Judith H. Simpson

Macronutrient content of donor human breast milk

Background Nutritional analysis of donated human milk has been suggested as a means of optimising its use. Methods We analysed pooled, single donor milk samples using the MIRIS Human Milk Analyser to obtain values for fat, protein, lactose and calculated energy content. These values were compared with those of formula milks and then extrapolated to demonstrate whether donated human expressed breast milk (DEBM)±fortification would meet preterm nutritional requirements. We demonstrated the potential variability in macronutrient intake from unselected DEBM use by comparing energy intake from milk samples with energy values on the 3rd percentile (nutrient poor) with intake from milk with values on the 97th percentile (nutrient rich). Results 179 sequential samples from 42 unique donors were analysed. Mean nutritional values, excluding protein, were comparable with those of term formula; energy 66±12 kcal/100 mLs, fat 4.0±1.4 g/100 mLs, protein 0.9±0.4 g/100 mLs and lactose 6.6±0.7 g/100 mLs. At volumes of 180 mL/kg/day 119 samples (66%) would have provided minimum preterm energy requirements without fortification however protein levels were low and even with fortification 39% of samples would fail to meet the recommended preterm requirements. The potential difference in energy intake between nutrient-poor and nutrient-rich milk was 88 kcal/kg/day. Interpretation In summary our data confirm the nutritional variability of DEBM and demonstrate the potential of nutritional analysis to target the use of donor milk according to energy content.

Sildenafil use in congenital diaphragmatic hernia

The postnatal management of severe congenital diaphragmatic hernia (CDH) remains challenging with few robust evidence-based interventions but many therapies based on case reports or small case series. A good example of this is sildenafil, a phosphodiesterase inhibitor, which is increasingly used in the management of pulmonary hypertension associated with CDH.1 2 We retrospectively audited sildenafil use in all infants with CDH managed in the co-located Queen Mother’s Hospital and the Royal Hospital for Sick Children, …

Severity of Non-Immune Hydrops Fetalis at Birth Continues to Predict Survival despite Advances in Perinatal Care

Objectives: To describe the aetiology and short-term outcome of live-born infants with non-immune hydrops fetalis (NIH), to identify predictors of mortality and to establish whether there has been any change in mortality over a 14-year period. Methods: A retrospective case note review of all liveborn neonates with NIH. Results: 30 infants were identified. Twenty (66%) had an identifiable aetiology. Ten (33%) survived to discharge. Survivors had significantly higher Apgar scores at 1 and 5 min (both p < 0.001). Mortality did not differ between the time periods 1990–1999 and 2000–2004. Conclusions: NIH continues to be associated with a significant mortality despite advances in perinatal care. Poor condition at birth is a strong predictor of death.

Use of Donor Human Milk and Maternal Breastfeeding Rates: A Systematic Review

The number of human milk banks is growing worldwide. The introduction of donor human milk (DHM) to neonatal units has been advocated as a strategy to promote maternal breastfeeding. However, concern has been raised that the introduction of DHM may actually lead to a decrease in maternal breastfeeding. To address this question, we conducted a systematic literature review of studies that assessed maternal breastfeeding rates before and after the introduction of DHM. We searched 7 electronic databases, carried out citation tracking, and contacted experts in the field. Where data for breastfeeding rates before and after the introduction of DHM were directly comparable, a relative risk was calculated. Our search identified 286 studies, of which 10 met the inclusion criteria. Definitions of patient populations and study outcomes varied, limiting meaningful comparison. Where possible, relative risks (RR) were calculated on aggregated data. The introduction of DHM had a significant positive impact on any breastfeeding on discharge (RR, 1.19; 95% confidence interval [CI], 1.06-1.35; P = .005) but none on exclusive maternal breastfeeding on discharge (RR, 1.12; 95% CI, 0.91-1.40; P = .27) or on exclusive administration of own mother’s milk (OMM) days 1 to 28 of life (RR, 1.08; 95% CI, 0.78-1.49; P = .65). A single-center study demonstrated a significant decrease in the percentage of feeds that were OMM after the introduction of DHM. In conclusion, the available data demonstrate some evidence of positive and negative effects on measures of maternal breastfeeding when DHM is introduced to a neonatal unit.

