Yet another confirmation of utility of probiotics in VLBW infants
http://www.jpedsurg.org/article/S0022-3468(15)00362-0/abstract?rss=yes
Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in preterm infants, affecting ~6–7% of very-low-birth-weight (VLBW) infants. Early intervention and aggressive treatment has improved clinical outcomes, but considerable morbidity continues to accrue to NEC survivors. This meta-analysis examines the impact of probiotics on the incidence of NEC and complications among VLBW infants.
Methods
A comprehensive literature search for all published randomized control trials (RCTs) assessing the use of probiotics to prevent NEC in VLBW infants was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966–2014). The incidences of NEC, sepsis, overall mortality, and time to reach full enteral feeds were analyzed.
Results
20 RCTs involving 5982 preterm VLBW infants were analyzed. Risk of NEC was reduced by 49.1% (RR = 0.509; 95% CI, 0.385–0.672; p < 0.001), and overall mortality by 26.9% among infants receiving probiotics (RR = 0.731; 95% CI, 0.577–0.926; p = 0.009). An 8.1% reduction in sepsis was also observed in infants receiving probiotics (RR = 0.919; 95% CI, 0.823–1.027; p = 0.137). Time to reach full enteral feeds was reduced by 1.2 days among infants receiving probiotics (MD: −1.217; 95% CI, −2.151 to −0.283; p = 0.011).
Conclusion
The use of probiotic supplementation in preterm VLBW infants is associated with a significant reduction in the risk of NEC and overall mortality. Additional studies are required to determine the optimal genus, species, and dose of probiotic.
Friday, July 31, 2015
Wednesday, July 22, 2015
Evaluating Persistent Hypoglycemia-Recommendations
http://www.jpeds.com/article/S0022-3476(15)00358-3/fulltext
For infants and younger children who are unable to reliably communicate symptoms, suggestted evaluation and management only of those whose Plasma Glucose concentrations are documented by laboratory quality assays to be below the normal threshold for neurogenic responses (<60 mg/dL [3.3 mmol/L]). GRADE 2+++0. Free fatty acids cannot be used by brain as fuel, whereas, Beta Hydroxy Buteric Acid (BOHB)and lactate can be used by the brain. When glucose level is <60mg/dl, measure lactate, FFA, BOHB, and HCO3 Insulin, cpeptide, GH (growth hormone)cortisol, acyl carnitine, and free carnitine may need to be measured.
HyperInhyperinsulinemic states--LOW BOHB, and FFA will be seen, and HCO3 will be normal.
In Fatty Acid Oxidation defects--- LOW BOHB, but INCREASED FFA, with normal HCO3 will be seen.
In Gluconeogenesis defects: LOW HOCO3, and INcreased Lactate is noted.
In GH, or Cortisol deficiency-Low HCO3, and Increased BOHB.
An exaggerated glycemic response (>30 mg/dL [>1.7 mmol/L]) is nearly pathognomonic of hyperinsulinism.
Because plasma insulin concentration is sometimes not above the lower limit of detection,
it is important to include the following tests when assessing the possibility of hypoglycemia due to hyperinsulinism: plasma BOHB and FFA (both inappropriately low; BOHB <1.5 mmol/L [<15 mg/dL] and FFA <1.0-1.5 mmol/L [<28-42 mg/dL]), and an increased glycemic response to glucagon. For neonates with a suspected congenital hypoglycemia disorder and older infants and children with a confirmed hypoglycemia disorder, recommend that the goal of treatment be to maintain a PG concentration >70 mg/dL.
For high-risk neonates without a suspected congenital hypoglycemia disorder, we suggest the goal of treatment be to maintain a PG concentration >50 mg/dL (>2.8 mmol/L) for those aged <48 hours and >60 mg/dL (>3.3 mmol/L) for those aged >48 hours.
For infants and younger children who are unable to reliably communicate symptoms, suggestted evaluation and management only of those whose Plasma Glucose concentrations are documented by laboratory quality assays to be below the normal threshold for neurogenic responses (<60 mg/dL [3.3 mmol/L]). GRADE 2+++0. Free fatty acids cannot be used by brain as fuel, whereas, Beta Hydroxy Buteric Acid (BOHB)and lactate can be used by the brain. When glucose level is <60mg/dl, measure lactate, FFA, BOHB, and HCO3 Insulin, cpeptide, GH (growth hormone)cortisol, acyl carnitine, and free carnitine may need to be measured.
