RBC Transfusions and Extension of IVH!!

http://onlinelibrary.wiley.com/doi/10.1111/j.1537-2995.2011.03081.x/abstract;jsessionid=77A09B82CD7BD12A05826302C638022C.d01t03

Red blood cell transfusion of preterm neonates with a Grade 1 intraventricular hemorrhage is associated with extension to a Grade 3 or 4 hemorrhage
Vickie L. Baer
RESULTS: Grade 1 IVH was identified in 417 neonates; 24 subsequently became a Grade 3, and 22 a Grade 4. These 46 were born earlier, 25 ± 2 weeks versus 30 ± 3 weeks (p = 0.000), with lower birth weight, 811 ± 284 g versus 1432 ± 603 g (p = 0.000); lower 5-minute Apgar scores, 5 ± 2 versus 8 ± 2 (p = 0.000); and slightly lower cord pH, 7.24 ± 0.16 versus 7.28 ± 0.10 (p = 0.009). Older gestational age was the most significant contributor lowering the odds of IVH extension (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.92-0.98). Administering a red blood cell (RBC) transfusion up to and on the day the Grade 1 was detected was the most significant contributor increasing the odds (OR, 2.92; 95% CI, 2.19-3.90) of extension. In both groups (resolving vs. extending) criteria for ordering transfusions were similar as was the proportion of transfusions given out of compliance with guidelines.

Conclusions:An association exists between RBC transfusion and extension of a Grade 1 IVH into a Grade 3 or 4. However, the explanation is unclear and could involve either the reasons transfusion are ordered or the transfusions themselves. Additional studies are needed to discover why neonates are more likely to have IVH extension if transfused.

NeOProM

NeOProM: Neonatal Oxygenation Prospective Meta-analysis Collaboration study protocol

http://www.biomedcentral.com/1471-2431/11/6
I am just presenting the summary of evidence as of now. Very interesting though!
In the Benefits of Oxygen Saturation Targeting (BOOST) trial , 358 infants born at less than 30 weeks' gestation were randomly assigned, from 3 weeks or more after birth until they breathed air, to target a SpO₂ range of either 91-94% or 95-98%. This trial found no evidence that higher SpO₂ targeting improved growth or development, but it did increase days of oxygen therapy and use of health care resources.
In a more recent cohort study, Tin et al that lower SpO₂ correlated with improved short term respiratory and growth outcomes in infants born at less than 28 weeks' gestation.
Babies in the neonatal intensive care units (NICU) targeting SpO₂ 70-90% had ROP surgery less often than those in the NICUs targeting SpO₂ 88-98% (6.2% v 27.2%, 80% relative risk reduction (RRR), p < style="color: rgb(153, 102, 51); font-style: italic;">ventilated less often (13.9 v 31.4 days), fewer needed oxygen at 36 weeks' postmenstrual age (18% v 46%, 61% RRR), and fewer were below the 3rd centile for weight at discharge (17% v 45%, 62% RRR) (all p <>v 53%) and cerebral palsy (15% v 17%) at one year were similar.

Long-term effects of routine morphine infusion in mechanically ventilated neonates on children’s functioning: Five-year follow-up of a randomized controlled trial.

http://www.painjournalonline.com/article/PIIS0304395911001266/abstract?rss=yes
conducted a follow-up study among 5-year-olds who, as mechanically ventilated neonates, had participated in a placebo-controlled trial on effects of morphine administration on pain and neurologic outcome. They were now tested on intelligence, visual motor integration, behavior, chronic pain, and health-related quality of life.
scores on one IQ subtest, “visual analysis,” were significantly negatively related to having received morphine and to open-label morphine consumption the first 28days. The finding of a significant effect of morphine on the “visual analysis” IQ subtest calls for follow-up at a later age focusing on the higher-order neurocognitive functions.

2) Lactobacillus reuteri accelerates gastric emptying and improves regurgitation in infants

http://www.ingentaconnect.com/content/bsc/ejci/2011/00000041/00000004/art00010
European Journal of Clinical Investigation, Volume 41, Number 4
Thirty-four infants completed the study (19 infants receiving probiotics and 15 placebo).At baseline, the whole group of infants was similar to the control group as regards anthropometric and physiological data. The median fasting antral area was significantly reduced, (P = 0·01) the delta in gastric emptying rate was significantly increased (P = 0·01) and the median episodes per day of regurgitation was reduced (, P  < 0·001) in the probiotic group compared to the placebo group. In the whole group, the frequency of regurgitation and the basal antral area showed a positive correlation (r = 0·53, P = 0·004). Conclusions  In infants with functional GER, L. reuteri DSM 17938 reduce gastric distension and accelerate gastric emptying. In addition, this probiotic strain seems to diminish the frequency of regurgitation.

