closed Caption.

It was a busy day; rather a chaotic day! Nothing seemed to go smoothly that day. The situation was wearing down the mortals swiftly. The high acuity in the unit was leading to paucity of patience.

As I was seriously contemplating, a colleague cozily meandered towards me. As she bent down towards my ear, I had an eerie feeling that she would literally bite my ear off. Such was the prevailing perception. She gently whispered in to my eager ears. It was Valentine’s Day! The whisper lingered just too long for a simple “we all love you”. A smile flashed on my mulling face, as I peeked at the distraught laced face. Smile, when you don’t understand was my philosophy, as it addresses 90% of the situations without repercussions.

In the midst of mess and distress, as I pose to be in less stress, and hence, not anticipating a better response, she ambled away. I noticed in the meantime, alarms denoting serious problem going off. I rushed to the baby’s bed side to assess and make appropriate changes.  The at-risk seemed at-best now. I discussed and dispersed from the bedside.

The whisperer strode to my chair huffing and puffing. “You can’t keep secrets can you?”- She looked irked and piqued. Surprise surfaced on my stoic face. I never heard any secrets, except for non-specific valentine wishes from her; that was what at least I thought she did! Hence, my dumb smile! I paused to ponder. “Secrets, which one?” I inquired. “Forget it!”, whisperer was visibly upset and marched away. I slowly walked towards her, and confessed my ignorance about her distress. “If I confide in you about an annoying colleague, you just don’t have to divulge it to her in such a swift manner” she burst out. I pointed towards my ear and confessed “don’t tell me secrets, not because I can’t keep them, but because I can’t hear them”. She then noticed the lack of aids of hearing and laughed out loudly.

Later, I was at a party. It was dim and had din. I was jiving to a lilting tune with my better half. A well-dressed man walked up to me and whispered. I laughed and said “you are right” concurring with him instantly about the peppy song. My laughter was cut short, when my wife answered him “his name is P…….”. Obviously, agreeing with something you don’t understand could be unseemly upsetting. If you whisper, I cannot decipher. If you still choose to do so, I need closed captioning from someone!

Probiotics-Prime Time For Routine Use!

http://www.jpeds.com/article/S0022-3476(13)01596-5/fulltext
ProPrems trial is very compelling as 95% of the study participants received breast milk!


Probiotic supplementation in preterm infants is perhaps the best studied yet least used therapy in neonatal medicine.¹, ² All recently published meta-analyses have reported significant impacts on important clinical outcomes.³, ⁴, ⁵ In the updated Cochrane meta-analysis,³ which includes 24 trials, there is a significant decrease in necrotizing enterocolitis (NEC) (relative risk [RR] 0.43, 95% CI 0.33-0.56; risk difference [RD] −0.03, 95% CI −0.04 to −0.02; P < .00001) and all-cause mortality (RR 0.65, 95% CI 0.52-0.81; RD −0.01, 95% CI −0.02 to −0.00, P = .01). Length of stay was 3-4 days shorter. There was no probiotic-related sepsis, although this is rarely reported outside trials.⁶

Probiotics are still infrequently used in North America. In 2012, only 8%-9% of very low birth weight (VLBW) infants in the Vermont Oxford Network received probiotics.⁷ It is time to consider changing guidance and practice.⁸ The authors of this editorial have differed on whether we have sufficient evidence to introduce prophylactic treatment. Tarnow-Mordi et al argued in 2010 that “the evidence that probiotics reduce mortality rates is as conclusive as that for surfactant for respiratory distress syndrome, cooling for hypoxic ischemic encephalopathy, or antenatal corticosteroids for threatened preterm labor.”⁹ In a companion commentary, Soll argued that the decision was far less clear.¹⁰ Trials had used multiple agents and doses. Few had studied extremely low birth weight infants, and few infants had received breast milk.
Many of these arguments have now been addressed. Wang reports subgroups of trials using Bifidobacteria alone, Lactobacilli alone, or the 2 combined.⁵ In all 3 subgroups, there were significant reductions, by about two-thirds, in the RR of NEC. The recently updated Cochrane Review includes 17 trials of >4900 VLBW infants.³ The RR risk of severe NEC for probiotics versus control was 0.41 (95% CI 0.31-0.56; RD −0.03, 95% CI −0.05 to −0.02; P < .00001). The treatment of 33 VLBW infants would prevent 1 case of severe NEC. The ProPrems study in 1099 very preterm infants in Australia and New Zealand is the largest ever randomized trial of probiotics.¹¹ Although there was no decrease in sepsis or the control mortality rate of 5.1%, the rate of NEC was halved (4.4% vs 2.2%; RR 0.46, 95% CI 0.23-0.93; P = .03), even though >95% of infants received breast milk.