Amy Mackley

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 (1.4%) of 2315 total 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.

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 babys condition, ‘the best source of information,’ and the person who told them ‘about important changes in their babys condition’ (P<0.01).Conclusion:Although the neonatologists role in parent education is satisfactory, the parents identified the nurses as the primary source of information.

Effect of antenatal corticosteroids on survival for neonates born at 23 weeks of gestation.

OBJECTIVE: To estimate if exposure to antenatal corticosteroids was associated with decreased rate of death in neonates born at 23 weeks of gestation. METHODS: This is a retrospective cohort study performed at three tertiary centers of neonates born at 23 weeks of gestation between 1998 and 2007. Stillbirths, voluntary terminations, or parental elected nonresuscitations were excluded. Clinical and demographic variables were examined to determine possible confounding variables. A multivariable logistic regression model was used to assess the effect of steroids on the odds of death after adjustment for these confounders. RESULTS: The sample included 181 neonates. Of the multiple variables examined (institution, race, diagnosis, illicit drug use, antibiotics, assisted reproduction, birth weight, gender, and route of delivery), only multiple gestations were significantly associated (P≤.15) with steroid use and increased odds of death (odds ratio [OR] 3.66, 95% confidence interval [CI] 1.05–12.73) and controlled for in the final model. The multivariable model revealed those exposed to antenatal corticosteroids had decreased odds of death (OR 0.32, 95% CI 0.12–0.84), with no significant differences in the occurrence of necrotizing enterocolitis among survivors (15.4% compared with 28.6%, P=.59) or severe intraventricular hemorrhage (23.1% compared with 57.1%, P=.17). In analyzing the effect of steroid dose, only a complete course of corticosteroids was associated with a decreased odds of death (OR 0.18, 95% CI 0.06–0.54). CONCLUSION: Neonates at 23 weeks of gestation whose mothers completed a course of antenatal corticosteroids had an associated 82% reduction in odds of death. LEVEL OF EVIDENCE: II

Forgotten parent: NICU paternal emotional response.

PURPOSE:To evaluate and compare the presence of perceived paternal stress and depressive symptomatology in fathers of preterm infants over time. SUBJECTS:Fathers of NICU infants born before 30 weeks of gestation. DESIGN:Prospective convenience sample. METHODS:Consenting fathers were given 2 self-report questionnaires: Center for Epidemiologic Studies-Depression Scale (CES-D) and Parent Stressor Scale: Infant Hospitalization (PSS:IH) on 7th (time 1), 21st (time 2), and 35th (time 3) days of life. Objective measurement of illness severity was quantified by Score for Neonatal Acute Physiology. Statistical methods included generalized linear estimating equation and mixed linear modeling. MAIN OUTCOME MEASURES:Stress and depressive symptomatology in fathers of preterm infants. RESULTS:Stress scores (PSS:IH) were unchanged over time (P = .62) indicating that fathers (n = 35) remain significantly stressed. Individual subcomponents of stress (parent role alteration, infant appearance/behavior, NICU sights/sounds) also remained constant over the study period (P = .05 for each). Stress scores over time were not modified by demographic characteristics (marriage, education, insurance). Mean depressive symptomatology scores (CES-D) decreased over time (P = .04). The percentage of fathers with elevated CES-D scores (>16) decreased from a baseline 60% but did not diminish between times 2 (39%) and 3 (36%). Parent Stressor Scale: Infant Hospitalization stress scores were correlated with CES-D depressive symptomatology scores (P < .01). Socioeconomic factors influenced initial CES-D scores, but only marriage ameliorated subsequent changes in measurements. Objective measurement of infant illness (Score for Neonatal Acute Physiology) did not influence paternal CES-D or PSS:IH scores. CONCLUSION:Fathers of premature infants in a medical NICU demonstrated elevated levels of stress that persisted across time for all domains of measured stress. Paternal self-reported stress and depressive symptomatology was independent of infant illness. One third of fathers had persistently elevated CES-D scores. If these findings are representative of general NICU population, then the emotional needs of our fathers are not being fully addressed.

Stress in fathers of surgical neonatal intensive care unit babies.

The purpose of this study was to identify and measure components of perceived stress in fathers of infants in a surgical neonatal intensive care unit (NICU). The Parent Stressor Scale: Infant Hospitalization (PSS:IH) was used to assess perceived stress in 22 fathers. Paternal stress was highest in the domains of “Parental Role Alteration” and “Infant Appearance and Behavior.” “Sights and Sounds” did not appear to be associated with self-reported stress. This study demonstrates elevated levels of perceived stress among fathers of surgical NICU babies. Attention to fathers may be assisted by findings.

Complementary and Alternative Medicine use in women during pregnancy: do their healthcare providers know?

