Improved method for revising the Israel birthweight references

OBJECTIVES

Birthweight is often used as an indicator of fetal health. Categorization of infants as small or large for gestational age has clinical significance. Due to growth differences between countries, it is important to have local reference data. The aim of the study was to describe an Israel population-based reference of birthweight by gestational age stratified for singletons/multiple births and gender.

METHODS

Data on birthweight and gestational age were obtained for the years 2010-2019 from the Ministry of Health Birth Registry. Implausible birthweight and gestational age values were excluded in a two step process. First, overtly implausible values were excluded using visual mapping. Then, infants whose birthweight was below or above the fifth interquartile range for each completed week were excluded.

RESULTS

During the 10-year period there were 1,761,884 infants delivered in Israel; 1,689,696 were included in the analysis. 4.4% of the live born infants were from multiple births. The mean birthweight of singletons (3251 g) was 947 ± 4 g higher than that of multiples (2304 g). The birthweight of the male multiple births began to differ from that of the singletons at 30 weeks; female multiple births began to deviate at 31 weeks. The increase in birthweight of singletons leveled after 42 weeks and those born after 43 weeks weighed less than infants born earlier. Comparison of the curves for singletons from the present study to those reported for the years 1993-2001 reveal a similar median but significant differences in the distribution of lower and higher percentiles.

CONCLUSIONS

Improved data collection and validation permitted inclusion of 96% of births for analysis. Use of interquartile range distribution to exclude values of birthweight/gestational age that were implausible improved validity. Compared to curves reported previously, changes were found in the distribution of birthweights for the upper and lower percentiles. Periodic updates of growth curve references are important.

Quality of care indicator performance was minimally changed in 2020 despite the COVID-19 pandemic

BACKGROUND

In 2020, the COVID-19 pandemic affected healthcare systems throughout the world, including the management of patients and compliance rates of quality indicators.

OBJECTIVE

To measure the impact in Israel of the COVID-19 pandemic on the indicator-relevant caseload and compliance rates of the quality indicators reported by medical services providers within the Israeli National Program for Quality Indicators (NPQI).

METHODS

Data was collected from the reports made to the NPQI by participating hospitals and medical service providers. The indicator results for the number of cases and compliance rates for 2019 were compared to those from 2020. We assessed and compared the results of the quality indicators in general hospitals, geriatric hospitals and departments, psychiatric hospitals and departments, emergency medical services (EMS), and Mother and Baby health centers.

RESULTS

We found a decrease in measurable cases in 2020 relative to 2019, especially in geriatric hospitals. In most indicators, compliance rates rose in 2020. Few indicators had lower compliance rates associated with COVID-19 pandemic regulations.

CONCLUSIONS AND POLICY IMPLICATIONS

Routine medical activity decreased in Israel in 2020 in comparison to 2019, as reflected by a decrease in cases, but compliance rates were better in most indicators. The results of our study imply that the functioning of healthcare quality measurement programs should not be interrupted during a pandemic. This not only allows measuring of the healthcare system's performance during a crisis, but also may assist in maintaining a high level of healthcare quality.

[TEACHING RESUSCITATION SKILLS ON A NEWLY DEAD INFANT]

Trainees in pediatrics and neonatology have to learn and remain updated regarding current lifesaving intubation procedures. The decrease in clinical indications for neonatal intubation limits their ability to practice and perfect procedures. Alternative methods for training, e.g., the use of manikins, do not satisfy the intended goal. Legitimization of the use of newly deceased infants for practice purposes is morally acceptable and may save lives. The requirement of mandatory parental consent for this type of training may result in reduced resuscitation capabilities and in loss of lives.

Eradication of Cytomegalovirus from Human Milk by Microwave Irradiation: A Pilot Study

BACKGROUND

Cytomegalovirus (CMV)-infected human milk (HM) can lead to significant CMV morbidity and mortality in preterm very-low-birth weight infants. The eradication of CMV in HM while preserving its properties poses a major clinical challenge.

OBJECTIVE

We aimed to compare two methods used to neutralize the virus in HM, one recognized as partially effective (freezing) and another not tested to date (microwave exposure).

MATERIALS AND METHODS

We sampled HM from 31 CMV-seropositive mothers whose infants were hospitalized at the Lis Maternity Hospital. Fifteen samples that were positive for CMV antigen were divided into five 5 mL aliquots: the first a control, the second was frozen at -20°C for 1 day, the third was frozen at -200°C for 3 days, and the fourth and fifth aliquots were exposed for 30 seconds to microwave radiation at a low-power setting (500 W) and high-power setting (750 W), respectively.

RESULTS

Only microwave radiation at a high-power setting led to complete neutralization of CMV in all samples. Low-power microwave irradiation had a 13% failure rate while 3-day freezing and 1-day freezing had failure rates of 7% and 20%, respectively.

CONCLUSION

It is possible to eradicate CMV successfully in HM by using microwave radiation at a high-power setting. Further studies are needed to evaluate the effect of microwave heating on breast milk properties.

[ISRAEL NEONATOLOGY: PRESENT AND FUTURE]

The practice of neonatology in Israel debuted in the 1970s as local enterprises by individual hospitals that needed to provide sick and preterm newly born infants with up-to-date and effective care. Descriptions of research and advances in humane and gentle treatment during neonatal care for preterm infants and their families, as well as prevention of neonatal infections, follow-up of preterm infants and care of full-term infants are presented in this issue. The Israel National Very Low Birth Weight (VLBW) Infant database provides an excellent source of knowledge, which has led to multiple scientific publications. Recent international comparisons of the outcome of preterm VLBW infants, made possible by this unique database in Israel, has provided the neonatal community and the Ministry of Health with insights as to the differences in prognosis between Israel and other countries, especially among extremely low birth weight infants. At the border of viability, mortality in Israelis significantly higher than that reported in other countries and proactive steps undertaken to examine these differences and prompt correctional action should be pursued. The Israel Ministry of Health started positive initiatives and should ensure that their steps are implemented at the preterm infant's bedside.

[A PROSPECTIVE FOLLOW-UP OF NON-PALPABLE TESTES IN NEONATES]

INTRODUCTION

Cryptorchidism is the most common genitourinary disorder in male neonates, with an incidence of 2-5% in term neonates and 30% in preterm infants. Known complications of this condition include impaired fertility and an increased risk of malignancy. This leads to a high frequency of imaging tests, specifically ultrasonography. Use of ultrasound aims to identify non-palpable testis, however current literature does not support such an approach.

GOALS

To evaluate the efficacy of clinical follow-up of cryptorchidism in neonates and to evaluate the need for ultrasonography.

METHODS

This prospective study was performed at the Lis Maternity Hospital in the Tel Aviv Sourasky Medical Center during a 14 month period. During that period some 4,500 male neonates were born at our hospital. Every newborn was examined within 8 hours of delivery by a pediatrician skilled in neonatal physical examinations. Excluded from the study were preterm infants, neonates in which prenatal examination demonstrated genitourinary abnormalities and neonates with additional congenital abnormalities. Healthy term babies in which one or both testes were not palpable were re-examined within a day by a senior neonatologist (M.B.) to establish their diagnosis, and then reexamined daily by the same physician until their discharge from the hospital. Babies who had one or both testis which were not palpable on discharge were followed-up weekly at a hospital clinic for 2 more weeks.

