Prolonged intravenous immunoglobulin treatment in very low birth weight infants with late onset sepsis

BACKGROUND

Neonatal infections are a leading cause of morbi-mortality despite advances in antimicrobials and neonatal care. Preterm infants have greater susceptibility to sepsis due to an immature immune system and lower immunoglobulin levels. Intravenous immunoglobulins (IVIG) have been used in several studies as an adjuvant treatment to improve this physiological immune deficiency, with different outcomes.

METHODS

Very low birth weight (VLBW) infants who developed sepsis in the neonatal ICU were studied. They were randomly divided in 2 groups: one group was treated with antibiotics (Group I), and the other received antibiotics plus a 500 mg/kg/day of IVIG during 7 days (Group II). Serum IgG concentration was determined at initiation, during and after treatment Group I, and daily during the 7 days of therapy in Group II.

RESULTS

The baseline IgG concentration in group II was 486 g/dL, and increased to 852 mg/dL after the first dose of IVIG (p < 0.01). After the seventh day of infusion a mean IgG level of 1898 mg/dL was achieved. A direct correlation (r = 0.94) between IgG concentration and days of treatment was observed. Blood cultures were positive in 70% of the infants in group I and 75.5% in group II. Staphylococcus epidermidis was the most frequent isolated bacteria in blood cultures. The lethality rate was 25.0% in group I and 5.0% in Group II (p < 0.03). We did not observe collateral effects with the administration of IVIG.

CONCLUSIONS

Prolonged therapy with IVIG seems to be safe and effective as an adjuvant treatment in VLBW infants with sepsis.

Neonatal and infant mortality of very-low-birth-weight infants in Taiwan: Does the level of delivery hospital matter?

BACKGROUND

To study the distribution of the birthplaces of very-low-birth-weight (VLBW) infants and examine whether delivery at different levels of hospital affects neonatal and infant mortality.

METHODS

This population-based cohort study was retrieved from Taiwan Maternal and Child Health Database. Livebirth singleton VLBW infants born between 2011 and 2014, with BW between 500 and 1499 g and gestational age ≥22 weeks were enrolled. The main outcomes were risk-adjusted odds ratios (aOR) of neonatal and infant mortality by birthplace, which was categorized as medical center (MC), regional hospital (RH), district hospital (DH), and clinic (C) based on Taiwan's hospital accreditation system.

RESULTS

Of 4560 VLBW infants enrolled, 3005 (66%) were born in MCs, 1181 (26%) in RHs, 213 (5%) in DHs, and 161 (4%) in Cs. Neonatal mortality rates were 10%, 15%, 16%, 17%, and infant mortality rates were 13%, 17%, 18%, 21%, if born in MCs, RHs, DHs and Cs, respectively. The aORs for neonatal and infant mortality were 1.94 (95% CI 1.53-2.48) and 1.67 (1.34-2.08) for those born in RHs, 2.26 (1.38-3.70) and 1.82 (1.16-2.86) for infants born in DHs/Cs, as compared to those born in MCs. For VLBW infants born in RHs, DHs, and Cs and postnatally transferred to MCs, the aORs of neonatal and infant mortality were lower than those who were not transferred.

CONCLUSION

VLBW infants born outside of MCs had higher neonatal and infant mortality and a two-fold higher risk of mortality than those born in MCs. When possible, VLBW infants should be born in MCs.

More than Just a Fad: Building and Maintaining a Small Baby Program

Survival rate for preterm infants has improved significantly in the last decade because of advancements in care provided by NICUs. Yet, a large proportion of extremely low birth weight (ELBW) infants continue to be at risk of being discharged home from NICUs with long-term co-morbidities. Several centers have introduced and described the concept of a focused program on the care of micro-preemies and demonstrated improved processes as well as outcomes utilizing a continuous improvement approach with adoption of standardized guidelines, checklists, and shared team values. The journey and effort that it takes to develop and sustain such a program have been described less. This article discusses the process of building a Small Baby Program using a change model framework, how the organization and staff bought into the concept, as well as the accomplishments and challenges experienced during the last 3 years as the program continues to evolve and grow.

The role of early-onset-sepsis in the neurodevelopment of very low birth weight infants

AIMS

The study investigated a putative association between early-onset-sepsis (EOS) and poor neurodevelopmental outcomes at 2 years corrected age in very low birth weight infants.

METHODS

This was a single-center cohort study on infants weighing less than 1500 g with a gestational age below 35 weeks at birth born between 2008 and 2011. Neurodevelopmental outcomes were assessed at follow-up with the Bayley Scales of Infant Development-II. EOS was defined as either culture-proven EOS or clinical EOS using blood culture, CrP levels, and clinical symptoms and treatment. Neurodevelopmental impairment (NDI) was defined as one or more of the following: Mental Developmental Index (MDI) and/or Psychomotor Developmental Index (PDI) scores lower than 70; presence of cerebral palsy.

