Tracheostomies in preterm infants associated with higher morbidities?

http://www.jpeds.com/article/S0022-3476(13)01560-6/abstract

Objectives

To evaluate the neurodevelopmental outcomes of very preterm (<30 infants="" p="" tracheostomy.="" underwent="" weeks="" who="">

Study design

Retrospective cohort study from 16 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network over 10 years (2001-2011). Infants who survived to at least 36 weeks (N = 8683), including 304 infants with tracheostomies, were studied. Primary outcome was death or neurodevelopmental impairment (NDI; a composite of ≥1 of developmental delay, neurologic impairment, profound hearing loss, severe visual impairment) at a corrected age of 18-22 months. Outcomes were compared using multiple logistic regression. We assessed the impact of timing by comparing outcomes of infants who underwent tracheostomy before and after 120 days of life.

Results

Tracheostomies were associated with all neonatal morbidities examined and with most adverse neurodevelopmental outcomes. Death or NDI occurred in 83% of infants with tracheostomies and 40% of those without (OR adjusted for center 7.0, 95% CI 5.2-9.5). After adjustment for potential confounders, odds of death or NDI remained higher (OR 3.3, 95% CI 2.4-4.6), but odds of death alone were lower (OR 0.4, 95% CI 0.3-0.7) among infants with tracheostomies. Death or NDI was lower in infants who received their tracheostomies before, rather than after, 120 days of life (aOR 0.5, 95% CI 0.3-0.9).

Conclusions

Tracheostomy in preterm infants is associated with adverse developmental outcomes and cannot mitigate the significant risk associated with many complications of prematurity. These data may inform counseling about tracheostomy in this vulnerable population.

Musings of A MedMan: Oh Mother! What is Thy Nature?

Musings of A MedMan: Oh Mother! What is Thy Nature?:   Oh our dear Mother You are the Nature’s Best For He created you, so He could Rest. By nature, you shower endless kindness T...

Oh Mother! What is Thy Nature?

 

Oh our dear Mother

You are the Nature’s Best

For He created you, so He could Rest.

By nature, you shower endless kindness

Through nurture, we taste your tenderness.

Drowned in the flood of your love, we are reminded of Nature’s force

Oh Mother!

Respecting you is respecting our Mother Nature

 For the Mother Nature, you are her human form.

Like trees with delicious peach,

You provide us delicious food moment we reach

Like the sun, and soft breeze

You are the light of our lives

 Gently caressing our painful Hives.

Our jabs and jeers, you take with a cheer.

To give love is thy nature-A Mother(’s) Nature.

 

Pradeep Alur.

 

 

Low Pre-Transfusion Hematocrit May Predispose to NEC!

http://www.earlyhumandevelopment.com/article/S0378-3782(14)00047-4/abstract

Feeding practices and other risk factors for developing transfusion-associated necrotizing entrocolitis.

Aims

The objective of this study is to determine the incidence of and risk factors for necrotizing enterocolitis (NEC) and transfusion-associated NEC (TANEC) in very-low-birth-weight (VLBW) infants pre/post implementation of a peri-transfusion feeding protocol.

Study design

A retrospective cohort study was conducted including all inborn VLBW infants admitted to the Duke intensive care nursery from 2002 to 2010. We defined NEC using Bell's modified criteria IIA and higher and TANEC as NEC occurring within 48hours of a packed red blood cell (pRBC) transfusion. We compared demographic and laboratory data for TANEC vs. other NEC infants and the incidence of TANEC pre/post implementation of our peri-transfusion feeding protocol. We also assessed the relationship between pre-transfusion hematocrit and pRBC unit age with TANEC.

