Positive Culture Samples of Infants with Neonatal Infections in a Tertiary Neonatal Center in Isfahan, Iran.

BACKGROUND: The prevalence of microorganisms in the neonatal intensive care unit (NICU) and neonatal internal wards is constantly changing, thus rendering the practice of empiric antibiotic therapy ineffective due to the resistance of these microorganisms. Therefore, the purpose of this study was to determine the relative frequency of positive cultures of Bactec, blood, cerebrospinal fluid (CSF) and urine in infants admitted to the NICU and neonatal internal ward in Al-Zahra hospital in 2011-2017. METHODS: In this cross-sectional descriptive study, we evaluated 466 positive culture samples from 2853 different cultures (blood, urine, CSF, etc) from infants admitted to the NICU and neonatal internal ward with clinical signs of neonatal infection in Al-Zahra hospital. Isfahan in 2011-2017. The samples were evaluated for type of microorganisms and sensitivity to antibiotics. RESULTS: Positive cultures among Bactec, blood, CSF and urine culture samples were reported at 15.5% (95% confidence interval [CI]: 12.8-18.1) 9.3% (95% CI: 6.8-11.7), 6.4% (95% CI: 4.3-8) and 28.6% (95% CI: 25.4-31.7), respectively. Staphylococcus epidermidis was the most common species in Bactec (46.7%; 95% CI: 38.7-54.6), blood (53.1%; 95% CI: 39.1-67), and CSF (37.1%; 95% CI: 21-53.1) cultures while Klebsiella pneumoniae was the most frequent species in urine culture (28%; 95% CI: 22.2-33.7). CONCLUSION: Considering the results of Bactec and blood cultures, it is essential to reduce staphylococcal infections in our settings.

Heated Humidified High Flow Nasal Cannula (HHHFNC) is not an effective method for initial treatment of Respiratory Distress Syndrome (RDS) versus nasal intermittent mandatory ventilation (NIMV) and nasal continuous positive airway pressure (NCPAP).

BACKGROUND: Noninvasive respiratory support techniques are widely used to treat respiratory distress syndrome (RDS) in preterm infants, and the effectiveness of these methods should be compared. In the current study, nasal continuous positive airway pressure (NCPAP), nasal intermittent mandatory ventilation (NIMV), and heated humidified high-flow nasal cannula (HHHFNC) were compared. MATERIALS AND METHODS: In the current bicenter clinical trial, 109 preterm infants with RDS not treated with surfactant were randomly assigned to three groups: NCPAP, NIMV, and HHHFNC. The initial outcomes including the failure of treatment within the first initial 72 h, and the duration of RDS treatment, and the secondary outcomes including the need for intubation, the need for surfactants, the duration of oxygen dependency, the incidence of pneumothorax, the patent ductus arteriosus, intraventricular hemorrhage, length of stay, and mortality were compared among the groups. RESULTS: The frequency of HHHFNC treatment failure (54.3%) was significantly higher compared with those of NIMV (21.6%) (P < 0.001, hazard ratio [HR] = 9.12, 95% confidence interval [CI] = 2.59 - 32.07) and NCPAP (35.1%) (P = 0.004, HR = 21.25, 95% CI = 2.51-180.08). The median duration of RDS treatment was longer (40 h) in the HHHFNC group, although it was not significantly different from those of NIMV (31.16 h) and NCPAP (38.91 h). CONCLUSION: Based on the high prevalence of failure of HHHFNC treatment than the other two methods (NCPAP and NIMV), HHHFNC is not recommended as the initial treatment of RDS.

Prebiotics for the prevention of hyperbilirubinaemia in neonates.

