51
|
Abstract
There have been amazing changes in outcomes of preterm (PT) infants in the past decades. Whereas early studies reported only survival rates, Dr. Julius Hess published the first outcome study of PT infants in Chicago in 1953. Dr. Lubchenco then published the 10-year follow-up of premature infants born in 1947-1953 and identified a 68% handicap rate. As a result of these early studies, the importance of evaluating NICU graduates both for surveillance and as an outcome of trials was recognized. During the 1970s, there was a gradual expansion in the number of follow-up programs in the United States (US) with an increasing number of follow-up studies published. In the 1980s, the importance of multicenter clinical research networks was recognized and the NICHD Neonatal Research Network (NRN) was initiated in 1986. Follow-up protocols, definitions, and outcomes have evolved over the last 30 years and will be reviewed with a focus on NICHD NRN studies.
Collapse
Affiliation(s)
- Susan R Hintz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, 750 Welch Rd, Suite 315, Palo Alto, CA 94304
| | - Jamie E Newman
- Public Health Research Division, RTI International, Research Triangle Park, NC
| | - Betty R Vohr
- Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics Women & Infants Hospital of Rhode Island, Providence, RI.
| |
Collapse
|
52
|
Sánchez-Tamayo T, Espinosa Fernández MG, Affumicato L, González López M, Fernández Romero V, Moreno Algarra MC, Salguero García E. [Reduction in necrotising enterocolitis after implementing an evidence-based enteral nutrition protocol in very low birth weight newborns]. An Pediatr (Barc) 2016; 85:291-299. [PMID: 27443828 DOI: 10.1016/j.anpedi.2016.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 06/05/2016] [Accepted: 06/09/2016] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION An unexpected increase in the incidence of necrotising enterocolitis (NEC) cases was observed in our hospital. Just in case, our feeding policy could be responsible, it was decided to conduct a systematic review and develop a clinical guideline regarding enteral nutrition of very low birth weight infants (VLBW). OBJECTIVE To assess the impact of the new feeding protocol in the incidence of NEC. METHOD A "before" (2011) and "after" (May 2012 - April 2013) study was performed on the new feeding protocol. This included initiation of enteral feeding in the absence of haemodynamic problems, a trophic feeding period of 5-7 days, and subsequent increments of 20-30ml/kg/day, of breast milk/donor human milk from the beginning. Probiotics were not administered. PRIMARY OUTCOME incidence of NEC II 2 Bell's stage. SECONDARY OUTCOMES focal intestinal perforation, overall mortality and mortality due to NEC, nosocomial sepsis; weight at 28 days and 36 weeks; % of infants with weight <p10 at discharge; and length of stay. RESULTS Of the 270 VLBW infants, 155 were included in the "before" group, and 115 in the "after" group. NEC significantly decreased (12/155 vs 1/115, P=.008). A decrease in mortality rate was also observed (17.4% vs 7.8%, P=.02). In four cases NEC was part of the sequence of events that led to death in the first cohort, with none in the second. There was no difference in the incidence of focal intestinal perforation or of the other secondary variables analysed. CONCLUSIONS Implementation of an evidence-based enteral feeding protocol leads to a decrease in incidence of NEC, without increasing hospital stay or the incidence of sepsis.
Collapse
Affiliation(s)
- Tomás Sánchez-Tamayo
- Grupo multidisciplinario de investigación pediátrica, Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga. Facultad de Medicina, Universidad de Málaga, Málaga, España.
| | - María Gracia Espinosa Fernández
- Grupo multidisciplinario de investigación pediátrica, Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga. Facultad de Medicina, Universidad de Málaga, Málaga, España
| | - Laura Affumicato
- Grupo multidisciplinario de investigación pediátrica, Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga. Facultad de Medicina, Universidad de Málaga, Málaga, España
| | - María González López
- Grupo multidisciplinario de investigación pediátrica, Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga. Facultad de Medicina, Universidad de Málaga, Málaga, España
| | - Verónica Fernández Romero
- Grupo multidisciplinario de investigación pediátrica, Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga. Facultad de Medicina, Universidad de Málaga, Málaga, España
| | - María Concepción Moreno Algarra
- Grupo multidisciplinario de investigación pediátrica, Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga. Facultad de Medicina, Universidad de Málaga, Málaga, España
| | - Enrique Salguero García
- Grupo multidisciplinario de investigación pediátrica, Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga. Facultad de Medicina, Universidad de Málaga, Málaga, España
| |
Collapse
|
53
|
Cooke RJ. Improving growth in preterm infants during initial hospital stay: principles into practice. Arch Dis Child Fetal Neonatal Ed 2016; 101:F366-70. [PMID: 26867763 DOI: 10.1136/archdischild-2015-310097] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/20/2016] [Indexed: 11/04/2022]
Abstract
Despite recent innovations in nutritional care, postnatal growth failure between birth and hospital discharge remains a significant problem in preterm infants. Whether or not it is entirely preventable is unclear. What is clear is that feeding practices and growth outcomes vary widely between neonatal intensive care units (NICUs). This partly reflects lack of data in key areas but it also reflects inconsistent translation of principles into practice and limitations in the way infants are fed and growth monitored in the NICU. These issues will be reviewed, in the process underline the key roles that audit, standardised feeding protocol, individualised nutritional care and a nutritional support team play in improving outcome in these high-risk infants.
