Understanding pediatric palliative care within interdisciplinary palliative programs: a qualitative study.

PURPOSE: To describe the process of delivery of pediatric palliative care from the perspective of a pediatric interdisciplinary team and the children's parents. METHODS: A qualitative descriptive case study was conducted. Purposeful sampling took place within a specialized pediatric palliative care Unit in Madrid (Spain), located at the Niño Jesus Hospital. The study participants included a specialized pediatric palliative care team from Madrid's pediatric palliative care program, other professional teams involved in interdisciplinary care and parents of children under pediatric palliative care. Data were collected via semi-structured interviews, focus groups and researchers' field notes. A thematic analysis was performed. RESULTS: This study included 28 participants (20 women, 8 men), of whom 18 were professionals who belonged to the pediatric palliative care interdisciplinary team, 4 professionals were from other units that collaborated with the pediatric palliative care, and 6 were parents (5 women, 1 man). The mean age of the pediatric palliative care members was 38.2 years (SD ± 7.9), that of the collaborating professionals was 40.5 (SD ± 6.8), and that of the parents was 44.2 (SD ± 5.4). Two main themes emerged: a) Pediatric palliative care has a distinct identity, associated with life. It represents the provision of special care in highly complex children, in the context of the home, far from the hospital environment; b) The team is key: its interdisciplinary organization provides a more comprehensive view of the child and their family, fosters communication among professionals, and improves coordination with other services involved in the care of children. The mindset shift experienced by ID-PPC professionals towards a palliative approach makes them more sensitive to the needs of their patients and leads them to develop specific skills in areas such as communication, decision-making, and adaptability that were identified as differentiating aspects of pediatric palliative care. CONCLUSIONS: Describing pediatric palliative care from the professional and parental perspective helps to establish realistic and comprehensive goals for the care of children and their parents. The findings of this study may help with the establishment of a pediatric palliative care team, as a necessary organizational change in a health care system that cares for children with complex and life-threatening conditions. Promoting training in pediatric palliative care, prioritizing more horizontal organizations, providing tools and spaces for coordination and communication between professionals from different services, together with the creation of a position of case coordinator in the care process of children could enhance the understanding of pediatric palliative care services.

The Emotional Experience of Caring for Children in Pediatric Palliative Care: A Qualitative Study among a Home-Based Interdisciplinary Care Team.

The healthcare providers caring for children with life-threatening illnesses experience considerable compassion fatigue. The purpose of this study was to describe the feelings and emotions of professionals working in an interdisciplinary pediatric palliative home care team. A qualitative case study was conducted, comprising 18 participants. A purposeful sampling technique approach was used including the home-based interdisciplinary pediatric palliative team. Data were collected via semi-structured interviews and researchers' field notes. A thematic analysis was performed. Two themes emerged: (a) changing life for the better, which described how professionals value life more and helping children and families provides compassion satisfaction, which is comforting and explains their dedication to care; (b) adverse effects of work highlighted the emotional burden of caring for children with life-limiting or life-threatening illnesses, which can affect their job satisfaction and may lead to burnout, showing how experiencing in-hospital child deaths with suffering leads professionals to develop an interest in specializing in pediatric palliative care. Our study provides information on possible causes of emotional distress in professionals caring for children with life-threatening illnesses and highlights strategies that can help them to reduce their distress.

Growth of Very Low Birth Weight Infants Who Received a Liquid Human Milk Fortifier: A Randomized, Controlled Multicenter Trial.

OBJECTIVES: To evaluate growth (weight, length, head circumference, and knee-heel length [KHL]) in very low birth weight (VLBW) infants (500-1500 g) who received human milk with a liquid fortifier (LHMF) with high protein and fatty acid content versus a traditional powder fortifier (PHMF) for 45 days or until discharge. METHODS: This was a multicenter, randomized, controlled trial. An intention-to-treat analysis was performed to determine adverse events and withdrawal causes. We also performed an efficacy analysis involving the infants who completed at least 2 weeks of study. RESULTS: Of the 158 infants enrolled in the study, 146 completed at least 2 weeks, and 125 completed the entire study. The biodemographic characteristics were similar between groups, with no differences in increments of weight (22.9 vs 22.7 g kg-1 day-1), length (1.03 vs 1.09 cm/week), head circumference (0.91 vs 0.90 cm/week), or KHL (3.6 vs 3.3 mm/week). The KHL increment was greater in infants weighing >1 kg receiving LHMF (3.7 vs 3.2 mm/week, P = 0.027). Although there were no significant differences in serious adverse events, the incidence difference of the composite outcome death/necrotizing enterocolitis between groups warrants attention (1.3% with LHMF and 8.1% with PHMF). CONCLUSION: There were no differences in the overall growth between VLBW infants receiving either fortifier.