Results

A total of 148/1380 (10.7%) infants developed NEC. Incidence of NEC decreased after initiating our peri-transfusion feeding protocol: 126/939 (12%) to 22/293 (7%), P=0.01. The proportion of TANEC did not change: 51/126 (41%) vs. 9/22 (41%), Pmore than 0.99. TANEC infants were smaller, more likely to develop surgical NEC, and had lower mean pre-transfusion hematocrits prior to their TANEC transfusions compared with all other transfusions before their NEC episode: 28% vs. 33%, P less than 0.001. Risk of TANEC was inversely related to pre-transfusion hematocrit: odds ratio 0.87 (0.79–0.95).

Conclusions

Pre-transfusion hematocrit is inversely related to risk of TANEC, which suggests that temporally maintaining a higher baseline hemoglobin in infants most at risk of NEC may be protective. The lack of difference in TANEC pre-/post-implementation of our peri-transfusion feeding protocol, despite an overall temporal decrease in NEC, suggests that other unmeasured interventions may account for the observed decreased incidence of NEC.

Effects of Early Inhaled Nitric Oxide Therapy and Vitamin A Supplementation on the Risk for Bronchopulmonary Dysplasia in Premature Newborns with Respiratory Failure

http://www.jpeds.com/article/S0022-3476%2813%2901475-3/abstract?elsca1=etoc&elsca2=email&elsca3=0022-3476_201404_164_4&elsca4=pediatrics

Objective

To assess whether the combination of early inhaled nitric oxide (iNO) therapy and vitamin A supplementation lowers the incidence of bronchopulmonary dysplasia (BPD) in premature newborns with respiratory failure.

Study design

A total of 793 mechanically ventilated infants (birth weight 500-1250 g) were randomized (after stratification by birth weight) to receive placebo or iNO (5 ppm) for 21 days or until extubation (500-749, 750-999, or 1000-1250 g). A total of 398 newborns received iNO, and of these, 118 (30%) received vitamin A according to their enrollment center. We compared patients who received iNO + vitamin A with those who received iNO alone. The primary outcome was a composite of death or BPD at 36 weeks postconceptual age.

Results

BPD was reduced in infants who received iNO + vitamin A for the 750-999 g birth weight group compared with iNO alone (P = .01). This group also showed a reduction in the combined outcome of BPD + death compared with iNO alone (P = .01). The use of vitamin A did not change the risk for BPD in the placebo group. Overall, the use of vitamin A was low (229 of 793 patients, or 29%). Combined therapy improved Bayley Scales of Infant Development II Mental and Psychomotor Developmental Index scores at 1 year compared with infants treated solely with iNO for the 500-749 g birth weight group.

Conclusions

In this retrospective analysis of the nonrandomized use of vitamin A, combined iNO + vitamin A therapy in preterm infants with birth weight 750-999 g reduced the incidence of BPD and BPD + death and improved neurocognitive outcomes at 1 year in the 500-749 g birth weight group.

Association between Postnatal Dexamethasone for Treatment of Bronchopulmonary Dysplasia and Brain Volumes at Adolescence in Infants Born Very Preterm

http://www.jpeds.com/article/S0022-3476(13)01379-6/abstract

Jeanie L.Y. Cheong, MD et.al

Objectives

To compare brain volumes in adolescents who were born extremely preterm (<28 a="" and="" brain="" determine="" dexamethasone="" dose="" effect="" gestation="" had="" if="" on="" p="" postnatal="" received="" response="" there="" to="" volumes.="" was="" weeks="" who="">

Study design

Geographical cohort study of extremely preterm adolescents born in 1991-1992 in Victoria, Australia. T1-weighted magnetic resonance imaging was performed at 18 years of age. Segmented and parcellated brain volumes were calculated using an automated segmentation method (FreeSurfer) and compared between groups, with and without adjustment for potential confounders. The relationships between total postnatal dexamethasone dose and brain volumes were explored using linear regression.

