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Singh NK, Will L, Al-Mulaabed S, Ruoss L, Li N, de La Cruz D, Gurka M, Neu J. Antibiotics Use and Its Effects on the Establishment of Feeding Tolerance in Preterm Neonates. Am J Perinatol 2024; 41:e2248-e2253. [PMID: 37308133 DOI: 10.1055/a-2108-1960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Antibiotics are one of the most widely used medications in today's neonatal intensive care units. Indiscriminate antibiotic usage persists in preterm newborns who are symptomatic due to factors linked to prematurity rather than being septic. Previous studies in older infants suggest that prior antibiotic administration is associated with possible dysmotility and microbial dysbiosis in the intestinal tract. We hypothesize that early antibiotic administration impacts high-risk preterm infants' tolerance to enteral feeding advancement. STUDY DESIGN As part of the Routine Early Antibiotic Use in SymptOmatic Preterm Neonates study, symptomatic preterm newborns without maternal infection risk factors were randomized to receive or not receive antibiotics, with C1 receiving antibiotics and C2 not. Of the 55 newborns that underwent pragmatic randomization, 28 preterm neonates in group C1 received antibiotics. RESULTS The premature neonates in the randomized groups who received antibiotics and those who did not showed no differences in sustained feeding tolerance. CONCLUSION Our investigation of the risk of feeding issues in babies who get antibiotics early in life revealed no differences between neonates who received antibiotics and those who did not when the randomized controlled trial data alone was reviewed. Given the sample sizes, it is uncertain if the preceding analysis is powerful enough to detect differences (a significant percentage of neonates who were randomly assigned to NOT get antibiotics subsequently received early treatment due to changing clinical conditions). This affirms the requirement for a meticulously designed prospective randomized study. KEY POINTS · Defining feeding tolerance for the first time in neonates.. · Patients from the REASON trial were evaluated.. · Preterm neonates were the focus of this study..
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Affiliation(s)
- Neel K Singh
- Department of Pediatrics, Division of Neonatology, Shands Children's Hospital, University of Florida, Gainesville, Florida
| | - Lester Will
- Department of Pediatrics, Division of Neonatology, Shands Children's Hospital, University of Florida, Gainesville, Florida
| | - Sharef Al-Mulaabed
- Department of Pediatrics, Presbyterian Medical Group, Albuquerque, New Mexico
| | - Lauren Ruoss
- Department of Pediatrics, Division of Neonatology, Shands Children's Hospital, University of Florida, Gainesville, Florida
| | - Nan Li
- Department of Pediatrics, Division of Neonatology, Shands Children's Hospital, University of Florida, Gainesville, Florida
| | - Diomel de La Cruz
- Department of Pediatrics, Division of Neonatology, Shands Children's Hospital, University of Florida, Gainesville, Florida
| | - Matthew Gurka
- Pediatrics Research Hub (PoRCH), Department of Pediatrics in the College of Medicine, University of Florida, Gainesville, Florida
| | - Josef Neu
- Department of Pediatrics, Division of Neonatology, Shands Children's Hospital, University of Florida, Gainesville, Florida
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2
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Lagerquist E, Al-Haddad BJS, Irvine J, Muskthel L, Rios A, Upadhyay K. Feeding volume advancement in preterm neonates: A level 4 neonatal intensive care unit quality improvement initiative. Nutr Clin Pract 2023; 38:1175-1180. [PMID: 37035908 DOI: 10.1002/ncp.10992] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/16/2023] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION Because of provider variability in feeding guideline application, a quality improvement (QI) initiative was begun to better standardize feeding initiation and advancement for preterm infants. Our specific, measurable, achievable, relevant, and timely aims included decreasing the time to reach full feeds by 35% and reducing the duration of central lines by 30% over 12 months in infants born between 25 and 30 weeks' gestation or with birth weight between 600 and 1250 g. METHODS Registered dietitians tracked central line days, parenteral nutrition (PN), enteral nutrition, fortification, guideline adherence, anthropometrics, necrotizing enterocolitis (NEC) cases, and central line-associated bloodstream infections (CLABSIs). QI progress charts were reviewed monthly. RESULTS Mean central line days decreased from 7.3 to 5.8. Days of PN decreased from 6.7 to 5.1. The day of life that enteral feeds were started decreased from 1.1 to 0.5. The number of days between starting enteral feeds and adding fortification decreased from 3.4 to 2.3 days. Full enteral feeds were achieved on average 2 days earlier. Birth weight was regained at around 10.2 days of life before the guideline was implemented and at a mean of 9.6 days after the guideline. There was no increase in cases of CLABSI or diagnoses of NEC. CONCLUSION After implementation of this feeding QI initiative at a level 4 neonatal intensive care unit, central line duration and PN use were decreased and infants reached full enteral feeds earlier without changes in cases of NEC, CLABSI, or time to regain birth weight.
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Affiliation(s)
- Eliza Lagerquist
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
| | - Benjamin J S Al-Haddad
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jill Irvine
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
| | - Lucy Muskthel
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
| | - Angel Rios
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
| | - Kirtikumar Upadhyay
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
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3
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Riddle S, Karpen H. Special Populations-Surgical Infants. Clin Perinatol 2023; 50:715-728. [PMID: 37536774 DOI: 10.1016/j.clp.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound healing, and provide optimal growth; impaired motility and altered intestinal flora leading to feeding intolerance requiring long-term parenteral nutrition; gastroesophageal reflux and poor feeding mechanics requiring tube feedings and support; growth failure; poor barrier function and risk of infection; and other long-term sequelae. Consequently, the surgical "at-risk" infant requires specialized nutritional support to meet their increased requirements to ensure adequate growth and meet the increased demands from critical illness.
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Affiliation(s)
- Stefanie Riddle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Heidi Karpen
- Emory University School of Medicine/Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, ECC Room 324, Atlanta, GA 30322, USA
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4
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Gerrard SD, Yonke JA, Seymour KA, Sunny NE, El-Kadi SW. Feeding medium-chain fatty acid-rich formula causes liver steatosis and alters hepatic metabolism in neonatal pigs. Am J Physiol Gastrointest Liver Physiol 2023; 325:G135-G146. [PMID: 37280515 DOI: 10.1152/ajpgi.00164.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 05/26/2023] [Accepted: 06/02/2023] [Indexed: 06/08/2023]
Abstract
Medium-chain fatty acids (MCFA) and long-chain fatty acids (LCFAs) are often added to enhance the caloric value of infant formulas. Evidence suggests that MCFAs promote growth and are preferred over LCFAs due to greater digestibility and ease of absorption. Our hypothesis was that MCFA supplementation would enhance neonatal pig growth to a greater extent than LCFAs. Neonatal pigs (n = 4) were fed a low-energy control (CONT) or two isocaloric high-energy formulas containing fat either from LCFAs, or MCFAs for 20 days. Pigs fed the LCFAs had greater body weight compared with CONT- and MCFA-fed pigs (P < 0.05). In addition, pigs fed the LCFAs and MCFAs had more body fat than those in the CONT group. Liver and kidney weights as a percentage of body weight were greater (P ≤ 0.05) for pigs fed the MCFAs than those fed the CONT formula, and in those fed LCFAs, liver and kidney weights as a percentage of body weight were intermediate (P ≤ 0.05). Pigs in the CONT and LCFA groups had less liver fat (12%) compared with those in the MCFA (26%) group (P ≤ 0.05). Isolated hepatocytes from these pigs were incubated in media containing [13C]tracers of alanine, glucose, glutamate, and propionate. Our data suggest alanine contribution to pyruvate is less in hepatocytes from LCFA and MCFA pigs than those in the CONT group (P < 0.05). These data suggest that a formula rich in MCFAs caused steatosis compared with an isocaloric LCFA formula. In addition, MCFA feeding can alter hepatocyte metabolism and increase total body fat without increasing lean deposition.NEW & NOTEWORTHY Our data suggest that feeding high-energy MCFA formula resulted in hepatic steatosis compared with isoenergetic LCFA or low-energy formulas. Steatosis coincided with greater laurate, myristate, and palmitate accumulation, suggesting elongation of dietary laurate. Data also suggest that hepatocytes metabolized alanine and glucose to pyruvate, but neither entered the tricarboxylic acid (TCA) cycle. In addition, the contribution of alanine and glucose was greater for the low-energy formulas compared with the high-energy formulas.
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Affiliation(s)
- Samuel D Gerrard
- School of Animal Sciences, Virginia Tech, Blacksburg, Virginia, United States
| | - Joseph A Yonke
- School of Animal Sciences, Virginia Tech, Blacksburg, Virginia, United States
| | - Kacie A Seymour
- School of Animal Sciences, Virginia Tech, Blacksburg, Virginia, United States
| | - Nishanth E Sunny
- Department of Animal and Avian Sciences, University of Maryland, College Park, Maryland, United States
| | - Samer W El-Kadi
- School of Animal Sciences, Virginia Tech, Blacksburg, Virginia, United States
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5
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Hair AB, Good M. Dilemmas in feeding infants with intestinal failure: a neonatologist's perspective. J Perinatol 2023; 43:114-119. [PMID: 36127395 DOI: 10.1038/s41372-022-01504-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 02/07/2023]
Abstract
Intestinal failure in neonatal and pediatric populations can be debilitating for patients and difficult to manage for clinicians. Management strategies include referral to an intestinal rehabilitation center, small volume trophic feeds to stimulate the intestine with cautious advancement of enteral nutrition using a standardized and evidence-based feeding protocol, and supplemental parenteral nutrition to optimize an infant's growth and nutrition. In this review, we discuss the causes of intestinal failure, parenteral nutrition strategies, enteral feeding initiation and advancement protocols, as well as the challenges in feeding an infant with intestinal failure.
