Steven B. Hoath

Amplitude-Integrated EEG Is Useful in Predicting Neurodevelopmental Outcome in Full-Term Infants With Hypoxic-Ischemic Encephalopathy: A Meta-Analysis

Hypoxic ischemic encephalopathy is a common cause of neurological complications resulting in chronic handicapping conditions, such as cerebral palsy. Amplitude-integrated electroencephalography (EEG) has been used in many European countries for more than a decade in the evaluation of infants with hypoxic ischemic encephalopathy but has not been widely used in the United States. The objective of this study was to evaluate the evidence supporting use of amplitude-integrated EEG as a quantitative predictor of neurodevelopmental outcome in full-term infants with hypoxic ischemic encephalopathy. To assess efficacy, the authors performed a meta-analysis of the literature evaluating the use of the amplitude-integrated EEG or cerebral function monitor in full-term infants with hypoxic ischemic encephalopathy and their neurodevelopmental outcome. A total of 8 studies were eligible for the primary meta-analysis. There was an overall sensitivity of 91% (95% CI 87-95) and a negative likelihood ratio of 0.09 (95% CI .06-.15) for amplitude-integrated EEG tracings to accurately predict poor outcome. Amplitude-integrated EEG is a valuable bedside tool for predicting long-term neurodevelopmental outcome in term infants with hypoxic ischemic encephalopathy. This information is useful in structuring communication and care plans for physicians and parents. Early assessment techniques such as amplitude-integrated EEG provide objective means for determining inclusion in clinical studies evaluating therapies for hypoxic ischemic encephalopathy and for predicting which patients are most likely to respond to treatment.

Early Bubble CPAP and Outcomes in ELBW Preterm Infants

OBJECTIVE: To test whether the introduction of early bubble continuous positive airway pressure (CPAP) results in improved respiratory outcomes in extremely low birth-weight infants.STUDY DESIGN: Outcomes of all infants between 401 and 1000u2009g born in a level 3 neonatal intensive care units (NICU) between July 2000 and October 2001 (period 2) were compared using historical controls (period 1). Early bubble (CPAP) was prospectively introduced in the NICU during period 1. Univariate and adjusted comparisons were made across time periods.RESULTS: Delivery room intubations, days on mechanical ventilation and use of postnatal steroids decreased (p<0.001) in period 2, while mean days on CPAP, number of babies on CPAP at 24 hours (p<0.001) and mean weight at 36 weeks corrected gestation also increased (p<0.05) after introduction of early bubble CPAP.CONCLUSIONS: Early bubble CPAP reduced delivery room intubations, days on mechanical ventilation, postnatal steroid use and was associated with increased postnatal weight gain with no increased complications.

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice

Title Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. Aim This paper is a discussion of evidence-based core measures for developmental care in neonatal intensive care units. Background Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America’s Joint Commission’s concept of ‘core measures’ for evaluating and accrediting healthcare organizations. This concept is applied to five disease- and procedure-independent measures based on the Universe of Developmental Care model. Data sources Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue. Discussion Five core measure sets for evidence-based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family-centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant-family dyads. Conclusion Standardized disease-independent core measures for developmental care establish minimum evidence-based practice expectations and offer an objective basis for cross-institutional comparison of developmental care programmes.

Biomedical Assessment and Instrumental Evaluation of Healthy Infant Skin

Abstract: The skin forms a critical structural boundary and a perceptual interface for the organism, yet the definition “healthy skin” is surprisingly difficult to describe. The present studys goal was to generate a technical definition of healthy infant skin by quantifying specific biophysical parameters before and after bathing in infants and correlating such parameters to a perceptual maternal evaluation. Fifty‐two healthy infants, 3–6 months old, were evaluated before and after freshwater bathing. Diapered skin had a higher transepidermal water loss (TEWL), surface hydration, moisture accumulation rate (MAT), and friction than nondiapered skin before the bath (pu2003<u20030.01). Bathing dramatically altered the biophysical properties at both skin sites, with decreased MAT and lower friction, indicating a drier skin surface (pu2003<u20030.01). Visual redness and dryness decreased after bathing (pu2003<u20030.01). Blinded grading of optical images showed a significant preference for the skin after bathing (pu2003<u20030.01). This study provides the first quantitative technical definition of healthy infant skin with positive correlation to perceptual assessment by independent observers (mothers). The findings support the hypothesis that water binding properties of the stratum corneum are altered by occlusion (diapering) and that bathing introduces acute changes in stratum corneum water interactions, leading to a drier skin surface and a preferred skin appearance.

Neonatal Skin Maturation—Vernix Caseosa and Free Amino Acids

Abstract:u2002 Neonatal skin hydration decreases rapidly postnatally and then increases, indicating adaptive changes in stratum corneum water handling properties. Transition from high to low humidity at birth may initiate filaggrin proteolysis to free amino acids. Neonatal skin with vernix caseosa retained is more hydrated than skin with vernix removed. This study examines the potential roles of free amino acids and vernix in postnatal adaptation of infant stratum corneum in vivo. Specifically, the ontogeny of free amino acid generation in neonatal stratum corneum and the role of vernix caseosa in postnatal adaptation were examined using high performance liquid chromatography. Free amino acids were quantified for infant skin samples collected at (i) birth and 1u2003month and (ii) birth and 24u2003hours after vernix caseosa retention or removal and compared to neonatal foreskin, vernix caseosa, and adult stratum corneum using t‐tests, analysis of variance, or univariate procedures. Free amino acids were extremely low at birth, significantly higher 1u2003month later but lower than in adults. Vernix caseosa retention led to significantly higher free amino acids 24u2003hours after birth compared to infants with vernix caseosa removed, and it paralleled the higher stratum corneum hydration of vernix caseosa‐retained skin. Vernix caseosa contained free amino acids, with glutamic acid and histidine levels higher than in infants. Free amino acids in vernix caseosa‐retained skin appear to originate from vernix caseosa. Free amino acids were lower in neonatal foreskin than adult forearm stratum corneum. Arginine was higher than citrulline at birth, but levels were comparable in older infants. The free amino acid increase at 1u2003month may be initiated by the humidity transition at birth and supports results in animals. The findings have implications for infant skin care practices.

