Adjustment of high flow nasal cannula rates using real-time work of breathing indices in premature infants with respiratory insufficiency.

OBJECTIVE: To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants. STUDY DESIGN: A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used. RESULTS: Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age <28 weeks, an incremental increase in HFNC flow rate decreased WOB (p < 0.001) and improved oxygen saturation and stability (p < 0.01). CONCLUSIONS: Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.

Do extremely preterm infants need retinopathy of prematurity screening earlier than 31 weeks postmenstrual age?

OBJECTIVE: To evaluate the utility of screening all extremely preterm infants for retinopathy of prematurity (ROP) at 4 weeks chronologic age, which is earlier than recommended by the 2018 AAP guidelines. STUDY DESIGN: Retrospective analysis of infants <27 weeks gestation from two tertiary NICUs between 2006 and 2018 who survived until first eye examination. RESULTS: 550 infants (gestational age 25.1 ± 1.2 weeks and birth weight 758 ± 323 g) had 1310 examinations performed by 32 weeks postmenstrual age (PMA), and 676 (51.6%) of these were prior to 31 weeks PMA. No examinations in infants prior to 31 weeks PMA met the criteria for laser therapy. Of 87/550 infants (15.8%) who required laser therapy, none did so prior to 32 weeks PMA. CONCLUSIONS: No infants born <27 weeks gestation were found to have severe ROP prior to 31 weeks PMA, supporting the most recent AAP recommendation of initiating ROP screening at 31 weeks PMA for extremely preterm infants.

Do infants in the neonatal intensive care unit diagnosed with urinary tract infection need a routine voiding cystourethrogram?

OBJECTIVE: To determine if infants diagnosed with urinary tract infection (UTI) in the neonatal intensive care unit (NICU) require a routine voiding cystourethrogram (VCUG). STUDY DESIGN: Retrospective data analysis from three centers for infants admitted to the NICU born between 2000 and 2013 and diagnosed with UTI. RESULTS: One hundred twenty-six infants from three centers were diagnosed with UTI during their hospitalization. Renal ultrasound (RUS) was performed in 115 infants (91.2%), of which 69 (60%) were abnormal. Mild to moderate hydronephrosis or pelviectasis were the most common abnormalities identified (n = 34, 30%). There were 14 infants (12%) with severe abnormalities on RUS. VCUG was performed in 71 infants (56%), of which 3 (4%) were interpreted as abnormal with grade 2 vesicoureteral reflux (VUR) or less (two infants were with normal RUS and one infant was with abnormal RUS). CONCLUSIONS: More than 50% of infants with a UTI had an abnormal RUS but severe abnormalities were found only in 11% of infants. Only 4% of infants with UTI had VUR; none of these infants had severe VUR on VCUG. A routine VCUG after UTI in the NICU has a low yield and may be reserved for infants with severe or persistent abnormalities on RUS.

Tidal volume monitoring during emergency neonatal transport.

OBJECTIVE: The study aim was to identify the frequency with which tidal volumes were achieved in a target range in infants requiring positive pressure ventilation on emergency transport. STUDY DESIGN: We performed a prospective observational study of infants requiring continued positive pressure ventilation during emergency transport after resuscitation and stabilization. Blindly recorded data were analyzed for percentage of breaths that were below range, in range, and above desired range of 4-6 mL/kg. RESULT: Fourteen patients were monitored during transport from the delivery room to the neonatal intensive care unit, and 15 patients were monitored during inter-facility transport. During delivery room transport, 21 and 7% of patients were in target range greater than 50 and 90% of the time, respectively. During inter-hospital transport, 60 and 7% of patients were in target range greater than 50 and 90% of the time, respectively. CONCLUSION: Clinical assessment of appropriate ventilation is difficult and often inaccurate during emergency neonatal transport. Improved monitoring of respiratory function to guide clinical status during transport is necessary. More investigation and implementation are urgently needed.

