Withholding feeding during transfusion: Standardization of practice and nutritional outcomes in premature infants.

OBJECTIVE: To evaluate the nutritional impact of a feed-holding guideline during transfusion for infants <32 weeks gestation. STUDY DESIGN: A pre-/post-interventional study was conducted after introduction of a guideline to hold feeds during transfusion. Demographic variables in addition to nutritional outcomes were collected on all infants admitted within 48 hours of birth with gestational age <32 weeks. Data was collected during a 6 month period pre-intervention and the 6 month period post-intervention. RESULTS: There were 145 eligible infants. Mean birth weight and gestational age were similar in both periods. In total, 98 infants received transfusions, and 82 of those had an active feeding order prior to at least one transfusion. Total transfusions per infant and transfusions ordered while an infant had active feeding orders were similar in both periods. Time to full feedings was decreased post-intervention (p <  0.001). Weight at 34 weeks, incidence of second IV placement, additional IV fluid use, and hypoglycemia were similar between groups.Of 593 total transfusions, 207 were ordered while an infant had an active order for enteral nutrition. Pre-intervention, 64% of transfusions had feeds held during transfusion. Post-intervention, 87% of transfusions had feeds held during transfusion. Feeds were held more often (p <  0.001) and for a shorter duration (p = 0.005) in the post-intervention group. CONCLUSION: Implementing a guideline standardizing feeding practices during transfusions in premature infants increases standardization of care and results in decreased variability in practice. Adverse nutritional consequences were not found after the introduction of the routine practice of holding feedings during transfusion in preterm infants.

Implementation of feeding guidelines in infants at risk of intestinal failure.

OBJECTIVE: To implement feeding guidelines to reduce advancement time and the incidence of parenteral nutrition-associated liver disease (PNALD) among intestinal surgical infants requiring parenteral nutrition (PN). STUDY DESIGN: Feeding guidelines with higher initial enteral nutrition (EN) volume and specific advancement criteria were implemented for surgical infants aged <6 months. Preimplementation and postimplementation outcomes were compared. RESULTS: There were 57 preimplementation and 33 postimplementation infants. The initial EN volume improved from 10 to 20 ml kg(-1) day(-1) (P<0.001). Time to reach 50% of goal calories from EN decreased by a median of 6 days (P=0.012) without a change in necrotizing enterocolitis incidence after resuming feeding. PNALD incidence decreased from 70% to 48% (P=0.046), and median peak direct bilirubin (DB) decreased from 5.6 to 2.3 mg dl(-1) (P=0.011). CONCLUSION: Feeding guideline implementation with higher initial feeding volume was well tolerated and resulted in faster achievement of 50% goal EN calories. PNALD incidence and peak DB were reduced.

The Neonatal Pain, Agitation and Sedation Scale and the bedside nurse's assessment of neonates.

OBJECTIVE: To determine the reliability of an objective measure of pain, agitation and sedation using the Neonatal Pain, Agitation and Sedation Scale (N-PASS) compared with nursing bedside assessment. STUDY DESIGN: Neonates admitted in neonatal intensive care unit over a 6-month period were eligible. Pain and sedation were assessed with N-PASS, and a subjective questionnaire was administered to the bedside nurse. RESULT: A total of 218 neonates were eligible (median: gestational age 34.6 weeks, age at assessment 7 days). N-PASS pain score correlated significantly with both nurses' pain score (Spearman coefficient (r)=0.37; P<0.001) and agitation score (r=0.56; P<0.001). N-PASS sedation score correlated with nurses' sedation score (r=-0.39; P<0.001). Adjusting for gestational age, day of life, intrauterine drug exposure and use of high frequency ventilation only slightly attenuated the correlations (r=0.36, 0.55 and -0.31, respectively). CONCLUSION: The N-PASS captures nursing assessment of pain, agitation and sedation in this broad population and provides a quantitative assessment of subjective descriptions that often drives patient therapy.

The impact of group B Streptococcus prophylaxis on early onset neonatal infections.

OBJECTIVE: To determine if changes have occurred in the causative pathogens and/or antibiotic susceptibility profiles in early onset neonatal infections since initiation of group B Streptococcus (GBS) prophylaxis and to determine risk factors for ampicillin/penicillin resistant microorganisms. STUDY DESIGN: Data on 220 infants with positive blood, urine, or cerebrospinal fluid cultures for bacteria or fungi at ≤seven days of age from 1990-2007 were examined and divided into three epochs, based on intrapartum antibiotic prophylactic (IAP) practices. Pathogens and antibiotic resistance were compared among epochs. RESULTS: A significant decrease in the incidence of GBS infections occurred over time, with no change in the incidence of other pathogens or the emergence of antibiotic resistance, including the very low-birthweight population. In regression analysis, ampicillin resistance was associated with male gender (OR 3.096). CONCLUSIONS: No emergence of antibiotic resistant pathogens was found following IAP use. Changing microorganisms and increasing antibiotic resistance found in prior studies are likely multifactorial. Further study is needed to continue to reduce the rates of common early onset pathogens.

