Infant Essential Fatty Acid Status Is Not Associated With Postoperative Wound Complication Severity

BACKGROUND

Neonates are susceptible to postoperative wound complications (POWCs), as prematurity, hypoxia, steroid use, immunosuppression, and malnutrition are all common comorbidities. Critically ill infants, dependent on parenteral nutrition, are at even further risk of developing essential fatty acid deficiency (EFAD). We hypothesized that POWC severity and EFAD were associated because of increased susceptibility to infections and impaired wound healing seen with EFAD.

METHODS

Institutional review board-approved (OUHSC10554), retrospective review from our academic Level IV Neonatal Intensive Care Unit. Infants aged <1 y who underwent a fascial-compromising gastrointestinal surgery from June 1, 2015, to March 15, 2019, and who had essential fatty acids (EFAs) measured ±2 wk from surgery were included. Three blinded investigators independently categorized POWC using the World Union of Wound Healing Society Surgical Wound Grading System. Infants were categorized into three groups: no POWC, POWC Grades 1 and 2 (superficial tissue nonintegrity), and POWC Grades 3 and 4 (deep tissue nonintegrity and complete dehiscence). EFA status and other possible POWC-associated factors were analyzed to determine any association with wound severity.

RESULTS

Fifty infants met the inclusion criteria. Half (25/50) had no POWC, 30% (15/50) had Grade 1 or 2, and 20% (10/50) had Grade 3 or 4. We found no association between EFAD and POWC severity.

CONCLUSIONS

In our cohort, EFA status did not predict POWC severity. At this time, we cannot suggest delaying elective surgical procedures to correct EFAD as an approach to preventing POWC.

Resources Recommended for the Care of Pediatric Patients in Hospitals

It is crucial that all children are provided with high-quality and safe health care. Pediatric inpatient needs are unique in regard to policies, equipment, facilities, and personnel. The intent of this clinical report is to provide recommendations for the resources necessary to provide high-quality and safe pediatric inpatient medical care.

THE OPIOID-EXPOSED NEONATE: A REVIEW OF THE OKLAHOMA EXPERIENCE

Neonatal abstinence syndrome from opioids (NAS-O) is a multisystem disorder resulting in neurological and gastrointestinal symptoms from the abrupt discontinuation of chronic fetal exposure to opioids. Increasing opioid use during pregnancy has led to a five-fold increase in NAS-O nationally over the past decade. Several knowledge gaps in our experiences with opioid-exposed neonates have been identified: 1) universal maternal screening; 2) diagnostic tools for newborn abstinence syndrome; 3) optimal treatment protocols; and 4) long-term neurodevelopmental effects of fetal opioid exposure. This review article gives a broad overview of the issues associated with screening, diagnosis, and management of opioid exposure in newborns as well as the issues with collecting accurate outcomes data to monitor efforts aimed at curbing opioid exposure in children and NAS-O. Data specific to Oklahoma is provided, when available.

Essential fatty acid deficiency during parenteral soybean oil lipid minimization

OBJECTIVE

To determine if parenteral lipid minimization in infants results in essential fatty acid (EFA) deficiency.

STUDY DESIGN

Prospective study of infants >30 days old and >34 weeks postmenstrual age receiving parenteral lipid minimization (<1.5 g kg^-1 per day) with either soybean oil or fish oil and >90% of total nutritional intake parenterally in the 14 days before a serum EFA sample. Nonparametric tests were used for statistical analyses with significance at 0.05.

RESULTS

Fifteen samples on soybean oil and nine on fish oil were included. Energy and macronutrient intakes and weight gain were similar between groups. Biochemical EFA deficiency occurred in 60% receiving soybean oil but none receiving fish oil (P<0.01). Average daily weight gain was 49% less in EFA deficient infants than EFA sufficient infants (P=0.02).

CONCLUSION

Infants on lipid minimization with parenteral soybean oil, but not fish oil, are at high risk of biochemical EFA deficiency with slower weight gain.

Electronic Alerts Improve Immunization Rates in Two-month-old Premature Infants Hospitalized in the Neonatal Intensive Care Unit

OBJECTIVE

To determine if an electronic alert improves 2 month immunization rates in infants remaining hospitalized in the neonatal intensive care unit.

