A randomized controlled trial of oropharyngeal therapy with mother's own milk for premature infants.

OBJECTIVE: To determine if oropharyngeal therapy with mother's own milk (OPT-MOM) reduces late-onset sepsis (L-OS; primary outcome), NEC, death, length of stay, time to full enteral nutrition (FEN) and full oral feeds in preterm infants (BW < 1250 g). DESIGN: Infants (N = 220) were randomized to Group A (milk) or B (placebo) and received 0.2 mL every 2 h for 48 h, then every 3 h until 32 weeks CGA. RESULTS: There were no significant differences in L-OS, NEC or death. Group A trended towards an 8-day reduction in stay, 8-day reduction in time to FEN and a 6-day reduction in time to full oral feeds, compared to B. While clinically relevant, due to large variability in outcomes and lack of power, p values were > 0.05. CONCLUSION: OPT-MOM did not reduce L-OS, NEC or death. Group A trended towards a reduced stay and better nutritional outcomes, but results were not statistically significant. CLINICALTRIALS: GOV: NCT02116699.

A retrospective analysis of the clinical effectiveness of subcutaneously tunneled femoral vein cannulations at the bedside: A low risk central venous access approach in the neonatal intensive care unit.

OBJECTIVE: The purpose of this retrospective analysis was to evaluate the clinical efficacy and safety of ultrasound (US)-guided, subcutaneously tunneled, femoral inserted central catheters (ST-FICCs) in the neonatal intensive care unit (NICU). METHODS: Following clinical success with ST-FICCs in adults, we expanded this practice to the neonatal population. In an 18-month retrospective cohort analysis (2018-2020) of 82 neonates, we evaluated the clinical outcome for procedural success, completion of therapy, and incidence of early and late complications for insertion of US-guided ST-FICCs in the NICU. RESULTS: Placement of ST-FICCs were successful in 100% of neonates (n = 82/82) with 94% to the right (n = 77/82) and 6% to the left common femoral veins (n = 5/82). Gestational age ranged 23-39 weeks with median age of 29 weeks. Birthweight ranged from 450 g to >2000 g. Weight at insertion ranged 570 to 3345 g and day of life 1 to 137, with median at day 5. Ultrasound guided femoral vein puncture was recorded on 74 patients, first attempt 63/74 (85%), second attempt 8/74 (11%) and third attempt 3/74 (4%). Catheter french used: 1.9Fr (n = 80/82), 2.6Fr (n = 1/82), and 3-Fr (n = 1/82). Catheter lengths were 8 to 20 cm, average 12cm. Catheter termination confirmed with posterior/anterior and lateral abdominal radiographs with inferior vena cava (IVC) (n = 33/82), IVC/right atrial junction (n = 31/82), or right atrium (n = 18/82). Atrial placements were retracted; no cases of malposition to the lumbar/renal/hepatic veins (n = 0/82). 1528 catheter days ranging 5 to 72 days (average 18). No insertion-related or post-insertion complications. All patients completed prescribed therapy with one catheter. CONCLUSION: Bedside placement of an ST-FICC is a safe route for central venous access in the NICU, preserving upper extremity vasculature, eliminates risks associated with sedation, fluoroscopy, tunneled and non-tunneled supra-diaphragmatic central venous insertion.

Impact of routine methicillin-resistant Staphylococcus aureus (MRSA) surveillance and cohorting on MRSA-related bloodstream infection in neonatal intensive care unit.

OBJECTIVE: To study the impact of methicillin-resistant Staphylococcus aureus (MRSA) surveillance on the incidence of MRSA-related bloodstream infection (BSI) in neonatal intensive care unit (NICU) and to evaluate cost-effectiveness of MRSA surveillance. STUDY DESIGN: MRSA surveillance policy was introduced in our NICU in April 2008. Pre-MRSA surveillance period (P1, April 2006-March 2008) was compared with the surveillance period (P2, April 2008-April 2010) for MRSA-related BSI (MRSA BSI). RESULTS: During P1 and P2, 1,576 and 1,512 neonates were enrolled. Of these, 3.8/1,000 and 5.3/1,000 developed MRSA BSI, respectively. During P2, 100% MRSA-related BSI occurred in MRSA-colonized neonates, as compared with zero in noncolonized group (p < 0.0001). Overall, 7 (30%) of the 23 neonates colonized during hospitalization developed MRSA BSI as compared with 1 of the 31 (3%) neonates colonized at admission (p = 0.007). Direct screening cost was $208 per patient. Since 28 neonates had to be screened to detect one colonization, $5,824 estimated per detection, excluding indirect costs. CONCLUSIONS: MRSA surveillance may protect non-MRSA colonized neonates from becoming colonized. This is of considerable importance because the acquisition of colonization during hospitalization was associated with a 10-fold increase in risk of developing MRSA BSI. Cost-effectiveness of MRSA surveillance remains debatable and further studies are needed to delineate cost-benefit ratio.