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Affiliation(s)
- Amy B Hair
- Division of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Misty Good
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
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6
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Dilemmas in human milk fortification. J Perinatol 2023; 43:103-107. [PMID: 36097287 DOI: 10.1038/s41372-022-01502-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/10/2022] [Accepted: 08/26/2022] [Indexed: 02/07/2023]
Abstract
Fortification of human milk is the standard of care for very low birth weight (VLBW) infants and is required to support adequate postnatal growth and development. Achieving adequate growth velocity and preventing growth faltering is critical for the developing neonatal brain and optimizing long-term neurodevelopmental outcomes. Mother's milk is the gold standard nutrition to feed preterm infants, however, it does not provide the nutrients needed to support the growth of VLBW infants. After the decision is made to use mother's milk (if available) or alternatively, donor human milk, many dilemmas exist with regards to additional treatment decisions surrounding the type of fortification to use, when to fortify, and the duration of fortification. In this article, we will review the differences in mother's milk compared to donor milk, the different types of human milk fortifiers, the optimal timing of fortification, and discuss when to discontinue human milk fortification.
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7
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Aurora M, Keyes ML, Acosta JG, Swartz K, Lombay J, Ciaramitaro J, Rudnick A, Kelleher C, Hally S, Gee M, Madhavan V, Roumiantsev S, Cummings BM, Nelson BD, Lerou PH, Matute JD. Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU. Pediatrics 2022; 150:189570. [PMID: 36164852 PMCID: PMC10026590 DOI: 10.1542/peds.2022-056616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.
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Affiliation(s)
- Megan Aurora
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors contributed equally to this work
| | - Madeline L Keyes
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- Harvard Neonatal-Perinatal Medicine Fellowship Program, Boston, Massachusetts
- These authors contributed equally to this work
| | | | | | - Jesiel Lombay
- Divisions of aNewborn Medicine
- Departments of Pediatrics
| | | | | | | | | | - Michael Gee
- Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Paul H Lerou
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
| | - Juan D Matute
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
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8
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Burge KY, Gunasekaran A, Makoni MM, Mir AM, Burkhart HM, Chaaban H. Clinical Characteristics and Potential Pathogenesis of Cardiac Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: A Narrative Review. J Clin Med 2022; 11:3987. [PMID: 35887751 PMCID: PMC9320426 DOI: 10.3390/jcm11143987] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/10/2022] Open
Abstract
Neonates with congenital heart disease (CHD) are at an increased risk of developing necrotizing enterocolitis (NEC), an acute inflammatory intestinal injury most commonly associated with preterm infants. The rarity of this complex disease, termed cardiac NEC, has resulted in a dearth of information on its pathophysiology. However, a higher incidence in term infants, effects on more distal regions of the intestine, and potentially a differential immune response may distinguish cardiac NEC as a distinct condition from the more common preterm, classical NEC. In this review, risk factors, differentiated from those of classical NEC, are discussed according to their potential contribution to the disease process, and a general pathogenesis is postulated for cardiac NEC. Additionally, biomarkers specific to cardiac NEC, clinical outcomes, and strategies for achieving enteral feeds are discussed. Working towards an understanding of the mechanisms underlying cardiac NEC may aid in future diagnosis of the condition and provide potential therapeutic targets.
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Affiliation(s)
- Kathryn Y. Burge
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Aarthi Gunasekaran
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Marjorie M. Makoni
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Arshid M. Mir
- Department of Pediatrics, Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Harold M. Burkhart
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Hala Chaaban
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
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9
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王 琳, 赵 小, 刘 辉, 邓 丽, 梁 红, 段 思, 杨 依, 张 华. [Evidence-based standardized nutrition protocol can shorten the time to full enteral feeding in very preterm/very low birth weight infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:648-653. [PMID: 35762431 PMCID: PMC9250396 DOI: 10.7499/j.issn.1008-8830.2202121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/06/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To investigate whether evidence-based standardized nutrition protocol can facilitate the establishment of full enteral nutrition and its effect on short-term clinical outcomes in very preterm/very low birth weight infants. METHODS A retrospective analysis was performed on the medical data of 312 preterm infants with a gestational age of ≤32 weeks or a birth weight of <1 500 g. The standardized nutrition protocol for preterm infants was implemented in May 2020; 160 infants who were treated from May 1, 2019 to April 30, 2020 were enrolled as the control group, and 152 infants who were treated from June 1, 2020 to May 31, 2021 were enrolled as the test group. The two groups were compared in terms of the time to full enteral feeding, the time to the start of enteral feeding, duration of parenteral nutrition, the time to recovery to birth weight, the duration of central venous catheterization, and the incidence rates of common complications in preterm infants. RESULTS Compared with the control group, the test group had significantly shorter time to full enteral feeding, time to the start of enteral feeding, duration of parenteral nutrition, and duration of central venous catheterization and a significantly lower incidence rate of catheter-related bloodstream infection (P<0.05). There were no significant differences between the two groups in the mortality rate and the incidence rate of common complications in preterm infants including grade II-III necrotizing enterocolitis (P>0.05). CONCLUSIONS Implementation of the standardized nutrition protocol can facilitate the establishment of full enteral feeding, shorten the duration of parenteral nutrition, and reduce catheter-related bloodstream infection in very preterm/very low birth weight infants, without increasing the risk of necrotizing enterocolitis.
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Affiliation(s)
| | | | | | | | | | | | | | - 华岩 张
- 费城儿童医院 及宾夕法尼亚大学佩雷尔曼医学院新生儿科,美国宾夕法尼亚州费城
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10
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D'Costa R, Fucile S, Dickson B, Gallipoli A, Dow KE. Benefits of a Standardized Enteral Feeding Protocol on the Nutrition and Health Outcomes of Very Low Birth Weight Preterm Infants. CAN J DIET PRACT RES 2022; 83:147-150. [PMID: 35503898 DOI: 10.3148/cjdpr-2022-003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Purpose: To compare nutrition and health outcomes before and after implementing a standardized enteral feeding protocol on nutrition and health outcomes in very low birth weight preterm infants.Methods: A retrospective chart review was performed evaluating preterm infants, born less than 34 weeks gestation and weighing less than 1500 g, before and after the implementation of a standardized enteral feeding protocol. Outcomes included weaning of parenteral nutrition, initiation and advancement of enteral feeds, initiation of human-milk fortifier (HMF), change in weight z-score and neonatal morbidities.Results: Fifty-six infants (30 in pre-group, 26 in post-group) met the inclusion criteria. Infants in the standardized enteral feeding protocol group started enteral feeds earlier (p = 0.039) and received full HMF fortification at lower weights (p = 0.033) than those in the pre-group. Fewer days on continuous positive airway pressure (p = 0.021) and lower rates of bronchopulmonary dysplasia (p = 0.018) were also observed in the post-group. Weaning of parenteral nutrition and weight z-score were not significantly different between groups. There were no differences in other morbidities.Conclusion: Study results suggest that adopting a standardized enteral feeding protocol may promote early initiation of enteral feeds and fortification.
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Affiliation(s)
- Rhea D'Costa
- Department of Pediatrics, Queen's University, Kingston, ON
| | - Sandra Fucile
- Department of Pediatrics, Queen's University, Kingston, ON.,School of Rehabilitation Therapy, Queen's University, Kingston, ON
| | - Brittany Dickson
- Neonatal Intensive Care Unit, Kingston Health Sciences Centre, Kingston, ON
| | | | - Kimberly E Dow
- Department of Pediatrics, Queen's University, Kingston, ON
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11
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Olowoyeye A, Basile E, Kim S, Thompson-Branch A. A Quality Improvement Project to Reduce Time to Full Enteral Feeds for Very Low Birth Weight Neonates. Hosp Pediatr 2022; 12:515-521. [PMID: 35415760 DOI: 10.1542/hpeds.2021-006238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adherence to standardized feeding guidelines has been proposed as a strategy to limit morbidity in very low birth weight neonates. Fostering adherence limits the variability in medicine that affects the quality of patient care. The aim of this study was to reduce by 20% the time to full enteral feeds in very low birth weight neonates in the NICU within a 12-month period. METHODS In a level IV regional perinatal center with low utilization of its feeding protocol, a 12-month quality improvement project was conducted with a key intervention of a feeding schedule calculator based on the unit standardized feeding protocol. Through studied education and implementation cycles, these feeding schedules were used to reduce time to full enteral feeds while monitoring adverse events related to their use. RESULTS During the course of this quality improvement project, our time to full enteral feeds of 160 ml/kg/day of feeds reduced from 24.7 days to 17.7 days after process changes with special-cause variation noted on control charts. We also showed a significant reduction in mean central line duration over the course of the project from a baseline of 19 days to 14.5 days. CONCLUSION Through a key intervention of a feeding volume calculator, we were able to reduce the time to full enteral feeds in neonates without any increase in adverse events of necrotizing enterocolitis or poor weight gain.
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Affiliation(s)
- Abiola Olowoyeye
- Department of Neonatology, Phoenix Children's Hospital, Phoenix, Arizona.,Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Eric Basile
- Department of Clinical Nutrition, Jack D. Weiler Hospital, Bronx, New York
| | - Susan Kim
- Department of Pediatrics Children's Hospital at Montefiore, Bronx, New York
| | - Alecia Thompson-Branch
- Department of Pediatrics Children's Hospital at Montefiore, Bronx, New York.,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
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12
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Dekonenko C, Fraser JD, Deans K, Fallat ME, Helmrath M, Kabre R, Leys CM, Burns RC, Corkum K, Dillon PA, Downard C, Wright TN, Gadepalli SK, Grabowski J, Hernandez E, Hirschl R, Johnson KN, Kohler J, Landman MP, Landisch RM, Lawrence AE, Mak GZ, Minneci P, Rymeski B, Sato TT, Slater BJ, Peter SSD. Does Use of a Feeding Protocol Change Outcomes in Gastroschisis? A Report from the Midwest Pediatric Surgery Consortium. Eur J Pediatr Surg 2022; 32:153-159. [PMID: 33368085 DOI: 10.1055/s-0040-1721074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Gastroschisis feeding practices vary. Standardized neonatal feeding protocols have been demonstrated to improve nutritional outcomes. We report outcomes of infants with gastroschisis that were fed with and without a protocol. MATERIALS AND METHODS A retrospective study of neonates with uncomplicated gastroschisis at 11 children's hospitals from 2013 to 2016 was performed.Outcomes of infants fed via institutional-specific protocols were compared with those fed without a protocol. Subgroup analyses of protocol use with immediate versus delayed closure and with sutured versus sutureless closure were conducted. RESULTS Among 315 neonates, protocol-based feeding was utilized in 204 (65%) while no feeding protocol was used in 111 (35%). There were less surgical site infections (SSI) in those fed with a protocol (7 vs. 16%, p = 0.019). There were no differences in TPN duration, time to initial oral intake, time to goal feeds, ventilator use, peripherally inserted central catheter line deep venous thromboses, or length of stay. Of those fed via protocol, less SSIs occurred in those who underwent sutured closure (9 vs. 19%, p = 0.026). Further analyses based on closure timing or closure method did not demonstrate any significant differences. CONCLUSION Across this multi-institutional cohort of infants with uncomplicated gastroschisis, there were more SSIs in those fed without an institutional-based feeding protocol but no differences in other outcomes.