Results

Of the 148 extremely preterm participants, 55 (37%) had received postnatal dexamethasone, with a cumulative mean dose of 7.7 mg/kg. Compared with participants who did not receive postnatal dexamethasone, those who did had smaller total brain tissue volumes (mean difference −3.6%, 95% CI [−7.0%, −0.3%], P value = .04) and smaller white matter, thalami, and basal ganglia volumes (all P < .05). There was a trend of smaller total brain and white matter volumes with increasing dose of postnatal dexamethasone (regression coefficient −7.7 [95% CI −16.2, 0.8] and −3.2 [−6.6, 0.2], respectively).

Conclusions

Extremely preterm adolescents who received postnatal dexamethasone in the newborn period had smaller total brain tissue volumes than those who did not receive postnatal dexamethasone, particularly white matter, thalami, and basal ganglia. Vulnerability of brain tissues or structures associated with postnatal dexamethasone varies by structure and persists into adolescence.

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.

Gavage Feeding-Continuous or Bolus?

It is a very well done in-vitro study published in 2010, yet has many practical implications.
Abstract

Substantial losses of nutrients may occur during tube (gavage) feeding of

fortified human milk. Our objective was to compare the losses of key macronutrients and

minerals based on method of fortification and gavage feeding method. We used clinically

available gavage feeding systems and measured pre- and post-feeding (end-point) nutrient

content of calcium (Ca), phosphorus (Phos), protein, and fat. Comparisons were made

between continuous, gravity bolus, and 30-minute infusion pump feeding systems, as well

as human milk fortified with donor human milk-based and bovine milk-based human milk

fortifier using an in vitro model. Feeding method was significantly associated with fat and

Ca losses, with increased losses in continuous feeds. Fat losses in continuous feeds were

substantial, with 40 ± 3 % of initial fat lost during the feeding process. After correction for

feeding method, human milk fortified with donor milk-based fortifier was associated with

significantly less loss of Ca (8 ± 4% vs. 28 ± 4%, p< 0.001), Phos (3 ± 4% vs. 24 ± 4%,

p < 0.001), and fat (17 ± 2% vs. 25 ± 2%, p = 0.001) than human milk fortified with a

bovine milk-based fortifier (Mean ± SEM).

Continuous Feedings of Fortified Human Milk Lead to Nutrient Losses of Fat, Calcium and Phosphorous.

Nutrients 2010, 2, 230-240; doi:10.3390/nu2030240Stefanie P. Rogers 1, Penni D. Hicks 2, Maria Hamzo 2, Lauren E. Veit 3 and Steven A. Abrams




  

Chorioamnionitis AND Retinopathy of Prematurity

http://www.karger.com/Article/FullText/357556

Abstract
Background: The role of chorioamnionitis (CA) in the development of retinopathy of prematurity (ROP) has not been well established. Objective: To conduct a systematic review and meta-analysis of the association between CA and ROP in preterm infants. Data Sources: The authors searched MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and PubMed, reviewed reference lists of relevant articles, abstracts and conference proceedings (Society for Pediatric Research, European Society for Paediatric Research 1990-2012), sought results of unpublished trials, and contacted the primary authors of relevant studies. Study Selection: Studies were included if they had a comparison group, examined preterm infants, and reported primary data that could be used to measure the association between exposure to CA and the development of ROP. Data Extraction: Two reviewers independently screened the search results, applied inclusion criteria and assessed methodological quality using the Newcastle-Ottawa Scale. One reviewer extracted data and a second reviewer checked data extraction. Summary relative risks (RRs) were calculated using a random effects model. Data Synthesis: We identified 1,249 potentially relevant studies from the electronic databases. Twenty-seven studies involving 10,590 preterm neonates with 2,562 cases of ROP were included. Taking into account all included studies without adjusting for gestational age (GA), CA was significantly associated with ROP (any stage) [summary RR 1.33 (95% CI 1.14-1.55, I² = 77%, p_{heterogeneity} < 0.0001)], and a borderline significant association was observed for severe ROP (stage ≥3) [summary RR 1.27 (95% CI 0.99-1.63, I² = 74%, p_{heterogeneity} < 0.0001)]. There was no publication bias with Begg's test. However, subgroup analysis of studies adjusting for GA showed no significant association on CA with ROP [summary RR 0.98 (95% CI 0.77-1.26, I² = 0%, p_{heterogeneity} = 0.89)]. Conclusion: Unadjusted analyses showed that CA was significantly associated with ROP (any stage) as well as with severe ROP (stage ≥ 3). However, the association disappeared on analysis of studies adjusting for GA. Hence, CA cannot be definitively considered as a risk factor for ROP, and further studies should adjust for potential confounding factors and report results by stage to clarify the association with severe ROP.

