Prognostic value of echocardiographic parameters in congenital diaphragmatic hernia: a systematic review and meta-analysis

BACKGROUND

Prognostication of mortality and decision to offer extracorporeal membrane oxygenation (ECMO) treatment in infants with congenital diaphragmatic hernia (CDH) can inform clinical management.

OBJECTIVE

To summarise the prognostic value of echocardiography in infants with CDH.

METHODS

Electronic databases Ovid MEDLINE, Embase, Scopus, CINAHL, the Cochrane Library and conference proceedings up to July 2022 were searched. Studies evaluating the prognostic performance of echocardiographic parameters in newborn infants were included. Risk of bias and applicability were assessed using the Quality Assessment of Prognostic Studies tool. We used a random-effect model for meta-analysis to compute mean differences (MDs) for continuous outcomes and relative risk (RR) for binary outcomes with 95% CIs. Our primary outcome was mortality; secondary outcomes were need for ECMO, duration of ventilation, length of stay, and need for oxygen and/or inhaled nitric oxide.

RESULTS

Twenty-six studies were included that were of acceptable methodological quality. Increased diameters of the right and left pulmonary arteries at birth (mm), MD 0.95 (95% CI 0.45 and 1.46) and MD 0.79 (95% CI 0.58 to 0.99), respectively) were associated with survival. Left ventricular (LV) dysfunction, RR 2.40, (95% CI 1.98 to 2.91), right ventricular (RV) dysfunction, RR 1.83 (95% CI 1.29 to 2.60) and severe pulmonary hypertension (PH), RR 1.69, (95% CI 1.53 to 1.86) were associated with mortality. Left and RV dysfunctions, RR 3.30 (95% CI 2.19 to 4.98) and RR 2.16 (95% CI 1.85 to 2.52), respectively, significantly predicted decision to offer ECMO treatment. Limitations are lack of consensus on what parameter is optimal and standardisation of echo assessments.

CONCLUSIONS

LV and RV dysfunctions, PH and pulmonary artery diameter are useful prognostic factors among patients with CDH.

Evaluation of Occupational Therapy and Music Therapy Co-Treatment in the Neonatal Intensive Care Unit

AIMS

To examine co-treatment with music therapy and occupational therapy with infants in the neonatal intensive care unit (NICU).

METHODS

A quasi-experimental design was used to study the effect of standard care occupational therapy (SCOT) vs co-treatment with music therapy (Co-Tx) on behavioral state and physiologic measures. 46 participants were enrolled in the study. Interventions were implemented in approximately 20-minute sessions. Physiologic measures, heart rate (HR) and oxygen saturation (SpO2), were collected using Sickbay. Behavioral measures were collected using The Face, Legs, Activity, Cry, and Consolability (FLACC) Pain Assessment Tool.

RESULTS

Mean heartrates during Co-Tx (161.3 ± 15.4 BPM) did not differ significantly compared to SCOT (161.8 ± 15.7 BPM). In unadjusted comparisons, mean SpO2 levels were significantly higher during Co-Tx than SCOT (95.48 ± 3.43% vs. 95.12 ± 3.71%, p = 0.046). There was a significant decrease in pre- to post-test FLACC scores for Co-Tx when compared to SCOT (decrease of 0.97 ± 1.96 vs. 0.61 ± 1.65, p = 0.023). In adjusted comparisons, there were no statistically significant differences in physiological outcomes.

CONCLUSIONS

Co-treatment with music therapy may create a more stable and regulated environment for NICU infants. Further research is recommended on music therapy co-treatment with rehabilitative therapies.

Viral Infections and Neonatal Necrotizing Enterocolitis: A Meta-analysis

CONTEXT

Necrotizing enterocolitis (NEC) is a devastating intestinal disease affecting preterm infants. Studies implicate viral infections in etiopathogenesis.

OBJECTIVE

To summarize the association of viral infections with NEC by systematic review and meta-analysis.

DATA SOURCES

We searched Ovid-Medline, Embase, Web of Science, and Cochrane databases in November 2022.

STUDY SELECTION

We included observational studies that examined the association between viral infections and NEC in newborn infants.

DATA EXTRACTION

We extracted data regarding the methodology, participant characteristics, and outcome measures.

RESULTS

We included 29 and 24 studies in the qualitative review and meta-analysis, respectively. The meta-analysis demonstrated a significant association between viral infections and NEC (odds ratio [OR], 3.81, 95% confidence interval: 1.99-7.30, 24 studies). The association remained significant after excluding the outliers (OR, 2.89 [1.56-5.36], 22 studies) and studies with poor methodology (OR, 3.33 [1.73-6.43], 22 studies). In subgroup analysis based on participants' birth weight, studies including very low birth weight infants only (OR, 3.62 [1.63-8.03], 8 studies) and non-very low birth weight infants only (OR, 5.28 [1.69-16.54], 6 studies) showed a significant association. In subgroup analysis based on specific viruses, infection with rotavirus (OR, 3.96 [1.12-13.95], 10 studies), cytomegalovirus (OR, 3.50 [1.60-7.65], 5 studies), norovirus (OR, 11.95 [2.05-69.84], 2 studies), and astrovirus (OR, 6.32 [2.49-16.02], 2 studies) was significantly associated with NEC.

LIMITATIONS

Heterogeneity of the included studies.

CONCLUSIONS

Viral infection is associated with an increased risk of NEC in newborn infants. We need methodologically sound prospective studies to assess the effect of preventing or treating viral infections on NEC incidence.

Inhaled Nitric Oxide Utilization in Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: A Propensity Score Analysis

Although used commonly, ability of inhaled nitric oxide (iNO) to improve outcomes in infants with congenital diaphragmatic hernia (CDH) who receive extracorporeal life support (ECLS) remains controversial. We sought to determine the association between pre-ECLS use of iNO and mortality in infants with CDH from the Extracorporeal Life Support Organization (ELSO) Registry. Neonates who underwent ECLS for CDH were identified from the ELSO Registry from 2009 to 2019. Patients were categorized into those treated with iNO versus not prior to initiating ECLS. Patients were then matched 1:1 for case-mix based on pre-ECLS covariates using the propensity score (PS) for iNO treatment. The matched groups were compared for mortality. The matched cohorts were also compared for ELSO-defined systems-based complications as secondary outcomes. There were a total of 3,041 infants with an overall mortality of 52.2% and a pre-ECLS iNO use rate of 84.8%. With 1:1 matching, there were 461 infants with iNO use and 461 without iNO use. Following matching, use of iNO was not associated with a difference in mortality (odds ratio [OR] = 0.805; 95% confidence interval [CI], 0.621-1.042; p = 0.114). Results were similar in unadjusted analyses, and after controlling for covariates in the full cohort of patients and in the 1:1 matched data. Patients receiving iNO had significantly higher odds of renal complications (OR = 1.516; 95% CI, 1.141-2.014; p = 0.004), but no other significant differences were observed among secondary outcomes. ECLS use of iNO in CDH patients was not associated with a difference in mortality. Future randomized controlled studies are needed to delineate the utility of iNO in CDH patients.

