W. P. F. Fetter

TUMOR-NECROSIS-FACTOR-ALPHA, INTERLEUKIN-1-BETA, AND INTERLEUKIN-6 PLASMA-LEVELS IN NEONATAL SEPSIS

ABSTRACT: Tumor necrosis factor-α, IL-1β, and IL-6 are thought to be involved in the pathogenesis of sepsis with gram-negative bacteria. We studied these cytokines during neonatal sepsis with mainly gram-positive bacteria. Ten newborns with clinical sepsis and 22 healthy controls were enrolled in the study. TNFα plasma levels proved to be increased in the newborns with sepsis up to 560 ± 234 pg/mL (ng/L)versus 36 ± 4 pg/mL (ng/L) in the control group (p < 0.005), whereas IL-6 plasma levels in newborns with sepsis were 79.700 ± 37.500 pg/mL (ng/L) versus 55 ± 28 pg/mL (ng/L) in the control group (p < 0.01). The IL-1β plasma levels were only slightly elevated in the group newborns with sepsis [up to 18 ± 5 pg/mL (ng/L)versus 7 ± 1 pg/mL (ng/L) in the control group (p < 0.01)]. After the start of therapy with antibiotics, both TNF α and IL-6 plasma levels decreased concomitantly with the improvement of the clinical situation within 2 d. These data confirm the abundant presence of TNF α and IL-6 during neonatal sepsis, whereas IL-1 β appeared to be present in small amounts only. Nevertheless, the IL-1 β but not the TNF αplasma level appeared to correlate inversely with the decrease in diastolic tension as standardized according to birth weight (R = 0.66,p = 0.04). TNF α, IL-1 β, and IL-6 were not correlated with any febrile response in the group with sepsis. Inasmuch as only moderate temperature increases were seen in these patients, we hypothesize that a low IL-1 β plasma level may explain the lack of a febrile response during neonatal sepsis.

Incidents and errors in neonatal intensive care: A review of the literature

Objectives: To examine the characteristics of incident reporting systems in neonatal intensive care units (NICUs) in relation to type, aetiology, outcome and preventability of incidents. Methods: Systematic review. Search strategy: Medline, Embase, Cochrane Library. Included: relevant systematic reviews, randomised controlled trials, observational studies and qualitative research. Excluded: non-systematic reviews, expert opinions, case reports and letters. Participants: hospital units supplying neonatal intensive care. Intervention: none. Outcome: characteristics of incident reporting systems; type, aetiology, outcome and preventability of incidents. Results: No relevant systematic reviews or randomised controlled trials were found. Eight prospective and two retrospective studies were included. Overall, medication incidents were most frequently reported. Available data in the NICU showed that the total error rate was much higher in studies using voluntary reporting than in a study using mandatory reporting. Multi-institutional reporting identified rare but important errors. A substantial number of incidents were potentially harmful. When a system approach was used, many contributing factors were identified. Information about the impact of system changes on patient safety was scarce. Conclusions: Multi-institutional, voluntary, non-punitive, system based incident reporting is likely to generate valuable information on type, aetiology, outcome and preventability of incidents in the NICU. However, the beneficial effects of incident reporting systems and consecutive system changes on patient safety are difficult to assess from the available evidence and therefore remain to be investigated.

Minimal enteral feeding, fetal blood flow pulsatility, and postnatal intestinal permeability in preterm infants with intrauterine growth retardation

Objective: To study the effect of minimal enteral feeding (MEF) on intestinal permeability and feeding tolerance in preterm infants with intrauterine growth retardation (gestational age < 37 weeks, birth weight for gestational age p < 10). Furthermore, to determine whether fetal blood flow pulsatility or intestinal permeability predict feeding tolerance in these infants. Design: Randomised controlled trial. Methods: Within 48 hours of birth, infants were randomised to MEF or no enteral feeding (NEF) for five days in addition to parenteral feeding. Intestinal permeability was measured by the sugar absorption test before (SAT1) and after (SAT2) the study. The sugar absorption test measured the urinary lactulose/mannitol (LM) ratio after oral ingestion of a solution (375 mosm) containing mannitol and lactulose. Charts of all infants were assessed for measures of feeding tolerance. Fetal blood flow pulsatility index (U/C ratio) was measured within the seven days before birth. Results: Of the 56 infants enrolled, 42 completed the study: 20 received MEF and 22 NEF. The decrease in LM ratio (LM ratio 1 − LM ratio 2) was not significantly different between the two groups (0.25 v 0.11; p  =  0.14). Feeding tolerance, growth, and incidence of necrotising enterocolitis were not significantly different between the two groups. Neither the U/C nor the LM ratio 1 predicted feeding tolerance. Conclusions: The results suggest that MEF of preterm infants with intrauterine growth retardation has no effect on the decrease in intestinal permeability after birth. Neither fetal blood flow pulsatility nor intestinal permeability predicts feeding tolerance.

