The Effect of Gestational and Lactational Age on the Human Milk Metabolome

Human milk is the ideal nutrition source for healthy infants during the first six months of life and a detailed characterisation of the composition of milk from mothers that deliver prematurely (<37 weeks gestation), and of how human milk changes during lactation, would benefit our understanding of the nutritional requirements of premature infants. Individual milk samples from mothers delivering prematurely and at term were collected. The human milk metabolome, established by nuclear magnetic resonance (NMR) spectroscopy, was influenced by gestational and lactation age. Metabolite profiling identified that levels of valine, leucine, betaine, and creatinine were increased in colostrum from term mothers compared with mature milk, while those of glutamate, caprylate, and caprate were increased in mature term milk compared with colostrum. Levels of oligosaccharides, citrate, and creatinine were increased in pre-term colostrum, while those of caprylate, caprate, valine, leucine, glutamate, and pantothenate increased with time postpartum. There were differences between pre-term and full-term milk in the levels of carnitine, caprylate, caprate, pantothenate, urea, lactose, oligosaccharides, citrate, phosphocholine, choline, and formate. These findings suggest that the metabolome of pre-term milk changes within 5–7 weeks postpartum to resemble that of term milk, independent of time of gestation at pre-mature delivery.

Effect of room temperature transport vials on DNA quality and phylogenetic composition of faecal microbiota of elderly adults and infants

BACKGROUND

Alterations in intestinal microbiota have been correlated with a growing number of diseases. Investigating the faecal microbiota is widely used as a non-invasive and ethically simple proxy for intestinal biopsies. There is an urgent need for collection and transport media that would allow faecal sampling at distance from the processing laboratory, obviating the need for same-day DNA extraction recommended by previous studies of freezing and processing methods for stool. We compared the faecal bacterial DNA quality and apparent phylogenetic composition derived using a commercial kit for stool storage and transport (DNA Genotek OMNIgene GUT) with that of freshly extracted samples, 22 from infants and 20 from older adults.

RESULTS

Use of the storage vials increased the quality of extracted bacterial DNA by reduction of DNA shearing. When infant and elderly datasets were examined separately, no differences in microbiota composition were observed due to storage. When the two datasets were combined, there was a difference according to a Wilcoxon test in the relative proportions of Faecalibacterium, Sporobacter, Clostridium XVIII, and Clostridium XlVa after 1 week's storage compared to immediately extracted samples. After 2 weeks' storage, Bacteroides abundance was also significantly different, showing an apparent increase from week 1 to week 2. The microbiota composition of infant samples was more affected than that of elderly samples by storage, with significantly higher Spearman distances between paired freshly extracted and stored samples (p < 0.001). When the microbiota profiles were analysed at the operational taxonomic unit (OTU) level, three infant datasets in the study did not cluster together, while only one elderly dataset did not. The lower microbiota diversity of the infant gut microbiota compared to the elderly gut microbiota (p < 0.001) means that any alteration in the infant datasets has a proportionally larger effect.

CONCLUSIONS

The commercial storage vials appear to be suitable for high diversity microbiota samples, but may be less appropriate for lower diversity samples. Differences between fresh and stored samples mean that where storage is unavoidable, a consistent storage regime should be used. We would recommend extraction ideally within the first week of storage.

Skills retention in Sudanese village midwives 1 year following Helping Babies Breathe training

BACKGROUND

Over 80% of deliveries in Sudan occur in isolated villages, attended by village midwives (VMWs). Upgrading newborn resuscitation skills with the Helping Babies Breathe (HBB) programme could improve newborn survival rates.

OBJECTIVE

To describe the competencies in newborn resuscitation of selected VMWs pre-HBB and post-HBB training.

METHODS

In a prospective intervention study, the VMWs' performances in the HBB Objective Structured Clinical Examination B simulated scenario (manikin requiring face-mask ventilation (FMV)) were digitally recorded and analysed prior to and 3 and 12 months following HBB training. Regular manikin-based practice was encouraged following training.

RESULTS

Pre-HBB training, 42% of 71 VMWs (of whom 61% were functionally illiterate) stimulated the non-breathing manikin by holding it by the legs and either stimulated/slapped (30.4%) or shook (12.7%) it, while 25% (18/71) provided manikin mouth-to-mouth ventilation. The low scorings on the 'preparation for birth' (0% and 3.1% at 3 and 12 months, respectively) were mainly due to failure to demonstrate the subitem of 'cleans hands'. The percentage of VMWs providing manikin FMV within the Golden Minute increased from 37.3% (25/67) to 72.3% (47/65) (p<0.005), but there were no significant differences in the number of VMWs producing at least five FMVs at 3 months (73%, 49/67) and 12 months (58%, 38/65), respectively.