Trends in Perinatal Practices and Neonatal Outcomes of Very Low Birth Weight Infants during a 16-year Period at NEOCOSUR Centers.

OBJECTIVE: To describe trends in mortality, major morbidity, and perinatal care practices of very low birth weight infants born at NEOCOSUR Neonatal Network centers from January 1, 2001, through December 31, 2016. STUDY DESIGN: A retrospective analysis of prospectively collected data from all inborn infants with a birthweight of 500-1500 g and 23-35 weeks of gestation. RESULTS: We examined data for 13 987 very low birth weight infants with a mean birth weight of 1081 ± 281 g and a gestational age of 28.8 ± 2.9 weeks. Overall mortality was 26.8% without significant changes throughout the study period. Decreases in early onset sepsis from 6.3% to 2.8% (P <.001), late onset sepsis from 21.1% to 19.5% (P = .002), retinopathy of prematurity from 21.3% to 13.8% (P <.001), and hydrocephalus from 3.8% to 2.4% (P <.001), were observed. The incidence for bronchopulmonary dysplasia decreased from 17.3% to 16% (P = .043), incidence of severe intraventricular hemorrhage was 10.4%, necrotizing enterocolitis 11.1%, and periventricular leukomalacia 3.8%, and did not change over the study period. Administration of antenatal corticosteroids increased from 70.2% to 82.3% and cesarean delivery from 65.9% to 75.4% (P <.001). The use of conventional mechanical ventilation decreased from 67.7% to 63.9% (P <.001) and continuous positive airway pressure use increased from 41.3% to 64.3% (P <.001). Survival without major morbidity increased from 37.4% to 44.5% over the study period (P <.001). CONCLUSIONS: Progress in perinatal and neonatal care at network centers was associated with an improvement in survival without major morbidity of very low birth weight infants during a 16-year period. However, overall mortality remained unchanged.

Growth restriction increases the risk of bronchopulmonary dysplasia, death, and sepsis in twins of 30 weeks or less of gestation. / Restricción de crecimiento aumenta el riesgo de displasia broncopulmonar, muerte y sepsis en gemelos de 30 o menos semanas de gestación.

INTRODUCTION: Multiple factors influence the risk of morbidity and mortality of premature infants with intrauterine growth restriction (IUGR). The comparison of twins with different intrauterine growth allows evaluating the effect of the restriction, excluding maternal factors and prenatal mana gement. Our objective was to assess the effect of IUGR on acute and chronic morbidity, and mortality of extreme preterm twins. PATIENTS AND METHOD: Twins weighing less than 1500 grams and gesta tion equal to or less than 30 weeks, of the Neocosur Network. Separate analyses were performed on concordant twin pairs, and on mild and severe discordant twins, evaluating the effect of IUGR on morbidity and mortality. A multivariate analysis was performed in order to establish the impact of this effect. RESULTS: 459 twin pairs, 227 concordant twins, 110 of mild discordance, and 122 of severe discordance. Among the concordant ones, there was only a difference in oxygen uptake at 36 weeks. In those of mild discordance, the smaller twin presented a lower frequency of hyaline membrane disease and required fewer doses of surfactant, but had a higher risk of bronchopulmonary dysplasia (BPD) or death. In severe discordant twins, the smaller one presented higher mortality, sepsis, use and permanence in mechanical ventilation, despite the lower frequency of hyaline membrane disease. In multiple regression analysis, the combined risk of BPD or death was higher in the smaller twin and of severe discordance. CONCLUSION: In discordant twins, the acute respiratory pathology was more frequent in the larger one, although the risk of BPD or death was higher in the one with IUGR.

The impact of home-based physical rehabilitation program on parents' experience with children in palliative care: a qualitative study.

