Garth McClure

Randomised controlled trial of an aggressive nutritional regimen in sick very low birthweight infants

AIMS To improve energy intake in sick very low birthweight (VLBW) infants; to decrease growth problems, lessen pulmonary morbidity, shorten hospital stay, and avoid possible feeding related morbidity. Morbidity in VLBW infants thought to be associated with parenteral and enteral feeding includes bronchopulmonary dysplasia, necrotising enterocolitis, septicaemia, cholestasis and osteopenia of prematurity. METHODS A prospective randomised controlled trial (RCT) comparing two types of nutritional intervention was performed involving 125 sick VLBW infants in the setting of a regional neonatal intensive care unit. Babies were randomly allocated to either an aggressive nutritional regimen (group A) or a control group (group B). Babies in group B received a conservative nutritional regimen while group A received a package of more aggressive parenteral and enteral nutrition. Statistical analysis was done using Student’st test, the Mann-Whitney U test, the χ2 test and logistic regression. RESULTS There was an excess of sicker babies in group A, as measured by initial disease severity (P <0.01), but mean total energy intakes were significantly higher (P <0.001) in group A at days 3 to 42 while receiving total or partial parenteral nutrition. Survival and the incidences of bronchopulmonary dysplasia, septicaemia, cholestasis, osteopenia and necrotising enterocolitis were similar in both groups. Growth in early life and at discharge from hospital was significantly better in babies in group A. There were no decreases in pulmonary morbidity or hospital stay. CONCLUSION Nutritional intake in sick VLBW infants can be improved without increasing the risk of adverse clinical or metabolic sequelae. Improved nutritional intake resulted in better growth, both in the early neonatal period and at hospital discharge, but did not decrease pulmonary morbidity or shorten hospital stay.

Results of heavy drinking in pregnancy

Summary. The outcome of pregnancy is reported for 23 women who had been drinking alcohol heavily and who were delivered in Belfast maternity hospitals during the last 4 years. Twenty‐one (91%) of the babies were small‐for‐gestational age and many had head circumference measurements <5th centile. Ten babies (44%) had abnormal facies consistent with the ‘fetal alcohol syndrome’ and 10 babies had congenital malformations of the heart, palate, genitalia and kidneys. Perinatal problems which included breech presentation, birth asphyxia, hypoglycaemia, polycythaemia, hypocalcaemia and withdrawal symptoms were frequently present. Most of the babies have shown delayed postnatal growth and six of the ten who are aged over 1 year have delayed development.

Iron Status of the Preterm Infant during the First Year of Life

The iron status of 49 preterm infants (mean gestational age 33.1 weeks) was assessed serially during the 1st year of life. Haemoglobin concentration, serum ferritin, serum transferrin, serum iron, and transferrin saturation were measured on nine occasions in each infant. In 16 infants of gestational age 28-32 weeks the haemoglobin concentration was significantly lower at 3, 6, and 9 weeks when compared to 33 infants of gestational age 33-36 weeks. For all other measures of iron status there were no significant differences between these gestational age groups. For the entire group of 49 infants the mean haemoglobin concentration reached a nadir of 11.2 g/dl at 9 weeks. Mean serum iron and transferrin saturation reached peaks of 24 mumol/l and 65%, respectively, at 3 weeks. The mean serum ferritin remained over 100 micrograms/l until after 18 weeks. 13 infants (26%) had iron deficiency defined as either serum ferritin less than 10 micrograms/1 (n = 10) or transferrin saturation less than 10% (n = 5) or both (n = 3).

Growth and development two years after artificial surfactant replacement at birth

Two year follow-up of 80 surviving preterm babies from a controlled trial of surfactant replacement is reported. There were no statistically significant differences in rates of hospital admission, respiratory infections or antibiotic treatment. Wheezing, skin rashes and food intolerance were reported by parents with similar frequency in each group. Weight, length and occipito-frontal circumference were similar at all ages up to and including 2 years. Median developmental quotient (Griffiths scales) was 100 in the treated group and 95 in the control group (P = 0.053). Rates of cerebral palsy were similar in each group although milder forms predominated in the treated group. It is concluded that artificial surfactant (dipalmitoylphosphatidylcholine and high-density lipoprotein) replacement at birth is not associated with adverse long term effects on preterm babies.

