Lars Garten

The mother as most important risk factor for colonization of very low birth weight (VLBW) infants with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E)

OBJECTIVES This study aimed to determine the prevalence of and risk factors for colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) and methicillin-resistant Staphylococcus aureus (MRSA) in very low birth weight (VLBW; <1500 g) infants and their mothers. METHODS This investigation was conducted in the perinatal centre at the Charité Berlin between May 2012 and June 2013. VLBW infants and their mothers were screened for colonization with ESBL-E and MRSA. Demographic and clinical data were obtained from the German nationwide surveillance system for nosocomial infections in VLBW infants (NEO-KISS) and used to perform univariate and multivariate analyses. RESULTS Of 209 VLBW infants, 12 (5.7%) were colonized with ESBL-E. Eighteen of 209 (8.6%) ESBL-E-tested neonates were related to an ESBL-E-positive mother. Univariate analysis, strain typing and multivariate analysis (OR 7.4, 95% CI 2.1-26.7, P = 0.002) identified an ESBL-E-positive mother and maternal-neonatal transmission as a main source of colonization. The prevalence of MRSA was 2.3% (5 of 221) among VLBW infants. One of the 221 (0.5%) MRSA-tested neonates was related to an MRSA-positive mother. No risk factors for transmission of MRSA could be detected in this study. CONCLUSIONS Our study demonstrated that maternal-neonatal transmission of ESBL-E from mother to child is an important risk factor for colonization of VLBW infants. As a consequence, routine ESBL-E screening of neonates and mothers should be considered as a means of reducing neonatal morbidity and mortality.

Online support for parents of preterm infants: a qualitative and content analysis of Facebook 'preemie' groups

Objective To qualitatively evaluate the content of communication in Facebook communities dedicated to preterm infants. Design The 25 largest public English-language Facebook groups focusing on preterm infants were identified. For each group, the 20 most recent wallposts and a maximum of the 15 first comments to these wallposts, and the 15 most recent discussion topics were analysed according to a thematic coding scheme. The purpose of each group was determined and personal characteristics of administrators and active posters were analysed. Results 1497 individual Facebook groups focusing on preterm infants were found, wherein the 25 largest had between 391 and 14 986 members. Non-profit fundraising groups comprised 48% of analysed groups and had the greatest number of members (median 1450, IQR 548–5435), followed by general awareness (24% of all groups, members: median 1183, IQR 658–2116) and interpersonal support groups (28% of all groups, members: median 823, IQR 484–1022). 85.0% of administrators and 91.5% of posters were women, and two-thirds of posts had been written by mothers of preterm infants. The analysis of posts, comments and discussion topics (n=1054) showed that ‘information sharing’ (31%) and ‘interpersonal support’ (53%) were the most common purposes. Conclusions Facebook groups related to preterm birth have become a popular tool for fundraising and awareness-raising. However, most group members use these forums for information sharing and interpersonal support. Given their popularity and reach, further research is warranted to understand the motivations, implications and risks of dynamic online communication among parents of preterm infants.

O father, where art thou? Parental NICU visiting patterns during the first 28 days of life of very low-birth-weight infants.

To study the frequency and duration of parental visits to neonatal intensive care units (NICU) during the first 28 days of life of preterm infants in relation to medical variables, sociodemographic factors, and subsequent outpatient follow-up examinations. Retrospective chart review of 127 infants with a birth weight less than 1500 g born between Jan 1, 2009, and Dec 31, 2009, at 2 tertiary NICUs. The average frequency of parental visits during the first 28 days of life declined significantly over time (P < .05) while the duration of visits remained constant. Average frequency and duration of visits per day were consistently lower in fathers than in mothers (median [interquartile range]: 0.6 [0.4–1.0] per day vs 1.1 [0.9–1.4] per day, 72.5 [32.1–108.9 [min/d vs 133.4 [75.4–174.3] min/d). While a history of treatment for infertility was correlated with significantly more frequent and longer parental NICU visits in the first 2 weeks, having older children at home was correlated with shorter visits during the first week. Visiting patterns showed no relation to attendance at follow-up examinations at 6 months corrected age. Mothers spend more time with their preterm infants in NICUs than fathers. We suggest measures to increase paternal involvement with hospitalized preterm infants.

Resolution of opioid-induced postoperative ileus in a newborn infant after methylnaltrexone.

