1
|
Salas AA, Gunn E, Carlo WA, Bell EF, Das A, Josephson CD, Patel RM, Tan S, Kirpalani H. Timing of Red Blood Cell Transfusions and Occurrence of Necrotizing Enterocolitis: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e249643. [PMID: 38700862 PMCID: PMC11069076 DOI: 10.1001/jamanetworkopen.2024.9643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/05/2024] [Indexed: 05/06/2024] Open
Abstract
Importance Observational studies often report that anemia and red blood cell (RBC) transfusions are associated with a higher risk of necrotizing enterocolitis (NEC) among extremely low-birthweight (ELBW) infants. Objective To evaluate whether there is a temporal association between 72-hour hazard periods of exposure to RBC transfusions and NEC among ELBW infants randomized to either higher or lower hemoglobin transfusion thresholds. Design, Setting, and Participants This post hoc secondary analysis of 1690 ELBW infants who survived to postnatal day 10 enrolled in the Transfusion of Prematures (TOP) randomized multicenter trial between December 1, 2012, and April 12, 2017, was performed between June 2021 and July 2023. Exposures First, the distribution of RBC transfusions and the occurrence of NEC up to postnatal day 60 were examined. Second, 72-hour posttransfusion periods were categorized as hazard periods and the pretransfusion periods of variable duration as control periods. Then, the risk of NEC in posttransfusion hazard periods was compared with that in pretransfusion control periods, stratifying the risk based on randomization group (higher or lower hemoglobin transfusion threshold group). Main Outcomes and Measures The primary outcome was incidence of NEC stage 2 or 3. Secondary outcomes included the incidence rates of NEC within five 10-day intervals, taking into account the number of days at risk. Results Of 1824 ELBW infants randomized during the TOP trial, 1690 were included in the present analysis (mean [SD] gestational age, 26.0 [1.5] weeks; 899 infants [53.2%] were female). After categorizing 4947 hazard periods and 5813 control periods, we identified 133 NEC cases. Fifty-nine of these cases (44.4%) occurred during hazard periods. Baseline and clinical characteristics of infants with NEC during hazard periods did not differ from those of infants with NEC during control periods. The risk of NEC was 11.9 per 1000 posttransfusion hazard periods and 12.7 per 1000 control periods (adjusted risk ratio, 0.95; 95% CI, 0.68-1.32; P = .74). This risk did not differ significantly between randomization groups, but the incidence rate of NEC per 1000 days peaked between postnatal days 20 and 29 in the lower hemoglobin transfusion threshold group. Conclusions and Relevance The findings of this post hoc analysis suggest that, among ELBW infants with the hemoglobin ranges occurring in the TOP trial, exposure to RBC transfusions was not temporally associated with a higher risk of NEC during 72-hour posttransfusion hazard periods. Given that the incidence rate of NEC peaked between postnatal days 20 and 29 among infants with lower hemoglobin values, a more in-depth examination of this at-risk period using larger data sets is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT01702805.
Collapse
Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham
| | - Elizabeth Gunn
- Department of Pediatrics, University of Alabama at Birmingham
| | | | | | - Abhik Das
- Statistical and Environmental Sciences Unit, RTI International, Washington, DC
| | - Cassandra D. Josephson
- Cancer and Blood Disorders Institute and Blood Bank/Transfusion Medicine, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
- Department of Oncology, John Hopkins University School of Medicine, Baltimore, Maryland
| | - Ravi M. Patel
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Sylvia Tan
- Statistical and Environmental Sciences Unit, RTI International, Washington, DC
| | - Haresh Kirpalani
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| |
Collapse
|
2
|
Salas AA. Revolutionizing Neonatal Nutrition: Rethinking Definitions and Standards for Optimal Care. Adv Nutr 2024:100235. [PMID: 38679235 DOI: 10.1016/j.advnut.2024.100235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024] Open
Affiliation(s)
- Ariel A Salas
- University of Alabama at Birmingham, Birmingham, Alabama.
| |
Collapse
|
3
|
Valcarce V, Salas AA, Ambalavanan N. Body composition of very preterm infants in mid-adulthood. Pediatr Res 2024; 95:1177-1178. [PMID: 38160219 DOI: 10.1038/s41390-023-03012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Vivian Valcarce
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ariel A Salas
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
4
|
Razzaghy J, Shukla VV, Gunawan E, Reeves A, Nguyen K, Salas AA. Early and exclusive enteral nutrition in infants born very preterm. Arch Dis Child Fetal Neonatal Ed 2023:fetalneonatal-2023-325969. [PMID: 38135494 DOI: 10.1136/archdischild-2023-325969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To characterise the effects of early and exclusive enteral nutrition with either maternal or donor milk in infants born very preterm (280/7-326/7 weeks of gestation). DESIGN Parallel-group, unmasked randomised controlled trial. SETTING Regional, tertiary neonatal intensive care unit. PARTICIPANTS 102 infants born very preterm between 2021 and 2022 (51 in each group). INTERVENTION Infants randomised to the intervention group received 60-80 mL/kg/day within the first 36 hours after birth. Infants randomised to the control group received 20-30 mL/kg/day (standard trophic feeding volumes). MAIN OUTCOME MEASURES The primary outcome was the number of full enteral feeding days (>150 mL/kg/day) in the first 28 days after birth. Secondary outcomes included growth and body composition at the end of the first two postnatal weeks, and length of hospitalisation. RESULTS The mean birth weight was 1477 g (SD: 334). Half of the infants were male, and 44% were black. Early and exclusive enteral nutrition increased the number of full enteral feeding days (+2; 0-2 days; p=0.004), the fat-free mass-for-age z-scores at postnatal day 14 (+0.5; 0.1-1.0; p=0.02) and the length-for-age z-scores at the time of hospital discharge (+0.6; 0.2-1.0; p=0.002). Hospitalisation costs differed between groups (mean difference favouring the intervention group: -$28 754; -$647 to -$56 861; p=0.04). CONCLUSIONS In infants born very preterm, early and exclusive enteral nutrition increases the number of full enteral feeding days. This feeding practice may also improve fat-free mass accretion, increase length and reduce hospitalisation costs. TRIAL REGISTRATION NUMBER NCT04337710.
Collapse
Affiliation(s)
- Jacqueline Razzaghy
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vivek V Shukla
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily Gunawan
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Audrey Reeves
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kelly Nguyen
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ariel A Salas
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
5
|
Razzaghy J, Zhang L, Yi N, Salas AA. Predicting body fat percentage at 36 weeks of postmenstrual age in infants born preterm: A diagnostic accuracy study. JPEN J Parenter Enteral Nutr 2023; 47:1056-1061. [PMID: 37709722 PMCID: PMC10843079 DOI: 10.1002/jpen.2561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 07/30/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Current standards for assessing body composition can be costly and technically challenging. There is a need for a predictive equation that combines multiple clinical and anthropometric factors to predictbody composition outcomes at 36 weeks of postmenstrual age (PMA) or discharge. METHODS To develop a widely applicable equation that predicts body fat percentage in preterm infants, we analyzed anthropometric data collected prospectively from a cohort of infants born very preterm between 2017 and 2018. We integrated clinical variables significantly associated with adiposity into a predictive equation using Bayesian linear regression models and leave-one-out cross-validation. RESULTS We analyzed data from 86 infants born at 32 weeks of gestation or less (median gestational age, 30 weeks; mean birthweight, 1471 ± 270 g). Weight gain and increase in length per week from birth to 36 weeks of PMA, midarm circumference at 36 weeks of PMA, male sex, and higher enteral fluid intake (>180 ml/kg/day) were the strongest predictors of body fat percentage in the model with the highest predictive value (R2 = 0.65). The correlation between actual and predicted body fat percentage using this Bayesian model was high (r = 0.82). CONCLUSIONS Weight gain and increase in length per week from birth to 36 weeks of PMA, midarm circumference at 36 weeks of PMA, male sex, and enteral fluid intake are significant predictors of body fat percentage at 36 weeks of PMA in very preterm infants.
Collapse
Affiliation(s)
- Jacqueline Razzaghy
- Department of Pediatrics, Division of Neonatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Li Zhang
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Nengjun Yi
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Ariel A. Salas
- Department of Pediatrics, Division of Neonatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
6
|
Jerome ML, Valcarce V, Lach L, Itriago E, Salas AA. Infant body composition: A comprehensive overview of assessment techniques, nutrition factors, and health outcomes. Nutr Clin Pract 2023; 38 Suppl 2:S7-S27. [PMID: 37721459 PMCID: PMC10513728 DOI: 10.1002/ncp.11059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/08/2023] [Accepted: 07/16/2023] [Indexed: 09/19/2023] Open
Abstract
Body composition assessment is a valuable tool for clinical assessment and research that has implications for long-term health. Unlike traditional measurements such as anthropometrics or body mass index, body composition assessments provide more accurate measures of body fatness and lean mass. Moreover, depending on the technique, they can offer insight into regional body composition, bone mineral density, and brown adipose tissue. Various methods of body composition assessment exist, including air displacement plethysmography, dual-energy x-ray absorptiometry, bioelectrical impedance, magnetic resonance imaging, D3 creatine, ultrasound, and skinfold thickness, each with its own strengths and limitations. In infants, several feeding practices and nutrition factors are associated with body composition outcomes, such as breast milk vs formula feeding, protein intake, breast milk composition, and postdischarge formulas for preterm infants. Longitudinal studies suggest that body composition in infancy predicts later body composition, obesity, and other cardiometabolic outcomes in childhood, making it a useful early marker of cardiometabolic health in both term and preterm infants. Emerging evidence also suggests that body composition during infancy predicts neurodevelopmental outcomes, particularly in preterm infants at high risk of neurodevelopmental impairment. The purpose of this narrative review is to provide clinicians and researchers with a comprehensive overview of body composition assessment techniques, summarize the links between specific nutrition practices and body composition in infancy, and describe the neurodevelopmental and cardiometabolic outcomes associated with body composition patterns in term and preterm infants.
