Arieh Riskin

Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition.

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infants own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

The relationship between delivery mode and mortality in very low birthweight singleton vertex-presenting infants

Objective  To investigate the factors associated with caesarean delivery and the relationship between mode of delivery and mortality in singleton vertex‐presenting very low birthweight (≤1500 g) live born infants.

Delivery Mode and Severe Intraventricular Hemorrhage in Single, Very Low Birth Weight, Vertex Infants

OBJECTIVE: To investigate the association between delivery mode and grade 3–4 intraventricular hemorrhage in singleton, vertex presenting, very low birth weight (VLBW) (1,500 g or less) liveborn infants. METHODS: The Israel National VLBW Infant Database includes perinatal and neonatal data on greater than 99% of all VLBW newborns. A total of 4,658 singleton vertex-presenting infants born at 24–34 weeks were included (1995–2004). Infants with lethal congenital malformations, delivery room deaths, and home deliveries were excluded. Our population-based observational study evaluated the effect of delivery mode and confounding variables on severe intraventricular hemorrhage using univariable and multivariable logistic regression analyses. RESULTS: The rate of severe intraventricular hemorrhage was 10.4%. Cesarean delivery rate was 54.3%. The rate of severe intraventricular hemorrhage was 7.7% for infants delivered by cesarean compared with 13.6% in vaginal delivery (P<.001). However, analysis according to gestational age showed that the rate of severe intraventricular hemorrhage was similar in cesarean and vaginal delivery in all gestational age groups. In the multivariable model, cesarean delivery had no effect on the odds for severe intraventricular hemorrhage (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.77–1.24). Other factors independently associated with severe intraventricular hemorrhage included gestational age (OR 0.71, 95% CI 0.68–0.75 for each week increase), maternal hypertensive disorder (OR 0.43, 95% CI 0.30–0.61), no antenatal steroids (OR 2.70, 95% CI 2.12–3.45), 1-minute Apgar score 0–3 (OR 1.72, 95% CI 1.33–2.21), delivery room resuscitation (OR 2.16, 95% CI 1.65–2.83), and non-Jewish ethnicity (OR 1.28, 95% CI 1.03–1.59). CONCLUSION: In this population-based study, the odds for severe intraventricular hemorrhage were not influenced by mode of delivery in vertex-presenting singleton VLBW infants after controlling for gestational age. LEVEL OF EVIDENCE: II

Iatrogenesis in Neonatal Intensive Care Units: Observational and Interventional, Prospective, Multicenter Study

OBJECTIVES. The goals were to determine the incidence of iatrogenic events in NICUs and to determine whether awareness of iatrogenic events could influence their occurrence. METHODS. We performed a prospective, observational, interventional, multicenter study including all consecutive infants hospitalized in 4 NICUs. In the first 3 months (observation period), the medical teams were unaware of the study; in the next 3 months (intervention period), they were made aware of daily ongoing monitoring of iatrogenic events by a designated “Iatrogenesis Advocate.” RESULTS. The numbers of infants admitted to the NICUs were comparable during the observation and intervention periods (328 and 369 infants, respectively). There was no difference between the 2 periods with respect to the number of infants of <1500 g, hospitalization days, or mean daily occupancy of the NICUs. Although the prevalence rates of iatrogenic events were comparable in the observation and intervention periods (18.0 and 18.2 infants with iatrogenic events per 100 hospitalized infants, respectively), the incidence rate decreased significantly during the intervention period (3.2 and 2.4 iatrogenic events per 100 hospitalization days of new admissions, respectively). Of all iatrogenic events, 7.9% were classified as life-threatening and 45.1% as harmful. There was no death related to an iatrogenic event. Eighty-three percent of iatrogenic events were considered preventable, of which 26.9% resulted from medical errors in ordering or delivery of medical care. Only 1.6% of all iatrogenic events were intercepted before reaching the infants, and only 47.0% of iatrogenic events were corrected. For younger and smaller infants, the rate of iatrogenic events was higher (57% at gestational ages of 24 to 27 weeks, compared with 3% at term) and the iatrogenic events were more severe and harmful. Increased length of stay was associated independently with more iatrogenic events. CONCLUSIONS. Neonatal medical teams and parents should be aware of the burden of iatrogenesis, which occurs at a significant rate.