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Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Katherine Deans
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Mary E Fallat
- Department of Surgery, Norton Children's Hospital, Louisville, Kentucky, United States
| | - Michael Helmrath
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Rashmi Kabre
- Department of Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, United States
| | - R Cartland Burns
- Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Kristine Corkum
- Department of Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Patrick A Dillon
- Department of Surgery, St Louis Children's Hospital PACT, St. Louis, Missouri, United States
| | - Cynthia Downard
- Department of Surgery, Norton Children's Hospital, Louisville, Kentucky, United States
| | - Tiffany N Wright
- Department of Surgery, Norton Children's Hospital, Louisville, Kentucky, United States
| | - Samir K Gadepalli
- Department of Surgery, C S Mott Children's Hospital, Ann Arbor, Michigan, United States
| | - Julia Grabowski
- Department of Pediatric Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Edward Hernandez
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, United States
| | - Ronald Hirschl
- Department of Surgery, C S Mott Children's Hospital, Ann Arbor, Michigan, United States
| | - Kevin N Johnson
- Department of Surgery, C S Mott Children's Hospital, Ann Arbor, Michigan, United States
| | - Jonathan Kohler
- Department of Surgery, University of Wisconsin Madison, Madison, Wisconsin, United States
| | - Matthew P Landman
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, United States
| | - Rachel M Landisch
- Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States
| | - Amy E Lawrence
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Grace Z Mak
- Department of Surgery, University of Chicago Comer Children's Hospital, Chicago, Illinois, United States
| | - Peter Minneci
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Beth Rymeski
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Thomas T Sato
- Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States
| | - Bethany J Slater
- Department of Surgery, University of Chicago Comer Children's Hospital, Chicago, Illinois, United States
| | - St Shawn D Peter
- Department of Surgery, Center for Prospective Trials, Children's Mercy Hospital, Kansas City, Missouri, United States
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13
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Tongo OO, Olwala MA, Talbert AW, Nabwera HM, Akindolire AE, Otieno W, Nalwa GM, Andang'o PEA, Mwangome MK, Abdulkadir I, Ezeaka CV, Ezenwa BN, Fajolu IB, Imam ZO, Umoru DD, Abubakar I, Embleton ND, Allen SJ. Enteral Feeding Practices for Very Preterm and Very Low Birth Weight Infants in Nigeria and Kenya. Front Pediatr 2022; 10:892209. [PMID: 35633964 PMCID: PMC9130927 DOI: 10.3389/fped.2022.892209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Optimizing nutrition in very preterm (28-32 weeks gestation) and very low birth weight (VLBW; 1,000 g to <1,500 g) infants has potential to improve their survival, growth, and long-term health outcomes. Aim To assess feeding practices in Nigeria and Kenya for very preterm and VLBW newborn infants. Methods This was a cross-sectional study where convenience sampling was used. A standard questionnaire was sent to doctors working in neonatal units in Nigeria and Kenya. Results Of 50 respondents, 37 (74.0%) were from Nigeria and 13 (26.0%) from Kenya. All initiated enteral feeds with breastmilk, with 24 (48.0%) initiating within 24 h. Only 28 (56.0%) used written feeding guidelines. Starting volumes ranged between 10 and 80 ml/kg/day. Median volume advancement of feeds was 20 ml/kg/day (IQR 10-20) with infants reaching full feeds in 8 days (IQR 6-12). 26 (52.0%) of the units fed the infants 2 hourly. Breastmilk fortification was practiced in 7 (14.0%) units, while folate, iron, calcium, and phosphorus were prescribed in 42 (84.0%), 36 (72.0%), 22 (44.0%), 5 (10.0%) of these units, respectively. No unit had access to donor breastmilk, and only 18 (36.0%) had storage facilities for expressed breastmilk. Twelve (24.0%) used wet nurses whilst 30 (60.0%) used formula feeds. Conclusion Feeding practices for very preterm and VLBW infants vary widely within Nigeria and Kenya, likely because of lack of locally generated evidence. High quality research that informs the feeding of these infants in the context of limited human resources, technology, and consumables, is urgently needed.
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Affiliation(s)
- Olukemi O. Tongo
- College of Medicine, University of Ibadan/University College Hospital, Ibadan, Nigeria
| | - Macrine A. Olwala
- Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Alison W. Talbert
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- *Correspondence: Alison W. Talbert
| | - Helen M. Nabwera
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Alder Hey Children's Hospital NHS Trust, Liverpool, United Kingdom
| | | | - Walter Otieno
- Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
- Department of Nutrition and Health, Maseno University, Maseno, Kenya
| | - Grace M. Nalwa
- Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
- Department of Nutrition and Health, Maseno University, Maseno, Kenya
| | | | | | - Isa Abdulkadir
- Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Chinyere V. Ezeaka
- College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | - Beatrice N. Ezenwa
- College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | - Iretiola B. Fajolu
- College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | - Zainab O. Imam
- Lagos State University Teaching Hospital, Lagos, Nigeria
| | | | - Ismaela Abubakar
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas D. Embleton
- Newcastle University, Newcastle upon Tyne, United Kingdom
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Stephen J. Allen
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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14
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Gavage-Feeding Assist Device to Improve Nursing Efficiency in a Resource-Limited Setup. Indian J Pediatr 2022; 89:5-6. [PMID: 34757574 DOI: 10.1007/s12098-021-04022-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
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15
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An Interdisciplinary Approach to Reducing NEC While Optimizing Growth: A 20-Year Journey. Adv Neonatal Care 2021; 21:433-442. [PMID: 34510070 DOI: 10.1097/anc.0000000000000929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) and postnatal growth restriction are significant clinical dilemmas that contribute to short- and long-term morbidities for the most premature infants. PURPOSE After a rise in NEC rates in a regional neonatal intensive care unit (NICU), improvement practices were implemented by an interdisciplinary quality improvement (QI) work group whose focus was initially on nutrition and growth. QI work was refocused to address both NEC and growth concurrently. METHODS Through various QI initiatives and with evolving understanding of NEC and nutrition, the work group identified and implemented multiple practices changes over 2-decade time span. A standardized tool was used to review each case of NEC and outcomes were continually tracked to guide QI initiatives. LOCAL FINDINGS Focused QI work contributed to a significant reduction in NEC rates from 16.2% in 2007 to 0% in 2018 for inborn infants. Exclusive human milk diet was a critical part of the success. Postnatal growth outcomes initially declined after initial NEC improvement work. Improvement work that focused jointly on NEC and nutrition resulted in improved growth outcomes without impacting NEC. IMPLICATIONS FOR PRACTICE Use of historical perspective along with evolving scientific understanding can guide local improvement initiatives. Work must continue to optimize lactation during NICU hospitalization. More research is needed to determine impact of care practices on gastrointestinal inflammation including medication osmolality, probiotics, and noninvasive respiratory support.
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16
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Aggarwal R, Plakkal N, Bhat V. Does oropharyngeal administration of colostrum reduce morbidity and mortality in very preterm infants? A randomised parallel-group controlled trial. J Paediatr Child Health 2021; 57:1467-1472. [PMID: 33908117 DOI: 10.1111/jpc.15529] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
AIM To evaluate whether a strategy of oropharyngeal administration of colostrum reduces morbidity and mortality in very preterm infants. METHODS A total of 260 neonates with gestational age 26-31 weeks at birth were randomised between August 2017 and August 2018 to receive 0.2 mL of human milk or placebo respectively via the oropharyngeal route, beginning within 24 h after birth, and continued every 3 h until oral feeds were initiated. The primary outcome was a composite of death, late-onset sepsis (LOS) or necrotising enterocolitis (NEC) in the neonatal period. RESULTS A total of 260 infants (mean gestational age 29.5 weeks, and mean birthweight 1201.7 g) were included in the primary analysis. The composite primary outcome occurred in 43 (33.6%) infants in the colostrum group and 38 infants (29.7%) in the placebo group, and the difference was not statistically significant (P = 0.50). Secondary outcomes including the incidence of death, NEC, LOS, probable sepsis, intraventricular haemorrhage, ventilator-associated pneumonia, retinopathy of prematurity, bronchopulmonary dysplasia, time to full feeds, time to regain birthweight, duration of hospital stay and survival to 6 months without major neurosensory impairment were also comparable between the two groups. CONCLUSION A strategy of oropharyngeal administration of colostrum in very preterm and extremely preterm neonates did not decrease the composite primary outcome of death, LOS or NEC. This finding is consistent with most published literature in the area.