CONCLUSIONS

VMWs, despite a high illiteracy rate, absorbed and sustained HBB skills for at least a year. Regular, low intensity, manikin-based skills training with peers may have helped sustain FMV, but not hand-cleansing skills.

End user bag-mask ability and perceptions of two infant resuscitation mannequins

AIM

To examine user ability and preference in performing bag-mask ventilation (BMV) with four different configurations of infant mannequins.

METHODS

Participants provided a 30-second period of BMV to a Resusci Baby mannequin (RB), NeoNatalie mannequin (NN), NN filled with air (NNA), NN filled with water (NNW) and NN filled with 50% air and 50% water mix (NNAW). Participants rated the fidelity of each configuration.

RESULTS

Of the 20 participants, 65% rated NNW as having a high level of fidelity (HLF) 'to hold' (50% for NNAW, 10% for RB and 0% for NNA) (p < 0.001). Half rated NNAW as having a HLF in 'tone' (40% for NNW, 20% for RB and 5% for NNA) (p = 0.008). About 45% of participants rated NNAW as having a HLF in 'appearance' (45% for the RB, 20% for NNA and 15% for NNW) (p = 0.035). About 35% of participants rated NNAW as having a HLF in how it 'felt to touch' (30% for NNW, 15% for RB and 10% for NNA) (p = 0.008). Half of participants rated NNAW as having a HLF in terms of 'weight' (45% for NNW, 40% for RB and 0% for NNA) (p = 0.003). Participants delivered the greatest number of effective ventilations to the NNW mannequin.

CONCLUSION

The NNW and NNAW configurations had the highest fidelity and had the highest percentage of effective ventilations delivered.

Auscultate, palpate and tap: time to re-evaluate

AIM

To determine the accuracy of current methods of heart rate (HR) assessment.

METHODS

All participants palpated a simulated pulsating umbilicus (UMB), listened to a tapping rate (TAP) and auscultated a simulated HR (AUSC). A simulated HR of 54, 88 and 128 beats per minute (bpm) was randomised for all methods.

RESULTS

Twenty-nine healthcare staff participated in this study. Correct assessment of HR of 54 bpm as being within the 0-59 range occurred in 17.2% UMB, 17.2% TAP and 31% AUSC and was obtained in <10 seconds by 48.3%, 65.5% and 62.1%, respectively. A rate of 88 bpm was correctly assessed as within the 60-100 range in 82.8% UMB, 79.3% TAP and 79.3% AUSC and was obtained in <10 seconds by 55.2%, 58.6% and 55.2%, respectively. A rate of 128 bpm was identified as >100 bpm by 96.6% UMB, 93.1% TAP, and 93.1% AUSC and was obtained in <10 seconds by 51.7%, 55.2% and 62.1%, respectively.

CONCLUSION

Current methods in assessing rates below 60 bpm are inaccurate and may overestimate HR. We recommend that these methods alone should not be relied upon in neonatal resuscitation and objective assessment of heart rate should be readily available at all newborn resuscitations.

Newborn Resuscitation Training Programmes Reduce Early Neonatal Mortality

BACKGROUND

Substantial health care resources are expended on standardised formal neonatal resuscitation training (SFNRT) programmes, but their effectiveness has not been proven.

OBJECTIVES

To determine whether SFNRT programmes reduce neonatal mortality and morbidity, improve acquisition and retention of knowledge and skills, or change teamwork and resuscitation behaviour.

METHODS

We searched CENTRAL, MEDLINE, PREMEDLINE, EMBASE, CINAHL, Web of Science and the Oxford Database of Perinatal Trials, ongoing trials and conference proceedings in April 2015, and included randomised or quasi-randomised trials that reported at least one of our specified outcomes.

RESULTS

SFNRT in low- and middle-income countries decreased early neonatal mortality [risk ratio (RR) 0.85 (95% CI 0.75-0.96)]; the number needed to treat for benefit [227 (95% CI 122-1,667; 3 studies, 66,162 participants, moderate-quality evidence)], and 28-day mortality [RR 0.55 (95% CI 0.33-0.91); 1 study, 3,355 participants, low-quality evidence]. Decreasing trends were noted for late neonatal mortality [RR 0.47 (95% CI 0.20-1.11)] and perinatal mortality [RR 0.94 (95% CI 0.87-1.00)], but there were no differences in fresh stillbirths [RR 1.05 (95% CI 0.93-1.20)]. Teamwork training with simulation increased the frequency of teamwork behaviour [mean difference (MD) 2.41 (95% CI 1.72-3.11)] and decreased resuscitation duration [MD -149.54 (95% CI -214.73 to -84.34); low-quality evidence, 2 studies, 130 participants].

