The impact of kangaroo mother care on work of breathing and oxygen saturation in very low birth weight infants with respiratory insufficiency

BACKGROUND: Kangaroo mother care (KMC) is defined as prolonged skin to skin care between a mother and infant with the infant lying in prone position on mom’s chest. KMC decreases morbidity and mortality and promotes physiologic stability. The aim of this study is to measure work of breathing (WOB) during KMC in very low birth weight (VLBW) infants on non-invasive respiratory support. METHODS: A prospective observational pilot study was conducted comparing WOB indices during standard care (SC) and KMC. Respiratory inductive plethysmography (RIP) measured WOB indices non-invasively: phase angle and labored breathing index. VLBW infants who were stable on non-invasive respiratory support were randomized to receive RIP measurements during KMC or during SC first. Summary statistics and mixed linear models were used to compare WOB and vital signs. RESULTS: A total of 32 infants were consented for the study, data collection and analysis was completed on 28 infants. There were no significant differences in mean phase angle during KMC or SC (73.5±4.6 SE deg vs 66.8±3.9 SE deg, p = 0.25). No differences in WOB and vital signs were detected. Controlling for respiratory support or randomization/first location did not change the results. CONCLUSION: In this pilot cohort, infants demonstrated no differences in work of breathing indices or oxygen saturation during KMC or SC while receiving non-invasive respiratory support. KMC appears to be safe and well tolerated with no worsened WOB. Larger studies should be performed to confirm our findings.

Characterization of Spirituality in Parents of Very Preterm Infants in a Neonatal Intensive Care Unit

OBJECTIVE

 This study aimed to characterize the spiritual beliefs, practices, and needs of parents of very preterm infants, those born <32 weeks of gestation, in a level-III NICU and to characterize parental perception of the spiritual support received in the neonatal intensive care unit (NICU).

STUDY DESIGN

 Within 14 days of their infants' birth, parents underwent a recorded semistructured interview. Responses were organized into unique themes using standard qualitative methods. Parents completed the Spiritual Involvement and Beliefs Scale (SIBS) and Spiritual Needs Inventory (SNI).

RESULTS

 Twenty-six parents from 17 families were interviewed and provided SIBS and SNI surveys. Interviews yielded seven major themes describing parents' spirituality and support. Most parents identified themselves as spiritual (n = 14) or sometimes spiritual (n = 2). A high SIBS score was associated with Christian religion (p = 0.007) and non-White race (p = 0.02). The SNI showed ≥80% of parents reported a "frequent" or "always" need for laughter, being with family, thinking happy thoughts, and talking about day-to-day things. The most commonly mentioned sources of spiritual support were parents' connection with a higher power through their faith (n = 12) or religious activities (n = 8). Many parents reported receiving sufficient spiritual support outside of the hospital during their unique experience in the NICU.

CONCLUSION

 Parents of infants born <32 weeks of gestation in our NICU commonly self-identified themselves as spiritual. Many parents have similar spiritual needs which are often met by sources outside of the hospital.

KEY POINTS

· Parents of infants born <32 weeks of gestation in our NICU commonly self-identify as spiritual.. · Many parents of preterm infants describe their spirituality as a personal experience.. · Many parents of preterm infants have similar spiritual needs.. · Many parents of preterm infants have their spiritual needs met outside of the hospital..

Relationship Between Placental Weight and Placental Pathology With MRI Findings in Mild to Moderate Hypoxic Ischemic Encephalopathy

Introduction

The placenta plays a critical role in fetal growth and development. Examination of the placenta may provide information on the timing and extent of adverse prenatal and perinatal events. Multiple studies demonstrate an association between placental changes and hypoxic-ischemic encephalopathy (HIE), but there are limited data on the association between placental pathology and MRI changes in HIE. This study assesses the relationship between placental pathology and MRI abnormalities in infants with HIE after receiving therapeutic hypothermia.

Methods

A retrospective study of 138 full-term infants who underwent therapeutic hypothermia for HIE at a single delivery center. Using logistic regression models, placental pathology and MRI results were analyzed to determine if placental abnormalities are associated with more significant MRI abnormalities. Placentas matched by gestational age and birthweight from a sample of convenience were included for comparison.

Results

Of the 138 infants who underwent therapeutic hypothermia for HIE, 84 had placental pathology and MRIs available. Of these, 30 had normal, and 54 had abnormal MRIs. Placental changes are not observed more frequently in the HIE cohort with abnormal MRI. Increased placenta weight: birthweight ratio is independently associated with increased odds of moderate-severe HIE compared to a convenient sample.

