Anne Twomey

Vitamin D nutritional status in preterm infants and response to supplementation.

Little is known about vitamin D status in preterm infants and their response to supplementation. To investigate this, we assessed serum 25-hydroxyvitamin D (25OHD) levels using RIA in a consecutive sample of stable preterm very low birth weight (VLBW) infants (born ≤ 32 weeks gestation or birth weight ≤ 1·5 kg), and we explored associated factors. Serum 25OHD level was first assessed once infants were tolerating feeds (n 274). If this first 25OHD level was below 50 nmol/l (20 ng/ml), which is the level associated with covering requirements in terms of skeletal health in the majority, then we recommended prolonged augmented vitamin D intake ( ≥ 10 μg (400 IU) daily) from a combination of fortified feeds and vitamin supplements and follow-up re-assessment at approximately 6 weeks corrected age (n 148). The first assessment, conducted at a median for chronological age of 18 (interquartile range (IQR) 11-28) d, found that 78 % had serum 25OHD levels below 50 nmol/l. Multivariable analysis demonstrated that the determinants of serum 25OHD levels were duration of vitamin D supplementation and gestational age at birth (r 2 0·215; P< 0·001). At follow-up, after a median of 104 (IQR 78-127) d, 87 % achieved levels ≥ 50 nmol/l and 8 % had levels >125 nmol/l, a level associated with potential risk of harm. We conclude that low 25OHD levels are an issue for preterm VLBW infants, warranting early nutritional intervention. In infants with serum 25OHD levels < 50 nmol/l, a vitamin D intake of ≥ 10 μg (400 IU) daily achieves target levels in the majority; however, further work is needed to determine the exact dose to safely meet target levels without overcorrection.

A Randomized Trial of Exothermic Mattresses for Preterm Newborns in Polyethylene Bags

BACKGROUND AND OBJECTIVE: Hypothermia on admission to the NICU is associated with increased mortality in preterm infants. Many newborns are hypothermic on admission despite using polyethylene bags (PBs). Using exothermic mattresses (EMs) in addition to PBs may reduce hypothermia but increase hyperthermia. We wished to determine whether placing preterm newborns in PBs on EMs in the DR results in more infants with rectal temperature outside the range 36.5 to 37.5°C on NICU admission. METHODS: Infants <31 weeks were randomly assigned before birth to treatment with or without an EM. All infants were placed in a PB and under radiant heat immediately after birth and brought to NICU in a transport incubator. Infants randomly assigned to EM were placed on a mattress immediately after delivery and remained on it until admission. Randomization was stratified by gestational age. Rectal temperature was measured with a digital thermometer on NICU admission. RESULTS: The data safety monitoring committee recommended stopping for efficacy after analyzing data from half the planned sample. We report data for 72 infants enrolled at this time. Fewer infants in PBs on EMs had temperatures within the target range (15/37 [41%] vs 27/35 [77%], P = .002) and more had temperatures >37.5°C (17/37 [46%] vs 6/35 [17%], P = .009). CONCLUSIONS: In very preterm newborns, using EMs in addition to PBs in the DR resulted in more infants with temperatures outside the normal range and more hyperthermia on NICU admission.

Randomized Trial of Prongs or Mask for Nasal Continuous Positive Airway Pressure in Preterm Infants

OBJECTIVE: To determine whether nasal continuous positive airway pressure (NCPAP) given with nasal prongs compared with nasal mask reduces the rate of intubation and mechanical ventilation in preterm infants within 72 hours of starting therapy. METHODS: Infants <31 weeks’ gestation treated with NCPAP were randomly assigned to receive it via either prongs or mask. Randomization was stratified by gestational age (<28 weeks, 28–30 weeks) and according to whether NCPAP was started as a primary treatment for respiratory distress or postextubation. Infants were intubated and ventilated if they fulfilled 2 or more of 5 failure criteria (worsening signs of respiratory distress; recurrent apnea treated with mask positive pressure ventilation; fraction of inspired oxygen >0.4 to keep oxygen saturation >88% sustained for 30 minutes; pH <7.2 on 2 blood gases ≥30 minutes apart; Pco2 >9 kPa [68 mm Hg] on 2 blood gases ≥30 minutes apart) within 72 hours of starting therapy. The groups were treated the same in all other respects. We recorded relevant secondary outcomes and analyzed data by using the intention-to-treat principle. RESULTS: We enrolled 120 infants. Thirty-two of 62 (52%) infants randomly assigned to prongs were intubated within 72 hours, compared with 16/58 (28%) of those randomly assigned to mask (P = .007). There were no statistically significant differences between the groups in any secondary outcomes. CONCLUSIONS: In premature infants, NCPAP was more effective at preventing intubation and ventilation within 72 hours of starting therapy when given via nasal masks compared with nasal prongs.