Neonatal systemic hypertension across the PHIS database: An update

BACKGROUND

The definition of systemic hypertension in the neonatal population remains elusive given the variability of normative blood pressure measurements. Inadequate literature exists about incidence, therapy and long-term management of systemic hypertension in neonates. We aimed to describe the current incidence of neonatal systemic hypertension, differences in demographic and risk factors data.

METHODS

Retrospective cohort of neonates (≤28 days) admitted to a neonatal intensive care unit participating in Pediatric Health Information System (PHIS) between Jan 2010 and December 2020 with an ICD 9/10 code for hypertension. Patients were excluded if they had congenital heart disease lesions that might contribute to systemic hypertension or had incomplete data.

RESULTS

There were a total of 2494 hypertensive patients among the 432,367 NICU patients meeting the study inclusion criteria, with an incidence of 0.6%. Patients with hypertension were significantly more likely to die before discharge compared to patients without HTN (8.4% versus 3.8%, respectively, p < 0.001). Of the 2494, 52.8% received at least one antihypertensive agent, with hydralazine being the most prescribed agent (29.7%).

CONCLUSION

Diagnosis of Systemic hypertension continues to increase in the neonatal population, despite absence of well-defined criteria necessitating targeted medical management. A consensus guideline which addresses this very important condition is beneficial.

Hospital variation in neonatal echocardiography among very preterm infants at US children's hospitals

OBJECTIVE

Estimate hospital variation in echocardiography (echo) among very preterm infants.

STUDY DESIGN

Retrospective cohort study of very preterm (<32 weeks) infants discharged between 2012 and 2019 from US children's hospitals. Echo exposure was identified using daily billing, and hospital variation was estimated after adjustment for illness severity. Variation in very early echo use (<3 days of life) was compared to exposure to treatment of a patent ductus arteriosus (PDA), and other practice patterns.

RESULTS

27,498 subjects across 39 children's hospitals were included. Very early echo use had the greatest hospital variation (3-34%). Increasing very early echo use was not associated with PDA treatment (p = 0.93), but was associated with nitric oxide (p < 0.01) and vasoactive medications (p < 0.01).

CONCLUSIONS

Hospital variation in echo use among preterm infants was greatest in the first few days of life and was associated with increasing nitric oxide and vasoactive medication use. The impact of this variation on clinical outcomes is uncertain and warrants further investigation.

The Effect of Contingent Singing on Infants with Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit

A significant component of care for infants with bronchopulmonary dysplasia (BPD) is providing an optimal environment for supporting neurodevelopment and growth. Interventions that support the behavioral and physiologic stability of this population may play an important role in improving overall outcomes. Contingent singing is a music intervention that allows the caregiver to tailor certain musical elements, such as rhythm and tempo, to match behavioral and physiologic cues and support the infant in achieving optimal stabilization. A randomized crossover design was used to study the effect of contingent singing on the behavioral state and physiologic measures compared to standard care practices in the neonatal intensive care unit (NICU). Data were collected on a sample of 37 infants diagnosed with BPD. There were no significant differences in the physiologic measures or behavioral states of infants in the contingent singing sessions compared to control sessions. Parents and staff reported favorable views of music therapy in the NICU, and there were no adverse responses from infants during contingent singing. Further research is needed to determine the effectiveness of this intervention on the physiologic stability of infants with BPD.

Growth and differentiation factor 15 (GDF15) levels predict adverse respiratory outcomes in premature neonates

Growth and differentiation factor 15 (GDF15) is a stress-responsive cytokine, and its expression increases during inflammation, hyperoxia, and senescence. Significantly, GDF15 is secreted by the placenta, and maternal levels increase throughout pregnancy. Serum GDF15 level is a promising biomarker for many lung diseases like pulmonary hypertension and pulmonary fibrosis. However, circulating GDF15 levels in preterm infants and their role as a predictor of respiratory outcomes have not been studied. We hypothesized that GDF15 levels would increase with gestational age at birth, and that postnatal GDF15 will be correlated with adverse respiratory outcomes in preterm infants. Scavenged blood samples were retrieved from 57 preterm infants at five time points, from birth until 36-weeks postmenstrual age (PMA). GDF15 levels were measured using ELISA in 114 samples. We performed two-sample t-test, correlation and linear regression, logistic regression, and mixed-effects linear models for statistical analysis, and significance was identified when p < 0.05. Contrary to our hypothesis, for every 1-week increase in gestational age at birth, the predicted GDF15 level decreased by 475.0 pg/ml (p < 0.001). Greater PMA was significantly associated with lower serum GDF15 levels (p < 0.001). Interestingly, higher GDF15 levels were associated with a longer need for mechanical ventilation (p = 0.034), prolonged respiratory support need (p < 0.001), and length of hospital stay (p = 0.006). In conclusion, in preterm infants, GDF15 levels show an inverse correlation with gestational age at birth, with higher levels in more preterm babies, and levels trend down postnatally. Furthermore, longitudinal GDF15 levels through 36 weeks PMA predict adverse respiratory outcomes in preterm infants.

Volume-guarantee vs. pressure-limited ventilation in evolving bronchopulmonary dysplasia

INTRODUCTION

Extremely premature infants are at high risk for developing bronchopulmonary dysplasia (BPD). While noninvasive support is preferred, they may require ventilator support. Although volume-targeted ventilation (VTV) has been shown to be beneficial in preventing BPD, no data exists to guide ventilator management of infants with evolving BPD. Thus, clinicians employ a host of ventilator strategies, traditionally time-cycled pressure-limited ventilation (PLV) and more recently volume-guarantee ventilation (VGV) (a form of VTV). In this study, we sought to test the hypothesis that use of VGV in evolving BPD is associated with improved clinical and pulmonary outcomes when compared with PLV.