The new 6-unit individualized curriculum for pediatric residents: the perspective of neonatology fellowship program directors.

OBJECTIVE: Starting in 2013, all pediatric residents entering fellowship must be provided six educational units whose structure is to be determined by their individual career plans. We sought to determine whether (1) neonatology fellowship program directors (PDs) consistently identify certain weaknesses among incoming fellows and (2) neonatology fellowship PDs agree on the most beneficial activities in which pediatric residents should participate to improve preparation for entry into neonatology fellowships. STUDY DESIGN: We sent a 21-question survey focused on the structure and implementation of the 6-unit curriculum to all members of the Organization of Neonatology Training Program Directors. RESULTS: Sixty-seven percent of PDs responded. Seventy-five percent cited insufficient procedural skills as the primary weakness of incoming fellows. More than 80% rated additional training in clinical neonatology, including procedural and resuscitation training, as 'beneficial' or 'highly beneficial'. In contrast, fewer than 40% of PDs gave the same positive ratings to activities broadly focused on scholarship. CONCLUSIONS: The results of the survey may help guide pediatric residency programs as they undertake development of these new curricular initiatives for individual residents entering neonatology.

Absorption and tolerability of aqueous chlorhexidine gluconate used for skin antisepsis prior to catheter insertion in preterm neonates.

OBJECTIVE: To assess chlorhexidine absorption and skin tolerability in premature infants, following skin antisepsis with 2% aqueous chlorhexidine gluconate (CHG) prior to peripherally inserted central catheter (PICC) placement. STUDY DESIGN: Neonates less than 32 weeks gestation had skin cleansed with CHG prior to PICC placement. CHG concentrations were measured on serial blood samples. Skin integrity was evaluated for 2 weeks after CHG exposure. RESULT: Twenty infants were enrolled; median gestational age was 28 2/7 weeks (range 24 3/7 to 31 4/7). Ten infants had detectable serum chlorhexidine concentrations (range 1.6 to 206 ng ml(-1)). Seven of these infants had their highest serum concentration 2 to 3 days following exposure. No CHG-related skin irritation occurred in any infant. CONCLUSION: CHG was detected in the blood of preterm infants receiving CHG skin antisepsis for PICC insertion. Highest serum concentrations occurred 2 to 3 days after exposure. Further investigation is needed to determine the clinical relevance of CHG absorption in preterm infants.

The impact of group B streptococcus prophylaxis on late-onset neonatal infections.

OBJECTIVE: To determine trends in late-onset neonatal infections and risk factors for ampicillin/penicillin-resistant microorganisms. STUDY DESIGN: Data on 584 infants with positive blood, urine or cerebrospinal fluid cultures for bacteria or fungi at 8-30 days of age from 1990 to 2007 were examined and divided into three epochs, based on intrapartum antibiotic prophylactic (IAP) practices. Pathogens and antibiotic resistance were compared among epochs. RESULT: The number of candidal infections increased over time for the entire population (P=0.006). There was an increased incidence of Gram-negative (P=0.009) and candidal infections (P=0.014) among very low-birthweight infants. Only Escherichia coli infections showed increasing ampicillin resistance over epochs (P=0.006). In regression analysis, ampicillin/penicillin resistance increased with IAP use (odds ratio 2.05). CONCLUSION: Changing microorganisms and increasing antibiotic resistance in late-onset neonatal infections are likely multifactorial but are increased with IAP use, which may identify an at-risk population. Increasing Candida infections require further investigation.

Cardiovascular instability after patent ductus arteriosus ligation in preterm infants: the role of hydrocortisone.

OBJECTIVE: Following patent ductus arteriosus (PDA) ligation, preterm infants may develop profound hypotension and respiratory failure. Prophylactic stress hydrocortisone (HC) has emerged as a therapy to prevent complications, postulating these infants do not synthesize steroids because of an immature hypothalamic-pituitary-adrenal axis. The purpose of this study was to compare outcomes in infants who received stress HC before their PDA ligations to those who did not. STUDY DESIGN: A retrospective chart review was performed of infants who underwent PDA ligations at our institution's neonatal intensive care unit. Data were collected on treatment with HC, and respiratory and cardiovascular support. RESULT: Gestational age (GA) and birth weight were lower in the HC group (24 vs 25 weeks, 632 vs 790 g), but age at time of surgery was similar (26 vs 21 days). Cardiorespiratory support was comparable between the groups pre- and post-operatively. In regression models that adjusted for GA, HC treatment was not independently related to respiratory support postoperatively, but was associated with a decrease in postoperative dopamine (2.2 mcg kg(-1) min(-1); P=0.03). Respiratory support postoperatively was predicted by preoperative respiratory support. GA and age at surgery were not independently associated with outcome. CONCLUSION: Preoperative stress HC was not associated with improved cardiorespiratory stability, regardless of GA. Further investigation is needed to identify infants who may benefit from this therapy.

Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant.

Chlorhexidine gluconate (CHG) is a widely used topical antiseptic that is recommended by the Centers for Disease Control and Prevention for skin cleansing before central venous catheter insertion in adults and children. Because of limited safety data, CHG is not recommended for use in children <2 months of age. CHG is, however, frequently used in Neonatal Intensive Care Units across the United States. Here, we will review the safety of CHG use in preterm infants.

Outcomes of early parenteral nutrition for premature infants.

OBJECTIVE: The objective of this study was to evaluate the safety and efficacy of early amino acid (early AA) administration in very low birth weight (VLBW) infants. STUDY DESIGN: A pre- and post-intervention study was conducted after initiating an early AA administration protocol. Clinical outcomes were collected for all VLBW infants admitted on the first day of life for 9 months before protocol initiation (standard parenteral nutrition (PN)), and 10 months after initiation of early AA. RESULT: In all, 88 infants met study criteria for standard PN, and 85 infants for early AA administration. The patient characteristics were similar between the groups. There were no differences in mortality, the day birth weight was regained, the day enteral feeds started, the duration of PN, the day full feeds achieved and weight at 32 weeks post-menstrual age. No differences were found for late sepsis, direct hyperbilirubinemia and chronic lung disease. Necrotizing enterocolitis (NEC) occurred more frequently in the early AA administration group (12 vs 1%, P=0.012). CONCLUSION: Early AA administration for VLBW infants was as efficacious as standard therapy, although increased NEC in the early AA period may have negatively affected growth and nutrition in that period.

Early cortisol values and long-term outcomes in extremely low birth weight infants.

OBJECTIVE: Both excess and insufficient levels of glucocorticoid in extremely low birth weight (ELBW) infants have been associated with adverse hospital outcomes, whereas excess glucocorticoid exposure has been associated with long-term adverse neurodevelopment. Our objective was to evaluate the relationship between neonatal cortisol concentrations and long-term outcomes of growth and neurodevelopment. STUDY DESIGN: As part of a multicenter randomized trial of hydrocortisone treatment for prophylaxis of relative adrenal insufficiency, cortisol concentrations were obtained at 12 to 48 h of postnatal age and at days 5 to 7 on 350 intubated ELBW infants, of whom 252 survived and returned for neurodevelopmental follow-up at 18 to 22 months corrected age. Cortisol values from each time point were divided into quartiles. Growth and neurodevelopmental outcome were compared for each quartile. RESULT: Median cortisol value was 16.0 microg per 100 ml at baseline for all infants, and 13.1 microg per 100 ml on days 5 to 7 in the placebo group. Outcomes did not differ in each quartile between treatment and placebo groups. Low cortisol values at baseline or at days 5 to 7 were not associated with impaired growth or neurodevelopment at 18 to 22 months corrected age. High cortisol values were associated with an increase in cerebral palsy, related to the increased incidence of severe intraventricular hemorrhage (IVH) and periventricular leukomalacia. CONCLUSION: Low cortisol concentrations were not predictive of adverse long-term outcomes. High cortisol concentrations, although predictive of short-term adverse outcomes such as IVH and periventricular leukomalacia, did not additionally predict adverse outcome. Further analysis into identifying factors that modulate cortisol concentrations shortly after birth could improve our ability to identify those infants who are most likely to benefit from treatment with hydrocortisone.

Parents' perception of the back-transport of very-low-birth-weight infants to community hospitals.

OBJECTIVE: To characterize parents' perception of back-transport of very-low-birth-weight (VLBW) infants from a regional referral neonatal intensive care unit (RR-NICU) to a community hospital (CH) for convalescent care. STUDY DESIGN: Mixed methods utilizing parental interview and medical record review. RESULT: Overall, 20% of parents selected the CH to which their child was transferred. Less than half of the parents wanted the transfer. Psychological comfort with the RR-NICU was the most frequently reported reason for opposing transfer. At the time of home discharge, most parents were satisfied with the transfer and felt prepared to care for their infant at home. CONCLUSION: Parents want their infants closer to home, but are worried about the unknown. They are willing to forfeit autonomy in decision-making regarding the site of convalescent care. Parents need better preparation for transfer. Including them in an advisory group that reviews transfer policies could ameliorate the transition.

The epidemiology of atypical chronic lung disease in extremely low birth weight infants.