Conclusion

In a study sample of babies with HIE, placental pathology was not associated with subsequent abnormal MRI findings. Compared to matched controls, babies with HIE had an elevation in placental weight/birthweight.

Breastfeeding and Formula Selection in Neonatal Abstinence Syndrome

OBJECTIVE

This study aimed to determine if formula selection, low lactose versus standard term formula, has an effect on outcomes with a comparison to breastfed infants.

STUDY DESIGN

Retrospective cohort study of neonates ≥35 weeks gestation born with Neonatal Abstinence Syndrome (NAS) was conducted from July 2014 to November 2016. Primary outcomes included length of pharmacologic treatment (LOT), and length of stay (LOS), and weight change per day comparing term standard and low lactose formula majority feeding infants with secondary outcomes comparing breast fed majority feeding infants.

RESULTS

After investigating feeding methods for 249 NAS infants, a direct comparison of formula groups showed no differences in LOS (3, 95% confidence interval [CI]: -1.1 to 7 days), LOT (3.9, 95% CI: -0.4 to 8.1 days), or weight change per day (-2.4, 95% CI: -11.7 to 6.9 g/day). Breastfeeding improved LOT by 6.9 (95% CI: 3.4-10.5) and 10.8 days (95% CI: 5.9-15.6) and LOS by 7.4 (95% CI: 4.1-10.7) and 10.3 (95% CI: 5.8-14.9) days all reaching significance, in comparison to term and low lactose formula groups, respectively. Weight change per day was greater in the breast versus formula feeding groups when compared individually.

CONCLUSION

We detected no benefit to low lactose formula in NAS infants. Breastfeeding is associated with clinical reduction in LOS and LOT but is associated with increased weight loss.

KEY POINTS

· Best formula choice for a neonatal abstinence syndrome (NAS) infant is unknown.. · Many NAS moms cannot breastfeed.. · Low lactose formula has no impact on NAS outcomes..

Parental protective factors and stress in NICU mothers and fathers

OBJECTIVE

Evaluate the effect of parental protective factors on parental stress at time of NICU admission and prior to discharge.

STUDY DESIGN

Parents of infants born at <35 weeks gestation were approached at a single level III NICU. Consenting parents completed a questionnaire on admission and prior to infant's discharge of demographic information and three validated instruments: (1) parental stress (PSS:NICU), (2) Parents' Assessment of Protective Factors (PAPF), and (3) health literacy (PHLAT-8).

RESULTS

Mean PSS:NICU Total score was 2.8 ± 0.9 (Time 1) and 2.6 ± 1.1 (Time 2). Mean PAPF scores in all subcategories were high (means >3, ±0.3-0.5) (Time 1, Time 2). There was no clinically significant association between PSS:NICU scores and PAPF or any of the other measured variables.

CONCLUSION

PAPF and other commonly implicated factors were not associated with perceived self-reported parental stress at time of NICU admission and prior to discharge.

Can Mozart Improve Weight Gain and Development of Feeding Skills in Premature Infants? A Randomized Trial

OBJECTIVE

 The study aimed to assess in a prospective randomized study the effect of Mozart's music on time to regain birth weight (BW) and development of oral feeding skills in babies born between 28^0/7 and 31^6/7 weeks of gestation.

STUDY DESIGN

 Healthy premature infants born between 28^0/7 and 31^6/7 completed weeks of gestation were randomized within 3 days of birth to either music or no music exposure. Infants in the music group were exposed to Mozart's double piano sonata twice per day for 14 days. The primary outcome was time to regain birth weight. The secondary outcome was development of oral feeding skills as evaluated by a speech/language pathologist blinded to the intervention. We hypothesized that exposure to Mozart's double piano sonata would decrease time to regain BW and improve feeding skills. A total of 32 newborns were needed to detect a 3-day difference in time to regain BW.

RESULTS

 Forty infants were enrolled and randomized. There were no significant differences between the two groups regarding the time to regain BW (p = 0.181) and the time to achievement of full oral feeds (p = 0.809).

CONCLUSION

 Exposure to Mozart's double piano sonata for 14 days after birth did not significantly improve time to regain BW or time to achieve full oral feedings in very premature infants. It is possible that Mozart's music has no effect or that the duration of music exposure was not sufficient to have a physiologic effect on growth and oral feeding skills.