DESIGN

Single-center, retrospective cohort review of premature infants born less than 28 weeks inborn to a Level 4 NICU from January 2015 to December 2020. Data abstracted included demographics, maternal and birth data, and ventilator data until death or discharge. Exposure to either VGV or PLV was also examined, including ventilator "dose" (number of time points from DOL 14, 21 and 28 the patient was on that particular ventilator) during the period of evolving BPD.

RESULTS

Of a total of 471 patients with ventilation data available on DOL 14, 268 were not ventilated and 203 were ventilated. PLV at DOL 21 and 28 was associated with significantly higher risk of BPD and the composite outcome of BPD or death before 36 weeks compared to VGV. Both increasing VGV and PLV doses were significantly associated with higher odds of BPD and the composite outcome. For each additional time point of VGV and PLV exposure, the predicted length of stay (LOS) increased by 15.3 days (p < 0.001) and 28.8 days (p < 0.001), respectively.

DISCUSSION

Our study demonstrates the association of use of VGV at DOL 21 and 28 with decreased risk of BPD compared to use of PLV. Prospective trials are needed to further delineate the most effective ventilatory modality for this population with "evolving" BPD.

Music therapy for preterm neonates in the neonatal intensive care unit: An overview of systematic reviews

AIM

To summarise the quantity and quality of evidence for using music therapy for preterm infants in the neonatal intensive care unit (NICU).

METHODS

We performed an overview of evidence for the effectiveness and safety of MT for preterm infants in the NICU. We performed a random-effects meta-analysis of data from studies that fit the definition of MT.

RESULTS

We identified 12 eligible systematic reviews and the methodological quality by AMSTAR-2 ranged from moderate to critically low. We identified 14 eligible randomised trials and 7 observational studies where the intervention fits the definition of MT. Meta-analysis of the RCTs showed that MT significantly decreases heart rate, mean difference (MD) (95% CI), -3.21 [-5.22, -1.19], respiratory rate, MD -2.93 [-5.65, -0.22], and maternal anxiety, MD -17.50 [-20.10, -14.90], and increases feeding volume, MD 29.59 [12.79, 46.38]. Long-term neurodevelopmental or safety outcomes were not reported. GRADE assessment of outcomes ranged from low to very low, downgraded for high risk of bias in the included studies, inconsistency and imprecision.

CONCLUSION

Low to very low certainty evidence suggests that MT in preterm infants improves short-term physiological parameters, feeding and maternal anxiety but safety and long-term outcomes were not reported.

O37 CONCOMITANT INTESTINAL RESECTION DOES NOT NEGATIVELY INFLUENCE LONG TERM OUTCOMES FOLLOWING COMPLEX ABDOMINAL WALL RECONSTRUCTION

Aim

Simultaneous intestinal resection increases infective risks following abdominal wall reconstruction. We investigated the frequency of those risks and its impact on long-term outcomes.

Material and Methods

Analysis of prospectively accrued data from patients undergoing AWR by a single surgeon (01/01/2014–31/12/2020). Comparison between AWR with (IR-AWR) and without (AWR) concomitant intestinal resection. Clinical review was undertaken 6 monthly for 24 months with ongoing telephone follow-up thereafter.

Results

101 repairs were performed within the study period (46 AWR,55 IR-AWR). IR-AWR patients underwent 129 gastrointestinal procedures including 30 gastrointestinal fistula,33 small bowel,19 colonic and 2 gastric resections.

Both groups were similar in terms of smoking status, diabetes, but obesity (BMI&gt;30) was more prevalent in AWR(23/46(50%)vs.16/55(29%); p=0.03). Hernia defects were the same for both groups; AWR median area (range) 511cm2(47–2171 cm2) and IR+AWR 471cm2(50–2827cm2) (p = 0.7).

Post-operative wound infection was more frequent following IR-AWR (20/55(36%) (Superficial incisional=13,deep incisional=6, cavity=1) vs. 6/46(13%)(N = 5,0,1 respectively);Odds ratio(OR)=3.8 (95% CI1.4-10.6); p=0.01). Patients undergoing IR-AWR were also more likely to experience ileus necessitating short-term postoperative parenteral nutrition (OR 3.3(1–10.8); p=0.05) and Clavien Dindo&gt;2 complications (OR4.4 (1.2–16.7); p=0.03). Within IR-AWR cohort there was a single anastomotic complication requiring re-laparotomy and one mesh infection treated with antibiotics.

Median follow-up= 25.2 months(range 1.2–88.8). 14 patients died during follow-up (AWR 7/46(15%), IR-AWR 7/55(13%); p=0.7). 5 were lost to follow-up (3AWR, 2 IR-AWR).

12(26%) AWR and 8(15%) IR-AWR reported either persistent or delayed onset chronic abdominal wall pain post repair(P = 0.14). Recurrent hernias occurred in 7/46(15%) AWR compared with 10/55(18%)IR-AWR(p = 0.5).

Conclusions

Despite more frequent short-term complications in IR-AWR patient outcomes are comparable at 2 years.

Parents' Perception of Fall Risk and Incidence of Falls in the Pediatric Ambulatory Environment

PURPOSE

To identify the parents' perspective of fall incidence and risks in the pediatric ambulatory environment.

DESIGN AND METHODS

A prospective descriptive correlational study was conducted in two large quaternary pediatric hospitals. Parents who accompanied their children to the clinic appointment were surveyed about falls their child experienced while at the clinic. Parent reported falls were compared to those reported in adverse event reporting systems (AERS) for the same period.

RESULTS

Data from 2327 completed parent surveys were analyzed. Parents reported 48 children fell and 139 falls. Only three falls were recorded in the AERS. Stepwise logistic regression was used to identify predictors of falls and a nomogram was created from the final model to facilitate patient fall risk screening. Three predictors of falls were identified: children under the age of five, children described by their parents as falling more at home than other children of the same age, and children who had a medical condition that impacts their ability to walk. A nomogram is provided to estimate the probability of falling for patients under 18 years of age in the ambulatory environment.

