Fluid, electrolytes, and nutrition: minutes matter

The incidence of and risk factors for hyperglycemia and hypoglycemia in preterm infants receiving early-aggressive parenteral nutrition

Introduction

Optimizing nutritional support helps prevent extra uterine growth restriction and adverse long-term outcomes in preterm infants.

Objectives

This study aimed to analyze the incidence of and risk factors for hyperglycemia and hypoglycemia in preterm infants receiving early-aggressive parenteral nutrition (PN).

Methods

This prospective observational study included preterm infants receiving PN at the Neonatal Intensive Care Unit of Dr. Soetomo General Hospital between April 2018 and May 2019. Potential risk factors analyzed included asphyxia, sepsis, respiratory distress syndrome, multiple congenital anomalies, mortality, necrotizing enterocolitis, retinopathy of prematurity, the postoperative period, inotropic administration, glucose infusion rate (GIR) > 10-12 mg/kg/min, GIR 4-<5.5 mg/kg/min, and increase in GIR <1 mg/kg/min.

Results

Of the 105 preterm infants included, hyperglycemia and hypoglycemia were found in 14 (13.3%) and 26 (24.8%) infants, respectively, with most incidents occurring in the first week (hyperglycemia: 85.7%; hypoglycemia: 88.5%). Sepsis was an independent risk factor for hyperglycemia (odds ratio [OR]: 8.743, 95% confidence interval [CI]: 2.392-31.959; P = 0.001). Hypoglycemia independent risk factors included the postoperative period (OR: 4.425, 95% CI: 1.218-16.073; P = 0.024) and use of GIR 4-<5.5 mg/kg/min (OR: 2.950, 95% CI: 1.035-8.405; P = 0.043).

Conclusion

Hyperglycemia and hypoglycemia can occur in preterm infants receiving early-aggressive PN; most cases occur within the first week of life. Hypoglycemia correlated with low glucose intake, and hyperglycemia correlated with sepsis. Monitoring blood glucose levels in preterm infants receiving PN, especially in the first weeks of life, may decrease morbidity associated with hyperglycemia or hypoglycemia.

The association between duration of postnatal weight loss and neurodevelopment outcomes in very low birth weight infants

BACKGROUND

Premature births account for around 11% of the world's live births. With the improvements in survival that have been achieved in recent years, the neurological outcomes of these infants have attracted greater attention. The aim of this study was to evaluate the association between postnatal weight loss and neurodevelopment outcomes of very low birth weight premature infants.

METHODS

This was a prospective cohort study that was conducted in a tertiary referral center. Premature infants of birth weight less than 1500 g born between October 2015 and January 2017 were enrolled. Perinatal-demographic characteristics, medical interventions, and nutrition records were collected. The Bayley III tests performed by licensed child psychiatrists at corrected ages 6, 12, and 24 months old were adopted as outcome measurements.

RESULTS

In total, 52 infants were enrolled. The mean birth weight was 1071 g and the mean gestational age was 29.0 weeks. According to the univariate analysis, the duration of postnatal weight loss had a significantly negative impact on motor outcomes at 12 and 24 months old. The negative impact remained robust after adjusting for confounding factors by multiple linear regression models. The effect of repeated measurement was further considered by generalized estimating equation (GEE) models. GEE models also demonstrated a negative association between the duration of body weight loss and motor scores.

CONCLUSION

The duration of postnatal weight loss might have a negative influence on long-term motor development in premature infants. Further studies of nutrition status and motor development are needed to elucidate the precise underlying mechanism.

The glucose infusion rate of parenteral nutrition in the first week of life in preterm infants: an observational study

Background

Most preterm infants require a continuous glucose infusion in the early postnatal period due to the interruption of the transplacental glucose supply after birth to promote better neurodevelopmental outcomes.

Aims

To investigate the glucose infusion rate (GIR) on parenteral nutrition (PN) in the first week of life administered in preterm infants and its effect on neonatal morbidity and mortality.

Methods

This study included 97 infants aged < 37 gestational weeks and weighed < 2500 g at birth. Infants recruited in this study were classified into 3 groups based on the GIR usage in parenteral nutrition as follows: GIR usage of 5- < 7 g/kg/day (Group I), GIR usage of 7–13 g/kg/day (Group II), and GIR usage of > 13–15 g/kg/day (Group III). Univariate and multivariate logistic regression analyzes were carried out to investigate whether the GIR usage in the three groups was associated with selected neonatal morbidities and mortality. Neonatal morbidities analyzed included respiratory distress syndrome (RDS), necrotizing enterocolitis, sepsis, retinopathy of prematurity, pulmonary hypertension, hypoglycemia, and hyperglycemia.