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Affiliation(s)
- Rahul Aggarwal
- Department of Neonatology, Apollo Cradle, Gurgaon, India.,Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Vishnu Bhat
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.,Department of Neonatology, Division of Research, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission's Research Foundation, Pondicherry, India
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17
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OuYang X, Yang CY, Xiu WL, Hu YH, Mei SS, Lin Q. Oropharyngeal administration of colostrum for preventing necrotizing enterocolitis and late-onset sepsis in preterm infants with gestational age ≤ 32 weeks: a pilot single-center randomized controlled trial. Int Breastfeed J 2021; 16:59. [PMID: 34419090 PMCID: PMC8379587 DOI: 10.1186/s13006-021-00408-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 08/06/2021] [Indexed: 01/19/2023] Open
Abstract
Background Oropharyngeal administration of colostrum (OAC) may provide immunoprotective and anti-inflammatory effects that potentially reduce the incidence of necrotizing enterocolitis (NEC) and late-onset sepsis and improve short-term outcomes. Our objective was to evaluate the role of OAC in the early prevention of NEC and late-onset sepsis in preterm infants with gestational age (GA) ≤ 32 weeks. Methods A pilot, single-center, 1:1 parallel randomized controlled trial was conducted in a 40-bed tertiary neonatal intensive care unit (NICU) in China from 1 January 2019 to 30 September 2020. Preterm infants were randomly divided into two groups with GA ≤ 32 weeks. The OAC group included preterm infants who received 0.4 ml of maternal colostrum via the oropharyngeal route every 3 h for 10 days beginning within the first 48 h after birth, and the control group included preterm infants who received normal saline instead. Data from the two groups were collected and compared. Results A total of 127 infants in the OAC group and 125 infants in the control group were enrolled. The incidence of NEC (Bell stage 2 or 3) and late-onset sepsis were lower in the OAC group [2.36% vs. 10.40%, relative risk (RR) 0.23 (95% confidence interval (CI) 0.07, 0.78), adjusted RR 0.23 (95% CI 0.06, 0.84); 4.72% vs. 13.60%, RR 0.35 (95% CI 0.14, 0.85), adjusted RR 0.36 (95% CI 0.14, 0.95)]. In addition, the incidence of proven sepsis and intraventricular hemorrhage (IVH) (stage 3 or 4) were lower in the OAC group [2.36% vs. 8.80%, RR 0.27 (95% CI 0.08, 0.94); 1.57% vs. 7.20%, RR 0.22 (95% CI 0.05, 0.99)], and the time to achieve full enteral feeding was shorter (23.13 ± 9.45 days vs. 28.50 ± 14.80 days). No adverse reactions were observed in either group. Conclusions Oropharyngeal administration of colostrum is a safe and simple NICU procedure that may yield a potential effect in decreasing the incidences of NEC, late-onset sepsis, and severe IVH and shorten the time to achieve full enteral feeding in preterm infants with GA ≤ 32 weeks. Trial registration Chinese Clinical Trial Registry, ChiCTR1900023697, Registered 8 June 2019, retrospectively registered.
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Affiliation(s)
- Xia OuYang
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, China
| | - Chang-Yi Yang
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, China
| | - Wen-Long Xiu
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, China.
| | - Yan-Hua Hu
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, China
| | - Su-Su Mei
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, China
| | - Qin Lin
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, China
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18
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Abstract
Necrotizing enterocolitis (NEC) is an inflammatory disease affecting premature infants. Intestinal microbial composition may play a key role in determining which infants are predisposed to NEC and when infants are at highest risk of developing NEC. It is unclear how to optimize antibiotic therapy in preterm infants to prevent NEC and how to optimize antibiotic regimens to treat neonates with NEC. This article discusses risk factors for NEC, how dysbiosis in preterm infants plays a role in the pathogenesis of NEC, and how probiotic and antibiotic therapy may be used to prevent and/or treat NEC and its sequelae.
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Affiliation(s)
- Jennifer Duchon
- Division of Newborn Medicine, Jack and Lucy Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1000 10th Avenue, New York, NY 10019, USA
| | - Maria E Barbian
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, 3rd Floor, Atlanta, GA 30322, USA
| | - Patricia W Denning
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Emory University Hospital Midtown, 550 Peachtree Street, 3rd Floor MOT, Atlanta, GA 30308, USA.
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19
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Edwards EM, Greenberg LT, Ehret DEY, Lorch SA, Horbar JD. Discharge Age and Weight for Very Preterm Infants: 2005-2018. Pediatrics 2021; 147:peds.2020-016006. [PMID: 33510034 DOI: 10.1542/peds.2020-016006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A complex set of medical, social, and financial factors underlie decisions to discharge very preterm infants. As care practices change, whether postmenstrual age and weight at discharge have changed is unknown. METHODS Between 2005 and 2018, 824 US Vermont Oxford Network member hospitals reported 314 811 infants 24 to 29 weeks' gestational age at birth without major congenital abnormalities who survived to discharge from the hospital. Using quantile regression, adjusting for infant characteristics and complexity of hospital course, we estimated differences in median age, weight, and discharge weight z score at discharge stratified by gestational age at birth and by NICU type. RESULTS From 2005 to 2018, postmenstrual age at discharge increased an estimated 8 (compatibility interval [CI]: 8 to 9) days for all infants. For infants initially discharged from the hospital, discharge weight increased an estimated 316 (CI: 308 to 324) grams, and median discharge weight z score increased an estimated 0.19 (CI: 0.18 to 0.20) standard units. Increases occurred within all birth gestational ages and across all NICU types. The proportion of infants discharged home from the hospital on human milk increased, and the proportions of infants discharged home from the hospital on oxygen or a cardiorespiratory monitor decreased. CONCLUSIONS Gestational age and weight at discharge increased steadily from 2005 to 2018 for survivors 24 to 29 weeks' gestation with undetermined causes, benefits, and costs.
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Affiliation(s)
- Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont; .,Department of Pediatrics, The Robert Larner, MD, College of Medicine and.,Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, The University of Vermont, Burlington, Vermont
| | | | - Danielle E Y Ehret
- Vermont Oxford Network, Burlington, Vermont.,Department of Pediatrics, The Robert Larner, MD, College of Medicine and
| | - Scott A Lorch
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, Vermont.,Department of Pediatrics, The Robert Larner, MD, College of Medicine and
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20
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Makker K, Ji Y, Hong X, Wang X. Antenatal and neonatal factors contributing to extra uterine growth failure (EUGR) among preterm infants in Boston Birth Cohort (BBC). J Perinatol 2021; 41:1025-1032. [PMID: 33589730 PMCID: PMC7883994 DOI: 10.1038/s41372-021-00948-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/16/2020] [Accepted: 01/20/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Identify antenatal and neonatal factors associated with primary outcome of EUGR. METHODS 1063 preterm infants from a subset of the BBC were included in this prospective cohort study. Regression analysis was carried out to evaluate associations of EUGR with antenatal factors and neonatal factors. RESULTS 6.1% of the infants had in-utero growth restriction (IUGR) at birth and 21.7% of infants had EUGR. The adjusted odds ratio for EUGR status were significant for birth weight (OR 0.99, p = 0.00, CI 0.99-0.99), for GA at birth (OR 4.58, p = 0.00, CI 3.25-6.44), for PDA (OR 2.9, p = 0.02, CI 1.17-7.1), for NEC (OR 5.14, p = 0.012, CI 1.44-18.3) and for day of life of reaching full feeds (OR 1.04, p = 0.001, CI 1.01-1.06). CONCLUSION This study highlights important factors associated with EUGR. Additional studies are needed to gain further insight.
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Affiliation(s)
- Kartikeya Makker
- Division of Neonatology Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Yuelong Ji
- grid.21107.350000 0001 2171 9311Center on the Early Life Origins of Disease, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Xiumei Hong
- grid.21107.350000 0001 2171 9311Center on the Early Life Origins of Disease, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Xiaobin Wang
- grid.21107.350000 0001 2171 9311Center on the Early Life Origins of Disease, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA ,grid.21107.350000 0001 2171 9311Division of General Pediatrics, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD USA
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21
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Yadav A, Siddiqui N, Debata PK. Two-hourly vs Three-hourly Feeding in Very Low Birthweight Neonates: A Randomized Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2189-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Khan S, Siow VS, Lewis A, Butler G, Narr M, Srinivasan S, Michaels M, Mollen K. An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis. J Surg Res 2020; 256:390-396. [PMID: 32771703 PMCID: PMC7864993 DOI: 10.1016/j.jss.2020.05.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/20/2020] [Accepted: 05/03/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Appendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. METHODS In 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. RESULTS Among the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). CONCLUSIONS This study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.
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Affiliation(s)
- Sidrah Khan
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vei Shaun Siow
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anthony Lewis
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gabriella Butler
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marissa Narr
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Suresh Srinivasan
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marian Michaels
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
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23
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Abstract
Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.
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24
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Gao C, Ehsan L, Jones M, Khan M, Middleton J, Vergales B, Perks P, Syed S. Time to regain birth weight predicts neonatal growth velocity: A single-center experience. Clin Nutr ESPEN 2020; 38:165-171. [PMID: 32690152 DOI: 10.1016/j.clnesp.2020.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Failure to Thrive (FTT) describes the development of an inappropriate pattern of growth, generally secondary to inadequate nutritional intake, and is associated with several negative outcomes. We describe key features among neonates with FTT as well as the variables that predicted their growth after birth at a Neonatal Intensive Care Unit. METHODS A retrospective single center study of 340 patients grouped into FTT (n = 100) and non-FTT (n = 240) was conducted. FTT was defined as having a weight <10th percentile on the Fenton 2013 curve at the time of discharge. For analyzing growth velocity, 204 patients were grouped into 4 quartiles based on their calculated growth velocity (grams/kilograms/day [g/kg/day]; 4th quartile had the highest velocity). Multivariate regression models were used to identify predictors of growth velocity. RESULTS When comparing FTT vs. non-FTT patients, lower birth weights (1897.9 ± 561.4 vs. 2445.9 ± 783.0 g, t(255.1) = -7.2, p < 0.001) and higher growth velocities (9.2 ± 3.9 vs. 8.0 ± 4.1 g/kg/day, t(153.6) = 2.2, p = 0.03) were noted. Among patients with higher growth velocities, birth weights were lower (1st to 4th quartiles: 2474.0 ± 677.0, 2000.0 ± 297.0, 1715.0 ± 285.0, 1533.0 ± 332.0 g, F(3, 200) = 46.5, p < 0.001, adjusted R2 = 0.4). Days to regain birth weight was the most consistent predictor of growth velocity in our overall patient sample (β [SE] = -0.3 [0.03], p < 0.001) and in the lowest growth velocity quartile subgroup (β [SE] = -0.3 [0.04], p < 0.001). CONCLUSIONS Days to regain birth weight was consistently the strongest predictor of neonatal growth velocity along with difference in gender positive predicting growth velocity in the total sample. This highlights the importance of the first week of life in growth pattern establishment.
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Affiliation(s)
- Calvin Gao
- School of Medicine, University of Virginia, Charlottesville, VA, USA; Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Lubaina Ehsan
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Marieke Jones
- Claude Moore Health Sciences Library, University of Virginia, Charlottesville, VA, USA
| | - Marium Khan
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jeremy Middleton
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Brooke Vergales
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Patti Perks
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Sana Syed
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA.