Collapse
|
54
|
Karpen HE. Nutrition in the Cardiac Newborns: Evidence-based Nutrition Guidelines for Cardiac Newborns. Clin Perinatol 2016; 43:131-45. [PMID: 26876126 DOI: 10.1016/j.clp.2015.11.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Both protein and energy malnutrition are common in neonates and infants with congenital heart disease (CHD). Neonates with CHD are at increased risk of developing necrotizing enterocolitis (NEC), particularly the preterm population. Mortality in patients with CHD and NEC is higher than for either disease process alone. Standardized feeding protocols may affect both incidence of NEC and growth failure in infants with CHD. The roles of human milk and probiotics have not yet been explored in this patient population.
Collapse
Affiliation(s)
- Heidi E Karpen
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
| |
Collapse
|
55
|
Rodriguez NA, Vento M, Claud EC, Wang CE, Caplan MS. Oropharyngeal administration of mother's colostrum, health outcomes of premature infants: study protocol for a randomized controlled trial. Trials 2015; 16:453. [PMID: 26458907 PMCID: PMC4603349 DOI: 10.1186/s13063-015-0969-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 09/21/2015] [Indexed: 12/03/2022] Open
Abstract
Background Extremely premature (birth weight < 1250 g) infants are at high risk for acquiring late-onset sepsis and necrotizing enterocolitis, which are associated with significant mortality and morbidity. Own mother's milk contains protective (immune and trophic) biofactors which provide antimicrobial, anti-inflammatory, antioxidant, and immunomodulatory functions, enhance intestinal microbiota, and promote intestinal maturation. Many of these biofactors are most highly concentrated in the milk expressed by mothers of extremely premature infants. However, since extremely premature infants do not receive oral milk feeds until 32 weeks post-conceptional age, they lack the potential benefit provided by milk (biofactor) exposure to oropharyngeal immunocompetent cells, and this deficiency could contribute to late-onset sepsis and necrotizing enterocolitis. Therefore, oropharyngeal administration of own mother's milk may improve the health outcomes of these infants. Objectives To compare the effects of oropharyngeal administration of mother’s milk to a placebo, for important clinical outcomes, including (1A) reducing the incidence of late-onset sepsis (primary outcome) and (1B) necrotizing enterocolitis and death (secondary outcomes). To identify the biomechanisms responsible for the beneficial effects of oropharyngeal mother’s milk for extremely premature infants, including; (2A) enhancement of gastrointestinal (fecal) microbiota (2B) improvement in antioxidant defense maturation or reduction of pro-oxidant status, and (2C) maturation of immunostimulatory effects as measured by changes in urinary lactoferrin. Methods/Design A 5-year, multi-center, double-blind, randomized controlled trial designed to evaluate the safety and efficacy of oropharyngeal mother’s milk to reduce the incidence of (1A) late-onset sepsis and (1B) necrotizing enterocolitis and death in a large cohort of extremely premature infants (n = 622; total patients enrolled). Enrolled infants are randomly assigned to one of 2 groups: Group A infants receive 0.2 mL of own mother's milk, via oropharyngeal administration, every 2 hours for 48 hours, then every 3 hours until 32 weeks corrected-gestational age. Group B infants receive a placebo (0.2 mL sterile water) following the same protocol. Milk, urine, oral mucosal swab, and stool samples are collected at various time points, before, during and after the treatment periods. Health outcome and safety data are collected throughout the infant’s stay. Trial registration ClinicalTrials.gov identifier: NCT02116699 on 11 April 2014. Last updated: 26 May 2015
Collapse
Affiliation(s)
- Nancy A Rodriguez
- NorthShore University HealthSystem, Evanston, IL, USA. .,University of Chicago Pritzker School of Medicine, Chicago, IL, USA. .,Clinician Researcher, Pritzker School of Medicine, Neonatal Nurse Practitioner, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL, 60201, USA.
| | - Maximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain.
| | - Erika C Claud
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
| | | | - Michael S Caplan
- NorthShore University HealthSystem, Evanston, IL, USA. .,University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
| |
Collapse
|
56
|
Abstract
We investigated whether a standardized feeding bundle reduces central line utilization in very low birth weight neonates. A chart review of infants ≤1500 g requiring a central line was prepared for 2009 to 2012. Infants were stratified into 3 weight groups: ≤750 g, 751 to 1000 g, and 1001 to 1500 g. The number of central line-associated bloodstream infections (CLABSIs) was recorded. Central line utilization decreased in all of the groups: 0.45 to 0.28 in ≤750 g infants, 0.4 to 0.27 in 751 to 1000 g infants, and 0.39 to 0.3 in 1001 to 1500 g infants (all of the P < 0.001). The CLABSIs rate was unchanged. Implementation of a feeding bundle decreased central line utilization. A feeding bundle had no effect on the rate of CLABSIs.
Collapse
|
57
|
Probiotics (Lactobacillus acidophilus and Bifidobacterium infantis) prevent NEC in VLBW infants fed breast milk but not formula [corrected]. Pediatr Res 2015; 77:381-8. [PMID: 25423074 DOI: 10.1038/pr.2014.192] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 09/04/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Specific probiotics prevent necrotizing enterocolitis (NEC). A mixture of lactobacilli and bifidobacteria (Infloran) was highly effective in Asian very-low-birth-weight (VLBW) infants. We analyzed the effect of Infloran on NEC, NEC severity, and the influence of enteral feedings (breast milk vs. formula) on NEC prevention in a cohort of European VLBW infants. METHODS Infloran was implemented for routine use at our department. VLBW infants receiving probiotics were prospectively followed (2010-2012) and compared with historic controls (2008-2009). Data on NEC, neonatal morbidity, feeding tolerance, and descriptive parameters on NEC cases were analyzed. RESULTS Infloran had no statistically significant impact on NEC (controls: 24/233 (10.3%); probiotics: 16/230 (7%); P = 0.2). However, NEC was significantly reduced in infants of the probiotics group who were fed any breast milk (20/179 (11.2%) vs. 10/183 (5.5%); P = 0.027), whereas it was ineffective in infants exclusively fed formula (4/54 (7.4%) vs. 6/44 (13.6%); P = 0.345). Occurrence of severe NEC (IIIb), time until full feeds, and gastric residuals were similar. CONCLUSION Infloran was of lower efficacy in a European VLBW cohort and showed a reduction of NEC only in infants fed breast milk. Future studies should investigate the influence of feeding formula or breast milk on the effect of probiotics.
Collapse
|
58
|
Dutta S, Singh B, Chessell L, Wilson J, Janes M, McDonald K, Shahid S, Gardner VA, Hjartarson A, Purcha M, Watson J, de Boer C, Gaal B, Fusch C. Guidelines for feeding very low birth weight infants. Nutrients 2015; 7:423-42. [PMID: 25580815 PMCID: PMC4303848 DOI: 10.3390/nu7010423] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 12/19/2014] [Indexed: 11/16/2022] Open
Abstract
Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.