Transient impairment of bowel function is a frequent and distressing problem in neonates on opioid-induced analgesia. Methylnaltrexone, a peripheral-acting μ-opioid receptor antagonist, has been studied in adults for the treatment of opioid-induced constipation in advanced illness and has been suggested as a promising therapeutic concept for reducing postoperative ileus. Here, we report on a newborn infant on fentanyl analgesia after major abdominal surgery with aggravated ileus. After 8 days of quiescent bowel, the patients intestinal dysmotility resolved within 15 minutes after intravenous administration of methylnaltrexone (0.15 mg/kg body weight). Methylnatrexone was repeated daily until cessation of fentanyl administration. There were no signs of pain or opioid withdrawal.

Protective Effect of Dual-Strain Probiotics in Preterm Infants: A Multi-Center Time Series Analysis

Objective To determine the effect of dual-strain probiotics on the development of necrotizing enterocolitis (NEC), mortality and nosocomial bloodstream infections (BSI) in preterm infants in German neonatal intensive care units (NICUs). Design A multi-center interrupted time series analysis. Setting 44 German NICUs with routine use of dual-strain probiotics on neonatal ward level. Patients Preterm infants documented by NEO-KISS, the German surveillance system for nosocomial infections in preterm infants with birth weights below 1,500 g, between 2004 and 2014. Intervention Routine use of dual-strain probiotics containing Lactobacillus acidophilus and Bifidobacterium spp. (Infloran) on the neonatal ward level. Main outcome measures Incidences of NEC, overall mortality, mortality following NEC and nosocomial BSI. Results Data from 10,890 preterm infants in 44 neonatal wards was included in this study. Incidences of NEC and BSI were 2.5% (n = 274) and 15.0%, (n = 1631), respectively. Mortality rate was 6.1% (n = 665). The use of dual-strain probiotics significantly reduced the risk of NEC (HR = 0.48; 95% CI = 0.38–0.62), overall mortality (HR = 0.60, 95% CI = 0.44–0.83), mortality after NEC (HR = 0.51, 95% CI = 0.26–0.999) and nosocomial BSI (HR = 0.89, 95% CI = 0.81–0.98). These effects were even more pronounced in the subgroup analysis of preterm infants with birth weights below 1,000 g. Conclusion In order to reduce NEC and mortality in preterm infants, it is advisable to add routine prophylaxis with dual-strain probiotics to clinical practice in neonatal wards.

Parallel assessment of prolonged neonatal distress by empathy-based and item-based scales

Objective: To evaluate the association between the empathy‐based Faces Pain Scale‐Revised (FPS‐R) and the item‐based Neonatal Pain, Agitation and Sedation Scale (N‐PASS) when used to assess prolonged distress in term and preterm infants.

Progressive multicystic encephalopathy : Is there more than hypoxia-ischemia?

Progressive multicystic encephalopathy following prenatal or perinatal hypoxia-ischemia is a well-described phenomenon in the literature. The authors report on a term infant with a devastating encephalopathy and severe neuronal dysfunction immediately after delivery without a known antecedent of prenatal or perinatal hypoxia or distress. Clinical and paraclinical findings in the patient are compared with those described in the literature. The authors focus on the specific results guiding to the final diagnosis of progressive multicystic encephalopathy and the timing of morphologic changes. As in this case, if the criteria of an acute hypoxic event sufficient to cause neonatal encephalopathy are not met, then factors other than hypoxia-ischemia may be leading to progressive multicystic encephalopathy.

Probiotics prevent necrotizing enterocolitis, sepsis and mortality in preterm infants: a multicenter analysis of more than 10,000 VLBW infants in German NICUs

Enteral supplementation of probiotics has been demonstrated to reduce the risk of severe necrotizing enterocolitis (NEC) and all-cause mortality in preterm infants.

Protracted maturation of pancreatic-specific elastase 1 excretion in preterm infants of extremely low gestational age.