The Association of Vitamin D Status with Acute Respiratory Morbidity in Preterm Infants

OBJECTIVE To assess the association between serum 25-hydroxyvitamin D (25OHD) levels and outcomes in preterm infants (<32 weeks gestation). STUDY DESIGN Serum 25OHD was measured in mothers and their infants within 24 hours of birth, before the start of enteral vitamin D supplementation, and at discharge from the neonatal intensive care unit. We evaluated the associations between vitamin D status and various early preterm outcomes. RESULTS Ninety-four preterm infants and their mothers were included; 92% of the infants had a 25OHD level≤50 nmol/L (20 ng/mL), and 64% had a 25OHD level<30 nmol/L (12 ng/mL). A low 25OHD level (<30 nmol/L) in preterm infants at birth was associated with increased oxygen requirement (P=.008), increased duration of intermittent positive-pressure ventilation during resuscitation at delivery (P=.032), and greater need for assisted ventilation (P=.013). CONCLUSION We observed a high prevalence of low 25OHD (<30 nmol/L), and found an association between vitamin D status and acute respiratory morbidity in preterm infants after birth.

A Randomized Trial of Nasal Prong or Face Mask for Respiratory Support for Preterm Newborns

BACKGROUND AND OBJECTIVE: Resuscitation guidelines recommend that respiratory support should be given to newborns via a face mask (FM) in the delivery room (DR). Respiratory support given to preterm newborns via a single nasal prong (SNP; ie, short nasal tube, nasopharyngeal tube) may be more effective. We wished to determine whether giving respiratory support to preterm newborns with a SNP rather than a FM reduces the rate of intubation in the DR. METHODS: Infants <31 weeks’ gestation were randomized just before delivery to SNP (endotracheal tube shortened to 5 cm) or FM. Randomization was stratified by gestation (<28 weeks, 28–30+6). Infants with apnea, respiratory distress, and/or heart rate <100 received positive pressure ventilation with a T-piece. The primary outcome was intubation and mechanical ventilation in the DR. Infants in both groups were intubated for heart rate <100 and/or apnea despite PPV and not solely for surfactant administration. All other aspects of treatment in the DR and NICU were the same. Relevant secondary outcomes were recorded and data were analyzed by using the intention-to-treat principle. RESULTS: One hundred forty-four infants were enrolled. The rate of intubation in the DR was the same in both groups (11/72 [15%] vs 11/72 [15%], P = 1.000]. Infants assigned to SNP had lower SpO2 at 5 minutes and received a higher maximum concentration of oxygen in the DR. There were no significant differences in other secondary outcomes. CONCLUSIONS: Giving respiratory support to newborn infants <31 weeks’ gestation via a SNP, compared with a FM, did not result in less intubation and ventilation in the DR.

Isolated acute non-cystic white matter injury in term infants presenting with neonatal encephalopathy.

We discuss possible aetiological factors, MRI evolution of injury and neuro-developmental outcomes of neonatal encephalopathy (NE). Thirty-six consecutive infants diagnosed with NE were included. In this cohort, four infants (11%) were identified with injury predominantly in the deep white matter on MRI who were significantly of younger gestation, lower birthweight with higher Apgars at one and five minutes compared to controls. Placental high grade villitis of unknown aetiology (VUA) was identified in all four of these infants. Our hypothesis states VUA may induce white matter injury by causing a local inflammatory response and/or oxidative stress during the perinatal period. We underline the importance of continued close and systematic evaluation of all cases of NE, including examination of the placenta, in order to come to a better understanding of the clinical presentation, the patterns of brain injury and the underlying pathophysiological processes.

Persistent vancomycin and high-level gentamicin-resistant Enterococcus faecium bacteremia and intra-aortic thrombus in an extremely low birth-weight infant

Vancomycin-resistant Enterococcus (VRE) sepsis is emerging as a significant problem in the intensive care setting. The treatment at any age is challenging, but there is a dearth of information on this infection and its treatment in the very premature infant. We describe successful treatment of persistent bacteremia caused by Enterococcus faecium with vancomycin and high-level gentamicin resistance in a 10-day-old former 23-week premature male infant.

