A Kılıç

An intention to achieve better postnatal in-hospital-growth for preterm infants: Adjustable protein fortification of human milk

OBJECTIVE We assessed the effect of human milk (HM) fortification with extra protein supplement by an adjustable protein fortification method according to the weekly blood urea nitrogen (BUN) levels on growth in hospitalized preterm infants. METHOD A prospective observational intervention study in 58 preterms born ≤32 weeks of gestation and fed with breast milk was conducted. Preterms who were given a commercial HM fortifier which provides an additional protein of 0.8 g/3 scales according to the standard feeding strategy served as a historical control group. Infants who were given extra protein in addition to the HM fortifier with another commercial protein supplement which provides an additional protein of 2.2g/1 scale comprised the intervention group. Additional protein supplementation was adjusted according to BUN levels weekly in the intervention group. Weight gain velocities (g/kg/day), length, head circumferences (HC) gain velocities (mm/day) and daily growth indexes for weight, height and HC (percentage per day) were calculated. RESULTS The median amount of daily enteral protein intake [4 (3.4-4.6) vs. 2.78 (2.1-3.1) g/kg/day, p < 0.0001] was significantly higher in the interventional group. Length (p = 0.008) and HC (p < 0.0001) gain velocities were significantly higher in the intervention group. Daily growth indexes for weight (2.2% vs. 1.8%, p = 0.026), for length (0.4% vs. 0.3%, p = 0.027) and for HC (0.48% vs. 0.36% per day, p = 0.003) were significantly higher in the intervention group. CONCLUSION A higher protein intake by adjustable protein fortification method without energy or volume change leads to improved postnatal in-hospital-growth in very low birth weight infants.

Effects of umbilical cord milking on the need for packed red blood cell transfusions and early neonatal hemodynamic adaptation in preterm infants born ≤1500 g: a prospective, randomized, controlled trial.

Objective: The aim of this study was to evaluate the effects of umbilical cord milking (UCM) on the need for packed red blood cell (PRBC) transfusion and hematologic and hemodynamic parameters in very-low–birth-weight infants. Methods: The infants were randomized into 2 groups: group 1 (UCM) and group 2 (control). The primary outcome was the number of PRBC transfusions during the first 35 days of life. The secondary outcome measures were the hemodynamic variables during the first 24 hours of life. Results: A total of 44 infants were included with 22 infants in each group. Two of 21 infants in group 1 and 4 of 21 infants in group 2 received transfusion in the first 3 days of life (P=0.384). The number and volume of PRBC transfusions were similar in both groups. However, the levels of hemoglobin (Hb) at the first and 24th hour of life were significantly higher in group 1. Phlebotomy volume was found as a statistically significant risk factor for the need for PRBC transfusion (P=0.005). Conclusions: UCM in delivery room results in a higher Hb level in the first day of life. In these groups of infants, phlebotomy losses may impact the transfusion need.

Management of patent ductus arteriosus in preterm infants: clinical judgment might be a fair option

Abstract Objective: The objective of this study was to find out the percentage of preterm infants that needed treatment for patent ductus arteriosus (PDA), when treatment decision was based on clinical signs and symptoms, besides echocardiographic findings. Methods: Daily echocardiographic evaluation was conducted in 39 preterms ≤296/7 weeks’ gestation. Patients with ductus arteriosus were closely followed-up for clinical symptoms of PDA for treatment decision until ductus arteriosus was closed either spontaneously or by treatment. Results: PDA was found in 25 (64%) infants. Mean gestational age and birth weight (BW) of the patients with PDA were 27.8 ± 1.2 and 998 ± 221 g, respectively. PDA closed spontaneously or had minimal ductal shunting before any signs and symptoms attributable to PDA were observed in 16 (41%) infants. Mean ductus size/BW ratio and mean left atrial/aortic root ratio were significantly higher in 9 (23%) symptomatic patients (2.06 ± 0.75 versus 1.32 ± 0.75 mm, p = 0.012 and 1.31 ± 0.52 versus 1.19 ± 0.2 mm, p = 0.043, respectively). PDA closure was observed after the first dose of ibuprofen in six of nine patients. Conclusion: Correlation of clinical signs with echocardiographic findings for the decision of PDA treatment can be appropriate to prevent unnecessary medical treatments.

Palivizumab use during respiratory syncytial virus outbreak in the neonatal intensive care unit