Objectives: The aim of the present study was to better understand the exocrine pancreatic function of extremely preterm infants. Methods: Pancreatic-specific elastase 1 (PSE1) activity was determined in spot stool samples of 69 preterm infants of gestational age <32 weeks and birth weight <1250 g. Assays were conducted on samples collected at 2 (N = 56), 4 (N = 46), and 6 weeks of age (N = 23). Results: PSE1 activity increased from week 2 (median [interquartile range] 84 [48–187] &mgr;g/g) to week 4 (164 [87–251 &mgr;g/g; P < 0.001) but not thereafter (169 [82–298] &mgr;g/g at week 6). The maturational increase in PSE1 activity was observed only in infants of gestational age <28 weeks (P < 0.001). At 2 weeks after birth, PSE1 levels were lower in infants of gestational age <28 weeks than in infants of gestational age ≥28 weeks (77 [43–110] vs 165 [56–300] &mgr;g/g; P = 0.019), but this difference was less pronounced at 4 weeks (153 [77–226] vs 230 [108–503] &mgr;g/g; P = 0.070) and had disappeared by 6 weeks (163 [76–258] vs 175 [85–418] &mgr;g/g; P = 0.576). In infants on full enteral feeding regimens 4 weeks after birth, PSE1 levels were associated with weight gain per unit of energy intake (Rs = 0.431; P = 0.005). This measure of weight gain was lower (P = 0.040) in infants with PSE1 levels <200 &mgr;g/g (0.110 [0.081–0.139] g/kcal, N = 25) than in those with PSE1 levels ≥200 &mgr;g/g (0.139 [0.117–0.157] g/kcal, N = 15). Administration of pancreatic enzymes to infants showing PSE1 excretion levels <200 &mgr;g/g did not enhance weight gain. Conclusions: Extremely preterm infants have limited exocrine pancreatic function during the first weeks of life, which may contribute to growth failure.

Hemolytic uremic syndrome in a preterm infant.

Sirs Diarrhea-associated hemolytic uremic syndrome (HUS) is primarily a food-borne disease following bacterial infection with Shiga toxin-producing Escherichia coli, Shigella, Salmonella, Campylobacter, Yersinia, Streptococcus pneumoniae. Therefore, breast-fed babies are not at primary risk of developing diarrheal HUS. We report on a preterm boy (birth weight 382 g, gestational age 25 weeks) who was treated with exogenous surfactant (day 1), mechanical ventilation (days 1–34), inhaled nitric oxide (days 6–17), sildenafil (days 18–44), ampicillin/gentamycin (day 1), cefotaxime/piperacillin (days 2–9), probiotics (Lactobacillus acidophilus and Bifidobacterium infantis) (days 10–25), erythropoietin (days 11–83), vitamin A (days 11–28), transfusions of red blood cells (day 2, day 3, day 6, day 12, day 24, day 32) and platelets (day 3, day 6, day 18, day 24, day 28, day 32, day 36) and parenteral nutrition (days 1–16). He was fed by gavage with incremental amounts of mother’s breast milk from birth onward. At 21 days of life, the boy developed a 5-day episode of fulminant diarrhea followed by acute onset of gross hematuria, proteinuria and polyuric renal failure (maximum diuresis 7.7 ml/kg per hour). Laboratory examinations showed increased concentrations of serum creatinine (maximum 106.1 μmol/l), hyperkaliemia (peak serum potassium 7.3 mmol/l), acute hemolytic anemia [hematocrit nadir 29%, increase in lactate dehydrogenase up to 910 U/l, drop in haptoglobin (nadir <0.2 g/l) and a drop in the platelet count (nadir 48×10/l)]. Peripheral blood smear revealed fragmentocytes. There were no signs of disturbed plasmatic coagulation or systemic infection, as judged by C-reactive protein and interleukin-6 serum concentrations. Stool samples were positive for Clostridium difficile toxins A and B, but not for Shiga toxin-producing E. coli, Salmonella, Shigella, Yersinia and Campylobacter spp., or adeno-, rota-, noroand enteroviruses. Neither Clostridium difficile toxin nor any Gram-negative bacteria could be detected in the mother’s breast milk. Specific treatment consisted of metronidazole given orally for 10 days (at this time, stool samples were negative for Clostridium difficile toxin), followed by a 10-day course of probiotics (Lactobacillus acidophilus and Bifidobacterium bifidum), as well as treatment for the symptoms with a maximum parenteral fluid intake of 240 ml/kg per day, packed red blood cells, and platelets. The boy recovered from most of the symptoms within a few days, except for diarrhea, which lasted for 14 days. There was neither persistent proteinuria nor arterial hypertension, and he was discharged well at 102 days. Clostridium difficile colitis is primarily a nosocomial infection associated with prolonged hospital stay and prior treatment with antibiotics such as ampicillin, cephaA. Kusztrich (*) Department of Pediatrics, Charité University Medical Center, Augustenburger Platz 1, 13353 Berlin, Germany e-mail: ariane.kusztrich@charite.de