Thyroid function in late preterm infants in relation to mode of delivery and respiratory support.

The relationship between thyroid function, mode of delivery, and illness in infants 34-36 weeks' gestation has not been well studied. We hypothesized that infants born by cesarean delivery and those with increased illness would have a reduction in thyroxine (T4) following birth. Total T4 and thyroid-stimulating hormone were obtained at birth (Time 1) and between days 2 and 5 (Time 2). The study sample included 129 infants 34-36 weeks' gestation. There were no differences in total T4 between infants born by cesarean or vaginal delivery (p=0.18), or between those requiring respiratory support compared to infants not requiring respiratory support (p=0.09). At Time 2, 93% of the study population had a total T4 below one standard error of the reference laboratory mean. In our study sample, despite many infants having a low total T4, there was no association between total T4 levels, respiratory support, or mode of delivery.

The influence of family characteristics on perinatal decision making.

OBJECTIVE: To determine whether parental characteristics affect estimates of best interests and intervention decisions for preterm infants. DESIGN AND METHODS: The study consisted of an anonymous questionnaire given to nurses, physicians, and students. The study included scenarios of 3 sets of parents, including a 16-year-old teenager, a couple who were lawyers, and a couple with a history of in vitro fertilization, about to deliver at 22 5/7 weeks, 24 weeks, or 27 5/7 weeks. Respondents were asked whether active intervention is in the infant's best interests and whether they would comply with family decisions. RESULTS: A total of 1105 questionnaires were sent out, with 829 respondents in Canada and the United States. At 22 5/7 weeks' gestation, 21% of the respondents thought that resuscitation was in the infant's best interest; among respondents who did not agree, 59% would intervene if the parents wished. At 27 5/7 weeks' gestation, 95% of respondents thought that resuscitation was in the infant's best interest, yet 34% would accept comfort care. Estimates of best interest, and willingness to comply, varied significantly by parental characteristics. At 22 5/7 weeks' gestation, 17% of respondents believed that resuscitation was in the best interest of the teenaged mother's infant compared with 26% of respondents who believed that resuscitation was in the best interest for the infants of the others; this difference persisted at 24 weeks. At 22 5/7 and at 24 weeks' gestation, compliance with active care despite believing that it not in the infant's best interest was significantly more frequent for the in vitro fertilization couple and the lawyers than for the teenaged mother. At 27 weeks' gestation, more than 93% of respondents complied for all parents. CONCLUSIONS: Caregivers frequently are ready to intervene actively, or not, despite believing that it is against the infant's best interest. Willingness to do so varies according to parental characteristics.

Mode of delivery and outcomes in very low-birth-weight infants in the vertex presentation.

We sought to determine the relationship between mode of delivery and neonatal outcomes in infants <1500 g in a vertex presentation. This was a retrospective cohort study of singleton, vertex-presenting infants weighing <1500 g in a level III neonatal intensive care unit between July 1993 and July 2006. Infants were divided into vaginal or cesarean delivery, and outcomes were compared with univariable and multivariable analysis. Of the 937 infants that met inclusion criteria, 402 (42.9%) underwent cesarean delivery. After controlling for potential confounding variables, there was no increased odds of death (odds ratio [OR] = 1.6: 95% confidence interval [CI] 0.8 to 3.0), severe intraventricular hemorrhage (IVH; OR = 1.2: 95% CI 0.7 to 1.2), necrotizing enterocolitis (OR = 0.82: 95% CI 0.35 to 1.9), or sepsis (OR = 0.79: 95% CI 0.44 to 13) in the vaginally delivered group compared with the cesarean group. In a post hoc analysis, this study had 80% power to detect an absolute difference in death or severe IVH of 6% between study groups, with an α of 0.05. In our population of very low-birth-weight infants, there was no association between mode of delivery and neonatal outcomes.

Forgotten parent: NICU paternal emotional response.

