Matthias Heckmann

Reference range for serum cortisol in well preterm infants

AIM To establish a reference range for serum cortisol concentrations in preterm infants with a gestational age of less than 30 weeks during the first two weeks of life. METHODS Infants were prospectively classified by the following exclusion criteria: surfactant administration, arterial hypotension, acute or uncontrolled infection, ventricular haemorrhage II° or above, serum glucose < 2.2 mmol/l, exchange transfusion, stress as a result of any kind of examination or nursing for at least 4 hours before blood sampling. The cortisol value was measured once using radioimmunoassay in each infant. RESULTS In appropriate for gestational age (AGA) infants (n = 37, median gestational age 27.7 weeks, median birthweight 1030 g) the distribution of the cortisol concentrations was non-Gaussian. These had a nearly normal distribution, when log10 values of the data were used. The points determined by mean (2 SD) on the logarithmic scale were transformed back to the original units to provide a reference range: 73–562 nmol/l. Gestational age was significantly (p = 0.033) associated with cortisol values (log10) with a regression coefficient (standard error) of −0.045 (0.020). Small for gestational age (SGA) infants (n = 8) had significantly higher cortisol values (median 357 nmol/l) than AGA infants (median 199 nmol/l) (p=0.028). CONCLUSIONS There is a strictly defined reference range of serum cortisol concentrations in AGA preterm infants.

Physiological adjustment to postnatal growth trajectories in healthy preterm infants

Background:International guidelines suggest that growth of preterm infants should match intrauterine rates. However, the trajectory for extrauterine growth may deviate from the birth percentile due to an irreversible, physiological loss of extracellular fluid during postnatal adaptation to extrauterine conditions. To which “new” physiological growth trajectory preterm infants should adjust to after completed postnatal adaptation is unknown. This study analyzes the postnatal growth trajectories of healthy preterm infants using prospective criteria defining minimal support, as a model for physiological adaptation.Methods:International, multi-center, longitudinal, observational study at five neonatal intensive care units (NICUs). Daily weights until day of life (DoL) 21 of infants with undisturbed postnatal adaptation were analyzed (gestational ages: (i) 25–29u2009wk, (ii) 30–34u2009wk).Results:981 out of 3,703 admitted infants included. Maximum weight loss was 11% (i) and 7% (ii) by DoL 5, birth weight regained by DoL 15 (i) and 13 (ii). Infants transitioned to growth trajectories parallel to Fenton chart percentiles, 0.8 z-scores below their birth percentiles. The new trajectory after completed postnatal adaptation could be predicted for DoL 21 with R2 = 0.96.Conclusion:This study provides a robust estimate for physiological growth trajectories of infants after undisturbed postnatal adaptation. In the future, the concept of a target postnatal trajectory during NICU care may be useful.

Length Normalized Indices for Fat Mass and Fat-Free Mass in Preterm and Term Infants during the First Six Months of Life

Objective: Postnatal tissue accretion in preterm infants differs from those in utero, affecting body composition (BC) and lifelong morbidity. Length normalized BC data allows infants with different body lengths to be compared and followed longitudinally. This study aims to analyze BC of preterm and term infants during the first six months of life. Methods: The BC data, measured using dual energy X-ray absorptiometry, of 389 preterm and 132 term infants from four longitudinal studies were combined. Fat-mass/length2 (FMI) and fat-free mass/length2 (FFMI) for postmenstrual age were calculated after reaching full enteral feeding, at term and two further time points up to six months corrected age. Results: Median FMI (preterm) increased from 0.4 kg/m2 at 30 weeks to 2.5, 4.3, and 4.8 kg/m2 compared to 1.7, 4.7, and 6 kg/m2 in term infants at 40, 52, and 64 weeks, respectively. Median FFMI (preterm) increased from 8.5 kg/m2 (30 weeks) to 11.4 kg/m2 (45 weeks) and remained constant thereafter, whereas term FFMI remained constant at 11 kg/m2 throughout the tested time points. Conclusion: The study provides a large dataset of length normalized BC indices. Followed longitudinally, term and preterm infants differ considerably during early infancy in the pattern of change in FMI and FFMI for age.

