Fresh frozen plasma and cryoprecipitate: Can we safely reduce their use in the NICU?

OBJECTIVE: To study patterns of use of Fresh Frozen Plasma (FFP) and Cryoprecipitate (CRYO) in a level 4 NICU and assess what proportions were not supported by literature. STUDY DESIGN: single centered retrospective observational. Charts of neonates admitted between 1/1/2010 to 12/31/2017 to CT Children's level 4 NICU were reviewed. Transfusions were assigned as "supported" or "non-supported" based on available evidence. Groups were compared using T-tests and chi-squared analyses. RESULTS: of 4110 total admissions, 197 (4.8%) received a total of 461 transfusions (374 FFP, 87 CRYO). Only 59% of FFP and 60% CRYO were supported by literature. Within the "non-supported" group the largest category was neonates transfused prophylactically. CONCLUSION: A large proportion of transfusions administered to neonates was not evidence-based, suggesting there are opportunities for improvement in use of these products.

Clinical and nutritional outcomes of two liquid human milk fortifiers for premature infants.

BACKGROUND: In preterm infants fortification of human milk with human milk fortifiers (HMF) to optimize nutrition and growth is standard practice. We compared clinical, nutrition and growth outcomes in infants receiving two types of liquid HMF (LHMF). METHODS: Clinical, nutrition and growth outcomes were compared between infants admitted to a level IV NICU, and born with birth weight less than or equal to 1800 grams, between 10/1/2014-12/31/2014 and received human milk with acidified LHMF (ALHMF) and between 1/1/2015-4/31/2015 and received human milk with heat treated LHMF (HTLHMF). RESULTS: Of the 85 qualifying infants, 67 received human milk and LHMF. ALHMF group had significantly higher incidence of metabolic acidosis and lower bicarbonate and base excess levels relative to infants receiving HTLHMF (P < 0.001). There were no significant differences by LHMF status in other clinical outcomes and nutrition and growth outcomes. In multivariate analyses, ALHMF use was associated with metabolic acidosis, and lower base excess and bicarbonate levels. CONCLUSION: In our study, the clinical, nutrition and growth outcomes between the two LHMF groups were similar. However, use of ALHMF in preterm infants was associated with increased incidence of metabolic acidosis in our cohort. Further randomized control trials are warranted to evaluate these findings.

Rates of intrauterine fetal demise and neonatal morbidity at term: determining optimal timing of delivery.

OBJECTIVE: To examine rates of unexplained intrauterine fetal demise (IUFD) and neonatal morbidity in uncomplicated term pregnancies to identify the optimal gestational age for delivery. METHODS: A retrospective case control study was performed with singleton pregnancies delivered between 37 0/7 weeks and 42 6/7 weeks. Exclusion criteria were "complicated pregnancies": emergency deliveries, maternal hypertension, diabetes, infection, fetal disease/malformations and placental abnormalities. RESULTS: Nineteen thousand two hundred and sixty-four maternal/infant pairs were examined. The overall rate of NICU admission was 2.7% and the rate of unexplained IUFD was 2.02 per 1000 births. The lowest rate of IUFD was found at 39 weeks (1.40 per 1000 births). Odds ratios adjusted for maternal smoking, ethnicity, age and mode of delivery showed 2.74 (95% CI 0.35-21.83) risk of IUFD at 42 versus 39 weeks, 2.09 (1.47-2.98) risk of NICU admission at 37 versus 38 weeks, 2.54 (1.62-3.97) risk of respiratory morbidity at 37 versus 38 weeks and 3.38 (1.84-6.18) risk of transient tachypnea of the newborn or respiratory distress syndrome at 37 versus 38 weeks. CONCLUSIONS: Neonatal respiratory morbidity was lowest for deliveries at 38-39 weeks. IUFD was 2.74 times more likely at 42 weeks versus 39 weeks. Our findings support current guidelines advising clinicians when to deliver term pregnancies.

Variability of Criteria for Pasteurized Donor Human Milk Use: A Survey of U.S. Neonatal Intensive Care Unit Medical Directors.