RESULTS

Of 405 eligible newborns in the study period 166 were included. Two had culture-proven and 29 clinical EOS. Median MDI scores in patients with EOS were 96 (IQR: 86-106) and in the control group 94 (84-106, p = 0.77). PDI scores in patients with EOS were 96 (86-106) and in the control group 99,5 (92-103, p = 0.03). Of infected patients 7/31 (24%) showed NDI as defined, whereas only 11/135 (8%) showed NDI in the control group (OR 3.3, p = 0.03). Multiple regression analyses identified chorioamnionitis and poor CRIB-Scores as individual risk factors for MDI or PDI values < 70.

CONCLUSION

In our study, EOS among VLBW-infants significantly impaired the neurodevelopment at 2 years corrected age. As shown in previous reports infection continues to be a problem and strategies for a reduction need further improvement.

Neonatal Hyperglycemia Related to Parenteral Nutrition Affects Long-Term Neurodevelopment in Preterm Newborn: A Prospective Cohort Study

(1) Background: Recent evidence reported a reduced tolerance of macronutrient parenteral intakes in subjects in critically ill conditions. We designed a prospective cohort study to evaluate the effects of hyperglycemia (HG) related to parenteral nutrition (PN) on neurodevelopment (NDV) in survived preterm newborns. (2) Methods: Enrolled newborns with gestational age < 32 weeks or birth weight < 1500 g, were divided in two cohorts: (A) exposed to moderate or severe HG (glucose blood level > 180 mg/dL) in the first week of life; (B) not exposed to HG. We considered as the primary outcome the rate of preterm newborns survived without NDV delay at 24 months of life, evaluated with Bayley Scales of Infants Development III edition. (3) Results: We analyzed 108 (A 32 vs. B 76) at 24 months of life. Newborns in cohort A showed a higher rate of cognitive and motor delay (A 44% vs. B 22 %, p = 0.024; A 38% vs. B 8%, p < 0.001). When adjusting for background characteristics, HG remained a risk factor for motor delay. (4) Conclusions: High nutritional intakes through PN soon after birth increase the risk of HG. The consequences of this severe metabolic complication affect long-term NDV and survival in preterm newborns.

Lipid Intake and Neurodevelopment in Preterm Infants

Preterm infants are born before the critical period of lipid accretion and brain development that occurs during the third trimester of pregnancy. Dietary lipids serve as an important source of energy and are involved in complex processes that are essential for normal central nervous system development. In addition to traditional neurodevelopmental testing, novel quantitative magnetic resonance imaging (MRI) techniques are now available to evaluate the impact of nutritional interventions on early preterm brain development. Trials of long-chain polyunsaturated fatty acid supplementation have yielded inconsistent effects on neurodevelopmental outcomes and quantitative MRI findings. Recent studies using quantitative MRI suggest a positive impact of early lipid intake on brain volumes and white matter microstructural organization by term-equivalent age.

Short-term outcome of very low-birth-weight infants in a tertiary care hospital in Saudi Arabia over a decade

BACKGROUND

Knowledge on short-term outcomes of preterm infants is important for quality control. Our objective was to analyze the outcomes of very low birth weight infants admitted to our neonatal intensive care unit over a ten years' period and to compare the results with internationally published data.

METHODS

We analyzed the outcome measures for all live born infants with birth weight (BW) of 400-1500 grams and gestational age (GA) of 23-32 weeks born at King Faisal Specialist Hospital & Research Centre between 2006 and 2015. Results were compared to data from four international neonatal networks.

RESULTS

During the study period, we admitted 528 infants born at a gestational age of≥23 and≤32 weeks with a very low birth weight (VLBW) of 400-1500 grams. Mean (SD) GA was 28 (2.4) weeks and mean (SD) BW was 1007 (290) grams. A hundred and twenty-nine (24.4%) infants were small for gestational age and major congenital anomalies were present in 56 (10.6 %) infants. The rate of bronchopulmonary dysplasia (BPD) was 24.4 %, necrotizing enterocolitis (NEC) 9.1%, patent ductus arteriosus (PDA) 29.9%, severe intraventricular hemorrhage (IVH)10.8 %, periventricular leukomalacia (PVL) 5.7%, severe retinopathy of prematurity (ROP) 8%, and late-onset sepsis was 18.8%. The incidences of major neonatal outcomes such as CLD, NEC, severe IVH and severe ROP were comparable to the international cohorts.

CONCLUSION

In our population of preterm infants, survival rates and complications of prematurity were comparable to international data.

