Robert Locke

Increased Odds of Necrotizing Enterocolitis After Transfusion of Red Blood Cells in Premature Infants

OBJECTIVES: To determine if infants with very low birth weight who receive packed red blood cell (PRBC) transfusions have increased odds of developing necrotizing enterocolitis (NEC), to determine the rate of NEC after PRBC transfusion, and to characterize the blood transfused preceding the onset of NEC. STUDY DESIGN: A retrospective cohort design was used. The study population included infants with a birth weight of <1500 g who were from a single center. NEC after transfusion was defined as NEC that occurred in the 48 hours after initiation of PRBC transfusion. Statistical analysis included unadjusted and multivariable analyses. RESULTS: The study sample included 2311 infants. A total of 122 infants (5.3%) developed NEC, and 33 (27%) of 122 NEC cases occurred after transfusion. NEC occurred after 33 (1.4%) of 2315 total transfusions. Infants who received a transfusion had increased adjusted odds (odds ratio: 2.3 [95% confidence interval: 1.2–4.2]) of developing NEC compared with infants who did not receive a transfusion. PRBCs transfused before NEC were predominantly (83%) from male donors and were a median of 5 days old. CONCLUSIONS: In our study sample, PRBC transfusion was associated with increased odds of NEC. The rate of NEC after transfusion was 1.4%. From our data we could not determine if PRBC transfusions were part of the causal pathway for NEC or were indicative of other factors that may be causal for NEC.

Forgotten parent: NICU paternal emotional response.

PURPOSE:To evaluate and compare the presence of perceived paternal stress and depressive symptomatology in fathers of preterm infants over time. SUBJECTS:Fathers of NICU infants born before 30 weeks of gestation. DESIGN:Prospective convenience sample. METHODS:Consenting fathers were given 2 self-report questionnaires: Center for Epidemiologic Studies-Depression Scale (CES-D) and Parent Stressor Scale: Infant Hospitalization (PSS:IH) on 7th (time 1), 21st (time 2), and 35th (time 3) days of life. Objective measurement of illness severity was quantified by Score for Neonatal Acute Physiology. Statistical methods included generalized linear estimating equation and mixed linear modeling. MAIN OUTCOME MEASURES:Stress and depressive symptomatology in fathers of preterm infants. RESULTS:Stress scores (PSS:IH) were unchanged over time (P = .62) indicating that fathers (n = 35) remain significantly stressed. Individual subcomponents of stress (parent role alteration, infant appearance/behavior, NICU sights/sounds) also remained constant over the study period (P = .05 for each). Stress scores over time were not modified by demographic characteristics (marriage, education, insurance). Mean depressive symptomatology scores (CES-D) decreased over time (P = .04). The percentage of fathers with elevated CES-D scores (>16) decreased from a baseline 60% but did not diminish between times 2 (39%) and 3 (36%). Parent Stressor Scale: Infant Hospitalization stress scores were correlated with CES-D depressive symptomatology scores (P < .01). Socioeconomic factors influenced initial CES-D scores, but only marriage ameliorated subsequent changes in measurements. Objective measurement of infant illness (Score for Neonatal Acute Physiology) did not influence paternal CES-D or PSS:IH scores. CONCLUSION:Fathers of premature infants in a medical NICU demonstrated elevated levels of stress that persisted across time for all domains of measured stress. Paternal self-reported stress and depressive symptomatology was independent of infant illness. One third of fathers had persistently elevated CES-D scores. If these findings are representative of general NICU population, then the emotional needs of our fathers are not being fully addressed.

Optimizing patient/caregiver satisfaction through quality of communication in the pediatric emergency department.

Background: Optimizing patient/family caregiver satisfaction with emergency department (ED) encounters has advantages for improving patient health outcomes, adherence with medical plans, patient rights, and shared participation in care, provider satisfaction, improved health economics, institutional market share, and liability reduction. The variables that contribute to an optimal outcome in the pediatric ED setting have been less well investigated. The specific hypothesis tested was that patient/family caregiver-provider communication and 24-hour postdischarge phone contact would be associated with an increased frequency of highest possible satisfaction scores. Methods: A consecutive set of Press Ganey satisfaction survey responses between June and December 2009 in a large tertiary referral pediatric ED was evaluated. Press Ganey responses were subsequently linked to defined components of the electronic medical record associated with each survey respondents ED visit to ascertain specific objective ED data. Multivariate modeling utilizing generalized linear equations was achieved to obtain a composite model of drivers of patient/caregiver satisfaction. Results: Primary drivers of satisfaction and willingness to return or refer others to the ED were as follows: being informed about delays, ease of the insurance process, overall physician rating, registered nurse attention to needs, control of pain, and successful completion of postdischarge phone call to a family caregiver. Multiple wait time variables that were statistically significant in univariate modeling, including total length of time in the ED, time in waiting room, comfort of waiting room, time in treatment room, and play items, were not statistically significant once controlling for the other variables in the model. Type of insurance, race, patient age, or time of year did not influence the models. Conclusions: Achieving optimal patient/caregiver satisfaction scores in the pediatric ED is highly dependent on the quality of the interpersonal interaction and communication of ED activities. Wait time and other throughput variables are less important than perceived quality of the health interaction and interpersonal communication. Patient satisfaction has advantages greater than market share and should be considered a component of the care-delivery paradigm.