METHODS

Institutional Review Board-approved retrospective chart review of 261 infants with birth weights <2 kg and still hospitalized at ≥ 58 days. Charts were reviewed between 2009 and 2013, before and after the 2011 electronic alert was instituted in the electronic medical record from days 56 to 67 to remind providers that immunizations were due. Order and administration dates of two-month vaccine components (Diphtheria, Haemophilus influenza B, Hepatitis B, Pertussis, Pneumococcal, Polio, Tetanus) were determined, and infants were considered fully immunized, partially immunized, or unimmunized by day 90 or discharge, whichever came first.

RESULTS

After the alert, the timing of vaccine orders decreased from day 67 to day 61 (p<0.0001) and vaccine administration decreased from day 71 to day 64 (p<0.0001). Missing vaccine orders decreased from 14% [17/121] to 3% [4/140] (p=0.001) with missing administrations decreasing from 21% [26/121] to 4% [6/140] (p<0.0001). Fully immunized rates increased from 71% [86/121] to 94% [132/140] (p<0.0001).

CONCLUSIONS

A significant improvement in immunization rates in two-month-old infants in the neonatal intensive care unit occurred by 90 days after implementing an alert in the electronic medical record.

Initial Dosing and Taper Complexity of Methadone and Morphine for Treatment of Neonatal Abstinence Syndrome

Background: Methadone and morphine are commonly used to treat neonatal abstinence syndrome (NAS). Limited data exist to describe the most appropriate initial doses and taper regimens of these agents. Objectives: Describe the median initial dose and frequency of methadone and morphine for NAS. Compare dose adjustments, time to symptom relief, and taper complexity between groups. Methods: Retrospective study of neonates receiving enteral methadone or morphine for NAS over a 4-year period. Data collection included medication regimen, abstinence scores based on the Modified Finnegan Neonatal Abstinence Scoring Tool, and adverse events. Planned home taper complexity was assessed using the Medication Taper Complexity Score–Revised (MTCS-R). The primary outcome was initial opioid dose. Secondary outcomes included number of dose adjustments, time to symptom relief, and MTCS-R score. Results: Fifty neonates were initially treated for NAS with methadone (n = 36) or morphine (n = 14). The median initial dose was 0.09 mg/kg (range = 0.03-0.2) for methadone and 0.04 mg/kg (range = 0.03-0.4) for morphine. The most common initial dosing interval was q8h for methadone versus q3h for morphine. Number of dose adjustments and time to symptom relief were similar between groups. Median MTCS-R scores were similar between groups. There was no difference in adverse events between groups. Limitations included small sample size, preference toward methadone use, and variability of initial opioid dosing and titration. Conclusions: There was significant variability in initial doses of both agents. Neonates receiving methadone required less frequent dosing than morphine, which may result in easier administration and may allow for safer outpatient administration.

Weekly and consecutive day neonatal intubation training: comparable on a pediatrics clerkship

PURPOSE

To determine whether medical student intubation proficiency with a neonatal mannequin differs according to weekly or consecutive day practice sessions during a six-week pediatric clerkship.

METHOD

From July 2010 through June 2011, the authors prospectively randomized 110 third-year medical students into three neonatal intubation practice groups: standard (control; no practice sessions), weekly (practice once/week for four consecutive weeks), or consecutive day (practice once/day for four consecutive days). At baseline, students performed intubation during individual sessions using a neonatal mannequin (SimNewB). Two reviewers, blinded to practice group, viewed videotapes of intubations and independently scored students on equipment selection, procedural skill steps, length of intubation attempts (in seconds), and the number of attempts (up to three) needed for a successful intubation. Videotaped individual final assessment intubation sessions during week six were evaluated in the same manner.

RESULTS

Students in the weekly and consecutive day practice groups performed better at the final assessment on all variables than students in the standard group (P < .001), but over six weeks, the authors detected no differences between the two distributed practice formats for any outcomes of interest.

CONCLUSIONS

Practice improved all aspects of neonatal intubation performance, including choosing the correct equipment, properly performing the skill steps, length of time to successful intubation, and success rate, for novice health care providers in a simulation setting. Over six weeks, neither practice format proved superior, but it remains unclear whether one format is superior for learning and skill retention over the long term or in actual practice.