KEY POINTS

· Classical music improves the medical condition of adults.. · Music decreases neonatal resting energy expenditure.. · Music exposure did not significantly impact weight gain.. · This clinical relevance warrants further evaluation..

Mindfulness Training among Parents with Preterm Neonates in the Neonatal Intensive Care Unit: A Pilot Study

OBJECTIVE

To evaluate the feasibility of a mindfulness-based training session (MBTS) for parents of neonates born at ≤32 weeks' gestation in a level 3 neonatal intensive care unit (NICU).

STUDY DESIGN

Within 14 days of admission, parents completed the Parental Stressor Scale: Neonatal Intensive Care Unit Questionnaire (PSS:NICU), Cognitive and Affective Mindfulness Scale (CAMS-R), and a survey on stress management techniques. Parents then participated in a MBTS with instruction in mindfulness-based practices and were asked to practice the techniques during the NICU stay. At discharge, parents repeated the surveys to evaluate their mindfulness-based practice experience.

RESULTS

Of the 98 parents approached, 51 consented to participate (52%). Of these, 28 completed MBTS, initial, and discharge surveys. One parent had previously practiced mindfulness. The majority of parents (79%) reported that mindfulness practice was helpful, and 71% stated that they would continue their practice after NICU discharge. There was no difference in PSS:NICU or CAMS-R at discharge.

CONCLUSION

An MBTS was feasible to provide to parents in our NICU. Parents practiced the mindfulness-based techniques and reported benefit from their mindfulness-based practice. Future studies are needed to evaluate if an MBTS is a valuable resource for NICU parents' coping.

Evaluating the Use of a Decision Aid for Parents Facing Extremely Premature Delivery: A Randomized Trial

OBJECTIVE

To assess decisional conflict and knowledge about prematurity among mothers facing extreme premature delivery when the counseling clinicians were randomized to counsel using a validated decision aid compared with usual counseling.

STUDY DESIGN

In this randomized trial, clinicians at 5 level III neonatal intensive care units in the US were randomized to supplement counseling using the decision aid or to counsel mothers in their usual manner. We enrolled mothers with threatened premature delivery at 22^0/7 to 25^6/7 weeks of gestation within 7 days of their counseling. The primary outcome was the Decisional Conflict Scale (DCS) score. One hundred mothers per group were enrolled to detect a clinically relevant effect size of 0.4 in the Decisional Conflict Scale. Secondary outcomes included knowledge about prematurity; scores on the Preparedness for Decision Making scale; and acceptability.

RESULTS

Ninety-two clinicians were randomized and 316 mothers were counseled. Of these, 201 (64%) mothers were enrolled. The median gestational age was 24.1 weeks (IQR 23.7-24.9). In both groups, DCS scores were low (16.3 ± 18.2 vs 16.8 ± 17, P = .97) and Preparedness for Decision Making scores were high (73.4 ± 28.3 vs 70.5 ± 31.1, P = .33). There was a significantly greater knowledge score in the decision aid group (66.2 ± 18.5 vs 57.2 ± 18.8, P = .005). Most clinicians and parents found the decision aid useful.

CONCLUSIONS

For parents facing extremely premature delivery, use of a decision aid did not impact maternal decisional conflict, but it significantly improved knowledge of complex information. A structured decision aid may improve comprehension of complex information.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01713894.

Feasibility and Effectiveness of Intervention With the Playskin Lift Exoskeletal Garment for Infants at Risk

BACKGROUND

Infants born preterm and/or with brain injury often exhibit delays in the development of reaching and object exploration, increasing their risk of associated delays in cognitive development.

OBJECTIVE

The objective of this study was to longitudinally evaluate feasibility of use of the novel Playskin Lift exoskeletal garment (Playskin; developed and trademarked by Dr. Lobo's Super Suits FUNctional Fashion and Wearable Technology Program at the University of Delaware, Newark, DE, USA), the assistive and rehabilitative effects of intervention with the garment on reaching and object exploration ability, and to relate changes in reaching and object exploration to changes in cognition during intervention for infants at risk for developmental delays.

DESIGN

A multiple baseline single-case design with 1- to 2-month Baseline, 4-month Intervention, and 1-month Postintervention phases was implemented.

METHODS

Ten infants born preterm and/or with brain injury, mean [SD] age 2.2 [1.3] months at the beginning of the study, were assessed biweekly throughout the study both with and without the Playskin Lift. Assessments included a Reaching Assessment and the cognitive subscale of the Bayley Scales of Infant and Toddler Development. Reaching and object exploration behaviors were coded from videos of the Reaching Assessment. Results were analyzed using multilevel modeling in SAS.

