Impact of an Infant-Driven Feeding Initiative on Feeding Outcomes in the Preterm Neonate.

BACKGROUND: Poor feeding techniques result in adverse outcomes for preterm infants. Infant-driven feeding (IDF) is a structured feeding method that standardizes neonatal cue-based feedings, and matches the neurodevelopmental stage of the preterm infant. The purpose of this quality improvement project is to assess whether initiation of an IDF initiative impacts time from first nipple feed (NF) to full NF and to discharge in infants born before 35 weeks' gestational age. Secondary aims include assessment of the impact of IDF on neonatal growth and feasibility of following an IDF protocol in a level III neonatal intensive care unit (NICU). METHODS: This quality improvement project assesses differences in time to first NF, length of hospital stay, and neonatal growth before and after usage of an IDF protocol. Eighty infants were included, 40 prior to and 40 after IDF intervention. Nurses were trained on IDF philosophy and methods prior to initiation. RESULTS: IDF was associated with discharge at a younger corrected gestational age (CGA), attainment of ad lib feeds at a younger CGA, and shorter amount of days between first NF and discharge. Infants utilizing IDF had slower weight gain, demonstrated by a larger drop in z score in the IDF group. The medical team and bedside nurses were able to follow the IDF protocol with few exceptions. IMPLICATIONS FOR PRACTICE/RESEARCH: IDF allows for optimization of a preterm infant's NICU stay and prepares infants for a safe discharge sooner. This could lead to increased parental satisfaction and decreased hospital cost. Further studies are indicated to ensure these benefits remain and focus on impact direct breastfeeding plays in the IDF model.

Ketamine as an Adjunct for Treatment of Methotrexate-induced Neurotoxicity.

Methotrexate (MTX) is used in the treatment of several childhood cancers and is a main component of the treatment regimen for osteosarcoma. MTX has been linked with side effects of varying severity; headaches, nausea, emesis, lethargy, blurred vision, aphasia, hemiparesis, paresis, convulsions, leukoencephalopathy, and arachnoiditis are symptoms of MTX toxicity. MTX-induced neurotoxicity can occur in up to 15% of patients receiving high-dose MTX. The effects may be transient but can have life-threatening implications, sometimes requiring intubation for respiratory support and airway protection. Elevated homocysteine levels in the cerebrospinal fluid are documented in cases of MTX-induced neurotoxicity; dextromethorphan is used as an initial treatment for MTX-induced neurotoxicity as it works as a noncompetitive antagonist for the N-methyl D-aspartate receptors and suppresses homocysteine activity. In severe cases requiring intubation, medications for sedation are utilized. Ketamine is also an N-methyl D-aspartate receptor antagonist, and as such, may be considered as an optimal treatment choice when sedation is required. We describe the use of ketamine in a pediatric patient with MTX-induced neurotoxicity. The use of ketamine in the treatment of MTX-induced neurotoxicity has not been described in the literature.