CONCLUSIONS

Parents may provide more reliable data regarding the incidence and risk factors for falls in the ambulatory environment than AERS, and it is possible to predict the probability of a fall given information from the parents.

PRACTICE IMPLICATIONS

Knowing who is at risk for falls creates opportunities for organizations to modify clinic procedures, train staff, and create physical environments that promote increased patient safety.

Economic analysis of prenatal fetoscopic vs open-hysterotomy repair of open neural tube defect

OBJECTIVE

Fetal repair of an open neural tube defect (ONTD) by open hysterotomy has been shown to reduce the need for ventriculoperitoneal shunting and improve motor outcomes for infants, but increases the risk of Cesarean section and prematurity. Fetoscopic repair is an alternative approach that may confer similar neurological benefits but allows for vaginal delivery and reduces the incidence of hysterotomy-related complications. We sought to compare the costs of care from fetal surgery until neonatal discharge, as well as the clinical outcomes, associated with each surgical approach.

METHODS

This was a retrospective cohort study of patients who underwent prenatal ONTD repair, using either the open-hysterotomy or the fetoscopic approach, at a single institution between 2012 and 2018. Clinical outcomes were collected by chart review. A cost-consequence analysis was conducted from the hospital perspective, and included all inpatient and ambulatory hospital and physician costs incurred for the care of mothers and their infants, from the time of maternal admission for fetal ONTD repair up to postnatal maternal and infant discharge. Costs were estimated using cost-to-charge ratios for hospital billing and the Medicare physician fee schedule for physician billing.

RESULTS

Seventy-eight patients were included in the analysis, of whom 47 underwent fetoscopic repair and 31 underwent open-hysterotomy repair. In the fetoscopic-repair group, compared with the open-repair group, fewer women underwent Cesarean section (53% vs 100%; P < 0.001) and the median gestational age at birth was significantly higher (38.1 weeks (interquartile range (IQR), 35.2-39.1 weeks) vs 35.7 weeks (IQR, 33.9-37.0 weeks); P < 0.001). No case of uterine dehiscence was observed in the fetoscopic-repair group, compared with an incidence of 16% in the open-repair group. After adjusting for baseline characteristics, there was no significant difference in the total cost of care between the fetoscopic-repair and the open-repair groups (median, $76 978 (IQR, $60 312-$115 386) vs $65 103 (IQR, $57 758-$108 103); P = 0.458).

CONCLUSIONS

Fetoscopic repair of ONTD, when compared with the open-hysterotomy approach, reduces the incidence of Cesarean section and preterm delivery with no significant difference in total costs of care from surgery to infant discharge. This novel approach may represent a cost-effective alternative to improve maternal and neonatal outcomes for this high-risk population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

In neonatal-onset surgical short bowel syndrome survival is high, and enteral autonomy is related to residual bowel length

BACKGROUND

In an era of improved management and treatment options, this study aims to describe the long-term outcomes and factors predictive of outcomes of neonatal-onset intestinal failure (IF) due to surgical short bowel syndrome (SBS).

METHODS

Retrospective, single-center cohort study of infants born between January 2011 and December 2018 with inclusion criteria: <44 weeks postmenstrual age at SBS diagnosis, <28 days on admission, parenteral nutrition dependence >60 days, and documented intestinal resection. Primary outcomes included survival and achievement of enteral autonomy (EA). Data analysis utilized Fisher.s exact test, Kruskal-Wallis test, survival analysis methods, Cox proportional hazards regression, linear regression and logistic regression.

RESULTS

Ninety-five patients (males 56%) were studied with median follow-up of 38 months (IQR 19, 59). Survival at last follow-up was 96%, and EA was achieved in 85%. Forty-eight patients had documented residual bowel length (RBL) with median length of 49 cm (IQR 36, 80). Survival in patients with RBL of <30cm (n = 8), 30-59cm (n = 19), and >60cm (n = 21) was 100%, 95%, and 95% respectively. Shorter RBL was associated with longer time to achieve EA (p = 0.007), but not with survival (p = 0.81). Delay in achieving EA was associated with absence of ileocecal valve (p = 0.002) and bloodstream infections (p < 0.001). Peak conjugated bilirubin correlated with increased mortality (p = 0.002).

CONCLUSION

Overall high rate of survival and achievement of EA was found in neonatal onset IF due to SBS. EA but not survival was correlated with RBL. Ileocecal valve, bloodstream infections, and conjugated bilirubin levels were the other predictive factors of outcomes.

Cumulative diagnostic imaging radiation exposure in premature neonates

BACKGROUND

To date, there has been limited work evaluating the total cumulative effective radiation dose received by infants in the neonatal intensive care unit. Most previous publications report that the total radiation dose received falls within the safe limits but does not include all types of ionizing radiation studies typically performed on this vulnerable patient population. We aimed to provide an estimate of the cumulative effective ionizing radiation dose (cED) in microSieverts (μSv) received by premature infants ≤32 weeks from diagnostic studies performed throughout their NICU stay, and predictors of exposures.

METHODS

Retrospective chart review from 2004-2011. Data included demographics, gestational age (GA), birth weight (BW), length of stay (LOS), clinical diagnosis, and radiological studies.

RESULTS

1045 charts were reviewed. Median GA = 30.0 weeks (SD 2.7, range 22.0-32.6). Median BW = 1340.0 grams (SD 445.4, range 420-2470). Median number of radiographic studies = 9 (SD 28.5, range 0-210). Median cED = 162μSv (range 0-9248). The cED was positively associated with LOS (p <  0.001) and inversely correlated with GA (p <  0.001) and BW (p <  0.001). Infants with intestinal perforation had the highest median cED 1661μSv compared to 162μSv for others (p <  0.001).

CONCLUSION

Our results provide an estimate of the cumulative effective radiation dose received by premature infants in a level 4 neonatal intensive care unit from all radiological studies involving ionizing radiation and identifies risk factors and predictors of such exposure. Radiation exposure in NICU is highest among the most premature and among infants who suffer from intestinal perforation.

Neonatal mortality rates and association with antenatal corticosteroids at Kamuzu Central Hospital

OBJECTIVE

Malawi has one of the highest child mortality rates in the world, and neonates account for nearly half of all under-five mortality. No previous study has reported neonatal outcomes in Malawi over 12 months. We aimed to evaluate outcomes in the neonatal intensive care unit (NICU) at Kamuzu Central Hospital (KCH) and to determine if there was an association between increased survival and antenatal corticosteroid (ACS) exposure.