Collapse
Affiliation(s)
- Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Balpreet Singh
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Lorraine Chessell
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Wilson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Marianne Janes
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Kimberley McDonald
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Shaneela Shahid
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Victoria A Gardner
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Aune Hjartarson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Margaret Purcha
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Watson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Chris de Boer
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Barbara Gaal
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Christoph Fusch
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| |
Collapse
|
59
|
Oropharyngeal administration of mother's milk to prevent necrotizing enterocolitis in extremely low-birth-weight infants: theoretical perspectives. J Perinat Neonatal Nurs 2015; 29:81-90. [PMID: 25633403 DOI: 10.1097/jpn.0000000000000087] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The oropharyngeal administration of mother's milk-placing drops of milk onto the infant's oral mucosa-may serve as a preventative strategy against necrotizing enterocolitis (NEC) for extremely low-birth-weight (ELBW: birth weight <1000 g) infants. Necrotizing enterocolitis is a devastating gastrointestinal disorder which is associated with significant mortality for ELBW infants. Survivors are at risk for costly and handicapping morbidities, including severe neurological impairment. The oropharyngeal administration of mother's milk to ELBW infants may serve to expose the infant's oropharynx to protective (immune and trophic) biofactors (also present in amniotic fluid) and may protect the infant against NEC. Emerging evidence suggests that this intervention may have many benefits for extremely premature infants including protection against bacteremia, NEC, and ventilator-associated pneumonia, an earlier attainment of full enteral feeds, enhanced maturation of oral feeding skills, improved growth, and enhanced breast-feeding outcomes. While more research is needed to definitively establish safety and efficacy of this intervention, this article will examine biological plausibility and will describe the theoretical mechanisms of protection against NEC for ELBW infants who receive this intervention. Nurses play a key role in advancing the science and practice of this intervention. Future directions for research and implications for nursing practice will also be presented.
Collapse
|
60
|
de Souza Rugolo LMS, Bentlin MR, Mussi-Pinhata M, de Almeida MFB, Lopes JMDA, Marba STM, Fiori HH, Procianoy RS, Leone CR. Late-onset sepsis in very low birth weight infants: a Brazilian Neonatal Research Network Study. J Trop Pediatr 2014; 60:415-21. [PMID: 25063461 DOI: 10.1093/tropej/fmu038] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Late-onset sepsis (LOS) is an important cause of morbidity and mortality in very low birth weight (VLBW) infants. AIM To determine the incidence, risk factors and etiology of LOS. METHODS LOS was investigated in a multicenter prospective cohort of infants at eight public university neonatal intensive care units (NICUs). Inclusion criteria included inborn, 23-33 weeks of gestational age, 400-1499 g birth weight, who survived >3 days. RESULTS Of 1507 infants, 357 (24%) had proven LOS and 345 (23%) had clinical LOS. Infants with LOS were more likely to die. The majority of infections (76%) were caused by Gram-positive organisms. Independent risk factors for proven LOS were use of central venous catheter and mechanical ventilation, age at the first feeding and number of days on parenteral nutrition and on mechanical ventilation. CONCLUSION LOS incidence and mortality are high in Brazilian VLBW infants. Most risk factors are associated with routine practices at NICU.
Collapse
Affiliation(s)
| | - Maria Regina Bentlin
- Department of Pediatrics, Botucatu School of Medicine, Sao Paulo State University-UNESP, Botucatu, SP, Brazil
| | | | | | | | | | - Humberto Holmer Fiori
- Department of Pediatrics, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | | |
Collapse
|
61
|
Shores DR, Bullard JE, Aucott SW, Stewart FD, Haney C, Nonyane BAS, Schwarz KB. Analysis of Nutrition Practices and Intestinal Failure–Associated Liver Disease in Infants With Intestinal Surgery. ACTA ACUST UNITED AC 2014. [DOI: 10.1177/1941406414558154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives: The incidence of intestinal failure–associated liver disease (IFALD) varies following intestinal surgical intervention in infants, ranging from 25% to 60%. Although IFALD resolves in some infants, 40% of infants who require long-term parenteral nutrition (PN) progress to liver failure. The purpose of this study was to investigate the incidence of IFALD at our center among infants requiring intestinal procedures and to assess postoperative feeding practices. Methods: We performed a retrospective review of infants with intestinal surgical procedures before 6 months of age from 2007 to 2012. Infants with preexisting liver disease, other than IFALD, were excluded. The primary outcome was incidence of IFALD during the initial hospitalization. Timing of IFALD development and median time to reach enteral nutrition goals were investigated. Results: The overall incidence of IFALD was 66% (54/82), and among infants requiring >60 days of PN, the incidence was 90% (27/30). Median direct bilirubin of those with IFALD was 7.5 mg/dL. Infants with IFALD were more likely to be premature (29 vs 38 weeks, P < .001), have necrotizing enterocolitis (54% vs 17%, P = .002), and have culture-positive infection (42% vs 7%, P = .001). Among the most recent 24 infants, the median time to introduce enteral nutrition postoperatively was 19 days (interquartile range = 9-27), and the median time to reach 50% of calories from enteral nutrition was 34 days (interquartile range = 23-50). Conclusions: The risk of IFALD is common at our center. Multidisciplinary preventive and therapeutic strategies need to be investigated. Future investigation will focus on the time to reach enteral nutrition goals as a modifiable risk factor.
