Are the current feeding volumes adequate for the growth of very preterm neonates?

Postnatal growth failure, a common problem in very preterm neonates associated with adverse neurodevelopmental outcome, has recently been shown not to be inevitable. There is a wide discussion regarding feeding practices of very preterm neonates, specifically regarding feeding volumes and nutrients supply to avoid postnatal growth failure. Current guidelines recommend an energy intake of 115–140 kcal /kg per d with a considerably higher upper limit of 160 kcal/kg per d. The feeding volume corresponding to this energy supply is not higher than 200 ml/kg in most cases. From the other side, randomised and observational studies used higher feeding volumes, and these were associated with better weight gain and growth, while no complications were noted. Taking into account the above, nutritional practices should be individualised in each very and extremely preterm infant trying to reduce postnatal growth failure, pointing out that available data are inconclusive regarding the effect of high-volume feeds on growth. Large clinical trials are necessary to conclude in the best feeding practices of very preterm neonates.

"Aggressive" Feeding of Very Preterm Neonates and Body Mass Index at School Age

INTRODUCTION

The effects of "aggressive" neonatal feeding policies of very preterm neonates (VPN) and the risk of metabolic syndrome later in life remain questionable. We aimed to evaluate the effect of our "aggressive" nutrition policies of VPN during hospitalisation on body mass index (BMI) at ages 2 and 8 years.

MATERIALS AND METHODS

Eighty four VPN, who received "aggressive" nutrition during hospitalisation in an effort to minimise postnatal growth restriction (PGR) (group A), and 62 term neonates, as controls (group B), were enrolled in the study. Group A was further divided in four subgroups depending on the type (A1: fortified expressed breast milk and preterm formula; A2: exclusively preterm formula) and quantity of milk received (A3: maximum feeds 180-210 mL/kg/day; A4: maximum feeds 210 and up to 260 mL/kg/day). BMI was calculated at ages 2 and 8 years and plotted on the centile charts.

RESULTS

There was no significant difference in BMI between groups A and B at 2 and 8 years, respectively, in both absolute BMI values and their centile chart distribution. There was no significant difference in BMI at 2 and 8 years either between subgroups A1 and A2 or between subgroups A3 and A4.

CONCLUSIONS

"Aggressive" and individualised feeding policy for VPN did not affect the BMI and obesity rates at ages of 2 and 8 years in our study population. The type and quantity of milk feeds had no impact on their BMI at school age. Further larger studies are needed to confirm our results.

Thromboelastometry: studying hemostatic profile in small for gestational age neonates-a pilot observational study

Scarce data exists about the hemostatic status of small for gestational age (SGA) neonates. We aimed at evaluating the hemostatic profile of SGA neonates, using thromboelastometry (TEM). This is an observational study performed in a Greek tertiary General Hospital during an 18-month period. Ninety-three neonates were included in the study: 48 appropriate for gestational age weight (AGA) neonates and 45 SGA neonates Extrinsically activated TEM (ex-TEM) parameters, such as clotting time, clot formation time, amplitude recorded at 5 and 10 min, a angle, maximum clot firmness, lysis index at 60 min, and also platelet count, were used for the evaluation of the hemostatic profile in all neonates. No statistically significant differences were noticed regarding all ex-TEM parameters between AGA and SGA neonates, while no event of hemorrhage or thrombosis was noticed in the study population.Conclusions: The coagulation system of SGA neonates seems to be fully functional, with no evident tendency toward coagulopathy or thrombosis, when compared with AGA neonates. TEM seems to provide a promising and valid assessment of coagulation and fibrinolysis systems and may be used as a valuable biomarker, in the future. Further studies, with large samples, are necessary to confirm our results. What is Known: • SGA neonates may present coagulation disorders mainly due to hepatic dysfunction, polycythemia, and thrombocytopenia owing to long-term intrauterine hypoxia. • In the literature, despite the statistically significant differences in laboratory results between SGA and AGA neonates, no clinical manifestations of significantly altered hemostasis were recorded. Data of TEM interpretation of hemostasis in SGA neonates are not available. What is New: • TEM seems to interpret coagulation mechanism of preterm and full-term SGA neonates and confirm previous relevant literature findings regarding hemostasis in these neonates.

