Does Early Intervention Programs Help Prevent Motor and Cognitive Impairment In Preterm Infants Post-Discharge From NICU?

Does Early Intervention Programs Help Prevent Motor and Cognitive Impairment In Preterm Infants Post-Discharge From NICU?

It is clear that preterm infants are at increased risk for neurodevelopmental delays compared to infants born at term1. Therefore, a number of developmental intervention programs have been introduced in the neonatal intensive care unit setting to help the extremely low birth weight (<1000 grams birth weight) to improve the functional outcomes. Many studies are since then conducted to evaluate the long-term benefits from these intervention programs.
Cochrane neonatal group (a premier evidence-based research organization of the country) recently evaluated the utility of these programs in a meta-analysis. The group appraised 25 studies published until 2015 on this topic and selected 12 studies after applying stringent criteria for bias, randomization, and appropriate allocation. The team published their results in November 2015.
Authors’ conclusions are as follows: “Early intervention programs for preterm infants have a positive influence on cognitive and motor outcomes during infancy, with cognitive benefits persisting into preschool age. With regards to motor outcomes, a meta-analysis of 12 studies showed a significant effect in favor of early developmental interventions at infancy only. The early developmental intervention programs described in this review had to begin within the first 12 months of life, had to focus on the parent-infant relationship and/or infant development and although they could begin while the baby was still in the hospital, had to include a component that was delivered post-discharge from the hospital." Though no effect was shown on cerebral palsy, the motor improvement was, however, noted.
They concluded that further research is needed to determine which early developmental interventions are most effective in improving cognitive and motor outcomes, and to discern the longer-term effects of these programs.
It is quite encouraging that these programs do have a positive impact on the outcomes in preterm infants. We hope more and more parents of high-risk preterm infants take advantage of these early developmental intervention programs provided.

1) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005495.pub4/abstract;jsessionid=0F403A87FD4F8ADAF80D0C3A06B49678.f02t02.

Ethereal Brew

Ethereal Brew
It has been 33 years since I have seen many of my friends from medical school. That thought brought a combination of elation and hesitation. One part of me was delighted, and the other trepidatious. How will I be received? Will I be disheartened or cheered? With the understanding that all of us are matured, and prosperous, I became more optimistic. The journey to San Diego began along the Pacific Coast Highway.
The route was so breathtaking that we could not bear forsaking. Mesmerized by the bewitching beach, my better-half walked down the pebbly path to quench her desire to drench in the ocean waves. She wandered towards the rocky cliffs, ignoring the signs of rip currents. I had no desire to wet even my feet, let alone my seat. As my spouse gleefully drifted towards the perilous Pacific risking the rip tides, I rushed behind her screaming her to halt. Suddenly, it seemed the ocean had a different notion and made a rapid motion with full emotion to abruptly stop my locomotion. It just didn't wet my feet but gave my torso, a salty treat, coercing me to join her. I held on to the blocks of rocks politely declining the active solicitation. The Pacific pacified later. Soaked in salt water, I glanced at my wife; she looked arid, and I felt horrid. Oblivious to the happening, reveling in Pacific roar, sultana turned around with a stunning smile swaying over her scintillating face, innocently inquiring, why am I wet? She was calm, but I needed a balm. She looked serene, and I needed dry-clean.

I had to abandon my shoes and drive bare feet. As we reached the reunion destination, I could feel the palpitation from excitation, as our congregation is going to end the long duration of separation. Everyone was still recognizable and delightful despite donning different shapes. An atmosphere of childish excitement prevailed.

As friends began to open up, lives began to unveil; we felt sad at what some of our buddies had to go through. In the end, they didn’t become casualties to the calamities but instead became champions of the conflicts; bricks the life threw at them. We admired their resilience. Though we were not part of their tribulations; we happily partook in their adulation. Everyone excelled in their fields.

Some went beyond the call of their duty and served in dangerous areas. Others offered voluntary services to uplift the downtrodden.