Result

Of 97 preterm infants included, 51.5% infants had a gestational age of 34- < 37 weeks, and 54.6% infants had a birth weight of 1500- < 2500 g. The multivariate logistic regression analysis showed that the GIR usage of 5- < 7 g/kg/day was an independent variable that significantly increased the risk of hypoglycemia (Adjusted Odds Ratio [AOR] = 4.000, 95% Confidence Interval [CI] = 1.384–11.565, P = 0.010) and reduced the risk of sepsis (AOR = 0.096, 95% CI = 0.012–0.757, P = 0.026). The GIR usage in all three groups did not increase the risk of mortality. For neonatal morbidity analyzed in this study, RDS (AOR = 5.404, 95%CI = 1.421–20.548, P = 0.013) was an independent risk factor of mortality.

Conclusion

The GIR usage of < 7 g/kg/day in PN in the first week of life administered to preterm infants was an independent variable in increasing hypoglycemia, but in contrast, reducing the risk of sepsis.

The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit

BACKGROUND

Following delivery, extremely premature infants are vulnerable to rapid development of hypothermia and hypoglycemia. To reduce local rates of these morbidities, a multidisciplinary team developed a protocol standardizing evidence-based care practices during the first hour after birth.

METHODS

Using quality improvement methodology, the Golden Hour protocol was implemented for all inborn infants <27 weeks' gestation. Data were collected (2012-2017) over three phases; pre-protocol (n = 80), Phase I (n = 42), and Phase II (n = 92).

RESULTS

There were no significant differences in infant characteristics. Improvements in hypothermia (59% vs 26% vs 38%; p = 0.001), hypoglycemia (18% vs 7% vs 4%; p = 0.012), and minutes to completion of stabilization [median (Q1,Q3) 110 (89,138) vs 111 (94,135) vs 92 (74,129); p = 0.0035] were observed.

CONCLUSIONS

Implementation of an evidence-based, Golden Hour protocol is an effective intervention for reducing hypothermia and hypoglycemia in extremely premature infants.

First Golden Hour of Life: A Quality Improvement Initiative

BACKGROUND

Very low birth-weight (<1500 g) infants are vulnerable to their environment during the first hour after birth. We designed an evidence-based golden hour protocol (GHP) with a goal to stabilize and perform admission procedures within 1 hour of birth at a level IIIB neonatal intensive care unit (NICU).

PURPOSE

The aim of this quality improvement project was to ascertain whether an evidence-based GHP would improve care efficiency and short-term outcomes.

METHODS

Rapid cycles of change using Plan Do Study Act were utilized to document progress and gain knowledge during the quality improvement project. Measures were plotted with statistical process control methods (SPC), which analyzed improvement over time.

RESULTS

Both admission temperature and glucose-level means were within reference range throughout the project and predicted a stable process. We observed significantly decreased time to initiation of intravenous fluids and antibiotics. An upward trend of surfactant administration within the first 2 hours of life was also observed.

IMPLICATIONS FOR PRACTICE

The use of a GHP provided an organized approach to admission procedures and care. By using a checklist and recording intervention times, NICU caregivers were more aware of time management for each intervention and were able to decrease time to initiation of intravenous fluids and antibiotics.

IMPLICATIONS FOR RESEARCH

Future research should focus on establishing normal blood pressure ranges and safe pain management during the "golden hour" and beyond. Future quality improvement should focus on improving subsequent temperature and blood glucose levels after admission umbilical artery and venous catheter placement.

The Influence of Method, Timing of Onset and Duration of Enteral Feeding on the Duration of Hospitalization of Newborn Infants in a Nigerian Special Care Baby Unit

Background:

Feeding practices among high-risk newborn babies have not been extensively studied in the resource-constrained parts of the world.

Aim:

To describe the pattern of milk use among infants in a resource-poor special care baby unit (SCBU) and relate these to the outcome of hospitalization.

Subjects and Methods:

Setting – SCBU of Olabisi Onabanjo University Teaching Hospital, Sagamu. Design – Prospective study of consecutively admitted inborn babies within the first 24 h of life. The data analyzed included the weight and estimated gestational age (EGA) of the babies, the age at the onset of and duration of feeds (breast milk and artificial milk [AM]).