Late onset of pulmonary hypertension in very low birth weight infants

INTRODUCTION

Pulmonary hypertension (PH) is a recognized complication of bronchopulmonary dysplasia (BPD). Recent guidelines recommend evaluating all infants with BPD for PH via echocardiogram, but the specific timing of this screening is controversial. We aimed to identify the timing of PH diagnosis in a cohort of very low birthweight infants (VLBW) to determine appropriate age at screening.

METHODS

We retrospectively reviewed data on 455 VLBW infants undergoing echocardiography at our institution. The timing of all echocardiograms, PH diagnosis on echocardiography, and BPD diagnosis at 36 weeks corrected age were extracted. PH was defined as dilation of the right sided chambers or RVH, flattening or leftward deviation of the septum, TR >25 mmHg, or 2/3 systemic pressures, or right to left shunting.

RESULTS

Fifteen VLBW infants had PH identified on echocardiography, of whom 11 had BPD and 2 died before BPD status at 36 weeks could be ascertained. PH was most often identified on echocardiography after 36 weeks corrected age, and typically around 40 weeks. Ten of the infants ultimately diagnosed with PH had previous echocardiograms performed that were negative for PH at 25-46 weeks.

CONCLUSIONS

In our cohort of VLBW infants, onset of PH was typically found later than the 36-38 week range used by recently described screening programs. These findings suggest a need to examine echocardiograms obtained after 36 weeks for evidence of late-onset PH in vulnerable infants born at VLBW.

Spontaneous Closure of the Ductus Arteriosus in Preterm Infants: A Systematic Review

The optimal management strategy for patent ductus arteriosus in preterm infants remains a topic of debate. Available evidence for a treatment strategy might be biased by the delayed spontaneous closure of the ductus arteriosus in preterm infants, which appears to depend on patient characteristics. We performed a systematic review of all literature on PDA studies to collect patient characteristics and reported numbers of patients with a ductus arteriosus and spontaneous closure. Spontaneous closure rates showed a high variability but were lowest in studies that only included preterm infants with gestational ages below 28 weeks or birth weights below 1,000 g (34% on day 4; 41% on day 7) compared to studies that also included infants with higher gestational ages or higher birth weights (up to 55% on day 3 and 78% on day 7). The probability of spontaneous closure of the ductus arteriosus keeps increasing until at least 1 week after birth which favors delayed treatment of only those infants that do not show spontaneous closure. Better prediction of the spontaneous closure of the ductus arteriosus in the individual newborn is a key factor to find the optimal management strategy for PDA in preterm infants.

Potential risk modifiers for severe intraventricular hemorrhage in very low birthweight infants requiring transport

BACKGROUND

Very low birthweight (VLBW) infants must undergo transport when born at a facility unequipped for their care. Previous research suggests an increased risk for intraventricular hemorrhage (IVH) associated with transport. It is unknown whether logistical aspects of transport, particularly mode and distance, or skill level of the resuscitation team are drivers of risk.

OBJECTIVE

To determine if the transport vehicle, distance traveled, or absence of advanced resuscitation team increased risk for severe IVH in outborn VLBW infants.

DESIGN/METHODS

Outborn VLBW infants, transported by specialized team via helicopter or ambulance to a Level IV NICU, were included; inborn VLBW infants served as controls. Infants transported >24 h after birth, by referring center's team, or without head ultrasound were excluded. Baseline clinical data were collected along with IVH grade, transport vehicle, distance traveled, and skill of resuscitation team.

RESULTS

Two hundred and ninety-three outborn were matched to 293 inborn infants. Outborn infants had increased incidence of severe IVH even when controlling for antenatal steroids, race, delivery method, and surfactant use (17% vs. 11%, OR = 1.6, 95% CI = 1.1-2.7). Despite this increased incidence, severe IVH was not associated with transport vehicle (p = .90; OR = 0.76, 95% CI = 0.34-1.7), distance traveled (p = .13; OR 0.84, 95% CI = 0.60-1.2), or skill of resuscitation team (p = .18; OR = 0.49, 95% CI = 0.21-1.1).

CONCLUSION

Compared to inborn, outborn infants had increased risk of severe IVH. Transport vehicle, distance traveled, and the skill of resuscitation team did not significantly impact risk.

Early Protein Intake Influences Neonatal Brain Measurements in Preterms: An Observational Study

Introduction: To limit extrauterine growth restriction, recent guidelines on nutrition of preterm neonates recommended high protein intake since the first day of life (DOL). The impact of this nutritional strategy on the brain is still controversial. We aimed to evaluate the effects of protein intake on early cerebral growth in very low birth weight newborns.