RESULTS

Of 4,500 male neonates born during the study period, 41 (0.9%) were diagnosed with a non-palpable testis, and 8 (0.18%) had bilateral non-palpable testes; 5 babies were lost to followup and excluded from the analysis; 26 of 44 testes (29%) became palpable before discharge from the nursery, by the 3rd day of life. After a weekly follow up from discharge, 13 (29%) additional testes became palpable over the 4-14th day of life. Overall, 88% of non-palpable testes became palpable by 14 days of age.

CONCLUSIONS

Close clinical follow-up during the first weeks after birth allows localizing most congenitally non-palpable testing and clarifying the need for performing imaging studies not routinely necessary to diagnose and refer babies with cryptorchidism for further treatment.

[THE ISRAEL NATIONAL VERY LOW BIRTH WEIGHT INFANT DATABASE]

BACKGROUND

Very low birth weight (VLBW ≤ 1,500g] infants represent approximately 1% of all live births in Israel but are responsible for about 45% of all infant deaths and account for 45% of all hospitalization days in the neonatal special and intensive care units (NICU's).

AIM

To identify perinatal and neonatal factors associated with mortality, morbidity and handicap among VLBW infants.

METHODS

Since 1995 data for > 99% of VLBW infants were received from all 27 NICU's in Israel. The data includes maternal obstetric history, infant's status at birth, deaths, major neonatal morbidities and treatments during the infant's hospitalization. The data are analyzed, collated and annual national and departmental reports prepared.

RESULTS

The database comprises information on 25,800 VLBW infants born from 1995-2011. Approximately 20% of VLBW infants were conceived by in-vitro fertilization, one-third of the births were multiple births and 60% of multiple births were the result of infertility treatments. Mortality declined significantly from 23.7% in 1995-1997 to 16.8% in 2010-2011. During this period significant decreases in major neonatal morbidities were documented: Late onset sepsis (> 3 days) decreased from 29.9% to 23.2% in 2010-2011; severe retinopathy of prematurity from 7.6% to 3.8% and periventricular leukomalacia from 8.3% to 5.0%. The rate of bronchopulmonary dysplasia increased from 9.5% in 1995-1997 to 13% in the period 2001-2006, subsequently declining to 10.8% in the last years.

CONCLUSION

Since 1995 the Israel national VLBW infant database has provided information at both national and hospital levels, documenting the improving care and outcomes for VLBW infants. The significant decline in VLBW infant mortality has been associated with a parallel decrease in major neonatal morbidities.

Reactivity and sleep in infants: a longitudinal objective assessment

Sleep patterns and temperament in the first year of life are closely related. However, research utilizing objective, rather than subjective measurements of sleep and temperament is scarce and results are inconsistent. In addition, a relative lack of longitudinal data prevents inference of causality between the two constructs. In this study, infant sleep was objectively assessed among 95 infants at 3, 6, and 12 months-of-age with an actigraph in the home setting. Reactivity to sound, light, and touch, a specific aspect of temperament, was behaviorally assessed at 3 and 6 months, both during sleep (at home) and during waking (at the laboratory). Expected maturational trends were recorded in sleep, with a temporal increase in sleep efficiency and percent of motionless sleep. Quadratic (i.e., inverse U shape) relations were found, especially among girls, when predicting change in sleep by reactivity thresholds, suggesting that both hyposensitive and hypersensitive infants are at risk for poor sleep quality. These are the first research findings suggesting that low reactivity in infancy might be associated with compromised sleep quality. The observed nonlinear effects may account for null or inconsistent results in previous studies that explored only linear associations between temperament and sleep. Future studies should address both extremes of the temperament continuum when exploring relations with sleep patterns.

Facial Expression in Response to Smell and Taste Stimuli in Small and Appropriate for Gestational Age Newborns

Small for gestational age newborns can later suffer from eating difficulties and slow growth. Nutritional preferences can be influenced by changes in sensory perception of smell and taste. To determine whether these could be detected at birth, the authors examined the different recognition pattern of smell and taste in small for gestational age newborns compared to appropriate for gestational age controls, as expressed by gusto-facial and naso-facial reflexes. The authors performed video analysis of facial expressions of 10 small for gestational age and 12 control newborns exposed to various tastes and smells. No difference in the facial recognition patterns for taste or smell was demonstrated between small for gestational age and controls, except for perception of distilled water. Newborns show recognizable patterns of facial expression in response to taste and smell stimuli. Perception of taste and smell in small for gestational age newborns is not different from controls, as measured by the method of facial recognition.

Higher Fat Content in Breastmilk Expressed Manually: A Randomized Trial

OBJECTIVE

This study aimed to evaluate the effect of milk expression method (manual expression versus electric pump) on the composition of breastmilk.

STUDY DESIGN

Data on 21 mothers of 21 newborns 48-72 hours postdelivery were collected and analyzed. The women were randomly assigned to express breastmilk manually followed by pump, or in reverse order. The fat, carbohydrate, and protein contents of the milk samples were analyzed using a human milk analyzer (Miris AB, Uppsala, Sweden).

RESULTS

The fat and energy contents of milk obtained through manual expression were higher than those obtained by pump (p=0.024 and p=0.04, respectively, by the Wilcoxon signed rank test). There were no significant differences in protein or carbohydrate content of milk obtained by either method of expression. The difference in fat content between milk obtained by the two methods was not correlated with mother's age, delivery method, gestational age at delivery, parity, or the interval between delivery and the time the sampled milk was obtained.

CONCLUSIONS

Manually expressed human milk had higher fat content than milk expressed by electric pump. We speculate that this difference is due to the presence of hindmilk in the manually expressed milk because the technique of massaging the breast during manual expression is more likely than the pump to eject hindmilk, which has been shown to have higher fat content than foremilk.

Sensitivity of the Automated Auditory Brainstem Response in Neonatal Hearing Screening

BACKGROUND

In a 2-stage neonatal hearing screening protocol, if an infant fails the first-stage abstract screening with an otoacoustic emissions test, an automated auditory brainstem response (ABR)test is performed. The purpose of this study was to estimate the rate of hearing loss detected byfirst-stage otoacoustic emissions test but missed by second-stage automated ABR testing.

METHODS

The data of 17 078 infants who were born at Lis Maternity Hospital between January 2013 and June 2014 were reviewed. Infants who failed screening with a transient evoked otoacoustic emissions (TEOAE) test and infants admitted to the NICU for more than 5 days underwent screening with an automated ABR test at 45 decibel hearing level (dB HL). All infants who failed screening with TEOAE were referred to a follow-up evaluation at the hearing clinic.

