Orna Flidel-Rimon

The fear of necrotizing enterocolitis versus achieving optimal growth in preterm infants- : an opinion

Very‐low‐birthweight (VLBW) infants suffer marked growth delay despite well‐intentioned efforts at combining enteral and parenteral nutrition. Fear of necrotizing enterocolitis (NEC) has traditionally influenced neonatologists toward delaying and progressing slowly with enteral feeding, while supporting the infant with parenteral nutrition. Current evidence suggests significant benefits of enteral feeding that is started early and advanced at rates of 20–35 ml/kg/d.

The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants

Objective: To study the effect of prenatal consultation (PC) with a neonatologist on the incidence and duration of human milk feeding (HMF) in preterm infants. Design/methods: A retrospective matched case‐control study was preformed at a perinatal centre. Study infants were preterm infants (23–35 wk) whose mothers had received PC emphasizing the importance of HMF. Control infants were matched by birthweight, gestational age and multiplicity. Results: Each group included 29 mothers and 46 preterm infants. Mean gestational age was 30.1 ± 3 wk in both groups. Mean birthweight was 1329 ± 489 (PC) and 1334 ± 441 g (control). PC infants received HMF for significantly longer, both in the hospital and after discharge (hospital: PC 37 ± 34 d vs control 15 ± 19 d, p = 0.001; discharge PC 60 ± 57d vs control 21 ± 32d; p= 0.0001). No significant difference in neonatal morbidity was detected between the groups.

Reduction in multiresistant nosocomial infections in neonates following substitution of ceftazidime with piperacillin/tazobactam in empiric antibiotic therapy

Aim: To evaluate the effect of a change in antibiotic protocol on pathogens that cause neonatal sepsis. Methods: Suspected sepsis was treated with amikacin together with ceftazidime in 1995–1998 and piperacillin/tazobactam in 1999–2002. Results: The annual rate for Klebsiella sepsis fell from 2.5 to 0.45 cases per 1000 admission days (p= 0.0001) between the two periods studied.

Limitations of the risk factor based approach in early neonatal sepsis evaluations

Aim:  Guidelines for detection of early neonatal sepsis employ a risk factor approach combined with laboratory parameters. In an era of increasing intrapartum antibiotic prophylaxis (IAP), we re‐assessed the approach as a whole and each of the risk factors individually.

Early adequate maternal weight gain is associated with fewer small for gestational age triplets.

Abstract Objective: To examine whether the recommended weight gain during the first 24 weeks reduces the frequency of SGA triplets. Study design: We used data collected by the Womens Health Division of Matria Healthcare, Inc (Marietta, GA). We studied the frequency of SGA triplets (birth weight <10th percentile by triplet standards) by weight gain, parity, and pregravid BMI category. Adequate weight gain was defined as >16.2 kg at 24 weeks and BMI categories were defined as underweight (<19.8), normal (19.8–26), and obese (BMI>26). Results: We studied 2890 triplet sets. Adequate weight gain reduces the frequency of SGA triplets, irrespective of pregravid BMI category and parity, except for obese nulliparous women. However, the reduced frequency of SGA infants was significant only in underweight nulli-paras (OR 0.3, 95% CI 0.1, 0.9). Conclusion: Higher pregravid BMI and parity seem to reduce the occurrence of SGA triplets. However, lean mothers, especially nulliparas, may be the most important target population for nutritional intervention in triplet pregnancies.