Collapse
Affiliation(s)
| | | | - Laura Lach
- Medical University of South Carolina, Charleston, SC
| | | | | |
Collapse
|
7
|
Gates A, Hair AB, Salas AA, Thompson AB, Stansfield BK. Nutrient Composition of Donor Human Milk and Comparisons to Preterm Human Milk. J Nutr 2023; 153:2622-2630. [PMID: 37517552 DOI: 10.1016/j.tjnut.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Human milk is the preferred diet for very low birth weight (VLBW, <1500 g) infants. When mother's own milk is unable to meet the needs of VLBW infants, donor human milk (DHM) is the preferred alternative. Unfortunately, the composition of DHM remains elusive and no comparative studies between preterm human milk and DHM have been performed previously. OBJECTIVES We aimed to analyze the nutrient content of commercial pooled DHM and compare nutrient content in DHM with that of early and mature preterm human milk. METHODS We analyzed nutrient content in 15 DHM samples provided from 7 commercial milk banks including calories, carbohydrate, fat, protein, sodium, chloride, potassium, zinc, calcium, phosphorus, magnesium, and vitamin D and compared each nutrient to early (7 d of life) and mature (28 d of life) preterm human milk samples (n = 28-36 per nutrient, gestational age = 28 ± 3 wk). Protein-to-energy ratio and carbohydrate-to-nonprotein energy ratio were calculated for each sample and compared. RESULTS Mean values for all macro- and micronutrients in DHM are reported. In comparison to early or mature preterm human milk, DHM had significantly lower protein, sodium, chloride, potassium, and zinc content. Calorie, carbohydrate, calcium, phosphorus, magnesium, and vitamin D content did not differ statistically between DHM and early or mature preterm human milk. Fat content was modestly lower in early but not mature human milk when compared with DHM. CONCLUSIONS We provide mean values for several macro- and micronutrients for DHM and identify key differences between DHM and preterm human milk, which may be considered when designing human milk-based feeding plans. This study was registered at clinicaltrials.gov as NCT05742815.
Collapse
Affiliation(s)
- Amy Gates
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA
| | - Amy B Hair
- Department of Pediatrics, College of Medicine, Baylor University, Houston, TX
| | - Ariel A Salas
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Amy B Thompson
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA
| | - Brian K Stansfield
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA.
| |
Collapse
|
8
|
Salas AA, Gunawan E, Nguyen K, Reeves A, Argent V, Finck A, Carlo WA. Early Human Milk Fortification in Infants Born Extremely Preterm: A Randomized Trial. Pediatrics 2023; 152:e2023061603. [PMID: 37551512 PMCID: PMC10471508 DOI: 10.1542/peds.2023-061603] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 08/09/2023] Open
Abstract
OBJECTIVES Enteral nutrition with unfortified human milk during the first 2 postnatal weeks often leads to cumulative protein and energy deficits among preterm infants. Fortified human milk administered soon after birth could increase fat-free mass (FFM) and improve growth in these infants. METHODS This was a masked, randomized trial. Starting on feeding day 2, extremely preterm infants 28 weeks or younger fed maternal or donor milk were randomized to receive either a diet fortified with a human-based product (intervention group) or a standard, unfortified diet (control group). This practice continued until the feeding day when a standard bovine-based fortifier was ordered. Caregivers were masked. The primary outcome was FFM-for-age z score at 36 weeks of postmenstrual age (PMA). RESULTS A total of 150 infants were randomized between 2020 and 2022. The mean birth weight was 795±250 g, and the median gestational age was 26 weeks. Eleven infants died during the observation period. The primary outcome was assessed in 105 infants (70%). FFM-for-age z scores did not differ between groups. Length gain velocities from birth to 36 weeks PMA were higher in the intervention group. Declines in head circumference-for-age z score from birth to 36 weeks' PMA were less pronounced in the intervention group. CONCLUSIONS In infants born extremely preterm, human milk diets fortified soon after birth do not increase FFM accretion at 36 weeks' PMA, but they may increase length gain velocity and reduce declines in head circumference-for-age z scores from birth to 36 weeks' PMA.
Collapse
Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily Gunawan
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kelly Nguyen
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Audrey Reeves
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Victoria Argent
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amber Finck
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Waldemar A. Carlo
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
9
|
Salas AA, Travers CP. The Practice of Enteral Nutrition: Clinical Evidence for Feeding Protocols. Clin Perinatol 2023; 50:607-623. [PMID: 37536767 PMCID: PMC10599301 DOI: 10.1016/j.clp.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Establishing full enteral nutrition in critically ill preterm infants with immature gastrointestinal function is challenging. In this article, we will summarize emerging clinical evidence from randomized clinical trials suggesting the feasibility and efficacy of feeding interventions targeting the early establishment of full enteral nutrition. We will also examine trial outcomes of higher volume feedings after the establishment of full enteral nutrition. Only data from randomized clinical trials will be discussed extensively. Future opportunities for clinical research will also be presented.
Collapse
Affiliation(s)
- Ariel A Salas
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA.
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA
| |
Collapse
|
10
|
Manasyan A, Salas AA, Nolen T, Chomba E, Mazariegos M, Tshefu Kitoto A, Saleem S, Naqvi F, Hambidge KM, Goco N, McClure EM, Wallander JL, Biasini FJ, Goldenberg RL, Bose CL, Koso-Thomas M, Krebs NF, Carlo WA. Diagnostic accuracy of ASQ for screening of neurodevelopmental delays in low resource countries. BMJ Open 2023; 13:e065076. [PMID: 37221030 PMCID: PMC10230914 DOI: 10.1136/bmjopen-2022-065076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 04/29/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVE The Bayley Scales of Infant Development (BSID) is the most used diagnostic tool to identify neurodevelopmental disorders in children under age 3 but is challenging to use in low-resource countries. The Ages and Stages Questionnaire (ASQ) is an easy-to-use, low-cost clinical tool completed by parents/caregivers that screens children for developmental delay. The objective was to determine the performance of ASQ as a screening tool for neurodevelopmental impairment when compared with BSID second edition (BSID-II) for the diagnosis of moderate-to-severe neurodevelopmental impairment among infants at 12 and 18 months of age in low-resource countries. METHODS Study participants were recruited as part of the First Bites Complementary Feeding trial from the Democratic Republic of Congo, Zambia, Guatemala and Pakistan between October 2008 and January 2011. Study participants underwent neurodevelopmental assessment by trained personnel using the ASQ and BSID-II at 12 and 18 months of age. RESULTS Data on both ASQ and BSID-II assessments of 1034 infants were analysed. Four of five ASQ domains had specificities greater than 90% for severe neurodevelopmental delay at 18 months of age. Sensitivities ranged from 23% to 62%. The correlations between ASQ communications subscale and BSID-II Mental Development Index (MDI) (r=0.38) and between ASQ gross motor subscale and BSID-II Psychomotor Development Index (PDI) (r=0.33) were the strongest correlations found. CONCLUSION At 18 months, ASQ had high specificity but moderate-to-low sensitivity for BSID-II MDI and/or PDI <70. ASQ, when administered by trained healthcare workers, may be a useful screening tool to detect severe disability in infants from rural low-income to middle-income settings. TRIAL REGISTRATION NUMBER NCT01084109.
Collapse
Affiliation(s)
- Albert Manasyan
- Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
- Department of Reproductive, Maternal, Newborn, and Child Health, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ariel A Salas
- Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Tracy Nolen
- Research Triangle Institute, Durham, North Carolina, USA
| | - Elwyn Chomba
- Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
- University of Zambia, Lusaka, Zambia
| | - Manolo Mazariegos
- Institute of Nutrition for Central America and Panamá (INCAP), Guatemala City, Panama
| | | | | | | | - K Michael Hambidge
- University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Norman Goco
- Research Triangle Institute, Durham, North Carolina, USA
| | | | - Jan L Wallander
- Psychological Sciences and Health Sciences Research Institute, University of California Merced, Merced, California, USA
| | - Fred J Biasini
- Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, UK
| | - Carl L Bose
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Nancy F Krebs
- University of Colorado Denver, Denver, Colorado, USA
| | - Waldemar A Carlo
- Department of Pediatrics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| |
Collapse
|
11
|
Aristizabal N, Holder MP, Durham L, Ashraf AP, Taylor S, Salas AA. Safety and Efficacy of Early Vitamin D Supplementation in Critically Ill Extremely Preterm Infants: An Ancillary Study of a Randomized Trial. J Acad Nutr Diet 2023; 123:87-94. [PMID: 35728797 DOI: 10.1016/j.jand.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite substantial evidence that vitamin D deficiency is highly prevalent among infants born extremely preterm (≤28 weeks' of gestation), several consensus statements do not recommend vitamin D doses >400 IU/day for these infants. Safety remains a concern. OBJECTIVE The study aim was to determine safety and efficacy profiles of enteral vitamin D in Black and White infants randomized to three different vitamin D doses soon after birth. DESIGN Ancillary study of a masked randomized clinical trial. PARTICIPANTS/SETTING Seventy-three infants born extremely preterm between 2012 and 2015 at a southern US academic neonatal unit (33' latitude) who had >90% compliance with the assigned intervention were included. INTERVENTION Infants were randomized to receive placebo (placebo group), 200 IU/day vitamin D (200 IU group), or 800 IU/day vitamin D (800 IU group) during the first 28 days after birth. MAIN OUTCOME MEASURES Safety outcomes included serum 25-hydroxy vitamin D (25[OH]D) and calcium concentrations. Efficacy outcomes included the predictive risk of bronchopulmonary dysplasia. STATISTICAL ANALYSIS Per-protocol analysis using unadjusted, repeated-measures mixed models. RESULTS Mean birth weight was 815 ± 199 g. Half were male and 56% were Black. Of 58 infants with 25(OH)D measurements at birth, 40 (69%) had vitamin D deficiency (<20 ng/mL). The mean difference in 25(OH)D in nanograms per milliliter between Postnatal Day 28 and Postnatal Day 1 was +9 in the placebo group, +23 in the 200 IU group, and +62 in the 800 IU group (P < 0.0001). The increase observed in 25(OH)D was more significant among Black infants. The predictive risk of severe bronchopulmonary dysplasia in the 200 IU and 800 IU groups was lower, but this difference did not reach statistical significance. No vitamin D or calcium toxicity was observed. CONCLUSIONS A vitamin D dose of 800 IU/day safely corrected vitamin D deficiency by Postnatal Day 14.