We read with great interest the papers by Dizdar et al. and by O’Connell et al. about the use of palivizumab during a respiratory syncytial virus (RSV) outbreak in neonatal intensive care units (NICUs), suggesting that palivizumab administration might have a role in controlling RSV outbreak and recommended early administration of palivizumab to terminate transmission as quickly as possible. We recently experienced a similar outbreak in our NICU, and controlled it according to the suggestions made in this paper. There were ten preterm (median gestational age: 29.3 weeks; range: 26.2e32 weeks; birth weight: 848e1520 g), two late preterm (>35 weeks’ gestational age) and four term infants in the NICU when two term newborns with bronchopneumonia and respiratory insufficiency were admitted to the NICU isolation unit between 29 February 2012 and 12 March 2012. Polymerase chain reaction (PCR) screening including RSV (A, B), coronavirus (A, B, C, D, E, OC43, HKU1), parainfluenza (1, 2, 3, 4), rhinovirus (A, B, C), influenza (A, B), bocavirus (1, 2, 3, 4), metapneumovirus and enterovirus, revealed RSV type B infection in these two patients. Although patients with RSV were cared for in separate isolation rooms, another preterm infant who had recovered from respiratory distress syndrome developed further respiratory distress after a week. Nasopharyngeal secretions obtained from this infant also revealed RSV type B infection and we decided to screen the remaining 15 infants for RSV. None of the asymptomatic patients was RSV PCR positive. In order to prevent an escalating NICU outbreak, palivizumab prophylaxis was administered to nine preterm infants, all of whom were <32 weeks of gestational age at birth, and one patient who had a congenital heart disease at a dosage of 15 mg/kg, in addition to strict contact precautions. Patients with RSV bronchiolitis recovered after about 10 days and we did not observe any additional cases with RSV. RSV infection was brought into the NICU by two patients with RSV bronchiolitis. Following this, one preterm patient, who was recovering from respiratory distress, developed RSV bronchiolitis. As NICUs like ours embrace a family-centred model for patient care, greater difficulties complying with effective infection control measures may emerge. We agree with Dizdar et al. and O’Connell et al. that palivizumab prophylaxis may have a role in the control of RSV epidemics in the NICU. If we had not given palivizumab prophylaxis after detection of index cases, a larger RSV outbreak might have occurred in our NICU. After a few small RSV NICU outbreaks in Turkey, the Turkish Neonatal Society now recommends RSV prophylaxis for premature infants in the NICU who are already candidates for the prophylaxis programme as outpatients when at least three RSV-positive patients are present in the NICU. This recommendation is similar to the one reported by the Spanish Neonatal Society which suggests palivizumab prophylaxis for preterm infants and newborns with haemodynamically significant congenital heart disease when such outbreaks occur.

PO-0516 Healthcare-associated Infections In A Turkey Neonatal Intensive Care Unit

Aim The aim of this study was to determine the incidence of (Healthcare-associated infection) HAI, causative organisms, associated risk factors in a neonatal intensive care unit in Turkey. Methods A prospective cohort study was conducted on patients admitted to the neonatal intensive care unit (NICU) from July 2011 to June 2012. The criteria that were used to diagnose infection were in accordance with the Centres for Disease Control and Prevention. The incidence, causative organisms, risk factors and mortality of healthcare-associated infections were assessed. Results The study included 352 patients, 37 of these developed HAIs, totaling 60 HAI episodes. Overall HAI patient rate was 17.04%, and 11.51 HAIs per 1000 NICU days. The most frequent HAIs were bloodstream infections (70%) and nosocomial pneumonia (18.3%). The central venous catheter/umblical catheter-related bloodstream infections (CVC/UC BSIs) rate was 18.3/1,000 catheter days; the ventilator-associated pneumonia (VAP) rate was 13.6/1,000 ventilator days; and the catheter-associated urinary tract infections rate found was 14.9/1,000 catheter days. Prematurity, gestational age less than 32 weeks, birth weight < 1500 g, mechanical ventilation, use of CVC/UC, use of urinary catheter, and total parenteral nutrition appeared to be associated with a significantly higher risk of HAI (p ≤ 0.05). The most frequent pathogens were Enterobacter spp. (18.5%) and Acinetobacter baumannii (13.8%). Overall mortality rate in neonates was 3.9%, and the mortality rate in neonates with HAI was 10.8%. Conclusions Healthcare-associated infection rates of our NICU were higher than international standards. The decrement of risk factors in newborns would help to improve the outcome.

A Case of Tuberous Sclerosis with Prenatally Diagnosed Cardiac Rhabdomyoma

Tuberous sclerosis is an autosomal dominant disorder in which hamartomas occur in several organs. The most common heart tumor in children is rhabdomyoma. Rhabdomyoma is often associated with tuberous sclerosis and can be diagnosed by echocardiography during the antenatal or postnatal period. Herein, we suggest that fetal echocardiography should be performed in cases with a positive family history of tuberous sclerosis. Additionally, tuberous sclerosis should be kept in mind in a case with fetal rhabdomyoma.

1321 The Management of Central Diabetes Insipidus in Neonatal Intensive Care Unit: Experience of Eight Cases

Neonatal central diabetes insipidus (DI) is extremely rare and etiology has not been documented extensively. Asphyxia, intraventricular hemorrhage, severe infections, and central nervous system abnormalities have been associated with central DI in neonatal intensive care units (NICU). Desamino-8-D-arginine vasopressin (DDAVP) has been in clinical use for the treatment of central DI. DDAVP preparations are available for intranasal, oral, subcutaneous, and intravenous administration. There is not clear data for the management and used DDAVP form for the central DI in neonates. In this article, we presented eight cases with different etiology of neonatal central DI. Six cases were preterm with intracranial hemorrhage and the other two patients were congenital toxoplasmosis one of which was preterm. All of the cases received oral desmopressin at a dose of 10 mcg/kg/day. And then oral desmopressin dosage was adjusted according to the serum sodium and urine output. All cases were treated successfully with oral DDAVP. Three cases who have intracranial hemorrhage died due to other preterm complication. According to our case series, oral DDAVP is an applicable, safe and effective form of DDAVP.