RESULTS

The Playskin Lift improved infants' reaching ability, hand orientation for grasp and object exploration, and multimodal object exploration when worn within sessions, especially during the Intervention phase. The garment also improved independent reaching and object exploration across time during the Intervention phase, with retention of gains in the Postintervention phase. Improvement in reaching ability was positively related to changes in cognitive outcomes during the Intervention phase.

LIMITATIONS

Limitations included modest sample size and the potential confounds of development and experience with time.

CONCLUSIONS

The Playskin Lift can serve as a feasible, effective, and accessible assistive and rehabilitative device to advance reaching, object exploration, and cognition for infants at risk for future delays.

Cryoprecipitate transfusions in the neonatal intensive care unit: a performance improvement study to decrease donor exposure

BACKGROUND

The objective of this study was to determine if a change in cryoprecipitate transfusion policy impacts donor exposure and fibrinogen level in a neonatal intensive care unit (NICU) population.

STUDY DESIGN AND METHODS

The cryoprecipitate policy was changed from transfusing 10ml/kg to a maximum of 1 unit per transfusion in January 2013. Data were obtained via retrospective chart review of all infants receiving cryoprecipitate transfusions from January 2008 to February 2015 in the NICU at Christiana Hospital.

RESULTS

A total of 103 neonates received a total of 144 cryoprecipitate transfusions. Before the policy change, term babies were more likely to be exposed to more than one donor compared to preterm babies (75% vs. 6%, p < 0.01). After the policy change, no babies were exposed to greater than one donor per transfusion and there were similar increases in posttransfusion fibrinogen level as before the policy change.

CONCLUSION

Limiting cryoprecipitate transfusions to 1 unit per transfusion decreased donor exposure in infants without negatively impacting posttransfusion fibrinogen levels. This is especially evident in term neonates.

Characterization of Spirituality in Maternal-Child Caregivers

OBJECTIVE

To characterize spiritual beliefs and support provided by maternal-child staff at three academic hospitals.

BACKGROUND

Parents in neonatal intensive care units (NICUs) believe that addressing spirituality is important. The spiritual beliefs and the support provided by NICU staff are currently unknown.

METHODS

This prospective study surveyed all maternal-child staff (NICU and Obstetrics): physicians, neonatal nurse practitioners, physician assistants, nurses, respiratory therapists, and social workers. Two validated tools were used: Spiritual Involvement and Beliefs Scale (SIBS) and Spiritual Care Inventory (SCI); SIBS assesses spiritual beliefs and practices, SCI assesses the perception of spiritual care that one provides. Demographic information, including self-identified religious affiliation, was collected.

RESULTS

Respondents of 406 completed surveys were mostly nurses, female, white, and Christian. SIBS scores ranged between 21 and 136. Higher SIBS score was associated with Christian religion (p = 0.001) and African American (p = 0.003) and Asian (p = 0.017) race, when controlling for site, age, gender, education, role in the NICU, and years in practice. A high SCI score was also associated with Christian religion (p = 0.01). There was a trend toward an association between SCI and older age (p = 0.051). There was an association between a high SIBS score and higher ratings on both SCI subscales used.

DISCUSSION

There is a wide range in spirituality and perceived spiritual support among maternal-child staff. This may coincide with the spiritual needs of families in the NICU.

A quality improvement initiative for delayed umbilical cord clamping in very low-birthweight infants

BACKGROUND

Due to clinical benefits, delayed cord clamping (DCC) is recommended in infants born before 37 weeks gestational age. The objective was to institute a delayed cord clamping program and to evaluate clinical outcomes one year after initiation.

METHODS

This study occured at Christiana Care Health System, a tertiary care facility with a 52 bed level 3 Neonatal Intensive Care Unit (NICU). A multidisciplinary team created a departmental policy, a DCC protocol and educational programs to support the development of a DCC program. A year after initiation of DCC, we evaluated two cohorts of very low birth weight (VLBW) infants (<1500 g) prior to (Cohort 1) and after initiation (Cohort 2) of DCC (n = 136 and n = 142 respectively). Chart review was conducted to evaluate demographic data and clinical outcomes. Analysis was completed with a retrospective, cohort analysis on an intention-to-treat basis.