BACKGROUND: Use of donor human milk (DHM) is increasing, but criteria for its use are not well defined. MATERIALS AND METHODS: We conducted a 34-question Internet-based survey of medical directors of U.S. level 3 and level 4 neonatal intensive care units (NICUs), with the goal of describing specifics of policies developed to guide DHM use in U.S. NICUs. Respondents reported NICU characteristics and details of policies concerning DHM use. Policy-specified criteria for DHM use, if any, were described. Bivariate and multivariate analyses were used to identify NICU characteristics associated with DHM use. RESULTS: Respondents returned 153 (33%) surveys, with use of DHM reported by 91 (59%). Donor human milk use was more likely with more than 100 annual admissions <1500 g at birth (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.7) and with Vermont-Oxford Network participants (OR, 4.6; 95% CI, 1.8-11.6). Among 72 NICUs reporting a written policy, criteria for providing DHM required birth weights varying from <1000 to <1800 g and/or gestational ages from <28 to <34 completed weeks, but criteria were reportedly waived in many circumstances. Policies regarding duration of DHM therapy were similarly varied. CONCLUSIONS: Criteria for initiating and continuing DHM vary widely among U.S. level 3 and level 4 NICUs. Donor human milk use is more frequent in NICUs with many very low-birth-weight admissions and among Vermont-Oxford Network participants. Further research is needed to define short- and long-term outcomes and cost benefits of DHM use in subgroups of NICU patients, particularly for uses other than necrotizing enterocolitis prevention.

Postpartum triage, services provided, and length of stay for infants born at 35 weeks gestation.

OBJECTIVES: The aim of this article is to (1) compare the care setting to which 35-week infants are initially triaged postpartum to the level of services subsequently provided; and (2) identify factors known at delivery or immediately postpartum associated with services received and length of stay during the birth hospitalization. STUDY DESIGN: In this multicenter retrospective study of 35-week infants born between 2007 and 2008, service capabilities of the initial postpartum care setting were categorized as level 1 or neonatal intensive care unit (NICU) using American Academy of Pediatrics definitions. Subsequent services actually provided were categorized as routine care, level 1, or >level 1. RESULTS: Over half of 431 studied infants were sent to a level 1 nursery postpartum. Of these, over 90% ultimately received routine care or level 1 services. Of 200 infants triaged to a NICU, the majority received only routine care or level 1 services. The great majority of infants requiring > level 1 services were identified promptly postpartum. Initial triage to the NICU was associated with significantly (p < 0.05) increased length of stay despite provision of similar services. CONCLUSIONS: This study suggests a need for improved triage of 35-week infants and provides tools for this purpose. Validation of the models presented here is warranted.

Optimal periods of exclusive breastfeeding associated with any breastfeeding duration through one year.

OBJECTIVE: To quantify optimal minimum durations of exclusive breastfeeding associated with maintenance of any breastfeeding at 15 time points during the first year of life. STUDY DESIGN: Mothers (n = 1189) from the prospective Infant Feeding Practices Study II cohort who initiated exclusive breastfeeding with healthy term infants were included. In a 80:20 split-sample validation study, receiver operating characteristic curves estimated optimal minimum durations of exclusive breastfeeding needed to predict maintenance of any breastfeeding at 15 time points during the first year (n = 951). Logistic regression estimated the predictive performance of the identified thresholds adjusted for maternal age, race, education, parity, support system, and return-to-work status. Results were validated in the remaining 20% (n = 238). RESULTS: Optimal minimum durations ranged from 4.0-17.1 weeks of exclusive breastfeeding associated with maintenance of any breastfeeding at 15 time points. All estimated threshold durations were statistically significant after adjustment. CONCLUSIONS: Using a methodological approach unique to breastfeeding duration research, the authors report optimal durations of exclusive breastfeeding associated with duration of any breastfeeding at time points throughout the first year. Perinatal clinicians, pediatricians, lactation professionals, policymakers, researchers, and families might apply these findings to achieve desirable collective breastfeeding duration outcomes.

Patterns and predictors of donor human milk non-consent in the neonatal ICU.