Stress in fathers of surgical neonatal intensive care unit babies.

The purpose of this study was to identify and measure components of perceived stress in fathers of infants in a surgical neonatal intensive care unit (NICU). The Parent Stressor Scale: Infant Hospitalization (PSS:IH) was used to assess perceived stress in 22 fathers. Paternal stress was highest in the domains of “Parental Role Alteration” and “Infant Appearance and Behavior.” “Sights and Sounds” did not appear to be associated with self-reported stress. This study demonstrates elevated levels of perceived stress among fathers of surgical NICU babies. Attention to fathers may be assisted by findings.

Increasing illness severity in very low birth weight infants over a 9-year period

BackgroundRecent reports have documented a leveling-off of survival rates in preterm infants through the 1990s. The objective of this study was to determine temporal changes in illness severity in very low birth weight (VLBW) infants in relationship to the outcomes of death and/or severe IVH.MethodsCohort study of 1414 VLBW infants cared for in a single level III neonatal intensive care unit in Delaware from 1993–2002. Infants were divided into consecutive 3-year cohorts. Illness severity was measured by two objective methods: the Score for Neonatal Acute Physiology (SNAP), based on data from the 1st day of life, and total thyroxine (T4), measured on the 5th day of life. Death before hospital discharge and severe intraventricular hemorrhage (IVH) were investigated in the study sample in relation to illness severity. The fetal death rate was also investigated. Statistical analyses included both univariate and multivariate analysis.ResultsIllness severity, as measured by SNAP and T4, increased steadily over the 9-year study period with an associated increase in severe IVH and the combined outcome of death and/or severe IVH. During the final 3 years of the study, the observed increase in illness severity accounted for 86% (95% CI 57–116%) of the variability in the increase in death and/or severe IVH. The fetal death rate dropped from 7.8/1000 (1993–1996) to 5.3/1000 (1999–2002, p = .01) over the course of the study.ConclusionThese data demonstrate a progressive increase in illness in VLBW infants over time, associated with an increase in death and/or severe IVH. We speculate that the observed decrease in fetal death, and the increase in neonatal illness, mortality and/or severe IVH over time represent a shift of severely compromised patients that now survive the fetal time period and are presented for care in the neonatal unit.

Complementary and Alternative Medicine use in women during pregnancy: do their healthcare providers know?

BackgroundThe National Institutes of Health reported in 2007 that approximately 38% of United States adults have used at least one type of Complementary and Alternative Medicine (CAM). There are no studies available that assess general CAM use in US pregnant women.The objectives of our study were to determine the prevalence and type of CAM use during pregnancy at one medical center; understand who is using CAM and why they are using it; and assess the state of patients’ CAM use disclosure to their obstetrical providers.MethodsA cross-sectional survey study of post-partum women was done to assess self-reported CAM use during pregnancy. Results of this survey were compared to results from a previous survey performed by this research team in 2006. Data were analyzed using binary logistic regression.ResultsIn 2013, 153 women completed the survey, yielding a response rate of 74.3%. Seventy-two percent and 68.5% of participants reported CAM use during their pregnancies in 2006 and 2013 respectively. The percentage of participants who reported discussing CAM use with their obstetrical providers was less than 1% in 2006 and 50% in 2013. Increased use of different CAM therapies was associated with increased maternal age, primagravida, being US-born, and having a college education (p ≤ 0.05). However, these factors were poor predictors of CAM use.ConclusionsGiven the frequency of CAM use and the difficulty in predicting who is using it, obstetrical providers should consider being informed about CAM and incorporating discussions about its use into routine patient assessments.

Racial differences in prenatal care of mothers delivering very low birth weight infants.

Objectives:To determine whether there are any racial differences in the prenatal care of mothers delivering very low birth weight infants (VLBW).Study Design:Retrospective cohort study of infants cared for at a single regional level III neonatal intensive care unit over a 9-year period, July 1993–June 2002, N=1234. The main outcome variables investigated included antenatal administration of steroids, delivery by cesarean section, and use of tocolytic medications. Both univariate and multivariate analyses were performed.Results:After controlling for potential confounding variables, white mothers delivering VLBWs had an increased odds of cesarean delivery (odds ratio 1.5, 95% confidence intervals (CI) 1.1–2.0), receiving antenatal steroids (1.3, CI 1.01–1.8), and tocolysis (1.4, CI 1.1–2.0) compared to black mothers. The models controlled for gestational age, multiple gestation, premature labor, clinical chorioamnionitis, maternal age, income, year of birth, and presentation.Conclusions:In our population of VLBWs, white mothers are more likely to receive antenatal steroids, tocolytic medications, and deliver by cesarean section when compared to black mothers. From our data we cannot determine the reasons behind these racial differences in care of mothers delivering VLBWs.

