S Alan

An intention to achieve better postnatal in-hospital-growth for preterm infants: Adjustable protein fortification of human milk

OBJECTIVEnWe assessed the effect of human milk (HM) fortification with extra protein supplement by an adjustable protein fortification method according to the weekly blood urea nitrogen (BUN) levels on growth in hospitalized preterm infants.nnnMETHODnA prospective observational intervention study in 58 preterms born ≤32 weeks of gestation and fed with breast milk was conducted. Preterms who were given a commercial HM fortifier which provides an additional protein of 0.8 g/3 scales according to the standard feeding strategy served as a historical control group. Infants who were given extra protein in addition to the HM fortifier with another commercial protein supplement which provides an additional protein of 2.2g/1 scale comprised the intervention group. Additional protein supplementation was adjusted according to BUN levels weekly in the intervention group. Weight gain velocities (g/kg/day), length, head circumferences (HC) gain velocities (mm/day) and daily growth indexes for weight, height and HC (percentage per day) were calculated.nnnRESULTSnThe median amount of daily enteral protein intake [4 (3.4-4.6) vs. 2.78 (2.1-3.1) g/kg/day, p < 0.0001] was significantly higher in the interventional group. Length (p = 0.008) and HC (p < 0.0001) gain velocities were significantly higher in the intervention group. Daily growth indexes for weight (2.2% vs. 1.8%, p = 0.026), for length (0.4% vs. 0.3%, p = 0.027) and for HC (0.48% vs. 0.36% per day, p = 0.003) were significantly higher in the intervention group.nnnCONCLUSIONnA higher protein intake by adjustable protein fortification method without energy or volume change leads to improved postnatal in-hospital-growth in very low birth weight infants.

Efficacy and safety of intravenous colistin in preterm infants with nosocomial sepsis caused by Acinetobacter baumannii.

OBJECTIVESnTo describe the efficacy of intravenous colistin on clinical and microbiological outcomes in preterm infants with nosocomial sepsis in neonatal intensive care unit (NICU) and define adverse events observed with this treatment.nnnMETHODSnThe records of preterm infants who received colistin with or without positive cultures in the NICU were retrospectively reviewed. Patients were evaluated for response to therapy and side effects.nnnRESULTSnA total of 21 preterm infants with medians of 28 weeks (23-36) gestational age and 870 g (620-2,650) birth weight were included. The median duration and dose of colistin therapy were 9 days (3-26) and 3 mg/kg/d (2-5). Recovery rate in patients including all with/without positive culture was 81% (17/21). Microbiological clearance by colistin was 69% (9/13). The major side effect observed was acute kidney injury (19%). At least 24% of infants required electrolyte supplementation during the colistin therapy. Magnesium levels were significantly lower at the end of the colistin therapy (p < 0.001). Acute kidney injury and electrolyte disturbances including hypomagnesemia were reversible in all surviving patients.nnnCONCLUSIONnWe suggest that renal function tests and serum electrolytes should be monitored closely and replaced in case of any need during the colistin therapy in preterm infants.

Congenital analbuminemia caused by a novel aberrant splicing in the albumin gene

Introduction: Congenital analbuminemia is a rare autosomal recessive disorder manifested by the presence of a very low amount of circulating serum albumin. It is an allelic heterogeneous defect, caused by variety of mutations within the albumin gene in homozygous or compound heterozygous state. Herein we report the clinical and molecular characterization of a new case of congenital analbuminemia diagnosed in a female newborn of consanguineous (first degree cousins) parents from Ankara, Turkey, who presented with a low albumin concentration (< 8 g/L) and severe clinical symptoms. Materials and methods: The albumin gene of the index case was screened by single-strand conformation polymorphism, heteroduplex analysis, and direct DNA sequencing. The effect of the splicing mutation was evaluated by examining the cDNA obtained by reverse transcriptase - polymerase chain reaction (RT-PCR) from the albumin mRNA extracted from proband’s leukocytes. Results: DNA sequencing revealed that the proband is homozygous, and both parents are heterozygous, for a novel G>A transition at position c.1652+1, the first base of intron 12, which inactivates the strongly conserved GT dinucleotide at the 5′ splice site consensus sequence of this intron. The splicing defect results in the complete skipping of the preceding exon (exon 12) and in a frame-shift within exon 13 with a premature stop codon after the translation of three mutant amino acid residues. Conclusions: Our results confirm the clinical diagnosis of congenital analbuminemia in the proband and the inheritance of the trait and contribute to shed light on the molecular genetics of analbuminemia.

