Does necrotizing enterocolitis affect growth and neurodevelopmental outcome in very low birth weight infants?

Aim  

To evaluate the effect of necrotizing enterocolitis (NEC) on growth and neurodevelopmental outcome.     

Do feeding practices during transfusion influence the risk of developing necrotising enterocolitis in preterm infants?

Our evidence‐based review set out to answer the clinical question ‘In a preterm infant (patient) with anaemia of prematurity, do feeding practices (intervention) during blood transfusion reduce the risk of developing transfusion‐associated necrotising enterocolitis (outcome)’? We found limited evidence that withholding feeding during red blood cell transfusion in preterm infants may reduce the risk of development of transfusion‐associated necrotising enterocolitis. As clinical equipoise seemingly exists, it seems reasonable for individual units to make their own decisions regarding whether to withhold or continue enteral feeds during red blood cell transfusion until further evidence is available. The UK‐based Withholding Enteral Feeds Around Transfusion (WHEAT) trial, a nation‐wide multi‐centre ‘opt‐out’ randomised controlled study, hopefully will definitively answer our clinical question. Further research in other areas of neonatal care, using this innovative study design, is needed and it is exciting to see such a study underway.     

Colonic pneumatosis intestinalis in preterm infants: different to necrotising enterocolitis with a more benign course?

Necrotising enterocolitis (NEC) is the predominant immaturity-associated disease of the bowel in the preterm neonate and leads to substantial mortality and long-term morbidity. Diagnostic features of NEC include, apart from the clinical presentation, laboratory and radiological parameters. Pneumatosis intestinalis (PI) on abdominal radiographs is regarded as a criterion of definitive proof for this disease entity. The objective of this presentation is to link the topographic pattern of PI to the clinical course in cases of suspected NEC. We report two cases of radiological appearance of colonic PI indicative of NEC without associated laboratory and/or macroscopic evidence of the disease, and with minor clinical symptoms only. Data from animal studies indicate that decreased blood supply to the small bowel is associated with more extensive bowel damage as compared to impaired colonic perfusion. Therefore the topographical distribution of PI might be a more specific sign as the general presence or absence of PI. Conclusion The topographical pattern of pneumatosis intestinalis may be predictive of the clinical course of inflammatory bowel disease in preterm infants. Received: 27 November 2000 and in revised form: 7 February 2001 / Accepted: 12 February 2001     

Should complete blood count be part of the evaluation of febrile infants aged ≤2 months?

Objective: To determine the utility and importance of total white blood cell count (WBC) and absolute neutrophil count (ANC) as markers of serious bacterial infection (SBI) in hospitalized febrile infants aged ≤2 months. Patients and methods: Data on WBC and ANC were collected prospectively for all infants aged ≤2 months who were hospitalized for fever at our centre. The patients were divided into two groups by the presence or absence of SBI. Results: A total of 1257 infants met the inclusion criteria, of whom 134 (10.7%) had a SBI. The area under the ROC curve was 0.73 (95% CI: 0.67–0.78) for ANC, 0.70 (95% CI: 0.65–0.76) for %ANC and 0.69 (95% CI: 0.61–0.73) for WBC. The independent contribution of these three tests in reducing the number of missed cases of SBI was significant. Conclusion: Complete blood cell count should remain as part of the routine laboratory assessment in this age group as it is reducing the number of missing infants with SBI. Of the three parameters, ANC and %ANC serve as better diagnostic markers of SBI than total WBC. However, more accurate tests such as C‐reactive protein and procalcitonin should also be part of the evaluation of febrile infants in these age group as they perform better than WBC or ANC for predicting SBI.     