Prevalence of Congenital Heart Disease Assessed by Echocardiography in 2067 Consecutive Newborns

http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2011.02248.x/abstract

Acta Paediatrica

Methods:  A cohort screening study was conducted in an unselected series of all live-birth newborns. Two-dimensional and color Doppler echocardiography was performed at 0 to 4 days of life in 2067 consecutive neonates who were born at the Hamamatsu University Hospital, Japan, between May 2005 and April 2010.

Results:  There were 104 cases of CHD in the 2067 live births. Ventricular septal defect and patent ductus arteriosus were the most frequent cardiac abnormalities. The prevalence of newborns with CHD who had signs or symptoms of CHD and/or required invasive intervention was 21.3 per 1000 live births. However, 60 patients (29.0 per 1000 live births) with CHD were asymptomatic and did not need invasive intervention. The overall prevalence of CHD in this series was 50.3 per 1000 live births.

Conclusion:  This prospective study using echocardiography for all newborns shows a higher prevalence of CHD than almost all of the previous studies.

http://www.springerlink.com/content/l82373354314746j/

Accuracy of Cardiac Auscultation in Asymptomatic Neonates with Heart Murmurs: Comparison Between Pediatric Trainees and Neonatologists

The overall ability of pediatric trainees in identifying congenital heart disease (CHD) was moderate [area under the curve (AUC) = 0.855] and significantly lower compared to neonatologists (AUC = 0.919, p = 0.007). However, at “lower” levels of clinical confidence (i.e., clinical diagnosis of possibly pathologic murmurs), pediatric trainees had good ability in excluding CHD (sensitivity 94.6%; negative likelihood ratio = 0.09). The ability of cardiac auscultation for diagnosing CHD in asymptomatic neonates is limited and dependent on the physician’s experience and level of clinical confidence. Echocardiography should remain an option for all neonates with a possibly pathologic murmur.
Bottom Line: If you are in a place where echocardiogram is not readily read by the pediatric cardiologist, then you may record it with Littman's stethoscope (Digital) and email it. Studies have shown that one can reduce the echiocardiograms being done to rule out a pathjological murmur.

How should an ideal spouse be in this digital world?

This analysis is based on real life observations. On the Valentine’s Day, I followed the tradition of buying flowers for my spouse. The flower’s tradition was followed by traditional I love you expression. She was ecstatic and very much appreciated what I did. Her feelings were genuine. It wasn’t long ago, that I had an argument with her about not replacing my pen, after she was done with it. Though the issue was trivial, it ticked me off. I rebuked her, but, she explained that as she was busy making dosas (Indian Pan cakes) and hence she could not get to it. I realized that she was trying to write a new recipe, when the dosa needed immediate attention. I was still piqued that I could not find my pen in time, discounting any credit that she rightfully deserved for trying to make the family happy with new dishes and giving us a break from the monotony. But, I wanted her to be perfect!

It was then my friend rang the bell and I gave a break to my sour feelings. He was craving to see my new HP Slate 500, my pride new possession. My mood changed swiftly from sour feelings to soaring spirits. I began to demonstrate with exhilarated eagerness all the hardware options it came with (USB port, two cameras, SD card slot etc.) unlike the Ipad. He was fired up by now and I could see the verve and sprightliness in his face. He earnestly asked if it has any apps! I smiled and showed with renewed vigor the Intel’s appup center and some free apps especially for tablet pcs. I double clicked on the Unit Converter app. It was a bit slow to open up. Alas! It took no time to shake his head and deliver his spirit smothering verdict-It is Windows! He completely discredited all the alluring attributes; it possessed but was irked by one app, which was sluggish! Before, I could react to his irrational judgment; I was paged to attend a cesarean delivery. I was baffled by his attitude. He out and out disparaged its worthy attributes and swayed in to negativity by one small inconsequential application.

After, I was done with the C-section, the resident was earnestly waiting to show me his new Iphone4. He was revved up and showed many of the features, which I was already familiar with. He further wanted to impress me with CNN app. Alas! It did not open despite multiple taps. He immediately switched to show me the text to speech option. The moment it initialized, it began speaking after every tap he made on the Iphone. “safari”, “address bar” www.google.com “oil companies”. It opened up the page, he wanted to scroll down and tapped on the bottom of the page-“screw your” it spoke as they were the last words on the screen and he was touching that part of the screen to scroll. There was no scrolling, but it again announced unabashed “screw your”. He was unperturbed and tried again, “screw your” spoke repeatedly to turn other people’s faces in dismay. Another Iphone owner came to his rescue and suggested that he should use 3 fingers to scroll, when text to speech was app was active. Finally, we all heaved a sigh of relief.