RESULTS

Twenty-four percent of the infants who failed the TEOAE and passed the automated ABR hearing screening tests were eventually diagnosed with hearing loss by diagnostic ABR testing (22/90). They comprised 52% of all of the infants in the birth cohort who were diagnosed with permanent or persistent hearing loss .25 dB HL in 1 or both ears (22/42).Hearing loss .45 dB HL, which is considered to be in the range of moderate to profound severity, was diagnosed in 36% of the infants in this group (8/22), comprising 42% of the infants with hearing loss of this degree (8/19).

CONCLUSIONS

The sensitivity of the diverse response detection methods of automated ABR devices needs to be further empirically evaluated.

Prevalence of breastfeeding difficulties in newborns with a lingual frenulum: a prospective cohort series

OBJECTIVE

The prevalence of a lingual frenulum in newborn infants is reportedly 0.3-12%. The purpose of this study was to describe the prevalence of a lingual frenulum based on the Coryllos classification in nonselected newborn infants after delivery, hypothesizing that it is higher than the values reported in the literature.

STUDY DESIGN

The lingual frenula of 200 healthy infants were evaluated by visual examination and palpation within the first 3 days after delivery. The frenulum was categorized according to the four Coryllos classifications. Each infant's mother responded, immediately after the examination, to a structured questionnaire on the quality and type of feeding. An additional structured telephone interview with the 179 breastfeeding mothers was conducted 2 weeks later.

RESULTS

All but one infant (n=199) had an observable or palpable lingual frenulum that was Coryllos type 1 (n=5), type 2 or 3 (n=147), or type 4 (n=47). Although our study was not powered enough to test for any correlation between the cessation of breastfeeding and the type of frenulum, we found no statistical correlation between the Coryllos type of lingual frenulum and the presence of breastfeeding difficulties.

CONCLUSIONS

A lingual frenulum is a normal anatomical finding whose insertion point and Coryllos classification are not correlated with breastfeeding difficulties. We suggest that the term "lingual frenulum" should be used for anatomical description and that the term "tongue-tie" be reserved for a lingual frenulum associated with breastfeeding difficulties in newborns.

Using topical benzocaine before lingual frenotomy did not reduce crying and should be discouraged

AIM

The US Food and Drug Administration has said that oral preparations containing benzocaine should only be used in infants under strict medical supervision, due to the rare, but potentially fatal, risk of methemoglobinemia. This study aimed to determine the analgesic effect of topical application of benzocaine prior to lingual frenotomy in infants with symptomatic tongue-tie. We hypothesised that the duration of crying immediately following frenotomy with topical benzocaine would be shorter than with no benzocaine.

METHODS

This randomised controlled study compared the length of crying after lingual frenotomy in term infants who did, or did not, receive topical application of benzocaine to the lingual frenulum prior to the procedure.

RESULTS

We recruited 21 infants to this study. Crying time was less than one minute in all of the subjects. The average length of crying in the benzocaine group (21.6 ± 13.6 sec) was longer than the length of crying in the control group (13.1 ± 4.0 sec), p = 0.103.

CONCLUSION

Contrary to our hypothesis, infants who were treated with topical benzocaine did not benefit from topical analgesia in terms of crying time. The use of benzocaine for analgesia prior to lingual frenotomy in term infants should therefore be discouraged.

Lingual frenotomy for breastfeeding difficulties: a prospective follow-up study

INTRODUCTION

Breastfeeding difficulties are sometimes attributable to tongue-tie with short-term relief after frenotomy. Limited follow-up is available, and predictors for nonsuccessful frenotomy have not yet been found.

PATIENTS AND METHODS

We recruited 264 mother-infant dyads who underwent lingual frenotomy for breastfeeding difficulties. Data regarding the indications, anatomy of the tongue, and the response of the infant were noted by the physician. Mothers were contacted by telephone at 2 weeks, 3 months, and 6 months after frenotomy to answer a questionnaire.

RESULTS

Two weeks after frenotomy, 89% of mothers were still breastfeeding. An improvement in breastfeeding was reported by three-quarters of the mothers, but, unexpectedly, 3% reported worsening. At 3 and 6 months after the procedure, 68% and 56% of mothers were still breastfeeding, respectively. We could not find any predictor to indicate those infants in whom breastfeeding would not improve.

CONCLUSIONS

There are favorable long-term effects of frenotomy on breastfeeding. Lingual frenotomy does not always alleviate breastfeeding difficulties, and rarely worsening ensues. We could not find any predictor for successful breastfeeding after frenotomy. We speculate that because the procedure is minor, in the event of breastfeeding difficulties, lingual frenotomy should be considered as an effective tool to assist in long-term breastfeeding.

Weight at weaning of preterm infants from incubator to bassinet: a randomized clinical trial

OBJECTIVE

To evaluate thermal responses, weight gain, and resting energy expenditure (REE) in preterm infants weaned from an infant incubator to a warming bassinet after reaching a body weight of either 1,500 or 1,600 g, respectively.

METHODS

Preterm infants weighing ≤ 1,500 g were randomly allocated for weaning from a convective incubator after reaching 1,500 g body weight (study group) or 1,600 g (controls). Postweaning body temperature was recorded at short intervals. REE was measured before and after weaning, while the weight gain was calculated daily.

RESULTS

All 21 enrolled infants were weaned successfully to a bassinet (room temperature). REE inside the incubator and in the warming bassinette was similar between infants weaned at 1,500 g and at 1,600 g (2.9 ± 6.8 vs. 1.1 ± 4.8 kcal/kg/d, respectively (p = 0.7). REE increased slightly after weaning in both groups. Weight gain and days from randomization to discharge did not differ between groups.

CONCLUSION

Weaning very low birth weight infants from an incubator to a warming bassinet at a body weight of 1,500 g is feasible and has no significant deleterious effects on weight gain and REE. The many benefits provided by such greater accessibility to premature infants are discussed.

The Prevalence of Alcohol, Substance and Cigarettes Exposure among Pregnant Women within a General Hospital and the Compliance to Brief Intervention for Exposure Reduction

BACKGROUND

Compliance and impact of a time-limited brief intervention (BI) for reducing exposure to alcohol, psychoactive substances and nicotine among women admitted to the hospital during pregnancy were assessed.

METHODS

Pregnant women (gestational week ≤30) from a medical center pre-delivery, emergency and high-risk units were interviewed about alcohol (AUDIT and TWEAK questionnaires), smoking (modified Fagerström) and psychoactive substance (modified ASI). All exposed women were invited to participate in a BI and underwent follow-up. Characteristics and rate of exposure were compared to a "standard-group" of non-selected women who arrived to the hospital directly solely to give birth.

RESULTS

Forty-six of the 108 study participants (42.6%) were exposed to smoking (85%), alcohol (41%), or drugs (39%), and 41 underwent the BI. Self-report of exposure was reduced significantly following BI but re-elevated post-delivery. Women belonging to the "standardgroup" were better educated, had lower lifetime rates of exposure, and gave birth to newborns with higher birth weights (3254.7±506.9 g vs. 2650.8±785.6 g for the study group).