Immaturity or Starvation? Longitudinal Study of Leptin Levels in Premature Infants

Objective: Leptin, the protein product of the ob gene, is a potential placental growth factor and is integral to the body’s system of energy regulation as shown in animal models. Premature infants are especially vulnerable to changes in energy regulation, and several studies have demonstrated a rapid fall in leptin values at birth. The purpose of the present investigation was to measure leptin levels in premature infants throughout hospitalization. Methods: Eligible infants were less than 32 weeks’ gestation, appropriate for gestational age, and hospitalized at Christiana Hospital Special Care Nursery. Serum samples for leptin analysis were drawn within 24 h of birth and twice a week thereafter until discharge. Concurrent growth measurements were obtained with each leptin sample. Body mass index, ponderal index, and midarm circumference/head circumference ratios were calculated to assess growth. Results: Leptin levels were low and remained low for the duration of the premature infants’ hospitalization (mean ± SD = 1.35 ± 0.63 ng/ml/ml, range 0–3.06). After controlling for weight, there was a small (r2 = 0.1, p < 0.00001) but significant correlation between leptin and postnatal age after 4 days of age. Despite an increase in caloric intake during the study period, there was no relationship between leptin and caloric intake. There were significant negative correlations between measurements of growth and both leptin and the leptin/weight ratio. Maternal diabetes and the use of steroids had small but significant effects on the leptin/weight ratio. Conclusion: In this population of predominantly female premature infants, leptin levels were very low as compared to term infants, children and adults, and did not change appreciably over the study period. The low leptin levels seen in these premature infants are similar to those levels seen in malnourished adults, anorexics, and in animal models of starvation. We speculate that a critical adipose store needs to be reached before increased amounts of leptin can be adequately produced. Persistently low leptin levels may also reflect an immaturity in the hypothalamic-pituitary-adrenal axis.

Transfusion volume in infants with very low birth weight: a randomized trial of 10 versus 20 ml/kg.

Background Although preterm infants often require transfusions of red blood cells for anemia of prematurity, the optimal volume of blood to be transfused has not been established. Observations Infants with birth weights between 500 and 1,500 g were randomly assigned to receive 10 or 20 mL/kg red blood cells. Infants with transfusions of 20 mL/kg had a greater hemoglobin (14.2 ± 1.9 vs. 12.0 ± 1.9 g/dL, P = 0. 003) and hematocrit (41.2 ± 5.9 vs. 32.3 ± 7.1%, P = 0.001) levels after transfusion compared with those who received transfusions of 10 mL/kg. There were no measured differences in pulmonary function in either group after transfusion. Conclusions Transfusion with 20 mL/kg red blood cells produces a significantly greater increase in hemoglobin and hematocrit levels than does a transfusion with 10 mL/kg, without any detrimental effects on pulmonary function.

Assessment of neonatal ventilation during high-frequency oscillatory ventilation.

Objective: To determine alterations in high-frequency oscillatory ventilation (HFOV) performance during clinical ventilator management. Design: Clinical investigation. Setting: Two level III intensive care nurseries in Wilmington, Delaware, and Philadelphia, Pennsylvania. Patients: Thirty infants 1.49 ± 1.01 kg with respiratory distress receiving HFOV. Interventions: Due to the demonstrated benchtop load sensitivity of the HFOV (SensorMedics 3100), we hypothesized that measured tidal volume (Vt/kg) and high-frequency minute ventilation (HFMV) would vary inversely with respiratory rate adjustments and that ventilator performance will be affected with endotracheal tube (ETT) suctioning. Both Vt/kg and HFMV were recorded using a novel hot-wire anemometry technique at the time of ETT suctioning or changes in ventilator settings. Measurements and Main Results: During HFOV it was found that Vt/kg = 2.52 ± 0.68 mL/kg and HFMV = 69 ± 45 ([mL/kg]2 × Hz); effective ventilation was observed in the range of HFMV = 29–113 ([mL/kg]2 × Hz). HFMV decreased with an increase in breathing frequency. Although there was a significant increase in the mean Vt/kg after suctioning events, there was no difference in Vt/kg or HFMV after disconnection of the ETT alone. There were significant alterations in HFOV performance as a result of clinical adjustments in respiratory rate and suctioning. In addition, we found that measured Vt during clinically effective HFOV is at least equivalent to expected deadspace. Conclusions: Measurement of tidal volume and HFMV may be clinically important in optimizing HFOV performance both during ETT suctioning and adjustments to breathing frequency.