BACKGROUND: Hyperbilirubinaemia occurs in approximately two-thirds of all newborns during the first days of life and is frequently treated with phototherapy. Although generally seen as safe, there is rising concern regarding phototherapy and its potentially damaging effects on DNA and increased side effects particularly for preterm infants. Other methods, such as enteral feeding supplementation with prebiotics, may have an effective use in the management of hyperbilirubinaemia in neonates. OBJECTIVES: To determine whether administration of prebiotics reduces the incidence of hyperbilirubinaemia among term and preterm infants compared with enteral supplementation of milk with distilled water/placebo or no supplementation. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 14 June 2018), Embase (1980 to 14 June 2018), and CINAHL (1982 to 14 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. SELECTION CRITERIA: We considered all RCTs that studied neonates comparing enteral feeding supplementation with prebiotics versus distilled water/placebo or no supplementation. DATA COLLECTION AND ANALYSIS: Two reviewers screened papers and extracted data from selected papers. We used a fixed-effect method in combining the effects of studies that were sufficiently similar. We then used the GRADE approach to assess the quality of the evidence. MAIN RESULTS: Three small studies evaluating 154 infants were included in this review. One study reported a significant reduction in the risk of hyperbilirubinaemia and rate of treatment with phototherapy associated with enteral supplementation with prebiotics (risk ratio (RR) 0.75, 95% confidence interval (95% CI) 0.58 to 0.97; one study, 50 infants; low-quality evidence). Meta-analyses of two studies showed no significant difference in maximum plasma unconjugated bilirubin levels in infants with prebiotic supplementation (mean difference (MD) 0.14 mg/dL, 95% CI -0.91 to 1.20, I² = 81%, P = 0.79; two studies, 78 infants; low-quality evidence). There was no evidence of a significant difference in duration of phototherapy between the prebiotic and control groups, which was only reported by one study (MD 0.10 days, 95% CI -2.00 to 2.20; one study, 50 infants; low-quality evidence). The meta-analyses of two studies demonstrated a significant reduction in the length of hospital stay (MD -10.57 days, 95% CI -17.81 to -3.33; 2 studies, 78 infants; I² = 0%, P = 0.004; low-quality evidence). Meta-analysis of the three studies showed a significant increase in stool frequency in the prebiotic groups (MD 1.18, 95% CI 0.90 to 1.46, I² = 90%; 3 studies, 154 infants; high-quality evidence). No significant difference in mortality during hospital stay after enteral supplementation with prebiotics was reported (typical RR 0.94, 95% CI 0.14 to 6.19; I² = 6%, P = 0.95; 2 studies; 78 infants; low-quality evidence). There were no reports of the need for exchange transfusion and incidence of acute bilirubin encephalopathy, chronic bilirubin encephalopathy, and major neurodevelopmental disability in the included studies. None of the included studies reported any side effects. AUTHORS' CONCLUSIONS: Current studies are unable to provide reliable evidence about the effectiveness of prebiotics on hyperbilirubinaemia. Additional large, well-designed RCTs should be undertaken in neonates that compare effects of enteral supplementation with prebiotics on neonatal hyperbilirubinaemia with supplementation of milk with any other placebo (particularly distilled water) or no supplementation.

The Prevalence of Complications of Prematurity among 1000 Newborns in Isfahan, Iran.

BACKGROUND: Different morbidity conditions are globally reported from different nations for premature infants. The aim of this study was to identify the relative frequency of some of the most important complications of prematurity in a population of about 1000 of very low birth weight (VLBW; i.e., infants with weight of <1500 g) premature infants in our city and publish the results of the project at the level of the urban community of Isfahan in order to use it for further decisions. MATERIALS AND METHODS: Demographic characteristics and information of prematurity complications of 1000-registered VLBW premature infants were collected and analyzed. RESULTS: The mean gestational age and birth weight were 30.19 ± 2.26 weeks and 1223.96 ± 227.77 g, respectively. Seven hundred and ninety-eight individuals (79.69%) had respiratory distress syndrome (RDS) which also had the most prevalence frequency, whereas the number of newborns who had chronic lung disease was 80, with the lowest prevalence of 8.01%. The prevalence of infantile mortality was 3.10%. CONCLUSION: Regarding advances in medical technologies and caring system, the mortality rate for premature neonates, even VLBW infants, has decreased significantly and survival rates are grown. Alongside the low death rates, managing complications related to prematurity period should be considered more, especially caring for respiratory management should be considered remarkably since RDS stands as the most prevalent disease among them. Efforts also should be made to reduce the number of diseases that worsen the prognosis, such as intraventricular hemorrhage.