CONCLUSION

Compliance of the exposed women to BI was high and contributed to exposure reduction during pregnancy but relapsed following delivery.

The effect of advanced maternal age upon human milk fat content

BACKGROUND

Little is known about the effect of maternal age on human milk (HM) composition. This study was designed to study fat content, estimated by creamatocrit (CMT), in HM collected in the first 2 weeks of life in older (≥ 35 years) compared with younger (<35 years) mothers.

STUDY DESIGN AND METHODS

Ninety lactating mothers (48 older, 42 younger) of newborns were recruited within the first 3 days of delivery. CMTs were measured at 72 hours, 7 days, and 14 days after delivery for HM in a capillary tube after centrifugation at 5,366 g for 5 minutes.

RESULTS

The groups did not differ in terms of maternal height and diet, infant birth weight, gestational age (GA), or pregnancy weight gain. They differed significantly in terms of maternal age and parity. Mean colostrum CMT was significantly higher in the group of older mothers. Colostrum CMT correlated positively with maternal age (R(2)=0.11, p=0.006) and inversely with GA (R(2)=0.1, p=0.03) but did not relate with either maternal weight or body mass index. CMT at age 7 days and 2 weeks was not affected by maternal age or GA. In multivariate regression analysis colostrum CMT correlated significantly only with maternal age and GA (R(2)=0.3, p<0.001).

CONCLUSIONS

Colostrum fat content of older mothers is much higher than that of younger mothers and inversely related with GA at delivery. This increase in colostrum fat content obtained from mothers with advanced age may be due to increased fat synthesis and excretion in milk, reduced water content of milk, or a combination of both.

Late-onset bloodstream infections in preterm infants: a 2-year survey

BACKGROUND

We determined the prevalence and risk factors for late-onset bloodstream infections (LO-BSI), the distribution of pathogens and the outcomes of affected preterm infants.

METHODS

The records of all preterm infants (<37 weeks gestation) born between 2004 and 2005 and hospitalized in the neonatal intensive care unit for >3 days were retrieved for this retrospective matched case-control study.

RESULTS

A total of 108 out of 1459 preterm infants (7.4%) had 142 episodes of LO-BSI. The highest LO-BSI rate (44%) was among 198 very-low-birthweight infants (<1500 g). The most common causative organisms were Coagulase-negative staphylococci and Klebsiella (60% and 13%, respectively). The mean hospital stay was 64 days for LO-BSI preterm infants versus 48 days for non-LO-BSI preterm infants. Congenital malformations and peripheral catheters were independent risk factors for LO-BSI. Crude mortality rates were 6.9% (LO-BSI) and 3.0% (non-LO-BSI), with an LO-BSI-attributable mortality of 3.9%.

CONCLUSION

LO-BSI frequently affect very-low-birthweight infants. Strategies to prevent LO-BSI should target peripheral catheters.

Neonatal absolute nucleated red blood cell counts do not predict the development of cystic periventricular leukomalacia

BACKGROUND

Infants with severe intraventricular-periventricular hemorrhage (IVH) have higher absolute nucleated red blood cell counts (aNRBC) at birth (a marker of intrauterine hypoxia) than controls. Periventricular leukomalacia (PVL) is known to be associated with prenatal and postnatal events. Whether PVL is also linked to intrauterine hypoxia is unknown.

OBJECTIVES

To test the hypothesis that infants with PVL have higher aNRBC counts at birth than controls.

METHODS

We studied 14 very low birth weight infants with PVL and compared them with 14 pair-matched controls without PVL. Head ultrasound scans were performed in all infants on days 3-5 and 21-25 of life. Paired tests, Fisher exact tests and stepwise logistic regression were performed for analysis.

RESULTS

The groups were similar for gestational age (GA), birth weight (BW), prolonged rupture of membranes (PROM), Apgar scores, IVH, and aNRBC counts. PVL correlated significantly with low partial pressure of CO2 (PCO2) and IVH (P < 0.01). In logistic regression, when GA, gender, PROM, antenatal steroid therapy, 1 (or 5) minute Apgar scores, IVH grade, nosocomial sepsis, patent ductus arteriosus, necrotizing enterocolitis (NEC), need for pressors, aNRBC counts and lowest PCO2 were used as independent variables, PCO2 (P = 0.002), IVH grade (P= 0.001), GA (P = 0.038), NEC (P = 0.061) and use of dopamine (P = 0.010) remained in the analysis (total R2 = 68.2%).

CONCLUSIONS

In contrast to severe IVH, aNRBC counts do not predict the development of PVL.

Changes in serum parathyroid hormone-related protein in breastfed preterm infants

BACKGROUND

Parathyroid hormone-related protein (PTHrP) has the ability to activate parathyroid hormone receptors and cause hypercalcemia. In a previous study we have demonstrated high concentrations of PTHrP in both term and preterm human milk (HM). PTHrP intestinal absorption and its influence upon calcium homeostasis of the preterm infant have not been studied yet. This study assessed the correlation between PTHrP concentrations in preterm HM and PTHrP in maternal and neonatal serum.

STUDY DESIGN

We collected samples of expressed HM obtained from 16 mothers of preterm infants (25-34 weeks of gestation) and drew blood samples from both mothers and infants on postpartum days 2 and 10. PTHrP concentrations were measured by two-site immunoradiometric assay. Blood calcium (Ca), phosphorus (P), and alkaline phosphatase (ALP) concentrations were also measured.

RESULTS

Neither maternal nor neonatal PTHrP serum concentrations varied significantly after 10 days of breastfeeding. There was a correlation between PTHrP concentrations in maternal serum and HM concentrations (R² = 0.24, p = 0.04), but not between HM and neonatal serum concentrations or between PTHrP concentrations in HM and preterm serum concentrations of Ca, P, and ALP.

CONCLUSIONS

Despite high concentrations of PTHrP in preterm HM, serum concentrations of PTHrP of breastfed preterm infants did not increase over time. There was no correlation between PTHrP concentrations in HM and neonatal serum Ca concentration.

Human milk fatty acids profile changes during prolonged lactation: a cross-sectional study

BACKGROUND

Human milk produced during prolonged lactation (> 1 year) is extraordinarily rich in fat and has a higher energy content than human milk produced during short lactation.

OBJECTIVES

To estimate the fatty acid (FA) profile of human milk and to test the hypothesis that the proportion of C12 and C14 (two dietary saturated FA known to most promote hypercholesterolemia) in human milk during prolonged lactation is similar to that in short lactation.

METHODS

We conducted a cross-sectional study of 30 mothers of term infants lactating for more than 1 year as compared with 25 mothers of full-term infants who lactated for 2-6 months. Milk was collected by manual expression in mid-breastfeeding.

RESULTS

The two groups did not differ in maternal height, weight, body mass index, diet, infant birth weight and gestational age, but mothers in the prolonged lactation group were significantly older. There was a significant correlation between lactation duration and C12 or C14. The percentage of all FA combined (except for C12 and C14) decreased significantly overtime. In contrast, C12:0 and C14:0 combined increased significantly during lactation (R2 = 10.0%, P < 0.03).