BACKGROUND: Pediatric palliative care programs aim to improve the quality of life of children with severe life-threatening illnesses, and that of their families. Although rehabilitation and physical therapy provides a valuable tool for the control of symptoms, it has been poorly researched to date. Since the family represents such a fundamental support in these cases, it is important to deepen our understanding regarding the value of implementing rehabilitation programs from the parents' perspective. AIM: The aim of this paper was to explore parents' experiences regarding the implementation of a physical rehabilitation program in pediatric palliative care. DESIGN: A qualitative methodology was chosen. SETTING: The unit of pediatric palliative care at the Hospital Niño Jesús (Madrid, Spain). POPULATION: The inclusion criteria were: 1) parents of children, irrespective of their diagnosis; 2) integrated within the program of palliative care at the time of study; 3) aged between 0-18 years; 4) must be receiving Home-Based Rehabilitation Program by the Pediatric Palliative Care team. Fourteen parents were included. METHODS: Purposeful sampling method was implemented. Data collection consisted of unstructured and semi-structured interviews. A thematic analysis was performed to interpret transcripts. Guidelines for conducting qualitative studies established by the Consolidated Criteria for Reporting Qualitative Research were followed. RESULTS: Three main themes were identified: 1) the meaning of physical rehabilitation to parents; 2) physical rehabilitation as an opportunity for patients to stay in their home environment; and 3) home-based physical rehabilitation as part of the families' social environment. CONCLUSIONS: The main needs of a home physical rehabilitation program are to decrease pain and suffering, together with improving family education and training. CLINICAL REHABILITATION IMPACT: The experience of rehabilitation programs at home is essential in order to improve both the quality of life and the quality of care of affected children and parents.

Restricción de crecimiento aumenta el riesgo de displasia broncopulmonar, muerte y sepsis en gemelos de 30 o menos semanas de gestación / Growth restriction increases the risk of bronchopulmonary dysplasia, death, and sepsis in twins of 30 weeks or less of gestation

INTRODUCCIÓN: Múltiples factores influyen en el riesgo de morbimortalidad del prematuro con restricción del crecimiento intrauterino (RCIU). La comparación de gemelos con crecimiento intrauterino discordante permite evaluar su efecto, excluyendo factores maternos y manejo prenatal. Nuestro objetivo fue evaluar el efecto de la RCIU sobre la morbilidad aguda, crónica y mortalidad, en parejas de recién nacidos gemelares prematuros extremos. PACIENTES Y MÉTODO: Gemelos menores de 1500 g y 30 semanas de gestación, de la Red Neocosur. Se realizaron análisis separados de pares de gemelos concordantes, discordantes leves y severos, evaluando el efecto de la RCIU sobre morbi-mortalidad. Se realizó análisis multivariado para establecer magnitud del efecto. RESULTADOS: 459 pares de gemelos, 227 concordantes, 110 discordantes leves y 122 severos. Entre los concordantes solo hubo diferencia en uso de oxígeno a las 36 semanas. En discordantes leves, el menor tuvo menos enfermedad de membrana hialina y requirió menos dosis de surfactante, pero tuvo un mayor riesgo de Displasia broncopulmonar (DBP) o muerte. En discordantes severos, el menor presentó mayor mortalidad, sepsis, utilización y permanencia en ventilación mecánica, pese a menor frecuencia de enfermedad de membrana hialina. En regresión múltiple, el riesgo combinado de DBP o muerte fue mayor en gemelo menor y discordante severo. CONCLUSIÓN: En gemelos discordantes, la patología respiratoria aguda fue más frecuente en el gemelo mayor, aunque el riesgo de DBP o muerte fue mayor en el gemelo con RCIU.

INTRODUCTION: Multiple factors influence the risk of morbidity and mortality of premature infants with intrauterine growth restriction (IUGR). The comparison of twins with different intrauterine growth allows evaluating the effect of the restriction, excluding maternal factors and prenatal mana gement. Our objective was to assess the effect of IUGR on acute and chronic morbidity, and mortality of extreme preterm twins. PATIENTS AND METHOD: Twins weighing less than 1500 grams and gesta tion equal to or less than 30 weeks, of the Neocosur Network. Separate analyses were performed on concordant twin pairs, and on mild and severe discordant twins, evaluating the effect of IUGR on morbidity and mortality. A multivariate analysis was performed in order to establish the impact of this effect. RESULTS: 459 twin pairs, 227 concordant twins, 110 of mild discordance, and 122 of severe discordance. Among the concordant ones, there was only a difference in oxygen uptake at 36 weeks. In those of mild discordance, the smaller twin presented a lower frequency of hyaline membrane disease and required fewer doses of surfactant, but had a higher risk of bronchopulmonary dysplasia (BPD) or death. In severe discordant twins, the smaller one presented higher mortality, sepsis, use and permanence in mechanical ventilation, despite the lower frequency of hyaline membrane disease. In multiple regression analysis, the combined risk of BPD or death was higher in the smaller twin and of severe discordance. CONCLUSION: In discordant twins, the acute respiratory pathology was more frequent in the larger one, although the risk of BPD or death was higher in the one with IUGR.