Intestinal microbiota in allergic and nonallergic 1-year-old very low birth weight infants after neonatal glutamine supplementation

Aim:  Previously, glutamine‐enriched enteral nutrition in very low birth weight infants (VLBW) decreased the incidence of atopic dermatitis at age 1 year. The aim of this study was to determine whether this effect is related to changes in intestinal bacterial species that are associated with allergy, such as bifidobacteria, clostridium histolyticum, clostridium lituseburense (Chis/lit group) and Escherichia coli at age 1 year.

89 The Effect of Enteral Supplementation of Neutral and Acidic Oligosaccharides on Intestinal Microbiota, Ph, Scfas and Siga in Preterm Infants

89 The Effect of Enteral Supplementation of Neutral and Acidic Oligosaccharides on Intestinal Microbiota, Ph, Scfas and Siga in Preterm Infants

386 Viral Infections and Neonatal Disease, the Vind-Study.

Introduction Viruses can cause serious neonatal infections. The incidence of viral infections in the NICU is not known. New diagnostics (PCR) and antiviral therapy make insight in incidence of viral infections possible and warranted.Objective to study the incidence of viral infections in neonates admitted to the NICU, suspected of having infection (pneumonia, sepsis, meningitis) and to study the value of PCR compared to culture and direct immunofluorescence.Methods Neonates on the ventilator and suspected of infection were included. Tracheal aspirate (TA), cerebrospinal fluid (CSF) and feces were tested for viral agents. TA: By viral culture; by Multiplex PCR on adenovirus, enterovirus, influenza A en B, parainfluenza 1 and 3, rhinovirus, RSV and chlamydia pneumoniae; by direct immunofluorescence for RSV, influenza A and B virus, parainfluenza virus, adenovirus, chlamydia pneumoniae and enterovirus. CSF: By PCR on enterovirus. Feces: By culture on enterovirus and adenovirus. The study period was 2 years to cover all seasons twice.Results in 2003–2004 72 patients were included in whom 86 episodes of infection occurred. Multiplex PCR of TA was positive in 5 episodes (rhinovirus 3, enterovirus 1, adenovirus 1). In the enterovirus positive patient PCR of CSF and culture of TA showed also enterovirus (echovirus type 6). In the rhinovirus positive episodes culture was positive for rhinovirus in only 1 episode. In 1 episode CMV was detected by culture. The overall incidence of viral infections was 7% (6/86). Bacterial bloodstream infections were the cause in 51% (44/86, 64% Coagulase Negative Staphylococcus). In 13% (11/86) only TA contained bacteria. In 1,1% (1/86) only urine contained bacteria. In 28% (24/86) no agent was found.Conclusion Viruses rarely cause infections in ventilated neonates admitted to the neonatal ward. No conclusions can be drawn about the value of PCR in comparison to conventional testing on viral agents.