CONCLUSIONS

Women who lactated for more than 1 year had higher C12 and C14 FA percentages in their milk than women who lactated for 2-6 months.

The effect of olfactory stimulation on energy expenditure in growing preterm infants

AIM

To test the hypothesis that olfactory stimulation in growing healthy preterm infants leads to an increase in resting energy expenditure (REE).

DESIGN

A prospective, randomized clinical trial with crossover was conducted in 20 healthy, appropriate weights for gestational age, gavage-fed preterm infants. Infants were studied while asleep and cared for in a skin servo-controlled convective incubator. Using a pipette, 15 drops of saturated solution of vanillin (Aldrich, Fallavier, France) were dripped to a cloth diaper that was placed on the opposite side of the incubator. REE was measured by indirect calorimetry (DeltaTrac II, Helsinki, Finland) exactly 1 h after feeding. Each infant was studied twice by randomization: after a period of 20 min of vanillin odour or after 20 min without vanillin odour.

RESULTS

We found no statistically significant difference in REE of preterm infants when exposed to vanillin odour (74.5 ± 10.1 kcal/kg/day) in comparison with their REE when not exposed to vanillin odour (79.0 ± 11.3 kcal/kg/day).

CONCLUSIONS

Vanillin odour does not significantly influence REE in metabolically and thermally stable preterm infants.

Neonatal polycythaemia: critical review and a consensus statement of the Israeli Neonatology Association

The aim of this paper is to critically review neonatal polycythaemia (NP) literature, in terms of definition, diagnosis and management. We reviewed all Medline articles on NP up to December 2009. (i) The textbook definition of NP [venous haematocrit (HCT) > 65%] is empirical and not based on statistical definition, symptoms or complications. (ii) Measurement of viscosity is not better than HCT in predicting complications. (iii) Normovolaemic NP because of increased erythropoiesis may be different from hypervolaemic polycythaemia because of excessive foetal transfusion. (iv) Coexisting hypoglycaemia may worsen long-term outcome. (v) Four clinical trials (CTs) studied partial exchange transfusion (PET) on outcomes. In all trials, PET was performed after 6 h of life. There is no evidence that PET improves neurodevelopmental outcome of asymptomatic NP, and it might increase the risk of necrotizing enterocolitis. These CTs have inherent design flaws: (a) CNS 'damage' may occur before PET. (b) Confounding variables that may affect outcome have not been studied. (vi) If PET is performed, normal saline is the best alternative. (vii) The long-term effect of PET on symptomatic infants has not been studied.

CONCLUSION

Current definition and management of NP are little evidence based, thus the need for a consensus based on expert opinion.

[Neonatal tongue-tie: myths and science]

Anatomical restraining of tongue movement (tongue-tie, ankyloglossia) has been known for centuries and the subject of dozens of articles. The heated debate persists on its clinical significance and indications for treatment. Most authorities in the field of infant feeding and Lactation agree that breastfeeding problems, such as nipple pain and latching difficulties, are common signs of clinicaLly significant tongue-tie and indications for performing a frenotomy, while the sole presence of a visible lingual frenulum is not. In contrast, the lack of a visible frenulum does not rule out the diagnosis of clinically significant tongue-tie since submucosal ties, also called "posterior tongue-tie", may interfere with efficient breastfeeding. Whether tongue-tie interferes with speech articulation to a significant extent is currently unknown. Theoretically, articulation of some consonants (e.g., /s/, /th/, /r/) would be affected by impeded tongue movement. These articulation problems are, however, Less common than tongue-tie itself, and children and adults characteristically use various compensatory techniques of mouth opening and tongue movements. When it is indicated, frenotomy is performed by lifting the tongue and snipping the frenulum with scissors. Complications of frenotomy are rare and consist mainly of self-limited minor bleeding. The significance of posterior tongue tie and the long-term effects of frenotomy performed during early infancy are unresolved issues.

Neonatal blood glucose concentrations in caesarean and vaginally delivered term infants

BACKGROUND

Little is known about the glucose concentrations at and after birth of infants delivered by caesarean section (CS), when compared with infants born vaginally (VD).

AIM

To compare venous cord blood glucose concentrations of term infants born after elective CS to infants born by VD. We studied the null hypothesis that mode of delivery does not affect neonatal blood glucose values.

METHODS

We compared cord blood glucose concentrations in healthy term infants born after VD (n = 16) or by elective CS (n = 21). Glucose concentrations were obtained immediately at birth from the umbilical cord. Kruskal-Wallis was used to compare glucose concentrations and demographic variables between the groups.

RESULTS

Gestational age was 39.6 ± 0.8 weeks in VD group vs. 38.7 ± 0.9 weeks in CS group, and birthweight was 3359 ± 494 vs. 3500 ± 528 g. Cord blood glucose concentration was higher in VD (81.3 ± 16.9 mg/dL) than CS infants (70.3 ± 9.7 mg/dL, p = 0.039). The change in blood glucose concentration over the first 2-h of life differed significantly between the two groups, being an increase in CS versus a decrease in VD infants (-3.5 ± 15.2 vs. -15.4 ± 24.6 mg/dL, p = 0.013).

CONCLUSIONS

Glucose concentrations in VD infants are higher than in infants born by elective CS without labour.

Effect of magnesium sulfate concentration on serum ionized magnesium in vitro

We undertook this in vitro study to quantify the effect that addition of magnesium (Mg) sulfate to neonatal serum, as compared with adult serum, might have on ionized Mg (Mg (2+)) concentration. We used one cord blood sample and one adult blood sample that we made hypermagnesemic by adding various amounts of magnesium sulfate to study five levels of serum Mg. Each sample was then studied at one of three levels of pH, from extreme alkalosis to extreme acidosis. We measured the changes in serum Mg (2+) and serum ionized calcium (Ca (2+)) in reaction to these changes in pH and Mg. At each pH level, there was an exponential increase in the serum Mg (2+) (and no significant change in serum Ca (2+)) with increasing serum Mg. Multiple regression analysis using Mg (2+) as the dependent variable and baseline Ca (2+), phosphorous, albumin, and blood type (adult versus cord blood) as well as blood pH and serum Mg as independent variables indicated that serum Mg and pH were the only variables significantly influencing serum Mg (2+). Within the range of serum Mg considered, the addition of magnesium sulfate in vitro causes an exponential increase in Mg (2+) and no significant change in serum Ca (2+).

Parathyroid hormone-related protein in preterm human milk

BACKGROUND

Parathyroid hormone-related protein (PTHrP) has the ability to activate parathyroid hormone receptors and cause hypercalcemia. High concentrations of PTHrP are found in human breastmilk of mothers of term-infants. It is not known whether PTHrP is excreted in preterm human milk. This study tested the hypothesis that PTHrP concentrations in milk obtained from mothers of preterm infants are similar to those found in milk from mothers of term infants.