Short term outcomes following intrauterine transfusion in Scotland

Aim To describe neonatal outcomes following intrauterine transfusion (IUT) for severe Rhesus isoimmunisation from 1993 to 2004. Results 116 neonates who had undergone 457 IUTs (median 4, range 1–9) were identified. Three neonates died, all before 1995 (two because of hypoxic ischaemic multiorgan failure and one because of overwhelming Escherichia coli sepsis). 13 neonates (11%) were delivered by emergency Caesarean section following either IUT complication or spontaneous onset of preterm labour. They were more likely to require intubation (p<0.0001), on-going respiratory support (p=0.0007) and an exchange transfusion (p=0.007). 23 (20%) required an exchange transfusion and 63 (54%) at least one top-up transfusion. Conclusions Management of severe Rhesus disease is associated with encouraging neonatal outcomes and most infants can be managed with phototherapy and a few top-up transfusions. IUT complications are rare but significantly increase neonatal mortality and morbidity. Antenatal counselling should address the likely postnatal course for these infants.

Four cases of congenital airway obstruction: optimising perinatal management.

Congenital anomalies causing airway obstruction in the newborn are potentially fatal. However if an effective airway can be maintained the long‐term prognosis is often excellent. We present four cases of airway obstruction, three of which were diagnosed antenatally. We discuss the role of antenatal imaging and review delivery options including the need for a multidisciplinary team approach. In conclusion, we recommend antenatal imaging with both ultrasound scan and magnetic resonance to inform perinatal management. Polyhydramnios, in association with suspected neonatal airway obstruction, should alert clinicians to a high‐risk situation. We recognize that even in skilled hands, securing an airway can be very difficult and alternatives such as maintenance of the fetomaternal circulation or extra‐corporeal life support should be considered.

Rationalized assessment of prolonged jaundice is safe and cost-effective.

Prolonged jaundice (PJ) in healthy term neonates is common and frequently benign. It can, however, be the earliest manifestation of underlying liver disease. Its management requires a balanced approach, avoiding over-investigation of well babies while ensuring the early identification of those with pathology. Currently marked heterogeneity exists in the assessment of PJ. Over a two-year period we prospectively audited the management of PJ in two Level 3 neonatal units prior to and after the introduction of a rationalized investigation algorithm in keeping with the recently published British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) guidelines (i.e. clinical examination and stool inspection combined with measurement of split bilirubin). In this study we reviewed initial practice and then evaluated the impact of our change in practice. A total of 197 babies, 1.5% of live births, were referred with PJ. Of these, 105 babies were included in the first part of the study and 92 babies were included in the second part. No pathology relating to PJ, such as infection, hepatitis or liver disease, was identified. Following the introduction of our rationalized algorithm, we demonstrated a statistically significant reduction in the number of return appointments (28 versus 7; P < 0.0009) and repeat investigations (37 versus 7; P < 0.0001). This represented a saving of £1575–2625 per year in laboratory costs alone. Contemporaneously, three infants presented with biliary atresia, none of whom were identified by PJ screening and all of whom were over seven weeks old at diagnosis. A rationalized approach to the assessment of PJ reduces workload and is cost-effective; however, the limitations of selective screening, irrespective of how streamlined it is, remain – if babies are not identified and referred, they cannot be screened. Population-based methodologies offer an alternative approach to the identification of cholestatic liver disease and are worthy of further consideration.

NICE recommendations for the formal assessment of babies with prolonged jaundice: too much for well infants?

Prolonged jaundice (PJ) is common, affecting 2–15% of all neonates and up to 40% of breastfed infants.1 It presents a challenge to health professionals, who must identify those infants with pathology while avoiding the unnecessary investigation of normal babies. National Institute for Health and Clinical Excellence (NICE) recently recommended, that in addition to a thorough examination, the formal assessment of PJ should include conjugated bilirubin, urine culture, glucose-6-phosphate dehydrogenase where ethnically appropriate, full blood count, blood group determination and Coombs test.2 The three studies referenced had methodological flaws, including all …

Change from intralipid to SMOF lipid is associated with improved liver function in infants with PN associated liver disease