Situación socioeconómica familiar y neurodesarrollo de prematuros de muy bajo peso al nacer a los dos años de edad / Family socioeconomic situation and neurodevelopment of very low birth weight premature babies at two years of age

La relación entre neurodesarrollo y contexto social ha sido poco estudiada. Este artículo buscó caracterizar a las familias donde crecen los prematuros de muy bajo peso al nacer con nivel socioeconómico bajo y medio bajo y explorar la posible asociación entre las características socio-familiares y el neurodesarrollo a los dos años. Métodos: Prematuros en seguimiento de un hospital público de Santiago de Chile nacidos entre 2009 y 2012 con encuestas retrospectivas sobre aspectos familiares y sociales, y datos de la evolución clínica fueron analizados. Se evaluó la relación entre los datos biológicos y sociales con neurodesarrollo normal o en déficit. Resultados: 162 casos fueron analizados, 32 por ciento fueron considerados con déficit de neurodesarrollo. Las variables biológicas asociadas con el déficit de neurodesarrollo fueron peso al nacer menor a 1000 g. (p < 0,001), uso de ventilación mecánica (p < 0,001), oxígeno dependencia a las 36 semanas edad corregida (EC) (p < 0,001), sepsis tardía (p < 0,001), hemorragia intra-cerebral (p < 0,05), leucomalacia (p < 0,05), hidrocefalia (p < 0,05), convulsiones en período neonatal (p < 0,01) y enterocolitis necrotizante (p < 0,01). Los padres contaban con educación media y superior y se mantuvieron como parejas estables durante el período evaluado. El problema de consumo de alcohol a nivel familiar se asoció con déficit de neurodesarrollo (p<0,05). Conclusiones: Las familias en general tienen los recursos socioeconómicos y de estructura relacionados con desarrollo infantil. Los determinantes biológicos pesaron más que los sociales para el desarrollo infantil.(AU)

Research is scarce on the association between neurodevelopment and social context. This paper aimed to characterize the families of children born preterm, with very low birthweight and of low socioeconomic status, and to explore the relation between socio-familial variables and neurodevelopment when children were two years old. Methods: We used a sample of infants who attended the well-child visits at a public hospital in Santiago de Chile, who were born between 2009 and 2012. Data came from the medical register and a retrospective survey applied to the children's primary caregivers, which covered the social variables. We analyzed the relation between biological and social characteristics of children and their neurodevelopmental deficit. Results: Out of 162 cases, 2 percent were considered to have neurodevelopmental deficit. The biological variables related to neurodevelopmental deficit were extreme low birthweight (p < 0.001), mechanic ventilation (p < 0.001), oxygen therapy at week 36 (p < 0.001), late-onset sepsis (p < 0.001), intraventricular hemorrhage (p < 0.05), leukomalacia (p < 0.05), hydrocephalus (p < 0.05), seizures (p < 0.01) and necrotising enterocolitis (p < 0.01). Most parents had at least complete secondary education and remained and as stable couple during the observed period. Problematic alcohol use by any member of the family was negatively related to the children's neurodevelopmental deficit (p<0.05). Conclusion: Most families have the socioeconomic resources and the family structure typically related with child development. The biological determinants of child development were more important than its social determinants.(AU)

Evaluación del consumo de antimicrobianos en una Unidad de Neonatologia: un trabajo en equipo para promover el uso racional de antimicrobianos / Evaluation of antimicrobial consumption in a Neonatology Unit: a team work to promote the rational use of antibiotics