Fluconazole prophylaxis is associated with a decreased rate of coagulase-negative Staphylococcal infections in a subset of extremely low birth weight neonates.

Fluconazole prophylaxis is being used efficaciously in the neonatal intensive care unit (NICU) for fungal prophylaxis in very low birth weight and extremely low birth weight (ELBW) neonates. Little is known about the effect of fluconazole prophylaxis on bacterial infections. The purpose of this study was to examine that issue in a subset of ELBW, those weighing ≤900 g at birth. This is a retrospective study conducted in a level III NICU at state-designated children hospital in New Jersey (USA). We examined the data from our records of neonates ≤ 900 g birth weight during the period March 1, 2007-February 28, 2011. Inclusion in the study was all infants ≤ 900 g before (n = 67) and after (n = 81) the institution of fluconazole prophylaxis. Fluconazole prophylaxis was accompanied by a significant decrease in both the rate and number of days of bacterial infections as well as co-infections. We found that the incidence of coagulase-negative Staphylococcus (CONS) decreased from 46.2 to 24.7 % (OR 2.63; 95 % CI 1.31-5.27). Similarly, days of infection also decreased significantly (p < 0.0001). These data suggest that fluconazole prophylaxis may be associated with a reduction in CONS infections in that subset of ELBW neonates.

Maternal sepsis, chorioamnionitis, and congenital Candida kefyr infection in premature twins.

This is the first reported case of maternal sepsis and placental transmission of Candida kefyr to premature fraternal twins. The mother consumed organic dairy products regularly throughout her pregnancy and developed sepsis with chorioamnionitis caused by C. kefyr. The twins developed respiratory distress at birth. The placenta, fetal membranes, and umbilical cords showed numerous colonies of yeasts, subsequently identified as C. kefyr. C. kefyr sepsis in preterm neonates should be considered when there is a significant maternal history of organic dairy product consumption during pregnancy.

Point-of-care testing for B-type natriuretic peptide in premature neonates with patent ductus arteriosus.

Patent ductus arteriosus (PDA) is highly prevalent in pre-term neonates (PTN) and has been recognized as a neonatal co-morbidity. The purpose of this study was to determine if levels of brain (or B-type) natriuretic peptide (BNP), a peptide secreted by ventricular myocytes in response to volume or pressure overload, correlate with the size of the PDA. In a prospective design, 52 PTN (no PDA: n=24; PDA: n=28) were studied after obtaining parental consent. Those with genetic anomalies and congenital heart disease, except for PDA and patent foramen ovale, were excluded. Echocardiographic estimates of the diameters of the PDA (or absence of PDA) were made concurrently with capillary blood collection for BNP assay. BNP levels in samples from PTN without PDA were 23.6 ng/L (median); 13.1 to 32.3 ng/L (IQR); initial samples (between days 3 and 7 of life) with small PDA (n=11), median 66.1 ng/L; 55.5 to 85.3 ng/L (IQR); with moderate PDA (n=6) median 284 ng/L; 204 to 622 ng/L (IQR); and with large PDA (n=11) 2410 ng/L median; 420 to 2770 ng/L (IQR). (p< 0.0001 for ANOVA; groupwise: p<0.05 for both no PDA vs. moderate and large PDA); Trend analysis suggested a strong association of BNP with size of PDA (p<0.001). Of 17 subjects with moderate to large PDA, pre and post-treatment (Ibuprofen; per standard protocol) data were obtained on 12 subjects. Pre-treatment BNP ranged from 111 to 5000 ng/L; post-treatment BNP decreased to 5.0 to 262 ng/L (p = 0.0005). Estimates of decision levels for treatment were made by examining dichotomized groups, i.e., no-to-small vs. moderate-to-large and using receiver-operator characteristic (ROC) curve analysis yielding a value of 123 ng/L. BNP may obviate repeated echocardiography as follow up after treatment, or to monitor future course of respiratory distress secondary to PDA in PTN.