2% chlorhexidine–70% isopropyl alcohol versus 10% povidone–iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial

Objective To determine whether 2% chlorhexidine gluconate–70% isopropyl alcohol (CHX–IA) is superior to 10% aqueous povidone–iodine (PI) in preventing catheter-related blood stream infection (CR-BSI) when used to clean insertion sites before placing central venous catheters (CVCs) in preterm infants. Design Randomised controlled trial. Setting Two neonatal intensive care units (NICUs). Patients Infants <31 weeks’ gestation who had a CVC inserted. Interventions Insertion site was cleaned with CHX–IA or PI. Caregivers were not masked to group assignment. Main outcome measures Primary outcome was CR-BSI determined by one microbiologist who was masked to group assignment. Secondary outcomes included skin reactions to study solution and thyroid dysfunction. Results We enrolled 304 infants (CHX–IA 148 vs PI 156) in whom 815 CVCs (CHX–IA 384 vs PI 431) were inserted and remained in situ for 3078 (CHX–IA 1465 vs PI 1613) days. We found no differences between the groups in the proportion of infants with CR-BSI (CHX–IA 7% vs PI 5%, p=0.631), the proportion of CVCs complicated by CR-BSI or the rate of CR-BSI per 1000 catheter days. Skin reaction rates were low (<1% CVC insertion episodes) and not different between the groups. More infants in the PI group had raised thyroid-stimulating hormone levels and were treated with thyroxine (CHX–IA 0% vs PI 5%, p=0.003). Conclusions We did not find a difference in the rate of CR-BSI between preterm infants treated with CHX–IA and PI, and more infants treated with PI had thyroid dysfunction. However, our study was not adequately powered to detect a difference in our primary outcome and a larger trial is required to confirm our findings. Trial registration This study was registered with the EU clinical trials register before the first patient was enrolled (Eudract 2011-002962-19). (https://www.clinicaltrialsregister.eu)

Neutrophil and monocyte Toll-Like Receptor 4, CD11b and Reactive Oxygen Intermediates and Neuroimaging Outcomes in Preterm Infants

Background:Activated leukocytes and infection are implicated in neonatal brain injury. Leukocyte surface receptors are increased in stroke models and may be targets for future adjunctive therapies.Methods:Serial blood samples were analyzed from preterm infants (n = 51; <32 wk gestation) on days 0, 1, 2, and 7 of life. Monocyte and neutrophil activation were evaluated via flow cytometry at baseline and following endotoxin stimulation ex vivo by measuring CD11b (activation), toll-like receptor 4 (TLR-4; endotoxin recognition) expression, and intracellular reactive oxygen intermediate (ROI) production (function).Results:Control preterm infants with normal neuroimaging had elevated baseline CD11b and TLR-4 expression and ROI production compared with adults as well as a robust immune response following endotoxin stimulation. Preterm infants with abnormal neuroimaging had increased neutrophil TLR-4 and ROI compared with all controls.Conclusion:Preterm infants have a robust immune response compared with adults. Increased TLR-4 expression in preterm infants with abnormal neuroimaging is similar to findings in adult stroke. In addition, ROI production may cause tissue injury. The modulation of these responses may be beneficial in preterm inflammatory disorders.

A review of neonatal attendances out of hours in a Dublin maternity hospital

BackgroundAll neonates have free open access to the Baby Clinic at the maternity hospitals in Dublin for assessment of neonatal health issues.Through observation, however there is an increase in number of neonates attending the hospital outside the Baby Clinic hours.AimsTo determine the number of neonates attending the acute neonatal service out of hours and to identify the percentage of neonates treated as true emergencyMethodsRetrospective chart review over a twelve-month period.ResultsSeven hundred and thirty-two neonates attended the hospital out of hours.The majority were diagnosed with gastrointestinal problems (228 / 31%), jaundice (101 /13.7%), respiratory problems (82 /11.1%) and skin disorders (79 /10.7%). Only 106 (14.4%) attendances warranted admissions.ConclusionsA large number of neonatal attendances did not require acute assessment out of hours and were managed by reassurance and maternal education. A centralized phone-in-triage system was suggested to relieve the strain on the acute neonatal service.