We were eager to appreciate, acknowledge others’ success, and even look up to them as role models. That signaled how much we have grown as better humans. Bidding goodbye was never easy. So, Divesh suggested we go for a hike. I wished it was on a bike. Alas, everyone wanted a walk and talked. We soon realized that we went very far. The terrain was rugged, and soles of my new cheap shoes were jagged. The rocks were hurting, and my legs were exerting. My pace decelerated. Then came the astounding announcement that rattlesnakes infested the area. I could neither run nor remain placid. I comprehended why Divesh became a proficient runner in this place. He became my instant idol and tried to emulate him, as the fear was gripping and galvanizing. He made bidding goodbye very easy for me. Maybe, our Indian marathon athletes should train here. They would become unbeatable and of course unstoppable.

We then drove to Palm Springs. A major part of the drive was very windy. When we stopped at the rest area, a bemused traveler pointed out at the thousands of windmills installed along the highway, wondering why people waste so much of money just to experience some breeze in the hot desert. His innocent incomprehension was insightful. I almost fainted. He thought it was from the heat!

After we had checked into the resort, we went for some snacks. I noticed a couple sitting outside beneath a beautiful umbrella. The husband had ordered some tea, and the waiter brought him the same. Just then a bird sat on the edge of the umbrella and enjoyed its pleasure of elimination. That fell right into the tea cup, unnoticed by the husband. As the man sipped the newly re-created tea, he was thrilled by the out of the world flavor, and profusely thanked the waiter, who was clueless.

The now hysterical husband went on to compel his innocent-half to savor the new flavor. He went for the server to find out what type of tea it was. In the meantime, the bird wanted to relive its pleasurable expulsion, dropped its droppings into the cup as the wise-half watched. Furious, she beckoned her jubilant-half to convince him to buy the birdie and not the tea from the resort for his ethereal experience of the exquisite bird brew.

If Fate Had A Date!

When you get a premium extra leg room on a long flight, you are instantly reminded of LG’s slogan “Life is good”. Well! I paid a premium to experience that prime feeling. However, when I was about to treasure that short term pleasure, life reminded me that pleasure in any measure will float away like a feather as Casio says “Expect the unexpected”. A baby in the backseat as if rigidly following Harley Davidson’s “American by birth, but Rebel by choice”, felt envious of my pleasure in leisure and began to express it with a deafening cry. The helpless mom trying to be considerate to others, and to herself picked her up, and meandered in to my cherished, premium leg space as if it was Disneyland’s “Happiest place on earth (or was it on flight!).

I had no choice but to retract my reveling limbs from my space of luxury. The cry now transformed into a mocking smirk on that intolerant infant. Mother pleased with her baby’s new found happiness, decided to linger longer than an hour. This procreator, and cry creator combination became an instant inspiration for similar pairs on the flight. One after another began to savor the Shangri-La with my begrudging benevolence. It seemed my premium space had Sony Playstation tag: “live in your world, play in ours”. I was made to sit and feel like McDonald’s “I’m lovin it!”. I could neither evade the charming smile of the child, nor reconcile with the aching recoiled legs of mine. I finally had to settle with Burger King’s way “Have it your Way!”

It was time to enjoy the joy of the ocean. As we landed in the island of seafood, vegetarian like me had sea, but not food! The resort’s chef had personally handpicked several fallen leaves and decoratively arranged them on a tiny plate, sprinkled with drops of dressing. When asked if there was any other variety of vegetarian food, he promised that he would have grass the next day, perhaps coinciding with lawn mowing tonight, I thought. Having had not so yummies in our tummies, we decided to venture out to see the creatures of the coral world. After forfeiting my biweekly paycheck for the entrance fees, we zoomed in to the coral park. We were then asked to buy some honey to feed the lorikeets. We gladly obliged, and eagerly awaited to satiate the culinary needs of this lorikeet. None came. Environmentalist excitedly informed that if they are not hungry, they wouldn’t feed. We waited. Having had only leaves for lunch, the honey was very tempting. Neither birds would have it, nor we could have it. I wished we were standing at the back of the crowd, so that we could cherish the nectar, which was looking like a loaf of meat for a hungry lion. Social constraints lead to extreme self-restraint.

