Rachel Porat

Effect of sustained pharmacologic vitamin E levels on incidence and severity of retinopathy of prematurity: A controlled clinical trial

The incidence and severity of retinopathy of prematurity (ROP) as affected by vitamin E prophylaxis at pharmacologic serum levels (5 mg/dl) were evaluated in a double-masked clinical trial of infants with a birth weight less than or equal to 2000 gm or a gestational age less than or equal to 36 weeks. The infants were enrolled by age 5 days and randomly assigned to receive parenterally administered, and later orally administered, free alpha-tocopherol (vitamin E) or its placebo. Study medication was continued until retinal vascularization was complete or active ROP had subsided, except in infants with a diagnosis of severe disease, in whom vitamin E was substituted for study medication. Acute ROP data were collected on 755 infants. Logistic regression analysis, with control for immaturity, oxygen exposure, and other illness risk factors, showed a decrease in incidence of ROP in vitamin E-treated infants (p = 0.003, all infants; p = 0.035, infants weighing less than or equal to 1500 gm at birth). Among the 424 infants weighing less than or equal to 1500 gm at birth, the age at enrollment influenced treatment effect (age day 0 to 1, p = 0.006 (n = 288) vs age day 2 to 5, p greater than 0.1 (n = 136]. Overall, 77.6% of infants with ROP had mild disease. Moderate to severe ROP was confined to infants weighing greater than or equal to 1500 gm at birth (25 given placebo, 25 given vitamin E), with progression to severe disease in nine placebo-treated versus three vitamin E-treated infants (p = 0.048). The incidence of severe ROP per se was not significantly decreased (all birth weights, p = 0.086; less than or equal to 1500 gm birth weight, p = 0.080); the sample size was too small, however, to assess this end point adequately. An increased incidence of sepsis and late-onset necrotizing enterocolitis was found among vitamin E-treated infants weighing less than or equal to 1500 gm at birth who received study medication for greater than or equal to 8 days (p = 0.006). Because most ROP is mild in degree and regresses completely, the risk/benefit ratio of pharmacologic prophylaxis for ROP is unfavorable. Treatment of moderate and severe ROP with vitamin E above physiologic serum levels (greater than 3 mg/dl) appears promising and should be further investigated. The interpretation of cicatricial outcome was confounded by the small number of patients involved and by subsequent treatment of severe ROP in placebo-treated infants with vitamin E.

Clinical correlations in infants in the neonatal intensive care unit with varying severity of gastroesophageal reflux.

Background Gastroesophageal reflux (GER) is frequently a benign condition in infancy with spontaneous resolution. In the neonatal intensive care unit (NICU), however, it can add to neonatal morbidity if not adequately diagnosed and treated. The objective of the current study was to analyze factors associated with GER in infants in the NICU and correlate them with the severity of the disease. Methods All infants in the NICU (n = 150; born November 1994 through April 1999) who were evaluated by a five-channel pH study to rule out GER were included in the study. Infants were grouped as normal, with a reflux index (RI) of less than 6 (n = 66); mild, with RI of 6 to 14 (n = 42); and severe, with RI of more than 14 (n = 42). Maternal and neonatal data were obtained. Clinical GER was defined as the presence of feeding problems (significant gastric residue or emesis) and medical improvement with antireflux measures and medications. Results There was no difference in birth weight, gestational age; incidence of patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, or chronic lung disease; and treatment with aminophylline or caffeine among the groups. Infants with mild and severe GER (RI 6–14 and >14) had significantly more clinical GER than the normal group (P = 0.0001). Additionally, infants with RI more than 14 had significantly more respiratory distress syndrome, lower hematocrits at the time of study and longer length of stay than those with no or mild GER (P = 0.02). Conclusion Infants with severe GER had lower hematocrits despite receiving more blood transfusions and iron therapy. Infants with severe GER also had prolonged hospital stays. Early diagnosis and aggressive management of GER may decrease neonatal morbidity and result in earlier discharge from the NICU.

Improved Outcome of Extremely Low Birth Weight Infants with Tegaderm ® Application to Skin