Population-based study of the incidence of congenital hip dysplasia in preterm infants from the Survey of Neonates in Pomerania (SNiP)

BackgroundSome etiological factors involved in developmental dysplasia of the hip (DDH) occur in the last trimester of pregnancy, which could result in a decreased incidence of DDH in preterm infants. The aim of this study was to compare the incidence of DDH between preterm and term infants.MethodsUltrasound of the hip joint was performed in 2,534 term infants and 376 preterm infants within the population-based Survey of Neonates in Pomerania (SNiP) study.ResultsA total of 42 (1.66%) term infants had DDH (Graf type II c, 0.8%; type D, 0.3% left and 0.4% right; type III a, 0.2% left). Eighteen infants had bilateral findings. Hip dysplasia occurred more frequently in female neonates (32/1,182 vs. 10/1,302, pu2009<u20090.023; 95% CI 0.012–0.022, χ2 test). A familial disposition for DDH was found in 169 (6.7%) term infants and 181 (7.1%) infants in the overall population. In preterm infants, dysplasia of the hip was found in only three late preterm infants with gestational age between 36 and 37xa0weeks (nu2009=u200997) and not in preterm infants <36xa0weeks gestational age (nu2009=u2009279). Regression analysis revealed a narrowly significant association between gestational week of birth and DDH (relative risku2009=u20091.17; 95% confidence interval 0.99–1.37; pu2009=u20090.065).ConclusionOur study suggests that preterm infants <36xa0weeks gestational age have a decreased risk of DDH.

GM‐CSF as successful salvage therapy of metamizole (dipyrone)‐induced agranulocytosis with Fournier's gangrene and severe septic shock in an adolescent

This case report describes the successful use of granulocyte and macrophage colony‐stimulating factor as salvage therapy and an alternative to hematopoietic stem cell transplantation in a 14‐year‐old adolescent with metamizole (dipyrone)‐induced agranulocytosis and severe septic shock.

Multimodal Therapy of Recurrent Severe Acute Disseminated Encephalomyelitis: The Role of Immunoadsorption

Background ▼ Plasmapheresis and immunoadsorption (IA) are methods of therapeutic apheresis in autoimmune neurologic diseases which are save in adults and children. Plasmapheresis may be replaced by IA in future due to a superior safety profi le in combination with equivalent effi cacy [ 4 ] . Depending on the pathomechanism of the particular disease effi cacy may even be better. Recently IA was reported to be an effi cient treatment of severe neurological defi cits in haemolytic uremic syndrome [ 3 ] . The course and cause of acute disseminated encephalomeyelitis (ADEM) is quite variable [ 1 , 2 ] . 15–36 % of patients with ADEM require intensive care therapy. In the group of intensive care patients mortality is high with 10–25 %. Therapy comprises high dose glucocorticoids, intravenous immunoglobulin (IVIG) and plasmapheresis [ 6 ] whereas IA has not been reported as a therapeutical option for this disease before.

Source and Quality of Enteral Nutrition Influences Oxidative Stress in Preterm Infants: A Prospective Cohort Study

BACKGROUNDnPreterm infants are at risk of oxidative stress from neonatal intensive care interventions. 8-Oxo-2-deoxyguanosine (8-oxodG), generated by oxygen radical attack on DNA, is a potential marker of oxidative stress. The aim of the present study was to investigate the impact of quality and source of enteral nutrition (EN) on renal excretion of 8-oxodG in preterm infants.nnnMETHODSnSpontaneous urine samples were collected on postnatal days 26-31 in 33 preterm infants. Infants were fed either breast milk (BM), formula (FM), or BM/FM mixtures. Daily iron (Fe) supplementation was started day 28 ± 1 postnatally. 8-oxodG was determined by highperformance liquid chromatography-electrochemical detection (HPLC-EC).nnnRESULTSnThe 8-oxodG/creatinine ratio was significantly higher in infants fed FM vs FM/BM (38.7 ± 28.7 vs 16.7 ± 12.2 nmol 8-oxodG/mmol creatinine, P < 0.0001) or BM (11.6 ± 10.4 nmol 8-oxodG/mmol creatinine, P < 0.0001). There was no significant effect of Fe supplementation (P = 0.547). 8-OxodG excretion showed significant interindividual variation but was similar within pairs of twins.nnnCONCLUSIONnQuality and source of EN seem to influence oxidative stress in preterm infants. The underlying pathophysiological mechanism is unclear and needs further investigation. It may be speculated that other mechanisms than Fe supplementation contribute to oxidative stress, such as cows milk protein-mediated up-regulation of the intestinal inflammatory cascade.