CONCLUSIONS

SFNRT in low- and middle-income countries reduces early neonatal mortality, but its effects on birth asphyxia and neurodevelopmental outcomes remain uncertain. Follow-up studies suggest normal neurodevelopment in resuscitation survivors.

Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room

Monitoring of preterm infants in the delivery room (DR) remains limited. Current guidelines suggest that pulse oximetry should be available for all preterm infant deliveries, and that if intubated a colorimetric carbon dioxide detector should provide verification of correct endotracheal tube placement. These two methods of assessment represent the extent of objective monitoring of the newborn commonly performed in the DR. Monitoring non-invasive ventilation effectiveness (either by capnography or respiratory function monitoring) and cerebral oxygenation (near-infrared spectroscopy) is becoming more common within research settings. In this article, we will review the different modalities available for cardiorespiratory and neuromonitoring in the DR and assess the current evidence base on their feasibility, strengths, and limitations during preterm stabilization.

Neonatal Sulfhemoglobinemia and Hemolytic Anemia Associated With Intestinal Morganella morganii

Sulfhemoglobinemia is a rare disorder characterized by the presence of sulfhemoglobin in the blood. It is typically drug-induced and may cause hypoxia, end-organ damage, and death through oxygen deprivation. We present here a case of non-drug-induced sulfhemoglobinemia in a 7-day-old preterm infant complicated by hemolytic anemia. Microbiota compositional analysis of fecal samples to investigate the origin of hydrogen sulphide revealed the presence of Morganella morganii at a relative abundance of 38% of the total fecal microbiota at the time of diagnosis. M morganii was not detected in the fecal samples of 40 age-matched control preterm infants. M morganii is an opportunistic pathogen that can cause serious infection, particularly in immunocompromised hosts such as neonates. Strains of M morganii are capable of producing hydrogen sulphide, and virulence factors include the production of a diffusible α-hemolysin. The infant in this case survived intact through empirical oral and intravenous antibiotic therapy, probiotic administration, and red blood cell transfusions. This coincided with a reduction in the relative abundance of M morganii to 3%. Neonatologists should have a high index of suspicion for intestinal pathogens in cases of non-drug-induced sulfhemoglobinemia and consider empirical treatment of the intestinal microbiota in this potentially lethal condition.

Phenotypic extremes in liveborn monozygotic twins with mosaic Edwards syndrome

Mosaic trisomy 18 (Edwards syndrome) in monozygotic diamniotic liveborn twins is rare. We describe such a case involving preterm male infants. Although both infants had a low percentage of trisomy 18 cells in peripheral blood leucocytes, their varied phenotypic presentation of mosaic trisomy 18 resulted in one twin surviving, with the other twin's demise at 1 month of age. Despite the presence of trisomy 18 in peripheral leucocytes, further analysis of a buccal smear and skin biopsy of the surviving twin did not show evidence of trisomy 18. Establishing such diagnoses in a timely manner is imperative for the child, parents and clinicians. The clinical course of these twins reflects the unpredictable prognosis associated with the diagnosis of mosaic trisomy 18, and emphasises the challenges that can be encountered when counselling parents.

The neonatal gut harbours distinct bifidobacterial strains

BACKGROUND

Recent studies have described the bifidobacterial composition of neonates at a species level; however, with advancing technologies we can gain insight into the diversity of the bifidobacterial microbiota residing within the infant gut.

OBJECTIVE

To compare species and strain diversity of culturable bifidobacterial populations in faecal samples obtained from healthy term infants on three different feeding regimes.

STUDY DESIGN

In total, 51 healthy term infants were recruited for this study and divided equally into three different groups (n=17) based on their feeding regime during the first 4 weeks of life. Culturable bifidobacterial populations were analysed at week 1, week 4 and 6 months of age. Isolates were characterised to species level by 16s rRNA-internally transcribed spacer (ITS) gene sequence analysis and to strain level by pulsed field gel electrophoresis (PFGE).