OBJECTIVE:Significant fluid and electrolyte disturbances occur in extremely low birth weight (ELBW) infants in the first few days of life. We investigated the effect of semipermeable polyurethane membrane (Tegaderm®) applied to the skin shortly after birth on fluid and electrolyte status and the clinical outcome in these infants.STUDY DESIGN:We reviewed charts of ELBW infants (BW<1.0 kg) born during 24 months prior to Tegaderm® application and 19 months after starting Tegaderm®. Data were collected daily from the first week of life and additional clinical morbidities were compared.RESULTS:A total of 39 infants from pre-Tegaderm® period (NOTEG) (mean±SD, BW 756±158 g, GA 26.1±1.9 weeks) were compared to 30 infants with extensive Tegaderm® application to chest, abdomen and extremities (TEG) (BW 802±160 g, GA 26.3±1.8 weeks). The groups were similar in maternal demographics as well as postnatal surfactant use. Throughout the first week of life, serum Na levels, daily fluid intake and daily weight loss were significantly higher in the NOTEG infants (all P≤0.04) while BUN/Serum creatinine levels were similar. Hypernatremia (Na>150 mEq/l) developed in 51% of NOTEG infants compared to 17% of TEG (P=0.0005) and daily fluid intake ≥170 ml/kg/day was required in 54 vs 13% (P=0.0008), respectively. The mean time to regain BW was significantly longer in NOTEG vs TEG infants, 20.7±7.4 vs 15.8±6.3 days, respectively (P<0.02). There were no statistical significant differences among the groups in incidence of IVH, NEC, PDA or nosocomial sepsis; however, respiratory outcome was better in TEG infants. They had significantly less BPD (58% in NOTEG vs 22% TEG (P=0.01)) and fewer infants in the TEG group required supplemental oxygen at discharge (58% vs 22% (P=0.01)). Survival was significantly higher in TEG 90% vs 64% in NOTEG infants (P=0.02).CONCLUSIONS:Semipermeable polyurethane membrane application to skin of ELBW infants shortly after birth decreased postnatal fluid and electrolyte disturbances and significantly improved their outcome by reducing severity of lung disease and decreasing mortality.

Randomized Controlled Trial of Early Parenteral Nutrition Cycling to Prevent Cholestasis in Very Low Birth Weight Infants

OBJECTIVES To compare the incidence of cholestasis in very low birth weight infants receiving cycled versus continuous parenteral nutrition, and to determine factors that predispose to parenteral nutrition-associated cholestasis (PNAC). STUDY DESIGN Preterm infants weighing ≤ 1250 g (n = 70) at birth were randomly assigned within the first 5 postnatal days to either cycle (n = 34) or continuous (n = 36) parenteral nutrition. Liver function tests were obtained at baseline, and sequentially thereafter. Cholestasis was defined as direct bilirubin >2 mg/dL. Infants with major congenital anomalies, congenital hepatic disease, clinically apparent congenital viral infection, and those who required major abdominal surgery were excluded. RESULTS The incidence of PNAC was similar in the 2 groups (cycle 32% vs continuous 31%; P = 1.0). Bilirubin and transaminases were similar in both groups by repeated measures of ANOVA. Gestational age, birth weight, and Apgar scores were significantly lower, and Clinical Risk Index for Babies II scores were significantly higher in infants who developed PNAC. Using backward selection logistic regression, bronchopulmonary dysplasia, duration of parenteral nutrition, and days to full enteral nutrition emerged as factors independently associated with PNAC. CONCLUSIONS Early prophylactic parenteral nutrition cycling in very low birth weight infants in this study did not reduce cholestasis. Time to full feedings is a significant predictor for PNAC in very low birth weight infants. Preterm infants with bronchopulmonary dysplasia are more likely to have PNAC as a comorbidity. The Clinical Risk Index for Babies II score may help identify those preterm infants who might benefit from future prospective prevention trials.

Neonatal nutrition: a brief review

BackgroundWith increasing survival of extremely premature infants, emphasis is now focused on the quality of these survivors’ lives. Possibly the most important factor in the premature’s ability to survive in the NICU and thrive is the ability to replicate in utero growth through enteral and parenteral nutrition.Data SourcesCurrent literature and review articles were retrieved from PubMed and personal files of the authors.ResultsThe use and complications of the various components of total parenteral nutrition (TPN) were reviewed. The composition of appropriate enteral feeds for the premature was reviewed as was the difficulties associated with the establishment of adequate enteral feeds in the premature infants.ConclusionsEarly initiation of amino acids in TPN and timely increases in the components of TPN can improve the caloric intake of prematures. Enteral feeds, particularly of breast milk, may be started within the first few days of life in all but hemodynamically unstable prematures. Newer lipid preparations show promise in reversing the hepatic damage of TPN associated cholestatic jaundice.

A comparison of the infant car seat challenge and the polysomnogram at the time of hospital discharge

Objective The American Academy of Pediatrics recommends all infants born at <37 weeks gestation spend a period of observation in a car seat prior to hospital discharge to assess for apnoea, bradycardia or oxygen desaturation. The most recent Cochrane review suggested further studies to determine if the infant car seat challenge (ICSC) accurately predicts the risk of clinically adverse events. We reviewed our experience with the ICSC and the polysomnogram (PSG) to determine if the ICSC accurately predicts the risk of adverse events when compared with the PSG. Study design Retrospective chart review of all infants in our institution who had an ICSC and a PSG between January 2005 and December 2008. Result 785 infants had ICSCs. In addition, 313 infants (56.6%) had an abnormal PSG, even though the vast majority, 158 (88.3%), passed their ICSC. There were no significant differences in gestational age at birth, birth weight, chronological age at study or postmenstrual age at study between infants who either passed or failed the ICSC with those who passed or failed the PSG. The sensitivity of the ICSC was 0.11 and specificity was 0.96. The positive predictive value of the ICSC was 0.77 and the negative predictive value was 0.45. Conclusions The ICSC has a low negative predictive value (0.45) when compared with the PSG as a reference standard for identifying adverse cardiorespiratory events. Although less time consuming and cumbersome than extended polysomnography, the ICSC is not a reliable substitute.