A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS

To compare the requirement for endotracheal ventilation in preterm infants treated with heated, humidified high‐flow nasal cannula (HHHFNC) with those treated with nasal intermittent positive pressure ventilation (NIPPV) for the primary treatment of respiratory distress syndrome (RDS).

The Impact of Rudeness on Medical Team Performance: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Iatrogenesis often results from performance deficiencies among medical team members. Team-targeted rudeness may underlie such performance deficiencies, with individuals exposed to rude behavior being less helpful and cooperative. Our objective was to explore the impact of rudeness on the performance of medical teams. METHODS: Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by 3 independent judges (blinded to team exposure) who used structured questionnaires to assess team performance, information-sharing, and help-seeking. RESULTS: The composite diagnostic and procedural performance scores were lower for members of teams exposed to rudeness than to members of the control teams (2.6 vs 3.2 [P = .005] and 2.8 vs 3.3 [P = .008], respectively). Rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance. A model specifying information-sharing and help-seeking as mediators linking rudeness to team performance explained an even greater portion of the variance in diagnostic and procedural performance (R2 = 52.3 and 42.7, respectively). CONCLUSIONS: Rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.

Is Visual Assessment of Jaundice Reliable as a Screening Tool to Detect Significant Neonatal Hyperbilirubinemia

OBJECTIVE To assess the reliability of visual assessment of bilirubin levels (BiliEye) in newborns as a screening tool to detect significant neonatal hyperbilirubinemia. STUDY DESIGN 5 neonatologists and 17 nurses estimated 3,532 BiliEye in 1,129 term and late preterm (> or = 35 weeks) infants before discharge from the nursery, at 62 +/- 24 hours. Total serum bilirubin (TSB) levels were measured concomitantly. RESULTS Mean TSB and BiliEye were 6.7 +/- 2.9 mg/dL (range, 0.4-18.2 mg/dL) and 6.6 +/- 3.2 mg/dL (range, 0.0-17.2 mg/dL), respectively, with good correlation (Pearsons r = 0.752, P < .0001), but other measures of agreement were poor. 61.5% of the 109 babies with TSB levels in high-risk zones were clinically misclassified. The area under curve (AUC) of the receiver-operating characteristics plotted for these high-risk zones was 0.825, but became low for early discharge (< or = 36 hours; AUC = 0.638) and late preterm (35-37 weeks; AUC = 0.613). There was significant interobserver variation (low weighted kappa, 0.363). CONCLUSIONS Although there was good correlation between BiliEye and actual TSB level, visual assessment was unreliable as a screening tool to detect significant neonatal hyperbilirubinemia before discharge. Babies with TSB levels within high-risk zones may be clinically misdiagnosed as low-risk, resulting in inadequate follow-up.

A novel method of distal end-tidal CO2 capnography in intubated infants: comparison with arterial CO2 and with proximal mainstream end-tidal CO2.