Palivizumab use during respiratory syncytial virus outbreak in the neonatal intensive care unit

We read with great interest the papers by Dizdar et al. and by O’Connell et al. about the use of palivizumab during a respiratory syncytial virus (RSV) outbreak in neonatal intensive care units (NICUs), suggesting that palivizumab administration might have a role in controlling RSV outbreak and recommended early administration of palivizumab to terminate transmission as quickly as possible. We recently experienced a similar outbreak in our NICU, and controlled it according to the suggestions made in this paper. There were ten preterm (median gestational age: 29.3 weeks; range: 26.2e32 weeks; birth weight: 848e1520 g), two late preterm (>35 weeks’ gestational age) and four term infants in the NICU when two term newborns with bronchopneumonia and respiratory insufficiency were admitted to the NICU isolation unit between 29 February 2012 and 12 March 2012. Polymerase chain reaction (PCR) screening including RSV (A, B), coronavirus (A, B, C, D, E, OC43, HKU1), parainfluenza (1, 2, 3, 4), rhinovirus (A, B, C), influenza (A, B), bocavirus (1, 2, 3, 4), metapneumovirus and enterovirus, revealed RSV type B infection in these two patients. Although patients with RSV were cared for in separate isolation rooms, another preterm infant who had recovered from respiratory distress syndrome developed further respiratory distress after a week. Nasopharyngeal secretions obtained from this infant also revealed RSV type B infection and we decided to screen the remaining 15 infants for RSV. None of the asymptomatic patients was RSV PCR positive. In order to prevent an escalating NICU outbreak, palivizumab prophylaxis was administered to nine preterm infants, all of whom were <32 weeks of gestational age at birth, and one patient who had a congenital heart disease at a dosage of 15 mg/kg, in addition to strict contact precautions. Patients with RSV bronchiolitis recovered after about 10 days and we did not observe any additional cases with RSV. RSV infection was brought into the NICU by two patients with RSV bronchiolitis. Following this, one preterm patient, who was recovering from respiratory distress, developed RSV bronchiolitis. As NICUs like ours embrace a family-centred model for patient care, greater difficulties complying with effective infection control measures may emerge. We agree with Dizdar et al. and O’Connell et al. that palivizumab prophylaxis may have a role in the control of RSV epidemics in the NICU. If we had not given palivizumab prophylaxis after detection of index cases, a larger RSV outbreak might have occurred in our NICU. After a few small RSV NICU outbreaks in Turkey, the Turkish Neonatal Society now recommends RSV prophylaxis for premature infants in the NICU who are already candidates for the prophylaxis programme as outpatients when at least three RSV-positive patients are present in the NICU. This recommendation is similar to the one reported by the Spanish Neonatal Society which suggests palivizumab prophylaxis for preterm infants and newborns with haemodynamically significant congenital heart disease when such outbreaks occur.

Influence of platelet count, platelet mass index, and platelet function on the spontaneous closure of ductus arteriosus in the prematurity

BACKGROUNDnThis study aims at evaluating the influence of platelet count, platelet mass index, and platelet function on the spontaneous closure of ductus arteriosus in prematurity.nnnMETHODSnAll preterm babies were divided into two groups, including Group 1 with open PDA and Group 2 with closed PDA. The variables of platelet count, mean platelet volume, platelet mass index, and platelet function were analyzed and compared between two groups of patients to identify the factors that significantly influenced spontaneous closure of ductus arteriosus.nnnRESULTSnTwenty-four patients were in the open PDA group, whereas 36 patients were in the closed PDA group. Mean GA and BW were 27.6xa0±xa01.8 (23.1-30.4) and 28xa0±xa01.6 (23.4-30.6) weeks and 1009xa0±xa0270 (585-1480) g and 1035xa0±xa0298 (505-1500) g in open PDA and closed PDA groups, respectively (pxa0>xa00.05). The incidence of Collagen-ADPxa0>xa0130xa0s was significantly higher in the open PDA group, and the levels of hemoglobin and hematocrit were significantly lower in the open PDA group (pxa0<xa00.05). Multivariate logistic regression analysis showed that respiratory distress syndrome (OR: 9, CI: 1.5-51.8) and collagen-ADPxa0>xa0130xa0s (OR: 5.7 CI: 1.55-21.3) are two independent factors associated with ductal patency.nnnCONCLUSIONnThis is the first study in the English literature providing evidence of the influence of platelet dysfunction on the spontaneous closure of ductus arteriosus in prematurity. Longer collagen-ADP duration is identified as a risk factor of ductal closure.