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25
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Abstract
In the United States, preterm birth rates have steadily increased since 2014. Despite the recent advances in neonatal-perinatal care, more than 40% of very low-birth-weight infants develop chronic lung disease (CLD) and almost 25% have feeding difficulties resulting in delayed achievement of full oral feeds and longer hospital stay. Establishment of full oral feeds, a major challenge for preterm infants, becomes magnified among those on respiratory support and/or with CLD. The strategies to minimize aerodigestive disorders include supporting nonnutritive sucking, developing infant-directed feeding protocols, sensory oromotor stimulation, and early introduction of oral feeds.
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26
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Progressive Metabolic Dysfunction and Nutritional Variability Precedes Necrotizing Enterocolitis. Nutrients 2020; 12:nu12051275. [PMID: 32365850 PMCID: PMC7281969 DOI: 10.3390/nu12051275] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/16/2022] Open
Abstract
Necrotizing Enterocolitis (NEC) is associated with prematurity, enteral feedings, and enteral dysbiosis. Accordingly, we hypothesized that along with nutritional variability, metabolic dysfunction would be associated with NEC onset. Methods: We queried a multicenter longitudinal database that included 995 preterm infants (<32 weeks gestation) and included 73 cases of NEC. Dried blood spot samples were obtained on day of life 1, 7, 28, and 42. Metabolite data from each time point included 72 amino acid (AA) and acylcarnitine (AC) measures. Nutrition data were averaged at each of the same time points. Odds ratios and 95% confidence intervals were calculated using samples obtained prior to NEC diagnosis and adjusted for potential confounding variables. Nutritional and metabolic data were plotted longitudinally to determine relationship to NEC onset. Results: Day 1 analyte levels of alanine, phenylalanine, free carnitine, C16, arginine, C14:1/C16, and citrulline/phenylalanine were associated with the subsequent development of NEC. Over time, differences in individual analyte levels associated with NEC onset shifted from predominantly AAs at birth to predominantly ACs by day 42. Subjects who developed NEC received significantly lower weight-adjusted total calories (p < 0.001) overall, a trend that emerged by day of life 7 (p = 0.020), and persisted until day of life 28 (p < 0.001) and 42 (p < 0.001). Conclusion: Premature infants demonstrate metabolic differences at birth. Metabolite abnormalities progress in parallel to significant differences in nutritional delivery signifying metabolic dysfunction in premature newborns prior to NEC onset. These observations provide new insights to potential contributing pathophysiology of NEC and opportunity for clinical care-based prevention.
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Tao J, Mao J, Yang J, Su Y. Effects of oropharyngeal administration of colostrum on the incidence of necrotizing enterocolitis, late-onset sepsis, and death in preterm infants: a meta-analysis of RCTs. Eur J Clin Nutr 2020; 74:1122-1131. [PMID: 31901083 PMCID: PMC7222151 DOI: 10.1038/s41430-019-0552-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/05/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022]
Abstract
Necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) are two major contributors to death among preterm infants. Oropharyngeal administration of colostrum (OAC) has been proved as an easy, safe, and economically viable technique to help preterm neonates to build up their immunity. In this review, we assessed the effects of OAC on preterm infants. Several mainstream databases were searched including PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and a website of clinical trials. Randomized controlled trials (RCTs) comparing OAC vs. placebo or no intervention in preterm infants (gestation age <34 weeks or birth weight <1500 g) were eligible. Overall, nine RCTs (n = 689) were included in the review. Meta-analysis showed no statistical significance in terms of the incidence of NEC (RR = 0.59, 95% CI = 0.33-1.06, p = 0.08), LOS (RR = 0.78, 95% CI = 0.60-1.03, p = 0.08) and mortality rate (RR = 0.63, 95% CI = 0.38-1.05, p = 0.07). No significant difference was found in the subgroup analysis, apart from the group of the undeveloped region in NEC and mortality. In addition, time was significantly reduced in terms of achieving full enteral feeding (MD = -3.60, 95% CI = -6.55-0.64, p = 0.02) and hospital stay (MD = -10.38, 95% CI = -18.47-2.29, p = 0.01). The results show that OAC does not reduce the incidences of NEC, LOS, and death in preterm infants, but there is a trend toward a positive effect. It is therefore recommended as routine care for preterm infants in the NICU.
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Affiliation(s)
- Jiaxin Tao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jing Mao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jixin Yang
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yanwei Su
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Cormack B, Oliver C, Farrent S, Young J, Coster K, Gilroy M, Page D, Little H, McLeod G. Neonatal dietitian resourcing and roles in New Zealand and Australia: A survey of current practice. Nutr Diet 2019; 77:392-399. [PMID: 31762224 DOI: 10.1111/1747-0080.12592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/05/2019] [Accepted: 10/21/2019] [Indexed: 11/26/2022]
Abstract
AIM Dietitian-led implementation of evidence-based nutrition support practices improves nutrient intakes, clinical outcomes and growth, decreases length of stay and related costs, and reduces intravenous nutrition costs and prescription errors. We aimed to investigate current neonatal dietitian resourcing and roles in New Zealand and Australian neonatal units, and to compare this with dietitian workforce recommendations and previously reported survey data. METHODS A two-part electronic survey was emailed to 50 Australasian Neonatal Dietitians Network members and other dietitians working in neonatal intensive care or special care baby units in New Zealand and Australia. The survey ran from July to October 2018. Descriptive statistics were used to examine the distribution of responses. Responses were compared with other similar surveys and British Dietetic Association workforce recommendations. RESULTS There was an 88% response rate for Part 1. Forty-eight percent of respondents had worked in neonatology for more than 5 years. Ward rounds were attended weekly or more often by 43% of respondents. One-third regularly attended neonatal conferences or grand rounds. The majority spent less than 25% of their neonatal service allocation on teaching, developing policy or research. All respondents reported their unit had written enteral feeding guidelines. The neonatal dietitian workforce is at 23% of recommended levels. CONCLUSIONS Australasian neonatal dietitians have great potential to add value in neonatal units which has not yet been fully realised. Funding reallocation, upskilling and on-going professional development are needed to ensure the neonatal dietitian workforce is at the recommended level to be safe, sustainable and effective.
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Affiliation(s)
- Barbara Cormack
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Colleen Oliver
- The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Shelley Farrent
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Jacqui Young
- Sunshine Hospital, Melbourne, Victoria, Australia
| | - Keryn Coster
- The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Melissa Gilroy
- Mater Health, Mater Mothers and Mater Mothers Private Hospitals, Brisbane, Queensland, Australia
| | - Denise Page
- Mater Health, Mater Mothers and Mater Mothers Private Hospitals, Brisbane, Queensland, Australia
| | - Helen Little
- Christchurch Women's Hospital, Christchurch, New Zealand
| | - Gemma McLeod
- King Edward Memorial and Princess Margaret Hospitals, Perth, Western Australia, Australia.,The University of Western Australia, Perth, Western Australia, Australia
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Shakeel F, Newkirk M, Sellers A, Shores DR. Postoperative Feeding Guidelines Improve Outcomes in Surgical Infants. JPEN J Parenter Enteral Nutr 2019; 44:1047-1056. [PMID: 31705574 DOI: 10.1002/jpen.1726] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Early introduction of enteral nutrition (EN) in postoperative infants improves intestinal adaptation, reducing the risk of intestinal failure-associated liver disease (IFALD). Our objective was to determine whether guideline use reduces feeding variability and improves outcomes in the neonatal intensive care unit (NICU). METHODS In a cohort study, surgical infants at risk for IFALD were evaluated pre and post implementation of feeding guidelines at 2 NICUs. A total of 167 guideline infants (2013-2018) were compared with 242 historical controls (2007-2013). Adherence was measured with timing and volume of initial postoperative feed. Primary outcomes were IFALD incidence and time to reach 50% and 100% of energy from EN. Secondary outcomes were parenteral nutrition (PN) days, postoperative necrotizing enterocolitis (NEC), central line-associated bloodstream infection (CLABSI), and length of stay (LOS). RESULTS Moderate IFALD decreased from 32% to 20% (P = .005) in the guideline group. Time to achieve 50% and 100% energy from EN was decreased from medians of 8 to 5 and 28 to 21 days, respectively (P < .001). There was an overall decrease in PN use from 41 to 29 days (P = .002), CLABSI incidence from 25% to 5% (P < .001), and LOS from 70 to 53 days (P = .030). Once stratified by diagnosis, infants with NEC showed greatest improvement and reduction in IFALD from 67% to 42% (P = .045). With no difference in postoperative NEC (P = .464). CONCLUSION Early standardized postoperative EN guidelines in intestinal-surgery infants was associated with improved outcomes, including faster achievement of feeding goals and reduced IFALD severity, especially in infants with NEC.
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Affiliation(s)
- Fauzia Shakeel
- Department of Maternal Fetal and Neonatal Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Melanie Newkirk
- Department of Nutritional Services, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Austin Sellers
- Department of Clinical and Translational Research Organization, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Darla R Shores
- Division of Gastroenterology, Hepatology and Nutrition, Johns Hopkins Children's Center, Baltimore, Maryland, USA
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30
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Xu JH, Coo H, Fucile S, Ng E, Ting JY, Shah PS, Dow K. A national survey of the enteral feeding practices in Canadian neonatal intensive care units. Paediatr Child Health 2019; 25:529-533. [PMID: 33354263 DOI: 10.1093/pch/pxz112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/28/2019] [Indexed: 11/14/2022] Open
Abstract
Aim Nutrition affects the growth and neurodevelopmental outcomes of preterm infants, yet controversies exist about the optimal enteral feeding regime. The objective of this study was to compare enteral feeding guidelines in Canadian neonatal intensive care units (NICUs). Method The research team identified key enteral feeding practices of interest. Canadian Neonatal Network site investigators at 30 Level 3 NICUs were contacted to obtain a copy of their 2016 to 2017 feeding guidelines for infants who weighed less than 1,500 g at birth. Each guideline was reviewed to compare recommendations around the selected feeding practices. Results Five of the 30 NICUs did not have a feeding guideline. The other 25 NICUs used 22 different enteral feeding guidelines. The guidelines in 40% of those NICUs recommend commencing minimal enteral nutrition (MEN) within 24 hours of birth and maintaining that same feeding volume for 24 to 96 hours. In 40% of NICUs, the guideline recommended that MEN be initiated at a volume of 5 to 10 mL/kg/day for infants born at <1,000 g. Guidelines in all 25 NICUs recommend the use of bovine-based human milk fortifier (HMF), and in 56% of NICUs, it is recommended that HMF be initiated at a total fluid intake of 100 mL/kg/day. Guidelines in only 16% of NICUs recommended routine gastric residual checks. Donor milk and probiotics are used in 76% and 72% of the 25 NICUs, respectively. Conclusion This study revealed substantial variability in recommended feeding practices for very low birth weight infants, underscoring the need to establish a national feeding guideline for this vulnerable group.
