Postdischarge Nutrition in Preterm Infants.

The field of postdischarge nutrition for preterm infants arose when concerns that using diets suitable for term infants-breastfeeding without fortification or standard formulas-might not meet the postdischarge nutritional needs of infants born preterm, who often exhibited growth restriction and evidence of undernutrition. A decade ago, there were already 27 randomized controlled trials (RCTs) of nutritional supplementation from which an eligible subsample of trials have provided evidence on whether nutritional fortification of human milk or nutrient-enriched formula favorably affects postdischarge growth in these infants. These RCTs also allowed exploration of the quality of growth, bone mineralization, and the ad libitum-fed infant's own regulation of milk volume and nutrient intake. Importantly, such RCTs, augmented by observational data on the links between growth and neurodevelopment, have allowed exploration of the potential impact of postdischarge nutrition on neurocognitive function. However, the interpretation of published data and the implication for practice has proven difficult and contentious. In this review, we examine, and to an extent reanalyze, existing evidence to elucidate its strengths and limitations, with the goal of adding more clarity to the ways in which this sizeable body of clinical scientific research may have a positive impact on the postdischarge nutritional approach to infants born preterm.

Quality improvement: A practical nursing program's admission test.

INTRODUCTION: Academic institutions are under pressure to maintain a nearly flawless retention rate, while graduating successful students. The use of standardized admission tests to provide data driven decisions regarding applicant selection is common. The varying reliability and validity of current standardized tests inspired a large Canadian academic institution to use a faculty developed admission test for admission to its practical nursing (PN) program. METHODS: The target population for this project was a purposive, convenience sample of graduated PN students from a large publically funded polytechnic institution in southern Ontario, Canada, who had completed the Canadian Practical Nurse Registration Examination (CPNRE) within 2014-2016 (n = 293). Data was obtained retrospectively, and included program entry grade-point average (GPA) and CPNRE result, as well as chemistry, English, biology, and math admission test scores. RESULTS: The predictors of chemistry, English, math admission test scores, and program entry GPA did not have an effect beyond the effects of the model's predictors. In this model, the R2 suggests that 9% of the variance can be explained, and 91% not explained. In consideration of all independent variables, findings indicate that mean biology admission test scores (M =74.96) are a predictor of student CPNRE success. Additionally, students who pass the CPNRE have a higher program GPA. CONCLUSIONS: Academic factors including program entry GPA, English, math, biology and chemistry admission scores are a fragment of the characteristics to be considered when determining the predictability of success in PN students. Therefore, it is imperative that program admission processes identify and measure nonacademic program entry criteria, as academic criterion have limited predictability. Furthermore, in isolation, academic admission criteria could be used to identify at-risk-students for appropriate remediation/counselling or as a placement test.

E-Mentoring for Doctor of Nursing Practice Students: A Pilot Program.

BACKGROUND: The growing number of online Doctor of Nursing Practice (DNP) programs, steady attrition rates, and shortage of faculty created an opportunity to explore the use of distance-mediated mentoring. METHOD: Twenty first-year DNP Nursing Leadership students were matched with DNP-prepared mentors in a formalized e-mentoring program. The Ideal Mentor Scale was used to determine what students desired most from the mentoring relationship in addition to midpoint and end-of-program surveys. RESULTS: Quantitative analysis revealed mentors and mentees found the relationship to be beneficial (p < .05). Mentees (89%) and mentors (92%) noted the program supplied adequate resources, and the majority of students would recommend the program. CONCLUSION: Having a mentor leads to both mentor- and mentee-perceived benefits. Recommendations include continuing to seek ways to improve the communication and commitment between the mentor and mentee in order to receive reciprocal program benefits. [J Nurs Educ. 2016;55(8):458-462.].

Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants.

OBJECTIVE: To evaluate the safety and explore the efficacy of recombinant human lactoferrin (talactoferrin [TLf]) to reduce infection. STUDY DESIGN: We conducted a randomized, double blind, placebo-controlled trial in infants with birth weight of 750-1500 g. Infants received enteral TLf (n = 60) or placebo (n = 60) on days 1 through 28 of life; the TLf dose was 150 mg/kg every 12 hours. Primary outcomes were bacteremia, pneumonia, urinary tract infection, meningitis, and necrotizing enterocolitis (NEC). Secondary outcomes were sepsis syndrome and suspected NEC. We recorded clinical, laboratory, and radiologic findings, along with diseases and adverse events, in a database used for statistical analyses. RESULTS: Demographic data were similar in the 2 groups of infants. We attributed no enteral or organ-specific adverse events to TLf. There were 2 deaths in the TLf group (1 each due to posterior fossa hemorrhage and postdischarge sudden infant death), and 1 death in the placebo group, due to NEC. The rate of hospital-acquired infections was 50% lower in the TLf group compared with the placebo group (P < .04), including fewer blood or line infections, urinary tract infections, and pneumonia. Fourteen infants in the TLf group weighing <1 kg at birth had no gram-negative infections, compared with only 3 of 14 such infants in the placebo group. Noninfectious outcomes were not statistically significantly different between the 2 groups, and there were no between-group differences in growth or neurodevelopment over a 1-year posthospitalization period. CONCLUSION: We found no clinical or laboratory toxicity and a trend toward less infectious morbidity in the infants treated with TLf. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00854633.

