Bolus Feeding Via Gastric Versus Oral Routes in Very Preterm Neonates.

BACKGROUND: We intend to investigate the association of bolus orogastric tube (BOG) and nipple bottle (N) feedings with postnatal growth in very premature neonates (VPN: gestational age between 28 and 33 weeks). MATERIAL AND METHODS: The days of life (DOL) to achieve full combined oral and gastric enteral nutrition (FEN) and attain body weight (BW) of 2200 g (Wt22) and the length of hospitalization (LOH) were retrospectively associated with clinical and BOG and N feeding-related variables via multivariate regression analyses. Correlations were performed to ascertain the strength of associations. RESULTS: In a cohort of 127 VPN, FEN demonstrated negative associations with gestational age (GA) and LOH and Wt22 with birth weight (BW). FEN showed positive associations with nil by mouth and intravenous fluid-nutrition days and with DOL to start and achieve full nipple feeding. LOH was associated with days on antibiotics and DOL to start and achieve full nipple feeding. Wt22 was associated with DOL to achieve full nipple feeding. The start day of BOG feeding had no independent associations and weak, highly significant positive correlations with Wt22, LOH, and FEN. CONCLUSION: Bolus orogastric tube feeding has no independent implications for postnatal growth, duration of hospitalization, or chronological age to attain full enteral nutrition in VPN unless combined with nipple feeding to provide enteral nutrition. Oral bottle feeding accelerates postnatal catch-up growth and full enteral nutrition acquisition while reducing hospitalization duration. Initiating nipple feeding at 32 weeks of postmenstrual age may be safe in stable VPN. Antibiotic therapy increases hospitalization duration.

Immediate Postnatal Microbial Colonization in Sick Term Neonates Admitted to NICU: Prevalence, Microbiota, and Associated Characteristics.

OBJECTIVE: The immediate postnatal rectal (RC) and nasopharyngeal colonization (NPC), their prevalence, taxa, and associated characteristics were investigated in sick term infants admitted to the neonatal intensive care unit. STUDY DESIGN: In a retrospective cohort single center study, nasopharyngeal (NPCx) and rectal (RCx) microbial cultures were obtained within 20 minutes of birth in mild-to- moderate sick term infants. Associations between the colonization and maternal-neonatal variables, including early neonatal course, were analyzed via logistic regression analysis. RESULTS: A total of 154 term infants were admitted for respiratory distress, hypoglycemia, maternal chorioamnionitis (CHO), and suspected neonatal sepsis; out of which, 80 (52%) were NPCx-positive (+) infants. The duration of rupture of membrane (ROM) was higher (15.5 ± 10.0 vs. 11.3 ± 11.0 hours, p = 0.02), while the respiratory support requirement (16.3 vs. 29.7%, p = 0.04) and occurrence of maternal group B Streptococcus (GBS) colonization lower (15.0 vs. 35.1%, p = 0.01) in NPCx+ infants. ROM increased (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.01-1.07), and maternal GBS colonization decreased the odds of positive nasopharyngeal cultures (OR: 0.31, 95% CI: 0.14-0.72). The major microorganisms isolated were Staphylococcus epidermidis (41%), α hemolytic Streptococcus (AHS; 16%), Escherichia coli (13%), and GBS (1.06%). Among the enrolled infants, 44 (28.5%) were RCx positive. The need for (11.4 vs. 27.3%, p = 0.03) and days on respiratory support (0.2 ± 0.6 vs. 0.8 ± 2.5, p = 0.03) were lower and the occurrence of CHO higher (41.0 vs. 23.2%, p = 0.04) in the RCx positive infants. Cesarean section (CS) was performed less frequently (18.2 vs. 55.5%, p = 0.001) and decreased the odds of having positive rectal cultures (OR: 0.21, 95% CI: 0.08-0.51). In total, 80% of the RCx positive infants isolated E. coli, and 6.8% Klebsiella. CONCLUSION: In sick term neonates, early NPC is dominated by SE and RC by E. coli. NPC is supported by ROM and declines by maternal GBS colonization, whereas RC decreases with CS. NPC is more common than RC in this population. KEY POINTS: · Early neonatal nasopharyngeal microbial colonization in sick term neonates, dominated by Staphylococcus epidermidis, is enhanced by the rupture of membrane and diminishes by maternal GBS colonization.. · Cesarean section decreases the rectal colonization, which is composed of E. coli as the predominant microorganism.. · The microbiota of early postnatal colonization in sick term neonates differs from that reported in healthy term infants..