Results:

Out of the 118 infants studied, (78.8%) 93/118 received breast milk and 16.1% (19/118) received AM. The mean age at the commencement of enteral feeding was 3.9 days. The age at the onset of suckling was negatively correlated with the EGA and body weight. The age at the onset and duration of enteral feeding were directly related to the duration of admission.

Conclusion:

More than three-quarter of the infants hospitalized in the unit received breast milk, but commencement was mostly delayed beyond the 3^rd day of life. The duration of admission may be related to the timing of onset and duration of milk use.

Probiotics and necrotizing enterocolitis

One of the most controversial areas in neonatology is whether probiotics should be provided routinely to preterm infants to prevent necrotizing enterocolitis (NEC). This review provides the reader with a brief overview of NEC and current concepts of its pathophysiology, discusses the microbial ecology of the intestine in preterm infants and factors that may lead to a "dysbiosis", summarizes studies of probiotics in preterm infants, elaborates on the need for regulation in this area, and discusses alternatives to probiotics and what is the future for the prevention of NEC.

Parenteral nutrition compromises neurodevelopment of preterm pigs

BACKGROUND

Despite advances in nutritional support and intensive care, preterm infants are at higher risk of compromised neurodevelopment.

OBJECTIVE

This study evaluated the contribution of total parenteral nutrition (PN) to compromised neurodevelopment after preterm birth.

METHODS

Preterm pigs were provided PN or enteral nutrition (EN) for 10 d. Neurodevelopment was assessed by observations of motor activity and evaluation of sensory/motor reflexes, brain weight, MRI, and cerebellar histology.

RESULTS

Despite similar gains in body weight, PN pigs had smaller brains (32 ± 0.4 vs. 35 ± 0.6 g; P = 0.0002) including the cerebellum, as well as reduced motor activity (P = 0.005), which corresponded to underdeveloped myelination (P = 0.004) measured by diffusion tensor imaging. PN resulted in lower serum triglycerides (17 ± 5.9 vs. 27 ± 3.1 mg/dL; P = 0.05), total cholesterol (31 ± 9.6 vs. 85 ± 8.1 mg/dL; P = 0.04), VLDL cholesterol (3.7 ± 1.2 vs. 5.7 ± 0.7 mg/dL; P = 0.04), and HDL cholesterol (16 ± 4.6 vs. 57 ± 7.3 mg/dL; P = 0.03) and nonsignificantly lower LDL cholesterol (10.7 ± 4.4 vs. 22.7 ± 2.9 mg/dL; P = 0.09).

CONCLUSIONS

The compromised neurodevelopment caused by total PN is a novel finding, was independent of confounding variables (disease, inconsistent gestational ages, diverse genetics, extrauterine growth retardation, and inconsistent neonatal intensive care unit protocols), and highlights a need to improve current PN solutions. The preterm pig is a translational animal model for improving nutrition support to enhance neurodevelopment of preterm infants requiring PN.

Outcomes of a Neonatal Golden Hour Implementation Project

The objective of this study was to implement and evaluate a quality improvement project (the golden hour pathway [GHP]) aimed at improving the quality and efficiency of care delivered to extremely low birth weight (ELBW) infants <28 weeks gestation and/or <1000 g birth weight during the first hour of life. Process improvement and patient data collected during the quality improvement cycles were compared with retrospective data for ELBW infants admitted to the study neonatal intensive care unit during the 2 years prior to GHP implementation. GHP implementation resulted in improvements compared with past internal performance in time to surfactant administration, time to administration of dextrose and amino acids, body temperature at admission, odds of developing chronic lung disease, and odds of developing retinopathy of prematurity. A standardized interdisciplinary approach to the care of ELBW infants in the first hour of life can lead to more efficient care delivery and contribute to improved outcomes.

Sixty golden minutes

The golden hour concept started in the trauma setting but is becoming more familiar in the neonatal intensive care unit (NICU). For a premature baby, the first hour of life can make the difference between a good outcome, a poor outcome, and death. The golden hour is 60 minutes of team-oriented and task-driven protocols. The focus is on resuscitation, thermoregulation, early administration of antibiotics for suspected sepsis, early intravenous parenteral nutrition, hypoglycemia management, and completed admission within one hour of life. To a premature baby, the first 60 minutes of life are golden and can last a lifetime.