Materials and Methods: We performed serial cranial ultrasound (cUS) scans at 3–7 DOL and at 28 DOL in very low birth weight newborns consecutively observed in the neonatal intensive care unit. We analyzed the relation between protein intake and cerebral measurements at 28 DOL performed by cUS.

Results: We enrolled 100 newborns (gestational age 29 ± 2 weeks, birth weight 1,274 ± 363 g). A significant (p < 0.05) positive correlation between enteral protein intake and biparietal diameter (r = 0.490^**), occipital–frontal diameter (r = 0.608^**), corpus callosum (length r = 0.293^*, genu r = 0.301^*), caudate head (right r = 0.528^**, left r = 0.364^**), and cerebellum (transverse diameter r = 0.440^**, vermis height r = 0.356^**, vermis width r = 0.377^**) was observed at 28 DOL. Conversely, we found a significant negative correlation of protein intake given by parenteral nutrition (PN) with biparietal diameter (r = −0.524^**), occipital–frontal diameter (r = −0.568^**), body of corpus callosum (r = −0.276^*), caudate head (right r = −0.613^**, left r = −0.444^**), and cerebellum (transverse diameter r = −0.403^**, vermis height r = −0.274^*, vermis width r = −0.462^**) at 28 DOL. Multivariate regression analysis showed that measurements of occipital–frontal diameter, caudate head, and cerebellar vermis at 28 DOL depend positively on protein enteral intake (r = 0.402^*, r = 0.305^*, and r = 0.271^*) and negatively by protein parenteral intake (r = −0.278^*, r = −0.488^*, and r = −0.342^*).

Conclusion: Brain development in neonatal life depends on early protein intake. High protein intake affects cerebral structures' measurements of preterm newborn when administered by PN. Positive impact on brain development encourages the administration of recommended protein intake mainly by enteral nutrition.

Improved brain growth and microstructural development in breast milk-fed very low birth weight premature infants

AIM

Breast milk feeding is linked to improved neurodevelopmental outcomes in very low birth weight (VLBW) infants, though the mechanisms are not well understood. This study utilised quantitative magnetic resonance imaging (qMRI) techniques to compare brain growth and white matter development in preterm infants receiving primarily breast milk versus formula feeds.

METHODS

We prospectively enrolled infants born at very low birth weight (<1500 g) and <32 weeks gestational age and performed MRI at term-equivalent age. We utilised volumetric segmentation to calculate regional and total brain volumes and diffusion tensor imaging to evaluate white matter microstructural organisation. Daily nutritional data were extracted from the medical record.

RESULTS

Nutritional and MRI data were obtained for 68 infants admitted within the first week of life (44 breast milk and 24 formula). Breast milk-fed infants demonstrated significantly larger total brain volumes (P = .04) as well as volumes in the amygdala-hippocampus and cerebellum (P < .01) compared with formula-fed. Infants receiving breast milk also demonstrated greater white matter microstructural organisation in the corpus callosum, posterior limb of internal capsule and cerebellum (P < .01 to .03).

CONCLUSION

VLBW infants receiving primarily breast milk versus preterm formula in this small exploratory study demonstrated significantly greater regional brain volumes and white matter microstructural organisation by term-equivalent age.

Effects on Gastroesophageal Reflux of Donkey Milk-Derived Human Milk Fortifier Versus Standard Fortifier in Preterm Newborns: Additional Data from the FortiLat Study

Background: Feeding intolerance is a frequent diagnosis in very preterm infants. As seen in the FortiLat trial, human milk fortification with the new donkey milk-derived human milk fortifier (DF) seems to improve feeding tolerance in these infants. The aim of this study was to evaluate the effects of using the DF compared with bovine milk-derived fortifier (BF) on gastroesophageal reflux (GER) in very low birth weight (VLBW) infants. Methods: Over a total of 156 preterm infants were enrolled into the FortiLat trial (GA <32 weeks and birth weight <1500 g) and randomized into the BF arm or DF arm, and we selected all infants with clinical signs of GER and cardiorespiratory (CR) symptoms. All the infants underwent CR and multichannel intraluminal impedance and pH (MII/pH) monitoring associated with gastric ultrasound to evaluate GER and gastric emptying time. Results: 10 infants were enrolled, and 5 were in the DF arm. At MII/pH, infants enrolled into the DF arm showed a lower GER frequency than BF arm infants (p = 0.036). Half gastric emptying time was similar in DF and BF arm infants (p = 0.744). Conclusion: The use of donkey-derived human milk fortifier reduced the GER frequency and consequently should be recommended in infants with feeding intolerance.

