"Light" on Phototherapy-Complications and Strategies for Shortening Its Duration, A Review of the Literature

Neonatal hyperbilirubinemia is an extremely common metabolic complication of the neonatal period which may be associated with bilirubin encephalopathy and even death. Adverse neurological consequences are preventable if a timely diagnosis and treatment are provided. Phototherapy is usually the preferred option to decrease hyperbilirubinemia. Although considered to be safe, evidence in recent years has shown that this treatment may not be free of side effects and short- and long-term unfavorable outcomes. These are usually mild or rare, but should be decreased or avoided if possible. Many useful complementary measures and treatments have been described that could shorten the duration of exposure to phototherapy. However, there is no current unequivocal recommendation to use any of the methods presented in this review. Our review aims to depict the wide range of possible complementary treatments to phototherapy, and to provide the scientific and clinical evidence available regarding their usefulness. It is essential that, while utilizing the full potential of phototherapy to treat hyperbilirubinemia, caregivers are aware of its side effects and possible inherent dangers, and seek ways to minimize the exposure to phototherapy to what is really needed for the newborn. Further studies are needed to clarify the preferred complementary treatments that could reduce the duration of exposure to phototherapy without impairing its effectiveness.

An Observational Study on the Use of Peripheral Intravenous Lines vs. Central Lines in a Neonatal Intensive Care Unit

Background and Objectives: There is a debate regarding the preferred intravenous (IV) access for newborns. Our aim was to study practices regarding the choice of vascular access and outcomes. Methods: A seven-month prospective observational study on IV lines used in all newborns admitted to Bnai Zion Medical Center’s neonatal intensive care unit (NICU). Results: Of 120 infants followed, 94 required IV lines. Infants born at ≤32 weeks gestation, or with a head circumference ≤29 cm were more likely to require two or more IV lines or a central line for the administration of parenteral nutrition or medications for longer periods. However, central lines (umbilical or peripherally inserted central catheters (PICC)) were not associated with better nutritional status at discharge based on weight z-scores. Only one complication was noted—a central line-associated bloodstream infection in a PICC. Conclusions: Our data suggest preferring central IV access for preterm infants born at ≤32 weeks or with a head circumference ≤29 cm. We encourage other NICUs to study their own data and draw their practice guidelines for preferred IV access (central vs. peripheral) upon admission to the NICU.

Utilizing umbilical cord blood - Minimizing blood sampling and pain in healthy infants at risk for polycythemia

BACKGROUND

Exposure to pain in early life was associated with long term consequences, therefore strategies for minimizing painful procedures in newborns should be employed. The utility and reliability of cord blood CBC was demonstrated before, however data regarding use of cord blood in healthy infants at risk for polycythemia are lacking.

METHODS

A single-center, paired-sampling prospective laboratory study including all healthy asymptomatic infants born after 36 weeks gestation who were SGA (<2500 g), LGA (>4000 g), or born to mothers with diabetes in pregnancy. Blood count indices were compared between umbilical and neonatal capillary or venous blood samples. In order to predict cut-off values for neonatal polycythemia using umbilical hematocrit, receiver operator curves (ROC) were plotted.

RESULTS

Paired samples were collected from 433 infants. Mean gestational age and birth-weight were 39.0 ± 1.3 weeks and 3489 ± 682 g. Hemoglobin, hematocrit and WBC values were lower in cord blood compared to neonatal, but PLT count was higher. Pearson r showed only modest correlation between peripheral capillary and umbilical or venous Hct - 0.35 (p < 0.001), and 0.44 (p < 0.001), respectively. In order to try and capture clinically significant polycythemia ROC was plotted for hematocrit >70% and <40%. In our cohort, using the calculated cutoff values (>51% and <35%) could have resulted in a decrease of 72% of neonatal blood draws.

CONCLUSION

This analysis should be interpreted with caution, as currently it cannot support the routine use of umbilical samples' hematocrits for making treatment decision in newborns at risk for polycythemia. Further larger studies are needed.

Perinatal Outcomes in Infants of Mothers with Diabetes in Pregnancy

BACKGROUND

The incidence of gestational diabetes mellitus (GDM) is increasing in parallel to the worldwide obesity and type 2 diabetes pandemic. Both GDM and pre-gestational diabetes mellitus (PGDM) are associated with short- and long-term consequences in the offspring. There are few recent studies addressing outcomes of newborns born to women diagnosed with GDM and PGDM in Israel.

OBJECTIVES

To assess perinatal complications in offspring of women with GDM and PGDM.

METHODS

The authors conducted a single-center retrospective case-control study of outcomes of all newborns whose mothers had been diagnosed with diabetes in pregnancy compared to randomly assigned controls born on the same date, whose mothers had no diabetes.

RESULTS

In the study period 2015-2017, 526 mothers diagnosed with GDM or PGDM and their newborn infants were identified. The authors randomly assigned 526 control infants. The rate of women with diabetes in pregnancy was 5.0%. Mothers with GDM and PGDM had higher rates of pre-eclampsia, multiple pregnancies, and preterm deliveries. Mothers with PGDM had significantly higher rates of intrauterine fetal demise (4.3%), congenital anomalies (12.8%), and small-for-gestational-age neonates (10.6%) compared to controls (0%, 3.2%, and 4.2%, respectively, P < 0.001). The risks for preterm or cesarean delivery, large-for-gestational-age neonate, respiratory morbidity, hypoglycemia, and polycythemia were increased in offspring of mothers with diabetes, especially PGDM.