Collapse
Affiliation(s)
- Natalia Aristizabal
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary Pat Holder
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Leandra Durham
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ambika P Ashraf
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sarah Taylor
- Department of Pediatrics, Yale University, New Haven, Connecticut
| | - Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
| |
Collapse
|
12
|
Durham L, Gunawan E, Nguyen K, Reeves A, Shukla V, Salas AA. Total Fluid Administration and Weight Loss during the First 2 Weeks in Infants Randomized to Early Enteral Feeding after Extremely Preterm Birth. Neonatology 2022; 120:257-262. [PMID: 36442467 PMCID: PMC10038856 DOI: 10.1159/000527430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Randomized trials have not reported the effects of the early progression of feeding volumes on fluid balance and neurodevelopment among infants born extremely preterm (≤28 weeks). METHOD Fluid, electrolyte, and neurodevelopment data of 60 extremely preterm infants randomly assigned to receive either 1 (early feeding group) or 4 days (late feeding group) of trophic feeding volumes at 20-24 mL/kg/day were analyzed. RESULTS Infants randomized to the early feeding group received less parenteral fluids, generated lower urine volumes, and had less excessive weight loss during the first 14 days after birth. The 7-point difference in cognitive scores and the 0.5 difference in weight-for-age z-scores favoring the early feeding group did not reach statistical significance. CONCLUSIONS In extremely preterm infants, early enteral feeding is associated with less total fluid administration and with less excessive weight loss during the first 2 weeks after birth. These short-term effects could have long-lasting benefits.
Collapse
Affiliation(s)
- Leandra Durham
- Department of Pediatrics/School of Medicine/University of Alabama at Birmingham/Birmingham, (AL,) USA
| | - Emily Gunawan
- Department of Pediatrics/School of Medicine/University of Alabama at Birmingham/Birmingham, (AL,) USA
| | - Kelly Nguyen
- Department of Pediatrics/School of Medicine/University of Alabama at Birmingham/Birmingham, (AL,) USA
| | - Audrey Reeves
- Department of Pediatrics/School of Medicine/University of Alabama at Birmingham/Birmingham, (AL,) USA
| | - Vivek Shukla
- Department of Pediatrics/School of Medicine/University of Alabama at Birmingham/Birmingham, (AL,) USA
| | - Ariel A. Salas
- Department of Pediatrics/School of Medicine/University of Alabama at Birmingham/Birmingham, (AL,) USA
| |
Collapse
|
13
|
Moya F, Salas AA. [Nutrición en prematuros con enfermedad pulmonar]. World Rev Nutr Diet 2022; 122:431-449. [PMID: 36174530 DOI: 10.1159/000526556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Fernando Moya
- Neonatology, Betty Cameron Children's Hospital, Wilmington, North Carolina, USA
| | - Ariel A Salas
- Department of Pediatrics, University of Alabama, Birmingham, Alabama, USA
| |
Collapse
|
14
|
Salas AA, Jerome M, Finck A, Razzaghy J, Chandler-Laney P, Carlo WA. Body composition of extremely preterm infants fed protein-enriched, fortified milk: a randomized trial. Pediatr Res 2022; 91:1231-1237. [PMID: 34183770 PMCID: PMC8237544 DOI: 10.1038/s41390-021-01628-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/19/2021] [Accepted: 06/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Critically ill extremely preterm infants fed human milk are often underrepresented in neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes. METHODS Masked randomized trial in which 56 extremely preterm infants 25-28 weeks of gestation were randomized to receive either fortified milk enriched with a fixed amount of extensively hydrolyzed protein (high protein group) or fortified milk without additional protein (standard protein group). RESULTS Baseline characteristics were similar between groups. In a longitudinal analysis, the mean percent body fat (%BF) at 30-32 weeks of postmenstrual age (PMA), 36 weeks PMA, and 3 months of corrected age (CA) did not differ between groups (17 ± 3 vs. 15 ± 4; p = 0.09). The high protein group had higher weight (-0.1 ± 1.2 vs. -0.8 ± 1.3; p = 0.03) and length (-0.8 ± 1.3 vs. -1.5 ± 1.3; p = 0.02) z scores from birth to 3 months CA. The high protein group also had higher fat-free mass (FFM) z scores at 36 weeks PMA (-0.9 ± 1.1 vs. -1.5 ± 1.1; p = 0.04). CONCLUSIONS Increased enteral intake of protein increased FFM accretion, weight, and length in extremely preterm infants receiving protein-enriched, fortified human milk. IMPACT Extremely preterm infants are at high risk of developing postnatal growth failure, particularly when they have low fat-free mass gains. Protein supplementation increases fat-free mass accretion in infants, but several neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes have systematically excluded critically ill extremely preterm infants fed human milk exclusively. In extremely preterm infants fed fortified human milk, higher enteral protein intake increases fat-free mass accretion and promotes growth without causing excessive body fat accretion.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Maggie Jerome
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amber Finck
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jacqueline Razzaghy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
15
|
Jerome M, Chandler-Laney P, Affuso O, Li P, Salas AA. Racial differences in growth rates and body composition of infants born preterm. J Perinatol 2022; 42:385-388. [PMID: 35067675 PMCID: PMC8917983 DOI: 10.1038/s41372-021-01305-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 12/01/2021] [Accepted: 12/21/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate racial disparities in weight gain velocity and body composition among preterm infants. STUDY DESIGN This observational study analyzed race differences in fat-free mass (FFM), fat mass (FM), percent body fat (%BF), and weight gain at discharge of infants born at 25-32 weeks of gestation. RESULTS No racial differences in FFM, FM and %BF measurements were found between black and white preterm infants after adjusting for birth weight, gestational age, and the presence/absence of breastfeeding (n = 143). Black infants born preterm had lower birthweights and higher weight gain from birth to discharge in unadjusted and adjusted models (13 ± 3 vs. 11 ± 3 g/kg/day; <0.001). CONCLUSION Black infants had higher weight gain from birth to discharge, but comparable body composition measurements at discharge. More research is needed to understand contributing factors and long-term implications of this finding.
Collapse
Affiliation(s)
- Maggie Jerome
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olivia Affuso
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peng Li
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
16
|
Gentle SJ, Meads C, Ganus S, Barnette E, Munkus K, Carlo WA, Salas AA. Improving Time to Independent Oral Feeding to Expedite Hospital Discharge in Preterm Infants. Pediatrics 2022; 149:184890. [PMID: 35229126 DOI: 10.1542/peds.2021-052023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Achievement of independent oral feedings remains the most common barrier to discharge in preterm infants. Early oral feeding initiation may be associated with a lower postmenstrual age (PMA) at independent oral feeding and discharge. In preterm infants born between 25 and 32 weeks' gestation, our aim was to decrease the PMA at independent oral feedings and discharge by 1 week between June 2019 and June 2020. METHODS Following formation of a multidisciplinary team, the following plan-do-study-act cycles were targeted: (1) oral feeding initiation at <33 weeks' PMA, (2) cue-based feeding, and (3) practitioner-driven feeding in infants who had not yet achieved independent oral feedings by 36 weeks' PMA. Outcome measures included the PMA at independent oral feeding and discharge. Process measures included adherence to cue-based feeding assessments and PMA at oral feeding initiation. RESULTS In total, 552 infants with a median gestational age of 30.3 weeks' (interquartile range 28.1-32.0) and birth weight of 1320 g (interquartile range 1019-1620) were included. The PMA at discharge decreased from 38.8 to 37.7 weeks during the first plan-do-study-act cycle, which coincided with an increase in the number of infants initiated on oral feeds at <33 weeks' PMA from 47% to 80%. The age at independent oral feeding decreased from 37.4 to 36.5 weeks' PMA. CONCLUSIONS In preterm infants born between 25 and 32 weeks' gestation, earlier oral feeding initiation was associated with a decreased PMA at independent oral feeding and discharge.