Evaluation and Risk Assessment of Congenital Anomalies in Neonates.

Congenital anomalies (CA) are a large heterogeneous group of disorders of abnormal morphogenesis or biochemistry which present at birth and carry widely variable implications for morbidity and mortality. They are the leading cause of infant mortality in the USA, with an incidence of 3-4% of all births. CA are the fourth leading cause of neonatal mortality worldwide, with an estimated 295,000 deaths annually. The enormous variability in the clinical presentation in terms of severity, time of occurrence, course, complications, management, and outcomes makes the evaluation of CA complicated, highly specific, and individualized. The anomalies can impart tremendous physical, social, and emotional distress on the patient with massive emotional, social, financial, and medical implications for the family and society. The diagnosis may remain elusive despite rigorous, elaborate, and extensive investigations in many cases. While the enormous strides in genetic testing and gene modification therapy have an encouraging impact on the diagnosis and treatment, the risk assessment of recurrence in the family and population of CA remains obscure in most cases due to the lack of information and referable evidence.

Placental histopathology in late preterm infants: clinical implications.

BACKGROUND: The etiopathogenesis of late preterm (LPT) birth is undetermined. Placental histopathology, which reflects an adverse intrauterine environment and is reportedly associated with preterm labor and neonatal morbidities, has not been studied in LPT infants. PURPOSE: We investigated placental pathological lesion as markers of an adverse intrauterine environment during LPT labor. METHODS: This retrospective case-control study compared placental histopathological and clinical variables between LPT and term neonates. Placental variables included chorioamnionitis, funisitis, hemorrhage, abruption, infarction, calcification, and syncytial knots. Maternal variables included age, substance abuse, pregnancyassociated diabetes mellitus and hypertension, duration of rupture of membrane, antibiotic use, and magnesium sulfate, whereas, those of neonates included gestational age, birth weight, race, sex, and Apgar scores. Standard statistical proedures were applied to analyze the data. RESULTS: Chorioamnionitis (50% vs. 17.8%, P<0.001) and funisitis (20% vs. 4.4%, P=0.002) were more common in term infants. Placental infarction rate was insignificantly higher in LPT infants (25.6% vs. 14.3%, P=0.08). The mothers in the LPT group were older (30.4 years vs. 28.1 years, P=0.05; odds ratio [OR], 1.06; 95% confidence interval [CI], 0.998-1.12, P=0.056) and more often suffered from hypertension (28.9 vs. 12.9 %, P=0.02), and received magnesium sulfate (48.9 vs. 20%, P< 0.001; OR, 2.86; 95% CI, 1.12-7.29, P<0.05). Duration of rupture of membrane was higher in term infants (13.6 hours vs. 9.1 hours, P<0.001). Chorioamnionitis (OR, 0.33; 95% CI, 0.13-0.79; P<0.05) was associated with a lower risk of LPT delivery. CONCLUSION: Placental infection is not a risk factor for LPT births. There is a nonsignificant predominance of vascular anomalies in LPT placentas. Higher maternal age, magnesium sulfate therapy, and maternal hypertension are clinical risk factors for LPT labor.

Complications associated with the current sequential pharmacological management of early postnatal hypotension in extremely premature infants.