Is there a difference in breast milk fatty acid composition of mothers of preterm and term infants

Abstract Objective: Arachidonic acid (ARA) (c20:4 w6) and docosahexanoic acid (DHA) (c22:6 w3) are of major importance for neural maturation and retinal function in infancy. Requirements in preterm infants are increased due to accelerated growth and limited body stores. Data regarding human milk fatty acid composition after preterm and full-term delivery is inconsistent. This study compared fatty acid composition in breast milk from full-term and preterm infants. Findings were correlated with maternal dietary intake. Methods: Human milk was obtained 4–5 days after full-term delivery (20 infants) and 4–5, 10–11 and 14–15 days after preterm delivery (21 infants, of whom 6 were born before 30 weeks). For fatty acid analysis, lipids were extracted, transesterified and separated by gas liquid chromatography. Results: Total fat content was similar in the two groups. FA composition including LCPUFA and specifically ARA & DHA were similar in full-term and preterm infants and in the sub-set born before 30 weeks. In preterm infants, postnatal age did not influence LCPUFA content. Conclusions: This study did not detect any effect of gestational age or postnatal age on milk LCPUFA content. Accordingly, the increased demand for LCPUFA and specifically DHA in preterm infants need to be met by other supplementation.

Is lumbar puncture (LP) required in every workup for suspected late-onset sepsis in neonates?

Neonatal meningitis is an uncommon but potentially devastating disorder. However, debate as to universal or selective inclusion of lumbar puncture (LP) in sepsis workups (SWUs) is reflected in the wide variability between centres in inclusion rates among very low birth weight (VLBW) infants (22–85%) (1). The primary argument in favour of universal inclusion of LP in SWUs is the observation that neonatal meningitis may occur in the presence of negative blood cultures. Wiswell reported negative blood cultures in 12 of the 43 infants (28%) with early neonatal meningitis (2). The Pediatrix group found a negative blood culture in 38% of the cases of meningitis, although the blood cultures were performed within 3 days of the LP and not necessarily concomitantly (3). The selective approach is reflected in clinical guidelines at the Neonatal Intensive Care Unit (NICU) at Kaplan Medical Center, Rehovot, Israel that only include the performance of LP as part of SWUs following assessment by an experienced senior physician. To assess the validity of this selective approach, we studied the indications for and the rate of inclusion of LP in SWUs for late-onset sepsis (LOS) or late-onset meningitis (LOM), defined as occurring after the age of 72 h and before discharge from the NICU. To explore the possibility of ‘missed’ or ‘partially treated meningitis’, we compared the rates of short and long-term complications between infants who underwent LP as part of their SWU (LP group) and those who were managed without an LP (no-LP group). Standard SWU in our unit includes two blood cultures obtained from different sites and a urine culture obtained by supra-pubic aspiration or catheter. The inclusion of LP is based on clinical considerations, such as general condition and abnormal neurological signs, together with risk factors such as extreme prematurity, central lines, mechanical ventilation and the presence of localized findings such as pneumonia or necrotizing enterocolitis (NEC). After obtaining the cultures, broad-spectrum antibiotic treatment is administered for 48 h and then discontinued when the cultures are negative or continued or modified if a pathogen is detected. This retrospective study included all infants born between 1999 and 2005 who were treated with antibiotics after the age of 72 h. Data collected included the reason for antibiotic treatment, sepsis workup components, clinical course and morbidity and mortality. Short-term complications included the need for a second SWU within 48 h after discontinuing antibiotic treatment. Causes of death were reviewed. Long-term complications included the development of unexplained hydrocephalus or hearing impairment. The LP and no-LP groups were compared by univariate analysis employing Chi-square test for noncontinuous variables and Student’s t-test (nonpaired) for continuous variables. The results showed that of the 1590 newborn infants admitted to the NICU during the study period, 341 (21%) were treated with antibiotics for 492 episodes of suspected LOS. Of the 341 study infants, 210 had VLBW and 102 had extremely low birth weight (<1000 g, ELBW). LP was performed in 349 ⁄ 492 (71%) episodes; of these, in 18 episodes the LP was performed after a positive blood culture result was received. The study groups comprised LP 259 ⁄ 341 (76%) infants and no-LP 82 ⁄ 341 (24%) infants. The LP group included 36 infants who had more than one SWU, but in whom an LP was omitted at least once. Sub-group analysis found no significant differences between this group, and the rest of the sample and, as such, this group was included in the main analysis. No significant differences were found between the LP and no-LP groups in birth weight (BW) and gestational age (GA) (BW: LP 1446 ± 655 g, no LP 1553 ± 1009 g, p = 0.26; GA LP 30.5 ± 4.5 weeks, no LP 30.7 ± 5.2 weeks, p = 0.74). Acta Pædiatrica ISSN 0803–5253