Association of Fentanyl With Neurodevelopmental Outcomes in Very-Low-Birth-Weight Infants

Background: Opioids are commonly used in the neonatal intensive care unit (NICU). Negative neurodevelopmental effects in the short-term setting have been associated with opioids ; however, long-term studies have been limited. Objective: The primary objective was to determine if there is a dose relationship between fentanyl and neurodevelopmental outcomes, as measured by Bayley Scales of Infant and Toddler Development (Bayley-III) composite scores for language, cognition, and motor skills. Secondary objectives included comparison of Bayley-III scores and neurodevelopmental impairment classification based on fentanyl exposure. Methods: A retrospective evaluation of 147 very-low-birth-weight infants with Bayley-III scores obtained at a chronological age of 6 months to 2 years at clinic follow-up was conducted. Univariate and multivariable linear regression analyses were used to determine if there was a dose-related association between fentanyl and neurodevelopmental outcomes. To evaluate secondary outcomes, patients were divided based on cumulative fentanyl dose (“high-dose” versus “low/no-dose”). Results: The univariate analysis found a statistically significant decrease in cognition ( P = .034) and motor skills scores ( P = .006). No association was found in the multi-variable regression between fentanyl cumulative dose and Bayley-III scores. There was a significant decrease in the motor skills score between the high-dose versus low/no-dose group, 94 ± 20 versus 102 ± 15, respectively ( P = .026); however, no statistical differences were noted for language or cognition scores or neurological impairment classification. Conclusions: When controlling for other variables, the cumulative fentanyl dose did not correlate with neurodevelopmental outcomes. Further evaluation of benefits and risks of opioids in premature infants are needed.

Postnatal malnutrition of extremely low birth-weight infants with catch-up growth postdischarge

OBJECTIVE

To assess nutritional intakes and subsequent growth of extremely low birth-weight (BW) infants.

STUDY DESIGN

Chart review of 69 extremely low BW infants stratified into two groups by BW: < or =750 g (group 1; n=27) or 751 to 1000 g (group 2; n=42). Dietary intakes, weights, and head circumferences (HC) were collected through discharge and at 1 month postdischarge. The differences between goals and intakes were calculated weekly during hospitalization. Descriptive comparisons were made between growth parameters at birth, discharge, and follow-up.

RESULTS

Total energy and protein deficits were inversely related to BW. Both groups exhibited extrauterine growth retardation while hospitalized. After discharge, the rates of weight gain and HC growth increased, leading to some growth recovery at follow-up.

CONCLUSIONS

Existing feeding methods resulted in sizeable deficits in energy and protein, particularly for the smallest infants. Changing current practices to limit these deficits is essential to improving postnatal growth.

Increased incidence of parenteral nutrition-associated cholestasis with aminosyn PF compared to trophamine

OBJECTIVE

To compare the incidence of parenteral nutrition-associated cholestasis (PNAC) between two pediatric parenteral amino-acid formulations, Aminosyn PF (APF) and Trophamine (TA).

SETTING

Tertiary newborn intensive-care nursery.

SUBJECTS

A total of 661 neonates who received either TA or APF.

DESIGN

Retrospective. The incidence of PNAC was determined in three groups: Group I (TA, 8/19/97 to 8/19/98, n=335), Group II (APF, 8/20/98 to 1/28/99, n=157), and Group III (TA, 1/29/99 to 8/1/99, n=169).

RESULTS

No PNAC developed in any infant receiving parenteral nutrition (PN) for < 3 weeks. Of 141 patients given PN for > or =21 days, 24 were diagnosed with PNAC: Group I (TA, 10/78, 12.8%), Group II (APF, 9/27, 33.3%), and Group III (TA, 5/36, 13.9%). The incidence of PNAC was significantly higher in infants who received APF (p=0.043). Using logistic regression, only birth weight, duration of PN, and use of APF were significant risk factors for the development of PNAC. Despite an earlier initiation of enteral feedings, APF recipients developed PNAC sooner, had higher peak direct bilirubin levels, and remained jaundiced longer.

CONCLUSIONS

The use of APF was temporally associated with a greater than two-fold increase in the incidence of PNAC compared to periods of exclusive TA use. In the absence of significant differences in parenteral nutrient or energy intake in neonates who developed PNAC, we speculate that possible differences between the amino-acid compositions of TA and APF may be responsible for the observed differences in the incidence of PNAC.

Reversible cystic dilatation of distal airways due to foreign body

We describe a child with foreign body aspiration whose chest radiograph showed an unusual appearance of multiple round lucencies simulating bronchiectasis. This appearance is contrary to the usual appearance of emphysema due to the check-valve type of obstruction. This report is particularly useful for pediatricians and family physicians, who should be aware of the variable appearances of foreign body aspiration. Our case emphasizes the necessity of early bronchoscopy in pediatric patients with unresolving pneumonia.