The effect of neutral oligosaccharides on fecal microbiota in premature infants fed exclusively with breast milk: A randomized clinical trial.

OBJECTIVE: This study was designed to compare the efficacy and safety of enteral supplementation of a prebiotic mixture (SCGOS/LCFOS) on faecal microbiota in very premature infants who fed exclusively with human-milk. METHODS: This double-center randomized control trial was conducted from December 2012 to November 2013 in the tertiary Neonatal Intensive Care Units of the Isfahan University of Medical Sciences. Fifty preterm infants (birth weight ≤1500 g who were not fed with formula) were randomly allocated to have enteral (tube feeding) supplementation with a prebiotic mixture (SCGOS/LCFOS; 9:1) or receive no prebiotics. FINDINGS: The primary outcome (e.g., the effect of the prebiotic mixture on fecal microbiota pattern) was clearly different between the two groups. Despite greater coliforms colony counts in first stool cultures in the prebiotic group (Group P) (P = 0.67), coliforms were significantly lower in the third stool cultures in the Group P (P < 0.001). Furthermore, despite the much higher Lactobacillus colony counts, in the first stool cultures, in the control group (Group C) (P = 0.005); there was a trend toward significantly increased Lactobacillus colony counts in the Group P during the study, but the difference between Lactobacillus colony counts, in the third stool cultures, between two groups was no longer statistically significant (P = 0.11). Interestingly, the median length of hospital stay was significantly less in the Group P (16 [12.50-23.50] vs. 25 [19.50-33.00] days; P = 0.003). CONCLUSION: This suggests that it might have been "the complete removal of formula" which manifests a synergistic effect between nonhuman neutral oligosaccharides (prebiotics) and human oligosaccharides, which in turn, led to the rapid growth of beneficial Lactobacillus colonies in the gut of breast milk-fed preterm infants, while decreasing the number of pathogenic coliforms microorganisms. Therefore, further studies with larger sample sizes are recommended to investigate the issue.

Caffeine Administration to Prevent Apnea in Very Premature Infants.

BACKGROUND: Apnea intervals frequently occur in premature infants. Periods of apnea occur more often with decreases in gestational age. Periods of apnea can cause damage to the infant's developing brain and other organs. This study was designed to investigate the preventive effects of caffeine on apnea incidence in higher-risk neonates. METHODS: In this single-center randomized control trial study, premature infants with a birth weight of ≤1200 g were eligible for enrollment. Twenty-six infants were randomly assigned to receive 20 mg/kg caffeine, as the loading dose, which was followed by 5 mg/kg daily as the maintenance dose until the 10th day of life; these infants were compared with 26 infants in the control group. Primary outcomes were incidence of apnea, bradycardia, and cyanosis. RESULTS: Fifty-two infants were enrolled (26 in the caffeine group and 26 in the control group). The preventive effect of caffeine on apnea was significant in these infants. The relative risk for incidence of apnea in preterm neonates with a birth weight of <1200 g was 0.250 (95% confidence interval, 0.097-0.647). Only four infants (15.4%) in the caffeine group developed apnea, compared with 16 (61.5%) in the control group (p = 0.001). CONCLUSION: It seems that preventative effects of caffeine on apnea become apparent by using the drug in very premature infants.

Prebiotics for the management of hyperbilirubinemia in preterm neonates.