STUDY DESIGN

We introduced a prospective, observational electronic database to collect 122 de-identified variables related to neonatal outcomes for all neonates admitted to the KCH NICU over 12 months. Patients with congenital anomalies were excluded. We compared neonatal mortality rates in neonates who were exposed to ACS compared to those who were not. Statistical methodology included the Wilcoxon rank sum test, Fisher's exact test, and logistic regression.

RESULTS

Of 2051 neonates admitted to the KCH NICU, the overall neonatal mortality rate was 23.1% and remained similar across 12 months. Mortality was inversely related to birth weight, and outborn neonates referred to KCH had the highest mortality rate (29%). After controlling for confounding covariates, inborn infants exposed to ACS had significantly lower odds of death compared to those without exposure to ACS (adjusted odds ratio = 0.46, 95% confidence interval: 0.24-0.88, p = 0.020).

CONCLUSION

Lower birth weight, outborn, and no ACS exposure were associated with increased mortality. ACS was associated with a 54% reduction in odds of mortality in inborn neonates highlighting the need for further evaluations of ACS use in resource-limited settings.

Growth, Body Composition, and Neurodevelopmental Outcomes at 2 Years Among Preterm Infants Fed an Exclusive Human Milk Diet in the Neonatal Intensive Care Unit: A Pilot Study

Background: Long-term outcomes of preterm infants fed an exclusive human milk-based (EHM) diet using a donor human milk-based fortifier are not well defined. Materials and Methods: Infants ≤1,250 g birth weight (BW) were studied prospectively at two outpatient visits: 12-15 and 18-22 months corrected age (CA). Dual-energy X-ray absorptiometry and Bayley Scales of Infant and Toddler Development III (BSID-III) were performed at 18-22 months CA. Results: In this pilot study, 51 preterm infants (gestational age 27.8 ± 2.6 weeks and BW 893 ± 204 g) were evaluated. While anthropometric z-scores were significantly lower at discharge compared with birth, z-scores returned to birth levels by 12-15 months CA (length and head circumference [HC]) and 18-22 months CA (weight). Body composition at 2 years of age was similar to term-matched controls. Inpatient growth was significantly correlated with bone density, lean mass (LM), and fat-free mass at 18-22 months CA. Increased mother's own milk (MOM) was significantly correlated with decreased fat mass indices. BSID-III showed that 0% of cognitive composite scores were <70. Conclusions: In addition to returning to BW, length, and HC z-scores by 2 years of age, body composition analysis revealed that increase in body size was appropriate as reflected by LM and bone density similar to matched term controls without an increase in fat mass. No child had severe cognitive developmental delay using a cutoff score of 70. Inpatient growth and increased receipt of MOM correlated with favorable growth and body composition outcomes. Positive outcomes as shown in this study to confirm postdischarge safety of an EHM diet during hospitalization.

New generation lipid emulsions increase brain DHA and improve body composition, but not short-term neurodevelopment in parenterally-fed preterm piglets

New generation, multicomponent parenteral lipid emulsions provide key fatty acids for brain growth and development, such as docosahexaenoic acid (DHA) and arachidonic acid (AA), yet the content may be suboptimal for preterm infants. Our aim was to test whether DHA and AA-enriched lipid emulsions would increase activity, growth, and neurodevelopment in preterm piglets and limit brain inflammation. Cesarean-delivered preterm pigs were given three weeks of either enteral preterm infant formula (ENT) or TPN with one of three parenteral lipid emulsions: Intralipid (IL), SMOFlipid (SMOF) or an experimental emulsion (EXP). Activity was continuously monitored and weekly blood sampling and behavioral field testing performed. At termination of the study, whole body and tissue metrics were collected. Neuronal density was assessed in sections of hippocampus (HC), thalamus, and cortex. Frontal cortex (FC) and HC tissue were assayed for fatty acid profiles and expression of genes of neuronal growth and inflammation. After 3 weeks of treatment, brain DHA content in SMOF, EXP and ENT pigs was higher (P < 0.01) in FC but not HC vs. IL pigs. There were no differences in brain weight or neuron density among treatment groups. Inflammatory cytokine TNFα and IL-1β expression in brain regions were increased in IL pigs (P < 0.05) compared to other groups. Overall growth velocity was similar among groups, but IL pigs had higher percent body fat and increased insulin resistance compared to other treatments (P < 0.05). ENT pigs spent more time in higher physical activity levels compared to all TPN groups, but there were no differences in exploratory behavior among groups. We conclude that a soybean oil emulsion increased select brain inflammatory cytokines and multicomponent lipid emulsions enriched with DHA and AA in parenteral lipids results in increased cortical DHA and improved body composition without affecting short term neurodevelopmental outcomes.

Human Milk Use in the Preoperative Period Is Associated with a Lower Risk for Necrotizing Enterocolitis in Neonates with Complex Congenital Heart Disease

OBJECTIVE

To evaluate the hypothesis that feeding volumes exceeding 100 mL/kg/d and exposure to cow's milk formula preoperatively increase the risk for preoperative necrotizing enterocolitis (NEC) in infants with complex congenital heart disease.

STUDY DESIGN

All infants, of any gestational age, with an isolated cardiac lesion at high risk for NEC (ductal-dependent lesions, transposition of the great arteries, truncus arteriosus, and aorto-pulmonary window) admitted to Texas Children's Hospital from 2010 to 2016 were included. NEC was defined based on the modified Bell criteria. Feeding regimen information and relevant covariates were collected. Logistic regression was used to evaluate the association of feeding regimen and other potential risk factors with NEC.

RESULTS

In this single-center, retrospective cohort of 546 infants, 3.3% developed Bell stage I-III NEC preoperatively. An exclusive unfortified human milk diet was associated with a significantly lower risk of preoperative NEC (OR 0.17, 95% CI 0.04-0.84, P = .03) in a multivariable regression model controlling for cardiac lesion, race, feeding volume, birth weight small for gestational age, inotrope use presurgery/pre-NEC, and prematurity. Feeding volumes exceeding 100 mL/kg/d were associated with a significantly greater risk of preoperative NEC (OR 3.05, 95% CI 1.19-7.90, P = .02).