Long term predictive value of Doppler studies in high risk fetuses

Objective To determine whether the predictive value of Doppler ultrasonography extends beyond the perinatal period.

Comparison between creatine kinase brain isoenzyme (CKBB) activity and Sarnat score for prediction of adverse outcome following perinatal asphyxia.

Abstract Aim: To assess whether plasma creatine kinase brain isoenzyme (CKBB) levels or Sarnat scores are more accurate for prediction of poor neurological outcome in babies with suspected birth asphyxia. Methods: In a retrospective study of 97 babies CKBB levels were compared to the presence of severe hypoxic ischaemic encephalopathy (HIE) as a predictive test for these outcomes: developmental delay, cerebral palsy, visual problems, deafness or death from perinatal asphyxia. The tests were compared using positive predictive values (PPV) and likelihood ratios (LR) with confidence intervals (CI) Results: 3 babies had died from perinatal asphyxia and 14 survivors were found to have neurological or developmental problems. CKBB was elevated in babies with severe HIE (p=0.0004). A receiver operator characteristic (ROC) curve showed the optimal discriminating value for CKBBto be 21 IU/L but theCKBB was a poor predictive test. For prediction of adverse outcome: CKBB > 21 sensitivity 76％, specificity 40％, PPV 21％ and LR 1.3 (95％ CI 0.8–1.7). Severe HIE sensitivity 53％, specificity 95％, PPV 69％ and LR 10.6 (95％ CI 3.8–29.2). Conclusion: CKBB is elevated following birth asphyxia but is a poor predictor of adverse neurological outcome.

Controlled trial of new formulae for feeding low birth weight infants

Over a 13-month period 85 babies were randomly allocated to one of three groups at birth. Babies in Group A were fed SMA Low Birth Weight, Group B Prematalac and Group C Preaptamil. A fourth group, the control group was fed expressed breast milk (EBM). The babies were studied when they were on full enteral feeds until weight was greater than 2.0 kg. Weight gain was greatest in Group B compared to the other three groups but there was no significant difference in gain of length or occipito-frontal circumference. The babies in Group B had a lower volume of feeds and lower energy intake than the other groups but had a significantly higher sodium intake which was reflected in higher mean sodium levels. This may have accounted for the increased weight gain. There was no significant difference in serum calcium, osmolality, total protein or haematocrit.

PHOTOTHERAPY IN RHESUS HÆMOLYTIC DISEASE

Abstract A controlled trial of the use of phototherapy in the management of infants with rhesus haemolytic disease is reported. Phototherapy was administered for 4 days, starting after the transfer of infants from the labour ward to the neonatal special-care unit. Forty-five phototherapytreated infants required 50 exchange transfusions while seventy-eight control infants required 132 exchange transfusions. This difference is significant at the 1% level. 19 late exchanges were required in the treated group, compared with 92 in the control group. This is again significant at the 1% level. In the treated group no ill-effects were noted during or after phototherapy. It is suggested that phototherapy can reduce the requirements for exchange transfusions in rhesus haemolytic disease.

Noninvasive methods of body composition analysis in preterm infants:--comparison with dilution of 2H218O.

Very low birth weight (VLBW; < 1500 g) infants account for 1% of births in the developed world, but greater than half of the neonatal mortality rate. Advances in neonatal intensive care have resulted in a significant increase in survival of VLBW infants. As survival has increased, greater attention has focused on the nutrition and growth of these babies. The ability to estimate body composition is of central importance to these studies. Chemical analysis has shown that newborn babies differ greatly from adults in terms of body composition, and that this difference increases with degree of prematurity1,2.

Neonatal death in Northern Ireland

A survey of neonatal deaths occurring over two years in Northern Ireland disclosed that many hospitals where babies could be born probably could not be staffed and equipped to deal effectively with major perinatal problems. The incidence of congenital malformations, especially neural tube defects, was high. A reduction in neonatal deaths from this cause might be expected if facilities for antenatal diagnosis and termination of pregnancy were made available, although this raises grave ethical problems. Many infants died of prematurity and the idiopathic respiratory distress syndrome. A considerable reduction in neonatal deaths might be expected with improved care at the place of delivery backed by a regional centre with facilities for transporting and treating severely ill infants needing intensive care.