T. Donovan

Fetal macrosomia and pregnancy outcomes

Background:u2002 Pregnancies with a macrosomic fetus comprise a subgroup of high‐risk pregnancies. There is uncertainty in the clinical management and outcomes of such pregnancies.

Pharmacokinetics of dexamethasone following single-dose intravenous administration to extremely low birth weight infants

The single-dose pharmacokinetics of dexamethasone were studied in 7 extremely low birth weight infants of mean (+/- SD) gestational age 25.6 +/- 0.5 weeks suffering bronchopulmonary dysplasia. A mean peak dexamethasone concentration of 250.5 +/- 70.7 ng/ml was obtained following an intravenous bolus dose (0.369 +/- 0.04 mg/kg dexamethasone) of dexamethasone sodium phosphate. Dexamethasone was measured in plasma by HPLC. Mean clearance (0.143 +/- 0.028 litres/kg/h) was approximately half that reported previously in children and adults, while the half-life (9.26 +/- 3.34 h) was 2- to 3-fold longer than in these patients. The volume of distribution (1.9 +/- 0.483 litres/kg) was larger than reported in a previous study in adults, but was similar to that determined in pediatric and adult patients in another study.

Long-term review of sutureless ward reduction in neonates with gastroschisis in the neonatal unit

BACKGROUNDnA sutureless ward reduction (SWR) protocol was implemented in the neonatal intensive care unit of a tertiary level hospital in 1999. Although the short-term outcomes associated with SWR have been documented, the long-term outcomes are unknown.nnnMETHODSnRetrospective data were collected from the medical records of all neonates with gastroschisis from September 1999 to December 2010. Data on their growth and development and the prevalence of any health problems were collected.nnnRESULTSnEighty-eight patients with gastroschisis were managed over an 11 year period. Forty-four of these patients received SWR, with 2 deaths in the neonatal period. In the 42 survivors, 35 patients were reviewed at a median age of 7 years and 10 months (range, 6-134 months; interquartile range, 37-124 months). One patient experienced failure to thrive and developmental delay, and later died of a medical complication. Thirty-two patients (91.4%) developed an umbilical hernia, only 2 of whom required umbilical herniotomy. Four patients (11.4%) developed small bowel obstruction, all within the first year.nnnCONCLUSIONnMost patients with SWR exhibited normal growth with minimal bowel complications. Despite the high incidence of umbilical hernia, the majority resolved spontaneously and did not require subsequent herniotomy.

Current management of transitional feeding issues in preterm neonates born in Queensland, Australia.

BACKGROUNDnMany preterm neonates display difficulty establishing suck-feeding competence in the weeks following birth. Ineffective management of transitional feeding issues may cause patient complications, and can contribute to increased length of stay.nnnAIMSnGiven that many neonatal nurseries appear to vary in their neonatal feeding management practices, the aim of this study was to investigate and document the routine level of support and intervention currently provided for preterm neonates with transitional feeding issues across the various level II (special care) nurseries (SCNs) in Queensland, Australia.nnnMETHODSnA questionnaire was mailed to all Queensland SCNs in 2005 (n=36). The questionnaire contained a series of closed-choice and short-answer questions designed to obtain information from each SCN regarding their current practices for managing transitional feeding issues in preterm neonates. Results were confirmed during a follow-up phone call.nnnRESULTSnResponses were obtained from 29 SCNs (80.6%). None of these nurseries reported having any formal, written policies regarding the management of transitional feeding issues in preterm neonates. Wide variations were reported in relation to the suck-feeding assessments and interventions used by staff within the various SCNs. Of the 29 nurseries, 4 (13.8%) reported using checklists or assessments to judge readiness for suck-feeds, and 5 (17.2%) reported using pulse oximetry to judge tolerance of suck-feeding attempts. Eighteen SCNs (62.1%) reported offering some form of active intervention to assist neonates with transitional feeding issues, with the most common intervention techniques reported being non-nutritive sucking during tube feeds, pre-feeding oral stimulation, and actively pacing suck-feeds. Twenty-two SCNs (75.4%) reported having access to a lactation consultant to assist mothers with breastfeeding issues.nnnCONCLUSIONSnDifferences were reported in the routine management of transitional feeding issues in preterm neonates across the various SCNs in Queensland. It is suggested that evidence based guidelines need to be developed, and that, in order to do this, further research studies are required to determine current best practice, as well as to answer remaining questions.