METHODS

We collected samples of expressed human milk obtained from 27 mothers of preterm infants (27-34 weeks' gestation) and from 16 mothers of full-term infants. Samples were collected within the first 72 hours postpartum (colostrum) and again at 1 and 2 weeks postpartum. PTHrP concentrations in these samples were measured by two-site immunoradiometric assay.

RESULTS

PTHrP concentrations were significantly higher in samples obtained after 1 week postpartum than in samples obtained during the first 72 hours of life in breastmilk obtained from mothers of both term and preterm infants (P < 0.0001). PTHrP concentrations were similar in colostrum and after 1 week in term and preterm milk. PTHrP concentrations after 2 weeks of lactation were significantly higher in samples obtained from mothers of term infants (P < 0.006).

CONCLUSION

Human milk expressed by mothers of preterm infants contains amounts of PTHrP similar to those measured in milk expressed by mothers of term infants.

Effect of music by Mozart on energy expenditure in growing preterm infants

OBJECTIVE

The rate of weight gain in preterm infants who are exposed to music seems to improve. A potential mechanism could be increased metabolic efficiency; therefore, we conducted this study to test the hypothesis that music by Mozart reduces resting energy expenditure (REE) in growing healthy preterm infants. DESIGN. A prospective, randomized clinical trial with crossover was conducted in 20 healthy, appropriate-weight-for-gestational-age, gavage-fed preterm infants. Infants were randomly assigned to be exposed to a 30-minute period of Mozart music or no music on 2 consecutive days. Metabolic measurements were performed by indirect calorimetry.

RESULTS

REE was similar during the first 10-minute period of both randomization groups. During the next 10-minute period, infants who were exposed to music had a significantly lower REE than when not exposed to music (P = .028). This was also true during the third 10-minute period (P = .03). Thus, on average, the effect size of music on REE is a reduction of approximately 10% to 13% from baseline, an effect obtained within 10 to 30 minutes.

CONCLUSIONS

Exposure to Mozart music significantly lowers REE in healthy preterm infants. We speculate that this effect of music on REE might explain, in part, the improved weight gain that results from this "Mozart effect."

Energy expenditure for breastfeeding and bottle-feeding preterm infants

OBJECTIVE

We hypothesized that resting energy expenditure (REE) would be higher after breastfeeding than after bottle-feeding.

METHODS

Nineteen preterm infants (gestational age: 32 weeks) in stable condition who were nourished entirely with their mothers' breast milk were assigned randomly to feeding either by bottle or at the breast. Each infant served as his or her own control subject. REE was measured for 20 minutes after feeding. Breast milk quantity was evaluated with prefeeding and postfeeding weighing. REE values for bottle-feeding and breastfeeding were compared with paired t tests.

RESULTS

Contrary to our null hypothesis, the group's mean REE values after bottle-feeding and breastfeeding were very similar (284.7 +/- 26.8 kJ/kg per day [68.3 +/- 6.4 kcal/kg per day] vs 282.6 +/- 28.5 kJ/kg per day [67.5 +/- 6.8 kcal/kg per day]; not significant). The duration of feeding was significantly longer for breastfeeding than for bottle-feeding (20.1 +/- 7.9 vs 7.8 +/- 2.9 minutes; P < .0001).

CONCLUSION

There was no significant difference in REE when infants were breastfed versus bottle-fed. Longer feeding times at the breast did not increase REE. We speculate that it is safe to recommend feeding at the breast for infants born at >32 weeks when they can tolerate oral feeding.

Sleep and physical growth in infants during the first 6 months

The aim of this study was to explore the relationships between infant sleep patterns and infant physical growth (weight for length ratio) using both objective and subjective sleep measures. Ninety-six first-born, healthy 6-month-old infants and their parents participated in the study. Infant sleep was assessed by actigraphy for four consecutive nights and by the Brief Infant Sleep Questionnaire (BISQ). In addition, parents were asked to complete background and developmental questionnaires. Questions about feeding methods were included in the developmental questionnaire. Infants' weight and length were assessed during a standard checkup at the infant-care clinic when the infants were 6 months old. Significant correlations were found between infant sleep and growth after controlling for potential infant and family confounding factors. Actigraphic sleep percentage and reported sleep duration were correlated negatively with the weight-to-length ratio measures. Sex-related differences in the associations between sleep and physical growth were found. Breast feeding at night was correlated with a more fragmented sleep, but not with physical growth. These findings suggest that sleep is related significantly to physical growth as early as in the first months of life. The study supports increasing evidence from recent studies demonstrating a link between short sleep duration and weight gain and obesity in young children.

Neonatal respiratory morbidity after elective cesarean section

OBJECTIVE

The objective of this study was to examine the rate of respiratory morbidity in neonates delivered by elective cesarean delivery (ECD) at term, with a definite confirmation of gestational age (GA) by 1st-trimester ultrasound.

METHODS

Consecutive women carrying a singleton pregnancy and undergoing ECD at term (>38 1/7 weeks), confirmed by 1st-trimester ultrasound, were included in the study group. Multiple gestations, cesarean section (CS) in labor, CS performed after rupture of membranes and induced deliveries were excluded. The control group included women with a singleton pregnancy at term (>38 1/7 weeks) who delivered spontaneously. This group of women was randomly selected during the study period.

RESULTS

The study group included 277 women delivered by ECD. The control group consisted of 311 women. Five newborns in the study group and none in the control group were admitted to the neonatal intensive care unit (NICU) due to respiratory disorders (p < 0.02). Excluding diabetic women did not change the results. On multivariate analysis, no other factors were found to independently influence the risk of respiratory complications.

CONCLUSION

In our study, the rate of respiratory morbidity was found to be significantly higher in neonates delivered by ECD compared to those delivered vaginally. The fact that GA was confirmed by 1st-trimester ultrasound makes iatrogenic prematurity an unlikely sole cause for this excess morbidity.

Effect of birth weight and postnatal age upon resting energy expenditure in preterm infants

Our objective was to establish the role of gestational age, birth weight, and postnatal age upon resting energy expenditure (REE) in incubated preterm infants. We hypothesized that at the time these infants are close to being weaned from their incubator, their REE is inversely related to gestational age or birth weight and directly related to postnatal age and weight gain. Infants born at a birth weight of 500 to 2000 g were eligible for the study when they reached a weight of 1500 to 2100 g. All infants were clinically and thermally stable while cared for in a skin servo controlled incubator. REE (kcal/kg body weight/d) was measured 2 hours after feeding while the infants were quietly asleep, using a Datex oxygen consumption analyzer (DELTATRAC II (TM); Datex-Ohmeda Instrumentarium, Helsinki, Finland), based on the principles of indirect calorimetry. There were 42 infants recruited in the study. In univariate analysis, no significant correlation was found between gestational age and REE, but REE was significantly and inversely correlated with birth weight ( R(2) = 0.243, P < 0.001). There was also a significant correlation between REE and postnatal age ( R(2) = 0.203, P = 0.003) and with weight gain ( R(2) = 0.176, P = 0.006). In backward stepwise regression analysis, the effect of birth weight or postnatal age or daily weight gain (g) upon REE remained significant even after taking into account sex, energy intake, and type of feeding. Birth weight, postnatal age, and daily weight gain significantly affect REE, even after taking into account energy intake, sex, and type of feeding. Weight may be a more important parameter in the control of thermoregulation of the preterm infant than gestational age.