Collapse
Affiliation(s)
| | - Claire Meads
- Rehabilitation Services, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Shae Ganus
- Rehabilitation Services, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Barnette
- Rehabilitation Services, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | |
Collapse
|
17
|
Salas AA, Carlo WA, Do BT, Bell EF, Das A, Van Meurs KP, Poindexter BB, Shankaran S, Younge N, Watterberg KL, Higgins RD. Growth Rates of Infants Randomized to Continuous Positive Airway Pressure or Intubation After Extremely Preterm Birth. J Pediatr 2021; 237:148-153.e3. [PMID: 34157349 PMCID: PMC8478787 DOI: 10.1016/j.jpeds.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/03/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effects of early treatment with continuous positive airway pressure (CPAP) on nutritional intake and in-hospital growth rates of extremely preterm (EPT) infants. STUDY DESIGN EPT infants (240/7-276/7 weeks of gestation) enrolled in the Surfactant Positive Airway Pressure and Pulse Oximetry Trial (SUPPORT) were included. EPT infants who died before 36 weeks of postmenstrual age (PMA) were excluded. The growth rates from birth to 36 weeks of PMA and follow-up outcomes at 18-22 months corrected age of EPT infants randomized at birth to either early CPAP (intervention group) or early intubation for surfactant administration (control group) were analyzed. RESULTS Growth data were analyzed for 810 of 1316 infants enrolled in SUPPORT (414 in the intervention group, 396 in the control group). The median gestational age was 26 weeks, and the mean birth weight was 839 g. Baseline characteristics, total nutritional intake, and in-hospital comorbidities were not significantly different between the 2 groups. In a regression model, growth rates between birth and 36 weeks of PMA, as well as growth rates during multiple intervals from birth to day 7, days 7-14, days 14-21, days 21-28, day 28 to 32 weeks PMA, and 32-36 weeks PMA did not differ between treatment groups. Independent of treatment group, higher growth rates from day 21 to day 28 were associated with a lower risk of having a Bayley-III cognitive score <85 at 18-22 months corrected age (P = .002). CONCLUSIONS EPT infants randomized to early CPAP did not have higher in-hospital growth rates than infants randomized to early intubation.
Collapse
Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Barbara T. Do
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Krisa P. Van Meurs
- Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Brenda B. Poindexter
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA
| | | | - Noelle Younge
- Department of Pediatrics, Duke University, Durham, NC
| | | | - Rosemary D. Higgins
- National Institute of Child Health and Human Development, Bethesda, MD and Department of Global and Community Health, George Mason University, Fairfax, VA
| | | |
Collapse
|
18
|
Salas AA, Bhatia A, Carlo WA. Postnatal growth of preterm infants 24 to 26 weeks of gestation and cognitive outcomes at 2 years of age. Pediatr Res 2021; 89:1804-1809. [PMID: 32942289 PMCID: PMC7965787 DOI: 10.1038/s41390-020-01158-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/25/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Weight z scores at 36 weeks of postmenstrual age (PMA) define postnatal growth failure (PGF) and malnutrition. This study aimed to determine weight z scores at 36 weeks PMA that are associated with adverse cognitive outcomes at 2 years of age. METHODS In this retrospective cohort study, 350 infants 24-26 weeks of gestation born between 2006 and 2014 and followed at 2 years were included. Weight z scores at birth and at 36 weeks PMA were calculated using the INTERGROWTH-21st growth curves. The primary outcome was cognitive delay at 2 years of age (Bayley-III cognitive score < 85). RESULTS Neither the traditional definition of PGF (z score below -1.3) nor the recently proposed definition of malnutrition (z score decline of 1.2 or greater) was associated with cognitive delay. Both a weight z score below -1.0 at 36 weeks PMA (RR: 1.65; 95% CI: 1.10-2.49; p < 0.05) and a decline below -1.0 in weight z score from birth to 36 weeks PMA (RR: 1.40; 95% CI: 1.00-1.94; p < 0.05) were associated with a higher risk of cognitive delay. CONCLUSION With optimal cutoffs, INTERGROWTH-21st weight z scores can predict the risk of cognitive delay. IMPACT New growth curves generated with longitudinal data could overcome some limitations of traditional growth curves generated with cross-sectional data. When these new growth curves are used to assess the growth of preterm infants, alternative definitions for postnatal growth alterations may be needed. This study examines the association between postnatal growth alterations defined by the INTEGROWTH-21st growth curves and adverse cognitive outcomes at 2 years of age. With alternative definitions of postnatal growth failure and malnutrition, the INTERGROWTH-21st growth curves can help establish the association between postnatal growth of extremely preterm infants and adverse neurodevelopmental outcomes in early childhood.
Collapse
Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Anisha Bhatia
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
19
|
Salas AA, Travers CP, Jerome ML, Chandler-Laney P, Carlo WA. Percent Body Fat Content Measured by Plethysmography in Infants Randomized to High- or Usual-Volume Feeding after Very Preterm Birth. J Pediatr 2021; 230:251-254.e3. [PMID: 33248115 PMCID: PMC7914146 DOI: 10.1016/j.jpeds.2020.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
We measured percent body fat by air-displacement plethysmography in 86 infants born at <32 weeks of gestation randomized to receive either high-volume (180-200 mL/kg/day) or usual volume feeding (140-160 mL/kg/day). High-volume feeding increased percent body fat by ≤2% at 36 weeks of postmenstrual age (within a predefined range of equivalence). TRIAL REGISTRATION: ClincialTrials.gov: NCT02377050.
Collapse
Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, School of Medicine, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Colm P. Travers
- Department of Pediatrics, School of Medicine, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Maggie L. Jerome
- Department of Nutrition Sciences, School of Health
Professions, University of Alabama at Birmingham. Birmingham, AL, USA
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, School of Health
Professions, University of Alabama at Birmingham. Birmingham, AL, USA
| | - Waldemar A. Carlo
- Department of Pediatrics, School of Medicine, University of
Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
20
|
Salas AA, Jerome ML, Chandler-Laney P, Ambalavanan N, Carlo WA. Serial assessment of fat and fat-free mass accretion in very preterm infants: a randomized trial. Pediatr Res 2020; 88:733-738. [PMID: 32634820 PMCID: PMC7581604 DOI: 10.1038/s41390-020-1052-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Clinicians could modify dietary interventions during early infancy by monitoring fat and fat-free mass accretion in very preterm infants. METHODS Preterm infants were randomly assigned to either having reports on infant body composition available to the clinicians caring for them (intervention group) or not having reports available (control group). All infants underwent serial assessments of body composition by air-displacement plethysmography before 32 weeks of postmenstrual age (PMA) and at 36 weeks PMA. The primary outcome was percent body fat (%BF) at 3 months of corrected age (CA). RESULTS Fifty infants were randomized (median gestational age: 30 weeks; mean ± SD birth weight: 1387 ± 283 g). The mean %BF increased from 7 ± 4 before 32 weeks PMA to 20 ± 5 at 3 months CA. The differences in mean %BF between the intervention group and the control group were not statistically significant at 36 weeks PMA (14.5 vs. 13.6) or 3 months CA (20.8 vs. 19.4). Feeding practices and anthropometric measurements during hospitalization did not differ between groups. CONCLUSIONS Serial assessments of body composition in both intervention and control groups showed consistent increments in %BF. However, providing this information to clinicians did not influence nutritional practices or growth. IMPACT Serial assessments of body composition in preterm infants at 32 and 36 weeks postmenstrual age show consistent increments in % body fat up to 3 months of corrected age. However, providing this information to the clinician did not influence nutritional practices or growth.
Collapse
Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35249
| | - Maggie L. Jerome
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35249
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35249
| | | | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35249
| |
Collapse
|
21
|
Salas AA. Early career investigator highlight biocommentary. Pediatr Res 2020; 88:688. [PMID: 32916681 DOI: 10.1038/s41390-020-01129-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
22
|
Travers CP, Wang T, Salas AA, Schofield E, Dills M, Laney D, Yee A, Bhatia A, Winter L, Ambalavanan N, Carlo WA. Higher- or Usual-Volume Feedings in Infants Born Very Preterm: A Randomized Clinical Trial. J Pediatr 2020; 224:66-71.e1. [PMID: 32464224 DOI: 10.1016/j.jpeds.2020.05.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/05/2020] [Accepted: 05/15/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether higher-volume feedings improve postnatal growth among infants born very preterm. STUDY DESIGN Randomized clinical trial with 1:1 parallel allocation conducted from January 2015 to June 2018 in a single academic medical center in the US. In total, 224 infants with a birth weight 1001-2500 g born at <32 weeks of gestation were randomized to higher-volume (180-200 mL/kg/d) or usual-volume (140-160 mL/kg/d) feedings after establishing full enteral feedings (≥120 mL/kg/d). The primary outcome was growth velocity (g/kg/d) from randomization to study completion at 36 weeks of postmenstrual age or hospital discharge if earlier. RESULTS Growth velocity increased among infants in the higher-volume group compared with the usual-volume group (mean [SD], 20.5 [4.5] vs 17.9 [4.5] g/kg/d; P < .001). At study completion, all measurements were higher among infants in the higher-volume group compared with the usual-volume group: weight (2365 [324] g, z score -0.60 [0.73] vs 2200 [308] g, z score -0.94 [0.71]; P < .001); head circumference (31.9 [1.3] cm, z score -0.30 [0.91] vs 31.4 [1.3] cm, z score -0.53 [0.84]; P = .01); length (44.9 [2.1] cm, z score -0.68 [0.88] vs 44.4 [2.0], z score -0.83 [0.84]; P = .04); and mid-arm circumference (8.8 [0.8] cm vs 8.4 [0.8] cm; P = .002). Bronchopulmonary dysplasia, patent ductus arteriosus, necrotizing enterocolitis, or other adverse outcomes did not differ between groups. CONCLUSIONS In infants born very preterm weighing 1001-2500 g at birth, higher-volume feedings increased growth velocity, weight, head circumference, length, and mid-arm circumference compared with usual-volume feedings without adverse effects. TRIAL REGISTRATION ClinicalTrials.gov; NCT02377050.