Very preterm neonates receiving "aggressive" nutrition and early nCPAP had similar long-term respiratory outcomes as term neonates

BACKROUND

The impact of the consistent implementation of "aggressive" nutrition by means of intensive early neonatal nutritional support up to 40-44 weeks postmenstrual age and the use of nasal continuous positive airway pressure (nCPAP) within the first hour of life on the respiratory function of very premature neonates (VPN) at school age is unclear.

METHOD

Respiratory function was evaluated in 108 VPN and 70 term controls. Growth, frequency of lower respiratory tract infections, re-hospitalization, and spirometry were recorded up to 8-10 years of age. Comparison was carried out between the two study groups.

RESULTS

There was no significant difference in forced expiratory volume in 1 s and forced vital capacity at 8 years of age, and also in lower respiratory tract infections and re-hospitalization due to them, up to 8 years of age between preterm and term neonates. No significant difference was found in spirometry measurements neither between premature neonates with and without BPD nor between the two subgroups of preterms and term neonates.

CONCLUSION

"Aggressive" nutrition, persistent nCPAP use, and their impact on early postnatal growth probably positively affect the respiratory function of our study population. These very encouraging results need to be confirmed by larger studies.

Successful control of a neonatal outbreak caused mainly by ST20 multidrug-resistant SHV-5-producing Klebsiella pneumoniae, Greece

Background

Extended spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) infection can cause significant morbidity and mortality in neonates. We investigated a nosocomial ESBL-Kp outbreak in a neonatal intensive care unit (NICU) of the University Hospital of Larissa (UHL), Central Greece.

Methods

A total of sixty-four ESBL-Kp were studied; twenty six isolates were recovered from the NICU and were compared with thirty-eight randomly selected isolates from different wards of the hospital during the period March- December 2012. All isolates were characterized by antimicrobial susceptibility testing, ESBL-production by double-disk synergy test, molecular typing using BOX-PCR, whereas selected isolates were further characterized by beta lactamase and virulence gene content, multilocus sequence typing and phylogenetic analysis. All neonates affected by ESBL-Kp were put under strict contact isolation, along with appropriate infection control measures.

Results

The outbreak strain of ST20 multidrug-resistant SHV-5-producing K. pneumoniae was identified in all infected (n = 13) and three colonized neonates. A novel ST (ST1114) was also identified among SHV-5 producers (n = 10) recovered from nine colonized infants, but it was not related with ST20. Both STs were identified only in the NICU and not in other wards of the hospital. No ESBL-Kp were isolated from the hands of the nursing staff and the environment. Although we were not able to identify the source of the outbreak, no ESBL-Kp were isolated in the NICU after this period and we assumed that the outbreak was successfully controlled. All neonates received parenteral nutrition and most of them were delivered by caesarean section and showed low gestational age (<32 weeks) and low birth weights (<1500 g).

Conclusion

According to our knowledge, this is the first description of an outbreak of multidrug-resistant SHV-5 producing K. pneumoniae assigned to ST20.

Successful control of an echovirus 6 meningitis outbreak in a neonatal intensive care unit in central Greece

We report an outbreak of echovirus 6 meningitis in a neonatal intensive care unit in central Greece from July to August 2011. The most probable source of the outbreak was a mother; during hospitalization, her neonate was initially infected, followed by 7 more. Stricter infection control measures were implemented, and no other cases have been observed.

Gastric emptying of preterm neonates receiving domperidone

OBJECTIVES

Immature gut motility in very low birth weight infants causes feeding intolerance. We evaluated the effect of domperidone, a prokinetic agent, on gastric emptying in very low birth weight infants.