Collapse
Affiliation(s)
- Darla R. Shores
- Department of Pediatrics, Division of Gastroenterology & Nutrition (DRS, CH, KBS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Division of Neonatology (JEB, SWA), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of General Pediatric Surgery (FDS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (BASN)
| | - Janine E. Bullard
- Department of Pediatrics, Division of Gastroenterology & Nutrition (DRS, CH, KBS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Division of Neonatology (JEB, SWA), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of General Pediatric Surgery (FDS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (BASN)
| | - Susan W. Aucott
- Department of Pediatrics, Division of Gastroenterology & Nutrition (DRS, CH, KBS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Division of Neonatology (JEB, SWA), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of General Pediatric Surgery (FDS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (BASN)
| | - F. Dylan Stewart
- Department of Pediatrics, Division of Gastroenterology & Nutrition (DRS, CH, KBS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Division of Neonatology (JEB, SWA), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of General Pediatric Surgery (FDS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (BASN)
| | - Courtney Haney
- Department of Pediatrics, Division of Gastroenterology & Nutrition (DRS, CH, KBS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Division of Neonatology (JEB, SWA), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of General Pediatric Surgery (FDS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (BASN)
| | - Bareng A. S. Nonyane
- Department of Pediatrics, Division of Gastroenterology & Nutrition (DRS, CH, KBS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Division of Neonatology (JEB, SWA), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of General Pediatric Surgery (FDS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (BASN)
| | - Kathleen B. Schwarz
- Department of Pediatrics, Division of Gastroenterology & Nutrition (DRS, CH, KBS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Division of Neonatology (JEB, SWA), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of General Pediatric Surgery (FDS), Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (BASN)
| |
Collapse
|
62
|
|
63
|
Wallenstein MB, Arain YH, Birnie KL, Andrews J, Palma JP, Benitz WE, Chock VY. Red blood cell transfusion is not associated with necrotizing enterocolitis: a review of consecutive transfusions in a tertiary neonatal intensive care unit. J Pediatr 2014; 165:678-82. [PMID: 25039042 PMCID: PMC4845907 DOI: 10.1016/j.jpeds.2014.06.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 05/12/2014] [Accepted: 06/04/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To explore the association between red blood cell transfusion and necrotizing enterocolitis (NEC) in a neonatal intensive care unit with liberal transfusion practices. STUDY DESIGN A retrospective cohort study was conducted for all infants weighing <1500 g who received at least 1 packed red blood cell transfusion between January 2008 and June 2013 in a tertiary neonatal intensive care unit. The primary outcome was NEC, defined as Bell stage II or greater. The temporal association of NEC and transfusion was assessed using multivariate Poisson regression. RESULTS The study sample included 414 very low birth weight infants who received 2889 consecutive red blood cell transfusions. Twenty-four infants (5.8%) developed NEC. Four cases of NEC occurred within 48 hours of a previous transfusion event. Using multivariate Poisson regression, we did not find evidence of a temporal association between NEC and transfusion (P = .32). CONCLUSION There was no association between NEC and red blood cell transfusion. Our results differ from previous studies and suggest that the association between NEC and transfusion may be contextual.
Collapse
Affiliation(s)
- Matthew B. Wallenstein
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Yassar H. Arain
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Krista L. Birnie
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jennifer Andrews
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA,Division of Transfusion Medicine, Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Jonathan P. Palma
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA,Division of Systems Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - William E. Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Valerie Y. Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
64
|
Reisinger KW, Elst M, Derikx JPM, Nikkels PGJ, de Vries B, Adriaanse MPM, Jellema RK, Kramer BWW, Wolfs TGAM. Intestinal fatty acid-binding protein: a possible marker for gut maturation. Pediatr Res 2014; 76:261-8. [PMID: 24956227 DOI: 10.1038/pr.2014.89] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 04/02/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gut immaturity is linked with postnatal intestinal disorders. However, biomarkers to assess the intestinal developmental stage around birth are lacking. The aim of this study was to gain more insight on intestinal fatty acid-binding protein (I-FABP) as an indicator of gut maturity. METHODS Antenatal I-FABP distribution and release was investigated in extremely premature, moderately premature, and term lambs, and these findings were verified in human urinary samples. Ileal I-FABP distribution was confirmed in autopsy material within 24 h postnatally. RESULTS Median (range) serum I-FABP levels were lower in extremely premature lambs compared with moderately premature lambs (156 (50.0-427) vs. 385 (100-1,387) pg/ml; P = 0.02). Contrarily, median early postnatal urine I-FABP levels in human infants were higher in extremely premature compared with moderately premature and term neonates (1,219 (203-15,044) vs. 256 (50-1,453) and 328 (96-1,749) pg/ml; P = 0.008 and P = 0.04, respectively). I-FABP expression was most prominent in nonvacuolated enterocytes and increased with rising gestational age (GA) in ovine and human tissue samples. The epithelial distribution pattern changed from a phenotype displaying I-FABP-positive enterocytes merely in the crypts early in gestation into a phenotype with I-FABP expressing cells exclusively present in the villus tips at term in ovine and human tissue. CONCLUSION In this ovine and human study, increasing GA is accompanied by an increase in I-FABP tissue content. Cord I-FABP levels correlate with gestation in ovine fetuses, identifying I-FABP as a marker for gut maturation. Raised postnatal urine I-FABP levels in preterm human infants may indicate intestinal injury and/or inflammation in utero.