The impact of evaluating platelet transfusion need by platelet mass index on reducing the unnecessary transfusions in newborns

Abstract Introduction: Almost 95% of the platelet transfusions (PTs) conducted in the neonatal intensive care unit (NICU) are prophylactic transfusions. Guidelines for prophylactic PTs are based on platelet counts, but not on platelet functions. Nowadays, in order to reduce unnecessary transfusions, utilizing platelet mass index (PMI) was investigated. The aim of study is to find out whether PTs performed in our NICU during last 2 years were in accordance with the current guideline and to evaluate whether the frequency of PTs should be reduced if PMI was considered. Methods: Forty-three infants who received 96 prophylactic PTs were enrolled in the study. The guideline utilized in our NICU advocate keeping the platelet count: (a) >100u2009000 in pre/post-operative, (b) >50u2009000 in unstable and (c) >20u2009000 in stable patients. According to PMI criteria, PT should be performed if PMI: (a) <800 in pre/post-operative, (b)<400 in unstable and (c) <160 in stable patients. Results: In all, 53.2% of PTs should not be given if the decision was in accordance with the current guideline. If decision for every PT was made according to the current guideline and taking PMI into consideration, an additional 11.5% reduction in total PTs could be achived. Conclusion: We suggest that better compliance with the new guidelines which take platelet functions into account may yield lower transfusion rate, lower costs and better conservation of blood bank resources.

PO-0516 Healthcare-associated Infections In A Turkey Neonatal Intensive Care Unit

Aim The aim of this study was to determine the incidence of (Healthcare-associated infection) HAI, causative organisms, associated risk factors in a neonatal intensive care unit in Turkey. Methods A prospective cohort study was conducted on patients admitted to the neonatal intensive care unit (NICU) from July 2011 to June 2012. The criteria that were used to diagnose infection were in accordance with the Centres for Disease Control and Prevention. The incidence, causative organisms, risk factors and mortality of healthcare-associated infections were assessed. Results The study included 352 patients, 37 of these developed HAIs, totaling 60 HAI episodes. Overall HAI patient rate was 17.04%, and 11.51 HAIs per 1000 NICU days. The most frequent HAIs were bloodstream infections (70%) and nosocomial pneumonia (18.3%). The central venous catheter/umblical catheter-related bloodstream infections (CVC/UC BSIs) rate was 18.3/1,000 catheter days; the ventilator-associated pneumonia (VAP) rate was 13.6/1,000 ventilator days; and the catheter-associated urinary tract infections rate found was 14.9/1,000 catheter days. Prematurity, gestational age less than 32 weeks, birth weight < 1500 g, mechanical ventilation, use of CVC/UC, use of urinary catheter, and total parenteral nutrition appeared to be associated with a significantly higher risk of HAI (p ≤ 0.05). The most frequent pathogens were Enterobacter spp. (18.5%) and Acinetobacter baumannii (13.8%). Overall mortality rate in neonates was 3.9%, and the mortality rate in neonates with HAI was 10.8%. Conclusions Healthcare-associated infection rates of our NICU were higher than international standards. The decrement of risk factors in newborns would help to improve the outcome.