RESULTS

There were no differences in demographic factors between the two cohorts. We demonstrated a 73 % compliance rate with the delayed cord clamping protocol and a decrease in the percentage of VLBW infants requiring red blood cell transfusion from 53.7 to 35.9 % (p = 0.003). We also found a decreased need for respiratory support in the second cohort with no increases in the balancing measures of admission hypothermia and jaundice requiring phototherapy. During the Control Phase ongoing monitoring and education has led to a 93.7 % compliance rate.

CONCLUSIONS

A multidisciplinary team including key leadership from the obstetric and pediatric departments allowed for the rapid and safe implementation of DCC.

Prolonged early antibiotic use and bronchopulmonary dysplasia in very low birth weight infants

OBJECTIVE

The objective of the article is to determine if > 48 hours of antibiotic treatment during the 1st week of life is associated with subsequent isolation of bacteria from the endotracheal tube (ETT), and an increased risk of bronchopulmonary dysplasia (BPD).

STUDY DESIGN

Retrospective cohort study of very low birth weight infants. Routine weekly surveillance ETT cultures were obtained to monitor bacterial colonization in all intubated infants. Risk factors for BPD were assessed using unadjusted and multivariable analyses.

RESULTS

In the study sample (n = 906), infants with BPD (n = 182) were more likely to have received > 48 hours antibiotic treatment (31 vs. 14%, p < 0.01) and have a resistant gram-negative bacilli in ETT (7 vs. 2%, p = 0.0001) compared with infants without BPD. Treatment with > 48 hours of antibiotics remained associated with BPD (adjusted odds ratio, 2.2; 95% confidence interval, 1.4-3.5) after controlling for confounding variables.

CONCLUSIONS

Antibiotic duration > 48 hours in the 1st week of life was associated with subsequent BPD and the presence of resistant bacteria in routine ETT cultures.

Instability of delay classification and determination of early intervention eligibility in the first two years of life

The purpose of this study was to determine the effectiveness of the Bayley Scales of Infant Development, Third Edition (Bayley-III) to track development and classify delays in low- and high-risk infants across the first two years of life. We assessed cognitive, language, and motor development in 24 low-risk full-term and 30 high-risk preterm infants via seven assessments performed between 3 and 24 months corrected age. The Bayley-III resulted in highly unstable delay classifications, low sensitivities, and poor positive predictive values across time. The results highlight that early intervention professionals, researchers, and policy makers should: (1) emphasize clinical opinion and prevalence of risk factors rather than standardized assessment findings when classifying delays and determining eligibility for services, and (2) develop more effective developmental assessments for infants and young children.

Decreased incidence of pneumothorax in VLBW infants after increased monitoring of tidal volumes

BACKGROUND AND OBJECTIVE

Pneumothorax is common in very low birth weight (VLBW) infants. In our NICU, we noted an above average incidence of pneumothorax compared with similar NICUs based on Vermont Oxford Network benchmarking. The quality improvement project was designed to decrease the incidence of pneumothorax in VLBW infants in a tertiary care NICU.

METHODS

The project was divided into 2 periods. During period 1, all VLBW infants were followed for 6 months for the presence of pneumothorax. A multidisciplinary team met regularly to review cases of pneumothorax and identify potential causes. High tidal volumes (VT) (>6 mL/kg) were noted around the time of occurrence of pneumothorax. Guidelines were developed for improved monitoring and rapid feedback of VT and peak inspiratory pressure between nursing staff and clinicians. During period 2, these guidelines were implemented and VLBW infants were again followed for 6 months. The incidence of pneumothorax was tracked. Run charts were used to monitor changes.

RESULTS

The incidence of pneumothorax in VLBW infants decreased from 10.4% to 2.6% after the intervention (P = .04). By using process control, a reduction in pneumothorax was achieved in period 2.

CONCLUSIONS

Increased vigilance and real-time monitoring of VT and peak inspiratory pressure decreased the incidence of pneumothorax in our population of VLBW infants. These interventions can be considered in other NICUs with an above-average risk adjusted incidence of pneumothorax in VLBW infants. Our data illustrate the benefits of comparative benchmarking and organized quality improvement in advancing patient care outcomes.

Clinical research nursing: evidence today, better practices tomorrow

Most nurses are very familiar with the need for evidence-based practice, yet far fewer actually participate in the research that is a vital underpinning to evidence-based practice. This article explains the specialty of clinical research nursing and offers suggestions for getting involved.

Is a small platelet mass associated with intraventricular hemorrhage in very low-birth-weight infants?