Early postnatal hypotension in premature infants is treated with escalating doses of vasopressor-inotropes (VI), followed by hydrocortisone if VI therapy fails. The adverse effects of this standard clinical practice have not been well reported. In a retrospective case-control study, we compared the complications associated with VI and hydrocortisone (HCVI) treatments in extremely low-birth-weight infants (≤1000 g) with contemporaneous normotensive medication-naïve controls via standard univariate and multivariate analyses. Birth weight, gestational age, and receipt of antenatal steroids did not differ between VI (n = 74) and control (n = 124) groups, while the occurrence of gestational diabetes mellitus and risks for patent ductus arteriosus, intraventricular-periventricular hemorrhage, spontaneous intestinal perforation, ventriculomegaly, and bronchopulmonary dsyplasia were higher in VI. Infants in the HCVI group (n = 69) had lower birth weight, gestational age, and receipt of antenatal steroids and higher risks for intraventricular-periventricular hemorrhage, bronchopulmonary dysplasia, air leaks, and patent ductus arteriosus than controls. Whereas the occurrences of spontaneous intestinal perforation, ventriculomegaly, and maternal diabetes mellitus did not differ, that of maternal hypertension trended to be lower in HCVI recipients (P = 0.06). In conclusion, hypotensive extremely low-birth-weight infants treated with VI or with HCVI are susceptible to intraventricular-periventricular hemorrhage, bronchopulmonary dysplasia, and patent ductus arteriosus. Furthermore, those who receive inotropes are at risk for spontaneous intestinal perforation and ventriculomegaly. Maternal diabetes mellitus increases the occurrence of hypotension, which responds to VI. Maternal hypertension does not contribute to VI responsive and tends to decrease the occurrence of VI-refractory hypotension.

A comparative analysis of ante- and postnatal clinical characteristics of extremely premature neonates suffering from refractory and non-refractory hypotension: Is early clinical differentiation possible?

BACKGROUND: About 25% of hypotensive ELBW infants are refractory to intravascular volume expansion and inotropic drugs (VI) and require hydrocortisone (HC). Such neonates suffer from complications of prolonged hypotension and extended therapy with VI. ELBW infants with refractory hypotension (RH) are clinically and biochemically indistinguishable from those who respond to VI. OBJECTIVE: Early identification and differentiation of ELBW infants susceptible to steroid dependent hypotension from those who respond to inotropic medications. METHODS: In a retrospective study the ante- and postnatal clinical characteristics of ELBW infants who received hydrocortisone (HC) for refractory hypotension (RH) were compared to those who responded to volume-inotropes (VI). RESULTS: Infants in HC group had lower birth weight (BW, 675±121g) and gestational age (GA, 25.1±1.3weeks) and higher mean airway pressure and oxygen requirements, all independent of antenatal steroid (ANS) exposure. The receipt of ANS (p 0.01) and occurrences of maternal diabetes mellitus (GDM, p 0.01) were lower in HC group. ANS (OR 0.5, 95% CI 0.2-0.9, p 0.01) and GDM (OR 0.3, 95% CI 0.09-0.9, p 0.04) reduced the risk for RH. HC group had higher risk for IVH (OR 2.1, 95% CI 1.02-4.2 p=0.04) which declined in the multivariate analysis. A trend towards lower risk of ventriculomegaly (VM) was noted in HC group (OR 0.3, 95% CI 0.1-1.1), which became significant after controlling for BW (OR 0.2 95% CI 0.07-0.9, p 0.04). Similar trend was noted for maternal hypertension. CONCLUSION: Hypotension in ELBW infants who are ≤25wks of GA and unexposed to ANS and GDM is refractory to VI therapy. Such neonates may benefit from an initial therapy with, or earlier institution of hydrocortisone. The trend towards a higher risk for VM with VI therapy needs validation in future studies.

Postnatal Transitional Weight Loss and Adverse Outcomes in Extremely Premature Neonates.

The early postnatal weight loss (EPWL) is highly variable in the extremely low birth weight infants (birth weight <1000 g, ELBW). It is reported to be unassociated with adverse outcomes within a range of 3-21% of birth weight. Its wide range might have contributed to this lack of association. The aim of our paper is to study the effects of maximum EPWL, graded as low, medium and large on clinical outcomes in ELBW infants. In a retrospective cohort observational study EPWL was measured as maximum weight loss from birth weight (MWL) in ELBW infants and grouped as low (5-12%) moderate (18.1-12%) and high (18-25%). The clinical course and complications of infants were compared between the groups. Gestational age (GA) was highest and surfactant administration, peak inspiratory pressure requirement, fluid intake, urinary output, oxygen dependent days and the number of oxygen dependent infants at age 28 days were lower in the low MWL compared to the high MWL group. However, all these significant P-values declined after controlling for GA. Diabetes mellitus and pregnancy associated hypertension were not noted in mothers in high MWL group, whereas 38% of mothers in low MWL group suffered from the latter (P=0.05). Maximum postnatal transitional weight loss, assessed in the range of low, moderate and high, is not associated with adverse outcomes independent of gestational age in ELBW infants. Maternal hypertension decreases EPWL in them.