The use of piperacillin/tazobactam (in association with amikacin) in neonatal sepsis: Efficacy and safety data

Piperacillin/tazobactam (P/T) has been used in NICU since 1999 as part of the empirical treatment for presumed sepsis. We studied the microbiological and clinical efficacy and safety of P/T use in newborns with sepsis, using a retrospective analysis of medical records of all newborns treated with P/T (in association with amikacin) during 1999–2003. P/T plus amikacin was used for 353 episodes of presumed sepsis occurring in 252 newborns: 105 episodes occurred in 100 newborns treated for 5–14 d while in 248 (70%) episodes the treatment was discontinued after 2–3 d. 123 pathogens were isolated from the blood cultures (40 in the 5–14 d group and 83 in those treated for 2–3 d only). There were 56 Gram-negative, 55 Gram-positive and 12 Candida spp. isolates. Klebsiella spp. (40%) and E. coli (30%) were the most commonly isolated Gram-negative pathogens; coagulase-negative Staphylococcus (CONS) represented 95% of the Gram-positive pathogens isolated. Pathogen eradication was achieved within 48–72 h of therapy in 93% Gram-negative organisms. There were no clinical, laboratory or cranial ultrasound adverse effects associated with P/T use. We conclude that P/T in association with amikacin is microbiologically and clinically efficacious and safe in the treatment of sepsis in newborns.

Indomethacin tocolysis and white matter injury in preterm infants

Objective. This study aims to clarify the relationship between indomethacin tocolysis and neonatal white matter injury (WMI) in preterm infants. Methods. We conducted a retrospective review of preterm infants born at 24–32 weeks who had sufficient cranial ultrasound examinations (CUS) to determine the incidence and severity of abnormalities. Infants with normal CUS were compared on univariate and multivariate analyses with infants with the different forms of WMI. Results. On multivariate logistic regression analysis, indomethacin tocolysis was significantly correlated with periventricular echogenicity (PVE; OR 2.84 95% CI 1.41–5.7, p = 0.003), but not with periventricular leucomalacia (PVL; OR 1.83 95% CI0.6–5.6, p = 0.29). Indomethacin was not related to increased risk for periventricular-intraventricular hemorrhage or periventricular hemorrhagic infarction. Conclusion. These findings suggest caution in the use of indomethacin as a tocolytic therapy.

Correlation of transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) levels after phototherapy

Abstract Aim: To investigate the correlation between transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) in jaundiced infants before and after, but not during phototherapy. Methods: This study prospectively investigated the correlation between TcB and TsB in term and near term infants before and after phototherapy. Results: Overall 673 pairs of measurements (TcB and TsB) were performed on 371 infants of ≥35 weeks gestation and with birth weight above 2000 g. Of these 337 sets were from 200 infants who had not been treated with phototherapy (Group 1) and 336 measurements from 171 infants taken between 1 h and 5 d after phototherapy (Group 2). The correlation coefficient between TcB and TsB in the whole cohort was r = 0.72. The correlation was low during the first 8 h after phototherapy (r = 0.56), but thereafter the correlation returned to the range of 0.65–0.8. Using the Sobel test, no significant difference was found between the correlation coefficients at the different time periods, with the possible exception of the difference between 1 and 8 h and 9 and 16 h which was of borderline significance with a p value of 0.06. Conclusion: This study demonstrates good correlation between TcB and TsB by 8 h after phototherapy. This adds validity to community-based screening programs employing TcB measurements plotted on TsB nomograms. Such programs may contribute to prevention of tragic cases of bilirubin-induced neurologic damage.