Risk factors for pulmonary candidiasis in preterm infants with a birth weight of less than 1250 g

To evaluate the epidemiology of pulmonary candidiasis (PC) and to identify risk factors in premature infants during the 1st month of life, all infants with a birth weight <1250 g admitted to our neonatal intensive care unit with PC between January 1994 and December 2001 were retrospectively reviewed. Infants with PC ( n =20) were compared with a control group ( n =20), matched for gestational age and birth weight, with regard to possible perinatal and postnatal risk factors. Among 325 infants with a birth weight <1250 g, 20 out of 233 ventilated infants (8.6%) developed PC. Candida albicans ( n =12) and C. parapsilosis ( n =4) were the predominant isolates. Neonates with PC were significantly different from controls with regard to male prevalence ( P =0.002), rates of preterm premature rupture of membranes (PPROM) ( P =0.02), longer duration of antibiotic therapy ( P =0.01) and of ventilation ( P =0.02). The difference between groups did not attain significance with regard to postnatal dexamethasone administration, duration of central vein catheterisation and duration of parenteral nutrition. Multivariate logistic regression analysis indicated as significant predictors of PC, among perinatal data, the male gender (OR =26.3; 95%CI 2.44 to 284) and PPROM (OR =12.3; 95%CI 1.16 to 130) and, among postnatal data, the duration of ventilation (OR =1.54; 95%CI 1.01 to 2.34). Conclusion:The presence of preterm premature rupture of membranes and the duration of ventilation are significant risk factors for developing pulmonary candidiasis and should be considered in the preventive efforts to reduce this disease in infants with a birth weight <1250 g.     

Does lactate level in the first 12 hours of life predict mortality in extremely premature infants?

Aims:   To determine if high lactate levels within the first 12 h of life independently or in combination with Clinical Risk Index for Babies (CRIB) II can predict mortality in extremely premature babies.
Study Design:   A retrospective review of medical charts of babies born between 2001 and 2003 with birthweight <1000 g or gestation <28 weeks was performed. Blood gases and highest umbilical lactate levels in first 12 h of life were noted. Area under the curve (AUC) was calculated for lactate, CRIB and CRIB II as a predictor of mortality. The AUC for lactate and CRIB II were combined using discriminant analysis.
Results:   Two hundred nineteen infants were included in the study, 41 (18.7%) of whom died. The AUC for lactate was 0.67 ( P  < 0.001), while AUCs for CRIB and CRIB II score were 0.81 ( P  < 0.001) and 0.82 ( P  < 0.001), respectively. The AUC for the combined measure of lactate and CRIB II was 0.82, similar to CRIB II.
Conclusions:   Lactate predicts mortality in premature infants, but was found to be inferior to CRIB and CRIB II. Adding lactate level to CRIB II score does not improve its predictive ability.     

Does the use of glycerin laxatives decrease feeding intolerance in preterm infants?

BACKGROUND:

Glycerin laxatives are often prescribed in the neonatal population for meconium evacuation and to promote enteral feeding. However, the literature regarding their effectiveness has not been systematically reviewed.

OBJECTIVE:

To assess the effectiveness of glycerin enema or suppository in preventing feeding intolerance in preterm infants at ≤32 weeks’ gestational age or weighing ≤1500 g at birth.

METHODS:

The Medline, Embase, Cochrane Library, Scopus and Web of Science databases were searched to identify studies that evaluated glycerin enemas/suppositories for feeding intolerance. Using the Evidence Evaluation Worksheet adapted from the American Heart Association’s International Liaison Committee on Resuscitation, eligible studies were scored for quality, level of evidence and direction of support.

RESULTS:

Two clinical studies that evaluated meconium evacuation and feeding intolerance were included. One study showed no difference in the time to complete meconium evacuation or establishment of full enteral feeds, while the other showed that the times to first meconium passage and full enteral feeding were significantly shorter, and the rate of sepsis was lower in the glycerin enema group.

CONCLUSION:

The evidence regarding the effectiveness of glycerin laxatives for improving feeding tolerance is inconclusive in infants at ≤32 weeks’ gestational age or weighing ≤1500 g at birth.     