Growth patterns in preterm infants born appropriate for gestational age.

Aim:u2003 This study aimed to document the growth patterns of a contemporary cohort of preterm infants born appropriate for gestational age (AGA). It was hypothesised that preterm AGA (PT‐AGA) infants would display poorer growth than full‐term AGA (FT‐AGA) infants.

Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants

BACKGROUNDnBreastmilk remains the optimal form of enteral nutrition for term and preterm infants until up to six months postnatal age. Mothers of preterm infants who have not established suck feeds must express their breastmilk and often have difficulty in maintaining sufficient volume for their infants needs (Donath 2008). In preterm infants, donor breastmilk reduced the occurrence of necrotising enterocolitis, when compared with formula feeds (McGuire 2003). Also, case-control studies have suggested that breastmilk is associated with an improvement in feeding tolerance, a reduction in significant gastrointestinal infective events (Beeby 1992) and a reduction in late-onset sepsis (Schanler 1999) when compared with formula feeds in preterm hospitalised infants.nnnOBJECTIVESnTo assess the effect of medication given for at least seven days to mothers of preterm infants whose breastmilk is insufficient for their infants needs on the outcomes of expressed milk volume and duration of breastfeeding.nnnSEARCH METHODSnWe searched the Cochrane Pregnancy and Childbirth Groups Trials Register (31 December 2011).nnnSELECTION CRITERIAnRandomised and quasi-randomised controlled trials of breastmilk-augmenting medications (compared with placebo or with other augmenting medications) in mothers with preterm hospitalised infants whose breastmilk volumes failed to meet their infants requirements. We did not include trials with a cluster-randomised or cross-over design.nnnDATA COLLECTION AND ANALYSISnBoth review authors independently assessed studies for inclusion, assessed risk of bias, and extracted data. Any differences were resolved by consensus. Data were checked for accuracy.nnnMAIN RESULTSnTwo trials (involving 59 mothers) that examined the use of domperidone in a total of 59 mother-infant pairs met the inclusion criteria. Meta-analysis of these trials showed a modest increase in expressed breastmilk (EBM) of 99.49 mL/day (95% confidence intervals -1.94 to 200.92; random-effects, T² 3511.62, I² 63%) in mothers given domperidone. Both trials gave the same dose of domperidone (10 mg three times per day) with a duration of seven days in the smaller trial and 14 days in the larger.Neither trial showed significant improvements in longer-term outcomes of breastfeeding in a preterm population and no adverse effects were reported.nnnAUTHORS CONCLUSIONSnTwo studies with a total of 59 mothers suggest modest improvements in short-term EBM volumes when a medication is used after insufficient EBM occurs in mothers following preterm delivery. In both studies, the medication was commenced ≧14 days post delivery and following insufficient EBM supply with other lactation supports.Currently, no studies support prophylactic use of a galactagogue medication at any gestation. Use of any galactagogue medication has only been examined at more than 14 days post delivery and after full lactation support has been given. Further trials should examine larger groups of preterm mothers and consider breastfeeding outcomes over a longer period.

Orogastric and intravenous indomethacin administration to very premature neonates with patent ductus arteriosus: Population pharmacokinetics, absolute bioavailability, and treatment outcome