OBJECTIVE

We sought to determine whether, among very low-birth-weight (VLBW) neonates, the platelet mass was associated with common perinatal factors, and whether a low platelet mass in the first days following birth was associated with a higher incidence and/or severity of intraventricular hemorrhage (IVH).

STUDY DESIGN

This was a cross-sectional, retrospective cohort analysis of VLBW infants admitted to a level 3 neonatal intensive care unit from June 2003 to July 2006, n=408. Platelet mass was calculated and recorded on the day of birth and for 2 consecutive days thereafter. All neonates had a screening cranial sonogram on day 4 of life. Statistical analysis included analysis of variance and Mann-Whitney U-test.

RESULT

Neonates born to mothers with pre-eclampsia had a smaller platelet mass (1921 fl/nl ± 603 vs 2297 fl/nl ± 747; P<0.01). The same was found among neonates with intrauterine growth restriction (IUGR). In contrast, neonates born after histological chorioamnionitis had a larger platelet mass (2400 fl/nl ± 749 vs 2036 fl/nl ± 674; P<0.01). No effect of platelet mass, measured on the day of birth, was observed related the outcomes of IVH, severe IVH or death. However, those with a platelet mass <10th percentile on the 2 subsequent days following birth were more likely to have severe IVH or death.

CONCLUSION

Among VLBW neonates, pre-eclampsia and IUGR are associated with a lower platelet mass, owing to their effect on platelet count. Histological chorioamnionits is associated with a larger platelet mass. A mass <10th percentile on the days following birth was associated with severe IVH and/or death, but it remains unclear whether this is a cause of, or an effect of, the IVH.

Increased odds of necrotizing enterocolitis after transfusion of red blood cells in premature infants

OBJECTIVES

To determine if infants with very low birth weight who receive packed red blood cell (PRBC) transfusions have increased odds of developing necrotizing enterocolitis (NEC), to determine the rate of NEC after PRBC transfusion, and to characterize the blood transfused preceding the onset of NEC.

STUDY DESIGN

A retrospective cohort design was used. The study population included infants with a birth weight of <1500 g who were from a single center. NEC after transfusion was defined as NEC that occurred in the 48 hours after initiation of PRBC transfusion. Statistical analysis included unadjusted and multivariable analyses.

RESULTS

The study sample included 2311 infants. A total of 122 infants (5.3%) developed NEC, and 33 (27%) of 122 NEC cases occurred after transfusion. NEC occurred after 33 (0.5%) of 6484 [corrected] transfusions. Infants who received a transfusion had increased adjusted odds (odds ratio: 2.3 [95% confidence interval: 1.2-4.2]) of developing NEC compared with infants who did not receive a transfusion. PRBCs transfused before NEC were predominantly (83%) from male donors and were a median of 5 days old.

CONCLUSIONS

In our study sample, PRBC transfusion was associated with increased odds of NEC. The rate of NEC after transfusion was 1.4%. From our data we could not determine if PRBC transfusions were part of the causal pathway for NEC or were indicative of other factors that may be causal for NEC.

Thyroid function in term and late preterm infants with respiratory distress in relation to severity of illness

BACKGROUND

Transient hypothyroxinemia is common in extremely premature infants, but has not been extensively investigated in ill term and late preterm infants. We hypothesized that free thyroxine (T(4)) levels in term and late preterm infants with respiratory distress would be inversely related to severity of illness

METHODS

Eligible infants included those had > or =35 weeks of gestation requiring mechanical ventilation or nasal continuous positive airway pressure. Thyroid function (thyroid-stimulating hormone, T(4), free T(4) [fT(4)], and free triiodothyronine) and cortisol levels were collected at four specified intervals (birth, day 2, day 3, and day 5 of life). Illness severity was measured using score for neonatal acute physiology (SNAP). Infants with an SNAP > or =10 were considered to have severe illness. Statistical analysis included repeated measures analysis of variance.

RESULTS

A total of 20 patients were enrolled in the study. The mean gestational age of study infants was 37.0 +/- 1.7 weeks. Infant with SNAP > or =10 had a diminished thyroid-stimulating hormone at birth. There was an inverse correlation between SNAP at birth and fT(4.) There was also an inverse correlation between lowest measured fT(4) and highest mean airway pressure, oxygenation index, and A-a gradient. Infants who received inhaled nitric oxide had diminished fT(4) levels compared to infants who did not receive this therapy. There were no differences in cortisol in those infants with and without SNAP > or =10 during the study period.