HyperInhyperinsulinemic states--LOW BOHB, and FFA will be seen, and HCO3 will be normal.
In Fatty Acid Oxidation defects--- LOW BOHB, but INCREASED FFA, with normal HCO3 will be seen.
In Gluconeogenesis defects: LOW HOCO3, and INcreased Lactate is noted.
In GH, or Cortisol deficiency-Low HCO3, and Increased BOHB.
An exaggerated glycemic response (>30 mg/dL [>1.7 mmol/L]) is nearly pathognomonic of hyperinsulinism.
Because plasma insulin concentration is sometimes not above the lower limit of detection,
it is important to include the following tests when assessing the possibility of hypoglycemia due to hyperinsulinism: plasma BOHB and FFA (both inappropriately low; BOHB <1.5 mmol/L [<15 mg/dL] and FFA <1.0-1.5 mmol/L [<28-42 mg/dL]), and an increased glycemic response to glucagon. For neonates with a suspected congenital hypoglycemia disorder and older infants and children with a confirmed hypoglycemia disorder, recommend that the goal of treatment be to maintain a PG concentration >70 mg/dL.
For high-risk neonates without a suspected congenital hypoglycemia disorder, we suggest the goal of treatment be to maintain a PG concentration >50 mg/dL (>2.8 mmol/L) for those aged <48 hours and >60 mg/dL (>3.3 mmol/L) for those aged >48 hours.
Automating inspired oxygen to targeted SpO2 in preterm infants
Automated control of inspired oxygen in ventilated preterm infants: crossover physiological study
Mithilesh Lal1, Win Tin1,and Sunil Sinha
Aim
To evaluate the efficacy of automated control of the fraction of inspired oxygen (FiO2) in comparison to manual FiO2 control in maintaining target pulse oxygen saturation (SpO2) range.
Methods
Crossover physiologic study involving preterm infants requiring mechanical ventilation and supplemental oxygen. Each infant was studied for 2 consecutive 12-hour in a random sequence. Outcome measures included the proportion of time with SpO2 within and outside the target range of 90-95%, extreme hypoxaemia (<80%) and hyperoxaemia (≥98%).
Results
Complete dataset was available in 27 infants. The percentage of time (median, IQR) within the target range was higher during automated control 72.8 (58.8-82.6) compared to manual control 59.6 (49.3-73.3), p=0.031. Corresponding reduction in percent time below the target range was 18.1 (12.7-23.6) versus 25.9 (17.8-30.7), p=0.028, and above the target range 4.8 (3-16) versus 10.1 (6.4-22.5), p=0.026. Median (IQR) percent time spent with severe hypoxaemia (SpO2<80%) and severe hyperoxaemia (SpO2≥98%) were 1.3 (0.1-2.9) versus 3.2 (1.4-6.1), p= 0.022 and 0.08 (0.05-0.36) versus 1.7 (0.7-6.8), p=0.001 respectively. Median number of manual adjustments of FiO2 per 12-hour was 0 and 63 respectively.
Conclusion
Automated control of FiO2 significantly improved compliance of oxygen saturation targeting and significantly reduced exposure to hypoxaemia as well as hyperoxaemia.
Sunday, July 5, 2015
Strategies in PPROM in Preterm Infants
There is usually pulmonary hypoplasia with relatively normal compliance.
Strategy: Use low PEEP, as high PEEP can interfere with venous return, and cardiac output.
There is usually pulmonary vasoconstriction, and hypertension.
Strategy: Keep PaO2 above 50mm Hg.
Frequent Echocardiograms to evaluate shunting across PDA.
Use iNO as needed.
Ventricular dysfunction, and or systemic hypotension.
Strategy: May use volume and or inotropics (dobutamine if LV dysfunction, and dopamine if systemic hypotension)
Use inotropes if there is LV systolic dysfunction with or without left atrial dialatation before using iNO to avoid pulmonary edema.
Source: Journal of Pediatrics, 2015, Dr. de Waal, and Dr. Kluckow.
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