Social determinants of health and the neonate in the neonatal intensive care

It is increasingly recognised that social determinants of health such as socioeconomic inequalities, parental education level, addiction behaviors, mental health difficulties and breast-feeding rates all influence immediate and long-term outcomes in neonatal intensive care unit (NICU) graduates. Awareness, recognition and appropriate management of these risks may help alleviate some of these effects. This review looks at various social determinants and their effects on patients and families in the NICU.     

Visits by the family to the neonatal intensive care unit

AIM: To investigate visiting frequency of family members, including mother, father, siblings and grandparents and associated factors during hospitalisation of preterm infants. METHODS: The study included all premature (< 37 weeks) infants born in Tampere University Hospital in 1997-1998 admitted to the neonatal intensive care unit (NICU) with a birth weight less than 2500 g (n = 210). Maternal and infant data and visits made by family members were compiled from the infants' hospital records. RESULTS: The length of the infants' hospitalisation varied from 2 to 133 days (median 26, quartiles 19, 45). Mothers visited the NICU on average 6.7 days/week; fathers 4.8 days/week. Mothers visited less frequently the lower the gestational age and the longer the distance between home and hospital. Fathers visited less frequently if distance from home to hospital was longer and if the infant had siblings. A total of 92% of siblings and 80% of grandparents visited the hospital. CONCLUSIONS: The results showed active visiting by the parents in the NICU. A lower gestational age was associated with lower visiting frequency for mothers. In contrast, more practical limitations such as geographical distance and other children to be taken care of had greater effect on the visiting frequency for fathers.     

Surveillance of infection in neonatal intensive care units

Monitoring infection rates is increasingly regarded as an important contributor to safe and high quality health care, especially in intensive care settings. Early-onset neonatal sepsis rates are an important indicator of ante- and intra-partum care, especially as medicalisation of obstetric practice increases. However, surveillance of late-onset neonatal sepsis is required to monitor the quality of Neonatal Intensive Care Unit (NICU)-related care. Infection surveillance on NICUs presents a number of unique challenges, including defining infections, the preponderance of coagulase-negative staphylococci as both pathogens and commensals, and allowing for the influence of important risk factors. Ideally an infection surveillance programme should permit benchmarking of infection rates, and multi-centre programmes have been reported to decrease the incidence of healthcare-associated infections on NICUs. However, further research is required to identify the most clinically- and cost-effective means of surveying NICU-acquired infections before a national programme can be implemented. Until then, considerable value can be obtained from local infection surveillance.     

Individualized developmental care in a Dutch NICU: short-term clinical outcome

AIM: To compare the short-term clinical outcomes of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) and conventional care. METHODS: A prospective phase-lag cohort study was performed in a Dutch tertiary level neonatal intensive care unit (NICU). Infants born before 30 weeks of gestational age (GA) were included, 26 in the conventional and 25 in the NIDCAP group. Outcomes were respiratory status, cerebral ultrasound findings, growth and length of NICU stay. RESULTS: At study entry, NIDCAP infants had a lower birth weight (mean [SD]: 1043 [191] vs. 1154 [174] g, p = 0.044), were more often small for GA (8 vs. 2, p = 0.038), had smaller head circumferences (mean [SD]: 25.1 [1.3] vs. 26.1 [1.8] cm, p = 0.041) and were less often multiples (6 vs. 14, p = 0.029) than conventional care infants. During NICU stay, more infants in the NIDCAP group developed pneumonia (9 vs. 3, p = 0.040) due to nosocomial infections. After adjustment for these differences, a decreased risk for more severe cerebral damage in favour of NIDCAP was seen (Odds ratio: 0.12, 95% CI: 0.03-0.46, p = 0.002). No differences were observed for the other outcomes. CONCLUSIONS: We conclude with precaution that in this phase-lag cohort study NIDCAP may have resulted in less severe cerebral damage, but was not associated with other clinical outcomes. In light of these findings, NIDCAP deserves further exploration.     

Risk factors associated with gut and nasopharyngeal colonization by common Gram-negative species and yeasts in neonatal intensive care units patients

Aim

To characterize dynamics of mucosal colonization of neonates by common aerobic Gram negative species and Candida spp. and to identify independent perinatal, neonatal, and environmental factors influencing the colonization process.

Study design

The nasopharyngeal (n = 1145) and rectal (n = 1242) swabs were collected on admission and thereafter twice a week in neonates with risk factors of early onset sepsis (n = 276) admitted within the first 72 h of life. The association between colonization by different microbes and a total of 22 predefined risk factors was assessed using univariate and multiple logistic regression analyses.