BACKGROUND: Previous research has not evaluated predictors of donor human milk (DHM) non-consent status in a neonatal intensive care unit (ICU) setting within the United States. The purpose of this study is to identify and describe maternal and infant factors associated with DHM consent status in a Level IV inner-city neonatal ICU. MATERIALS AND METHODS: Demographics and additional maternal/infant data were stratified by DHM consent and compared with the appropriate parametric/nonparametric hypothesis testing statistic. A predictive multivariable logistic regression model was constructed, adjusted for independent predictors identified in the bivariate analysis (p≤0.2) using a backwards selection process (retention threshold p≤0.1). The adjusted odds ratios generated from the multivariable model identified predictors independently associated with DHM non-consent. RESULTS: Data were analyzed for 113 mother-infant dyads from the first 18 months of a DHM program, with 65 mothers consenting to DHM and 48 not consenting. Race, ethnicity, marital status, education, delivery mode, and presence of a breastfeeding duration goal qualified for inclusion into the multivariable model. Only race and marital status were retained in the final model. In this sample, black race, other race, and being married are all independent predictors for DHM non-consent. CONCLUSIONS: Black race, other race, and marital status statistically predicted DHM non-consent in a Level IV inner-city neonatal ICU. These results are relevant to all neonatal ICUs who use DHM and to those who are developing DHM programs.

The Effect of a Donor Milk Policy on the Diet of Very Low Birth Weight Infants.

BACKGROUND: Use of donor milk (DM) to supplement mother's own milk (MOM) in the neonatal intensive care unit (NICU) is steadily increasing based on health and developmental benefits to premature infants. A paucity of data exists documenting the effect of DM use on the diet of very low birth weight (VLBW) infants related to the implementation of a DM policy. OBJECTIVE: This study aimed to compare VLBW enteral intake type in the first 28 days of life before versus after establishing a DM policy. METHODS: This single-center pre-post prospective cohort study included all inborn infants ≤ 1500 grams in a level 4 NICU remaining hospitalized at 28 days and admitted either before (pre-DM period, October 2009-March 2010) or after (DM period, October 2010-September 2012) implementing a DM policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and daily volume of enteral intake as MOM, DM, and formula. The proportion of enteral feeds from these sources during the first 28 days of life was compared pre-DM versus DM. RESULTS: Compared to pre-DM baseline, formula exposure was significantly decreased, and human milk exposure and proportion of diet as human milk increased. The proportion of infants fed exclusively human milk increased. Exposure to and proportion of diet as MOM was unchanged. Infants were fed earlier in the DM period. CONCLUSION: Establishment of a DM policy was associated with reduced exposure to formula, promoting an exclusively human milk diet, with earlier initiation of feeds and no decrease in use of MOM.

Donor human milk bank data collection in north america: an assessment of current status and future needs.

BACKGROUND: The Human Milk Banking Association of North America (HMBANA) is a nonprofit association that standardizes and facilitates the establishment and operation of donor human milk (DHM) banks in North America. Each HMBANA milk bank in the network collects data on the DHM it receives and distributes, but a centralized data repository does not yet exist. In 2010, the Food and Drug Administration recognized the need to collect and disseminate systematic, standardized DHM bank data and suggested that HMBANA develop a DHM data repository. OBJECTIVES: This study aimed to describe data currently collected by HMBANA DHM banks and evaluate feasibility and interest in participating in a centralized data repository. METHODS: We conducted phone interviews with individuals in different HMBANA milk banks and summarized descriptive statistics. RESULTS: Eight of 13 (61.5%) sites consented to participate. All respondents collected donor demographics, and half (50%; n = 4) rescreened donors after 6 months of continued donation. The definition of preterm milk varied between DHM banks (≤ 32 to ≤ 40 weeks). The specific computer program used to house the data also differed. Half (50%; n = 4) indicated that they would consider participation in a centralized repository. CONCLUSIONS: Without standardized data across all HMBANA sites, the creation of a centralized data repository is not yet feasible. Lack of standardization and transparency may deter implementation of donor milk programs in the neonatal intensive care unit setting and hinder benchmarking, research, and quality improvement initiatives.