When should phototherapy be stopped? A pilot study comparing two targets of serum bilirubin concentration

OBJECTIVE

The objective of this study was to compare the outcome of two groups of jaundiced newborns randomized to one of the two targets of total serum bilirubin (TSB) for phototherapy discontinuation.

DESIGN

Infants treated with phototherapy were assigned to two groups: in the 'high-threshold' group, phototherapy was interrupted when TSB decreased to >/=1 mg/dL (17 micromol/L) below the limit requiring phototherapy and in the 'low-threshold' group when TSB decreased to >/=3 mg/dL (51 micromol/L) below the same limit.

RESULTS

Fifty-two infants were enrolled, 25 in the high- and 27 in the low-threshold group. Phototherapy duration was significantly shorter in the high- than in the low-threshold group (22.3 +/- 13 vs. 27.6 +/- 12 h, respectively, p = 0.03). Length of hospital stay was 84+/-30 h in the high- and 94 +/- 24 h in the low-threshold group (p = 0.05). Additional phototherapy was required in 20% of the high- versus 18% of the low-threshold group (p = 0.58). In the presence of haemolysis or G6PD deficiency, 28% of the infants required re-phototherapy and 8.3% when such factors were absent (p = 0.06).

CONCLUSION

Phototherapy duration may be shortened by using higher TSB limits for interruption. When hyperbilirubinaemia is accompanied by risk factors, the infants should be followed for longer periods, since some of them will need re-phototherapy.

Reducing blood transfusion requirements in preterm infants by a new device: a pilot study

OBJECTIVE

To test a new device designed to salvage red blood cells (RBCs) from blood samples drawn from preterm infants, with the intent of decreasing blood loss and lowering the requirements for RBC transfusions.

DESIGN

A case-controlled pilot study was conducted in two Israeli neonatal intensive care units in large municipal hospitals. Twenty low-birthweight preterm infants were randomly and equally divided into the ErythroSave group or a control group. All blood tests in the study group (except for complete blood count and coagulation parameters) were obtained during the first week of life by the new device in the study group and by ordinary syringes in the control group. The main outcome measure was the total number of units of blood needed.

RESULTS

The average volume of blood obtained for laboratory analyses from each infant was 27 mL in the ErythroSave group and 24 mL in controls (not significant). The average volume of transfused packed cells was 6.4 mL for the ErythroSave group and 21.3 mL for the controls (p = 0.008).

CONCLUSION

The use of ErythroSave for sampling blood significantly reduced blood transfusion requirements in premature infants compared to sampling by conventional syringes.

Energy expenditure in growing preterm infants receiving massage therapy

OBJECTIVE

Massage therapy has been consistently shown to increase weight gain in preterm infants. The mechanism of this presumed improved metabolic efficiency is unknown. We conducted the following trial to test the hypothesis that massage therapy reduces energy expenditure in growing healthy preterm infants.

STUDY DESIGN

A prospective, randomized, cross-over design study was conducted in 10 healthy, appropriate weights for gestational age, gavage fed preterm infants. Each infant was studied twice: after a period of either 5 days of massage therapy, or after a period of 5 days without massage therapy. Infants were randomized to 5 days of massage followed by 5 days of no massage (n = 5) or the opposite sequence (n = 5). During the massage therapy period, massage was provided daily for three 15 minute periods at the beginning of each 3 hour period every morning. Metabolic measurements were performed by indirect calorimetry, using the Deltatrac II Metabolic cart.

RESULTS

Energy expenditure was significantly lower in infants after the 5 day massage therapy period (59.6 +/- 3.6 Kcal/Kg/ 24 hours) than after the period without (63.1 +/- 5.4 Kcal/Kg/ 24 hours) (p = 0.05).

CONCLUSIONS

Energy expenditure is significantly lowered by 5 days of massage therapy in metabolically and thermally stable preterm infants. This decrease in energy expenditure may be in part responsible for the enhanced growth caused by massage therapy.

Neonatal nucleated red blood cells in infants of overweight and obese mothers

OBJECTIVE

The perinatal outcome of the infant of obese mother is adversely affected and in theory, may involve fetal hypoxia. We hypothesized that an index of fetal hypoxia, the neonatal nucleated red blood cell (NRBC) count, is elevated in infants of overweight and obese mothers.

STUDY DESIGN

Absolute NRBC counts taken during the first 12 hours of life in 41 infants of overweight and obese mothers were compared to 28 controls.

RESULTS

Maternal body mass index and infant birthweight were significantly higher in the overweight and obese group (P < 0.01). Hematocrit, corrected white blood cell and lymphocyte counts did not differ between groups. The absolute NRBC count was higher (P = 0.01), and the platelet count lower (P = 0.05) in infants of overweight and obese mothers than in controls. In stepwise regression analysis, the absolute NRBC count in infants of overweight and obese mothers remained significantly higher even after taking into account birthweight or gestational age and Apgar scores (P < 0.02).

CONCLUSION

Infants of overweight and obese mothers have increased nucleated red blood cells at birth compared with controls. We speculate that even apparently healthy fetuses of overweight and obese mothers are exposed to a subtle hypoxemic environment.

Increased energy expenditure after dilutional exchange transfusion for neonatal polycythemia

OBJECTIVE

Hypothermia is a known symptom of neonatal polycythemia (NP) and its pathophysiology is unclear. The effect of partial dilutional exchange transfusion (PET) upon resting energy expenditure (REE) is unknown. We aimed to test the hypothesis that PET leads to an increase in REE.

STUDY DESIGN

11 patients with NP who underwent PET and 10 controls without polycythemia were studied. NP was defined as a venous HCT >/=0.65. Per protocol, symptomatic infants and/or those with venous HCT > or =0.70 underwent PET. REE was measured just prior and 23 hours after PET in patients with NP and at identical ages in the control group. Infants were studied in a skin servo controlled radiant warmer, while clinically and thermally stable, prone and asleep. Measurements were stopped during body movements (less than 5% of the time of measurement). Metabolic measurements were performed by indirect calorimetry, using the Deltatrac II Metabolic monitor (Datex-Ohmeda, Helsinki, Finland). This instrument uses the principle of the open circuit system that allows continuous measurements of oxygen consumption (Vo(2)) and carbon dioxide production (Vco(2)) using a constant flow generator. REE measurements were corrected for the infant weight (Kcal/kg/d). Comparison of REE values between groups was performed using paired Wilcoxon ranked test.