We then proceeded to the turtle feeding. We didn’t realize that they ate carrots, broccoli etc. it seemed they had a better vegetarian menu than ourselves in the resort. I offered with the pretext to feed the not so hungry turtles. However, the staff showed no interest thus depriving me of the option to satisfy my growling stomach. Interestingly, I saw a couple with some enticing vegetarian snack trying to feed the beastly looking Iguanas. Out of sheer curiosity combined with bare necessity, I approached the couple and enquired where did they get it? The naïve couple couldn’t remember the place or the name, much to my chagrin. But, offered the delicious dissert to me. My face gleamed, my appetite beamed until my esteemed couple screamed “please, feel free to feed the iguanas”. I glanced at them as gloom began to bloom, and muttered “of course, thank you”.

As we boarded our long flight back, we couldn’t carry food from the airport, as it was too small to have any vegetarian options. We were happy to see the cheese platter on the flight menu. We asked for platter, and water, and attendant thought it will make us fatter and gave us the latter to shatter the prospect of eating any veggie matter. I asked for peanuts, she explained to me the cost cuts. My initial hope was great, but as fate had its date, I was left without a plate, and continued my hunger state.

Oh! Mother..

Oh! Mother, our appreciation, how can we Show
You are our hearts doctor, for you Know
When our spirits are Low.
You hug, and laugh to make our spirits Glow
And happiness, you love to Bestow
In our best, and ill times, you are with us like a Shadow
Who is that not yet experienced your mollifying affection Flow
In our hearts the love seeds, you Sow
Peace & prosperity, you love to see in us Grow
You are like colors of Rainbow
We love to look up to and Bow
Oh! Mother, our appreciation, how can we Show.
Pradeep Alur.
May 8, 2016.

Antenatal Betamethasone in Late Preterm Deliveries

http://www.nejm.org/doi/full/10.1056/NEJMoa1516783?query=featured_home

multicenter, randomized trial involving women with a singleton pregnancy at 34 weeks 0 days to 36 weeks 5 days of gestation who were at high risk for delivery during the late preterm period (up to 36 weeks 6 days). The participants were assigned to receive two injections of betamethasone or matching placebo 24 hours apart. The primary outcome was a neonatal composite of treatment in the first 72 hours (the use of continuous positive airway pressure or high-flow nasal cannula for at least 2 hours, supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least 4 hours, extracorporeal membrane oxygenation, or mechanical ventilation) or stillbirth or neonatal death within 72 hours after delivery.

Results

The primary outcome occurred in 165 of 1427 infants (11.6%) in the betamethasone group and 202 of 1400 (14.4%) in the placebo group (relative risk in the betamethasone group, 0.80; 95% confidence interval [CI], 0.66 to 0.97; P=0.02). Severe respiratory complications, transient tachypnea of the newborn, surfactant use, and bronchopulmonary dysplasia also occurred significantly less frequently in the betamethasone group. There were no significant between-group differences in the incidence of chorioamnionitis or neonatal sepsis. Neonatal hypoglycemia was more common in the betamethasone group than in the placebo group (24.0% vs. 15.0%; relative risk, 1.60; 95% CI, 1.37 to 1.87; P<0.001).

Conclusions

Administration of betamethasone to women at risk for late preterm delivery significantly reduced the rate of neonatal respiratory complications.

Hypoglycemia management podcast

The NLRP3 inflammasome is critically involved in the development of bronchopulmonary dysplasia

Nature Communications 6, Article number: 8977 doi:10.1038/ncomms9977
http://www.nature.com/ncomms/2015/151127/ncomms9977/full/ncomms9977.html
www.sciencedaily.com/releases/2016/01/160115140128.htm