Collapse
Affiliation(s)
- Kostan W Reisinger
- Department of Surgery, Maastricht University Medical Center and Nutrition and Toxicology Research Institute (NUTRIM), Maastricht, The Netherlands
| | - Marieke Elst
- Department of Pediatrics, Maastricht University Medical Center and School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
| | - Joep P M Derikx
- Department of Surgery, Maastricht University Medical Center and Nutrition and Toxicology Research Institute (NUTRIM), Maastricht, The Netherlands
| | - Peter G J Nikkels
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - Bart de Vries
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marlou P M Adriaanse
- Department of Pediatrics & Nutrition and Toxicology Research Institute Maastricht (NUTRIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Reint K Jellema
- 1] Department of Pediatrics, Maastricht University Medical Center and School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands [2] Department of Pediatrics & School for Mental Health and NeuroScience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Boris W W Kramer
- 1] Department of Pediatrics, Maastricht University Medical Center and School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands [2] Department of Pediatrics & School for Mental Health and NeuroScience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Tim G A M Wolfs
- Department of Pediatrics, Maastricht University Medical Center and School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
| |
Collapse
|
65
|
|
66
|
Impact of standardized feeding guidelines on enteral nutrition administration, growth outcomes, metabolic bone disease, and cholestasis in the NICU. J Pediatr Gastroenterol Nutr 2014; 59:93-8. [PMID: 24517917 DOI: 10.1097/mpg.0000000000000314] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The objectives of this study were to determine whether the implementation of standardized feeding guidelines (SFGs) in a neonatal intensive care unit had an impact on the administration of enteral nutrition, growth, and bone and liver health. METHODS This was a retrospective chart review of infants ≤ 32 weeks' gestation and ≤ 1500 g at birth who received enteral nutrition either via traditional care (TC) or via SFGs. The outcomes of the study were to determine the day of life the first enteral feedings were started, the day of life full, fortified enteral feedings were established, the day of life the infant returned to birth weight, the change in weight z score from birth to day of life 30, and the presence of metabolic bone disease and cholestasis. RESULTS There were 128 infants in the TC group and 125 infants in the SFG group. Based on the Cox regression, no significant differences were found between the 2 groups in the length of time to the first feed (P=0.110; CI 1.03-1.70), in the length of time to full, fortified enteral feedings (P=0.334; CI 0.87-1.44), in the length of time to return to birth weight (P=0.545; CI 0.77-1.28), incidence of metabolic bone disease (P=0.990), or incidence of cholestasis (P=0.926). CONCLUSIONS This study provides preliminary evidence that SFGs have an effect on enteral nutrition administration, growth, and morbidity for preterm infants. Although the findings were not statistically significant, they are clinically relevant.