METHODS

The study was conducted in a crossover design. Gastric emptying was assessed ultrasonographically by measuring the time it took the antral cross sectional area of the stomach to reach half of the value of the 1st measurement on 2 occasions: (1) upon administration of domperidone (0.3 mg/kg/8 h p.o.) for at least 2 days and (2) while patients received an equal quantity of sterile water. 11 infants were randomly assigned to receive domperidone before the 1st measurement and the remaining afterwards. There was a 3-5 day interval between the 2 measurements. At the time when both measurements were performed, every neonate had been receiving the same quantity and quality of milk. 12 infants were formula-fed while 10 were fed their own mother's supplemented milk.

RESULTS

22 infants with a mean (SD) birth weight of 1,377 g (319) and a mean (SD) gestational age of 30.2 weeks (2.1) were studied. The mean (SD) antral cross sectional area half-value time (in minutes) was 47.6 (23.9) in the domperidone group and 68.2 (25.5) in the control group (p = 0.008). There was no significant difference between formula-fed neonates and neonates fed their own mother's milk in either group.

CONCLUSIONS

Domperidone significantly reduces gastric emptying in preterm neonates, and this may account for its effect in cases of disturbances related to gut motility.

Predictive markers of radiation pneumonitis

Radiation pneumonitis is an acute-phase response to radiation therapy and a common complication that affects a patient's quality of life. Under the need to reduce the incidence and severity of radiation-induced pulmonary complications as well as to identify patients at risk, several investigations on potential predictive markers of radiation pneumonitis have been conducted. The present study reviews the currently available knowledge on biomolecules of potential predictive value for radiation pneumonitis.

Serum paraoxonase/arylesterase activities in phenylketonuric patients on diet

AIM

To compare serum paraoxonase/arylesterase (PON-aryl) activities in phenylketonuric (PKU) patients with high and low phenylalanine (Phe) blood concentration.

PATIENTS AND METHODS

Seventeen poorly controlled PKU children (off diet) underwent clinical and laboratory examinations before and after 30 days adhering to their special diet (on diet), whereas controls (N=24) were examined once. Lipid, lipoprotein levels and paraoxonase (PON 1) activities were measured with the Bayer Advia 1650 Clinical Chemistry System. Apolipoprotein AI (Apo AI) levels were determined by the Dade Behring BN ProSpec nephelometer, whereas total antioxidant capacity (TAC), PON-aryl and Phe levels were measured spectrophotometrically.

RESULTS

Phe significantly differed among the groups. Lipids and lipoproteins, except high-density-lipoprotein-cholesterol (HDL-C) and Apo AI, were higher when off diet than those on diet. HDL-C and Apo AI were similar in patients and controls. TAC (0.99+/-0.19 mmol/l) was significantly lower when the patients were off diet than when they adhered to diet and controls (1.71+/-0.20 and 1.81+/-0.20 mmol/l P<0.001 respectively). PON 1 and PON-aryl activities (68+/-2 U/min/ml, 88+/-26 KU (min/ml) in children with high Phe were reduced as compared with those with low blood Phe levels (152+/-41 U/min/ml, 107+/-23 KU/min/ml P<0.001) and controls (146+/-43 U/min/ml, 109+/-41 KU/min/ml P<0.001). The enzyme activities positively correlated with HDL-C and Apo AI when PKU patients were on diet and controls as well as with TAC in all the groups, whereas negatively correlated with Phe levels.

CONCLUSIONS

PON-aryl activities are strongly related to the dietary control of PKU patients.

Theophylline and gastric emptying in very low birthweight neonates: a randomised controlled trial

BACKGROUND

Theophylline treatment causes side effects such as tachycardia, hyperglycaemia, abdominal distension, and vomiting. The latter two are probably the result of delayed gastric evacuation.

OBJECTIVE

To study the effect of theophylline on gastric emptying time in preterm infants.

PATIENTS

The subjects were 18 premature neonates with a mean (SD) birth weight of 1302 (240) g and a mean (SD) gestational age of 28.7 (1.9) weeks.

MAIN OUTCOME MEASURES

In each case, gastric emptying was measured on two occasions: once when the newborns were being treated with theophylline and once when they were not. Half of the cases were randomised to receive theophylline before the initial measurement. The opposite was applied for the rest. Gastric emptying was assessed ultrasonically by measuring the change in antral cross sectional area (ACSA) at regular intervals over 120 minutes.