Results

Throughout the study about half of the patients had rectal (55.8%) or nasopharyngeal colonization (42.8%) with common Gram-negative microorganisms. Colonization dynamics and risk factors were in general similar for a given bacterial species in both mucosal sites; nonfermentative microbes more often found in nasopharyngeal swabs and Enterobacteriaceae in rectal swabs. All organisms except Escherichia coli were influenced by the duration of intensive care unit stay but other risk factors were species specific, perhaps reflecting their mode of acquisition. While colonization by E. coli and Candida albicans was associated with perinatal factors like term birth, vaginal delivery, and breast milk feeding; colonization by Klebsiella pneumoniae, Enteribacter cloacae, Acinetobacter spp. and non-albicans Candida spp. were mostly determined by hospital environment (treatment unit and period, artificial interventions and their duration) and gestation age ≤ 28 weeks.

Conclusions

The knowledge of risk factor profiles may permit the development of strategies to prevent heavy colonization and subsequent invasive disease in high risk infants.     

Late-onset sepsis due to Salmonella Typhi in a preterm infant in a French neonatal unit

We report a case of late-onset sepsis caused by Salmonella Typhi in a one-month old preterm infant hospitalised in our neonatal unit. An investigation of the index case was undertaken to identify the source of contamination. The patient made a complete recovery.     

中国新生儿重症监护病房中实施家长参与早产儿住院期间综合管理与常规护理的平行对照研究

目的探讨在中国NICU实施家长参与早产儿住院期间综合管理（FICare）的可行性。方法以平行对照设计试验方案,对在中南大学湘雅三医院NICU中符合FICare组纳入标准的早产儿行FICare模式干预（建立FICare组医护团队,NICU改造,掌握六步洗手法、脐带护理、口腔护理、留置胃管管饲、婴儿洗澡、袋鼠式搂抱、称体重、皮肤护理、母乳喂养等）,选择同期NICU中符合对照组纳入标准的早产儿以常规护理模式干预。主要观察住院时间,次要观察体重增长速度、开始胃肠内喂养时间和达到全胃肠内喂养的时间、母乳喂养率、院内感染率、总氧疗时间、出院30 d内再次入院率和纠正胎龄37周时NBNA评分;附加观察FICare组家长出现在NICU后FICare医护团队工作期间心理压力、医疗费用、研究期间的医疗纠纷投诉率、病房额外开支、实施FICare后与前1年同期NICU的不良事件数量等。结果FICare组和对照组分别纳入30和60例,两组基线具可比性。FICare组和对照组NICU住院时间分别为（25.9±7.1）d和（29.2±6.0）d,差异有统计学意义（P=0.035）。两组开始胃肠内喂养日龄、院内感染率差异无统计学意义;FICare组与对照组比较,达全胃肠内喂养时间较快、母乳喂养率较高、体重增长速度较快、总的氧疗时间较短、出院30 d内再次入院率较低、纠正胎龄37周时NBNA评分较高,差异均有统计学意义。当FICare组家长出现在NICU,6/6名护士均在工作期间感觉心理压力增加）,护士自愿报名参加FICare课题组却增加了7人,没有医疗纠纷投诉, 总医疗费用减少,实施FICare后与前1年同期相比NICU的不良事件数量下降（每月2.2 vs 4次）。结论在中国NICU实施FICare具可行性,继续开展FICare的后续研究是安全的,但医护人员工作压力和NICU的额外支出有所增加。     

The use of mechanical ventilation protocols in Canadian neonatal intensive care units

OBJECTIVES:To identify the proportion of Canadian neonatal intensive care units with existing mechanical ventilation protocols and to determine the characteristics and respiratory care practices of units that have adopted such protocols.METHODS:A structured survey including 36 questions about mechanical ventilation protocols and respiratory care practices was mailed to the medical directors of all tertiary care neonatal units in Canada and circulated between December 2012 and March 2013.RESULTS:Twenty-four of 32 units responded to the survey (75%). Of the respondents, 91% were medical directors and 71% worked in university hospitals. Nine units (38%) had at least one type of mechanical ventilation protocol, most commonly for the acute and weaning phases. Units with pre-existing protocols were more commonly university-affiliated and had higher ratios of ventilated patients to physicians or respiratory therapists, although this did not reach statistical significance. The presence of a mechanical ventilation protocol was highly correlated with the coexistence of a protocol for noninvasive ventilation (P<0.001, OR 4.5 [95% CI 1.3 to 15.3]). There were overall wide variations in ventilation practices across units. However, units with mechanical ventilation protocols were significantly more likely to extubate neonates from the assist control mode (P=0.039, OR 8.25 [95% CI 1.2 to 59]).CONCLUSION:Despite the lack of compelling evidence to support their use in neonates, a considerable number of Canadian neonatal intensive care units have adopted mechanical ventilation protocols. More research is needed to better understand their role in reducing unnecessary variations in practice and improving short- and long-term outcomes.     