Does caffeine impair cerebral oxygenation and blood flow velocity in preterm infants?

Aim: The aim of the study is to assess the effects of an intravenous 10 mg/kg loading dose of caffeine base in cerebral oxygenation, cerebral Doppler blood flow velocity and cardiac output in preterm infants. Methods: Preterm neonates <34 weeks gestation were investigated at 1 and 4 h following the loading dose of caffeine using Doppler cerebral sonography, cardiac echocardiography and cerebral spatially resolved near‐infrared spectroscopy. Results: Forty infants were studied with a mean gestational age (mean ± standard deviation) of 27.7 (±2.5) weeks, birth weight of 1155 (±431) g and a postnatal age of 2.8 (±2.2) days. Mean Anterior Cerebral Artery peak and time average mean blood flow velocity fell significantly by 14% and 17.7%, respectively at 1 h post‐caffeine loading dose, which recovered partially by 4 h. Cerebral Tissue Oxygenation Index fell from pre‐dose levels by 9.5% at 1 h with partial recovery to 4.9% reduced at 4 h post‐dose. There were no significant changes in left or right ventricular output, transcutaneous oxygen saturation, transcutaneous PCO₂ or total vascular resistance. Conclusions: A loading dose of 10 mg/kg caffeine base resulted in significant reduction at 1 h post‐dose in cerebral oxygenation and cerebral blood flow velocity with partial recovery at 4 h.     

Does the addition of clonidine to opioid therapy improve outcomes in infants with Neonatal Abstinence Syndrome?

To undertake a literature search and critical appraisal of best available evidence to answer the clinical question: Does the addition of clonidine (I) to standard treatment with an opioid (C) improve outcomes (O) in infants with Neonatal Abstinence Syndrome? A search of both comprehensive (MedLine and Embase) and pre‐filtered databases (Dynamed, UpToDate and TRIP), utilising Boolean Operators to combine search terms appropriately. Three relevant studies were identified. One paper describing the outcomes of a randomised controlled trial by Agthe et al. (2009) most accurately answered the clinical question posed. This paper was critically appraised, and evidence applied to the clinical scenario. The use of clonidine as an adjunct to opioid in the management of infants with NAS reduces the total number of treatment days and dose of opioid required to control symptoms. However, there is a higher risk of rebound in symptoms post‐cessation of opioid and clinicians need to account for this in their discharge planning. More large scale, multi‐centre high‐quality research is needed to clarify the role of clonidine in the treatment of NAS: as monotherapy versus adjunct, the optimal dose and longer‐term impact on neurodevelopment.     

Does retrograde diastolic flow in the descending aorta signify impaired systemic perfusion in preterm infants?

High-volume systemic-to-pulmonary ductal shunting occurs frequently in preterm infants and is indicated by diastolic flow reversal in the descending aorta (DAo). We studied the relationship between ductal diameter, diastolic DAo reversal, and left ventricular output (LVO); and superior vena caval (SVC) flow (upper body perfusion) and DAo flow (lower body perfusion) in preterm (<31 wk) infants. Echocardiographic assessments were performed at 5, 12, 24, and 48 h postnatal age (80 infants, median gestation 28 wk, 1060 g). Incidence of ductal patency fell from 100% at 5 h to 72% at 48 h; incidence of pure systemic-to-pulmonary shunting increased from 66% to 95% of infants with patent ducts. In infants with duct diameter greater than the median, 35-48% of infants had DAo flow reversal. In infants with duct diameter greater than median, DAo reversal was associated with 23-29% increases in LVO at 5-48 h, and 35% decreases in DAo flow volume at 24-48 h, but no differences in SVC flow. In conclusion, a large duct with left-to-right shunting is common in preterm infants. Retrograde DAo flow is a marker of high-volume shunt, evidenced by increased LVO. Preterm infants with high-volume ductal shunt may have preserved upper body perfusion but reduced lower body perfusion.