CONCLUSIONS

The findings suggest that an unfortified exclusive human milk diet may reduce the risk of preoperative NEC in infants with complex congenital heart disease.

Preoperative Feeds in Ductal-Dependent Cardiac Disease: A Systematic Review and Meta-analysis

CONTEXT

Our aim for this review is to determine if preoperative feeds in neonates with ductal-dependent congenital heart disease are harmful or beneficial.

OBJECTIVES

To summarize current evidence for preoperative feeding in neonates with ductal-dependent congenital heart disease.

DATA SOURCES

We used the following databases: Medline, Embase, and Cochrane Central Register of Controlled Trials.

STUDY SELECTION

We included observational studies in which the following outcomes were addressed: necrotizing enterocolitis (NEC), hospital length of stay (LOS), time to achieve full postoperative enteral feeding, and feeding intolerance.

DATA EXTRACTION

Two reviewers independently screened each study for eligibility and extracted data. Methodologic quality was assessed by using a standardized item bank, and certainty of evidence for each outcome was assessed by using Grading of Recommendations Assessment, Development and Evaluation criteria.

RESULTS

Five retrospective cohort studies were eligible for inclusion, for which risk of bias was significant. When comparing neonates who received preoperative feeds with those who did not, there was no significant difference in NEC (pooled odds ratio = 1.09 [95% confidence interval 0.06-21.00; P = .95]; 3 studies, 6807 participants, very low certainty evidence), hospital LOS (mean of 14 days for those not fed versus 9.9 days for those fed preoperatively; P < .01; 1 study, 57 participants, very low certainty evidence), or feeding intolerance (odds ratio = 2.014 [95% confidence interval 0.079-51.703; P = .67]; 1 study, 56 participants, very low certainty evidence). No data were available for the outcome time to achieve full postoperative enteral feeding. All studies were observational and had small sample sizes.

CONCLUSIONS

There is insufficient evidence to suggest that preoperative enteral feeds in patients with ductal-dependent cardiac lesions adversely influence the rate of NEC, LOS, or feeding intolerance.

Optimizing Delivery of Breast Milk for Premature Infants: Comparison of Current Enteral Feeding Systems

Background

Incomplete delivery of fat from expressed breast milk (EBM) during enteral feeding to premature neonates remains a significant problem. Feeding system manufacturers have introduced changes to the enteral syringe design to improve fat delivery that have not yet been evaluated in the literature.

Methods

This study compares percentage delivery of fat from EBM using 2 major enteral feeding systems in various configurations with silicone and polyurethane tubing material and ENFit and Legacy connection systems at 3 clinically relevant infusion rates.

Results

The percent of fat delivery from EBM was significantly higher for the eccentric syringe system than the concentric system (P = 0.036) but did not vary significantly across infusion rates (P = 0.081). Silicone tubing had a significantly higher percent of fat delivery than polyurethane tubing within the eccentric syringe system (P = 0.039) but did not vary significantly across infusion rates (P = 0.105). There was no significant difference between ENFit and Legacy connectors using eccentric syringes with silicone tubing (P = 0.360).

Conclusion

We demonstrate that changes to syringe design and tubing material are effective and improve fat delivery from EBM, which may result in improved growth and outcomes in premature infants. The eccentric syringe marginally improves fat delivery in comparison with the concentric syringe, and silicone tubing significantly improves fat delivery compared with polyurethane tubing.

Optimizing the Use of Human Milk Cream Supplement in Very Preterm Infants: Growth and Cost Outcomes

BACKGROUND

An exclusive human milk-based diet has been shown to decrease necrotizing enterocolitis and improve outcomes for infants ≤1250 g birth weight. Studies have shown that infants who received an exclusive human milk diet with a donor-human milk-derived cream supplement (cream) had improved weight and length velocity when the cream was added to mother's own milk or donor-human milk when energy was <20 kcal/oz using a human milk analyzer. Our objective was to compare growth and cost outcomes of infants ≤1250 g birth weight fed with an exclusive human milk diet, with and without human milk cream, without the use of a human milk analyzer.

METHODS

Two cohorts of human milk-fed premature infants were compared from birth to 34 weeks postmenstrual age. Group 1 (2010-2011) received a donor-human milk fortifier, whereas Group 2 (2015-2016) received donor-human milk fortifier plus the commercial cream supplement, if weight gain was <15 g/kg/d.

RESULTS

There was no difference in growth between the 2 groups for weight (P = 0.32) or head circumference (P = 0.90). Length velocity was greater for Group 1 (P = 0.03). The mean dose of donor-human milk fortifier was lower in Group 2 (P < 0.001). Group 2 saved an average of $2318 per patient on the cost of human milk products (P < 0.01).

CONCLUSIONS

Infants receiving a human milk diet with cream supplementation for growth faltering achieve appropriate growth in a cost-effective feeding strategy.

Association between elevated placental polycyclic aromatic hydrocarbons (PAHs) and PAH-DNA adducts from Superfund sites in Harris County, and increased risk of preterm birth (PTB)

The preterm birth (PTB) rate in Harris County, Texas, exceeds the U.S. rate (11.4% vs.9.6%), and there are 15 active Superfund sites in Harris County. Polycyclic aromatic hydrocarbons (PAHs) are contaminants of concern (COC) at Superfund sites across the nation. In this investigation, we tested the hypothesis that higher levels of exposure to PAHs and PAH-DNA adducts in placenta of women living near Superfund sites contribute to the increased rate of PTBs. Levels of benzo[a]pyene (BP), benzo[b]fluorene (BbF) and dibenz[a,h]anthracene (DBA), were higher in placentae from preterm deliveries compared with term deliveries in women living near Superfund sites, whereas this was not the case for women living in non-Superfund site areas. Among the PAHs, DBA levels were significantly higher than BP or BbF, and DBA levels were inversely correlated with gestational age at delivery and birth weight. Bulky PAH-DNA adducts are more prevalent in placental tissue from individuals residing near Superfund sites. Expression of Ah receptor (AHR) and NF-E2-related factor 2 (NRF2) was decreased in preterm deliveries in subjects residing near Superfund sites. Unbiased metabolomics revealed alterations in pathways involved in pentose phosphate, inositol phosphate and starch and sucrose metabolism in preterm subjects in Superfund site areas. In summary, this is the first report showing an association between PAH levels, DNA adducts, and modulation of endogenous metabolic pathways with PTBs in subjects residing near Superfund sites, and further studies could lead to novel strategies in the understanding of the mechanisms by which PAHs contribute to PTBs in women.