Independent predictors of human milk receipt at neonatal intensive care unit discharge.

OBJECTIVE: The aim of this study is to construct a predictive model for very low birth weight (VLBW) infants' receipt of mother's own milk within 24 hours before neonatal intensive care unit (NICU) discharge. STUDY DESIGN: Vermont Oxford Network (VON) clinical data were analyzed retrospectively for VLBW infants admitted between 2002 and 2012 at an inner city, level IV NICU with a well-established lactation program. Bivariate analyses compared infant characteristics between recipients and nonrecipients of human milk before 24 hours of NICU discharge. Independent predictors identified in the bivariate analyses (p ≤ 0.05), were eligible for inclusion into a multivariable logistic regression model. RESULTS: We observed a 60.4% human milk feeding rate at NICU discharge. Multiple independent maternal (black race and Hispanic ethnicity) and clinical factors (need for mechanical ventilation, patent ductus arteriosus, late-onset sepsis, or discharge to home on a cardiorespiratory monitor) positively predicted the outcome. CONCLUSIONS: Our results were inconsistent with previous studies and suggest that a strong NICU lactation program in combination with a community-based peer counselor program may increase rates of human milk receipt among VLBW infants born to black/Hispanic mothers and those with more complicated neonatal courses.

Increased neonatal morbidity despite pulmonary maturity for deliveries occurring before 39 weeks.

OBJECTIVE: To compare neonatal outcomes following deliveries <39 weeks after confirmation of fetal lung maturity with scheduled deliveries ≥39 weeks. METHODS: A retrospective cohort study examining neonatal outcomes of women who were delivered following documented fetal pulmonary maturity at 36, 37, and 38 weeks compared to women undergoing a scheduled delivery at 39, 40, and 41 weeks. The χ(2)-test and Student's t-test were used to compare categorical and continuous data, respectively. RESULTS: Delivery prior to 39 weeks following fetal pulmonary maturity was associated with a 8.4% composite neonatal morbidity rate as compared to 3.3% for deliveries at 39 weeks or greater (relative risk [RR] 2.9; confidence interval [CI] 2.4-3.6). Neonatal respiratory morbidity was significantly higher (5.4%) for those delivering at less than 39 weeks with documented fetal pulmonary maturity as compared to 2.1% for those delivering at 39 weeks or greater (RR 3.0; CI 2.3-3.9). Increased neonatal morbidity persisted for those delivered prior to 39 weeks even after excluding all diabetics (p < 0.001). Significant increases in neonatal morbidity were noted for deliveries prior to 39 weeks regardless of the mode of delivery. CONCLUSION: Despite fetal pulmonary maturity, delivery before 39 weeks is associated with significantly increased neonatal morbidity when compared to scheduled deliveries at 39 weeks or greater.

Midaortic syndrome in a premature infant.

Hypertension is an unusual finding in premature infants and warrants an extensive workup. Well-known causes of hypertension include endocrine, renal and cardiac anomalies. Coarctation of the thoracic aorta, a well-recognized cardiac anomaly leading to hypertension can manifest at various ages including the newborn period. In contrast, midaortic syndrome (MAS), also known as midaortic dysplastic syndrome, is a rare clinical syndrome involving hypoplasia of the abdominal aorta (AA) 1 with varying degrees of narrowing of the visceral branches, often presenting as intractable hypertension. Though there are case reports describing this condition in older children and adults, the diagnosis of MAS can be extremely difficult in neonates, especially in preterm low-birth-weight infants. We describe a rare case of a premature infant who presented with congestive heart failure in utero and intractable hypertension postnatally. This is the youngest reported case of MAS with autopsy confirmation in the literature.

Full-term neonatal intenstive care unit admission in an urban community hospital: the role of respiratory morbidity.