Resumen Antecedentes: Los antimicrobianos (ATM) son uno de los medicamentos más utilizados en recién nacidos (RN) hospitalizados. El uso indiscriminado de ATM trae consecuencias negativas como son el predominio de bacterias resistentes a los ATM usualmente utilizados y asociaciones individuales a morbilidad relevante como son la displasia broncopulmonar, enterocolitis necrosante, sepsis tardía y/o muerte. Objetivo: Registrar y evaluar las tendencias del uso de ATM a lo largo del tiempo en RN hospitalizados en el Servicio de Neonatología (SRN) del Complejo Asistencial Dr. Sótero del Río, con el fin de objetivar los cambios en la práctica habitual de la indicación de ATM. Un objetivo secundario fue evaluar el impacto de estas conductas sobre la resistencia antimicrobiana. Métodos: Estudio de cohorte, prospectivo, observacional, unicéntrico, en todos los pacientes hospitalizados entre enero de 2011 y diciembre de 2014. Se registró el peso al nacer, días de hospitalización, indicación y días de uso de ATM para cada paciente. El uso de ATM fue cuantificado por medio de distintas tasas: días de indicación de un o más ATM para el consumo global (TUA), sumatoria total de días de uso (STUA) como para los ATM más frecuentemente utilizados. Cada tasa calculada por 100 días hospitalizados. Además, se registró la susceptibilidad antimicrobiana de las bacterias más frecuentemente aisladas en nuestro servicio: Staphylococcus coagulasa negativa (SCN) y bacilos gramnegativos (BGNs). Resultados: El 34,7% de los pacientes hospitalizados recibió algún tipo de antimicrobiano, correspondiendo 32,3% a antibacterianos. El ATM más utilizado fue ampicilina (20,2% del total) y luego cefadroxilo (11,6%). El TUA no cambió entre 2011 y 2014. La STUA disminuyó en 10,7% entre 2011 y 2014 (p < 0,05). En el análisis por rangos de peso, en el grupo < 750 g disminuyó la tendencia de uso de vancomicina (descenso de uso en 9,9%) y un aumento de 18,8% para metronidazol. Por otra parte, hubo un aumento en el uso del régimen de piperacilina/tazobactam en el grupo > 1.500 g. Al evaluar la susceptibilidad antimicrobiana, hubo una disminución de la susceptibilidad a cloxacilina en SCN entre 2011 y 2014 desde 27 a 10,3%, respectivamente. Para BGN hubo una disminución desde 76,9 a 40,5% en la susceptibilidad a cefalosporinas de tercera generación, principalmente debido a Klebsiella pneumoniae que pasó a ser el BGN predominante, con un aumento de 6,7 a 50% en los años 2011 y 2014, respectivamente. Para Klebsiella pneumoniae la susceptibilidad a cefalosporinas de tercera generación descendió desde 77 a 22%. Por último, amikacina mostró una actividad sobre 85% en todos los BGNs entre 2011 y 2014. Conclusiones: Es recomendable planificar y mantener un registro continuo del consumo de ATM tanto como terapia y profilaxis, idealmente llevar el TUA, el STUA y siendo categorizado por tipo de ATM y rango de peso de los RN. En forma concomitante, es de considerable importancia analizar y evaluar la susceptibilidad de microorganismos. Es esencial que un equipo interdisciplinario prepare este registro, y que continuamente proporcione retroalimentación a los profesionales que mantienen el funcionamiento de las unidades de cuidados neonatales.

Background: Antibiotics (ATB) are drugs widely used in hospitalized newborns. The indiscriminate use of ATBs promote the rise of resistant bacteria to the most commonly indicated antimicrobials. In addition, ATB prescription presents associations to morbidity, such as bronchopulmonary dysplasia, necrotizing enterocolitis, late sepsis and even death. All of the above leads to an increase in health care costs. Aim: To record and to evaluate trends of antibiotic use over time in hospitalized NB in the Neonatology Unit at Dr. Sótero del Río Hospital, in order to objectify the changes in the usual practice of the ATM indication. A secondary objective was to assess its impact on antimicrobial resistance. Methods: Cohort, observational, prospective unicenter study which included all hospitalized patients between January 2011 and December 2014. Birth weight, hospitalization days, ATB indication and days of ATB use were recorded for each patient. The use of ATB was quantified by means of different rates; days of indication of one or more ATBs for global consumption (RUA), total sum of days of use (TSUA) and for the most frequently used ATBs. Each calculated rate for 100 days hospitalized. In addition, the antimicrobial susceptibility of the most frequently isolated bacteria in our service: coagulase-negative Staphylococcus (SCN) and Gram-negative bacilli (BGN) were recorded continuously. Results: The 34.7% of the hospitalized patients received some type of antimicrobial agent. ATBs were 32.3% of medicines used. The most widely used was ampicillin (with 20.2% of the total) and cefadroxyl (with 11.6%). The RUA did not change during the study time, but STUA decreased by 10.7% between 2011 and 2014 with p < 0.05. When subgroup analyzes were divided by weight ranges, in the < 750 g group, the use of vancomycin decreased in use by 9.9% and an increase of 18.8% for metronidazole was observed. On the other hand, there was an increase in the use of the piperacillin-tazobactam regimen in the range > 1,500 g. When evaluating antimicrobial susceptibility, there was a decrease in susceptibility for oxacillin in SCN between 2011 and 2014 from 27% to 10.3% respectively. In addition, for Gram negative there was a decrease from 76.9% to 40.5% in susceptibility to third generation cephalosporins, mainly due to Klebsiella pneumoniae, which became the predominantly isolated BGN with an increase of 6.7% to 50% between 2011 and 2014, respectively. For K. pneumoniae the loss of susceptibility to third generation cephalosporins decreased from 77% to 22%. Finally, amikacin showed an activity over 85% in all BGNs between 2011 and 2014. Conclusions: It is advisable to plan and to maintain a continuous record of ATB consumption, as well as therapy and prophylaxis, being categorized by ATB type and range of newborn weight. It is of considerable importance to analyze and to evaluate the susceptibility of microorganisms. It is essential that an interdisciplinary team prepare this recording, and to continuously provide feedback to professionals who maintain the functioning of neonatal care units.