Collapse
Affiliation(s)
- Colm P Travers
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL.
| | - Timothy Wang
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL; Department of Pediatrics, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Ariel A Salas
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Erin Schofield
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL; Department of Pediatrics, Division of Neonatology, University of Maryland, Baltimore, MD
| | - Madeline Dills
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL; Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Deborah Laney
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Aaron Yee
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL; Department of Pediatrics, Division of Neonatology, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Anisha Bhatia
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Lindy Winter
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A Carlo
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
23
|
Salas AA, Meads C, Ganus S, Bhatia A, Taylor C, Chandler-Laney P, Imtiaz MH, Sazonov E. Quantitative assessment of nutritive sucking patterns in preterm infants. Early Hum Dev 2020; 146:105044. [PMID: 32361560 PMCID: PMC8506900 DOI: 10.1016/j.earlhumdev.2020.105044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess patterns of nutritive sucking in very preterm infants ≤32 weeks of gestation. STUDY DESIGN Very preterm infants who attained independent oral feeding were prospectively assessed with an instrumented feeding bottle that measures nutritive sucking. The primary outcome measure was nutritive sucking performance at independent oral feeding. RESULT We assessed nutritive sucking patterns in 33 very preterm infants. We recorded 63 feeding sessions. The median number of sucks was 784 (IQR: 550-1053), the median sucking rate was 36/min (IQR: 27-55), and the median number of sucking bursts during the first 5 min of oral feeding was 14 (IQR: 12-16). Maximum sucking strength correlated with the number of sucks (r = 0.62; p < 0.01). No safety concerns were identified during the study. CONCLUSION The quantitative analysis of nutritive sucking patterns with a newly developed instrumented bottle in stable, very preterm infants is safe and feasible. More research is needed to develop and refine the instrument further.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35249, USA.
| | - Claire Meads
- Department of Physical Medicine & Rehabilitation, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Shae Ganus
- Department of Physical Medicine & Rehabilitation, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Anisha Bhatia
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Caitlin Taylor
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Masudul H Imtiaz
- Department of Electrical and Computer Engineering, University of Alabama, Tuscaloosa, AL 35487, USA
| | - Edward Sazonov
- Department of Electrical and Computer Engineering, University of Alabama, Tuscaloosa, AL 35487, USA
| |
Collapse
|
24
|
Gentle S, El-Ferzli G, Winter L, Salas AA, Philips Iii JB. Oxygen saturation histogram monitoring to reduce death or retinopathy of prematurity: a quality improvement initiative. J Perinatol 2020; 40:163-169. [PMID: 31506527 DOI: 10.1038/s41372-019-0486-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/15/2019] [Accepted: 07/20/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Maintaining preterm infants within a goal oxygen saturation range challenges care providers. Through periodic assessment of saturation trends on infants' bedside histogram reports, our initiative aimed to (1) increase time spent at goal saturations and (2) reduce death or severe retinopathy of prematurity. STUDY DESIGN The initiative integrated histogram monitoring into provider, respiratory, and nursing care. Achieved oxygen saturations, chart audits, and bedside histogram monitoring flowsheets provided process measures with the outcome measure of death or severe retinopathy of prematurity. RESULTS In infants <29 weeks' gestation (n = 518), the rate of death or severe retinopathy of prematurity prior to hospital discharge decreased from 32.1% to 18.0%. Time at goal saturations (90-95%) increased from 48.7% to 57.6%. CONCLUSION In infants born at <29 weeks' gestation, periodic, multidisciplinary oxygen saturation histogram monitoring improved time at goal saturations and was associated with a reduction in death or severe retinopathy of prematurity.
Collapse
Affiliation(s)
- Samuel Gentle
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - Lindy Winter
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ariel A Salas
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | |
Collapse
|
25
|
Garg P, Pinotti R, Lal CV, Salas AA. Transfusion-associated necrotizing enterocolitis in preterm infants: an updated meta-analysis of observational data. J Perinat Med 2018; 46:677-685. [PMID: 29176013 DOI: 10.1515/jpm-2017-0162] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/16/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The number of observational studies that report an association between packed red blood cell (PRBC) transfusions and necrotizing enterocolitis (NEC) has increased. The primary objective of this study was to evaluate the association between PRBC transfusions and NEC in observational studies. METHODS Medline, Embase and Cochrane Library databases as well as the Pediatrics Academic Societies abstract archives were systematically searched to identify observational studies that investigated the association between PRBC transfusions and NEC. Key search terms included premature infant, blood transfusion and necrotizing enterocolitis. The generic inverse variance method with a random-effects model was used to meta-analyze selected studies. Odds ratios (ORs) and confidence intervals (CIs) were calculated. RESULTS A meta-analysis of 17 observational studies that reported the association between PRBC transfusions and NEC was performed. The meta-analysis revealed no evidence of an association between PRBC transfusions and a higher risk of NEC (OR: 0.96; 95% CI: 0.53-1.71; P=0.88). The effect estimates that suggested an association between PRBC transfusion and NEC in matched case-control studies (OR: 1.20; 95% CI: 0.58-2.47; P=0.63) differed from those reported in cohort studies (OR: 0.51; 95% CI: 0.34-0.75; P=<0.01). CONCLUSIONS This updated meta-analysis of predominantly low-to-moderate quality observational studies suggests that there is no significant association between PRBC transfusions and NEC. A higher quality of evidence on this topic is needed.
Collapse
Affiliation(s)
- Parvesh Garg
- University of Mississippi School of Medicine, Department of Pediatrics, Jackson, MS, USA
| | - Rachel Pinotti
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, Brooklyn, NY, USA
| | - C Vivek Lal
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL, USA
| | - Ariel A Salas
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL, USA
| |
Collapse
|
26
|
Bhatia A, Salas AA. Does tight glycaemic control with insulin therapy in the early neonatal period improve long-term outcomes? Acta Paediatr 2018; 107:2032-2033. [PMID: 30230020 DOI: 10.1111/apa.14518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Anisha Bhatia
- Division of Neonatology, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ariel A Salas
- Division of Neonatology, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
27
|
Salas AA, Li P, Parks K, Lal CV, Martin CR, Carlo WA. Early progressive feeding in extremely preterm infants: a randomized trial. Am J Clin Nutr 2018; 107:365-370. [PMID: 29529231 PMCID: PMC6692650 DOI: 10.1093/ajcn/nqy012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/11/2018] [Indexed: 11/13/2022] Open
Abstract
Background Due to insufficient evidence, extremely preterm infants (≤28 wk of gestation) rarely receive early progressive feeding (small increments of feeding volumes between 1 and 4 d after birth). We hypothesized that early progressive feeding increases the number of full enteral feeding days in the first month after birth. Objective The aim of this study was to determine the feasibility and efficacy of early progressive feeding in extremely preterm infants. Design In this single-center randomized trial, extremely preterm infants born between September 2016 and June 2017 were randomly assigned to receive either early progressive feeding without trophic feeding (early feeding group) or delayed progressive feeding after a 4-d course of trophic feeding (delayed feeding group). Treatment allocation occurred before or on feeding day 1. The primary outcome was the number of full enteral feeding days in the first month after birth. Secondary outcomes were death, necrotizing enterocolitis (NEC), culture-proven sepsis, growth percentiles at 36 wk postmenstrual age, use of parenteral nutrition, and need for central venous access. Results Sixty infants were included (median gestational age: 26 wk; mean ± SD birth weight: 832 ± 253 g). The primary outcome differed between groups (median difference favoring the early feeding group: +2 d; 95% CI: 0, 3 d; P = 0.02). Early progressive feeding reduced the use of parenteral nutrition (4 compared with 8 d; P ≤ 0.01) and the need for central venous access (9 compared with 13 d; P ≤ 0.01). The outcome of culture-proven sepsis (10% compared with 27%; P = 0.18), restricted growth (weight, length, and head circumference <10th percentile) at 36 wk postmenstrual age (25% compared with 50%; P = 0.07), and the composite outcome of NEC or death (27% compared with 20%; P = 0.74) did not differ between groups. Conclusion Early progressive feeding increases the number of full enteral feeding days in extremely preterm infants. This trial was registered at www.clinicaltrials.gov as NCT02915549.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Peng Li
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Kelli Parks
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Charitharth V Lal
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Camilia R Martin
- Department of Neonatology and Division of Translational Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Waldemar A Carlo
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
28
|
Salas AA, Woodfin T, Phillips V, Peralta-Carcelen M, Carlo WA, Ambalavanan N. Dose-Response Effects of Early Vitamin D Supplementation on Neurodevelopmental and Respiratory Outcomes of Extremely Preterm Infants at 2 Years of Age: A Randomized Trial. Neonatology 2018; 113:256-262. [PMID: 29393233 PMCID: PMC5860938 DOI: 10.1159/000484399] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many extremely preterm infants have low vitamin D concentrations at birth, but early childhood outcomes after vitamin D supplementation have not been reported. OBJECTIVE To determine a dose-response relationship between increasing doses of enteral vitamin D in the first 28 days after birth and cognitive scores at 2 years of age. METHODS In this phase II double-blind dose-response randomized trial, infants with gestational ages between 23 and 27 weeks were randomly assigned to receive placebo or a vitamin D dose of 200 or 800 IU/day from day 1 of enteral feeding to postnatal day 28. The primary outcome of this follow-up study was Bayley III cognitive score at 22-26 months of age. RESULTS Seventy of 80 survivors had a follow-up evaluation at 2 years of age (88%). There were no significant differences in cognitive scores between supplementation groups (p = 0.47). Cognitive scores did not differ between the higher vitamin D dose group and the placebo group (median difference favoring the 800 IU group: +5 points; 95% CI: -5 to 15; p = 0.23). The linear trend between increasing doses of vitamin D and reduction of neurodevelopmental impairment (placebo group: 54%; 200 IU group: 43%; 800 IU group: 30%; p = 0.08) or language impairment (placebo group: 64%; 200 IU group: 57%; 800 IU group: 45%; p = 0.15) was not statistically significant. Respiratory outcomes at 2 years of age (need for supplemental oxygen or asthma medications) did not differ between groups. CONCLUSION In extremely preterm infants, early vitamin D supplementation did not significantly improve cognitive scores. Though underpowered for clinically meaningful differences in early childhood outcomes, this trial may help determine dosing for further investigation of vitamin D supplementation.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | |
Collapse
|
29
|
Salas AA. Reply to the Commentary "Vitamin D Intake in Preterm Infants: Too Little, Too Much, or Just the Right Amount?". Neonatology 2018; 113:265. [PMID: 29393269 DOI: 10.1159/000486126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