1797 Do Non-Invasive Ventilatory Strategies Work in Micro-Premature Infants who are at the Limits of Viability?

Aim To evaluate the non-invasive ventilatory support in micro-premature infants who are at the limits of viability. Methods This prospective cohort study from January-2009 to December 2011 included infants born before 26 weeks’. During resuscitation, stabilisation and transport infants were ventilated with a T-piece resuscitator, and all received prophylactic surfactant at a dose of 100 mg/kg. If respiratory drive was present, infants were extubated to NCPAP. The demographic and clinical features of the infants were assessed. Results Twenty-four infants born during the study period. Antenatal steroid rate was 16.7%. Mean gestational age(GA) and birth weight(BW) were 24.3±0.9 weeks, and 660.2±125.5 g, respectively. The presence of premature rupture of membranes and chorioamnionitis rate was 54%. Only five(21%) of 24 infants could be extubated to NCPAP, and three of these five were intubated in first 3-days. Only two(8.3%) infants succeeded on NCPAP, and the GAs’ were 24.6 and 25.1 weeks, the BWs’ were 1010 and 730 g. The rate of NEC, PDA, İVH and pulmonary hemorrhage were 29%, 36%, 36% and 21%, respectively in infants who survived more than 2 days. The overall mortality rate was 92%, the duration of hospitalization was between one and 137 days. Conclusion In our study, it has been seen that NCPAP may not be an effective ventilation strategy in premature infants who are at the limits of viability. The high proportion of chorioamnionitis in this group may affect the ventilation and the following problems. These babies are needed to be care at very special settings.

232 The Timing of Surfactant Prophylaxis in Very-Low-Birth-Weight Preterms: Is Earlier Better?

Aim To determine whether the immediate bolus strategy treatment could decrease the subsequent need for ventilation compared to the administration of surfactant prophylaxis at 15-minutes. Methods All infants born before 29 weeks’, and infants born at 29 to 30 weeks’ without antenatal steroid(ANS) were randomized. Infants of group-1 were intubated immediately after birth, of group-2 received standard resuscitation measures, than were intubated at 15-minutes. All received 100 mg/kg surfactant. During these managements infants were ventilated with T-piece(NeoPuff). Then infants were extubated to NCPAP(Infant Flow®) if respiratory drive was present. The primary outcome was the need for MV within the first 3-days of life. The secondary outcomes were neonatal morbidities, mortality and duration of hospitalization. Results Total of 80 newborns were enrolled (fourty infants in each group). Prenatal and natal features were similar in groups. Ten infants in group-1, 13 infants in group-2 couldn’t be extubated after surfactant. GA and BW of them were lower than the extubated infants. Six infants in group-1, four infants in group-2 needed MV during the first 3-days. Total respiratory support duration was lower in group-1. There were no significant differences between the groups with a respect to PDA, NEC, IVH, sepsis, ROP, BPD, mortality and duration of hospitalization. Conclusion Our study didn’t demonstrate a superiority of the immediate bolus strategy of surfactant prophylaxis combined with early-NCPAP to the administration of surfactant at 15-minutes after birth with early-NCPAP. Surfactant prophylaxis at-15 minutes with early-NCPAP seems to be sufficiently effective to yield favorable outcomes in small preterm infants.

Oral Lactoferrin Prophylaxis to Prevent Sepsis and Necrotising Enterocolitis of Very Low Birth Weight Neonates in Neonatal Intensive Care Unit and Effect on T-Regulatory Cells

Aim of the study is to evaluate whether oral administration of lactoferrin (LF) can enhance host defense and reduce late onset sepsis and NEC in VLBW infants, and to determine its effect on regulatory-T cells. The study was designed as a prospective, placebo-controlled, randomized trial in VLBW infants, who were randomly assigned to receive orally either 200 mg LF (n=25) or placebo (n=25) daily. Episodes of suspected and culture proven late onset sepsis and NEC were recorded. CD4+25+ FOXP3+ lymphocytes were determined by flow cytometry at birth and discharge. Prenatal, natal and postnatal characteristics of the groups were similar. Mean gestational ages of groups were 30,3±2,5 and 29,5±1,6 weeks, and birth weights were 1307±262,1g and 1290±346,7g, respectively. During hospitalization period 14 vs 4 culture proven sepsis were observed in control and study group, respectively (p< 0,05). In group 2, none of the patients experienced grade 2 and 3 NEC, while 5 babies from Group 1 (p>0,05). Regulatory-T cell levels at birth and at discharge were similar in two groups. The increase in FOXP3 expression at discharge was significantly higher in oral LF group (p< 0,05).In this study, oral LF significantly lowered culture proven sepsis rate. Similar effect was observed in NEC rate but without statistical significance. The treated group took shorter time to reach full enteral feedings and no adverse effect was observed. The significant higher increase in FOXP3 expression in the LF group can be the mechanism for protective effects of LF on late onset sepsis and NEC.