But, I was shocked, as he continued-“look at this operating system, why will I ever go for any other smartphone, when this is so outstanding!” I was bewildered by the opposing attitudes of Microsoft and Apple fans. One was focused on the negative trait, however petty it was, and the other on the positive attributes solely. It then dawned upon me that my own behavior was not much different from my friend who was disappointed by one dopey app, since all he wanted was a perfect operating system, which probably does not exist. I was also so focused on petty inconsequential aspect of my wife that for a moment, I completely ignored the larger positive side of my spouse. My reaction to my friend’s judgment is in many ways akin to how our spouses feel about us when we express our intolerance to their short comings, ignoring everything they do for us.

What, if we adopt the attitude of this Apple fan in real life, which was so focused upon what the Iphone did for him on the whole, ignoring the aberrations? We will probably remain happy and take care of our spouses giving them their due appreciation and regard. Though this won’t sway me to become an Apple fan will make me a fan of an Apple fan!

211 G to A Variation of UDP-Glucuronosyl Transferase 1A1 Gene and Neonatal Breastfeeding Jaundice

http://journals.lww.com/pedresearch/Abstract/2011/02000/211_G_to_A_Variation_of_UDP_Glucuronosyl.14.aspx

The uridine diphosphate glucuronosyl transferase 1A1 (UGT1A1) gene polymorphism was shown to contribute to the development of neonatal hyperbilirubinemia. We hypothesize that the variation of UGT1A1 gene may contribute to neonatal breastfeeding jaundice. We prospectively enrolled 688 near-term and term infants who were exclusively breastfed (BF group) or were supplemented by infant formula partially (SF group) before onset of hyperbilirubinemia.

Neonates with nucleotide 211 GA or AA variation in UGT1A1 genotypes had higher peak serum bilirubin levels and higher incidence of hyperbilirubinemia than WTs (GG). This phenomenon was only seen in BF group but not in SF group when subset analysis was performed. This suggests that neonates who carry the nucleotide 211 GA or AA variation within coding region in UGT1A1 gene are more susceptible to develop early-onset neonatal breastfeeding jaundice.

Milking Compared With Delayed Cord Clamping to Increase Placental Transfusion in Preterm Neonates: A Randomized Controlled Trial

http://journals.lww.com/greenjournal/Fulltext/2011/02000/Milking_Compared_With_Delayed_Cord_Clamping_to.2.aspx
Methods: All delivered before 33 completed weeks of gestation. In this single-center trial, women were randomized to either standard treatment (clamping the cord for 30 seconds after delivery) or repeated (four times) milking of the cord toward the neonate.
Results: Mean birth weight was 1,263±428 g in the clamping group and 1,235±468 g in the milking group, with mean gestational age of 29.2±2.3 weeks and 29.5±2.7 weeks, respectively. Mean hemoglobin values for each group at 1 hour after birth were 17.3 g/L for clamping and 17.5 g/L for milking (P=.71).
median number of transfusions within the first 42 days of life (median [range]: clamping group 0 [0–7]; milking group 0 [0–20]; P=.76).
My Point: We need to assess how much time was spent in milking and if associated chorioamniobnitis is an issue and if IVH incidence is different.

Oseltamivir-NICU experience

http://www.nature.com/jp/journal/vaop/ncurrent/full/jp2010159a.html
About 11 infants were treated for H1N1 and 21 were prophylaxed with Oseltamivir.
Age ranged from 2 days to 11.4 months (mean, 2.1 months). Corrected gestational age and weight at initiation of oseltamivir ranged from 32 to 86 weeks (mean, 41 weeks) and 775 to 8635 g (mean, 3074 g), respectively.

Conclusion:

Oseltamivir appears to be well tolerated in preterm and term neonates and infants with complex underlying conditions. More studies are needed to determine optimal dosing for treatment and prophylaxis in this vulnerable age group.

Levetiracetam in Neonatal Seizures

http://jcn.sagepub.com/content/early/2011/01/06/0883073810384263.abstract
Published as a retrospective study from CHOP, Philadelphia in Journal of Child Neurology. Twenty three neonates were given levetiracetam in a dosage of 16mg/kg +/- 6mg/kg.
Levetiracetam was associated with a greater than 50% seizure reduction in 35% (8 of 23), including seizure termination in 7. Further study is warranted to determine optimal levetiracetam dosing in neonates and to compare efficacy with other antiseizure medications.