RESULTS

In total,173 bifidobacterial strains were detected across all three groups from 2295 isolates, 42% (72 of 173) of which were detected in the prebiotic-fed group, followed by 30% (52 of 173) and 28% (49 of 173) in the breastfed and non-prebiotic-fed groups, respectively. Surprisingly, only two of the 51 infants harboured an identical bifidobacterial strain which was not present in the other 49 infants. Prebiotic supplementation in the early neonatal period increased the prevalence of Bifidobacterium longum in infants, in addition to promoting strain diversity. B. longum was the dominant species recovered from all three groups during the first 6 months of life, followed by Bifidobacterium breve and Bifidobacterium bifidum.

CONCLUSIONS

This study reveals a hitherto unknown level of diversity at the strain level among bifidobacteria isolated from different infants and the influence prebiotic formula feeding has on the bifidobacterial population.

Perfusion index in the preterm infant immediately after birth

AIM

To evaluate PI in preterm infants during the first 10 min of life.

DESIGN/METHODS

An observational study was conducted in the delivery room on preterm infants (less than 32 week gestation). PI values were obtained from a pre ductal saturation probe placed on the right wrist. Analysis was performed on the first 10 min of data to investigate the correlation of PI with gestational age, heart rate, blood pressure, and lactate values.

RESULTS

33 infants with a median gestational age of 29 wks (IQR, 26-30 wks) and median birth weight of 1205 g (IQR, 925-1520 g) were included for analysis. The overall median PI value for the first 10 min was 1.3 (IQR, 0.86-1.68). There was no significant correlation found between delivery room PI and gestational age(r=0.28, 95% CI: -0.09, 0.59), lactate levels (r=-0.25, 95% CI: -0.62, 0.18) and blood pressure values (r=-0.18, 95% CI: -0.46, 0.20). An average correlation value of r=-0.417 (95% CI: - 0.531, -0.253) was found between PI and heart rate values. There was no statistical difference between the median of the median PI value over the first 5 min of life compared to the second 5 min (p=0.22). Variability, as quantified by the IQR, was higher in the first 5 min compared to the second 5 min: median of 0.5(IQR, 0.27, 0.92) vs 0.2(IQR, 0.10, 0.30) (p<0.00).

CONCLUSIONS

Delivery room PI values are easily obtained, however, have significant variability over the first 5 min of life and may add little to delivery room assessment.

Quantitative or qualitative carbon dioxide monitoring for manual ventilation: a mannequin study

AIM

To compare the effectiveness of an in-line EtCO2 detector (DET) and a quantitative EtCO2 detector (CAP), both attached to a t-piece resuscitator, during PPV via a face mask.

METHODS

Paediatric trainees were randomly assigned to determine the method of PPV they commenced with (No device (ND), DET or CAP). Participants used each method for 2 min. Participants were video-recorded to determine the amount of effective ventilations delivered with each method.

RESULTS

Twenty-three paediatric trainees provided a total of 6035 ventilations, and 91.2% were deemed effective. The percentages of median effective ventilations with the ND, the DET and the CAP were 91.0%, 93.0% and 94.0%, respectively. Fourteen (61%) of the trainees indicated a preference for the DET method, 8 (35%) for the CAP method, and 1 (4%) of the trainees indicated a preference for the ND method. Capnography was the most effective method per patient.

CONCLUSION

There was no adverse effect with the addition of EtCO2 detectors. Trainees favoured methods of EtCO2 monitoring during ventilation. The NeoStat device was the preferred device by the majority. The greatest efficacy was achieved with the capnography device. Capnography may enhance face mask ventilation.

Current research suggests that the future looks brighter for cerebral oxygenation monitoring in preterm infants

Brain injuries remain a significant problem for preterm infants, despite extensive physiological monitoring. Near infrared spectroscopy (NIRS) monitoring in the neonatal intensive care unit has to date remained limited to research activities.

CONCLUSION

This review highlights the increasing clinical application of NIRS in delivery suites and neonatal units. Four randomised controlled trials incorporating NIRS monitoring suggest that the future may indeed be brighter for this technology in the care of very preterm infants.

Perceptions of webcams in the neonatal intensive care unit: here's looking at you kid!

INTRODUCTION

Many tertiary neonatal units employ a restricted visiting policy. Webcams have previously been implemented in the neonatal unit setting in several countries.

OBJECTIVES

This study aims to determine the views from parents, physicians, and nursing staff before implementation of a webcam system.

METHODS

A questionnaire-based study.