ABNORMAL PNEUMOGRAMS (PNGS) IN INFANTS WITH IN UTERO COCAINE EXPOSURE

Widespread abuse of cocaine among the general population has focused new interest on its effects on the developing fetus. Abnormal cardiorespiratory patterns and increased risk for Sudden Infant Death Syndrome (SIDS) have been reported in infants with intrauterine narcotic exposure, but few data exist for infants with in-utero exposure to cocaine only (IUC). As part of an ongoing prospective study to determine the risk of SIDS in infants with IUC, we enrolled users of cocaine alone and obtained the following: 1) maternal drug history 2) maternal and infant urine drug screen 3) PNGs with a minimum of 6 hours sleep, scored for short (10-15 seconds) and long (>15 seconds) apneas, % periodic breathing and bradycardias (<80 for >5 seconds). Maternal cocaine use included 70% free basing, 20% snorting, 10% by IV or oral.Twenty infants, each followed for 6 mos., have been evaluated thus far (birthweight 2616 ± 588 gms, gestational age 37.6 ± 2.6 wks., and Apgar scores of 8 ± 2 at 1 min. and 9 ± 1 at 5 min.). Withdrawal, evaluated by standard neonatal abstinence scoring, was monitored for ≥ 24 hrs.; maximal score recorded was 5.1 ± 3.7. Urine screen was positive for cocaine in 60% of mothers aE tine of delivery; 6 or their infants were positive as well.Evaluation or PNG demonstrated the only abnormal finding to be apnea >15 seconds in 4 out of the 20 infants, 3 of whom also had positive urine screens for cocaine. The 4th infant was first tested at 35 wks post-conceptional age; at 37 wks a repeated PNG was normal. None of the term infants exhibited clinical apnea during the hospitalizatipn, however, one has subsequently been readmitted with a near-miss episode.We conclude that infants with IUC demonstrate abnormal respiratory patterns as evaluated by PNGs. The prolonged apneas are more likely to occur in infants with apparent recent cocaine exposure as reflected by the positive urine in 3 of the 4 patients with abnormal PNGs. Further evaluation is currently in progress to determine: 1) if prolonged apnea is only an immediate postnatal risk, 2) it prolonged apnea places IUC infants at increased risk for SIDS.

Parenteral and Enteral Nutrition of the Low Birth Weight Infant

With increasing survival of extremely premature infants, emphasis is now focused on the quality of these survivors’ lives. Possibly the most important factor in the premature’s ability to survive in the NICU and thrive is the ability to replicate in utero growth through enteral and parenteral nutrition. Early initiation of amino acid administration and timely increases in the components of TPN, amino acids, carbohydrate, and lipid can improve the caloric intake of prematures. Insulin administration strictly for the purpose of increasing weight gain, though, is not indicated. Enteral feeds, particularly of breast milk, may be safely started within the first few days of life in all but hemodynamically unstable infants. Human milk is the preferred means of enteral nutrition in the low birth weight infant. However, it must be supplemented with protein, Ca, and P in order to provide sufficient nutrition to allow the premature to replicate in utero growth. Immaturity of the premature infant’s gut often makes it difficult to accomplish full enteral feeds in a timely fashion, leading to the prolonged need for TPN. TPN-associated cholestasis is the major complication of prolonged TPN administration; however, newer lipid preparations show promise in reversing the hepatic damage of TPN-associated cholestatic jaundice.

The Ultra Low Birth Weight (LBW) Infants May Be Particularly Vulnerable to Intestinal Perforation (IP) 1103

Reports indicate that for preterm infants intestinal perforation (IP) is an emerging disease (Acta Ped 1996). Others quote high mortality (48%) with NEC and perforation (Surgery 1996) but no specific cause is delineated. Recently, we experienced an increased incidence of IP in ELBW infants.

WHEN ARE LONG BONE RADIOGRAPHS NECESSARY IN NEONATES WITH SUSPECTED CONGENITAL SYPHILIS? † 1336

WHEN ARE LONG BONE RADIOGRAPHS NECESSARY IN NEONATES WITH SUSPECTED CONGENITAL SYPHILIS? † 1336