OBJECTIVE. The objective of this study was to evaluate a novel method of distal end-tidal CO2 capnography by comparison with Paco2 and with the more standard method that measures mainstream proximal end-tidal CO2 in intubated infants. METHODS. Included in the study were all infants who were ventilated with conventional mechanical ventilation and intubated with a double-lumen endotracheal tube in our NICU during the study period. Data were collected prospectively from 2 capnographs simultaneously and compared with Paco2. Sidestream distal end-tidal CO2 was measured by a Microstream capnograph via the extra port of a double-lumen endotracheal tube. Mainstream proximal end-tidal CO2 was measured via capnograph connected to the endotracheal tube. RESULTS. Twenty-seven infants (median [range] birth-weight: 1835 [490–4790] g; gestational age: 32.5 [24.8–40.8] weeks) participated in the study. We used for analysis 222 and 212 measurements of distal end-tidal CO2 and proximal end-tidal CO2, respectively. Distal compared with proximal end-tidal CO2 had a better correlation with Paco2 and a better agreement with Paco2. The accuracy of distal end-tidal CO2 decreased, but it remained a useful measure of Paco2 in the high range of Paco2 (≥60 mmHg) or in conditions of severe lung disease. A subanalysis for infants who weighed <1500 g (13 infants, 84 observations) revealed a good correlation and agreement between distal end-tidal CO2 and Paco2 and poor correlation and agreement for proximal end-tidal CO2. CONCLUSIONS. Distal end-tidal CO2 measured via a double-lumen endotracheal tube was found to have good correlation and agreement with Paco2, remained reliable in conditions of severe lung disease, and was more accurate than the standard mainstream proximal end-tidal CO2.

Postdischarge Infant Mortality Among Very Low Birth Weight Infants: A Population-Based Study

OBJECTIVE. The objective of this study was to identify factors that were associated with death after discharge from the NICU of very low birth weight infants in a population-based study. METHODS. From a national cohort of 13430 very low birth weight infants who were born in Israel from 1995 to 2003, 10602 infants were discharged from the hospital and composed the study population. Demographic and clinical data regarding the pregnancy, delivery, and neonatal course were obtained from the Israel national very low birth weight infant database. Data on each case of death during the postdischarge period until 1 year of age were provided by the Ministry of Health from national linked birth and death certificates. Univariate analyses and a multivariable logistic regression analyses were performed to examine the perinatal and neonatal risk factors for postdischarge death. RESULTS. The postdischarge mortality rate was 7.5 per 1000 (80 of 10602 infants discharged from the hospital). The death rate was significantly higher in non-Jewish infants, infants who were born to young mothers, and infants who were born to low-educated mothers. After adjustment for demographic characteristics and perinatal and neonatal variables, postdischarge mortality was independently associated with congenital malformations, neonatal seizures, necrotizing enterocolitis, and bronchopulmonary dysplasia. CONCLUSION. Although the postdischarge death rate was relatively low in our cohort of very low birth weight infants, attention should be focused on the subgroups of infants who are at higher risk to decrease their mortality further.

Glucose-6-Phosphate Dehydrogenase Deficiency and Borderline Deficiency: Association with Neonatal Hyperbilirubinemia

OBJECTIVE To characterize the occurrence of glucose-6-phosphate dehydrogenase (G6PD) deficiency and its association with neonatal hyperbilirubinemia. STUDY DESIGN This study involved an evaluation of G6PD data for 2656 newborns from a universal newborn screening program. RESULTS Mean G6PD activity was 14.2 ± 3.3 U/g Hb. Some 2.71% of the newborns were G6PD-deficient, and 1.77% had borderline G6PD activity, with male and female predominance, respectively. G6PD deficiency was more prevalent in newborns of Sephardic Jew and Muslim Arab backgrounds. The infants with G6PD deficiency had higher bilirubin levels at the time of discharge from the nursery. Infants with low and borderline G6PD activity were more likely to require phototherapy (22.2% and 25.5%, respectively, vs 7.6% of infants with normal G6PD activity; P < .005) and to have more referrals for exacerbation of jaundice (15.3% and 14.9%, respectively, vs 6.1%; P < .005). Mean G6PD activity was higher in preterm infants born at 27-34 weeks gestational age compared with those born later (16.3 ± 1.8 U/g Hb vs 14.8 ± 2.0 U/g Hb). Based on sex distribution and theoretical genetic calculations for the rate of heterozygous females, we propose that the range of borderline G6PD activity should be 2-10 U/g Hb rather than the currently accepted range of 2-7 U/g Hb. CONCLUSIONS There is association between G6PD deficiency and significant neonatal hyperbilirubinemia. Increased risk is also associated with borderline G6PD activity. The suggested new range for borderline G6PD activity should enhance the identification of females at risk. G6PD activity is higher in preterm infants.