Development and growth in very preterm infants in relation to NIDCAP in a Dutch NICU: two years of follow-up

Aim: To study development and growth in relation to newborn individualized developmental and assessment program (NIDCAP®) for infants born with a gestational age of less than 30 weeks.
Methods: Developmental outcome of surviving infants, 25 in the NIDCAP group and 24 in the conventional care group, in a prospective phase-lag cohort study performed in a Dutch level III neonatal intensive care unit (NICU) was compared. Main outcome measure was the Bayley scales of infant development-II (BSID-II) at 24 months corrected age. Secondary outcomes were neurobehavioral and developmental outcome and growth at term, 6, 12 and 24 months.
Results: Accounting for group differences and known outcome predictors no significant differences were seen between both care groups in BSID-II at 24 months. At term age NIDCAP infants scored statistically significant lower on neurobehavioral competence; motor system (median [IQR] 4.8 [2.9–5.0] vs. 5.2 [4.3–5.7], p = 0.021) and autonomic stability (median [IQR] 5.7 [4.8–6.7] vs. 7.0 [6.0–7.7], p = 0.001). No differences were seen in other developmental outcomes. After adjustment for background differences, growth parameters were comparable between groups during the first 24 months of life.
Conclusion: At present, the strength of conclusions to be drawn about the effect of NIDCAP on developmental outcome or growth at 24 months of age is restricted. Further studies employing standardized assessment approaches including choice of measurement instruments and time points are needed.     

Cholestasis in neonatal intensive care unit: incidence, aetiology and management

Aim:  Prevalence, aetiology, management and outcome of cholestasis were evaluated in infants admitted to neonatal intensive care unit (NICU).
Methods:  Medical records of all infants admitted to two Italian level III NICUs from January 2005 to August 2007 were retrospectively reviewed. The role of ursodeoxycholic acid (UDCA) therapy was also investigated.
Results:  Twenty-seven of 1289 enrolled infants developed cholestasis. In 25 infants, cholestasis had a multifactorial basis, while in two, no aetiology was found. UDCA did not significantly affect clinical and biochemical course of cholestasis. During a period of 12 months, eight cholestatic infants died, one underwent liver transplantation and 18 fully recovered.
Conclusion:  Infants admitted in NICU have a rate of cholestasis higher than that reported in the general population of live births; in most cases, cholestasis is associated to multiple risk factors and shows a favourable outcome. UDCA does not seem to affect clinical course of cholestasis in this setting.     

纤维支气管镜在NICU中的应用进展

纤维支气管镜诊疗技术已成为NICU中的一项重要的辅助诊疗手段,其应用提高了新生儿呼吸系统疾病的临床诊治水平.随着设备的改进、医务人员操作水平的不断提高,目前已应用于体重低至600 g的早产儿.本文着重介绍了近年来纤维支气管镜在危重症新生儿应用的新进展、主要诊断和治疗适应证,同时探讨了其在新生儿应用中的安全性.     

Prenatal and postnatal factors affecting short-term survival of very low birth weight infants

Factors affecting the survival of 175 preterm infants born with body weight <1500 g were examined. The still-birth and perinatal mortality rates were 143 and 446 per 1000 births respectively; neonatal death rate was 447 per 1000 live births. Survival improved progressively with increasing gestational age, and survival was better for infants born after 27 weeks of gestation. Neither maternal nor labour and delivery variables significantly affected survival. Male infants had half the survival rate of females. Birth asphyxia, hypercapnia and respiratory distress syndrome were the most common forms of morbidity, occurring in >20% of the population. Infants with such pathology had significantly lower survival rates.Abbreviations VLBW very low birth weight - NICU neonatal intensive care units - PROM premature rupture of the membranes - RDS respiratory distress syndrome - RR relative risk - SGA small for gestational age - AGA adequate for gestational age - ELBW extremely low birth weight The Italian Collaborative Study on Preterm Delivery was carried out by the following investigators: Maurizio Bonati, Carlo Brambilla, Fabio Colombo and Gianni Tognoni, Milan (Co-ordinating Centre); Cristina Begher, Salvatore Bottino, Umberto Faluto and Mario Maccabruni, Monza (MI); Bruno Granati and Paola Zanor, Padova, Pierangelo Burtuletti, Gabriella Manenti and Giuliana Pasinetti, Bergamo; Carlo Corchia, Sassari; Enrico Bertino, Aldo Capra, Wanda Combetto, Maria Pia Corradin, Claudio Fabris and Claudio Martano, Torino; Michele Angiolillo and Luigi Gaioni, Mantova; Rosanna Casellato and Giorgio Suppi, Treviso; Augusto Montaguti, Cesena; Susanna Martignoni and Antonio Tomassini, Varese; Paolo Bianchi and Giuliano Palmerio, Seriate (BG); Fulvia Cellani, Francesco Grossi and Vincenzo Rossi, Lodi (MI); Antonia Carlino, Crena (CR); Alessandra Favero, Stefano Quaranta and Raffaella Tornaghi, Milan; Giuseppe Assenza, Fiesole (FI); Massimo Bardi, Arturo Manzoni, Daria Mattioni and Ferruccio Pizzigoni, Trescore (BG); Mario Berzioli and Vittorio Marsoni, Montebelluna (TV); Giovanni Buzzi and Angela Tudisco, Casale Monferrato (AL); Gabriele Oppo, Arezzo; Domenico Fichera, Calcinate (BG); Giuseppe Marraro and Alberto Vecchione, Merate (CO)