30
|
Salas AA, Kabani N, Travers CP, Phillips V, Ambalavanan N, Carlo WA. Short versus Extended Duration of Trophic Feeding to Reduce Time to Achieve Full Enteral Feeding in Extremely Preterm Infants: An Observational Study. Neonatology 2017; 112:211-216. [PMID: 28704816 DOI: 10.1159/000472247] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/27/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Trophic feeding compared to no enteral feeding prevents atrophy of the gastrointestinal tract. However, the practice of extending the duration of trophic feeding often delays initiation of full enteral feeding in extremely preterm infants. We hypothesized that a short duration of trophic feeding (3 days or less) is associated with early initiation of full enteral feeding. METHODS A total of 192 extremely preterm infants (23-28 weeks' gestation) born between 2013 and 2015 were included. Infants were divided into 2 groups according to the duration of trophic feeding (short vs. extended). The primary outcome was time to achieve full enteral feeding and the safety outcome was necrotizing enterocolitis (NEC) and/or death. RESULTS A short duration of trophic feeding was associated with a reduction in time to achieve full enteral feeding after adjustment for birth weight, gestational age, race, sex, type of enteral nutrition, and day of initiation of trophic feeding (mean difference favoring a short duration of trophic feeding: -4.1 days; 95% CI: -2.3 to -5.8; p < 0.001). A short duration of trophic feeding was not associated with a higher risk of NEC and/or death after achieving full enteral feeding (AOR: 0.91; 95% CI: 0.30-2.77; p = 0.87). CONCLUSIONS A short duration of trophic feeding is associated with early initiation of full enteral feeding. A short duration of trophic feeding is not associated with a higher risk of NEC, but our study was underpowered for this safety outcome. Randomized trials are needed to test this study hypothesis.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | |
Collapse
|
31
|
Salas AA, Carlo WA, Ambalavanan N, Nolen TL, Stoll BJ, Das A, Higgins RD. Gestational age and birthweight for risk assessment of neurodevelopmental impairment or death in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F494-F501. [PMID: 26895876 PMCID: PMC4991950 DOI: 10.1136/archdischild-2015-309670] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/07/2016] [Accepted: 01/24/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND The risk of poor outcomes in preterm infants is primarily determined by birthweight (BW) and gestational age (GA). It is not known whether BW is a better outcome predictor than GA. OBJECTIVE To test whether BW is better than GA (measured in days, rather than completed weeks) for prediction of neurodevelopmental impairment (NDI) and death. DESIGN/METHODS Extremely preterm infants born at the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network centres between 1998 and 2009 were studied. For the unadjusted analysis, the associations of GA (in days based on best obstetrical estimate) and BW (in grams) with NDI or death were compared using area under the curve (AUC). Adjusted analyses were performed using birth year, sex, race, antenatal steroids, singleton birth, pre-eclampsia, Apgar score at 5 min and small for GA as covariates. RESULTS 10 652 preterm infants (89%) had outcome data at 18-22 months' corrected age. The mean BW was 678 g (SD: 155) and the mean GA was 173 days (SD: 10) or 245/7 weeks (SD: 13/7). The AUC for NDI or death was 80% with BW and 79% with GA (p=0.82). Unadjusted and adjusted analyses did not differ. NDI or death rates decreased with increasing GA through 26 weeks (estimated risk reduction with each additional day of gestation: 2.2%). CONCLUSION Both BW in grams and GA in days are good predictors of NDI and death in a preterm population selected on the basis of reliable GA. TRIAL REGISTRATION NUMBER NCT00009633.
Collapse
Affiliation(s)
- Ariel A. Salas
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Waldemar A Carlo
- University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Tracy L Nolen
- RTI International, Research Triangle Park, NC, United States
| | | | - Abhik Das
- RTI International, Research Triangle Park, NC, United States
| | - Rosemary D. Higgins
- GDB and FU Subcommittee, NICHD Neonatal Research Network, Bethesda, MD, United States
| | | |
Collapse
|
32
|
Fort P, Salas AA, Nicola T, Craig CM, Carlo WA, Ambalavanan N. A Comparison of 3 Vitamin D Dosing Regimens in Extremely Preterm Infants: A Randomized Controlled Trial. J Pediatr 2016; 174:132-138.e1. [PMID: 27079965 PMCID: PMC4925243 DOI: 10.1016/j.jpeds.2016.03.028] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 01/12/2016] [Accepted: 03/09/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the optimal dose of vitamin D supplementation to achieve biochemical vitamin D sufficiency in extremely low gestational age newborns in a masked randomized controlled trial. STUDY DESIGN 100 infants 23 0/7-27 6/7 weeks gestation were randomized to vitamin D intakes of placebo (n = 36), 200 IU (n = 34), and 800 IU/d (n = 30) (approximating 200, 400, or 1000 IU/d, respectively, when vitamin D routinely included in parenteral or enteral nutrition is included). The primary outcomes were serum 25-hydroxy vitamin D concentrations on postnatal day 28 and the number of days alive and off respiratory support in the first 28 days. RESULTS At birth, 67% of infants had 25-hydroxy vitamin D <20 ng/mL suggesting biochemical vitamin D deficiency. Vitamin D concentrations on day 28 were (median [25th-75th percentiles], ng/mL): placebo: 22 (13-47), 200 IU: 39 (26-57), 800 IU: 84.5 (52-99); P < .001. There were no differences in days alive and off respiratory support (median [25th-75th percentiles], days): placebo: 1 (0-11), 200 IU: 0 (0-8), and 800 IU: 0.5 (0-22); P = .63, or other respiratory outcomes among groups. CONCLUSIONS At birth, most extremely preterm infants have biochemical vitamin D deficiency. This biochemical deficiency is reduced on day 28 by supplementation with 200 IU/d and prevented by 800 IU/d. Larger trials are required to determine if resolution of biochemical vitamin D deficiency improves clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov: NCT01600430.
Collapse
Affiliation(s)
- Prem Fort
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Teodora Nicola
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Carolyne M. Craig
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | |
Collapse
|
33
|
Salas AA, Smith KA, Rodgers MD, Phillips V, Ambalavanan N. Seasonal Variation in Solar Ultra Violet Radiation and Early Mortality in Extremely Preterm Infants. Am J Perinatol 2015; 32:1273-6. [PMID: 26039891 DOI: 10.1055/s-0035-1554797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vitamin D production during pregnancy promotes fetal lung development, a major determinant of infant survival after preterm birth. Because vitamin D synthesis in humans is regulated by solar ultraviolet B (UVB) radiation, we hypothesized that seasonal variation in solar UVB doses during fetal development would be associated with variation in neonatal mortality rates. METHODS This cohort study included infants born alive with gestational age (GA) between 23 and 28 weeks gestation admitted to a neonatal unit between 1996 and 2010. Three infant cohort groups were defined according to increasing intensities of solar UVB doses at 17 and 22 weeks gestation. The primary outcome was death during the first 28 days after birth. RESULTS Outcome data of 2,319 infants were analyzed. Mean birth weight was 830 ± 230 g and median gestational age was 26 weeks. Mortality rates were significantly different across groups (p = 0.04). High-intensity solar UVB doses were associated with lower mortality when compared with normal intensity solar UVB doses (hazard ratio: 0.70; 95% confidence interval: 0.54-0.91; p = 0.01). CONCLUSION High-intensity solar UVB doses during fetal development seem to be associated with risk reduction of early mortality in preterm infants. Prospective studies are needed to validate these preliminary findings.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly A Smith
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mackenzie D Rodgers
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Vivien Phillips
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | |
Collapse
|
34
|
Salas AA, Cuna A, Bhat R, McGwin G, Carlo WA, Ambalavanan N. A randomised trial of re-feeding gastric residuals in preterm infants. Arch Dis Child Fetal Neonatal Ed 2015; 100:F224-8. [PMID: 25552280 DOI: 10.1136/archdischild-2014-307067] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 12/07/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine whether re-feeding of gastric residual volumes reduces the time needed to achieve full enteral feeding in preterm infants. DESIGN Parallel-group randomised controlled trial with a 1:1 allocation ratio. SETTING Regional referral neonatal intensive care unit. PATIENTS 72 infants of gestational age 23(0/7) to 28(6/7) weeks receiving minimal enteral nutrition (<24 mL/kg/day) during the first week after birth. INTERVENTIONS Infants were randomised to either be re-fed with gastric residual volumes (Re-feeding group) or receive fresh formula/human milk (Fresh-feeding group) whenever large gastric residual volumes were noted. MAIN OUTCOME MEASURE The primary efficacy end point was time to achieve full enteral feeding (≥120 mL/kg/day) after randomisation. RESULTS The mean time to full enteral feeding was 10.0 days in the Re-feeding group and 11.3 days in the Fresh-feeding group (mean difference favouring re-feeding: -1.3 days; 95% CI -2.9 to 0.3; p=0.11). The composite safety end point of spontaneous intestinal perforation, surgical necrotising enterocolitis, or death occurred in 6 of 36 infants (17%) in the Re-feeding group versus 10 of 36 infants (28%) in the Fresh-feeding group (p=0.26). CONCLUSIONS Re-feeding gastric residual volumes in extremely preterm infants does not reduce time to achieve full enteral feeding. This trial suggests that re-feeding might be as safe as fresh feeding, but further research is needed, due to lack of sufficient statistical power in this study for safety analysis. TRIAL REGISTRATION NUMBER NCT01420263NCT01420263.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alain Cuna
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Ramachandra Bhat
- Department of Pediatrics, University of Maryland, Baltimore, Maryland, USA
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | |
Collapse
|
35
|
Kelleher J, Salas AA, Bhat R, Ambalavanan N, Saha S, Stoll BJ, Bell EF, Walsh MC, Laptook AR, Sánchez PJ, Shankaran S, VanMeurs KP, Hale EC, Newman NS, Ball MB, Das A, Higgins RD, Peralta-Carcelen M, Carlo WA. Prophylactic indomethacin and intestinal perforation in extremely low birth weight infants. Pediatrics 2014; 134:e1369-77. [PMID: 25349317 PMCID: PMC4533280 DOI: 10.1542/peds.2014-0183] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Prophylactic indomethacin reduces severe intraventricular hemorrhage but may increase spontaneous intestinal perforation (SIP) in extremely low birth weight (ELBW) infants. Early feedings improve nutritional outcomes but may increase the risk of SIP. Despite their benefits, use of these therapies varies largely by physician preferences in part because of the concern for SIP. METHODS This was a cohort study of 15,751 ELBW infants in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network from 1999 to 2010 who survived beyond 12 hours after birth. The risk of SIP was compared between groups of infants with and without exposure to prophylactic indomethacin and early feeding in unadjusted analyses and in analyses adjusted for center and for risks of SIP. RESULTS Among infants exposed to prophylactic indomethacin, the risk of SIP did not differ between the indomethacin/early-feeding group compared with the indomethacin/no-early-feeding group (adjusted relative risk [RR] 0.74, 95% confidence interval [CI] 0.49-1.11). The risk of SIP was lower in the indomethacin/early-feeding group compared with the no indomethacin/no-early-feeding group (adjusted RR 0.58, 95% CI 0.37-0.90, P = .0159). Among infants not exposed to indomethacin, early feeding was associated with a lower risk of SIP compared with the no early feeding group (adjusted RR 0.53, 95% CI 0.36-0.777, P = .0011). CONCLUSIONS The combined or individual use of prophylactic indomethacin and early feeding was not associated with an increased risk of SIP in ELBW infants.
