Pieter Koorts

Determination of umbilical venous catheter tip position with radiograph.

Objectives: To compare the cardiac silhouette method with the vertebral body method in predicting the umbilical venous catheter tip position on ultrasound; to measure the length of the target zone for the umbilical venous catheter tip; and to determine the time taken for a neonatologist to ascertain position of the umbilical venous catheter tip with ultrasound. Design: Prospective cohort study. Setting: Neonatal ICU. Patients: Newborn infants with an umbilical venous catheter. Interventions: Ultrasound scans to determine the umbilical venous catheter tip position were performed within an hour of corresponding anteroposterior chest-abdominal radiograph. Measurements and Main Results: Two hundred paired radiograph and ultrasound scans in 82 newborn infants were analyzed. Each radiograph was reviewed independently by an experienced neonatologist who recorded the position of the umbilical venous catheter tip by vertebral level and by the cardiac silhouette method. For each method, the sensitivity, specificity, and positive and negative predictive values were calculated for the prediction of the true position of the catheter tip on ultrasound. The umbilical venous catheter tip was well positioned in just 28 of 200 scans. The cardiac silhouette method was superior to the vertebral level method for all test variables, with a sensitivity and specificity of 86% and 94% compared with 61% and 74%. The length of the target zone approximates to a single T8 vertebral body height on radiograph. Conclusions: For radiograph and ultrasound scans performed within an hour of each other, the cardiac silhouette method more accurately predicts umbilical venous catheter tip than vertebral body level and methods described in previous studies. Catheters are frequently malpositioned. The length of the target zone for optimal umbilical venous catheter tip position is short. Ultrasound assessment of umbilical venous catheter tip position is quick.

A randomised controlled trial of blended learning to improve the newborn examination skills of medical students.

Objective To evaluate the hypotheses that a blended learning approach would improve the newborn examination skills of medical students and yield a higher level of satisfaction with learning newborn examination. Method Undergraduate medical students at a tertiary teaching hospital were individually randomised to receive either a standard neonatology teaching programme (control group), or additional online access to the PENSKE Baby Check Learning Module (blended learning group). The primary outcome was performance of newborn examination on standardised assessment by blinded investigators. The secondary outcomes were performance of all ‘essential’ items of the examination, and participant satisfaction. Results The recruitment rate was 88% (71/81). The blended learning group achieved a significantly higher mean score than the control group (p=0.02) for newborn examination. There was no difference for performance of essential items, or satisfaction with learning newborn examination. The blended learning group rated the module highly for effective use of learning time and ability to meet specific learning needs. Conclusions A blended learning approach resulted in a higher level of performance of newborn examination on standardised assessment. This is consistent with published literature on blended learning and has implications for all neonatal clinicians including junior doctors, midwifes and nurse practitioners.

Recent trends in the determination of vitamin D

The occurrence of vitamin D deficiency has become an issue of serious concern in the worldwide population. As a result numerous analytical methods have been developed, for a variety of matrices, during the last few years to measure vitamin D analogs and metabolites. This review employs a comprehensive search of all vitamin D methods developed during the last 5 years for all applications, using ISI Web of Science(®), Scifinder(®), Science Direct, Scopus and PubMed. Particular emphasis is given to sample-preparation methods and the different forms of vitamin D measured across different fields of applications such as biological fluids, food and pharmaceutical preparations. This review compares and critically evaluates a wide range of approaches and methods, and hence it will enable readers to access developments across a number of applications and to select or develop the optimal analytical method for vitamin D for their particular application.

EFFECT OF PASTEURISATION ON THE CONCENTRATIONS OF VITAMIN D COMPOUNDS IN DONOR BREAST MILK.

Aim Breastmilk is considered the most important nutrient and source of supplementation for both term and preterm infants.1 It is composed of many important nutrients, including vitamin D.2 The content of this vitamin in breast milk is usually low, even for lactating mothers with adequate vitamin D status.2 3 Preterm infants are at the great risk of vitamin D deficiency due to decreased transplacental transfer.4 Premature infants are the main recipients of pasteurised donor human milk (PDHM), when their mothers are unable to provide their own. This study aims to evaluate the effect of pasteurisation on the concentrations of vitamin D compounds in donor breast milk. Method A total of 16 participants, who donated breast milk to the RBWH milk bank, were recruited in this study. Milk samples were obtained pre- and post-Holder pasteurisation. Liquid chromatography tandem mass spectrometry (LC-MS/MS) was used to analyse the samples for vitamins D2 and D3 and 25-hydroxyvitamins D2 and D3 (25(OH)D2 and 25(OH)D3). The significance of differences in vitamin D concentrations between the two groups of milk samples was assessed using the Wilcoxon matched-pairs signed rank test, in which P<0.05 was considered significant. Results Pasteurisation resulted in a significant reduction (P<0.05) in the content of D2, D3, 25(OH)D2 and 25(OH)D3, with P values of 0.0001 for all targeted analytes. The concentrations of the vitamin D analogues in non-pasteurised milk ranged from 3.6 to 5.0 pM (D2), 1.0 to 9.8 pM (D3), 1.4 to 2.1 pM (25(OH)D2) and 1.2 to 9.3 pM (25(OH)D3). The concentrations of the vitamin D analogues in post-pasteurised milk ranged from 3.0 to 4.0 pM (D2), 0.6 to 9.5 pM (D3), 1.2 to 1.7 pM (25(OH)D2) and 1.1 to 9.1 pM (25(OH)D3). Losses of vitamin D compounds resulting from the pasteurisation process ranged from 10% to 20%. Conclusion Pasteurisation significantly affected the concentration of vitamin D compounds in pasteurised donor breast milk.