RESULTS

The mean (SD) ACSA half time in the newborns receiving theophylline was 52 (19) minutes compared with 37 (16) minutes in those not receiving theophylline. This difference is significant (p < 0.05).

CONCLUSIONS

Treatment with theophylline seems to delay gastric emptying in very low birthweight neonates, and this must be taken into consideration when this drug is used to treat apnoea of prematurity.

The effect of antenatal corticosteroids on gut peptides of preterm infants--a matched group comparison: corticosteroids and gut development

BACKGROUND

Postnatal glucocorticosteroid administration has trophic effects on the gastrointestinal tract of preterm infants. The aim of the present study was to investigate whether antenatal glucocorticosteroids affect the secretion of gastrointestinal peptides that are involved in the regulation of secretion, motility and mucosal protection of the gastrointestinal tract.

METHODS

Plasma levels of gastrin, motilin and vasoactive intestinal peptide (VIP) were estimated in 28 preterm infants with a mean birth weight of 1280 g, and mean gestational age of 30.5 weeks, whose mothers had received a full course of antenatal glucocorticosteroids (GC group) and in 17 preterm infants with mean birth weight of 1200 g, mean gestational age of 30.2 weeks, whose mothers had not received corticosteroids (control group). GI peptides were estimated on two occasions: (a) Immediately after birth and (b) following the initiation of enteral feeding.

RESULTS

Gastrin levels in the GC group were significantly higher both immediately after birth (early measurement) and also after receiving enteral feeding (late measurement) (p<0.001, p<0.05, respectively) but the increase in plasma gastrin concentration was identical in both groups (32 vs. 33 pg/ml). Motilin levels in the GC group were also significantly higher as compared to the control group but only in the late measurement (p<0.001). Gastrin and motilin levels in both groups were significantly higher in the late measurement as compared to the early measurement (GC group: p<0.001, p<0.001, respectively;

CONTROLS

p<0.001, p<0.01, respectively). There was no significant difference in VIP levels between the two groups both in the early and the late measurements.

CONCLUSION

Antenatal glucocorticoids (GCs) stimulate gastrin secretion in the fetus but not in the neonate. Contrary to this, corticosteroid effect on motilin is seen only postnatally following the introduction of enteral feeding. Glucocorticosteroids appear to have no effect on VIP levels. Plasma gastrin and motilin levels increase significantly following the introduction of enteral feeding regardless of the use of steroids.

Enteral feeding of premature infants with Saccharomyces boulardii

BACKGROUND

Saccharomyces boulardii (SB) is a yeast that acts both as a probiotic and as a polyamine producer. Probiotics prevent the overgrowth of pathogens in the gut while polyamines enhance intestinal maturation. The aim of this randomized study was to investigate the ability of SB to modify the gut microbial ecology and its function.

METHODS

A total of 87 healthy babies with gestational age 28-32 weeks were studied. They were randomly assigned to receive a preterm formula to which SB or maltodextrins was added for 30 days. Evaluations were made on the following: SB tolerance and weight gain, faecal flora analysis, intestinal D-xylose absorption and faecal lipid excretion.

RESULTS

SB was well tolerated by the infants. There was no difference in weight gain between the two groups. Median log of colony forming units per gram of faeces for Escherichia coli and enterococci was significantly lower in the SB group [E. coli: 2.67 (0.045) vs. 2.75 (0.058), P<0.001; enterococci: 2.14 (0.359) vs. 2.19 (0.138), P<0.05]. On the other hand, the number of bifidobacteria and staphylococci in the stools was significantly higher in the SB group [bifidobacteria: 2.65 (0.083) vs. 2.27 (0.075), P<0.001; staphylococci: 1.23 (0.869) vs. 0.6 (0.281), P<0.001]. D-Xylose and lipid absorption was not improved by SB [median blood D-xylose: 1.5 (0.4) mmol/l vs. 1.35 (0.3) mmol/l, P>0.1; median stool steatocrit: 64% (3.05%) vs. 65% (2.72%) P>0.5].