Collapse
Affiliation(s)
- John Kelleher
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ramachandra Bhat
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Shampa Saha
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Abbot R. Laptook
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Pablo J. Sánchez
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island
| | - Seetha Shankaran
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Ellen C. Hale
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nancy S. Newman
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - M. Bethany Ball
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abhik Das
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California; and
| | - Rosemary D. Higgins
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | | | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | |
Collapse
|
36
|
Salas AA, Bhat R, Dabrowska K, Leadford A, Anderson S, Harmon CM, Ambalavanan N, El-Ferzli GT. The value of Pa(CO2) in relation to outcome in congenital diaphragmatic hernia. Am J Perinatol 2014; 31:939-46. [PMID: 24515620 DOI: 10.1055/s-0034-1368088] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Postnatal assessment of disease severity is critical for analysis of mortality rates and development of future interventions in congenital diaphragmatic hernia (CDH). OBJECTIVE The objective of this study was to stratify the risk of mortality based on arterial Paco 2. METHODS Retrospective analysis of infants (n = 133) with CDH admitted to a regional extracorporeal membrane oxygenation (ECMO) center in two different periods: period I (1987-1996; n = 46) and period II (2002-2010; n = 87). RESULTS The mortality rate (37%) was similar in both periods (p = 0.98). Paco 2 < 60 mm Hg in the first arterial blood gas (ABG) was an independent predictor of survival in both periods (p = 0.03). The predicted survival rate was 84% if initial Paco 2 was < 55 mm Hg. For infants with initial Paco 2 > 55 mm Hg treated with ECMO (n = 83), the predicted survival rate was 11% if the Paco 2 was > 88 mm Hg before the initiation of ECMO. CONCLUSION Paco 2, a surrogate of lung hypoplasia, may be useful for risk stratification in CDH. Paco 2 < 60 mm Hg in the first ABG may indicate milder pulmonary hypoplasia. A Paco 2 > 80 mm Hg in the first ABG and/or before ECMO may indicate severe pulmonary hypoplasia.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ramachandra Bhat
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Katarzyna Dabrowska
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alicia Leadford
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Scott Anderson
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carroll M Harmon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - George T El-Ferzli
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
37
|
Salas AA, Faye-Petersen OM, Sims B, Peralta-Carcelen M, Reilly SD, McGwin G, Carlo WA, Ambalavanan N. Histological characteristics of the fetal inflammatory response associated with neurodevelopmental impairment and death in extremely preterm infants. J Pediatr 2013; 163:652-7.e1-2. [PMID: 23664630 PMCID: PMC3744601 DOI: 10.1016/j.jpeds.2013.03.081] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 02/18/2013] [Accepted: 03/29/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To test the hypothesis that increasing severity of the fetal inflammatory response (FIR) would have a dose-dependent relationship with severe neurodevelopmental impairment or death in extremely preterm infants. STUDY DESIGN We report 347 infants of 23-28 weeks gestational age admitted to a tertiary neonatal intensive care unit between 2006 and 2008. The primary outcome was death or neurodevelopmental impairment at the 18- to 22-month follow-up. Exposure status was defined by increasing stage of funisitis (stage 1, phlebitis; stage 2, arteritis with or without phlebitis; stage 3, subacute necrotizing funisitis) and severity of chorionic plate vasculitis (inflammation with or without thrombosis). RESULTS A FIR was detected in 110 placentas (32%). The rate of severe neurodevelopmental impairment/death was higher in infants with subacute necrotizing funisitis compared with infants without placental/umbilical cord inflammation (60% vs 35%; P < .05). Among infants with stage 1 or 2 funisitis, the presence of any chorionic vasculitis was associated with a higher rate of severe neurodevelopmental impairment/death (47% vs 23%; P < .05). After adjustment for confounding factors, only subacute necrotizing funisitis (risk ratio, 1.87; 95% CI, 1.04-3.35; P = .04) and chorionic plate vasculitis with thrombosis (risk ratio, 2.21; 95% CI, 1.10-4.46; P = .03) were associated with severe neurodevelopmental impairment/death. CONCLUSION Severe FIR, characterized by subacute necrotizing funisitis and severe chorionic plate vasculitis with thrombosis, is associated with severe neurodevelopmental impairment/death in preterm infants.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ona M. Faye-Petersen
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brian Sims
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Myriam Peralta-Carcelen
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Stephanie D Reilly
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Namasivayam Ambalavanan
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, United States
| |
Collapse
|
38
|
Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T, Owen J, Ambalavanan N, Carlo WA. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. Lancet 2013; 382:326-30. [PMID: 23739521 DOI: 10.1016/s0140-6736(13)60775-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Wiping of the mouth and nose at birth is an alternative method to oronasopharyngeal suction in delivery-room management of neonates, but whether these methods have equivalent effectiveness is unclear. METHODS For this randomised equivalency trial, neonates delivered at 35 weeks' gestation or later at the University of Alabama at Birmingham Hospital, Birmingham, AL, USA, between October, 2010, and November, 2011, were eligible. Before birth, neonates were randomly assigned gentle wiping of the face, mouth (implemented by the paediatric or obstetric resident), and nose with a towel (wipe group) or suction with a bulb syringe of the mouth and nostrils (suction group). The primary outcome was the respiratory rate in the first 24 h after birth. We hypothesised that respiratory rates would differ by fewer than 4 breaths per min between groups. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01197807. FINDINGS 506 neonates born at a median of 39 weeks' gestation (IQR 38-40) were randomised. Three parents withdrew consent and 15 non-vigorous neonates with meconium-stained amniotic fluid were excluded. Among the 488 treated neonates, the mean respiratory rates in the first 24 h were 51 (SD 8) breaths per min in the wipe group and 50 (6) breaths per min in the suction group (difference of means 1 breath per min, 95% CI -2 to 0, p<0·001). INTERPRETATION Wiping the nose and mouth has equivalent efficacy to routine use of oronasopharyngeal suction in neonates born at or beyond 35 weeks' gestation. FUNDING None.
Collapse
Affiliation(s)
- John Kelleher
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Leadford AE, Warren JB, Manasyan A, Chomba E, Salas AA, Schelonka R, Carlo WA. Plastic bags for prevention of hypothermia in preterm and low birth weight infants. Pediatrics 2013; 132:e128-34. [PMID: 23733796 PMCID: PMC3691528 DOI: 10.1542/peds.2012-2030] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hypothermia contributes to neonatal mortality and morbidity, especially in preterm and low birth weight infants in developing countries. Plastic bags covering the trunk and extremities of very low birth weight infants reduces hypothermia. This technique has not been studied in larger infants or in many resource-limited settings. The objective was to determine if placing preterm and low birth weight infants inside a plastic bag at birth maintains normothermia. METHODS Infants at 26 to 36 weeks' gestational age and/or with a birth weight of 1000 to 2500 g born at the University Teaching Hospital in Lusaka, Zambia, were randomized by using a 1:1 allocation and parallel design to standard thermoregulation (blanket or radiant warmer) care or to standard thermoregulation care plus placement inside a plastic bag at birth. The primary outcome measure was axillary temperature in the World Health Organization-defined normal range (36.5-37.5°C) at 1 hour after birth. RESULTS A total of 104 infants were randomized. At 1 hour after birth, infants randomized to plastic bag (n = 49) were more likely to have a temperature in the normal range as compared with infants in the standard thermoregulation care group (n = 55; 59.2% vs 32.7%; relative risk 1.81; 95% confidence interval 1.16-2.81; P = .007). The temperature at 1 hour after birth in the infants randomized to plastic bag was 36.5 ± 0.5°C compared with 36.1 ± 0.6°C in standard care infants (P < .001). Hyperthermia (>38.0°C) did not occur in any infant. CONCLUSIONS Placement of preterm/low birth weight infants inside a plastic bag at birth compared with standard thermoregulation care reduced hypothermia without resulting in hyperthermia, and is a low-cost, low-technology tool for resource-limited settings.