A population pharmacokinetic model was developed after administration of orogastric and/or intravenous indomethacin for the treatment of patent ductus arteriosus in preterm infants. Plasma indomethacin concentrations (n = 227) were obtained from 90 preterm infants of median gestational age 27 weeks, mean postnatal age of 12 days, and a mean current weight (WT) of 1010 g. Infants received one to three courses of indomethacin (0.1 mg/kg per day for 6 days). A one-compartment model was fitted to the data to obtain estimates of clearance (CL), volume of distribution (V), absorption rate constant (Ka) and orogastric bioavailability (F), using NONMEM. Model robustness was assessed by bootstrapping with replacement (500 samples). The structural model was: CL (L/h) = 0.0166 (WT ÷ 0.936)1.54; V (L) = 0.484 (WT ÷ 0.936)1.41; F = 0.986; Ka (h−1) = 0.786. The interindividual variability for CL and V was 57.7% and 45.6%, respectively. There remained considerable residual unexplained variability (45.4%). Mean (range) conditional estimates from individual infants for CL, V, and elimination half-life were 18.9 (4.7-45.5) mL/h/kg, 509 (191-1120) mL/kg, and 20.0 (12.0-37.3) hours, respectively. Complete ductus closure occurred in 67% of patients. Infants of lower gestational age or birth weight had less chance of successful ductal closure. There was no obvious dose-response relationship between systemic exposure to varying plasma indomethacin concentrations and ductus closure, which does not support individualized indomethacin dosing based on monitoring to a target plasma concentration.

Application of routine monitoring data for determination of the population pharmacokinetics and enteral bioavailability of phenytoin in neonates and infants with seizures

This study investigated the population pharmacokinetics and the enteral bioavailability of phenytoin (PTN) in neonates and infants with seizures. Data from 83 patients were obtained retrospectively from medical records. A 1-compartment model was fitted to the log-transformed concentration data using NONMEM. Between-subject variability and interoccasion variability were modelled exponentially together with a log transform, both-sides exponential residual unexplained variance model. Covariates in nested models were screened for significance. Model robustness was assessed by bootstrapping with replacement (n = 500) from the study data. The parameters of the final pharmacokinetic model were clearance (L/h) = 0.826·[weight (WT, kg) ÷ 70]0.75·[1 + 0.0692·(postnatal age (d) − 11)]; volume of distribution (L) = 74.2·[WT (kg) ÷ 70]; absolute enteral bioavailability = 0.76; absorption rate constant (h−1) = 0.167. The between-subject variability for clearance and volume of distribution was 74.2% and 65.6%, respectively. The interoccasion variability for clearance was 54.4%. The unexplained variability was 51.1%. Final model parameter values deviated from median bootstrap estimates by less than 9%. Phenytoin disposition in neonates and infants can be described satisfactorily by linear pharmacokinetics. The values of allometrically scaled clearance and volume were similar to adult values, suggesting no major kinetic differences between adults and infants on the basis of size alone. Postnatal age independently influenced clearance. Switching from enteral to intravenous routes may require a dosage adjustment. The results of this study provide a basis for more rational prescribing of phenytoin in infants and neonates.

Preliminary evaluation of a system for neonatal teleconsultation

We assessed the efficacy of a system for teleconsultation in the care of newborns via real-time video (NEMO, Neonatal Examination and Management Online). The study was conducted in the controlled environment of a tertiary neonatal intensive care unit (NICU) before deployment for trial in remote hospitals. Eight ventilated infants were studied (their parents providing consent). A range of clinical tasks were completed by 14 medical staff. These included visual assessment of respiratory rate and perfusion, gathering of data from cot-side equipment, and the capture and interpretation of an X-ray image from an LCD screen. In total, 854 tests were completed using the system. In the visual infant assessment phase, 100% of participants read the endotracheal tube taped distance accurately within 1 cm, while agreement between participants and control on respiration rate (within 5 breaths/min) was 93%. When reviewing an X-ray image captured from an LCD screen, 85% of participants agreed with the control regarding endotracheal tube placement (high, normal or low). The results show that the NEMO system provides an efficacious means of presenting tertiary neonatal specialists with timely information beyond that currently available by ordinary telephone.

HEALTH LITERATUREFOR PARENTS OF CHILDREN WITH CEREBRAL PALSY

This study examined the use of and need for written educational material by the parents of 41 children with cerebral palsy, aged between five and 63 months. After their initial counselling, the majority felt that they needed written information. The parents of 31 children attempted to find suitable books or pamphlets, but in 13 cases they failed to do so or found the material unsatisfactory. A significant association was found between reading material which the parents found satisfactory and their knowledge about the basic features of cerebral palsy.