Postnatal Head Growth in Preterm Infants: A Randomized Controlled Parenteral Nutrition Study

http://pediatrics.aappublications.org/content/133/1/e120.abstract

BACKGROUND: Early postnatal head growth failure is well recognized in very preterm infants (VPIs). This coincides with the characteristic nutritional deficits that occur in these parenteral nutrition (PN) dependent infants in the first month of life. Head circumference (HC) is correlated with brain volume and later neurodevelopmental outcome. We hypothesized that a Standardized, Concentrated With Added Macronutrients Parenteral (SCAMP) nutrition regimen would improve early head growth. The aim was to compare the change in HC (ΔHC) and HC SD score (ΔSDS) achieved at day 28 in VPIs randomly assigned to receive SCAMP nutrition or a control standardized, concentrated PN regimen.

METHODS: Control PN (10% glucose, 2.8 g/kg per day protein/lipid) was started within 6 hours of birth. VPIs (birth weight <1200 1="" 28.="" 3.8="" actual="" assigned="" collected="" control="" daily="" data="" day="" days="" either="" for="" g="" gestation="" glucose="" hc="" intake="" kg="" lipid="" measured="" nutritional="" on="" or="" p="" per="" protein="" randomly="" regimen.="" remain="" scamp="" start="" the="" to="" was="" weekly.="" weeks="" were="">

RESULTS: There were no differences in demographic data between SCAMP (n = 74) and control (n = 76) groups. Comparing cumulative 28-day intakes, the SCAMP group received 11% more protein and 7% more energy. The SCAMP group had a greater ΔHC at 28 days (P < .001). The difference between the means (95% confidence interval) for ΔHC was 5 mm (2 to 8), and ΔSDS was 0.37 (0.17 to 0.58). HC differences are still apparent at 36 weeks’ corrected gestational age.

CONCLUSIONS: Early postnatal head growth failure in VPIs can be ameliorated by optimizing PN.

IVH outcomes in VLBW infants-Outcomes

http://pediatrics.aappublications.org/content/133/1/55.abstract

Intraventricular Hemorrhage and Neurodevelopmental Outcomes in Extreme Preterm Infants

on behalf of the New South Wales and Australian Capital Territory Neonatal Intensive Care Units’ Data Collection

OBJECTIVE: Not many large studies have reported the true impact of lower-grade intraventricular hemorrhages in preterm infants. We studied the neurodevelopmental outcomes of extremely preterm infants in relation to the severity of intraventricular hemorrhage.

METHODS: A regional cohort study of infants born at 23 to 28 weeks’ gestation and admitted to a NICU between 1998 and 2004. Primary outcome measure was moderate to severe neurosensory impairment at 2 to 3 years’ corrected age defined as developmental delay (developmental quotient >2 SD below the mean), cerebral palsy, bilateral deafness, or bilateral blindness.