Hand-held echocardiography in children with hypoplastic left heart syndrome

BACKGROUND

When performed by cardiologists, hand-held echocardiography (HHE) can assess ventricular systolic function and valve disease in adults, but its accuracy and utility in congenital heart disease is unknown. In hypoplastic left heart syndrome (HLHS), the echocardiographic detection of depressed right ventricular (RV) systolic function and higher grade tricuspid regurgitation (TR) can identify patients who are at increased risk of morbidity and mortality and who may benefit from additional imaging or medical therapies.

METHODS

Children with HLHS after Stage I or II surgical palliation (Norwood or Glenn procedures) were prospectively enrolled. Subjects underwent HHE by a pediatric cardiologist on the same day as standard echocardiography (SE). Using 4-point scales, bedside HHE assessment of RV systolic function and TR were compared with blinded assessment of offline SE images. Concordance correlation coefficient (CCC) was used to evaluate agreement.

RESULTS

Thirty-two HHEs were performed on 15 subjects (Stage I: n = 17 and Stage II: n = 15). Median subject age was 3.4 months (14 days-4.2 years). Median weight was 5.9 kg (2.6-15.4 kg). Bedside HHE assessment of RV systolic function and TR severity had substantial agreement with SE (CCC = 0.80, CCC = 0.74, respectively; P < .001). HHE sensitivity and specificity for any grade of depressed RV systolic function were 100% and 92%, respectively, and were 94% and 88% for moderate or greater TR, respectively. Average HHE scan time was 238 seconds.

CONCLUSIONS

HHE offers a rapid, bedside tool for pediatric cardiologists to detect RV systolic dysfunction and hemodynamically significant TR in HLHS.

Improved feeding tolerance and growth are linked to increased gut microbial community diversity in very-low-birth-weight infants fed mother's own milk compared with donor breast milk

BACKGROUND

Mother's own milk (MOM) is protective against gut microbiota alterations associated with necrotizing enterocolitis (NEC) and feeding intolerance among preterm infants. It is unclear whether this benefit is preserved with donor milk (DM) feeding.

OBJECTIVE

We aimed to compare microbiota development, growth, and feeding tolerance in very-low-birth-weight (VLBW) infants fed an exclusively human milk diet of primarily MOM or DM.

METHODS

One hundred and twenty-five VLBW infants born at Texas Children's Hospital were enrolled and grouped into cohorts based on percentage of MOM and DM in enteral feeds. Feeds were fortified with DM-derived fortifier per unit protocol. Weekly stool samples were collected for 6 wk for microbiota analysis [16S ribosomal RNA (rRNA) sequencing]. A research nurse obtained weekly anthropometrics. Clinical outcomes were compared via Wilcoxon's rank-sum test and Fisher's exact test, as well as multivariate analysis.

RESULTS

The DM cohort (n = 43) received on average 14% mothers' milk compared with 91% for the MOM cohort (n = 74). Diversity of gut microbiota across all time points (n = 546) combined was increased in MOM infants (P < 0.001). By 4 and 6 wk of life, microbiota in MOM infants contained increased abundance of Bifidobacterium (P = 0.02) and Bacteroides (P = 0.04), whereas DM-fed infants had increased abundance of Staphylococcus (P = 0.02). MOM-fed infants experienced a 60% reduction in feeding intolerance (P = 0.03 by multivariate analysis) compared with DM-fed infants. MOM-fed infants had greater weight gain than DM-fed infants.

CONCLUSIONS

Compared with DM-fed infants, MOM-fed infants have increased gut microbial community diversity at the phylum and genus levels by 4 and 6 wk of life, as well as better feeding tolerance. MOM-fed infants had superior growth. The incidence of NEC and other gastrointestinal morbidity is low among VLBW infants fed an exclusively human milk diet including DM-derived fortifier. This trial was registered at clinicaltrials.gov as NCT02573779.

Interrater Reliability of the Braden and Braden Q by Skin Champion Nurses

The interrater reliability of the Braden Q skin risk assessment scale has never been reported. The purpose of the study was to assess the interrater reliability among pediatric Skin Champion (SC) nurses with the use of the Braden and Braden Q scales. The pilot study included 16 paired SC nurses. Each pair of nurses attempted to assess 8 patients using the Braden and Braden Q scales. However, patient care requirements at the time of the study assessments limited the number slightly. The actual number of assessments with the Braden scale was n = 52 and the Braden Q was n = 63. The Intra-class Correlation Coefficient (ICC) for the Braden scale was 0.894, 95% confidence interval (CI) (0.823, 0.938), which is excellent agreement. The ICC for the Braden Q was 0.726, 95% CI (0.585, 0.824), which is fair to good agreement. Among the six subcategories on the Braden scale, mobility and activity had higher agreement scores among the SC nurses. Among the seven subcategories on the Braden Q scale, mobility and sensory perception had higher agreement scores. Nutrition and friction/shear subcategories on both scales had the lowest agreement scores. Subcategories with the lowest agreement usually have the greatest measurement error. Possible sources of error include unclear definitions of scoring criteria, different clinical data pulled from different locations in the chart. Error can be reduced by clarifying the subcategory definitions and standardizing the data used for the assessment and the location of each data point in the EMR. A high interrater agreement is the goal because it provides confidence that the scale is used reliably to identify high risk patients who require additional care to prevent harmful events.

Predictive value of oxygenation index for outcomes in left-sided congenital diaphragmatic hernia

BACKGROUND & OBJECTIVES

Congenital Diaphragmatic Hernia (CDH) is associated with significant morbidity and mortality. This study compares the efficacy of the highest oxygenation index in the first 48 h (HiOI) versus current prenatal indices to predict survival and morbidity.

METHODS

Medical records of 50 prenatally diagnosed, isolated, left-sided CDH patients treated from January 2011 to April 2016 were reviewed. Data abstracted included HiOI, lung to head ratio (LHR), observed to expected total fetal lung volume (O/E TFLV), percent liver herniation (%LH), 6 month survival, respiratory support at discharge, ventilator days and length of stay. Data were analyzed using parametric and nonparametric tests and regression analyses as appropriate.