CONCLUSIONS

In our study sample, there was an association between severity of illness and fT(4) levels at birth, and infants requiring inhaled nitric oxide showed decreased fT(4) over the study time. Further research is warranted to determine whether T(4) supplementation would be beneficial in term and late preterm infants with respiratory distress.

The association between maternal body mass index and severity of neonatal illness in very low birth weight infants

OBJECTIVE

To determine the effect of maternal body mass index (BMI) and pregnancy weight gain on neonatal illness severity in very low birth weight infants.

METHODS

Cohort study of infants with birth weight less than 1500 g at a level 3 Neonatal Intensive Care Unit from July 2003 to July 2005, n = 301. The main outcome included neonatal illness severity, as measured by the Score for Neonatal Acute Physiology (SNAP). SNAP was investigated in relationship to maternal BMI and pregnancy weight gain. Statistical analysis included Pearson correlation, ANOVA and multivariable linear regression.

RESULTS

At delivery and pre-pregnancy, 49 and 54% of mothers were overweight, respectively. Black mothers were more likely to be overweight with less pregnancy weight gain compared with white mothers. After controlling for confounding variables, maternal pre-pregnancy BMI, pregnancy BMI and weight gain were not associated with neonatal illness.

CONCLUSIONS

In our population of very low birth weight infants, maternal BMI was not associated with neonatal illness severity. Black mothers had higher pre-pregnancy BMI and less weight gain than white mothers. The significance of these differences needs further exploration.

Thrombopoietin following transfusion of platelets in preterm neonates

Thrombocytopenia is common in the neonatal intensive care unit. Transfusion of platelets is often required. The purpose of our study was to determine changes in thrombopoietin (Tpo) following transfusion of platelets in preterm neonates. Preterm neonates undergoing platelet transfusion were randomized to receive a transfusion volume of either 10 or 15 ml/kg. Blood was obtained for Tpo measurement pre-transfusion, one and 24 hours post-transfusion. Platelet Factor 4 (PF4) was also measured to quantify platelet activation. Statistical analysis was performed using repeated measures ANOVA, and Mann-Whitney U test as appropriate. Ten infants were enrolled in each group. Gestational age, birth weight, etiology of thrombocytopenia, and timing of transfusion did not differ between the 10 and 15 ml/kg groups. There were no differences between the groups in platelet count prior to and/or following transfusion. Both transfusion volumes were equally well tolerated. Tpo and PF4 did not differ between groups at any of the study time points. When both groups were analysed together, Tpo dropped 43% (95% confidence 37-49%, p = 0.01) 1-hour post compared to pre-transfusion. In conclusion the observed decrease in Tpo following platelet transfusion suggests that Tpo kinetics in neonates is similar to adults following transfusion. PF4 was not affected by transfusion. There was not an increase in platelet count following transfusion volume of 15 ml/kg compared to 10 ml/kg.

Increased preeclampsia in mothers delivering very low-birth-weight infants between 1994 and 2006

We sought to determine if there has been any change in the proportion of mothers with preeclampsia in a sample of very low-birth-weight (VLBW) infants over time. We performed a retrospective cohort study. Study sample included infants with birth weights 1500 g or less cared for from July 1994 to July 2006 ( n = 2045) from a single level 3 neonatal intensive care unit in Delaware. The main outcome examined was the occurrence of maternal preeclampsia over the study time. The proportion of mothers with preeclampsia delivering VLBW infants increased over time. After controlling for potential confounding variables, the odds of maternal preeclampsia were increased (1.3, 95% confidence interval 1.2 to 1.5) in infants born between 2003 and 2006 compared with those born between 1994 and 1997. In our population of VLBW infants, the proportion of mothers with the diagnosis of preeclampsia increased over time. From our investigation, we cannot determine if the increase in the proportion of mothers with preeclampsia is related to a true increase in the disease, changes in diagnostic surveillance, or other factors.

Very-low-birthweight neonates: do outcomes differ in multiple compared with singleton gestations?