Improving Understanding of Participation and Attrition Phenomena in European Cohort Studies: Protocol for a Multi-Situated Qualitative Study

BACKGROUND

Cohort studies represent a strong methodology for increasing one's understanding of human life-course development and etiological mechanisms. Retention of participants, especially during long follow-up periods, is, however, a major challenge. A better understanding of the motives for participation and attrition in cohort studies in diverse sociogeographic and cultural settings is needed, as this information is most useful in developing effective retention strategies.

OBJECTIVE

This study aims to improve our understanding of participation and attrition phenomena in a European cohort study of very preterm/very-low-birth-weight (VPT/VLBW) infants from various sociogeographic and cultural settings to better understand variability and ultimately contribute to developing novel and more "in-context" strategies to improve retention.

METHODS

This study uses a triangulation of multisituated methods to collect data on various cohorts in the Research on European Children and Adults Born Preterm (RECAP) network, which include focus group discussions, individual semidriven interviews, and a collaborative, reflexive visual methodology (participant-generated VideoStories) with relevant key actors involved with these cohort studies such as adult participants, parents (caregivers), cohort staff, health care professionals, and academic researchers. The methodological strategy aims to provide a shared flexible framework of various qualitatively driven methods to collect data on VPT/VLBW adult and child cohorts, from which research partners may choose and combine those most pertinent to apply in their own specific contexts. Data from all sources and sites will be submitted to a triangulation of phenomenological thematic analysis with discourse analysis.

RESULTS

As of January 2020, in this study, we enrolled 92 participants variously involved with child and adult RECAP partnering cohorts from six countries. Multisite enrollment and data collection are expected to be completed in all seven study settings by June 2020. Findings will be reported in future publications.

CONCLUSIONS

Qualitative research methods are a useful complement for enriching and illuminating quantitative results. We expect that opting for a multisituated study approach addressing the interplay of the lived experience of individuals in both researcher and researched stances of particular cohort study settings will contribute to filling some gaps in the understanding of participation variability and effectiveness of different implemented strategies in context. Moreover, health research subjects have traditionally been positioned as passive objects of study rather than active participants, even though they have the greatest stake in improving health care policies and practices. Including collaborative methods allows us to counteract the "top-down" model by handing over some research control to the very people who are providing the data on which research findings will be based while also acknowledging the value of their involvement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14997.

Mental health outcomes of adults born very preterm or with very low birth weight: A systematic review

Preterm birth research is poised to explore the mental health of adults born very preterm(VP; <32⁺⁰ weeks gestational age) and/or very low birth weight(VLBW; <1500g) through individual participant data meta-analyses, but first the previous evidence needs to be understood. We systematically reviewed and assessed the quality of the evidence from VP/VLBW studies with mental health symptoms or disorders appearing in adulthood, excluding childhood onset disorders. Participants (≥18 years, born >1970) included VP/VLBW individuals with controls born at term(≥37⁺⁰ weeks) or with normal birth weight(NBW; ≥2500g). Thirteen studies were included. Studies consistently showed an increased risk for psychotropic medication use for VP/VLBW adults in comparison to NBW/term controls, but whether VP/VLBW adults have an increased risk for mental health disorders or symptoms appearing in adulthood remains uncertain. The quality of the evidence was moderate (65.8%) to high (34.2%). Further research in larger samples is needed.

Chronotype in very low birth weight adults - a sibling study

Chronotype is the temporal preference for activity and sleep during the 24 h day and is linked to mental and physical health, quality of life, and mortality. Later chronotypes, so-called "night owls", consistently display poorer health outcomes than "larks". Previous studies have suggested that preterm birth (<37 weeks of gestation) is associated with an earlier chronotype in children, adolescents, and young adults, but studies beyond this age are absent. Our aim was to determine if adults born preterm at very low birth weight (VLBW, ≤1500 g) display different chronotypes than their siblings. We studied VLBW adults, aged 29.9 years (SD 2.8), matched with same-sex term-born siblings as controls. A total of 123 participants, consisting of 53 sibling pairs and 17 unmatched participants, provided actigraphy-derived data on the timing, duration, and quality of sleep from 1640 nights (mean 13.3 per participant, SD 2.7). Mixed effects models provided estimates and significance tests. Compared to their siblings, VLBW adults displayed 27 min earlier sleep midpoint during free days (95% CI: 3 to 51 min, p =.029). This was also reflected in the timing of falling asleep, waking up, and sleep-debt corrected sleep midpoint. The findings were emphasized in VLBW participants born small for gestational age. VLBW adults displayed an earlier chronotype than their siblings still at age 30, which suggests that the earlier chronotype is an enduring individual trait not explained by shared family factors. This preference could provide protection from risks associated with preterm birth.