RESULTS

There were 101 responses. Parental computer usage was 83%. The majority of parents indicated that they would use the webcam system. Parents felt that a webcam system would reduce stress. Members of the nursing staff were most concerned about privacy risks (68%), compared with parents who were confident in the security of these systems (92%, p-value < 0.001). Seventy two percent of nurses felt that a webcam system would increase the stress levels of staff as compared with less than 20% of the physicians (p-value < 0.001).

DISCUSSION

The majority of parents who completed the questionnaire have positive attitudes toward implementation of a webcam system in the NICU. Education of health care staff is required before implementation.

A review of carbon dioxide monitoring in preterm newborns in the delivery room

INTRODUCTION

The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements.

AIM

To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room.

METHODS

Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials.

RESULTS

The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B.

DISCUSSION

CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.

Early postnatal EEG features of perinatal arterial ischaemic stroke with seizures

Background

Stroke is the second most common cause of seizures in term neonates and is associated with abnormal long-term neurodevelopmental outcome in some cases.

Objective

To aid diagnosis earlier in the postnatal period, our aim was to describe the characteristic EEG patterns in term neonates with perinatal arterial ischaemic stroke (PAIS) seizures.

Design

Retrospective observational study.

Patients

Neonates >37 weeks born between 2003 and 2011 in two hospitals.

Method

Continuous multichannel video-EEG was used to analyze the background patterns and characteristics of seizures. Each EEG was assessed for continuity, symmetry, characteristic features and sleep cycling; morphology of electrographic seizures was also examined. Each seizure was categorized as electrographic-only or electroclinical; the percentage of seizure events for each seizure type was also summarized.

Results

Nine neonates with PAIS seizures and EEG monitoring were identified. While EEG continuity was present in all cases, the background pattern showed suppression over the infarcted side; this was quite marked (>50% amplitude reduction) when the lesion was large. Characteristic unilateral bursts of theta activity with sharp or spike waves intermixed were seen in all cases. Sleep cycling was generally present but was more disturbed over the infarcted side. Seizures demonstrated a characteristic pattern; focal sharp waves/spike-polyspikes were seen at frequency of 1–2 Hz and phase reversal over the central region was common. Electrographic-only seizure events were more frequent compared to electroclinical seizure events (78 vs 22%).

Conclusions

Focal electrographic and electroclinical seizures with ipsilateral suppression of the background activity and focal sharp waves are strong indicators of PAIS. Approximately 80% of seizure events were the result of clinically unsuspected seizures in neonates with PAIS. Prolonged and continuous multichannel video-EEG monitoring is advocated for adequate seizure surveillance.

Addressing the taboo of medical error through IGBOs: I got burnt once!

BACKGROUND

An I Got Burnt Once (IGBO) is a near-miss or actual clinical event, related to patient safety, that leaves a lasting impact on the health professional (HP) involved. The purpose of this study was to collect and categorize IGBOs from a variety of pediatric HPs and to determine whether the individual's clinical practice was altered as a result.

METHODS

Semistructured interviews involved recollection of an IGBO and subsequent changes in clinical practice. The IGBOs were classified into one of the seven Canadian Medical Education Directives for Specialists (CanMEDS) roles and outcome of the event.

RESULTS

Of the 38 pediatric HPs approached (25 doctors and 13 female nurses), 35 recalled an IGBO. Most (74 %) were classified to the CanMEDS Medical Expert role (with subcategorization into diagnostics (37 %), treatment (34 %), and clinical management (31 %) followed by communicator (14 %) and collaborator (12 %) roles). Half (55 %) of the respondents considered the IGBO event to be potentially life threatening event to the patient, resulting in no harm (63 %), disability (14 %), and fatality in 17 % of the cases. Most respondents (92 %) stated that IGBOs affected their medical practice for months and sometimes years after the event.

CONCLUSIONS

Most practitioners can recall an IGBO in their clinical practice. IGBOs may be a potential source of medical risk avoidance and reduction strategies, and worthy of further investigation by "deep dives" or root cause analysis.

Emergence of opiate-induced neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is the clinical picture of infants withdrawing from in-utero substance exposure. The incidence of NAS rose in Dublin maternity hospitals in the 1970's and '80's in parallel with increasing in opiate abuse in that city. The purpose of this study was to determine if a similar pattern was emerging in Cork University Maternity Hospital. Data from the Erinville Hospital (2000-2007) and CUMH (2008-2011) were compared. Sixteen cases of NAS were identified, two at Erinville Hospital (22,987 deliveries; incidence = 0.09/1000 deliveries) and 14 at CUMH (37,414 deliveries; incidence = 0.38/1000 deliveries; p < 0.01). Five of the 16 mothers were using heroin, while ten were on methadone maintenance. All were multi-drug abusers. Newborns requiring pharmacotherapy for NAS (5/16) had prolonged hospitalisations compared to those requiring supportive care. NAS in Cork is increasing. Primary, secondary and tertiary preventative measures are warranted to prevent further escalation.