The purpose of this study is to determine if outcomes for very-low-birthweight (VLBW) neonates differ in multiple versus singleton gestations. This is a retrospective cohort study of neonates weighing less than 1500 g admitted to a neonatal intensive care unit from 1993 to 2004. Outcome variables were necrotizing enterocolitis, death, and/or severe intraventricular hemorrhage (IVH). Statistical analysis included univariate and multivariate analysis. During the study period, 1769 VLBW infants including 465 multiples and 1304 singletons were identified. Gestational age and birthweight were similar; conversely white race (68% multiples versus 43% singletons), maternal age (28.7 +/- 5.7 versus 26.1 +/- 6.5 years), born at facility (95% versus 86%), antenatal steroids (74% versus 58%), preeclampsia (14% versus 24%), and preterm labor (74% versus 62%) were significantly different. Correcting for these, VLBW multiples had a higher odds ratio (OR) of death and/or severe IVH, OR 1.4 (1.03-1.95). In our population, VLBW multiple gestations were at elevated odds for death and/or severe IVH compared with VLBW singletons.

Newborn screening levels of 17-hydroxyprogesterone in very low birth weight infants and the relationship to chronic lung disease

OBJECTIVES

17-Hydroxyprogesterone (17-OHP), an intermediary hormone in cortisol synthesis, has been shown to be elevated in premature infants. However, the relationship between levels of 17-OHP with chronic lung disease (CLD) have not been extensively explored. The objective of this study was to determine whether there is an association between CLD and levels of 17-OHP in a population of very low birth weight infants.

STUDY DESIGN

Cohort study of very low birth weight infants cared for at a single level 3 NICU during a 3-year period from July 2001-July 2004, n=435. Infants had a minimum of one screen for 17-OHP. 17-OHP was measured on the 5th day of life and at 2-4 weeks of life as part of the State of Delaware Newborn Screening Program. Statistical analysis included chi-squared, Pearson correlation, and logistic regression.

RESULTS

Levels of 17-OHP were higher at the time of the 1st screen compared to the 2nd screen (42.2 +/- 36.7 vs 23.5 +/- 32.3 ng/ml, respectively, p = 0.01). After controlling for potential confounding variables, gestational age and prenatal steroids were independently associated with 17-OHP. However, logistic regression analysis showed no association between a 1 log increase in levels of 17-OHP with the outcomes of CLD (odds ratio 1.7, 95% CI 0.7-3.8), or death and/or CLD (odds ratio 2.1, 95% CI 0.9-4.8).

CONCLUSIONS

In our population of very low birth weight infants elevated levels of 17-OHP were not associated with the development of CLD.

Communicating with parents of premature infants: who is the informant?

OBJECTIVES

To determine what sources of information are most helpful for neonatal intensive care unit (NICU) parents, who provides NICU parents with the information, and also what expectations parents have regarding obtaining information.

STUDY DESIGN

A 19-item questionnaire was given to the parents of infants 32 weeks or younger prior to discharge from the NICU.

RESULTS

Out of the 101 parents who consented, almost all of the parents (96%) felt that 'the medical team gave them the information they needed about their baby' and that the 'neonatologist did a good job of communicating' with them (91%). However, the nurse was chosen as 'the person who spent the most time explaining the baby's condition, 'the best source of information,' and the person who told them 'about important changes in their baby's condition' (P<0.01).

CONCLUSION

Although the neonatologist's role in parent education is satisfactory, the parents identified the nurses as the primary source of information.

Cytokine load in prestorage leukoreduced PRBC transfusions in premature infants

OBJECTIVE

Despite the high frequency of packed red blood cell (PRBC) transfusions given to premature neonates, there has been no previous investigation in this population to determine whether small-volume PRBC transfusions using prestorage leukoreduction techniques (1) provide a cytokine load in the transfusate and (2) if there is a load, whether that load alters serum cytokine levels after transfusion.

STUDY DESIGN

In all, 27 PRBC units, which were leukoreduced at the time of donation, were followed for cytokine analysis for the duration of the unit's shelf life (1 to 42 days). Infants who received transfusion from these units had cytokines measured pre and post-transfusion.

RESULTS

There were no significant levels of interleukin 6 (IL-6), interleukin 10 (IL-10), interleukin 1 beta (IL-1beta), or human tumor necrosis factor alpha (TNF-alpha) detected during the storage time period. Nine premature infants who received transfusions from these units had serum cytokines levels measured pre- vs post-PRBC transfusion, with no evidence of alterations (IL-6 p=0.51, IL-10 p=0.10, IL-1beta p=0.44, TNF-alpha p=0.86).

CONCLUSIONS

The determination of a nondetectable or very low level of a cytokine load contained within the PRBC transfusate, combined with the absence of evidence of an in vivo cytokine effect, is important in establishing the safety profile for PRBC blood-banking methods used with premature neonates.