[Evaluation of antimicrobial consumption in a Neonatology Unit: a team work to promote the rational use of antibiotics]. / Evaluación del consumo de antimicrobianos en una Unidad de Neonatologia: un trabajo en equipo para promover el uso racional de antimicrobianos.

BACKGROUND: Antibiotics (ATB) are drugs widely used in hospitalized newborns. The indiscriminate use of ATBs promote the rise of resistant bacteria to the most commonly indicated antimicrobials. In addition, ATB prescription presents associations to morbidity, such as bronchopulmonary dysplasia, necrotizing enterocolitis, late sepsis and even death. All of the above leads to an increase in health care costs. AIM: To record and to evaluate trends of antibiotic use over time in hospitalized NB in the Neonatology Unit at Dr. Sótero del Río Hospital, in order to objectify the changes in the usual practice of the ATM indication. A secondary objective was to assess its impact on antimicrobial resistance. METHODS: Cohort, observational, prospective unicenter study which included all hospitalized patients between January 2011 and December 2014. Birth weight, hospitalization days, ATB indication and days of ATB use were recorded for each patient. The use of ATB was quantified by means of different rates; days of indication of one or more ATBs for global consumption (RUA), total sum of days of use (TSUA) and for the most frequently used ATBs. Each calculated rate for 100 days hospitalized. In addition, the antimicrobial susceptibility of the most frequently isolated bacteria in our service: coagulase-negative Staphylococcus (SCN) and Gram-negative bacilli (BGN) were recorded continuously. RESULTS: The 34.7% of the hospitalized patients received some type of antimicrobial agent. ATBs were 32.3% of medicines used. The most widely used was ampicillin (with 20.2% of the total) and cefadroxyl (with 11.6%). The RUA did not change during the study time, but STUA decreased by 10.7% between 2011 and 2014 with p < 0.05. When subgroup analyzes were divided by weight ranges, in the < 750 g group, the use of vancomycin decreased in use by 9.9% and an increase of 18.8% for metronidazole was observed. On the other hand, there was an increase in the use of the piperacillin-tazobactam regimen in the range > 1,500 g. When evaluating antimicrobial susceptibility, there was a decrease in susceptibility for oxacillin in SCN between 2011 and 2014 from 27% to 10.3% respectively. In addition, for Gram negative there was a decrease from 76.9% to 40.5% in susceptibility to third generation cephalosporins, mainly due to Klebsiella pneumoniae, which became the predominantly isolated BGN with an increase of 6.7% to 50% between 2011 and 2014, respectively. For K. pneumoniae the loss of susceptibility to third generation cephalosporins decreased from 77% to 22%. Finally, amikacin showed an activity over 85% in all BGNs between 2011 and 2014. CONCLUSIONS: It is advisable to plan and to maintain a continuous record of ATB consumption, as well as therapy and prophylaxis, being categorized by ATB type and range of newborn weight. It is of considerable importance to analyze and to evaluate the susceptibility of microorganisms. It is essential that an interdisciplinary team prepare this recording, and to continuously provide feedback to professionals who maintain the functioning of neonatal care units.

[Nutrition in the preterm hospitalized newborn. Recommendations of the Chilean Neonatology Branch, Chilean Pediatric Society]. / Nutrición intrahospitalaria del prematuro. Recomendaciones de la Rama de Neonatología de la Sociedad Chilena de Pediatría.

Recommendations based on current publications are presented for postnatal preterm nutrition, depending on birth weight: less 1000g, between 1000 and 1500g, and above 1500g, as well for the development periods: adaptation, stabilisation, and growth. A review is also presented on the nutritional management of morbidities that affect or may affect nutrition, such as: osteopenia, bronchopulmonary dysplasia, patent ductus arteriosus, red cell transfusion, and short bowel syndrome.

Composición de leche materna en madres de recién nacidos de pretermino menor a 33 semanas / Composition of breast milk in mothers of preterm infants less than 33 weeks