ABBREVIATIONS

AGA: Appropriate for gestational age; ELBW: Extremely low birth weight, ≤ 1000 grams; FMBR: Finnish Medical Birth Registry; HeSVA: Helsinki Study of Very low birth weight Adults; MSFsc: Midsleep on free days, corrected for sleep debt; SGA: Small for gestational age, ≤ -2 SD; VLBW: Very low birth weight, ≤ 1500 grams; WASO: Wake after sleep onset.

Portal venous gas by ultrasound in advance of impending necrotizing enterocolitis of a very low birth weight infant

Necrotizing enterocolitis (NEC) is a serious complication of premature infants, portal venous gas (PVG) under X-ray, and ultrasound is a typical manifestation of this disease. We report a case of a very low birth weight (VLBW) infant with PVG unexpectedly detected by ultrasound before the onset of NEC. After positive ultrasound result, clinical manifestations, X-ray, and lab tests confirmed the diagnosis of NEC. This is the first report of a similar case, demonstrating the value of ultrasonography in prediction or early diagnosis of NEC, which may change our understanding of the disease and the timing of examination.

Stopping caffeine in premature neonates: how long does it take for the level of caffeine to fall below the therapeutic range?

Background: Caffeine is routinely used in preterm infants for apnea of prematurity. Preterm infants are usually monitored for 5 days after discontinuation of caffeine to assess for possible recurrence of apnea. Our objective was to determine if the serum concentration of caffeine decreases to a subtherapeutic level 5 days after its discontinuation.Methods: This is a retrospective analysis of caffeine levels after the drug was discontinued in preterm neonates (birth weight ≤1500 g) born between January 2010 and June 2017. The primary outcome was the proportion of infants with therapeutic levels of caffeine 5 days after the drug was stopped.Results: Caffeine levels were measured in 353 samples from 280 infants (birth weight 1246 ± 390 g and gestational age 29.2 ± 2.4 weeks) after discontinuation of the drug. Five and more days after discontinuation of caffeine, 29.3% (82/280) of the infants had caffeine levels ≥5 mg/L. Approximately 41% (75/181) of the caffeine levels measured between 5 and 7 days and 18% (17/95) between 8 and 10 days were ≥5 mg/L. A caffeine dose of >5 mg/kg/day when discontinued was associated with the caffeine level of ≥5 mg/L (OR 2.3, 95% CI 1.28-4.13, p = .005).Conclusions: Preterm infants treated with caffeine frequently had therapeutic levels of caffeine 5-10 days after discontinuation of the drug. The infants receiving higher doses were more likely to have a therapeutic level of caffeine 5 days after stopping the medication. Preterm infants should be monitored for recurrence of apnea for more than 5 days after stopping caffeine or levels should be monitored prior to discharge.

Nutritional Intake Influences Zinc Levels in Preterm Newborns: An Observational Study

(1) Background: Zinc is a key element for protein synthesis in preterm newborns. Early aggressive nutrition, promoting protein synthesis, may increase zinc consumption; (2) Methods: We performed a prospective observational study, to assess the relationship between early macronutrients intake and serum zinc levels, in preterm newborns with Gestational Age (GA) of 24–35 weeks, consecutively observed in Neonatal Intensive Care Unit (NICU). (3) Results: We enrolled 130 newborns (GA 31.5 ± 2.8). A significant negative correlation between serum zinc level at 28 days of life and energy (r −0.587, p < 0.001) and protein intake (r −0.556, p < 0.001) in the first week of life was observed. Linear regression analysis showed that zinc levels depended on energy (β −0.650; p < 0.001) and protein (β −0.669; p < 0.001) intake given through parenteral nutrition (PN) in the first week of life; (4) Conclusions: zinc status of preterm neonates was influenced by early protein and energy intake. An additional zinc supplementation should be considered when high protein and energy intake are received by preterm newborns in the first week of life.

Application of Neurally Adjusted Ventilatory Assist in Premature Neonates Less Than 1,500 Grams With Established or Evolving Bronchopulmonary Dysplasia

Background: Very low birth weight premature (VLBW) infants with bronchopulmonary dysplasia (BPD) often need prolonged respiratory support, which is associated with worse outcomes. The application of neurally adjusted ventilatory assist ventilation (NAVA) in infants with BPD has rarely been reported. This study investigated whether NAVA is safe and can reduce the duration respiratory support in VLBW premature infants with established or evolving BPD. Methods: This retrospective matched-cohort study included patients admitted to our NICU between April 2017 to April 2019 who were born at <32 weeks' gestation with birthweight of <1,500 g. The study groups (NAVA group) were infants who received NAVA ventilation as a sequel mode of ventilation after at least 2 weeks of traditional respiratory support after birth. The control group were preterm infants who required traditional respiratory support beyond first 2 weeks of life and were closely matched to the NAVA patients by gestational age and birthweight. The primary outcome was to compare the total duration of respiratory support between the NAVA group and the control group. The secondary outcomes were comparisons of duration of invasive and non-invasive support, oxygen therapy, length of stay, severity of BPD, weight gain and sedation need between the groups. Results: There were no significant differences between NAVA group and control group in the primary and most of the secondary outcomes (all P > 0.05). However, NAVA was well tolerated and there was a decrease in the need of sedation (p = 0.012) after switching to NAVA. Conclusion: NAVA, when used as a sequel mode of ventilation, in premature neonates <1,500 g with evolving or established BPD showed a similar effect compared to conventional ventilation in respiratory outcomes. NAVA can be safely used in this patient population and potentially can decrease the need of sedation.

