Pamela Cairns

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.

Hypernatraemia: why bother weighing breast fed babies?

Editor—Hypernatraemic dehydration is associated with cerebral oedema, intracranial haemorrhage, hydrocephalus, gangrene, and death,1 but is notoriously difficult to detect clinically. It is accepted in paediatric practice that weighing is an essential part of the assessment of an infants hydration. In Bristol, one neonate a month is admitted with hypernatraemic dehydration secondary to delayed recognition of inadequate lactation. We believe that …

Unusual site for oesophageal perforation in an extremely low birth weight infant

Abstract A male infant born at 26 weeks gestation became unwell at 10 days of age with blood-stained pharyngeal aspirates. The chest radiograph revealed a feeding tube in the right pleural cavity, indicating a perforation of the thoracic oesophagus. The infant had had a chest drain inserted on the right side on two previous occasions. These had been allowed to remain across the mediastinum at the site of the subsequent perforation. The infant was successfully managed conservatively with no long-term sequelae The unusual site of the perforation led us to conclude that pressure necrosis from the drains was a contributing factor in the aetiology. Conclusion Oesophageal perforations in the neonate, in contrast to the adult, can be managed conservatively.

Ex‐utero intrapartum treatment for cervical teratoma

A 25 year old primigravida was referred to the fetal medicine unit at 19 weeks of gestation following a routine anomaly ultrasound scan which had detected a mass in the neck. A further ultrasound assessment con®rmed an anterior neck mass measuring 30 x 30 x 30 mm with cystic and solid components, highly suggestive of a cervical teratoma. The stomach bubble was present, amniotic ̄uid volume was normal and the tongue was visualised with normal movements suggesting that there was no oesophageal or tracheal obstruction at that time. The implications were discussed with the couple and the risks of polyhydramnios, preterm delivery, pulmonary insuf®ciency, dif®cult intubation at birth and neonatal mortality and morbidity related to the delivery and to subsequent surgery were described. The couple was offered conservative management, intensive care with neonatal surgery, termination of pregnancy, and karyotyping. They elected to continue the pregnancy with regular assessments, and declined karyotyping. Consultations were arranged with a paediatric surgeon, a neonatologist and a family support worker. Regular ultrasound assessments showed growth of the tumour to a maximum of 82 x 62 x 56mm. The fetus continued to swallow amniotic ̄uid but polyhydramnios developed at 32 weeks of gestational age (deepest pool 10 cm, amniotic ̄uid index 31.8 cm). The condition of the fetus was stable over the following two weeks and the woman was admitted at 35 weeks of gestation for a planned delivery due to the high risk of early spontaneous onset of labour. Dexamethasone injections had been given two-weekly from 26 weeks to 34 weeks of gestation. A multidisciplinary team was coordinated to perform an ex-utero intrapartum treatment procedure at lower segment caesarean section. The team consisted of two maternal anaesthetists, two obstetricians, a neonatologist, two paediatric anaesthetists, a theatre-sister and two midwives. The mother underwent continuous monitoring of her blood pressure, electrocardiogram and oxygen saturation. Anaesthesia was induced by a rapid-sequence technique, with thiopentone 400 mg and suxamethonium 100 mg intravenously, followed by tracheal intubation. Anaesthesia was maintained with iso ̄urane at 0.7% to 1.8% expired, vecuronium 6 mg and fentanyl 100 mg. The dose of inhalation agent was titrated to uterine relaxation to preserve uteroplacental circulation and fetal gas exchange. Maternal systolic blood pressure was maintained at 80±90 mmHg during the time of tocolysis with intravenous ̄uids and methoxamine 1mg. The woman was placed in a modi®ed lithotomy position with her legs supported in Lloyd-Davies stirrups. This allowed optimal access to the fetal head for endotracheal intubation. A low transverse abdominal incision exposed the uterus. A transverse lower uterine segment hysterotomy was performed and the fetal head was eased into the wound in an occipito-transverse position. It was gently rotated to an occipito-posterior position and the left upper limb was delivered. A uterine stapling device was not necessary as haemostasis was achieved by pressure of the fetal shoulders on the hysterotomy incision. A pulse-oximeter was attached to the fetal hand. A loop of umbilical cord lay alongside the shoulder and the fetal heart rate was palpable in the umbilical cord throughout the procedure. The fetus received an intramuscular injection of vecuronium (0.2 mg/kg), fentanyl (10 mg/kg), and atropine (20 mg/kg) into the arm. This ensured that the fetus was anaesthesised, did not have bradycardia induced by vagal stimulation, and made no attempt to breathe during intubation. The tumour was extremely large and occupied the whole of the anterior aspect of the neck, thereby making any attempt at tracheostomy impossible. A full range of intubating aids were available, including a neonatal ®breoptic bronchoscope (Olympus 2.2mm), and a rigid bronchoscope (Storz 3.0mm). Oral endotracheal intubation was eventually achieved using a small Mackintosh laryngoscope, a gum elastic bougie and a 3.0mm Portex endotracheal tube. The correct position of the tube was con®rmed by observing an end-tidal carbon dioxide trace and bilateral expansion of the fetal chest. The procedure took 29 minutes from delivery of the fetal head during which

Neurodevelopmental Outcome of Very Low Birth Weight Infants enrolled in a Trial of Early Enhanced Nutrition † 1217

Neurodevelopmental Outcome of Very Low Birth Weight Infants enrolled in a Trial of Early Enhanced Nutrition † 1217