Collapse
Affiliation(s)
| | | | - Albert Manasyan
- University of Alabama at Birmingham, Birmingham, Alabama
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; and
| | | | - Ariel A. Salas
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Waldemar A. Carlo
- University of Alabama at Birmingham, Birmingham, Alabama
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; and
| |
Collapse
|
40
|
Abstract
OBJECTIVES Pulmonary hypertension is associated with bronchopulmonary dysplasia in extremely low birth weight (ELBW) infants and contributes to morbidity and mortality. The objective was to determine the prevalence of pulmonary hypertension among ELBW infants by screening echocardiography and evaluate subsequent outcomes. METHODS All ELBW infants admitted to a regional perinatal center were evaluated for pulmonary hypertension with echocardiography at 4 weeks of age and subsequently if clinical signs suggestive of right-sided heart failure or severe lung disease were evident. Management was at discretion of the clinician, and infants were evaluated until discharge from the hospital or pre-discharge death occurred. RESULTS One hundred forty-five ELBW infants (birth weight: 755 ± 144 g; median gestational age: 26 weeks [interquartile range: 24-27]) were screened from December 2008 to February 2011. Overall, 26 (17.9%) were diagnosed with pulmonary hypertension at any time during hospitalization (birth weight: 665 ± 140 g; median gestational age: 26 weeks [interquartile range: 24-27]): 9 (6.2%) by initial screening (early pulmonary hypertension) and 17 (11.7%) who were identified later (late pulmonary hypertension). Infants with pulmonary hypertension were more likely to receive oxygen treatment on day 28 compared with those without pulmonary hypertension (96% vs 75%, P < .05). Of the 26 infants, 3 died (all in the late group because of cor pulmonale) before being discharged from the hospital. CONCLUSIONS Pulmonary hypertension is relatively common, affecting at least 1 in 6 ELBW infants, and persists to discharge in most survivors. Routine screening of ELBW infants with echocardiography at 4 weeks of age identifies only one-third of the infants diagnosed with pulmonary hypertension. Further research is required to determine optimal detection and intervention strategies.
Collapse
Affiliation(s)
- Ramachandra Bhat
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; and
| | | | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; and
| | | |
Collapse
|
41
|
Nearing GB, Salas AA, Granado-Villar D, Chandler BD, Soliz A. Psychosocial parental support programs and short-term clinical outcomes in extremely low-birth-weight infants. J Matern Fetal Neonatal Med 2011; 25:89-93. [PMID: 21366394 DOI: 10.3109/14767058.2011.557790] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe the association between an individualized psychosocial parental support (PPS) program and short-term clinical outcomes of extremely low-birth-weight (ELBW) infants admitted to the neonatal intensive care unit (NICU). METHODS Medical records of ELBW infants (<1000 g) hospitalized in the NICU at Miami Children's Hospital between July 2006 and June 2008 were reviewed. Outborn infants admitted during their first 72 h of life and discharged home were included. Parents were divided in two groups according to their participation status in the PPS program. Neonatal outcomes in both groups were compared. RESULTS Forty-one infants were included (n = 41). Mean gestational age was 26.7±2 weeks, and birth weight was 860±125 g. Median length of stay (LOS) was 96 days (quartile range: 76-112 days). PPS was provided to 33.3% of these infants' parents. The median LOS in the PPS group was significantly lower than in control group (86 vs. 99 days; p < 0.05). No other differences in short-term neonatal outcomes were found. CONCLUSIONS The addition of individualized psychosocial parent support programs to standard care in the NICU may reduce LOS in surviving infants discharged home. Further larger and randomized prospective studies are needed.
Collapse
Affiliation(s)
- Graciela B Nearing
- Department of Psychiatry, Miami Children's Hospital, Miami, FL 33155, USA.
| | | | | | | | | |
Collapse
|
42
|
Salas AA, Salazar HJ, Velasco VH. Haemophilusinfluenzae type b conjugate vaccine for preventing pneumonia in infants hospitalized for bronchiolitis: a case-control study. Int J Infect Dis 2009; 14:e68-72. [PMID: 19497772 DOI: 10.1016/j.ijid.2009.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Revised: 03/08/2009] [Accepted: 03/10/2009] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haemophilus influenzae type b (Hib) conjugate vaccine reduces the risk of pneumonia in infants. OBJECTIVE To determine the effect of Hib conjugate vaccine (HibCV) on the prevention of pneumonia as a complication among infants hospitalized for bronchiolitis. METHODS This record-based case-control study was conducted at The Children's Hospital "Dr. Ovidio Aliaga U" in La Paz, Bolivia during 2003 and 2004. Cases were infants hospitalized for bronchiolitis under 1 year of age who developed radiological pneumonia during hospitalization. Controls were patients who had good clinical progress without the use of antibiotics. Pneumonia was defined by alveolar consolidation on chest X-ray that justified the use of antibiotics. RESULTS Eighty patients were studied (16 cases and 64 controls). Their median age was 4.5 months. Demographic and clinical features were similar in both groups, except for a higher proportion of vomiting (56.3% vs. 28.1%; p<0.05) in the case group. The percentage of unvaccinated infants was significantly higher in cases (68.8% vs. 26.6%; p<0.05) and the length of hospital stay longer (8.5+/-5.4 vs. 3.1+/-2.2 days; p<0.05). There was a strong association between unvaccinated infants and the occurrence of pneumonia as a complication (odds ratio 6.1, 95% confidence interval 1.8-20.1; p<0.01). CONCLUSIONS Unvaccinated infants admitted for bronchiolitis have a higher risk of radiologically confirmed pneumonia. Larger studies are needed to validate these results and reconsider the burden of Hib infection among infants in less developed countries.
Collapse
Affiliation(s)
- Ariel A Salas
- Division of General Pediatrics, Clinica Caja Petrolera de Salud, 2525 Arce Ave., PO Box 3943, San Jorge, La Paz, Bolivia.
| | | | | |
Collapse
|
43
|
Abstract
OBJECTIVE To determine the clinical and epidemiological features of infants with extreme hyperbilirubinemia who require exchange transfusion (ET). STUDY DESIGN Term and near-term infants admitted to a paediatric hospital over a 5-year period in La Paz, Bolivia, were included in the study if they met the following criteria: age less than 30 days; total serum bilirubin (TSB) levels > or =428 micromol/L (> or =25 mg/dL) on admission and if they had undergone an ET. RESULTS Fifty-six infants were identified during the study period. Most of them were exclusively breastfed (98.2%). Median age at admission was 7 days. Weight loss of more than 12% since birth, as well as dehydration, was registered in more than one-third of cases. Extreme hyperbilirubinemia was considered as secondary to increased enterohepatic circulation (EHC) in most cases (73%). The mean TSB level on admission was 531.8 micromol/L (31.1 mg/dL). Fifteen infants (26.8%) showed signs of acute bilirubin encephalopathy (ABE). Early ABE was reversible after ET in most cases but all infants with advanced ABE developed severe kernicteric sequelae. Nine patients (16.1%) developed adverse events attributable to ET. CONCLUSIONS Dehydration and weight loss in breastfed infants appeared to be an important factor associated with extreme hyperbilirubinemia and secondary brain damage during the first week of life. This may well be avoided if signs of ABE and its associated conditions are identified appropriately by follow-up programmes.
Collapse
Affiliation(s)
- Ariel A Salas
- Department of Postgraduate Education and Research, Children's Hospital Dr. Ovidio Aliaga U, La Paz, Bolivia.
| | | |
Collapse
|
44
|
Affiliation(s)
- Ariel A Salas
- Department of Postgraduate Education and Research, Children's Hospital Dr. Ovidio Aliaga Uria, La Paz, Bolivia.
| | | |
Collapse
|
45
|
Affiliation(s)
- J Collins
- Department of Radiology, University of Wisconsin Hospital and Clinics, Madison 53792-3252, USA
| | | |
Collapse
|
46
|
Abstract
Previous articles in this column have discussed how new information technologies are revolutionizing medical education. In this article, two staff members from the Association of American Medical College's Division of Medical Education discuss how the Association (the AAMC) is working both to support the introduction of new technologies into medical education and to facilitate dialogue on information technology and curriculum issues among AAMC constituents and staff. The authors describe six AAMC initiatives related to computing in medical education: the Medical School Objectives Project, the National Curriculum Database Project, the Information Technology and Medical Education Project, a professional development program for chief information officers, the AAMC ACCESS Data Collection and Dissemination System, and the internal Staff Interest Group on Medical Informatics and Medical Education.
Collapse
Affiliation(s)
- A A Salas
- Division of Medical Education, Association of American Medical Colleges, Washington, D.C. 20037, USA.
| | | |
Collapse
|