OBJECTIVE: To determine the incidence and associated complications of atypical chronic lung disease (ACLD) in extremely low birth weight infants. STUDY DESIGN: All infants born at Johns Hopkins Hospital between 1996 and 2001, with birthweight <1000 g, gestational age <31 weeks, no major anomalies or genetic syndromes, and living at least 21 days were eligible for inclusion. Data pertaining to demographics, hospital course, diagnosis of atypical chronic lung disease, patterns of surfactant use, complications of prematurity and severity of lung disease were collected. RESULT: Using inclusion criteria, 215 eligible infants were identified, of which 185 had hospital charts available for review. Twenty-eight infants (15%) met the criteria for atypical chronic lung disease. Of the remaining 157 infants, 57 patients met the criteria for mild bronchopulmonary dysplasia (BPD) (supplemental oxygen requirement at 28 days of life), 38 patients had moderate/severe BPD (supplemental oxygen requirement at both 28 days of life and 36 weeks post-menstrual age), and 38 infants did not have chronic lung disease. Infants with ACLD had much higher rates of sepsis (46%) and pneumothorax (18%) than infants in the comparison groups. CONCLUSION: Infants with respiratory distress syndrome in the first week of life, which initially resolves are still at risk for an atypical form of chronic lung disease. The prolonged respiratory support they require as a result of this type of lung disease increases their risk for complications of prematurity, which may outlast their lung disease. We speculate that inflammation secondary to infection acquired shortly after birth may be an important step in the pathogenesis of ACLD.

Hospitalization as a measure of morbidity among very low birth weight infants with chronic lung disease.

OBJECTIVE: To examine the spectrum of hospitalization and rehospitalization among very low birth weight (VLBW, <1500 gm) infants with severe chronic lung disease during the first 2 years of life. POPULATION: All 124 VLBW infants admitted to our center from October 1988 to September 1990 who were oxygen and ventilator dependent at 21 days of age. One hundred infants survived to discharge, of whom two subsequently died. The 98 surviving infants are the subject of this report. METHODS: The duration of the neonatal stay, the use of a long-term care facility, and rehospitalizations were recorded to a postnatal age of 24 months. The duration of these hospitalizations and the total duration of hospitalization during the first year of life were correlated with demographic and perinatal risk factors and 20-month outcome. RESULTS: The 98 infants spent a median of 125 days (range, 44 to 365) of their first year hospitalized; the neonatal stay accounted for 85% of this time. Forty-nine of the infants (50%) were rehospitalized in their first year (median stay, 14 days), and 36 (37%) were rehospitalized in their second year (median stay, 7 days). Long-term care facility stay and rehospitalizations accounted for 6% and 9% of the first-year hospitalizations, respectively. A median of 9 days (range, 1 to 365) of the second year of life were spent in hospital. The infants rehospitalized during their first year of life did not differ significantly from those not requiring rehospitalization with regard to maternal demographic descriptors, birth data, severity of chronic lung disease, or measures of 20-month outcome. Both duration of neonatal stay and total hospital stay during the first year were significantly associated with all measures of chronic lung disease severity and with 20-month neurodevelopmental outcome measures, whereas the duration of rehospitalization was associated only with duration of oxygen dependence. CONCLUSION: Among infants with severe chronic lung disease, the total duration of hospitalization during the first year of life provides a better index of morbidity than the number or duration of rehospitalizations alone.

Rigorous management of insulin-dependent diabetes mellitus during pregnancy.

The effect of rigorous management of insulin-dependent diabetes mellitus (IDDM) during pregnancy on the perinatal outcome was assessed by comparing 78 prepartum gravid patients with IDDM managed prospectively with 78 matched controls. The diabetic women were treated with insulin by either infusion pump or split-dose therapy, with the goal of normalization of the fasting blood sugars and hemoglobin Hb A1c values. Differences in the perinatal outcome were evaluated by either chi-square or analysis of variance. Of the women with IDDM, 14% where White class B, 43% class C, 26% class D, 17% classes R and F. The mean Hb A1c value in the first half of pregnancy was 8.49% +/- 2.30%, and 7.34% +/- 1.79% in the second half. Women with IDDM had higher rates of premature delivery (31% vs. 10%, P = 0.003), pre-eclampsia (15% vs. 5%, P = 0.035), and cesarean section (55% vs. 27%, P = 0.002). Complications of infants born to diabetic mothers included large size for gestational age (41% vs. 16%, P = 0.0002), hypoglycemia (14% vs. 1%, P = 0.0025), hyperbilirubinemia (46% vs. 23%, P = 0.0002), and respiratory distress (12% vs. 1%, P = 0.008). The Apgar scores and mortality were similar. Congenital malformations occurred in 7.7% of infants of diabetic mothers and 1.3% of controls (P = 0.05). The maternal Hb A1c level did not correlate with the infant size for gestation. Although the improved medical management of IDDM has decreased neonatal mortality, significant perinatal complications persist.