Collapse
|
67
|
Discrimination of GutCheck(NEC): a clinical risk index for necrotizing enterocolitis. J Perinatol 2014; 34:468-75. [PMID: 24651734 PMCID: PMC4420242 DOI: 10.1038/jp.2014.37] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 01/28/2014] [Accepted: 02/05/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Better measures are needed to identify infants at risk for developing necrotizing enterocolitis (NEC) and facilitate communication about risk across transitions. Although NEC is multi-factorial, quantification of composite risk for NEC in an individual infant is not clearly defined. The objective of this study was to describe the derivation, validation and calibration testing of a novel clinical NEC risk index, GutCheck(NEC). Individual risk factors were weighted to assess composite odds of developing NEC. GutCheck(NEC) is designed to improve communication about NEC risk and coordination of care among clinicians across an infant's clinical course. STUDY DESIGN On the basis of a synthesis of research evidence about NEC risk and an e-Delphi study including 35 neonatal experts, we identified NEC risk factors believed by the experts to be most relevant for a NEC risk index, then applied a logistic model building process to derive and validate GutCheck(NEC). De-identified data from the Pediatrix BabySteps Clinical Data Warehouse (discharge date 2007 to 2011) were split into three samples for derivation, validation and calibration. By comparing infants with medical NEC, surgical NEC and those who died to infants without NEC, we derived the logistic model using the un-matched derivation set. Discrimination was then tested in a case-control matched validation set and an un-matched calibration set using receiver operating characteristic curves. RESULT Sampled from a cohort of 58 820 infants, the randomly selected derivation set (n=35 013) revealed nine independent risk factors (gestational age, history of packed red blood cell transfusion, unit NEC rate, late-onset sepsis, multiple infections, hypotension treated with inotropic medications, Black or Hispanic race, outborn status and metabolic acidosis) and two risk reducers (human milk feeding on both days 7 and 14 of life, and probiotics). Unit NEC rate carried the most weight in the summed score. Validation using a 2:1 matched case-control sample (n=360) demonstrated fair to good discrimination. In the calibration set (n=23 447), GutCheck(NEC) scores (range 0 to 58) discriminated those infants who developed surgical NEC (area under the curve (AUC)=0.84, 95% confidence interval (CI) 0.82 to 0.84) and NEC leading to death (AUC=0.83, 95% CI 0.81 to 0.85), more accurately than medical NEC (AUC= 0.72, 95% CI 0.70 to 0.74). CONCLUSION GutCheck(NEC) represents weighted composite risk for NEC and discriminated infants who developed NEC from those who did not with very good accuracy. We speculate that targeting modifiable NEC risk factors could reduce national NEC prevalence.
Collapse
|
68
|
Hamilton E, Massey C, Ross J, Taylor S. Early enteral feeding in very low birth weight infants. Early Hum Dev 2014; 90:227-30. [PMID: 24612934 DOI: 10.1016/j.earlhumdev.2014.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 02/07/2014] [Accepted: 02/11/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM Debate exists about when to initiate enteral feeding (EF) in very low birth weight (VLBW) preterm infants. This retrospective study compared the effectiveness of an education-based quality improvement project and the relationship of time of the first EF to necrotizing enterocolitis (NEC) or death incidence and parenteral nutrition (PN) days in VLBW infants. STUDY DESIGN/SUBJECTS VLBW infants born in 2 epochs were compared for hour of the first feed, PN days, NEC or death incidence, and feeding type. The 2 epochs were temporally divided by a quality improvement initiative to standardize initiation of EF in postnatal hours 6-24. RESULTS 603 VLBW infants were included. Median time of feed initiation decreased from 33 (Epoch 1) to 14h (Epoch 2) (p<0.0001). Median PN days were 14 vs. 12, respectively (p=0.07). The incidence of NEC or death was 13.4% vs. 9.5%, respectively (p=0.14). When controlling for birth weight, gestational age, race, gender, and time period, earlier feed initiation was associated with decreased NEC or death (p=0.003). Evaluation of the relationship of early EF (defined as within the first 24h) in Epoch 2 alone showed that early EF was significantly associated with decreased NEC or death (6.3 vs 15.1%) (RR, 95% CI=0.28, 0.13-0.58) and less PN days (p<0.0001). CONCLUSIONS In a VLBW infant cohort, an education-based process improvement initiative decreased time of EF initiation to a median of 14h with no associated increase in NEC or death. In fact, results suggest that earlier feeding is associated with decreased NEC or death.
Collapse
Affiliation(s)
- Emily Hamilton
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States.
| | - Cynthia Massey
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Julie Ross
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Sarah Taylor
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| |
Collapse
|
69
|
Ehrenkranz RA. Ongoing issues in the intensive care for the periviable infant--nutritional management and prevention of bronchopulmonary dysplasia and nosocomial infections. Semin Perinatol 2014; 38:25-30. [PMID: 24468566 DOI: 10.1053/j.semperi.2013.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The focus of this paper is to describe the following: (1) the benefits of implementing feeding guidelines, (2) management practices associated with the prevention of BPD, and (3) management practices associated with prevention of nosocomial infection.