CONCLUSIONS

Despite all the advancements in prenatal care, diabetes in pregnancy, both PGDM and GDM, is still associated with significant morbidities and complications in offspring. Better preconception and inter-pregnancy care might reduce these risks.

The Impact of Routine Evaluation of Gastric Residual Volumes on the Time to Achieve Full Enteral Feeding in Preterm Infants

OBJECTIVE

To evaluate the time to full enteral feedings in preterm infants after a practice change from routine evaluation of gastric residual volume before each feeding to selective evaluation of gastric residual volume , and to evaluate the impact of this change on the incidence of necrotizing enterocolitis (NEC).

STUDY DESIGN

Data were collected on all gavage-fed infants born at ≤34 weeks gestational age (GA) for 2 years before (n = 239) and 2 years after the change (n = 233).

RESULTS

The median GA was 32.0 (IQR: 29.7-33.0) weeks before and 32.4 (30.4-33.4) weeks after the change (P = .02). Compared with historic controls, infants with selective evaluations of gastric residual volumes weaned from parenteral nutrition 1 day earlier (P < .001) and achieved full enteral feedings (150 cc/kg/day) 1 day earlier (P = .002). The time to full oral feedings and lengths of stay were similar. The rate of NEC (stage ≥ 2) was 1.7% in the selective gastric residual volume evaluation group compared with 3.3% in the historic control group (P = .4). Multiple regression analyses showed that the strongest predictor of time to full enteral feedings was GA. Routine evaluation of gastric residual volume and increasing time on noninvasive ventilation both prolonged the attainment of full enteral feedings. Findings were consistent in the subgroup with birth weights of <1500 g. Increased weight at discharge was most strongly associated with advancing postmenstrual, age but avoidance of routine evaluations of gastric residual volume also was a significant factor.

CONCLUSIONS

Avoiding routine evaluation of gastric residual volume before every feeding was associated with earlier attainment of full enteral feedings without increasing risk for NEC.

Evaluation and Management of Newborns with Suspected Early-Onset Sepsis: Comparison of Two Approaches and Suggestion for Guidelines

Objective Although its incidence is declining with the widespread use of intrapartum antibiotics, early-onset sepsis (EOS) continues to be associated with high morbidity and mortality. Maternal, infant, and peripartum risk factors, as well as infant's laboratory tests, have been used to try and identify asymptomatic newborns at risk. In this study, we reevaluate the management of newborns at risk for EOS by comparing our outcomes using two different approaches. Study Design Comparison of clinical data and outcomes of newborns at risk for EOS between two study periods, in which we have used two different protocols for their evaluation and management. Results Although outcomes were not different, adoption of the criteria suggested in the 2012 American Academy of Pediatrics guidelines in the second era resulted in increased utilization of diagnostic laboratory tests and increased use of empiric antibiotic treatments with less yield in a population with a low incidence of EOS (< 0.3/1,000 live births), such as ours. Conclusion In asymptomatic newborns at risk for EOS, careful assessment of a set of maternal, infant, and peripartum risk factors and their severity combined with careful clinical observation, judicious use of laboratory evaluations, and empiric antibiotic treatment only in selected cases seem to be appropriate.

Post-hemorrhagic hydrocephalus and diabetes insipidus in preterm infants

We present two cases of transient central diabetes insipidus in preterm neonates with post-hemorrhagic hydrocephalus. Although the association between intraventricular hemorrhage and diabetes insipidus has been described in preterm infants, the association between diabetes insipidus and hydrocephalus, and the fact that such central diabetes insipidus could be reversible with the reduction of ventricular size, either because of spontaneous resolution or the placement of ventriculo-peritoneal shunt is first described here in neonates.

Is it justified to include urine cultures in early (< 72 hours) neonatal sepsis evaluations of term and late preterm infants?

OBJECTIVE

Evaluate the need for urine culture in early neonatal sepsis workup of term and late preterm infants.

STUDY DESIGN

Urine culture by suprapubic aspiration or catheter was included in early sepsis evaluations of 173 term and late preterm newborns (mean gestational age 38.6 ± 2.0 weeks) during a 6-month study period. A historic control group included 182 newborns (38.6 ± 2.9 weeks) who had sepsis evaluations without routine urine cultures a year earlier.

RESULTS

Urine cultures were sampled in 106 (61%) of the study group, No significant differences were found between study and control groups in the rate of bacteremia (1.73% versus 2.2%) or urinary tract infection (UTI; 0.94% versus 1.1%), which was low. Early UTIs were not accompanied by bacteremia or structural anomalies and were associated with exacerbation of neonatal jaundice in two of three infants.

CONCLUSIONS

There seems to be no justification for routine urine culture in early neonatal sepsis workup of term and late preterm infants, unless there are accompanying clinical symptoms, usually related to neonatal jaundice.