Randomized Control Trial of Human Recombinant Lactoferrin: A Substudy Reveals Effects on the Fecal Microbiome of Very Low Birth Weight Infants.

UNLABELLED: The purpose of this study is to evaluate the effects of enteral lactoferrin on the fecal microbiome and contrast those influences with the neonatal intensive care unit (NICU) environment. We theorized that lactoferrin and the NICU habitat shape the fecal microbial composition of very preterm infants. Although functions attributed to lactoferrin include intestinal immune system development and emergence of a healthy gut microbiota, evidence is limited. Twenty-one very low birth weight (VLBW <1500 g) infants received twice-daily talactoferrin (TLf, a drug designation for recombinant human lactoferrin) or its excipient by gastric gavage from day 1-28 of life. Twenty-four-hour fecal samples were collected on day 21 of life and compared with fecal operational taxonomy units (OTUs) in treated and control infants in 2 NICUs. Workflow included fecal DNA isolation, generation of amplicons for the V1-V3 region of bacterial 16S ribosomal RNA, and sequencing of a gel-purified multiplex amplicon library using a Roche 454 GS FLX Titanium (Roche, Branford, Connecticut) platform and protocols. Fecal OTUs per infant were higher in NICU 1 vs NICU 2 (P < .001), consistent with fewer antibiotic days (P < .02) and a shorter duration of parenteral nutrition (P < .007) in NICU 1. Proteobacteria and Firmicutes were the major phyla in infants treated with TLf and placebo. Among Enterobacteriaceae, TLf prophylaxis reduced Enterobacter and Klebsiella, but increased Citrobacter in feces of VLBW infants. Citrobacter caused no neonatal infections in the study population. OTUs for Clostridiaceae increased in NICU 1 among infants treated with TLf. Importantly, OTUs of staphylococci were barely detectable in both NICUs among infants fed TLf. Fewer hospital-acquired infections occurred in infants treated with TLf vs controls, although the reduction was seen mostly in coagulase-negative staphylococci-related bloodstream and central line infections (P = .06). TLf modified the fecal microbiome in VLBW infants, but care practices in the NICU habitat also contributed. Future research must establish whether elimination vs enrichment of gut-related microbiota reduces clinically significant hospital-acquired infections and promotes a healthy commensal microflora in the intestines of VLBW infants. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00854633.

Monitoring Resource Utilization in a Health Care Coordination Program.

PURPOSE OF THE STUDY: This initial article describes the development of a health care coordination intervention and documentation system designed using the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Atlas framework for Centers for Medicare & Medicaid-funded innovation project, Leveraging Information Technology to Guide High-Tech, High-Touch Care (LIGHT). PRIMARY PRACTICE SETTING(S): The study occurred at an academic medical center that serves 114 counties. Twenty-five registered nurse care managers (NCMs) were hired to work with 137 providers in 10 family community and internal medicine clinics. METHODOLOGY AND SAMPLE: Patients were allocated into one of the four tiers on the basis of their chronic medical conditions and health care utilization. Using a documentation system on the basis of the AHRQ domains developed for this study, time and touch data were calculated for 8,593 Medicare, Medicaid, or dual-eligible patients. RESULTS: We discovered through the touch and time analysis that the majority of health care coordination activity occurred in the AHRQ domains of communication, assess needs and goals, and facilitate transitions, accounting for 79% of the NCM time and 61% of the touches. As expected, increasing tier levels resulted in increased use of NCM resources. Tier 3 accounted for roughly 16% of the patients and received 159 minutes/member (33% of total minutes), and Tier 4 accounted for 4% of patients and received 316 minutes/member (17% of all minutes). In contrast Tier 2, which did not require routine touches per protocol, had 5,507 patients (64%), and those patients received 5,246 hours of health care coordination, or 57 minutes/member, and took 48% of NCM time. IMPLICATIONS FOR CASE MANAGEMENT: 1. The AHRQ Care Coordination Atlas offered a systematic way to build a documentation system that allowed for the extraction of data that was used to calculate the amount of time and the number of touches that NCMs delivered per member. 2. Using a framework to systematically guide the work of health care coordination helped NCMs to think strategically about the care being delivered, and has implications for improving coordination of care. 3. For the purpose of reimbursement and communication with payers about quality metrics, it is vital that the type of touches and amount of time spent in delivering care coordination be documented in a manner that can be easily retrieved to guide practice decisions.

Early Persistent Blood Eosinophilia in Necrotizing Enterocolitis Is a Predictor of Late Complications.