The pathogenesis of bronchopulmonary dysplasia (BPD), a devastating lung disease in preterm infants, includes inflammation, the mechanisms of which are not fully characterized. Here we report that the activation of the NLRP3 inflammasome is associated with the development of BPD. Hyperoxia-exposed neonatal mice have increased caspase-1 activation, IL1β and inflammation, and decreased alveolarization. Nlrp3−/− mice have no caspase-1 activity, no IL1β, no inflammatory response and undergo normal alveolarization. Treatment of hyperoxia-exposed mice with either IL1 receptor antagonist to block IL1β or glyburide to block the Nlrp3 inflammasome results in decreased inflammation and increased alveolarization. Ventilated preterm baboons show activation of the NLRP3 inflammasome with increased IL1β:IL1ra ratio. The IL1β:IL1ra ratio in tracheal aspirates from preterm infants with respiratory failure is predictive of the development of BPD. We conclude that early activation of the NLRP3 inflammasome is a key mechanism in the development of BPD, and represents a novel therapeutic target for BPD.

Association of Coffee Consumption with Total and Cause-Specific Mortality in Three Large Prospective Cohorts

CIRCULATIONAHA.115.017341 Published online before print November 16, 2015,
doi: 10.1161/CIRCULATIONAHA.115.017341

http://circ.ahajournals.org/content/early/2015/11/10/CIRCULATIONAHA.115.017341.abstract

Background—The association between consumption of caffeinated and decaffeinated coffee and risk of mortality remains inconclusive.

Methods and Results—We examined the associations of consumption of total, caffeinated, and decaffeinated coffee with risk of subsequent total and cause-specific mortality among 74,890 women in the Nurses' Health Study (NHS), 93,054 women in the NHS 2, and 40,557 men in the Health Professionals Follow-up Study. Coffee consumption was assessed at baseline using a semi-quantitative food frequency questionnaire. During 4,690,072 person-years of follow-up, 19,524 women and 12,432 men died. Consumption of total, caffeinated, and decaffeinated coffee were non-linearly associated with mortality. Compared to non-drinkers, coffee consumption one to five cups/d was associated with lower risk of mortality, while coffee consumption more than five cups/d was not associated with risk of mortality. However, when restricting to never smokers, compared to non-drinkers, the HRs of mortality were 0.94 (0.89 to 0.99) for ≤ 1 cup/d, 0.92 (0.87 to 0.97) for 1.1-3 cups/d, 0.85 (0.79 to 0.92) for 3.1-5 cups/d, and 0.88 (0.78 to 0.99) for > 5 cups/d (p for non-linearity = 0.32; p for trend < 0.001). Significant inverse associations were observed for caffeinated (p for trend < 0.001) and decaffeinated coffee (p for trend = 0.022). Significant inverse associations were observed between coffee consumption and deaths due to cardiovascular disease, neurological diseases, and suicide. No significant association between coffee consumption and total cancer mortality was found.

Conclusions—Higher consumption of total coffee, caffeinated coffee, and decaffeinated coffee was associated with lower risk of total mortality.

More ...
reports the effect is clear only among those who drink coffee and “never smoked.” Among those, there was a 6% to 8% lower death rate connected to drinking up to 3 cups daily, and a 15% lower rate among those who drank 3 to 5 cups, and a 12% lower rate among those who drank over 5 cups daily. One possibility suggested is that coffee drinkers “drink less soda,” while it is also suggested that the lignans and chlorogenic acid in coffee “could reduce inflammation and help control blood sugar,” and so “reduce the risk of heart disease,” which was 10% lower among coffee drinkers. In addition, coffee drinkers had a 9% to 37% lower rate of death from “neurological diseases such as Parkinson’s and dementia.” They also had “between 20% and 36% lower rates of suicide.”

Vivaha Bhojanambu-My attempt

Slow Advancement of Enteral Feeds in VLBW Infants-Is It Harmful?

Cochrane Database Syst Rev. 2015 Oct 15;10:CD001241

Morgan J, Young L, McGuire W.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001241.pub6/abstract

MAIN RESULTS:

We identified nine randomised controlled trials in which 949 infants participated. Most participants were stable preterm infants with birth weights between 1000 and 1500 g. Fewer participants were extremely preterm, extremely low birth weight, or growth-restricted. The trials typically defined slow advancement as daily increments of 15 to 24 mL/kg and faster advancement as 30 to 40 mL/kg. Meta-analyses did not show statistically significant effects on the risk of NEC (typical RR 1.02, 95% CI 0.64 to 1.62; typical RD -0.00, 95% CI -0.03 to 0.03) or all-cause mortality (typical RR 1.18, 95% CI 0.90 to 1.53; typical RD 0.03, 95% CI -0.02 to 0.08). Slow feeds advancement delayed the establishment of full enteral nutrition by one to five days and increased the risk of invasive infection (typical RR 1.46, 95% CI 1.03 to 2.06; typical RD 0.07, 95% CI 0.01 to 0.13; number needed to treat for an additional harmful outcome 14, 95% CI 8 to 100).