PURPOSE: To evaluate and compare the presence of perceived paternal stress and depressive symptomatology in fathers of preterm infants over time. SUBJECTS: Fathers of NICU infants born before 30 weeks of gestation. DESIGN: Prospective convenience sample. METHODS: Consenting fathers were given 2 self-report questionnaires: Center for Epidemiologic Studies-Depression Scale (CES-D) and Parent Stressor Scale: Infant Hospitalization (PSS:IH) on 7th (time 1), 21st (time 2), and 35th (time 3) days of life. Objective measurement of illness severity was quantified by Score for Neonatal Acute Physiology. Statistical methods included generalized linear estimating equation and mixed linear modeling. MAIN OUTCOME MEASURES: Stress and depressive symptomatology in fathers of preterm infants. RESULTS: Stress scores (PSS:IH) were unchanged over time (P = .62) indicating that fathers (n = 35) remain significantly stressed. Individual subcomponents of stress (parent role alteration, infant appearance/behavior, NICU sights/sounds) also remained constant over the study period (P = .05 for each). Stress scores over time were not modified by demographic characteristics (marriage, education, insurance). Mean depressive symptomatology scores (CES-D) decreased over time (P = .04). The percentage of fathers with elevated CES-D scores (>16) decreased from a baseline 60% but did not diminish between times 2 (39%) and 3 (36%). Parent Stressor Scale: Infant Hospitalization stress scores were correlated with CES-D depressive symptomatology scores (P < .01). Socioeconomic factors influenced initial CES-D scores, but only marriage ameliorated subsequent changes in measurements. Objective measurement of infant illness (Score for Neonatal Acute Physiology) did not influence paternal CES-D or PSS:IH scores. CONCLUSION: Fathers of premature infants in a medical NICU demonstrated elevated levels of stress that persisted across time for all domains of measured stress. Paternal self-reported stress and depressive symptomatology was independent of infant illness. One third of fathers had persistently elevated CES-D scores. If these findings are representative of general NICU population, then the emotional needs of our fathers are not being fully addressed.

Effect of antenatal corticosteroids on survival for neonates born at 23 weeks of gestation.

OBJECTIVE: To estimate if exposure to antenatal corticosteroids was associated with decreased rate of death in neonates born at 23 weeks of gestation. METHODS: This is a retrospective cohort study performed at three tertiary centers of neonates born at 23 weeks of gestation between 1998 and 2007. Stillbirths, voluntary terminations, or parental elected nonresuscitations were excluded. Clinical and demographic variables were examined to determine possible confounding variables. A multivariable logistic regression model was used to assess the effect of steroids on the odds of death after adjustment for these confounders. RESULTS: The sample included 181 neonates. Of the multiple variables examined (institution, race, diagnosis, illicit drug use, antibiotics, assisted reproduction, birth weight, gender, and route of delivery), only multiple gestations were significantly associated (P

Stress in fathers of surgical neonatal intensive care unit babies.

The purpose of this study was to identify and measure components of perceived stress in fathers of infants in a surgical neonatal intensive care unit (NICU). The Parent Stressor Scale: Infant Hospitalization (PSS:IH) was used to assess perceived stress in 22 fathers. Paternal stress was highest in the domains of "Parental Role Alteration" and "Infant Appearance and Behavior." "Sights and Sounds" did not appear to be associated with self-reported stress. This study demonstrates elevated levels of perceived stress among fathers of surgical NICU babies. Attention to fathers may be assisted by findings.

Homocysteine levels in preterm infants: is there an association with intraventricular hemorrhage? A prospective cohort study.