1321 The Management of Central Diabetes Insipidus in Neonatal Intensive Care Unit: Experience of Eight Cases

Neonatal central diabetes insipidus (DI) is extremely rare and etiology has not been documented extensively. Asphyxia, intraventricular hemorrhage, severe infections, and central nervous system abnormalities have been associated with central DI in neonatal intensive care units (NICU). Desamino-8-D-arginine vasopressin (DDAVP) has been in clinical use for the treatment of central DI. DDAVP preparations are available for intranasal, oral, subcutaneous, and intravenous administration. There is not clear data for the management and used DDAVP form for the central DI in neonates. In this article, we presented eight cases with different etiology of neonatal central DI. Six cases were preterm with intracranial hemorrhage and the other two patients were congenital toxoplasmosis one of which was preterm. All of the cases received oral desmopressin at a dose of 10 mcg/kg/day. And then oral desmopressin dosage was adjusted according to the serum sodium and urine output. All cases were treated successfully with oral DDAVP. Three cases who have intracranial hemorrhage died due to other preterm complication. According to our case series, oral DDAVP is an applicable, safe and effective form of DDAVP.

1797 Do Non-Invasive Ventilatory Strategies Work in Micro-Premature Infants who are at the Limits of Viability?

Aim To evaluate the non-invasive ventilatory support in micro-premature infants who are at the limits of viability. Methods This prospective cohort study from January-2009 to December 2011 included infants born before 26 weeks’. During resuscitation, stabilisation and transport infants were ventilated with a T-piece resuscitator, and all received prophylactic surfactant at a dose of 100 mg/kg. If respiratory drive was present, infants were extubated to NCPAP. The demographic and clinical features of the infants were assessed. Results Twenty-four infants born during the study period. Antenatal steroid rate was 16.7%. Mean gestational age(GA) and birth weight(BW) were 24.3±0.9 weeks, and 660.2±125.5 g, respectively. The presence of premature rupture of membranes and chorioamnionitis rate was 54%. Only five(21%) of 24 infants could be extubated to NCPAP, and three of these five were intubated in first 3-days. Only two(8.3%) infants succeeded on NCPAP, and the GAs’ were 24.6 and 25.1 weeks, the BWs’ were 1010 and 730 g. The rate of NEC, PDA, İVH and pulmonary hemorrhage were 29%, 36%, 36% and 21%, respectively in infants who survived more than 2 days. The overall mortality rate was 92%, the duration of hospitalization was between one and 137 days. Conclusion In our study, it has been seen that NCPAP may not be an effective ventilation strategy in premature infants who are at the limits of viability. The high proportion of chorioamnionitis in this group may affect the ventilation and the following problems. These babies are needed to be care at very special settings.

232 The Timing of Surfactant Prophylaxis in Very-Low-Birth-Weight Preterms: Is Earlier Better?

Aim To determine whether the immediate bolus strategy treatment could decrease the subsequent need for ventilation compared to the administration of surfactant prophylaxis at 15-minutes. Methods All infants born before 29 weeks’, and infants born at 29 to 30 weeks’ without antenatal steroid(ANS) were randomized. Infants of group-1 were intubated immediately after birth, of group-2 received standard resuscitation measures, than were intubated at 15-minutes. All received 100 mg/kg surfactant. During these managements infants were ventilated with T-piece(NeoPuff). Then infants were extubated to NCPAP(Infant Flow®) if respiratory drive was present. The primary outcome was the need for MV within the first 3-days of life. The secondary outcomes were neonatal morbidities, mortality and duration of hospitalization. Results Total of 80 newborns were enrolled (fourty infants in each group). Prenatal and natal features were similar in groups. Ten infants in group-1, 13 infants in group-2 couldn’t be extubated after surfactant. GA and BW of them were lower than the extubated infants. Six infants in group-1, four infants in group-2 needed MV during the first 3-days. Total respiratory support duration was lower in group-1. There were no significant differences between the groups with a respect to PDA, NEC, IVH, sepsis, ROP, BPD, mortality and duration of hospitalization. Conclusion Our study didn’t demonstrate a superiority of the immediate bolus strategy of surfactant prophylaxis combined with early-NCPAP to the administration of surfactant at 15-minutes after birth with early-NCPAP. Surfactant prophylaxis at-15 minutes with early-NCPAP seems to be sufficiently effective to yield favorable outcomes in small preterm infants.