Breastfeeding motivation in Pomerania: Survey of neonates in Pomerania (SNiP-Study)

BackgroundThe Nationale Stillkommission was founded in Germany in 1994 to increase the acceptance of breastfeeding as the primary means of infant nutrition. Scientific studies like “Stillen und Säuglingsernährung (SuSe-Studie)”, and regional studies in Bavaria, Freiburg, Hamburg, and Berlin demonstrated breastfeeding initiation rates of 90 to 95%, but the total breastfeeding rate decreased to 25–61% after infants were 6xa0months old. One predictor of breastfeeding duration may be maternal motivation. The present study aimed to describe breastfeeding motivation.MethodsWe analysed data collected in 2004–2008, during a previous study, the Survey of Neonates in Pomerania (SNiP). We retrieved data regarding maternal breastfeeding motivation, family environment, and socioeconomic factors. We constructed a quantitative breastfeeding-motivation score to identify factors involved in maternal breastfeeding.ResultsNinety five percent of mothers who gave birth in the study period and area provided information in the survey. The breastfeeding initiation rate was 88.4%. Mothers’ intentions to provide exclusive breastfeeding (only breast milk, no other liquids or infant formula) increased linearly from 71.9% in 2005 to 76.8% in 2008. Women motivated to provide exclusive breastfeeding were, on average, older, primiparous, and able to deliver spontaneously more often than women with less breastfeeding motivation. Furthermore, women with no motivation to provide exclusive breastfeeding and women that intended to provide breastfeeding combined with a complementary nutrition source had visited prenatal classes less frequently, had lower levels education, had lower average incomes, had a German nationality more often, and used tobacco more often than women motivated to provide exclusive breastfeeding.ConclusionsBreastfeeding intentions increased during the SNiP Study. This study identified several factors that might serve for targeted breastfeeding promotion in mothers younger than 25xa0years, mothers with low education, and multiparous mothers or women who have received a caesarean section. Furthermore, breastfeeding motivation might be enhanced during pregnancy and/or after delivery by providing prenatal classes.

PO-0460 Identifying Trajectories For Healthy Postnatal Growth Of Preterm Infants

Background Growth of preterm infants should follow intrauterine rates. Postnatal loss of extracellular fluid shifts growth trajectories to a percentile below that in-utero. Which ‘new’ trajectory a preterm infant should adjust to after completed postnatal adaptation is unknown. Objective 1) To develop a model for postnatal growth trajectories of preterm infants by characterising growth of such infants which required only minimal postnatal support; 2) to predict trajectories for healthy postnatal growth in any given infant. Methods Inclusion criteria: infants with (A) 30–35 and (B) 24–29 weeks GA, admitted 2008–2012 to participating hospitals. Exclusion criteria: (A)+(B) maternal diabetes/substance use, nosocomial sepsis (positive blood culture until day of life (DoL) 21 (A) nCPAP >3 days, not on full enteral feeds by DoL 10, (B) mechanical ventilation on DoL >3, FiO2≥0.3 within first 21 DoL, NEC >stage 2, IVH >2, PVL. Models to predict body weight trajectories on DoL 14 and 21 were developed. Results 890 infants were eligible of 6915 meeting inclusion criteria. Infants had maximum weight loss by DoL 5, regained birth weight by DoL 11 and showed stable growth parallel to intrauterine percentiles during DoL 7–21. Surprisingly the new trajectory was independent from GA with a z-score difference from birth of (A) -0.96 ± 0.75 and (B) -0.88 ± 0.67 at DoL14. Linear regression models predicted weight at DoL 14 (R2=0.88) and 21 (R2=0.82). Abstract PO-0460 Figure 1 Preterm FFMI increases progressively until 40 weeks, then remains constant over time like terms Conclusions 1) The study provides robust estimates of ideal postnatal growth trajectories for preterm infants. 2) The impact on long-term outcome using these trajectories for nutritional adjustment needs to be assessed, ideally in an RCT.

Serum Cortisol Levels of Well, Ill and Preterm Infants treated with Catecholamines < 30 Weeks of Gestational Age † 1528

Serum Cortisol Levels of Well, Ill and Preterm Infants treated with Catecholamines < 30 Weeks of Gestational Age † 1528