BACKGROUND: The purpose of this study was to characterize total homocysteine (tHcy) levels at birth in preterm and term infants and identify associations with intraventricular hemorrhage (IVH) and other neonatal outcomes such as mortality, sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, and thrombocytopenia. METHODS: 123 infants < 32 weeks gestation admitted to our Level III nursery were enrolled. A group of 25 term infants were enrolled for comparison. Two blood spots collected on filter paper with admission blood drawing were analyzed by a high performance liquid chromatography (HPLC) method. Statistical analysis included ANOVA, Spearman's Rank Order Correlation and Mann-Whitney U test. RESULTS: The median tHcy was 2.75 micromol/L with an interquartile range of 1.34 - 4.96 micromol/L. There was no difference between preterm and term tHcy (median 2.76, IQR 1.25 - 4.8 micromol/L vs median 2.54, IQR 1.55 - 7.85 micromol/L, p = 0.07). There was no statistically significant difference in tHcy in 31 preterm infants with IVH compared to infants without IVH (median 1.96, IQR 1.09 - 4.35 micromol/L vs median 2.96, IQR 1.51 - 4.84 micromol/L, p = 0.43). There was also no statistically significant difference in tHcy in 7 infants with periventricular leukomalacia (PVL) compared to infants without PVL (median 1.55, IQR 0.25 - 3.45 micromol/L vs median 2.85, IQR 1.34 - 4.82 micromol/L, p = 0.07). Male infants had lower tHcy compared to female; prenatal steroids were associated with a higher tHcy. CONCLUSION: In our population of preterm infants, there is no association between IVH and tHcy. Male gender, prenatal steroids and preeclampsia were associated with differences in tHcy levels.

Increase in platelet count is not affected by the platelet yield of single donor pheresed platelets.

OBJECTIVES: To determine if the rise in platelet count after transfusion in neonates is associated with platelet yield of the pheresed platelet unit. STUDY DESIGN: Cohort study of infants in a level 3 Neonatal Intensive Care Unit that received single donor platelets (SDP). Platelet rise in infants were compared between 3 groups: underproduction, destruction, and idiopathic. The main outcome variable studied was the rise in platelet count posttransfusion. Statistical analysis included analysis of variance, Pearson correlation, and multivariate linear regression. RESULTS: The gestational age was 28+/-4.5 weeks. The platelet yield was 4.2+/-0.7 (x10(11)) and resultant platelet rise was 71+/-58.6x1000/mm3. Infants with platelet underproduction (n=30) had a greater rise compared with infants with platelet destruction (n=51) after transfusion (95.3+/-58 vs. 59.6+/-57.5x1000/mm3, P=0.01). After controlling for confounding variables, there was no correlation between the platelet yield and platelet rise, but the etiology of the thrombocytopenia remained associated with increased platelet rise. CONCLUSIONS: There was no association between platelet yield of SDP and platelet rise. Infants with thrombocytopenia related to platelet underproduction had a greater rise in platelets after transfusion compared with those with platelet destruction, independent of yield or volume of the SDP transfusion.

Ghrelin and cholecystokinin in term and preterm human breast milk.

AIM: To determine whether ghrelin and cholecystokinin (CCK) are present in significant quantities in term and preterm human breast milk, and to identify their source. METHODS: Samples were collected from 10 mothers who delivered term infants and 10 mothers who delivered preterm infants. Estimated fat content was measured. Ghrelin and CCK levels were measured in whole and skim breast milk samples using radioimmunoassays (RIA). Reverse transcriptase-polymerase chain reaction (RT-PCR) was performed using RNA from human mammary epithelial cells (hMECs) and mammary gland with primers specific to ghrelin. RESULTS: The median ghrelin level in whole breast milk was 2125 pg/ml, which is significantly higher than normal plasma levels. There was a direct correlation between whole milk ghrelin levels and estimated milk fat content (r=0.84, p<0.001). Both the mammary gland and hMECs produced ghrelin. While CCK was detected in some samples, levels were insignificant. Infant gestational age, birthweight, maternal age, and maternal pre-pregnancy body mass index did not significantly affect the results. CONCLUSION: Ghrelin, but not CCK, is present in breast milk. Since the mammary gland produces ghrelin message, and ghrelin levels in breast milk are higher than those found in plasma, we conclude that ghrelin is produced and secreted by the breast.