CONCLUSIONS

An SB-supplemented formula is well tolerated by preterm infants, it has a beneficial effect on stool flora bringing it closer to that of breast fed babies but it does not improve D-xylose or lipid gut absorption.

The effect of low-dose erythromycin on whole gastrointestinal transit time of preterm infants

The aim of the study was to determine the effect of a low oral dose of erythromycin on whole gastrointestinal transit time [WGTT]. Erythromycin [EM] [1.5 mg/kg, 6 hourly] or placebo was given first over 7 days in a double blind randomized crossover study of 21 preterm infants with feed intolerance. Median [range] birth weight was 1420 [690, 2200] g and postconceptual age 32. 5 [20, 36.4] weeks. WGTT was assessed on day 3 of each treatment, by timing the transit of carmine red through the gut. Treatments were compared using Student's paired t test.

RESULTS

WGTT was significantly shorter following EM treatment as compared to placebo: mean [SD] 10.16 [4.6] h vs. 15. 9 [7.2] h, p<0.01.

CONCLUSION

Oral low-dose EM significantly shortens WGTT of feed-intolerant preterm infants.

Effect of low-dose cisapride on gastric emptying and QTc interval in preterm infants

The aim of the study was a prospective survey of the effects of low-dose cisapride on gastric emptying and QTc interval in very low birthweight infants. Twenty low birthweight infants were studied: mean (SD) gestation 30.5 (2.2) wk; birthweight 1320 (150)g. Gastric emptying was assessed ultrasonically in 15 of these infants, in a randomized blind crossover study, following 24-h low-dose oral cisapride administration (0.1 mg/kg given 8 hourly), or placebo. The QTc interval was also determined in all 20 infants following a 7-d course of cisapride or placebo.

CONCLUSIONS

Cisapride significantly shortened both gastric emptying time and QTc interval (p < 0.05) compared to placebo. All infants completed the study without any apparent adverse effects. In conclusion, low-dose cisapride administration significantly improves gastric emptying without increasing the QTc interval.

Reduction of susceptibility to NK lysis in cisplatin-resistant K562 cell lines

The development of resistance to cisplatin (CDDP) occurs both in vitro and in vivo. We cultured K562 cells with continuous exposure to gradually increasing doses of CDDP and produced CDDP resistant K562 sublines. CDDP-resistant sublines were found to be cross-sensitive to Mit-C and cross-resistant to DXR and cyclophosphamide. These sublines were tested for their susceptibility to NK-mediated lysis using NK cells isolated from 10 healthy donors and 12 patients with breast cancer. K562/B6 and K562/C9 CDDP-resistant sublines were more resistant (22 +/- 5% and 19 +/- 3% lysis, respectively for Ca patients, and 34 +/- 6 and 31 +/- 5% for healthy donors) than the maternal K562 cells (36 +/- 3% for Ca patients and 55 +/- 5% for healthy individuals). The correlation of cisplatin resistance, with a diminished susceptibility by NK lysis, should permit the selection of patients suitable for cisplatin-based chemotherapy.

Gut hormone levels in neonates under phototherapy

Gastrin, vasoactive intestinal peptide (VIP) and neurotensin plasma levels were measured in three groups of healthy term newborn infants, on the 3rd, 4th and 5th days of life. Group A consisted of 15 babies without jaundice. Group B comprised of 15 babies with mild jaundice (bilirubin levels < 256 mumol/l) and group C included 15 babies with marked jaundice (bilirubin levels > 256 mumol/l) who received phototherapy for at least 24 h. There was no significant difference in gut hormone levels between groups A and B. Infants in group C had significantly lower gastrin levels compared to infants in groups A and B, on both days 4 and 5. VIP levels on the 4th day of life were significantly higher in group C in comparison to groups A and B. Neurotensin levels in the three groups did not differ significantly. Increased stool number was noted in infants in group C. Increased VIP levels in jaundiced infants under phototherapy may be the cause of increased stool frequency, through stimulation of intestinal water and electrolyte secretion.