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Affiliation(s)
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario
| | - Sandra Fucile
- Department of Pediatrics, Queen's University, Kingston, Ontario
| | - Eugene Ng
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Joseph Y Ting
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Prakesh S Shah
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario.,Department of Pediatrics, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario
| | - Kimberly Dow
- Department of Pediatrics, Queen's University, Kingston, Ontario
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Barr PA, Mally PV, Caprio MC. Standardized Nutrition Protocol for Very Low‐Birth‐Weight Infants Resulted in Less Use of Parenteral Nutrition and Associated Complications, Better Growth, and Lower Rates of Necrotizing Enterocolitis. JPEN J Parenter Enteral Nutr 2018; 43:540-549. [DOI: 10.1002/jpen.1453] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/22/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Priscilla A. Barr
- Department of Food and Nutrition Services NYU Langone Health New York New York USA
| | - Pradeep V. Mally
- Division of Neonatology Hassenfeld Children's Hospital at NYU Langone New York University School of Medicine New York New York USA
| | - Martha C. Caprio
- Division of Neonatology Hassenfeld Children's Hospital at NYU Langone New York University School of Medicine New York New York USA
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32
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Gephart SM, Moore EF, Fry E. Standardized Feeding Protocols to Reduce Risk of Necrotizing Enterocolitis in Fragile Infants Born Premature or with Congenital Heart Disease: Implementation Science Needed. Crit Care Nurs Clin North Am 2018; 30:457-466. [PMID: 30447806 DOI: 10.1016/j.cnc.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although a unit-adopted standardized feeding protocol (SFP) for neonates is standard of care, implementation strategies for SFPs vary across neonatal and pediatric intensive care. Besides improving growth and reducing feeding interruptions, SFPs reduce risk for necrotizing enterocolitis in infants with heart disease or born premature. The purpose of this article is to bridge the gap between recommended and actual care using SFPs.
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Affiliation(s)
- Sheila M Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, PO Box 210203, Tucson, AZ 85721, USA.
| | - Emily F Moore
- Regional cardiology program, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Emory Fry
- Cognitive Medical Systems, 9444 Waples Street, Suite 300, San Diego, CA 92121, USA
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Garg BD, Balasubramanian H, Kabra NS, Bansal A. Effect of oropharyngeal colostrum therapy in the prevention of necrotising enterocolitis among very low birthweight neonates: A meta-analysis of randomised controlled trials. J Hum Nutr Diet 2018; 31:612-624. [PMID: 30073712 DOI: 10.1111/jhn.12585] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Necrotising enterocolitis (NEC) is one of the most common life-threatening emergencies of the gastrointestinal tract in preterm neonates. The present study aimed to determine the efficacy of oropharyngeal colostrum with respect to reducing NEC in preterm neonates. METHODS A literature search was conducted for various randomised control trials by searching the Cochrane Central Register of Controlled Trials, PubMed, EMBASE and ongoing clinical trials. Randomised or quasi-randomised trials comparing oropharyngeal colostrum versus placebo in neonates (birthweight ≤ 1500 g or gestational age ≤ 32 weeks) were included in the review. The methodological quality of each trial was independently reviewed by the authors. For categorical and continuous variables, typical estimates for relative risk and typical estimates for weighted mean difference were calculated, respectively. A random effect model was assumed for meta-analysis. RESULTS In total, four eligible trials were included in the review. Oropharyngeal colostrum therapy was not associated with a statistically significant reduction in the incidence of NEC stage ≥2 [typical relative risk (RR) = 0.64; 95% confidence interval (CI) = 0.27-1.49], mortality from any cause (typical RR = 0.86; 95% CI = 0.15-4.80) and time to reach full feed [typical weighted mean difference (WMD) = -3.26; 95% CI = -8.87 to 2.35]. Duration of hospital stay was significantly less in the control group (typical WMD = 9.77; 95% CI = 3.96-15.59). CONCLUSIONS The current evidence is insufficient for recommending oropharyngeal colostrum as a routine clinical practice in the prevention of NEC. We emphasise the need for large randomised controlled trials with an adequate sample size and validated clinical outcomes in preterm neonates.
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Affiliation(s)
- B D Garg
- Surya children's Medicare Pvt. Ltd, Mumbai, India
| | | | - N S Kabra
- Surya children's Medicare Pvt. Ltd, Mumbai, India
| | - A Bansal
- Jan Sewa Tantia University, Sri Ganganagar, India
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34
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A quality improvement initiative to reduce necrotizing enterocolitis across hospital systems. J Perinatol 2018; 38:742-750. [PMID: 29679047 DOI: 10.1038/s41372-018-0104-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/27/2018] [Accepted: 02/28/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is a devastating intestinal disease in premature infants. Local rates of NEC were unacceptably high. We hypothesized that utilizing quality improvement methodology to standardize care and apply evidence-based practices would reduce our rate of NEC. STUDY DESIGN A multidisciplinary team used the model for improvement to prioritize interventions. Three neonatal intensive care units (NICUs) developed a standardized feeding protocol for very low birth weight (VLBW) infants, and employed strategies to increase the use of human milk, maximize intestinal perfusion, and promote a healthy microbiome. RESULTS The primary outcome measure, NEC in VLBW infants, decreased from 0.17 cases/100 VLBW patient days to 0.029, an 83% reduction, while the compliance with a standardized feeding protocol improved. CONCLUSION Through reliable implementation of evidence-based practices, this project reduced the regional rate of NEC by 83%. A key outcome and primary driver of success was standardization across multiple NICUs, resulting in consistent application of best practices and reduction in variation.
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Passaro RC, Savoie KB, Huang EY. Use of a Gastroschisis Feeding Guideline to Improve Standardization of Care and Patient Outcomes at an Urban Children's Hospital. Nutr Clin Pract 2018; 33:545-552. [DOI: 10.1002/ncp.10083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- R. Colby Passaro
- College of Medicine; University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Kate B. Savoie
- College of Medicine; University of Tennessee Health Science Center; Memphis Tennessee USA
- Division of Pediatric Surgery; Le Bonheur Children's Hospital; Memphis Tennessee USA
- Department of General Surgery; University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Eunice Y. Huang
- College of Medicine; University of Tennessee Health Science Center; Memphis Tennessee USA
- Division of Pediatric Surgery; Le Bonheur Children's Hospital; Memphis Tennessee USA
- Department of General Surgery; University of Tennessee Health Science Center; Memphis Tennessee USA
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Necrotizing Enterocolitis in Infants with Hypoplastic Left Heart Syndrome Following Stage 1 Palliation or Heart Transplant. Pediatr Cardiol 2018; 39:774-785. [PMID: 29392349 DOI: 10.1007/s00246-018-1820-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/20/2018] [Indexed: 10/18/2022]
Abstract
Previous studies of necrotizing enterocolitis (NEC) among infants with hypoplastic left heart syndrome (HLHS) were conducted in single centers or had small sample sizes. This study aimed to determine the mortality rate and the risk factors for NEC among infants with HLHS who were discharged over a 10-year period (2004-2013) from 41 Pediatric Health Information System affiliated children's hospitals. Either stage 1 palliation and/or heart transplant were completed prior to patient's death or hospital discharge. We compared the characteristics of infants with HLHS who did not develop NEC and those who developed medical or surgical NEC and of patients who had medical vs. surgical NEC. The primary outcome was mortality over time and by birth weight category (low birth weight [LBW], birth weight < 2500 vs. ≥ 2500 g). Multivariable analyses were performed to identify the risk factors for developing NEC and for mortality among infants with HLHS. The study evaluated 5720 infants with HLHS including 349 patients (6.1%) with medical or surgical NEC. Fifty-two patients (0.9%) required laparotomy or percutaneous abdominal drainage. On univariable analysis, the overall mortality rate for infants who developed NEC was significantly higher than infants who did not develop NEC (23.5 vs. 13.9%, P < 0.001). On multivariable analysis, neither medical nor surgical NEC was a significant predictor of mortality in the study population. LBW infants were at higher risk for mortality in both the univariable and the multivariable models. Nevertheless, LBW did not significantly predispose infants with HLHS to develop NEC. Our results provide a national benchmark incidence of NEC, its risk factors, and outcomes among a large cohort of infants with HLHS and establish that NEC is not a significant risk factor for mortality in this population.
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Shores DR, Alaish SM, Aucott SW, Bullard JE, Haney C, Tymann H, Nonyane BAS, Schwarz KB. Postoperative Enteral Nutrition Guidelines Reduce the Risk of Intestinal Failure-Associated Liver Disease in Surgical Infants. J Pediatr 2018; 195:140-147.e1. [PMID: 29402454 PMCID: PMC5869117 DOI: 10.1016/j.jpeds.2017.11.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/14/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the effectiveness of postoperative feeding guidelines in reducing the incidence and severity of intestinal failure-associated liver disease (IFALD) among infants. STUDY DESIGN Two cohorts of infants <6 months old undergoing intestinal surgery were compared: preguideline (retrospective data from 2007 to 2013; n = 83) and postguideline (prospective data from 2013 to 2016; n = 81). The guidelines included greater initial enteral nutrition volumes of 20 mL/kg/d and daily feeding advancement if tolerated. The primary outcomes were incidence of IFALD (peak direct bilirubin [DB] >2 mg/dL) and severity (DB >5 mg/dL for moderate-severe). Multiple logistic regression was used to determine the odds of developing IFALD. Other outcomes were time to reach 50% and 100% goal calories from enteral nutrition and the incidence of necrotizing enterocolitis after feeding. RESULTS The incidence of IFALD decreased from 71% to 51% (P = .031), and median peak DB decreased from 5.7 to 2.4 mg/dL (P = .001). After adjusting for diagnosis and prematurity, the odds of developing IFALD of any severity were reduced by 60% (OR 0.40, 95% CI 0.20-0.85), and the odds of developing moderate-to-severe IFALD were reduced by 72% (OR 0.28, 95% CI 0.13-0.58) with guideline use. Time to reach 50% enteral nutrition decreased from a median of 10 to 6 days (P = .020) and time to reach 100% enteral nutrition decreased from 35 to 21 days (P = .035) with guideline use. The incidence of necrotizing enterocolitis after initiating enteral nutrition did not change (5% vs 9%, P = .346). CONCLUSIONS Implementation of feeding guidelines reduced time to reach feeding goals, significantly reducing IFALD incidence and severity.