A novel role for vernix caseosa as a skin cleanser.

Objectives: Skin cleansing is a complex process involving endogenous and exogenous mechanisms. This study examines the role of vernix caseosa in the process of skin cleansing in the perinatal period. Methods: Vernix was evaluated as an exogenously applied skin cleanser using digitized image analysis which quantified residual carbon particles following a standardized cleansing assay. In addition, the detachment of vernix from human cadaveric skin and Gore-Tex® supports was investigated following timed exposures to a variety of commonly used commercial surfactants. Detachment was quantified spectrophotometrically as increased turbidity at 650 nm. Results: Image analysis showed that exogenous application of vernix exhibited a cleansing capability comparable or superior to standard skin cleansers. Dose-dependent increases in solution turbidity (vernix detachment) were seen following exposure of vernix-covered Gore-Tex vehicles to sodium laureth sulfate, sodium lauryl sulfate, and cocamidopropyl betaine solutions. Similar results were seen with cadaveric skin. Conclusions: These results demonstrate a role for vernix caseosa as a skin cleanser. Previous views of vernix as a soil or skin contaminant at birth need to be reevaluated.

The universe of developmental care: a new conceptual model for application in the neonatal intensive care unit.

Developmental care for high-risk infants is practiced in most neonatal units around the world. Despite its wide acceptance, inconsistency in its definition and application has resulted in criticism regarding its scientific merit. The universe of developmental care model proposed in this article is the first major reformulation of neonatal developmental care theory since Als synactive theory. Neither the developing brain nor the environment exists in isolation, and therefore are dependent on each other for all caregiving activities. Central to this model is the concept of a shared surface, manifested most obviously by the skin that forms the critical link between the body/organism and environment and becomes the focal point for human interactions. The components of the model and its theoretical underpinnings, its practical application and direction for future clinical practice, education, and research are presented.

Influence of tumour necrosis factor-α polymorphism −308 and atopy on irritant contact dermatitis in healthcare workers*

Background. Chronic irritant hand dermatitis is an issue for healthcare workers and may negatively impact infection control.

Neurodevelopmental Outcomes of Extremely Low Birth Weight Infants Ventilated With Continuous Positive Airway Pressure vs. Mechanical Ventilation

ObjectiveTo compare continuous positive airway pressure (CPAP) vs. traditional mechanical ventilation (MV) at 24xa0h of age as predictors of neurodevelopmental (ND) outcomes in extremely low birth weight (ELBW) infants at 18–22xa0months corrected gestational age (CGA).MethodsInfants ≤1000xa0g birth weight born from January 2000 through December 2006 at two hospitals at the Cincinnati site of the National Institute of Child Health and Human Development Neonatal Research Network were evaluated comparing CPAP (nu2009=u2009198) vs. MV (nu2009=u2009109). Primary outcomes included the Bayley Score of Infant Development Version II (BSID-II), presence of deafness, blindness, cerebral palsy, bronchopulmonary dysplasia and death.ResultsVentilatory groups were similar in gender, rates of preterm prolonged rupture of membranes, antepartum hemorrhage, use of antenatal antibiotics, steroids, and tocolytics. Infants receiving CPAP weighed more, were older, were more likely to be non-Caucasian and from a singleton pregnancy. Infants receiving CPAP had better BSID-II scores, and lower rates of BPD and death.ConclusionsAfter adjusting for acuity differences, ventilatory strategy at 24xa0h of age independently predicts long-term neurodevelopmental outcome in ELBW infants.

Epidermal barrier treatments based on vernix caseosa.

Background/Aims: Premature infants lack the vernix caseosa, have an incompetent stratum corneum (SC) barrier and are predisposed to infection. Use of topical agents to improve barrier function has had mixed outcomes. The aim was to determine the effect of vernix versus common barrier creams on the rate and quality of the epidermal barrier repair following controlled wounding. Methods: Minor wounds were created with (1) laser ablation in the minipig and (2) tape stripping of mother’s volar skin as a model for premature skin. Native vernix was applied to the mother’s tape-stripped skin. Treatments were no occlusion (NO), vernix and a petrolatum-based cream (PBC) in the pig, and NO, vernix, PBC, an oil-in-water cream (OWC), a semipermeable film (SP) and full occlusion (FO) in adults. Results: Outcomes for both trials were barrier recovery and skin hydration (moisture accumulation rate, MAT), initial hydration, erythema and dryness in adults. Vernix and PBC produced greater barrier repair than NO in the pig. SP produced greater recovery than NO and FO in adults. Vernix yielded greater recovery than FO and was similar to PBC, OWC and NO. Vernix had a directionally higher MAT than OWC and directionally higher initial hydration than NO. Conclusions: The findings suggest that vernix-based topical creams would be effective for the treatment of epidermal wounds and show promise to augment SC repair and maturation in infants.