Introducción: La leche materna es recomendada como el alimento más adecuado en el primer año de vida, ya que proporciona los sustratos necesarios para el crecimiento del recién nacido. En los últimos años se ha ampliado el estudio de la composición de la leche materna y su relación sobre el efecto de la nutrición en los recién nacidos de pre termino. Objetivo: investigar la composición de macronutrientes en leche materna de recién nacidos prematuros (<33 semanas). Métodos: análisis de contenido de proteínas, carbohidratos y lípidos en muestras de leche materna de recién nacidos prematuros (menor que 33 semanas) recolectadas longitudinalmente, según protocolo de estudio. Resultados: Se presenta variabilidad en muestras recolectadas en tres semanas consecutivas de edad posnatal, dando contenido de proteína que vario de 1,34g/dl (DS +/- 0.11) a 1,05 g/dl (DS +/- 0.10) con (p menor que 0,05). Hidratos de carbono vario de 6,20 g/dl (DS +/- 0.17) a 6.77 g/dl (DS+/-±0.22) con (p menor que 0,05). Lípidos vario de 4.10 g/dl (DS +/- 0.39) a 4.33 g/dl (DS +/- 0.26) con (p=0,075).Discusión: Estos datos proporcionan una visión más detallada de la ingesta de nutrientes de los recién nacidos prematuros alimentados con leche materna.

Introduction: Breast milk is recommended as the most suitable food in the first year of life, as it provides the substrates required for growth of the newborn. In recent years it has expanded the study of the composition of breast milk and their relationship on the effect of nutrition in preterm infants. Objective: To investigate the macronutrient composition of breast milk in preterm infants (33 weeks). Methods: Analysis of protein, carbohydrates and lipids in breast milk samples from preterm (<33 weeks) collected longitudinally, according study protocol. Results: We present variability in samples collected in three consecutive weeks of postnatal age, giving protein content ranged from 1.34 g / dl (SD +/- 0.11) to 1.05 g / dl (SD +/- 0.10) with (p < 0.05). Carbon hydrates 6.20 g / dl (SD +/- 0.17) to 6.77 g / dl (SD +/- 0.22) with (p <0.05). Fat of 4.10 g / dl (SD +/- 0.39) to 4.33 g / dl (SD +/- 0.26) with (p = 0.075).Discussion: These data provide a more detailed picture of the nutrient intake ofpreterm infants fed breast milk.

Long-chain polyunsaturated fatty acids supplementation in preterm infants.

PURPOSE OF REVIEW: Extremely low birth weight and very low birth weight infants are born immature and are commonly sick and are, therefore, not able to receive appropriate enteral or sufficient parenteral nutrition to meet the needs for optimal brain, lung and gut growth and development. RECENT FINDINGS: We provide an updated view of essential fatty acid metabolism and discuss the potential protective effect of fatty acids that serve as precursors for eicosanoids and docosanoids. The balance of n-3 or n-6 long-chain polyunsaturated fatty acids (LCPUFAs) supplied may enhance or ameliorate the effects of hypoxia, inflammation, infection, thrombosis and oxidative damage of key organs (lung, brain and retina). In addition, n-3 and n-6 LCPUFAs are necessary for normal structure and function of the central nervous system and sensory organ development. These lipids generate eicosanoids that are mediators of oxidative damage, as well as potential protectors of retina, brain cortex, lung and vascular endothelium. SUMMARY: n-3 and n-6 LCPUFAs may condition in part the long-term consequences of preterm birth. Early n-3 and n-6 LCPUFA supply may moderate the impact of hypoxia and oxidative damage, thus affecting the recovery from injury, later organ (brain, retina, lung, gut, liver and skin) growth and neurodevelopmental outcomes.

Evaluation of adequacy of protein and energy.

Growth assessment is the most common measure of nutritional adequacy in pediatrics, especially when evaluating nutrition of preterm neonates. The American Academy of Pediatrics defines postnatal nutrient intake to promote growth as one that "approximates the rate of growth...for a normal fetus of the same post-menstrual age." It is known that in the fetus, fat and lean body mass are accreted progressively as gestation progresses, whereas postnatal growth and observed accretion of fat and lean body mass differ. This review discusses anthropometric measures used to assess growth, biochemical markers used to monitor nutritional sufficiency, and the effect of growth trajectory in preterm infants on health outcomes later in life.

Compartmental analyses of 2H5-alpha-linolenic acid and C-U-eicosapentaenoic acid toward synthesis of plasma labeled 22:6n-3 in newborn term infants.