Isolated Placental Inflammation and Vasculopathy: Clinical Implications in the Extremely Low Birth Weight Infants.

The predictive values of placental histopathologies are compromised by a non-segregation of common anomalies. The effects of isolated pure placental inflammation (PI) and vasculopathy-coagulopathy (PV) were compared with normal (NL) placentas in extremely premature infants (ELBW, birth weight < 1000 g). PI infants required lower peak inspiratory pressure on day 3. More infants in PV were oxygen dependence on day 28. PV had an increased risk of intraventricular-periventricular hemorrhage (IVH, OR 4.9, 95% CI 1-24.7, p = 0.05). NL infants were unexposed to PPROM or maternal hypertension, had highest requirement for surfactant, did not develop IVH and periventricular leukomalacia (PVL) and none of them were Caucasian. CONCLUSIONS: In ELBW infants (1) pure placental vasculopathy-coagulopathy is a risk factor for IVH, (2) a non- pathological intrauterine environment is nonconducive to IVH and PVL, (3) pure placental inflammation is protective for acute pulmonary disease, (4) Caucasian mothers are more susceptible to adverse intrauterine environment.

Placental histopathology in the extremely low birth weight infants.

Our objective was to evaluate the placental histopathology (PH) in extremely low birth weight infants (ELBW, birth weight < 1000 g) and to determine if placental histopathological findings are associated with neonatal mortality in them. The PH of all ELBW infants (gestational age 23-30 weeks) born during a 3-year study period was prospectively evaluated and compared with term infants (gestational age > or = 37 weeks). Additionally PH of ELBW infants who expired within 28 days of life was compared with those who survived beyond 28 days. Student's t test, chi(2) test and Pearson's correlation coefficient tests were utilized for data analysis. The occurrences of placental infection (chorioamnionitis, HCA), umbilical cord inflammation (funisitis, vasculitis, and subacute necrotizing funisitis, analyzed collectively as HFV), and abruption were higher in ELBW (n = 105) compared to term infants (n = 61, p = 0.001, 0.0002, and 0.0002, respectively). Placental findings did not differ between the surviving (n = 71) and nonsurviving (n = 51) ELBW infants. Birth weight and gestational age were higher in the surviving group (p = 0.003 and 0.001, respectively). Placental abruption was found more commonly in the presence of HCA and HFV in ELBW infants as opposed to maternal hypertension in term infants. All ELBW placentas with HFV had concomitant findings of HCA whereas only 42% of ELBW placentas with HCA had findings of HFV compared to 24% in term infants (p = 0.09). There was a weak inverse correlation between HCA and birth weight in all (r = - 0.3, p = 0.01) but not in ELBW infants (r = 0.2, p = 0.07). We conclude that placental and umbilical cord inflammation and placental abruption are more commonly present in ELBW compared to term infants. However, these findings do not contribute to neonatal mortality in ELBW infants. Forty-two percent of placental (maternal) inflammation cases have concomitant cord (fetal) inflammation in ELBW infants. Finally HCA correlates inversely with birth weight in neonates.

Continuing care of NICU graduates.

After a prolonged and complicated hospital stay, the NICU graduate enters the world with unique and complex medical problems. A well-coordinated multidisciplinary approach is essential in the follow-up care of these infants. The crucial issues for the pediatrician who cares for these infants are assisting in the catch-up growth and the ongoing healing process with good nutritional supplementation, while preventing further problems by detecting and treating illness early. Timely inclusion of other appropriate health care personnel and facilities in the care may be crucial and rewarding. The role of the pediatrician in helping these infants attain their full physical, neurodevelopmental, emotional, and psychosocial potential by providing optimal care is invaluable. With appropriate support most NICU graduates will become productive and well-adjusted adults. The pediatrician plays a major role in completing this process and contributes to the eventual success of the neonatal intensive care that these infants are subjected to at the very beginning of their lives.