Selective Treatment of PDA in High-Risk VLBW Infants With Birth Weight ≤800 g or <27 Weeks and Short-Term Outcome: A Cohort Study

Background: Patent ductus arteriosus (PDA) causing significant left to right shunt can increase key morbidities in preterm infants. Yet, treatment does not improve outcomes and spontaneous closure is the natural course of PDA. The Impact of PDA on 23-26-week gestation infants is uncertain. Selective treatment of such infants would likely balance outcomes. Objective: To test the hypothesis that treatment of PDA in high-risk VLBW infants [birth weight ≤800 g or gestation <27 weeks, hemodynamically significant, ductal diameter (DD, ≥1.6 mm), and mechanical ventilation] and expectant management in low-risk infants will reduce the need for treatment and surgical ligation, without altering short term morbidities. Methods: This prospective observational study was initiated subsequent to the introduction of a new treatment protocol in 2016. The 12-months before and after protocol introduction were, respectively, defined as standard and early selective treatment periods. In the early selective treatment cohort, PDA was treated with indomethacin, maximum of two courses, 1 week apart. Surgical ligation was considered after 30 days of age if indicated (DD ≥2 mm, mechanical ventilation). Primary outcomes were need for treatment and rate of ligation. Protocol compliance and secondary outcomes were documented. Results: 415 infants were studied, 202 and 213 in the standard treatment and early selective treatment cohorts, respectively. Numbers treated (per protocol) in the standard treatment and early selective treatment cohorts were 27.7 and 19.3% (56/202 and 41/213) (p = 0.049), and the respective ligation rates were 7.54 and 2.96% (P = 0.045). Secondary outcomes were comparable. Conclusion: The early selective treatment protocol reduced the rates of treatment and surgical ligation of PDA, without altering key morbidities. Further studies under a randomized control trial setting is warranted.

Changes in the Composition of the Gut Microbiota and the Blood Transcriptome in Preterm Infants at Less than 29 Weeks Gestation Diagnosed with Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a common chronic lung condition in preterm infants that results in abnormal lung development and leads to considerable morbidity and mortality, making BPD one of the most common complications of preterm birth. We employed RNA sequencing and 16S rRNA gene sequencing to profile gene expression in blood and the composition of the fecal microbiota in infants born at <29 weeks gestational age and diagnosed with BPD in comparison to those of preterm infants that were not diagnosed with BPD. 16S rRNA gene sequencing, performed longitudinally on 255 fecal samples collected from 50 infants in the first months of life, identified significant differences in the relative levels of abundance of Klebsiella, Salmonella, Escherichia/Shigella, and Bifidobacterium in the BPD infants in a manner that was birth mode dependent. Transcriptome sequencing (RNA-Seq) analysis revealed that more than 400 genes were upregulated in infants with BPD. Genes upregulated in BPD infants were significantly enriched for functions related to red blood cell development and oxygen transport, while several immune-related pathways were downregulated. We also identified a gene expression signature consistent with an enrichment of immunosuppressive CD71+ early erythroid cells in infants with BPD. Intriguingly, genes that were correlated in their expression with the relative abundances of specific taxa in the microbiota were significantly enriched for roles in the immune system, suggesting that changes in the microbiota might influence immune gene expression systemically.IMPORTANCE Bronchopulmonary dysplasia (BPD) is a serious inflammatory condition of the lung and is the most common complication associated with preterm birth. A large body of evidence now suggests that the gut microbiota can influence immunity and inflammation systemically; however, the role of the gut microbiota in BPD has not been evaluated to date. Here, we report that there are significant differences in the gut microbiota of infants born at <29 weeks gestation and subsequently diagnosed with BPD, which are particularly pronounced when infants are stratified by birth mode. We also show that erythroid and immune gene expression levels are significantly altered in BPD infants. Interestingly, we identified an association between the composition of the microbiota and immune gene expression in blood in early life. Together, these findings suggest that the composition of the microbiota may influence the risk of developing BPD and, more generally, may shape systemic immune gene expression.