AUTHORS' CONCLUSIONS:

The available trial data suggest that advancing enteral feed volumes at daily increments of 30 to 40 mL/kg (compared to 15 to 24 mL/kg) does not increase the risk of NEC or death in VLBW infants. Advancing the volume of enteral feeds at slow rates results in several days of delay in establishing full enteral feeds and increases the risk of invasive infection. The applicability of these findings to extremely preterm, extremely low birth weight, or growth-restricted infants is limited. Further randomised controlled trials in these populations may be warranted to resolve this uncertainty.

Neonatal brain MRI: how reliable is the radiologist’s eye?

http://link.springer.com/article/10.1007%2Fs00234-015-1609-2


Introduction

White matter (WM) analysis in neonatal brain magnetic resonance imaging (MRI) is challenging, as demonstrated by the issue of diffuse excessive high signal intensity (DEHSI). We evaluated the reliability of the radiologist’s eye in this context.


Methods

Three experienced observers graded the WM signal intensity on axial T2-weighted 1.5T images from 60 different premature newborns on 2 occasions 4 weeks apart with a semi-quantitative classification under identical viewing conditions.


Results

The intra- and inter-observer correlation coefficients were fair to moderate (Fleiss’ kappa between 0.21 and 0.60).


Conclusion

This is a serious limitation of which we need to be aware, as it can lead to contradictory conclusions in the challenging context of term-equivalent age brain MRI in premature infants. These results highlight the need for a semiautomatic tool to help in objectively analyzing MRI signal intensity in the neonatal brain.

Digital Stethoscope Attachment-EKO

https://ekodevices.com/whitepapers/Eko_for_Primary_Care_Whitepaper.pdf

It is small digital attachment to any stethoscope, and it instantaneously coverts an analog to a digital mode. It can record, amplify, and show the visualization of heart sounds.

Should we follow Resolved Antenatal Hydronephrosis?

http://link.springer.com/article/10.1007%2Fs00467-015-3080-z

Background

Prenatal ultrasonography has greatly enhanced detection of congenital genitourinary abnormalities. However, although persistent prenatal hydronephrosis (PPH) is typically imaged and followed postnatally, it remains unclear if prenatal hydronephrosis that resolves in utero (RPH) should be similarly managed. We determined postnatal abnormalities associated with RPH and compared these to those associated with PPH.

Methods

We performed a retrospective review of all consecutive patients evaluated for prenatal hydronephrosis over 24 months. Patients were followed prenatally with serial ultrasounds and postnatally with ultrasonography and a voiding cystourethrogram.

Results

Of the consecutive 165 patients enrolled in the study, 72 had RPH. The average prenatal anterior–posterior renal pelvis length was significantly longer in patients with PPH (5.5 mm) than in those with RPH (4.9 mm) (p = 0.01). Recurrent postnatal hydronephrosis occurred in 44 % of patients with RPH, with eventual resolution in 34 % of those affected. In comparison, 29 % of PPH cases resolved postnatally. Mean time to resolution was statistically shorter for PPH (116 days) than for RPH (175 days) (p = 0.01). Seven PPH patients required surgery, while no RPH patients needed intervention (difference was statistically significant).

Conclusions

A significant number of RPH children had postnatal hydronephrosis. Despite a slower resolution time, no children with RPH required intervention. Although RPH may recur postnatally, the significantly lower chance of intervention being required suggests that these children may not require postnatal imaging.

Metanalysis of Probiotics Advantage in Reducing NEC in VLBW Infants

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.

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.