389 Intestinal Permeability and Mechanical Ventilation in Preterm Infants

INTRODUCTION. EFFECTS OF MECHANICAL VENTILATION ON INTESTINAL PERMEABILITY HAVE NOT YET BEEN STUDIED IN PRETERM INFANTS. WE HYPOTHESIZE THAT MECHANICAL VENTILATION INCREASES INTESTINAL PERMEABILITY, AND REDUCES THE NATURAL DECLINE OF INTESTINAL PERMEABILITY IN THE FIRST WEEK OF LIFE.METHODS. INTESTINAL PERMEABILITY WAS MEASURED BY THE SUGAR ABSORPTION TEST, IN WHICH URINARY EXCRETION OF LACTULOSE (L) AND MANNITOL (M) IS MEASURED AFTER ORAL INGESTION. THE SUGAR ABSORPTION TEST WAS PERFORMED AT 2 TIMEPOINTS (<48 H AFTER BIRTH AND AT DAY 5–8) IN 3 GROUPS: I INFANTS NOT VENTILATED AT ALL (N=7); II INFANTS VENTILATED AT TIMEPOINT 1 BUT NOT AT TIMEPOINT 2 (N=24); III INFANTS VENTILATED AT BOTH TIMEPOINTS (N=12).RESULTS. BOTH MEAN (+/-SD) GESTATIONAL AGE AND BIRTHWEIGHT WERE HIGHER IN GROUP I (31.6+/-1.6WKS, 1477+/-428G) AND II (31+/-2.5WKS, 1709+/-542G) THAN IN GROUP III (28.3+/-1.4 WKS, 1070+/-359G) (P<0.05). THE MEAN (+/-SD) L/M RATIO 1 WAS HIGHER IIN GROUP I (0.667+/-0.356) THAN IN GROUP II (0,360+/-0.349) (P<0.005) BUT NOT HIGHER THAN IN GROUP III (0.482+/-0.309) (P=0.26). THE L/M RATIO 2 WAS NOT DIFFERENT IN THE 3 GROUPS (0.187+/-0.086, 0.244+/-0.172, 0.187+/-0.181 RESPECTIVELY). CORRECTED FOR THE DIFFERENCES IN L/M RATIO 1, THE DECREASE OF L/M RATIO WAS NOT DIFFERENT IN THE 3 GROUPS.CONCLUSIONS. In CONTRAST TO OUR HYPOTHESIS, WE DID NOT FIND A HIGHER INTESTINAL PERMEABILITY IN MECHANICAL VENTILATED INFANTS COMPARED TO NON-VENTILATED INFANTS, MEASURED <48 H AFTER BIRTH. FURTHERMORE, WE DID NOT FIND A SMALLER DECREASE IN INTESTINAL PERMEABILITY IN THE FIRST WEEK OF LIFE IN VENTILATED INFANTS COMPARED TO NON-VENTILATED INFANTS. FURTHER STUDIES ARE NEEDED TO ELUCIDATE THE EFFECT OF MECHANICAL VENTILATION ON INTESTINAL PERMEABILITY IN PRETERM INFANTS.INTRODUCTION. EFFECTS OF MECHANICAL VENTILATION ON INTESTINAL PERMEABILITY HAVE NOT YET BEEN STUDIED IN PRETERM INFANTS. WE HYPOTHESIZE THAT MECHANICAL VENTILATION INCREASES INTESTINAL PERMEABILITY, AND REDUCES THE NATURAL DECLINE OF INTESTINAL PERMEABILITY IN THE FIRST WEEK OF LIFE.METHODS. INTESTINAL PERMEABILITY WAS MEASURED BY THE SUGAR ABSORPTION TEST, IN WHICH URINARY EXCRETION OF LACTULOSE (L) AND MANNITOL (M) IS MEASURED AFTER ORAL INGESTION. THE SUGAR ABSORPTION TEST WAS PERFORMED AT 2 TIMEPOINTS (<48 H AFTER BIRTH AND AT DAY 5–8) IN 3 GROUPS: I INFANTS NOT VENTILATED AT ALL (N=7); II INFANTS VENTILATED AT TIMEPOINT 1 BUT NOT AT TIMEPOINT 2 (N=24); III INFANTS VENTILATED AT BOTH TIMEPOINTS (N=12).RESULTS. BOTH MEAN (+/-SD) GESTATIONAL AGE AND BIRTHWEIGHT WERE HIGHER IN GROUP I (31.6+/-1.6WKS, 1477+/-428G) AND II (31+/-2.5WKS, 1709+/-542G) THAN IN GROUP III (28.3+/-1.4 WKS, 1070+/-359G) (P<0.05). THE MEAN (+/-SD) L/M RATIO 1 WAS HIGHER IIN GROUP I (0.667+/-0.356) THAN IN GROUP II (0,360+/-0.349) (P<0.005) BUT NOT HIGHER THAN IN GROUP III (0.482+/-0.309) (P=0.26). THE L/M RATIO 2 WAS NOT DIFFERENT IN THE 3 GROUPS (0.187+/-0.086, 0.244+/-0.172, 0.187+/-0.181 RESPECTIVELY). CORRECTED FOR THE DIFFERENCES IN L/M RATIO 1, THE DECREASE OF L/M RATIO WAS NOT DIFFERENT IN THE 3 GROUPS.CONCLUSIONS. In CONTRAST TO OUR HYPOTHESIS, WE DID NOT FIND A HIGHER INTESTINAL PERMEABILITY IN MECHANICAL VENTILATED INFANTS COMPARED TO NON-VENTILATED INFANTS, MEASURED <48 H AFTER BIRTH. FURTHERMORE, WE DID NOT FIND A SMALLER DECREASE IN INTESTINAL PERMEABILITY IN THE FIRST WEEK OF LIFE IN VENTILATED INFANTS COMPARED TO NON-VENTILATED INFANTS. FURTHER STUDIES ARE NEEDED TO ELUCIDATE THE EFFECT OF MECHANICAL VENTILATION ON INTESTINAL PERMEABILITY IN PRETERM INFANTS.

Een pasgeborene met een thrombus in het rechteratrium en persisterende Staphylococcus aureus–sepsis

SummaryWe describe a neonate with an infected right atrial thrombus. The infected thrombus caused an ongoing Staphylococcus aureus-sepsis. Data in literature on treatment of infected thrombi in neonates are limited. Our patient was successfully treated with antibiotics and heparin. If an infected cardiac thrombus in a neonate does not cause severe hemodynamic problems or pulmonary embolism, treatment with antibiotics and heparin can be sufficient.SamenvattingWe beschrijven een pasgeborene met een geïnfecteerde thrombus in het rechteratrium. De geïnfecteerde thrombus veroorzaakte een persisterende Staphylococcus aureus–sepsis. Gegevens over de behandeling van geïnfecteerde thrombi bij pasgeborenen in de literatuur zijn beperkt. Onze patiënt werd succesvol behandeld met heparine en antibiotica. Deze therapie kan worden toegepast bij pasgeborenen indien de thrombus geen ernstige hemodynamische problemen of pulmonale embolieën heeft veroorzaakt.

Fat malabsorption in preterm and term neonates is due to impaired uptake of long chain fatty acids

Fat malabsorption in preterm and term neonates is due to impaired uptake of long chain fatty acids