RESULTS

Patients with and without NP had nearly identical baseline REE. In patients with NP, REE increased from 44.0 +/- 6.6 Kcal/Kg/d to 48.3 +/- 5.1 Kcal/Kg/d after PET (P<0.05). Furthermore, the increase in REE following PET correlated inversely with the decrease in hematocrit. There was no significant change in REE over time in the control group. In the NP group, symptomatic infants (n=5) had a significantly greater increase in REE following PET than non-symptomatic ones (1.4 +/- 6.3 vs. 7.8 +/- 4.9 Kcal/Kg/d, p<0.05).

CONCLUSIONS

Energy expenditure of polycythemic infants increases following PET, in a manner proportional to the decrease in hematocrit. Symptomatic polycythemic infants have a greater rise in REE following PET than non-symptomatic ones. We speculate that polycythemia leads to a decreased REE that might be remedied by PET.

Consistent circadian variations in creamatocrit over the first 7 weeks of lactation: a longitudinal study

OBJECTIVE

The objective of this study was to test the hypothesis that fat content of expressed human milk from mothers of preterm infants is higher in samples expressed in the evening than in the morning during the first 7 weeks of lactation.

METHODS

The authors collected samples of expressed human milk obtained from 22 mothers of growing preterm infants, born at 26 to 31 weeks gestation, who routinely expressed all their milk every 3 hours using breast pump from the beginning of the second week to the seventh week after delivery. One aliquot was obtained from the first morning expression and the second from the evening expression. The entire aliquot was collected and mixed, and creamatocrit (CMT) was measured in a capillary. Results are expressed as mean +/- standard deviation (SD), and analyses were by repeated measures analysis of variance.

RESULTS

Mean CMT was significantly higher in evening than morning samples during the whole lactation period, week after week (p < 0.0001). Neither CMT values nor the morning-evening difference in CMT values correlated with gestational age, birth weight, or week of lactation. Morning CMT correlated significantly with evening CMT (R(2) = 0.28, p < 0.0001).

CONCLUSIONS

Circadian variations in CMT are consistent during the first 7 weeks of lactation. The authors speculate that if higher caloric content expressed human milk is needed in a specific preterm infant, evening samples should be used preferentially, if available.

Changes in energy expenditure in preterm infants during weaning: a randomized comparison of two weaning methods from an incubator

We aimed to compare resting energy expenditure (REE) of infants exposed to either one of two weaning methods and to confirm the increase in REE during weaning from incubator. The study was a prospective randomized clinical trial of weaning preterm infants using either of two methods. REE was measured at baseline and 6, 23, 30, and 47 h, using indirect calorimetry. At measurement, infants were clinically and thermally stable, asleep, 2 h after feeding. Forty-two patients were randomized to "open incubator" (n = 23) or "warming bassinet" (n = 19). The groups did not differ in baseline clinical characteristics. REE increased significantly in both groups within 23 h, and remained stable at 30 and 47 h. At 6 and 23 h, the incubator group had significantly higher increase in REE than the warming bassinet group. By 30 h and at 47 h post-weaning, the REE of both groups became similar. In conclusion, REE increases significantly at weaning from incubator. The warming bassinet delays the increase in REE observed when infants are weaned using a turned off incubator. Whether one method is superior to the other in terms of thermic stress cannot be determined from this study.

Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study

PURPOSE

Ankyloglossia ("tongue-tie") occurs in nearly 5% of neonates, but its clinical significance relating to breast-feeding difficulties is controversial. We tested the hypothesis that in infants with ankyloglossia referred because of breast-feeding difficulties, frenotomy alleviates the symptoms.

METHODS

Twenty-five mothers of healthy infants with ankyloglossia were recruited because of sore nipples. Infants were randomized to either of 2 sequences: (1) frenotomy, breast-feeding, sham, breast-feeding (n = 14) or (2) sham, breast-feeding, frenotomy, breast-feeding (n = 11). The mothers as well as all personnel taking care of the child after each sham or frenotomy procedure were masked as to the study sequence. In every sequence, and after each sham or frenotomy procedure, a standardized latch score and pain score were obtained from the mother.

RESULTS

There was a significant decrease in pain score after frenotomy than after sham (P = .001). There was also a nearly significant improvement in latch after the frenotomy in these mothers (P = .06).

CONCLUSION

Frenotomy appears to alleviate nipple pain immediately after frenotomy. We speculate that ankyloglossia plays a significant role in early breast-feeding difficulties, and that frenotomy is an effective therapy for these difficulties.

Circadian variations in fat content of expressed breast milk from mothers of preterm infants

BACKGROUND

Little is known about circadian variations of the fat content in expressed human milk by mothers of preterm infants.

OBJECTIVE

To test the hypothesis that the fat content of expressed preterm human milk is higher in samples expressed in the evening (i.e. after 3 daily meals) than in the morning (after a night-long fast).

METHODS

We collected samples of expressed human milk obtained from 39 mothers of hospitalized growing preterm infants aged 7-14 days, with a gestational age at birth ranging from 26 to 33 weeks, who routinely expressed all their milk every 3 hours, during the day time, just before bed time, and as soon as they woke up, using a commercial breast pump (Medela AG, Baar, Switzerland). One sample was obtained from the first morning expression (between 0600 and 0900) and the second from the evening expression (between 2100 and 2400). The entire quantity of expressed milk was collected, mixed and measured in a capillary tube after centrifugation at 9000 rpm for 5 minutes. Creamatocrits (CMT) were performed in duplicates. Each sample was read independently by 2 investigators who were not aware of the origin and time of sampling and the results were averaged. Results are expressed as mean +/- SD, and analyses were by paired t-test and regression analysis.

RESULTS

CMT was significantly higher in evening than in morning samples (7.9 +/- 2.9% vs. 6.6 +/- 2.8%, P = 0.005). Neither CMT nor the morning-evening difference in CMT correlated with gestational age or birthweight. The morning CMT correlated significantly with the evening CMT (P < 0.001).

CONCLUSIONS

There are significant circadian variations in the CMT of expressed preterm human milk. We speculate that if higher caloric content of expressed human milk is needed in a specific preterm infant, evening sample, if available, should be used preferentially.

The prevalence of regurgitations in the first 2 days of life in human milk- and formula-fed term infants

PURPOSE

Very little is known about the prevalence of regurgitations in human milk-fed infants in the first days of life. The authors aimed to compare the frequency of regurgitations in formula- and breastfed infants in the first 2 days of life. It was hypothesized that human milk-fed infants experience less episodes of regurgitations than their formula-fed counterparts. DESIGN, SAMPLE, AND OUTCOME VARIABLES: Thirty-two (32) infants were formula fed and 31 were breastfed. In both groups, infants were fed ad libitum, as soon as the mother was ready to feed the infant. All regurgitations were noted on a collection form.

RESULTS

The number of regurgitations per infant in the first 48 hours of life was similar in breastfed (range 0 to 7) and formula-fed infants (range 0 to 8). There was also no difference in the number of regurgitations in the first or second 24-hour period. Eighteen of 31 of infants in the breastfed group and 17/32 in the formula fed groups had at least one episode of regurgitation during the 48-hour period.

CONCLUSIONS

Contrary to this hypothesis, human milk feeding did not confer a "protection" on regurgitations in these young neonates.