Time to positivity (TTP) of neonatal blood cultures: a trend analysis over a decade from Ireland

Background and aims: Blood culture (BC) remains gold standard for the evaluation and diagnosis of neonatal sepsis. Time when BC becomes positive and the type of microorganism isolated are crucial in deciding the antimicrobial management. Likely pathogenicity of organisms growing in BC could potentially be predicted based on the "time to positivity" (TTP). We aimed to estimate the predictive value of isolating a likely pathogenic organism depending on TTP; evaluate the aetiological trend and neonatal mortality rate due to culture-proven neonatal sepsis for over a decade and verify whether the application of a "36 hour rule" to discontinue empiric antibiotics in well newborn infants with negative BC would be safe.Methods: Retrospective review of BC results over a 14-year period from a regional neonatal unit in Ireland. Laboratory data were independently extracted in relation to BC results from the laboratory information management system (LIMS-iLAB). Neonatal mortality data were collected from multiple sources. Statistical analysis included logistic regression, chi-square, and Mann-Whitney U-test.Results: Over a 14-year period 11,432 neonatal BC specimens were incubated of which 605 (5.3%) turned positive. Overall, the commonest organism grown was coagulase-negative Staphylococcus (CoNS), 416 (68.8%). Main pathogenic organisms were Staphylococcus aureus 23 (3.8%), Enterococcus spp. 22 (3.6%), E.coli 21 (3.5%), group B Streptococcus (GBS) 18 (3.0%), and Klebsiella species 9 (1.5%). Gram-negative organisms had the shortest TTP, with Klebsiella spp. having a median TTP of 10 h and E. coli 11 h. For Gram-positives, GBS had a median TTP of 12 h, Enterococcus species 14 h, with S. aureus growing at a median time of 15 h. All of the Klebsiella spp. and other Coliforms were detected within 24 h, with, 95.2% of E.coli, 94.4% of GBS, 95.5% of Enterococci, and 95.7% of S. aureus, flagging positive in 24 h. Using logistic regression the omnibus test of the coefficients in the resulting model was significant (p < .001). Our observed coefficient (β) for TTP was 0.144; shorter the TTP higher was the likelihood of isolating a pathogenic organism, with an odds ratio (OR) of 1.155. We also report a relatively low blood culture proven sepsis-specific neonatal mortality rate of 0.403/1000 live births and in all such instances observed TTP was less than 24 h.Conclusion: Duration of this study exceeds that of most of the neonatal blood culture TTP analysis published to-date. A shorter TTP is an important adjunct to suggest the growth of a pathogenic organism while managing suspected neonatal sepsis. TTP if < 24 h per se would not necessarily confirm the growth of a highly pathogenic organism; however, if a positive growth is likely to happen for a significant neonatal pathogen, in more than 98% the TTP would be within 24 h. This offers the clinician more of negative predictive value than a positive one; when there is no growth in BC. Our observation on TTP reiterate the National Institute of Health and Care Excellence (NICE) guideline of discontinuation of empiric antibiotics after 36 h in and clinically well and BC negative newborn infants.

Successful conservative treatment of intestinal perforation in VLBW and ELBW neonates: a single centre case series and review of the literature

Background

The current standard treatment of neonates with intestinal perforation is surgery. However, the mortality rate after surgical treatment for intestinal perforation is very high for very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates. In this review, conservative treatment of pneumoperitoneum among VLBW and ELBW neonates is investigated.

Methods

Between January 2015 and December 2017, data from all of the VLBW and ELBW neonates with pneumoperitoneum who survived without surgical treatment were collected from Shenzhen Maternity and Child Healthcare Hospital in Guangdong, China. Twenty-two neonates with birth weight less than 1500 g were diagnosed with pneumoperitoneum. Following careful evaluation and discussion, eleven were treated conservatively and this was successful in eight. Details of the eight neonates including birth weight, gestational age, gender, risk factors, time of the perforation, treatment and prognosis were retrospectively recorded. A literature review was performed of previously reported cases that had used conservative treatment.

Results

The median gestational age and birth weight of the eight neonates were 27^+ 1 weeks (range 24w^+ 3 to 31w^+ 6) and 855 g (range 650 g to 1440 g), respectively. Pneumoperitoneum was confirmed by X-ray in all at a median of 8 days of life. They received full parenteral support for a median of 22 days. All eight neonates received a combination of piperacillin-tazobactam and meropenem as first-choice antibiotics, two of them also received fluconazole as anti-fungal medication. Median duration of hospitalisation was 80 days.

Conclusions

Conservative treatment with careful surveillance may be a practical choice for the VLBW and ELBW neonates with intestinal perforation. Further studies are needed for confirmation.