RESULTS: Of the 1472 survivors assessed, infants with grade III–IV intraventricular hemorrhage (IVH; n = 93) had higher rates of developmental delay (17.5%), cerebral palsy (30%), deafness (8.6%), and blindness (2.2%). Grade I–II IVH infants (n = 336) also had increased rates of neurosensory impairment (22% vs 12.1%), developmental delay (7.8% vs 3.4%), cerebral palsy (10.4% vs 6.5%), and deafness (6.0% vs 2.3%) compared with the no IVH group (n = 1043). After exclusion of 40 infants with late ultrasound findings (periventricular leukomalacia, porencephaly, ventricular enlargement), isolated grade I–II IVH (n = 296) had increased rates of moderate-severe neurosensory impairment (18.6% vs 12.1%). Isolated grade I–II IVH was also independently associated with a higher risk of neurosensory impairment (adjusted odds ratio 1.73, 95% confidence interval 1.22–2.46).

CONCLUSIONS: Grade I–II IVH, even with no documented white matter injury or other late ultrasound abnormalities, is associated with adverse neurodevelopmental outcomes in extremely preterm infants.

Randomized Trial of Exclusive Human Milk versus Preterm Formula Diets in Extremely Premature Infants

http://www.jpeds.com/article/S0022-3476(13)00865-2/abstract

Objective

To compare the duration of parenteral nutrition, growth, and morbidity in extremely premature infants fed exclusive diets of either bovine milk–based preterm formula (BOV) or donor human milk and human milk-based human milk fortifier (HUM), in a randomized trial of formula vs human milk.

Study design

Multicenter randomized controlled trial. The authors studied extremely preterm infants whose mothers did not provide their milk. Infants were fed either BOV or an exclusive human milk diet of pasteurized donor human milk and HUM. The major outcome was duration of parenteral nutrition. Secondary outcomes were growth, respiratory support, and necrotizing enterocolitis (NEC).

Results

Birth weight (983 vs 996 g) and gestational age (27.5 vs 27.7 wk), in BOV and HUM, respectively, were similar. There was a significant difference in median parenteral nutrition days: 36 vs 27, in BOV vs HUM, respectively (P = .04). The incidence of NEC in BOV was 21% (5 cases) vs 3% in HUM (1 case), P = .08; surgical NEC was significantly higher in BOV (4 cases) than HUM (0 cases), P = .04.

Conclusions

In extremely preterm infants given exclusive diets of preterm formula vs human milk, there was a significantly greater duration of parenteral nutrition and higher rate of surgical NEC in infants receiving preterm formula. This trial supports the use of an exclusive human milk diet to nourish extremely preterm infants in the neonatal intensive care unit.

The fortifier used was breast milk based.

Good News For Ultrashortbowel Syndrome!

http://www.jpeds.com/article/S0022-3476(13)00678-1/abstract
Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE

Objective

To examine treatment outcomes in pediatric patients with ultrashort small bowel (USSB) syndrome in an intestinal rehabilitation program (IRP).

Study design

We reviewed IRP records for 2001-2011 and identified 28 children with USSB (≤20 cm of small bowel). We performed univariate analysis using the Fisher exact test and Wilcoxon rank-sum test to compare characteristics of children who achieved parenteral nutrition (PN) independence with intact native bowel and those who did not. Growth, nutritional status, and hepatic laboratory test results were compared from the time of enrollment to the most recent values using the Wilcoxon signed-rank test.

Results

Of the 28 patients identified, 27 (96%) survived. Almost one-half (48%) of these survivors achieved PN independence with their native bowel. The successfully rehabilitated patients were more likely to have an intact colon and ileocecal valve (P = .01). Significant improvements in PN kcal/kg, total bilirubin, and height and weight z-scores were seen in all patients, but serum hepatic transaminase levels did not improve in the nonrehabilitated patients.

Conclusion

Enrollment in an IRP provides an excellent probability of survival for children with USSB. The presence of an intact ileocecal valve and colon are positively associated with rehabilitation in this population, but are not requisite. Approximately one-half of patients with USSB can achieve rehabilitation, with a median time to PN independence of less than 2 years. The USSB population can attain reduced PN dependence, improvement of PN-associated liver disease, and enhanced growth with the aid of an IRP.