OBJECTIVE: To investigate the incidence of respiratory morbidity among full-term neonatal intenstive care unit (NICU) admissions and identify risk factors for such admissions. METHODS: We performed a retrospective cohort study of NICU admissions between 1/06 and 12/08. We included neonates between 37 and 40 weeks with a diagnosis of transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, pneumothorax, and meconium aspiration syndrome. Obstetrical outcomes were compared with a control group of women during the same period whose neonates were not admitted to the NICU. RESULTS: Two-hundred two infants admitted to the NICU with respiratory morbidity were compared with 9580 controls. TTN comprised the majority of the respiratory morbidity. Only RDS was associated with cesarean delivery. CONCLUSION: RDS remains a significant morbidity in full-term NICU admission. When compared with controls, admissions to our NICU with any respiratory morbidity were more likely to be delivered by cesarean to a mother with hypertension or diabetes during pregnancy.

Perinatal and neonatal outcomes of triplet gestations based on placental chorionicity.

The purpose of our study was to evaluate perinatal and neonatal outcomes in triplet gestations in relation to placental chorionicity. We hypothesized that triplets containing a monochorionic pair (dichorionic triamniotic) would have increased morbidity compared with triplets without a monochorionic pair (trichorionic triamniotic). We retrospectively analyzed all triplet sets > or =20 weeks delivering at our institutions from January 1995 through April 2007. Data were collected via perinatal and neonatal databases, chart review, and placental pathology. Individuals in dichorionic triamniotic triplet sets (N = 75), when compared with trichorionic triamniotic triplets (N = 309), were more likely to have a lower mean birth weight (P < 0.001) and lower gestational age at delivery (P < 0.001), spend more days in the neonatal intensive care unit (P = 0.045), have culture-proven sepsis (P = 0.02), and require intubation (P = 0.05). Multivariate analysis demonstrated that dichorionicity is not an independent cause of morbidity, but results in earlier delivery and lower birth weight. Dichorionic triamniotic triplets are at increased risk for earlier deliveries and lower birth weight at delivery compared with trichorionic triamniotic triplets.

Betamethasone vs dexamethasone for the prevention of morbidity in very-low-birthweight neonates.

OBJECTIVE: The purpose of this study was to compare neonatal outcomes in very-low-birthweight infants who were exposed to antenatal betamethasone vs dexamethasone. STUDY DESIGN: We reviewed all inborn very-low-birthweight infants from January 1997 through February 2006. Maternal medical records were reviewed to determine the type of antenatal steroids that each patient received; neonatal outcomes were compared using chi-square and Student t tests. RESULTS: There were 334 very-low-birthweight infants who met the criteria for evaluation: 186 infants received betamethasone, and 148 infants received dexamethasone. There were no differences in race, gestational age at delivery, or mean birthweight between the 2 groups. There were significantly lower rates of respiratory distress syndrome and bronchopulmonary dysplasia in the betamethasone group, compared with the dexamethasone group. Other neonatal outcomes were similar in both groups. CONCLUSION: Antenatal betamethasone was associated with a significantly lower rate of pulmonary complications caused by prematurity, when compared with dexamethasone.

Have the year 2000 neonatal resuscitation program guidelines changed the delivery room management or outcome of meconium-stained infants?

OBJECTIVE: To study the impact of neonatal resuscitation program (NRP) guidelines on delivery room (DR) management of infants born through meconium-stained amniotic fluid (MSAF). STUDY DESIGN: A retrospective study of all term (>or=37 weeks) infants born through MSAF was performed. Patients were divided into two periods: pre year 2000 NRP and post year 2000 NRP. Meconium consistency, APGAR scores and intubation (INT) for suctioning and respiratory outcome were recorded. Groups were analyzed using chi (2) tests and stepwise logistic regression. RESULTS: The incidence of MSAF remained constant in period 1 (13.6%) and period 2 (13.1%) while the proportion of infants intubated fell from 67 to 41% (p<0.001). The incidence of meconium aspiration and nonspecific respiratory distress did not differ between groups. CONCLUSIONS: Since the implementation of year 2000 NRP guidelines, the rate of DR INT for tracheal suctioning has fallen significantly without a change in overall respiratory complications. Results of this study support the efficacy of year 2000 NRP recommendations.

Is bloodstream infection preventable among premature infants? A tale of two cities.

