Optimizing clinical care and training in the neonatal intensive care unit: the relationship between front line providers and physician trainees.

Changes in neonatal intensive care unit (NICU) coverage models, restrictions in trainee work hours, and alterations to the training requirements of pediatric house staff have led to a rapid increase in utilization of front-line providers (FLPs) in the NICU. FLP describes a provider who cares for neonates and infants in the delivery room, nursery, and NICU, and includes nurse practitioners, physician assistants, and/or hospitalists. The increasing presence and responsibility of FLPs in the NICU have fundamentally changed the way patient care is provided as well as the learning environment for trainees. With these changes has come confusion over role clarity with resulting periodic conflict. While staffing changes have addressed a critical clinical gap, they have also highlighted areas for improvement amongst the teams of NICU providers. This paper describes the current landscape and summarizes improvement opportunities with a dynamic neonatal interprofessional provider team.

Clinical characteristics of premature infants who orally feed on continuous positive airway pressure.

BACKGROUND: Between 32 and 34 weeks postconceptional age (PCA), premature infants typically achieve neuromuscular maturation to initiate the coordination of a nutritive suck triad. Many premature infants also require intubation, which has been associated with dysphagia in adults and infants. At our institution, despite these factors, some infants have been noted to tolerate oral feeds while on continuous positive airway pressure (CPAP). AIMS: Compare the clinical characteristics and duration of intubation in infants that initiate oral feedings on CPAP to infants that did not begin oral feeding on CPAP. STUDY DESIGN: Retrospective case control study. SUBJECTS: Infants with gestational age < 32 weeks who required CPAP at 32 weeks PCA. OUTCOME MEASURES: Oral feeding was defined as any oral feed ≥5 ml. Duration of intubation was defined as the number of intubated days prior to 32 weeks PCA. RESULTS: Of the 243 infants on CPAP at 32 weeks PCA, 31% (n = 76) began oral feeding on CPAP. Infants who initiated oral feeding on CPAP were of younger gestational age at birth (median 26 versus 27 weeks, p < 0.001) and remained intubated for longer (median 10.5 versus 2 days, p < 0.001). CONCLUSIONS: Infants who began oral feeding on CPAP had lower gestational age and longer duration of intubation than infants who started oral feeding off CPAP.

Relationship between Early Antibiotic Exposure and Short-Term Growth Velocity in Premature Neonates.

OBJECTIVE: To characterize the relationship between the duration of antibiotic administration during the first week of life and subsequent growth velocity during hospitalization. STUDY DESIGN: This was a retrospective study comparing the inhospital growth of infants born between 30 and 326/7 weeks' gestational age (GA) admitted to the Montefiore Weiler and Wakefield neonatal intensive care units between January 2009 and December 2015. Antibiotic duration during the first week of life was classified as no antibiotics, <5 days of antibiotics, or ≥5 days of antibiotics. Differences between discharge and birth weight Z-scores were compared between the three groups using analysis of variance. RESULTS: Of the infants, 87% received antibiotics during the first week of life, with 16% of infants completing ≥5 days. Compared with infants receiving ≤5 days of antibiotics, infants treated with ≥5 days had a lower GA, lower Apgar scores, more invasive respiratory support, longer duration of total parenteral nutrition, delayed initiation of enteral feeding, and a higher weight Z-score on admission and discharge (p < 0.05). However, there was no distinction in growth between the three groups assessed by the difference between admission and discharge weight Z-scores (p = 0.64), growth velocity (gram/kilogram/day) (p = 0.104), or an exponential growth velocity outcome (p = 0.423). CONCLUSION: Early antibiotic exposure was not associated with increased growth velocity between birth and discharge. Our study was limited by its retrospective nature and lack of follow-up data postdischarge.

Beyond bacteria: a study of the enteric microbial consortium in extremely low birth weight infants.

Extremely low birth weight (ELBW) infants have high morbidity and mortality, frequently due to invasive infections from bacteria, fungi, and viruses. The microbial communities present in the gastrointestinal tracts of preterm infants may serve as a reservoir for invasive organisms and remain poorly characterized. We used deep pyrosequencing to examine the gut-associated microbiome of 11 ELBW infants in the first postnatal month, with a first time determination of the eukaryote microbiota such as fungi and nematodes, including bacteria and viruses that have not been previously described. Among the fungi observed, Candida sp. and Clavispora sp. dominated the sequences, but a range of environmental molds were also observed. Surprisingly, seventy-one percent of the infant fecal samples tested contained ribosomal sequences corresponding to the parasitic organism Trichinella. Ribosomal DNA sequences for the roundworm symbiont Xenorhabdus accompanied these sequences in the infant with the greatest proportion of Trichinella sequences. When examining ribosomal DNA sequences in aggregate, Enterobacteriales, Pseudomonas, Staphylococcus, and Enterococcus were the most abundant bacterial taxa in a low diversity bacterial community (mean Shannon-Weaver Index of 1.02 ± 0.69), with relatively little change within individual infants through time. To supplement the ribosomal sequence data, shotgun sequencing was performed on DNA from multiple displacement amplification (MDA) of total fecal genomic DNA from two infants. In addition to the organisms mentioned previously, the metagenome also revealed sequences for gram positive and gram negative bacteriophages, as well as human adenovirus C. Together, these data reveal surprising eukaryotic and viral microbial diversity in ELBW enteric microbiota dominated bytypes of bacteria known to cause invasive disease in these infants.