BACKGROUND: Eosinophils infiltrate intestinal tissue during necrotizing enterocolitis (NEC) and adult bowel diseases. We theorized that epithelial damage causes eosinophilic activation and recruitment at NEC onset. OBJECTIVE: We studied the relationship between persistent blood eosinophilia and medical or surgical complications during NEC. METHODS: NEC cases and controls at MU Children's Hospital (2008-2013) underwent review. A Likert scale measured NEC severity. We utilized an SPSS database for statistical analyses. RESULTS: Of 50 NEC cases, infants in group 1 (n = 15) had eosinophilia <2 days after onset and those in group 2 (n = 25) had NEC but no persistent eosinophilia. Group 3 (n = 46) consisted of controls, i.e. infants without NEC matched for birth weight and gestational age and group 4 (n = 4) of preterm infants with infection and ≤5 days of eosinophilia. Hematologic assessment defined persistent eosinophilia as ≥5% eosinophils for ≥5 days after NEC onset. Absolute eosinophil counts were 2 times higher in group 1 than in group 2 (p = 0.002). The mean duration of eosinophilia was 8 days in group 1 versus 1 day in group 2 (p < 0.001). A Likert score of NEC severity was 3-fold higher in group 1 than in group 2 (p < 0.001). Compared to group 2, group 1 infants were 8 times more likely to have hepatic fibrosis or intestinal strictures. CONCLUSIONS: Early persistent blood eosinophilia is not currently a predictor of complications after the onset of NEC. This biomarker identifies immature infants at a high risk for adverse outcomes during NEC convalescence.

Lactoferrin and necrotizing enterocolitis.

PURPOSE OF REVIEW: There is an intense interest among neonatal caregivers as to whether lactoferrin given enterally may reduce the incidence of necrotizing enterocolitis in preterm infants. This review presents scientific and clinical evidence that lactoferrin alleviates or prevents this life-threatening disease. RECENT FINDINGS: Preclinical studies in neonatal rats showed that lactoferrin given orally before enteral infection with pathogenic Escherichia coli reduced bacteremia and mortality. A multicentered clinical trial found that very low-birth weight preterm infants given bovine lactoferrin had a significant reduction in late-onset sepsis; there was also a trend towards a diminished incidence of necrotizing enterocolitis. Although multicentered trials of lactoferrin use in preterm infants are near completion, regulatory burdens required to bring lactoferrin to the bedside may limit its availability. SUMMARY: Extremely preterm infants should receive colostrum, a natural lactoferrin concentrate, immediately after birth and, ideally, continue on breast milk throughout the hospital stay. This practice appears well tolerated, but additional experience will tell us whether this practice reduces the prevalence of necrotizing enterocolitis.

Paneth cells and antibacterial host defense in neonatal small intestine.

Paneth cells are specialized epithelia in the small bowel that secrete antimicrobial proteins. Paneth cells are vital to the innate immunity of the small bowel in adult mammals, but their role during neonatal infection of the small bowel is not well established. Dithizone selectively damages Paneth cells, and when dithizone-treated newborn rats are infected enterally with Escherichia coli, the numbers of E. coli cells in their jejunal and ileal lavage fluid are significantly increased compared to controls. The data support that Paneth cells are necessary for neonatal antibacterial defense.

Prenatal smoking and alterations in newborn heart rate during transition.

OBJECTIVE: To evaluate the effects of prenatal cigarette smoke exposure on newborn heart rate following the physiologic challenge of birth. DESIGN: Nonexperimental, comparative. PARTICIPANTS: A convenience sample of 130 full-term, healthy newborns who were born at a suburban medical center. MAIN OUTCOME MEASURES: Cotinine is the major metabolite of nicotine and was measured in venous cord blood. The heart rate was monitored at 1 minute intervals during the first 4 hours of life. Infants were categorized into three groups based on the cotinine level: < 0.05 ng/ml (n = 68), 0.05-6.0 ng/ml (n = 39), and > 6.0 ng/ml (n = 23). These levels corresponded, respectively, to no exposure, passive, and active exposure of the mother to nicotine. RESULTS: A one-way ANOVA was significant for maximum heart rate, F(2, 127) = 9.26, p = .001; range of heart rate, F(2, 127) = 5.4, p = .006; and variance of heart rate, F(2, 127) = 5.24, p = .007. Post hoc multiple comparisons found that newborns with cotinine levels > 6.0 ng/ml differed significantly from infants with cotinine levels < 0.05 ng/ml and 0.05-6.0 ng/ml in maximum heart rate, range of heart rate, and variance of heart rate. CONCLUSIONS: These findings suggest that newborns with cotinine levels > 6.0 ng/ml have a limited ability to maximize and vary their heart rate. Cardiac output in the newborn is primarily dependent on heart rate. If unable to maximize cardiac output during times of stress, the newborn is potentially at an increased risk for morbidity and possible mortality.