BACKGROUND: During early postnatal development, the nervous system accretes docosahexaenoic acid (DHA; 22:6n-3), a highly unsaturated n-3 (omega-3) fatty acid (FA) used in the formation of neural cell membranes. DHA, which is present in human breast milk, may also be biosynthesized from n-3 FAs such as 18:3n-3 [alpha-linolenic acid (ALA)] or 20:5n-3 [eicosapentaenoic acid (EPA)]. An important concern is to what extent these precursors can supply DHA to the developing infant. OBJECTIVE: We analyzed measurements of fractional percentages of plasma (2)H(5)-ALA and (13)C-U-EPA directed toward the synthesis of labeled 22:6n-3 in 11 newborn infants by using compartmental modeling procedures. DESIGN: One-week-old infants received doses of (2)H(5)-ALA and (13)C-U-EPA ethyl esters enterally. We drew blood from the infants periodically and analyzed the plasma for endogenous and labeled n-3 FAs. From the time-course concentrations of the labeled FAs, we determined rate constant coefficients, fractional synthetic rates, and plasma turnover rates of n-3 FAs. RESULTS: In infants, approximately 0.04% of the (2)H(5)-ALA dose converted to plasma (2)H(5)-EPA. Plasma (2)H(5)-EPA and (2)H(5)-22:5n-3 [docosapentaenoic acid (DPA)] efficiently converted to (2)H(5)-DPA and (2)H(5)-DHA, respectively. The percentage of plasma (13)C-U-EPA directed toward the synthesis of (13)C-DHA was lower than the percentage of plasma (2)H(5)-EPA that originated from (2)H(5)-ALA. CONCLUSIONS: Endogenously synthesized EPA was efficiently converted to DHA. In comparison, preformed EPA was less efficiently used for DHA biosynthesis, which suggests a differential metabolism of endogenous EPA compared with exogenous EPA. However, on a per mole basis, preformed EPA was 3.6 times more effective toward DHA synthesis than was ALA. Newborns required an intake of approximately 5 mg preformed DHA. kg(-1) x d(-1) to maintain plasma DHA homeostasis.

Compartmental analyses of plasma 13C- and 2H-labeled n-6 fatty acids arising from oral administrations of 13C-U-18:2n-6 and 2H5-20:3n-6 in newborn infants.

Efficacy of (13)C-U-18:2n-6 and (2)H(5)-20:3n-6 toward synthesis of labeled-20:4n-6 was studied in newborn infants utilizing compartmental models of plasma labeled n-6 fatty acids (FA). Ten infants received oral doses of (13)C-U-18:2n-6 and (2)H(5)-20:3n-6 ethyl esters (100 and 2 mg/kg, respectively). Rate constant coefficients and half-lives (t((1/2))) of n-6 FA were determined from the time-course concentrations of labeled-FA. Plasma n-6 FA values approximated steady state concentrations. Synthetic and utilization rates were calculated. Eight percent (range, 2-21%) of plasma (13)C-U-18:2n-6 was used for synthesis of (13)C-18:3n-6, -20:2n-6, and -20:3n-6. Seventy percent of (13)C-20:3n-6 (mean, CV: 0.26) was available for synthesis of (13)C-20:4n-6. The percentage of (2)H(5)-20:3n-6 converted to (2)H(5)-20:4n-6 was lower (mean: 26%, p < 0.02) than the (13)C-labeled analogue. Turnover of 18:2n-6 in subjects and of 20:4n-6 in plasma was 4.2 g/kg/d (CV: 0.58) and 4.3 mg/kg/d (CV: 0.81), respectively. Intake of 18:2n-6 and 20:4n-6 were estimated to be 3.0 g/kg/d (+/-1.7) and 2.8 mg/kg/d (+/- 2.2), respectively. Infants required additional 18:2n-6 and 20:4n-6 (mean: 1.2 g and 1.5 mg/kg/d) above predicted intake amounts to maintain plasma concentrations of 18:2n-6 and 20:4n-6, in order to spare FA from fat stores.

Infants with intrauterine growth restriction have impaired formation of docosahexaenoic acid in early neonatal life: a stable isotope study.

This study evaluated the arachidonic acid (AA) and docosahexaenoic acid (DHA) formation from d5-labeled linoleic acid (d5-LA) and alpha-linolenic acid (d5-LNA) precursors in infants with intrauterine growth restriction (IUGR) compared with control groups matched by gestational age (GA) or birth weight. We compared DHA and AA formation from deuterated precursors d5-LA and d5-LNA in 11 infants with IUGR with 13 and 25 control subjects who were appropriate for GA and matched by GA and by birth weight, respectively. After an enteral administration of d5-LA and d5-LNA, we determined unlabeled and d5-labeled fatty acids at 24, 48, and 96 h in plasma. Absolute concentrations and area under the curve (AUC) over the 96-h study were used for analysis. Absolute concentration of d5-DHA and the product/precursor ratio of the d5-labeled AUCs indicated a less active DHA formation from LNA in infants with IUGR compared with their GA-matched (2-fold) and birth weight-matched (3-fold) control subjects. The ratios of eicosapentaenoic and n-3 docosapentaenoic acid to DHA were also affected. Similar evaluation for the n-6 series was not significant. DHA metabolism is affected in infants with IUGR; the restricted DPA to DHA conversion step seems to be principally responsible for this finding.