Effect of pasteurisation on the concentrations of vitamin D compounds in donor breastmilk

Abstract Premature infants are the main recipients of pasteurised donor human milk (PDHM), when their mothers are unable to provide their own. In this study, we evaluated the effect of pasteurisation on the concentrations of vitamin D compounds in donor breastmilk. Milk samples were obtained pre- and post-Holder pasteurisation. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to analyse the samples for vitamins D2 and D3 (D2 and D3) and 25-hydroxyvitamins D2 and D3 (25(OH)D2 and 25(OH)D3). The significance of differences in vitamin D concentrations between the two groups of milk samples was assessed using the Wilcoxon matched-pairs signed rank test, in which p < 0.05 was considered significant. Pasteurisation resulted in a significant reduction (p < 0.05) in the content of D2, D3, 25(OH)D2 and 25(OH)D3. The losses ranged from 10% to 20% following pasteurisation.

TO INVESTIGATE THE EFFECT OF THE PASTEURISATION PROCESS ON TRACE ELEMENTS IN DONOR BREAST MILK

Aim To investigate the effect of the pasteurisation process on trace elements in donor breast milk. Method Premature infants often receive donor breast milk when the mother is unable to produce sufficient breast milk. It is widely accepted that donor milk has considerable advantages over formula milk.1 The Royal Brisbane and Womens Hospital (RBWH) has a milk bank that receives milk donated by women which undergoes a pasteurisation process.2 This study investigated the effect of pasteurisation on a range of trace elements in donor milk. A total of 14 participants who donated to the milk bank were recruited in this study. A 2 ml sample was collected pre- and post- pasteurisation, and frozen at −80 °C. Post-natal age of the milk was documented. Inductively-coupled plasma mass-spectrometry was used to analyse the following trace elements – zinc (Zn), copper (Cu), selenium (Se), manganese (Mn), iodine (I), iron (Fe), molybdenum (Mo) and bromine (Br). The study received ethical approval from RBWH and The University of Queensland Ethics Committee. Results No significant difference was found between the levels of any of the trace elements tested pre- and post-pasteurisation. The following p-values were calculated – Zn (0.82), Cu (0.80), Se (0.97), Mn (0.63), I (0.99), Fe (0.05), Mo (0.41), Br (0.59). The following ranges in mcg/L of trace elements were calculated – Zn (365.4–5460.0), Cu (157.6–820.5), Se (10.6–23.7), Mn (0.55–3.24), I (66.4–215.3), Fe (101.5–473.1), Mo (0.20–5.45), Br (704.9–3379.0). Spearmans rank correlation analysis showed significant correlations between post-natal age of milk and trace elements – Zn (ρ=−0.578), Se (ρ=−0.627). Fe (ρ=−0.704), and Mo (ρ=−0.534). No significant correlation was found for Cu, Mn, I, and Br. Conclusion This study found that the pasteurisation process had minimal effect on trace element levels in donor breast milk. However, it was noted that there was a correlation between post-natal age of donor milk and Zn, Se, Fe and Mo. Further work is needed to establish factors that may influence levels of trace elements in donor milk such as post-natal age.

Breast milk donation after neonatal death in Australia: a report

Lactation and breast milk can hold great value and meaning for grieving mothers who have experienced a recent death of an infant. Donation to a human milk bank (HMB) as an alternative to discarding breast milk is one means of respecting the value of breast milk. There is little research, national policy discussion, or organizational representation in Australia on the subject of breast milk donation after infant death. On 29 November 2013 the Mercy Hospital for Women in Melbourne, Australia hosted Australia’s first National Stakeholder Meeting (NSM) on the topic of milk donation after neonatal death. The NSM drew together representatives from Australian HMBs, neonatal intensive care units (NICUs) currently using donor human milk, and Australia’s chief NICU parent support organization. The NSM was video-recorded and transcribed, and analyzed thematically by researchers. This article reports the seven dominant themes discussed by stakeholders during the NSM: the spectrum of women’s lactation and donation experiences after infant death; the roles of the HMB and NICU in meeting the needs of the bereaved donor; how bereaved mothers’ lactation autonomy may interface with a HMB’s donation guidelines; how milk donation may be discussed with bereaved mothers; the variation between four categories of milk donation after neonatal death; the impact of limited resources and few HMBs on providing donation programs for bereaved mothers in Australia. This article provides evidence from researchers and practitioners that can assist HMB staff in refining their bank’s policy on milk donation after infant death, and provides national policy makers with key considerations to support lactation, human milk banking, and bereavement services nation-wide.