BackgroundThe National Institutes of Health reported in 2007 that approximately 38% of United States adults have used at least one type of Complementary and Alternative Medicine (CAM). There are no studies available that assess general CAM use in US pregnant women.The objectives of our study were to determine the prevalence and type of CAM use during pregnancy at one medical center; understand who is using CAM and why they are using it; and assess the state of patients’ CAM use disclosure to their obstetrical providers.MethodsA cross-sectional survey study of post-partum women was done to assess self-reported CAM use during pregnancy. Results of this survey were compared to results from a previous survey performed by this research team in 2006. Data were analyzed using binary logistic regression.ResultsIn 2013, 153 women completed the survey, yielding a response rate of 74.3%. Seventy-two percent and 68.5% of participants reported CAM use during their pregnancies in 2006 and 2013 respectively. The percentage of participants who reported discussing CAM use with their obstetrical providers was less than 1% in 2006 and 50% in 2013. Increased use of different CAM therapies was associated with increased maternal age, primagravida, being US-born, and having a college education (p ≤ 0.05). However, these factors were poor predictors of CAM use.ConclusionsGiven the frequency of CAM use and the difficulty in predicting who is using it, obstetrical providers should consider being informed about CAM and incorporating discussions about its use into routine patient assessments.

Work of breathing indices in infants with respiratory insufficiency receiving high-flow nasal cannula and nasal continuous positive airway pressure

Objective:To compare work of breathing (WOB) indices between two nCPAP settings and two levels of HFNC in a crossover study.Study Design:Infants with a CGA 28–40 weeks, baseline of HFNC 3–5 lpm or nCPAP 5-6 cmH2O and fraction of inspired oxygen ⩽40% were eligible. WOB was analyzed using respiratory inductive plethysmography (RIP) for each of the four modalities: HFNC 3 and 5 lpm, nCPAP 5 and 6 cmH2O. N=20; Study weight 1516 g (±40 g).Result:Approximately 12 000 breaths were analyzed indicating a high degree of asynchronous breathing and elevated WOB indices at all four levels of support. Phase angle values (means) (P<0.01): HFNC 3 lpm (114.7°), HFNC 5 lpm (96.7°), nCPAP 5 cmH2O (87.2°), nCPAP 6 cmH2O (80.5°). The mean phase relation of total breath (PhRTB) (means) (P<0.01): HFNC 3 lpm (63.2%), HFNC 5 lpm (55.3%), nCPAP 5 cmH2O (49.3%), nCPAP 6 cmH2O (48.0%). The relative labored breathing index (LBI) (means) (P⩽0.001): HFNC 3 lpm (1.39), HFNC 5 lpm (1.31), nCPAP 5 cmH2O (1.29), nCPAP 6 cmH2O (1.26). Eighty-two percent of the study subjects—respiratory mode combinations displayed clustering, in which a proportion of breaths either occurred predominantly out-of-phase (relative asynchrony) or in-phase (relative synchrony).Conclusion:In this study, WOB indices were statistically different, yet clinically similar in that they were elevated with respect to normal values. These infants with mild-to-moderate respiratory insufficiency demonstrate a meaningful elevation in WOB indices and continue to require non-invasive respiratory support. Patient variability exists with regard to biphasic clustered breathing patterns and the level of supplemental fraction of inspired oxygen ⩽40% alone does not provide guidance to the optimal matching of WOB indices and non-invasive respiratory support.

Volumetric MRI and MRS and early motor development of infants born preterm.

Purpose: To investigate the relationship between volumetric magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) in infants born less than 30 weeks gestation and early motor development at 6 months adjusted age. Methods: Twenty infants born preterm and 4 born at term (control) underwent MRI with volumetric analysis and MRS prior to neonatal intensive care unit discharge. Infants were assessed using the Bayley Scale of Infant Development at 6 months adjusted age. Results: At 6 months, infants born preterm with low motor scores had a reduction in their subcortical gray matter. No differences were detected in other brain structures. N-acetylaspartate/choline correlated with white matter (R = 0.45, P = .03), gray matter (R = 0.43, P = .04), and cerebellar volume (R = 0.6, P = .002) but not with 6-month motor performance. Conclusion: There is an association between diminished subcortical gray matter volume and low motor scores. Our data suggest that volumetric MRI performed prior to hospital discharge may have some role in counseling parents about potential motor delays.

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.

Transfusing neonates based on platelet count vs. platelet mass: A randomized feasibility-pilot study

Abstract The objective of this study was to obtain pilot data on which to judge the feasibility and sample size needed for a future comparative-effectiveness trial of platelet transfusions in the NICU. We conducted a limited-scope pilot trial in which neonates were randomized to receive platelet transfusions based on platelet mass vs. platelet count, using preset “transfusion-trigger” values. Analysis included parental consent rate, number of platelet transfusions given, bleeding episodes recorded, and mortality rate. Statistical analysis included ANOVA and Chi-square. A convenience sample of 30 were randomized; 15 per group. No differences were found between groups in gestational age, birth weight, race, gender or clinical diagnoses. The study consent rate was 52% (30/58). No differences were found in number of platelet transfusions received, bleeding episodes, or mortality. Lack of a trend in transfusion-reduction resulted in inability to estimate the number needed in a future comparative-effectiveness trial. Using platelet mass, rather than platelet count, for a NICU platelet transfusion trigger is feasible. However, any future comparative-effectiveness trial, testing the hypothesis that a platelet mass-based trigger reduces the transfusion rate will likely require a very large sample size.