RESULTS

HiOI was associated with significantly increased LOS (p<0.001), respiratory support at discharge (p<0.001), greater ventilator days (p=0.001) and higher odds of death (p=0.004) with risk of death increasing by 5% for every one-unit increase in OI. HiOI was statistically a better predictor of LOS than O/E TFLV (p=0.007) and %LH (p=0.02).

CONCLUSIONS

In isolated, left-sided CDH patients, HiOI is associated with higher mortality, greater length of stay, more ventilator days and increased respiratory support at discharge. HiOI is a better predictor of length of stay than O/E TFLV and %LH.

TYPE OF STUDY

Retrospective Study LEVEL OF EVIDENCE: II.

Characteristics of Isolated Ventricular Septal Defects Less Likely to Close In Utero

OBJECTIVES

To determine the characteristics of fetal ventricular septal defects (VSDs) that will be less likely to close prenatally.

METHODS

In this 4-year retrospective cohort study, 148 fetuses had a diagnosis of a VSD during a comprehensive fetal anatomy survey. The VSD diagnosis was confirmed by color and pulsed wave Doppler studies. These fetuses were followed monthly until their birth. They had postnatal echocardiography performed within 1 month of age to assess the persistence of a VSD. Fisher exact, Wilcoxon rank sum, and log rank tests and bivariate and multivariate logistic regressions were used to examine the association of each individual variable with prenatal VSD closure.

RESULTS

One hundred twenty-five of 148 fetuses (84%) had prenatal VSD closure at a mean gestational age ± SD of 26.9 ± 4.5 weeks. Fetuses with a persistent VSD more frequently had other cardiac defects than the closed VSD group (12 of 23 versus 5 of 125; P < .001). Fetuses having a persistent VSD more frequently had an abnormal karyotype (9 of 23 versus 5 of 125; P < .001). The persistent VSDs were larger in their initial size (5.9 ± 8.4 mm versus 2.7 ± 0.8 mm; P = .002) and in their maximal prenatal size (6.0 ± 9.1 mm versus 2.9 ± 0.9 mm; P < .001). The presence of associated cardiac defects (adjusted odds ratio = 0.071; P = .031) and an abnormal karyotype (adjusted odds ratio = 0.058; P = .021) were significantly associated with a lower likelihood of prenatal VSD closure. All VSDs with a maximal size of 2 mm or less closed prenatally.

CONCLUSIONS

Fetuses with a complex cardiac defect or an abnormal karyotype were less likely to have prenatal VSD closure.

Nurses' Early Recognition of Neonatal Sepsis

OBJECTIVE

To determine nurses' perceptions of the most common physiologic and behavioral indicators of neonatal sepsis.

DESIGN

Descriptive correlational study.

SETTING

A women's and children's hospital in an academic medical center in the southwestern United States.

PARTICIPANTS

Nurses (N = 181) who cared for neonates in the mother-infant and NICU settings.

METHODS

Participants completed an e-mail survey developed from the literature to ascertain their perceptions of which physiologic and behavioral indicators were most often associated with neonatal sepsis. Descriptive and inferential statistics were used to analyze the data.

RESULTS

Participants identified six signs and symptoms as indicators most often associated with sepsis: two were physiologic and four were behavioral. Recognition of these indicators was not related to level of nursing education but was associated with working in the NICU. Seventy-three percent of participants reported that they suspected that newborns were septic before evaluation and diagnosis of septicemia.

CONCLUSION

Nurses can identify the physiologic and behavioral indicators related to neonatal sepsis. Early recognition, expressed as their intuitive knowing, should be considered a valuable clinical tool. Understanding that different practice settings influence identification of signs and symptoms is important. Integration of this knowledge into formal care surveillance could potentially lower the threshold for early evaluation and treatment and thereby improve outcomes.

Incidence, Severity, and Association With Adverse Outcome of Hyponatremia in Children Hospitalized With Heart Failure

Hyponatremia is a common finding in adults hospitalized with heart failure (HF) and is associated with longer hospital stays and increased mortality. The significance of hyponatremia in children with HF is not known. We sought to determine the incidence of hyponatremia and association with clinical outcome in children hospitalized with HF. Admission and inpatient serum sodium concentrations were analyzed in 141 consecutive children hospitalized with acute decompensated HF. Inclusion criteria include patients (age, birth to 21 years) with biventricular hearts who were hospitalized for HF from January 2007 to December 2012. The primary composite end point was death, cardiac transplantation, or the use of mechanical circulatory support (MCS) during hospitalization. Data for 141 patients were included in the analysis. The cohort included 48 patients (34%) with preexisting HF. Mean serum sodium at admission was 136 ± 4 mmol/L (range 124 to 150 mmol/L). Hyponatremia (serum sodium <135 mmol/L) was present in 45 patients (32%) at admission. Seventy-one patients (75%) with normal serum sodium concentrations at admission subsequently developed acquired hyponatremia during their hospitalization. Hyponatremia persisted at discharge in 17 of 66 patients (26%). Fifty-eight patients (41%) reached the composite end point during hospitalization (death, n = 15; cardiac transplantation, n = 27; MCS, n = 46). Hyponatremia at admission was independently associated with death, cardiac transplantation, or the use of MCS during hospitalization (odds ratio 3.1, p = 0.02). In conclusion, hyponatremia occurs commonly in children hospitalized with acute decompensated HF and is associated with increased risk of in-hospital mortality, cardiac transplantation, and need for MCS.

Development and Evaluation of the Barriers to Nurses’ Participation in Research Questionnaire at a Large Academic Pediatric Hospital

The purposes of this study were to survey nurses at a large pediatric hospital to examine barriers to nursing research and to develop the Barriers to Nurses’ Participation in Research Questionnaire (BNPRQ) in preparation for its use at other institutions. The BNPRQ was created and refined through iterative pilot testing. Exploratory factor analysis was applied, and composite scores were computed for the identified factors. The two latent factors “Research Resources” and “Personal Relevance of Research” were extracted. The independent item “lack of time to do research” represented the largest barrier to research. Factor and item scores differed according to subject characteristics. Findings from this study will be used to create targeted interventions to reduce barriers to research participation prevalent in specific groups of nurses. By using the BNPRQ developed in this study, researchers and administrators at other institutions can identify and address barriers to research among their nurses.