Background and aims Parenteral nutrition associated liver disease (PNALD) accounts for substantial morbidity and mortality in infants with intestinal failure. Lipid formulations may be important determinants of PNALD development. Newer lipid preparations e.g. SMOF lipid (SMOF) containing omega-3 and medium chain triglycerides have theoretical benefits over standard soya-based lipid (eg: intralipid (IL) and may minimise PNALD. This study aimed to investigate the effects of a change in lipid formulation, from IL to SMOF, on liver function in infants with PNALD. Method This retrospective review was performed following an initial pilot study. Data were obtained by case-note review of infants with PNALD (conjugated bilirubin (CB) >50 µmol/L) commenced initially on IL and subsequently changed to SMOF, as per Unit protocol. Liver function (CB, AST, ALT levels, and the change in each of these per week: ΔCB, ΔAST, ΔALT) was compared before and after change in lipid (figure 1). Abstract G79(P) Figure 1 Change in CB per week (δCB) before and during SMOF therapy. Results Data were obtained for 14 infants of median (range) gestation 29 (24-40) weeks, birth weight 1.23 (0.53-3.66) kg. Median duration of parenteral nutrition was 89 (19-212) days. Median age at change from IL to SMOF was 50 (22-142) days. Change from IL to SMOF was associated with a significant reduction in ΔCB after 2 weeks and 4 weeks of SMOF therapy (table 1 and figure 1) i.e. the weekly rate of increase in CB levels was reduced (and later reversed) after change to SMOF. Accordingly, absolute CB levels stabilised after change from IL to SMOF. ΔAST and ΔALT, and absolute levels of AST and ALT, also trended lower after 4 weeks of SMOF therapy. Abstract G79(P) Table 1 Liver function before and during SMOF therapy Liver function Duration of SMOF Mean (SD) Pre SMOF 2 weeks 4 weeks Change per week (umol/L/week) Change in CB 12.2 (13.3) 0.3 (13.9)* −0.6 (10.6)* Change in ALT 13.2 (21.9) 24.7 (78.8) 2.42 (19) Change in AST 6.61 (32.2) 35.3 (130.6) 0.24 (11.6) Mean level (umol/L) CB 80.7 (30.4) 79.8 (24.7) 87.5 (29.0) ALT 158 (337) 95 (142) 60 (42) AST 317 (781) 152 (269) 78 (36) * P<0.05 compared to Pre SMOF Conclusions Change from IL to SMOF was associated with improved liver function in infants with PNALD. This data supports the use of SMOF in infants requiring long-term PN therapy to minimise PNALD. Further study is required to determine the optimum timing for commencement of SMOF use.

Optimal Distribution and Utilization of Donated Human Breast Milk A Novel Approach

Background: The nutritional content of donated expressed breast milk (DEBM) is variable. Using DEBM to provide for the energy requirements of neonates is challenging. Objective: The authors hypothesized that a system of DEBM energy content categorization and distribution would improve energy intake from DEBM. Methods: We compared infants’ actual cumulative energy intake with projected energy intake, had they been fed using our proposed system. Eighty-five milk samples were ranked by energy content. The bottom, middle, and top tertiles were classified as red, amber, and green energy content categories, respectively. Data on 378 feeding days from 20 babies who received this milk were analyzed. Total daily intake of DEBM was calculated in mL/kg/day and similarly ranked. Infants received red energy content milk, with DEBM intake in the bottom daily volume intake tertile; amber energy content milk, with intake in the middle daily volume intake tertile; and green energy content milk when intake reached the top daily volume intake tertile. Results: Actual median cumulative energy intake from DEBM was 1612 (range, 15-11 182) kcal. Using DEBM with the minimum energy content from the 3 DEBM energy content categories, median projected cumulative intake was 1670 (range 13-11 077) kcal, which was not statistically significant (P = .418). Statistical significance was achieved using DEBM with the median and maximum energy content from each energy content category, giving median projected cumulative intakes of 1859 kcal (P = .0006) and 2280 kcal (P = .0001), respectively. Conclusion: Cumulative energy intake from DEBM can be improved by categorizing and distributing milk according to energy content.