The effect of pasteurization on trace elements in donor breast milk

Objective:Premature infants often receive pasteurized donor human milk when mothers are unable to provide their own milk. This study aims to establish the effect of the pasteurization process on a range of trace elements in donor milk.Study Design:Breast milk was collected from 16 mothers donating to the milk bank at the Royal Brisbane and Women’s Hospital. Samples were divided into pre- and post-pasteurization aliquots and were Holder pasteurized. Inductively coupled plasma mass spectrometry was used to analyze the trace elements zinc (Zn), copper (Cu), selenium (Se), manganese (Mn), iodine (I), iron (Fe), molybdenum (Mo) and bromine (Br). Differences in trace elements pre- and post-pasteurization were analyzed.Results:No significant differences were found between the trace elements tested pre- and post-pasteurization, except for Fe (P<0.05). The median (interquartile range, 25 to 75%; μg l−1) of trace elements for pre- and post- pasteurization aliquots were—Zn: 1639 (888–4508), 1743 (878–4143), Cu: 360 (258–571), 367 (253–531), Se: 12.34 (11.73–17.60), 12.62 (11.94–16.64), Mn: (1.48 (1.01–1.75), 1.49 (1.11–1.75), I (153 (94–189), 158 (93–183), Fe (211 (171–277), 194 (153–253), Mo (1.46 (0.37–2.99), 1.42 (0.29–3.73) and Br (1066 (834–1443), 989 (902–1396).Conclusions:Pasteurization had minimal effect on several trace elements in donor breast milk but high levels of inter-donor variability of trace elements were observed. The observed decrease in the iron content of pasteurized donor milk is, however, unlikely to be clinically relevant.

Transient neonatal zinc deficiency in exclusively breastfed preterm infants

We describe seven cases of transient neonatal zinc deficiency (TNZD), with the clinical and demographic features summarised in Table 1 and clinical images in Figures 1 and 2. The early dermal features included scrotal oedema, a ‘dribble rash’, and alopecia. All infants demonstrated marked irritability, which resolved rapidly when zinc supplementation was instituted. Infants were treated with various oral liquid zinc preparations, 1–6 mg elemental zinc/kg/day. Treatment duration in our cohort varied markedly, ranging from 2 weeks to 14 months. Our infants are now 15–50 months post‐natal age and all thriving without physical or neurocognitive impairment; however, infant 7 was lost to medical follow‐up shortly after diagnosis. Half of the mothers had excessive milk supply, discarding up to 1.8 l (i.e. 75%) of expressed breast milk per day throughout lactation to the time of diagnosis. While the zinc content in the milk was in the low normal range, 60–75% of the zinc excreted in the breast milk per 24 h was discarded.

G490(P) Neuroprotective benefit of antenatal magnesium sulfate for preterm infants. Is it the magnesium or the sulfate

Aims To determine whether antenatal magnesium sulfate (MgSO4) administration correlates with circulating sulfate level in very/extremely preterm infants, and specifically whether non-exposed infants become sulphate deficient. Methods Ion chromatography was used to measure plasma sulfate levels in preterm infants (<32 wk gestation) whose mothers did or did not receive antenatal MgSO4. Results Within 24 hours after birth, supra-physiological plasma sulfate levels were measured in infants whose mothers received MgSO4 (mean±SD mmol/L 774±397, n=26), whereas sulfate levels in the group without MgSO4 (257±162, n=10) were similar to that found in term cord blood. At 3 days and at 1 and 4 weeks of age, babies without antenatal MgSO4 had reduced plasma sulfate level (3d: 190±96, n=49; 1 wk 118±61, n=67; 4 wk 125±79, n=6) whereas the group with antenatal MgSO4 therapy maintained normal levels (3d: 287±160, n=68; 1 wk 250±125, n=119; 4 wk 228±89, n=56). Conclusions These data positively correlate antenatal MgSO4 administration with neonatal plasma sulfate levels, and suggest that unexposed preterm infants (who lack the capacity to generate sulphate) rapidly become sulphate depleted. Animal models and human studies demonstrate that sulphate is important for modulating brain development. It may be, therefore, that the neuroprotective benefit of antenatal MgSO4 for preterm infants is attributable to the sulphate rather than the magnesium content. If sulfate neuroprotection is proven, then neonatal sulfate supplementation (in place of antenatal MgSO4) may prove a simple and effective, low-cost, low-risk intervention universally available to all preterm infants to improve their chances of a normal neurodevelopmental outcome.