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Affiliation(s)
- Darla R Shores
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Samuel M Alaish
- Department of General Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Susan W Aucott
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Janine E Bullard
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Courtney Haney
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Heidi Tymann
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Bareng A S Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kathleen B Schwarz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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38
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Gephart SM, Hanson C, Wetzel CM, Fleiner M, Umberger E, Martin L, Rao S, Agrawal A, Marin T, Kirmani K, Quinn M, Quinn J, Dudding KM, Clay T, Sauberan J, Eskenazi Y, Porter C, Msowoya AL, Wyles C, Avenado-Ruiz M, Vo S, Reber KM, Duchon J. NEC-zero recommendations from scoping review of evidence to prevent and foster timely recognition of necrotizing enterocolitis. Matern Health Neonatol Perinatol 2017; 3:23. [PMID: 29270303 PMCID: PMC5733736 DOI: 10.1186/s40748-017-0062-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/28/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Although decades have focused on unraveling its etiology, necrotizing enterocolitis (NEC) remains a chief threat to the health of premature infants. Both modifiable and non-modifiable risk factors contribute to varying rates of disease across neonatal intensive care units (NICUs). PURPOSE The purpose of this paper is to present a scoping review with two new meta-analyses, clinical recommendations, and implementation strategies to prevent and foster timely recognition of NEC. METHODS Using the Translating Research into Practice (TRIP) framework, we conducted a stakeholder-engaged scoping review to classify strength of evidence and form implementation recommendations using GRADE criteria across subgroup areas: 1) promoting human milk, 2) feeding protocols and transfusion, 3) timely recognition strategies, and 4) medication stewardship. Sub-groups answered 5 key questions, reviewed 11 position statements and 71 research reports. Meta-analyses with random effects were conducted on effects of standardized feeding protocols and donor human milk derived fortifiers on NEC. RESULTS Quality of evidence ranged from very low (timely recognition) to moderate (feeding protocols, prioritize human milk, limiting antibiotics and antacids). Prioritizing human milk, feeding protocols and avoiding antacids were strongly recommended. Weak recommendations (i.e. "probably do it") for limiting antibiotics and use of a standard timely recognition approach are presented. Meta-analysis of data from infants weighing <1250 g fed donor human milk based fortifier had reduced odds of NEC compared to those fed cow's milk based fortifier (OR = 0.36, 95% CI 0.13, 1.00; p = 0.05; 4 studies, N = 1164). Use of standardized feeding protocols for infants <1500 g reduced odds of NEC by 67% (OR = 0.33, 95% CI 0.17, 0.65, p = 0.001; 9 studies; N = 4755 infants). Parents recommended that NEC information be shared early in the NICU stay, when feedings were adjusted, or feeding intolerance occurred via print and video materials to supplement verbal instruction. DISCUSSION Evidence for NEC prevention is of sufficient quality to implement. Implementation that addresses system-level interventions that engage the whole team, including parents, will yield the best impact to prevent NEC and foster its timely recognition.
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Affiliation(s)
- Sheila M. Gephart
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | | | | | | | | | - Suma Rao
- Banner Health, Banner University Medical Center-Phoenix, Phoenix, AZ USA
- Phoenix Perinatal Associates, Mesa, AZ USA
- Clinical Assistant Professor and Vice-Chair, Department of Pediatrics, The University of Arizona, Tucson, AZ USA
| | - Amit Agrawal
- Banner Health, Thunderbird Medical Center, Glendale, AZ USA
- Envision Physician Services, Lawrenceville, GA USA
| | - Terri Marin
- Augusta University College of Nursing, Athens, GA USA
| | - Khaver Kirmani
- Banner Health, Cardon Children’s Medical Center, Mesa, AZ USA
- Phoenix Perinatal Associates, Mesa, AZ USA
| | - Megan Quinn
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
- Banner Health, Cardon Children’s Medical Center, Mesa, AZ USA
| | - Jenny Quinn
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
- NorthBay Medical Center, Fairfield, CA USA
| | - Katherine M. Dudding
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | - Jason Sauberan
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA USA
| | - Yael Eskenazi
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | - Caroline Porter
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | - Christina Wyles
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | - Shayla Vo
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | - Kristina M. Reber
- Nationwide Children’s Hospital and The Ohio State Wexner Medical Center, Columbus, OH USA
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Snyder R, Herdt A, Mejias-Cepeda N, Ladino J, Crowley K, Levy P. Early provision of oropharyngeal colostrum leads to sustained breast milk feedings in preterm infants. Pediatr Neonatol 2017; 58:534-540. [PMID: 28550982 DOI: 10.1016/j.pedneo.2017.04.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 02/07/2017] [Accepted: 04/28/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Oropharyngeal colostrum (OC) application strategies have been shown to be feasible and safe for very low birth weight (VLBW) infants. Evidence to support the nutritional and clinical advantages of OC care remains somewhat theoretical. The objectives of this study were to a) confirm the feasibility and safety of OC application in preterm infants and b) determine if OC application is associated with improved nutritional and clinical outcomes from birth to discharge. We hypothesized that OC application in the first few days would promote sustained breast milk feedings through discharge. METHODS An observational longitudinal study was conducted in 133 VLBW infants during 2013-14, after an OC protocol was adopted. Maternal and infant characteristics, infant vital signs during administration, nutritional outcomes, and common neonatal morbidities were assessed and compared to 85 age- and weight-matched VLBW infants from a retrospective control cohort from 2012, prior to the implementation of the OC protocol. RESULTS There were no adverse events or changes in vital signs during the application of OC. VLBW infants who received OC continued to receive the majority of their enteral feeds from human breast milk at six 6 of age and through discharge (p < 0.01). There was no difference in maternal characteristics known to affect breast milk production, and rates of common neonatal morbidities were statistically similar between groups. CONCLUSION OC application for VLBW infants is safe and practical in a neonatal intensive care unit setting and is associated with increased rates of breast milk feeding.
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Affiliation(s)
- Ruth Snyder
- Pediatrics, Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ, USA; MidAtlantic Neonatology Associates, Morristown, NJ, USA.
| | - Aimee Herdt
- Pediatrics, Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ, USA; MidAtlantic Neonatology Associates, Morristown, NJ, USA.
| | - Nancy Mejias-Cepeda
- Pediatrics, Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ, USA.
| | - John Ladino
- Pediatrics, Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ, USA; MidAtlantic Neonatology Associates, Morristown, NJ, USA.
| | - Kathryn Crowley
- Pediatrics, Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ, USA; MidAtlantic Neonatology Associates, Morristown, NJ, USA.
| | - Philip Levy
- Pediatrics, Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ, USA; MidAtlantic Neonatology Associates, Morristown, NJ, USA; Pediatrics, Washington University School of Medicine, Saint Louis, MO, USA.
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40
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Gephart SM, Wyles C, Canvasser J. Expert consensus to weight an adherence score for audit and feedback of practices that prevent necrotizing enterocolitis in very low birth weight infants. Appl Nurs Res 2017; 39:182-188. [PMID: 29422156 DOI: 10.1016/j.apnr.2017.11.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/15/2017] [Accepted: 11/02/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is a catastrophic abdominal complication threatening the life of premature infants, but adoption of prevention and early recognition practices differs as do NEC rates in Neonatal Intensive Care Units (NICUs). The purpose of this research was to validate and weight an evidence-based adherence score (aka NEC-Zero Adherence Score) to prevent and foster timely recognition of NEC. STUDY DESIGN An electronic Delphi (e-Delphi) approach was used to identify consensus. NEC experts were recruited via the NEC Society and surveyed until consensus and stability criteria for the Delphi were met (≥70% consensus and mean responses changed <15% between rounds). RESULTS Expert panelists (n=22) were experienced (M=17.6, SD 11years) and predominately physicians (68%) or neonatal nurse practitioners (18%). Consensus (>70% by item) supported a 10 point score. Points were distributed across 1) an exclusive human milk diet (5 points), 2) standardized feeding protocols (3 points), 3) antibiotic stewardship (1 point), and 4) a unit-specified approach to early recognition (1 point). Withholding feeding during transfusion was controversial (M=0.50, SD 0.73) and met consensus criteria to drop from the score. CONCLUSIONS Holding feeding during transfusion was dropped from the score. Relationships between the score and unit NEC rates as well as its utility for use in audit and feedback should be studied in the future.
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Affiliation(s)
- Sheila M Gephart
- The University of Arizona College of Nursing, Tucson, AZ, United States.
| | - Christina Wyles
- The University of Arizona College of Nursing, Tucson, AZ, United States
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Moreno Algarra MC, Fernández Romero V, Sánchez Tamayo T, Espinosa Fernández MG, Salguero García E. Variabilidad en las prácticas sobre alimentación enteral del prematuro entre hospitales españoles de la red SEN-1500. An Pediatr (Barc) 2017; 87:245-252. [DOI: 10.1016/j.anpedi.2016.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 09/19/2016] [Accepted: 09/26/2016] [Indexed: 12/20/2022] Open
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Moreno Algarra MC, Fernández Romero V, Sánchez Tamayo T, Espinosa Fernández MG, Salguero García E. Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network. An Pediatr (Barc) 2017. [DOI: 10.1016/j.anpede.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Jasani B, Patole S. Standardized feeding regimen for reducing necrotizing enterocolitis in preterm infants: an updated systematic review. J Perinatol 2017; 37:827-833. [PMID: 28358382 DOI: 10.1038/jp.2017.37] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/31/2016] [Accepted: 02/21/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A systematic review (2005) of observational studies has reported 87% reduction in the incidence of necrotizing enterocolitis (NEC) after introducing standardized feeding regimen (SFR) in preterm infants. Considering the many new studies in this field since 2005 and the continued health burden of NEC, we aimed to systematically review the incidence of NEC in preterm infants 'before' vs 'after' implementing a SFR. STUDY DESIGN PubMed, EMBASE, CINAHL and E-abstracts from the Pediatric Academic Society meetings and other pediatric and neonatal conference proceedings were searched in May 2016. Observational studies reporting incidence of NEC before and after implementing a SFR were included. Relevant data were extracted independently by two reviewers. Meta-analysis was conducted using random effects model (REM) and results rechecked with fixed effects model. RESULTS Pooled results from 15 observational studies (N=18 160) using REM showed that SFR significantly reduced the incidence of NEC (risk ratio 0.22; 95% confidence interval 0.13 to 0.36; P<0.00001; I2=74%). The results remained significant after comparing studies in two epochs (1978 to 2003 vs 2004 to 2016). CONCLUSION SFR continues to be an important tool in prevention of NEC in preterm infants.