CO2 sensitive receptors on labial palps of Rhodogastria moths (Lepidoptera: Arctiidae): physiology, fine structure and central projection

The tips of the labial palps of Rhodogastria possess a pit housing uniform sensilla, histologically characterized by wall-pores and receptor cells with lamellated outer dendrites. The receptor cell axons project to glomeruli in the deutocerebrum which are not innervated by antennal receptors. From their histology as well as from their central projection these sense organs are identical with palpal pit organs of other Lepidoptera (Lee et al. 1985; Kent et al. 1986; Lee and Altner 1986). Physiologically, the palp-pit receptors respond uniformly; they are most excitable by stimulation with carbon dioxide while they exhibit relatively moderate responses to various odorants. The responses to CO2 show a steep dose-response characteristic. In ambient atmosphere (i.e., ca. 0.03% CO2) the cells are in an excited condition already; the seeming 'spontaneous activity' exhibited in air is decreased if the preparation is kept under N2 or O2 or CO2-free air. There is hardly any adaptation of the responses to continuous or repeated stimulation. Perhaps CO2 sensitivity is correlated with sensilla characterized by both wall-pores and lamellated dendrites. Pilot tests indicate that CO2 perception might be widespread in the Lepidoptera, but the biological significance remains obscure.

A neuroanatomical study on the organization of the central antennal pathways in insects. III. Neuroanatomical characterization of physiologically defined response types of deutocerebral neurons in Periplaneta americana

1. Single unimodal (olfactory) or multimodal (olfactory and mechanosensory) neurons in the antennal lobe of the deutocerebrum of the American cockroach were characterized functionally by microelectrode recording, and their morphological types and positions in the brain were established by dye injection. Thus individual, physiologically identified neurons of known shape could be mapped in reference to the areas of soma groups, glomeruli, tracts and their projection regions in the brain. 2. All of these neurons send processes to deutocerebral glomeruli, i.e., the regions in which the axons of antennal sensory cells terminate. Output neurons have axons that leave the deutocerebrum whereas local interneurons are anaxonic. 3. An output neuron innervates only one glomerulus, sending its axon into the calyces of the corpora pedunculata (CP) in the protocerebrum, where by multiple branching they reach many CP neurons. The same axons send collaterals into the lateral lobe of the protocerebrum. Because of this arrangement, each deutocerebral glomerulus is represented individually and separately in the two projection regions. The fine structure of the endings of the deutocerebral axons in the protocerebrum is described. In the CP calyces they form microglomeruli with typical divergent connectivity. 4. A local interneuron innervates many glomeruli without sending processes to other parts of the brain. 5. Unimodal olfactory and multimodal neurons can be either output neurons or local interneurons; multimodal information is sent to the protocerebrum directly, in parallel with the unimodal information. 6. At least one glomerulus--the macroglomerulus of the male deutocerebrum--is specialized so as to provide an exclusive topographic representation of certain olfactory stimuli not represented elsewhere (female sexual pheromone).

A neuroanatomical study on the organization of the central antennal pathways in insects

Receptor cell axons from the antennal flagellum terminate in the glomeruli of the ipsilateral deutocerebrum in Periplaneta americana and Locusta migratoria. Processes from several groups of deutocerebral neurons also enter the glomeruli and terminate in characteristic branching patterns. There, they contact the antennal axons. Connections are both convergent and divergent. Not only do single central neurons collect the inputs from many receptor cells, but receptor axons were often observed to branch and terminate at more than one deutocerebral neuron. The axons from a portion of the neurons go to form the deutocerebral bundle of the tractus olfactorio-globularis. These axons of the bundle terminate in the ipsilateral calyx of the corpus pedunculatum and in the lateral lobus protocerebri. The processes of the majority of the deutocerebral neurons stay within the deutocerebrum itself and may serve as local interneurons. Part of some antennal fibers terminate in the lobus dorsalis. The lobus glomeratus receives inputs from the maxillary palps and also from processess of deutocerebral neurons. Electron microscopy of synaptic connections and anatomical experiments reveal a complicated pattern of connections between receptor axons and higher order neurons as well as between higher order neurons themselves within the glomeruli. The ratio of the number of antennal fibers to that of relay fibers could easily lead to the interpretation, that the deutocerebrum merely serves as a device for reducing the number of transmission channels. However, coupled with physiological data, anatomical details such as con- and divergence of input and interconnections between input channels suggest rather a filtering system and a highly complicated integrative network.