RBC Transfusions & Severe IVH!

http://onlinelibrary.wiley.com/doi/10.1111/j.1537-2995.2010.02980.x/abstract

RESULTS: Fifty-four cases were matched (1:2) with controls. No differences were found between cases and controls in initial pH, sepsis, ventilation, coagulation studies, or proportion with severe thrombocytopenia. However, during the period when the head ultrasound was normal, cases were more likely to have had a red blood cell (RBC) transfusion (p <>

CONCLUSION: These findings suggest a new hypothesis. Namely, RBC transfusions given before the development of an IVH are an independent risk factor for developing a severe IVH.

Point: One more reason to be mindful of what we do in the first week of life. This study does not mean that we have proved transfusions lead to IVH. But, it makes us pause and ponder of what we do so routinely.

Early Opioid Infusion and Neonatal Outcomes in Preterm Neonates ≤28 Weeks' Gestation

https://www.thieme-connect.com/ejournals/abstract/ajp/doi/10.1055/s-0030-1270112
A retrospective analysis of preterm infants ≤28 weeks' gestational age (GA) admitted to neonatal intensive care units in the Canadian Neonatal Network was conducted comparing infants on the basis of receipt of opioid infusion during day 1 and day 3 after birth.
A total 362 infants received opioid infusion on day 1 and day 3, whereas 4419 infants did not receive opioid infusion.

Neonates who received opioid infusion had higher risk for mortality (adjusted odds ratio [AOR] 1.57, 95% confidence interval [CI] 1.13, 2.18), severe neurological injury (AOR 1.63, 95% CI 1.30, 2.04), severe retinopathy of prematurity (AOR 1. 39, 95% CI 1.08, 1.79), and bronchopulmonary dysplasia (AOR 1.36, 95% CI 1.03, 1.79). Early exposure to opioid infusion in the first 3 days was associated with higher risk of adverse outcomes in extremely preterm infants.
POINT: Narcotics are known to produce apoptosis of neurons in animal models. So, ask yourself-do we need to give it today and if so, why? Everything we d, can affect the outcomes, so be judicious!

BP recording dock for Iphone/Ipad

http://www.ihealth99.com/video1
This is cool neat device, with which you can not only record the BP but share it with your doctors or well wishers. I believe it costs about $99.

RBC Transfusions-NEC?

http://www.jpeds.com/article/S0022-3476%2810%2900482-8/abstract

Results

The frequency of RBC transfusions was similar in NEC patients (47/93, 51%) and control patients (52/91, 58%). Late-onset NEC (>4 weeks of age) was more frequently associated with a history of transfusion(s) than early-onset NEC (adjusted OR, 6.7; 95% CI, 1.5 to 31.2; P = .02). Compared with nontransfused patients, RBC-transfused patients were born at earlier gestational ages, had greater intensive care needs (including at the time of onset of NEC), and longer hospital stay. A history of RBC transfusions within 48-hours before NEC onset was noted in 38% of patients, most of whom were extremely low birth weight infants.

Conclusions

In most patients, RBC transfusions were temporally unrelated to NEC and may be merely a marker of overall severity of illness. However, the relationship between RBC transfusions and NEC requires further evaluation in extremely low birth weight infants using a prospective cohort design.

My Word: Few recent studies did not show any correlation between transfusions and NEC. But,

my hypothesis is that: older the blood and lower the hct,

higher the chances for NEC or hematoschezia. Older blood may accumulate oxygen radicals secondary to hemolysis and cause vasoconstriction and ischemia.

Efficacy of Bifidobacterium breve and Lactobacillus casei oral supplementation on necrotizing enterocolitis in very-low-birth-weight preterm infants:a

http://www.ajcn.org/content/early/2010/10/27/ajcn.2010.29799.abstract
a double-blind, randomized, controlled trial
Design: A double-blind, randomized, controlled clinical trial was conducted in 231 preterm infants weighing from 750 to 1499 g at birth. The intervention group was composed of 119 infants who received human milk with probiotic supplementation (B. breve and L. casei) and a control group of 112 infants who received human milk containing no probiotics. The primary outcome was the occurrence of NEC stage ≥2 as defined by Bell's modified criteria.

Results: Four confirmed cases of NEC stage ≥2 by Bell's criterion occurred only in the control group.

Though the follow up is not mentioned in this article, they compared probiotic group with those receiving breast milk alone rather than with formula. That makes it interesting!

If Medical Degree was obtained online solely.