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Affiliation(s)
- B Jasani
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Perth, WA, Australia
| | - S Patole
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Perth, WA, Australia
- Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, WA, Australia
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Dicky O, Ehlinger V, Montjaux N, Gremmo-Féger G, Sizun J, Rozé JC, Arnaud C, Casper C. Policy of feeding very preterm infants with their mother's own fresh expressed milk was associated with a reduced risk of bronchopulmonary dysplasia. Acta Paediatr 2017; 106:755-762. [PMID: 28128874 DOI: 10.1111/apa.13757] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/17/2016] [Accepted: 01/23/2017] [Indexed: 01/30/2023]
Abstract
AIM Since 2005, the French Food Safety Agency has recommended that very preterm or low-birthweight babies should be fed with pasteurised, expressed breastmilk, and feeding policies on this vary widely in French neonatal units. We investigated the differences between using a mother's expressed milk, in fresh or pasteurised forms, for very preterm infants. METHODS This observational multicentre study analysed data on 926 very preterm infants: 636 from neonatal units who used the mother's own fresh milk and 290 who used the mother's milk after pasteurisation. We analysed necrotising enterocolitis, bronchopulmonary dysplasia, in-hospital mortality, late-onset sepsis, weight gain, length of hospital stay, the duration of parenteral nutrition and the duration of enteral feeding with a nasogastric tube. Multivariate analyses were conducted to assess the impact of maternal milk policies. RESULTS After adjustment, there was a reduced risk of bronchopulmonary dysplasia in the fresh milk group with an odds ratio of 0.40 and 95% confidence interval of 0.27-0.67 (p < 0.001). No other statistically significant differences were observed. CONCLUSION Feeding very preterm infants with their mother's expressed fresh milk was associated with a reduced risk of bronchopulmonary dysplasia, and further investigations are needed to evaluate the clinical impact of this practice.
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Affiliation(s)
- Odile Dicky
- Department of Neonatology; Children Hospital; University Hospital; Toulouse France
- U.1027; INSERM; Toulouse France
- Paul Sabatier University; Toulouse France
| | - Virginie Ehlinger
- U.1027; INSERM; Toulouse France
- Paul Sabatier University; Toulouse France
| | - Nathalie Montjaux
- Department of Neonatology; Children Hospital; University Hospital; Toulouse France
| | | | - Jacques Sizun
- Department of Woman, Mother and Child; University Hospital; Brest France
| | | | - Catherine Arnaud
- U.1027; INSERM; Toulouse France
- Paul Sabatier University; Toulouse France
- Clinical Epidemiology Unit; CHU Purpan; Toulouse France
| | - Charlotte Casper
- Department of Neonatology; Children Hospital; University Hospital; Toulouse France
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Implementation of Feeding Guidelines Hastens the Time to Initiation of Enteral Feeds and Improves Growth Velocity in Very Low Birth-Weight Infants. Adv Neonatal Care 2017; 17:139-145. [PMID: 27750266 DOI: 10.1097/anc.0000000000000347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Growth and nutrition are critical in neonatal care. Whether feeding guidelines improve growth and nutrition and reduce morbidity is unknown. PURPOSE Feeding guidelines for very low birth-weight (VLBW) infants were implemented in our neonatal intensive care unit (NICU) to start and achieve full enteral feeds sooner, and increase weight gain over the first month. METHODS Feeding guidelines for VLBW infants were implemented in January 2014, stratified by birth weight (<750, 750-1000, and 1000-1500 g). After trophic feedings, enteral feedings were advanced by 20 to 30 mL/kg/d.Data were analyzed for 2 years prior (baseline) and 6 months after (guideline) guidelines were implemented and included days to initiation of enteral feeds, days on total parenteral nutrition (TPN), and weight gain over the first month. Potential concomitant factors that could affect feeding tolerance were examined including indomethacin or dopamine treatment, delivery room cardiopulmonary resuscitation, and growth restriction. RESULTS A total of 95 infants with a birth weight of less than 1500 g were included (59 baseline and 36 guideline). Days to start enteral feeds decreased by 47% (P < .01) and days on TPN decreased by 25% (16 days vs 11 days; P < .01). Weight gain over the first month of life increased by 15% (p < .05). Dopamine and indomethacin use decreased during the study period, and small for gestational age infants were overrepresented in the guideline group. IMPLICATIONS FOR PRACTICE/RESEARCH Establishment of feeding guidelines for VLBW infants in our NICU reduced the days to start feeds and days on TPN while increasing weight gain over the first month. Improving growth and nutrition and reducing need for TPN in this vulnerable population may ultimately prevent infection and improve neurodevelopmental outcomes.
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Acylcarnitine Profiles Reflect Metabolic Vulnerability for Necrotizing Enterocolitis in Newborns Born Premature. J Pediatr 2017; 181:80-85.e1. [PMID: 27836286 PMCID: PMC5538349 DOI: 10.1016/j.jpeds.2016.10.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/29/2016] [Accepted: 10/05/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the association between newborn acylcarnitine profiles and the subsequent development of necrotizing enterocolitis (NEC) with the use of routinely collected newborn screening data in infants born preterm. STUDY DESIGN A retrospective cohort study was conducted with the use of discharge records for infants born preterm admitted to neonatal intensive care units in California from 2005 to 2009 who had linked state newborn screening results. A model-development cohort of 94 110 preterm births from 2005 to 2008 was used to develop a risk-stratification model that was then applied to a validation cohort of 22 992 births from 2009. RESULTS Fourteen acylcarnitine levels and acylcarnitine ratios were associated with increased risk of developing NEC. Each log unit increase in C5 and free carnitine /(C16 + 18:1) was associated with a 78% and a 76% increased risk for developing NEC, respectively (OR 1.78, 95% CI 1.53-2.02, and OR 1.76, 95% CI 1.51-2.06). Six acylcarnitine levels, along with birth weight and total parenteral nutrition, identified 89.8% of newborns with NEC in the model-development cohort (area under the curve 0.898, 95% CI 0.889-0.907) and 90.8% of the newborns with NEC in the validation cohort (area under the curve 0.908, 95% CI 0.901-0.930). CONCLUSIONS Abnormal fatty acid metabolism was associated with prematurity and the development of NEC. Metabolic profiling through newborn screening may serve as an objective biologic surrogate of risk for the development of disease and thus facilitate disease-prevention strategies.
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Martínez-Rodríguez L, Estañ J, Bermudez JD, Molina A, Hortelano V, Martinez-Costa C. Influence of nutritional variables on the onset of necrotizing enterocolitis in preterm infants: A case-control study. Early Hum Dev 2016; 103:193-198. [PMID: 27723519 DOI: 10.1016/j.earlhumdev.2016.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 09/17/2016] [Accepted: 09/27/2016] [Indexed: 02/04/2023]
Affiliation(s)
| | - Javier Estañ
- Neonatology Unit, Hospital Clínico Universitario de Valencia, Spain; Departments of Pediatrics, School of Medicine, University of Valencia, Spain.
| | - Jose D Bermudez
- Departments of Statistics, School of Medicine, University of Valencia, Spain.
| | - Agustin Molina
- Neonatology Unit, Hospital Clínico Universitario de Valencia, Spain.
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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. [DOI: 10.1016/j.anpede.2016.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Franco KA, O'Mara K. Impact of Computerized Provider Order Entry on Total Parenteral Nutrition in the Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2016; 21:339-345. [PMID: 27713674 DOI: 10.5863/1551-6776-21.4.339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES: To determine if computerized provider order entry (CPOE) implementation impacts the time it takes for preterm neonates to reach their parenteral macronutrient goals. METHODS: Retrospective review of neonates <1750 g receiving parenteral nutrition (PN) before and after the implementation of CPOE. Primary outcome was the attainment of parenteral macronutrient goals. Secondary outcomes included time to attainment, the frequency of electrolyte abnormalities, and the incidence of required adjustments made to PN orders by verification pharmacists. RESULTS: Goal PN was achieved by 12/47 (25.5%) intervention vs. 2/44 (4.5%) control group infants (p < 0.05). This goal was attained in 10.8 ± 7.5 days in the intervention group and 10 ± 4.2 days in the control group (p = 0.90). Goal protein was reached by 74.5% of CPOE patients vs. 36.4% of controls, p < 0.05. Lipid goals were achieved by 98% vs. 100% (p = 0.33) of patients and were attained at an average of 1.5 ± 0.8 days vs. 2.0 ± 1.1 days (p < 0.05). Abnormal serum electrolyte values occurred more frequently in the control group (0.79 vs. 1.12/day PN). Adjustments by a verification pharmacist were required in 5.6% of CPOE compared with 30.4% of control group orders (p < 0.05). CONCLUSIONS: CPOE parenteral nutrition increased the proportion of preterm neonates attaining overall macronutrient goals. With CPOE, protein goals were reached by more patients and goal lipids were achieved faster. This system also decreased the number of pharmacist interventions during verification of PN orders and appeared to positively impact the incidence of serum electrolyte disturbances.
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Affiliation(s)
- Kyle A Franco
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Keliana O'Mara
- University of Florida Health Shands Hospital, Gainesville, Florida
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50
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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.
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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.
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