Efficacy and user preference of two CO2 detectors in an infant mannequin randomized crossover trial

Assessment of effective ventilation in neonatal mask ventilation can be difficult. This study aims to determine whether manual ventilation with a T-piece resuscitator containing an inline CO2 detector (either a Pedi-Cap® CO2 detector or a Neo-StatCO2 <Kg® CO2 detector connected to a facemask) facilitates effective positive pressure ventilation compared to no device in a mannequin study. Paediatric and neonatal trainees were randomly assigned to determine which method they began with (no device, Pedi-Cap or a Neo-Stat). The participants used each method for a period of 3 min. They were video-recorded to determine the amount of effective ventilations delivered and the overall percentage efficiency of each method. Efficacy of ventilation was determined by comparing the number of manual ventilations delivered with the number of times chest rise was observed in the video recording. There were 19 paediatric trainees who provided a total of 7,790 ventilations, and 93% were deemed effective. The percentage of effective ventilations with the T-piece resuscitator alone, the PediCap and the NeoStat were 90, 94 and 96%, respectively. The difference was greatest in the first minute (T-piece resuscitator alone 87.5%, PediCap 94%, NeoStat 96%). Two thirds preferred the Neo-Stat. The use of a CO2 detector improves positive pressure ventilation in a mannequin model, especially in the first minute of positive pressure ventilation. The Neo-Stat CO2 detector was the preferred device by the majority of the participants.

Perfusion index in the very preterm infant

AIM

Perfusion Index (PI) is a quantifiable measurement of peripheral perfusion and may be a useful adjunct to the assessment of circulatory status in the newborn. (i) To assess reproducibility of PI and (ii) To determine whether there is a difference between simultaneously obtained limb measurements of PI in newborns <32 weeks GA in the transitional period.

METHODS

Perfusion Index was measured in newborns <32 weeks during the first 48 h of life. To examine reproducibility, the pulse oximetry probe was replaced on the same limb consecutively by the same operator. Upper and lower limbs were then simultaneously evaluated over a 5-min period. Heart rate, blood pressure, birth weight, ventilation requirement, inotrope use, lactate, PCO2 and CRIB-II score were also recorded.

RESULTS

Thirty infants were assessed. Intraclass correlation coefficient for reproducibility in the same limb was high (r value = 0.982 p < 0.001). Measurements obtained in the right upper limb were consistently higher than either lower limb. The median (IQR) PI for the entire cohort was 0.70 (0.29-1.35). No correlation existed between gestational age, birth weight, CRIB scores, systolic and diastolic blood pressure, mean blood pressure and median PI values.

CONCLUSION

Perfusion Index measurement is reproducible, and values are highest in the right upper limb. Wide differences between right upper and lower limb readings are most likely related to transitional circulatory changes.

The individual-specific and diverse nature of the preterm infant microbiota

OBJECTIVE

To examine the composition of the evolving microbiota of preterm infants at weeks 2 and 4 of life.

SETTINGS

The paediatric intensive care unit of the Cork University Maternity Hospital.

METHODS

The microbial diversity of faecal samples from 10 preterm infants was determined using 16S rRNA amplicon pyrosequencing technology.

RESULTS

In total, 452 863 sequences were obtained from 20 faecal samples collected from 10 preterm infants, allowing a level of analysis not previously reported. The preterm infant microbiota samples were dominated by Proteobacteria (46%), followed by Firmicutes (45%), while the phyla Actinobacteria (2%) and Bacteroidetes (7%) were detected at much lower levels at week 2 of life. This colonisation pattern was similar at week 4 of life. At the family level, Enterobacteriaceae were detected at 50% and 58% at weeks 2 and 4, respectively. The preterm infants were characterised by a lack of detectable Bifidobacterium and Lactobacillus genera commonly associated with the infant gut. In addition to the dominance of the Proteobacteria, a high level of interindividual variation was observed, indeed the relative proportions of different phyla, families and genera in different infants ranged from <1% to >90%.

CONCLUSIONS

The results indicate that in addition to an uncharacteristic microbiota relative to that reported for healthy term infants, there was a large interindividual variation in the faecal microbiota diversity of preterm infants suggesting that the preterm microbiota is individual-specific and does not display a uniformity among infants.