OBJECTIVE: We evaluated if prebiotics have benefits for the management of hyperbilirubinemia in preterm neonates. METHODS: Preterm neonates were entered into the study when enteral feeding volume met 30 mL/kg/day. They randomly received a mixture of short-chain galacto-oligosacarids/long-chain fructo-oligosacarids or distilled water (placebo) for 1 week. Total serum bilirubin level was measured by transcutaneous bilirubinometry. Stool frequency and meeting full enteral feeding during the study period were considered as secondary outcomes. RESULTS: Twenty-five neonates in each group completed the trial. Bilirubin level was decreased with the prebiotic (-1.3 ± 1.8 mg/dL, p = 0.004), but not placebo (-0.1 ± 3.3 mg/dL, p = 0.416). Peak bilirubin level was lower with the prebiotic than placebo (8.3 ± 1.7 versus 10.1 ± 2.2 mg/dL, p = 0.003). Stool frequency was increased with the prebiotic (0.7 ± 1.9 defecation/day, p = 0.014), but not with placebo (0.6 ± 1.5 defecation/day, p = 0.133). Average stool frequency (2.4 ± 0.4 versus 1.9 ± 0.5 defecation/day, p = 0.003) and frequently of meeting full enteral feeding (60% versus 16%, p = 0.002) were higher with the prebiotic than placebo. CONCLUSIONS: Prebiotic oligosaccharides increase stool frequency, improve feeding tolerance and reduce bilirubin level in preterm neonates and therefore can be efficacious for the management of neonatal hyperbilirubinemia.

The Effect of Neutral Oligosaccharides on Reducing the Incidence of Necrotizing Enterocolitis in Preterm infants: A Randomized Clinical Trial.

BACKGROUND: Necrotizing enterocolitis (NEC) is one of the most destructive diseases associated with conditions of neonatal prematurity. Supplementation with enteral prebiotics may reduce the incidence of NEC, especially in infants who fed exclusively with breast-milk. Therefore, we compared the efficacy and safety of enteral supplementation of a prebiotic mixture (short chain galacto-oligosaccharides/long chain fructo-oligosaccharides [SCGOS/LCFOS]) versus no intervention on incidence of NEC in preterm infants. METHODS: In a single-center randomized control trial 75 preterm infants (birth weight [BW] ≤1500 g, gestational age ≤34 weeks and were not fed with formula) on 30 ml/kg/day volume of breast-milk were randomly allocated to have enteral supplementation with a prebiotic mixture (SCGOS/LCFOS; 9:1) or not receive any prebiotic. The incidence of suspected NEC, feeding intolerance, time to full enteral feeds, duration of hospitalization were investigated. RESULTS: Differences in demographic characteristics were not statistically important. SCGOS/LCFOS mixture significantly reduced the incidence of suspected NEC, (1 [4.0%] vs. 11 [22.0%]; hazard ratio: 0.49 [95% confidence interval: 0.29-0.84]; P = 0.002), and time to full enteral feeds (11 [7-21] vs. 14 [8-36] days; P - 0.02]. Also duration of hospitalization was meaningfully shorter in the prebiotic group (16 [9-45] vs. 25 [11-80]; P - 0.004]. Prebiotic oligosaccharides were well tolerated by very low BW (VLBW) infants. CONCLUSIONS: Enteral supplementation with prebiotic significantly reduced the incidence of NEC in VLBW infants who were fed exclusively breast-milk. This finding suggests that it might have been the complete removal of formula which caused a synergistic effect between nonhuman neutral oligosaccharides (prebiotic) and human oligosaccharides.

Prophylactic aminophylline for prevention of apnea at higher-risk preterm neonates.

BACKGROUND: A few studies have been carried on preventive drugs for apnea of preterm neonates. OBJECTIVES: This study aimed to assess the safety and prophylactic effects of aminophylline on the incidence of apnea in premature neonates. PATIENTS AND METHODS: This study was a randomized clinical trial (RCT) research. The prophylactic effect of aminophylline on apnea was investigated in premature babies in our NICU (IRAN-Isfahan). In the study group (A), 5 mg/kg aminophylline was initially administered as a loading dose. Then, every 8 hours, 1.5 mg/kg was given as maintenance dose for the next 10 days. In the control group (C), no aminophylline was used during the first ten days of life. RESULTS: Fifty-two neonates were randomized for the study and all of them completed it. Primary outcomes were clearly different between the two groups. Only 2 infants (7.7%) who had been placed in aminophylline group developed apnea, as compared to 16 infants (61.5%) in the control group (P < 0.001). Three and four neonates (11.5%, 15.4%) in the aminophylline group developed bradycardia and cyanosis respectively, as compared to 16 infants (61.5%) who did not receive aminophylline (P < 0.001). Median time of need to NCPAP (Nasal Continuous Positive Airway Pressure) was 1 (0 - 4) days and 2.5 (0.5 - 6.5) days in group A and C, respectively (P = 0.03). No side effects were reported in neonates (P > 0.999). Median time of hospitalization was shorter in aminophylline group (P = 0.04). CONCLUSIONS: This study supports the preventative effects of aminophylline on apnea in extreme premature infants. In other words, the more premature an infant, the greater the preventative effect of aminophylline on the incidence of apnea and bradycardia.