BACKGROUND: Bloodstream infection (BSI) is a significant cause of morbidity and death encountered in the NICU. The rates of BSIs vary significantly in NICUs across the nation. However, no attempt has been made to correlate this variation with specific infection-control practices and policies. We experienced a significant increase in BSIs in the NICU at the George Washington University Hospital and were seeking additional precautionary measures to reduce BSI rates. Our objective was to review policies and practices associated with lower infection rates nationally and to test their reproducibility in our unit. DESIGN AND METHODS: Data on BSI rates in 16 NICUs were reviewed. The BSI rate at Connecticut Children's Medical Center (CCMC) was the lowest among those reviewed. A team from George Washington University Hospital conducted a site visit to CCMC to examine their practices. Differences in the aseptic precautions used for intravenous line management were noted at CCMC, where a closed medication system is used. This system was applied at George Washington University Hospital starting January 1, 2001. Infection rates among low birth weight infants (<2500 g) at George Washington University Hospital in the period from January 1998 to December 2000 (group 1) were compared with those in the period from January 2001 to December 2003 (group 2). Comparisons between the 2 cohorts were made with Fisher's exact test, the Kruskal-Wallis test, and Student's t test. Multivariate analysis was used to control for differences in birth weight, gestational age, central line days, and ventilator days. Analyses were repeated for the subgroup of very low birth weight infants (<1500 g). RESULTS: A total of 536 inborn low birth weight infants were included in this retrospective study (group 1, N = 169 infants; group 2, N = 367). The incidence of sepsis decreased significantly from group 1 to group 2 (25.4% and 2.2%, respectively). The reduction of sepsis observed in association with the new practice was statistically significant after controlling for birth weight, central line days, and ventilator days in a multiple regression model (regression coefficient: 0.95 +/- 0.29). The odds ratio of reduction in sepsis after implementation of the new practice was 2.6 (95% confidence interval: 1.5-4.5). The central line-related BSI rate decreased from 15.17 infections per 1000 line days to 2.1 infections per 1000 line days. The study included 233 very low birth weight infants, ie, 90 in group 1 and 143 in group 2. The rate of BSIs decreased significantly from group 1 to group 2 (46.7% and 5.6%, respectively). The decrease in sepsis rate remained significant in a multiple regression model (regression coefficient: 1.42 +/- 0.35). The odds ratio of decreased sepsis in relation to the new policy application among the very low birth weight infants was 4.15 (95% confidence interval: 2.1-8.3). CONCLUSION: Applying the closed medication system was associated with reduced BSI rates in our unit. This protocol was easily reproducible in our environment and showed immediate results. Serious attempts to share data can potentially optimize outcomes and standardize policies and practices among NICUs.

Can oral sucrose reduce the pain and distress associated with screening for retinopathy of prematurity?

OBJECTIVE: Infants undergoing eye exams to screen for retinopathy of prematurity (ROP) demonstrate physiologic and behavioral manifestations of pain and distress. Oral sucrose has analgesic properties that might reduce these effects. AIM: To determine the efficacy of oral sucrose in reducing the pain/distress of eye exams for ROP. METHODS: A total of 32 infants about to undergo ROP screening exams received either oral sucrose [S] (N=16) or sterile water [C] (N=16) in a randomized, prospective and blinded fashion. Outcome measures included HR, RR, O(2) saturation, BP, pain (premature infant pain profile) and percent of time spent crying during the eye exam. RESULTS: The groups were similar in GA (weeks) (28+/-1.6), BW (kg) (1.04+/-0.26), postnatal age (days) 50.8+/-20.3, and study weight (kg) 1.88+/-0.40). Both groups demonstrated significant increases in HR, BP, and pain score in response to the exam. Infants in both groups spent the majority of time actively crying during the exam ([S] 53+/-35% vs [C] 63+/-31%. Infants receiving [S] showed a small but significant drop in O(2) saturation. No significant differences were seen between groups in physiologic or behavioral responses to the eye exam. CONCLUSION: Oral [S] was not effective in reducing pain/distress from the ROP screening exam. Alternative strategies should be considered to achieve adequate pain relief.