Gut hormone concentrations in preterm infants with necrotizing enterocolitis

Blood levels of gastrin, neurotensin and vasoactive peptide (VIP) were estimated in 14 premature infants with necrotizing enterocolitis (NEC) and in 12 controls. In comparison to the control group, infants with NEC had (a) significantly lower gastrin levels both before [9.3 (7.8) versus 33.7 (27.1)] and after [52.4 (48.1) versus 100.8 (50.9)] the development of NEC; (b) significantly lower neurotensin levels only after the development of NEC [37.8 (10.4) versus 54.5 (20.6)1; and (c) no significant difference in VIP values [25.4 (9.7) versus 18.9 (9.9) and 24.5 (15.7) versus 26.1 (19.1)]. It is concluded that NEC can adversely affect gastrin and neurotensin concentrations in the blood.

Patterns of adenosine deaminase, ecto-5'-nucleotidase, poly(A)polymerase and surface light chain expression in chronic lymphocytic leukemias

The levels of activity of three enzymes have been measured in the circulating malignant lymphocytes of 47 patients with B chronic lymphocytic leukemia (CLL). These were the purine degradative enzymes, adenosine deaminase (ADA) and ecto-5'-nucleotidase (5'NT) and the enzyme responsible for the polyadenylation of mRNA, poly(A) polymerase. The patterns of activity of the above enzymes and the expression of surface immunoglobulin light chains were examined. A heterogeneity in the specific activity of the enzymes was observed which could not be attributed to variations of the percentage of B lymphocytes. A positive correlation was found between ADA and poly(A)polymerase activity (r = 0.383, p less than 0.01). Furthermore, the expression of immunoglobulin light chain phenotype was inversely related to 5'NT specific activity; CLL cases in which less than 20% of the cells expressed lambda chain phenotype, presented 5'NT specific activity of 16.7 +/- 3.3 (S.E.) nmol/h/10(6) cells, whereas in CLL cases with more than 20% of the cells expressing this phenotype the enzyme specific activity was 4.8 +/- 1.6 (S.E.) nmol/h/10(6) cells (p less than 0.02). These findings suggest that the simultaneous determination of enzymatic activities and immunological markers, might be useful in defining subsets in CLL and the subsequent clinical treatment.

Relation between the activity of poly(A)polymerase and the levels of protein synthesis in the lymphocytes of patients with chronic lymphocytic leukemia

The activity levels of the enzyme poly(A)polymerase and the levels of protein synthesis primed by endogenous messenger RNA (mRNA) as well as polyuridylic acid, poly(U) directed polyphenylalanine synthesis, were determined in lymphocytic extracts from 17 patients with chronic lymphocytic leukemia of the B cell type. The enzyme activity values have not been found to correlate with the poly(U)-protein synthesis, whereas a positive linear correlation has been established between the activity levels of poly(A)polymerase and the endogenous mRNA-primed protein synthesis (r = 0.735, p less than 0.01). This difference between exogenously and endogenously primed protein synthesis in concern with poly(A)polymerase is discussed.

Soluble cAMP-independent protein kinase from human spleen

A protein kinase (EC 2.7.1.37) was purified 2000-fold, from the soluble protein fraction of human spleen cells, using ion-exchange chromatography, ammonium sulfate fractionation, and gel filtration. This rapid procedure yielded 30% of the initial activity and an enzyme preparation with specific activity of 62 nmol min-1 mg-1 of protein. On the basis of disc gel electrophoresis in sodium dodecyl sulfate acrylamide gels and isoelectric focusing the enzyme preparation appears homogeneous and to consist of one polypeptide with a molecular weight of 43,000 and having a pI of 7.1. The purified enzyme activity is cyclic AMP and cGMP independent phosphorylates both alpha-casein and phosvitin, and uses Mg2+ ATP and Mg2+ GTP as phosphate donors, exhibiting an apparent Km of 2.0 and 6.6 X 10(-5)m, respectively. Furthermore, the enzyme activity is strongly inhibited by heparin (K50 = 0.1 micrograms/ml). These catalytic properties are characteristic of the enzyme casein kinase II, as described in several eukaryotic cells.