Reducing the incidence of chronic lung disease in very premature infants with aminophylline.

BACKGROUND: The objective of this study is to assess the safety and preventative effects of aminophylline on the incidence of chronic lung disease (CLD) in very premature infants. METHODS: This was a long follow-up randomized clinical trial. The prophylactic effect of aminophylline on the incidence of CLD was investigated in very premature infants. The study group received aminophylline for the 1(st) 10 days of life and control infants received no aminophylline during the 1(st) 10 days of life. RESULTS: Fifty-two infants participated (26 aminophylline, 26 controls). Premature infants on aminophylline had clearly shorter oxygen dependency time than those in the control group. Median time of oxygen dependency was 3 (0-9.5) days and 14 (3-40.5) days in group A and C, respectively (P: 0.001). Incidence of CLD was significantly different between the two groups. Only two infants (8.7%) on aminophylline developed CLD, when compared to 11 infants (44.0%), who did not receive aminophylline (P: 0.006). No side-effects were reported in the neonates (P: 1). CONCLUSIONS: This study supports the preventative effects of aminophylline on the incidence of CLD in very premature infants. In other words, the more premature the infants, the greater will be the preventative effect of aminophylline on the incidence of CLD.

Initial Treatment of Respiratory Distress Syndrome with Nasal Intermittent Mandatory Ventilation versus Nasal Continuous Positive Airway Pressure: A Randomized Controlled Trial.

BACKGROUND: Neonatal respiratory distress syndrome (RDS) in premature infants who survived and its complications are a common problem. Due to high morbidity and mechanical ventilation (MV) nowadays researchers in interested minimizing MV. To determine, in very low birth weight (BW) preterm neonates with RDS, if initial treatment with nasal intermittent mandatory ventilation (early NIMV) compared with early nasal continuous positive airway pressure (early NCPAP) obtains more favorable outcomes in terms of the duration of treatment, and the need for endotracheal tube ventilation. METHODS: In this single-center randomized control trial study, infants (BW ≤ 1500 g and/or gestational age ≤ 34 weeks) with respiratory distress were considered eligible. Forty-four infants were randomly assigned to receive early-NIMV and 54 comparable infants to early-NCPAP. Surfactants were given, when FIO2 requirement was of >30%. Primary outcomes were failure of noninvasive respiratory support, that is, the need for MV in the first 48 h of life and for the duration of noninvasive respiratory support in each group. RESULTS: 98 infants were enrolled (44 in the NIMV and 54 in the NCPAP group). The Preventive power of MV of NIMV usage (95.5%) was not lower than the NCPAP (98.1%) strength (hazard ratio: 0.21 (95% confidence interval: 0.02-2.66); P: 0.23). The duration of noninvasive respiratory support in the NIMV group was significantly shorter than NCPAP (the median (range) was 24 (18.00-48.00) h versus 48.00 (22.00-120.00) h in NIMV versus NCPAP groups; P < 0.001). Similarly, the duration of dependency on oxygen was less, for NIMV (the median (range) was 96.00 (41.00-504.00) h versus144.00 (70.00-1130.00) h in NIMV versus NCPAP groups; P: 0.009). Interestingly, time to full enteral feeds and length of hospital stay were more favorable in the NIMV versus the NCPAP group. CONCLUSIONS: Initial treatment of RDS with NIMV was safe, and well tolerated. Furthermore, NIMV had excellent benefits such as reduction of the duration of treatment, oxygen dependency period and length of hospital stay. Therefore, the primary mode with NIMV could be a feasible method of noninvasive ventilation in very premature infants.