Collapse
Affiliation(s)
- Richard A Ehrenkranz
- Department of Pediatrics and Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, PO Box: 208064, New Haven, CT 06520-8064.
| |
Collapse
|
70
|
Ehrenkranz RA. Extrauterine growth restriction: Is it preventable? JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2013.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
71
|
Extrauterine growth restriction: is it preventable? J Pediatr (Rio J) 2014; 90:1-3. [PMID: 24156834 DOI: 10.1016/j.jped.2013.10.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/14/2013] [Indexed: 11/23/2022] Open
|
72
|
Necrotizing enterocolitis: have we made any progress in reducing the risk? Adv Neonatal Care 2013; 13:317-24; quiz 325-6. [PMID: 24042135 DOI: 10.1097/anc.0b013e31829a872c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Necrotizing enterocolitis (NEC) is a disease affecting premature infants with potentially devastating complications in the neonatal intensive care unit (NICU). Inadequate knowledge regarding the underlying pathophysiology of this disease has contributed to the minimal progress made in decreasing the incidence and severity of NEC. Because of an improved survival rate of the most immature infants, the number of diagnosed cases of NEC is anticipated to increase. Unfortunately, decades of research have failed to reduce the risk or improve the prognosis of NEC, magnifying the need for risk-reduction strategies for decreasing significant NEC-related morbidity and mortality. Advancements in our understanding of this disease process have facilitated the development of several strategies that have been investigated in the risk reduction of NEC. This article discusses the pathophysiology and causes of NEC and presents strategies investigated regarding risk reduction of this devastating disease.
Collapse
|
73
|
Cormack B, Sinn J, Lui K, Tudehope D. Australasian neonatal intensive care enteral nutrition survey: implications for practice. J Paediatr Child Health 2013; 49:E340-7. [PMID: 23227901 DOI: 10.1111/jpc.12016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2011] [Indexed: 11/27/2022]
Abstract
AIM This survey investigated standardised feeding guidelines and nutrition policy in Australasian neonatal intensive care units and compared these with previously published surveys and international consensus nutrition recommendations. METHODS An electronic survey on enteral nutrition comprising a wide range of questions about clinical practice was e-mailed to all 25 Australasian neonatal intensive care unit directors of tertiary perinatal centres. RESULTS Twenty-five surveys were distributed; 24 (96%) were completed. All respondents preferred breast milk as the first feed. For infants <1000 g, 58% started feeds at 1 mL every 4 hours and 83% started enteral feeds on day 0-2 in the absence of contraindications. The identification of bile-stained gastric aspirates significant enough to withhold feeds varied. Multicomponent breast milk fortifiers were added by 58% when enteral feeds reached 150 mL/kg day, while 21% added these earlier at 120 mL/kg day or less. Iron supplementation was started at 4 weeks by 63% and at 6 weeks by 27%. Only 42% of units had a neonatal dietitian. Of the 24 units who responded, 58% had no written enteral feeding guidelines. CONCLUSION Enteral nutrition was initiated earlier than in the past. Great variation remains in clinical practices. Nutritional implications are discussed. Standardisation of feeding guidelines and enteral nutrition policy based on current evidence and international consensus nutrition recommendations may be beneficial and should be encouraged.
Collapse
|
74
|
Preventing necrotizing enterocolitis with standardized feeding protocols: not only possible, but imperative. Adv Neonatal Care 2013; 13:48-54. [PMID: 23360859 DOI: 10.1097/anc.0b013e31827ece0a] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
75
|
Abstract
Necrotizing enterocolitis (NEC) is the most common acquired gastrointestinal disease of premature neonates and is a serious cause of morbidity and mortality. NEC is one of the leading causes of death in neonatal intensive care units. Surgical treatment is necessary in patients whose disease progresses despite medical therapy. Surgical options include peritoneal drainage and laparotomy, with studies showing no difference in outcome related to approach. Survivors, particularly those requiring surgery, face serious sequelae.
Collapse
|
76
|
Cohen RS, McCallie KR. Feeding premature infants: why, when, and what to add to human milk. JPEN J Parenter Enteral Nutr 2012; 36:20S-4S. [PMID: 22237872 DOI: 10.1177/0148607111421342] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ronald S Cohen
- Lucile S. Packard Children's Hospital, Stanford University, Palo Alto, California, USA.
| | | |
Collapse
|