Practice ordering guidance for neonatal parenteral nutrition.

OBJECTIVE: Neonatal parenteral nutrition (PN) is designed for very low birth weight infants (BW < or = 1500 g) for whom enteral feedings are inadequate. Evaluating the clinical practice guidance (CPG) content of printed paper order forms could provide a baseline for comparison and serve as a reference for electronic neonatal nutrition order design systems. METHODS: A scoring system for clinical practice guidance was developed and applied to nine institutions printed paper PN order forms. CPG scores were assigned as: (1) generic reminder only, (2) prompt with order entry space, (3) patient specific reminder only, (4) patient specific recommendation with order entry space. User-friendliness and form completion time were also recorded. RESULTS: The overall CPG score for the six most common PN components was 1.85+/-0.68 (mean+/-1s.d.), consistent with a generic reminder, but short of a specific nutrient dose order field. Amino acid received the highest CPG score, 2.05+/-0.64; vitamins rated the lowest. The institution of origin was an independent predictor of the CPG score. CONCLUSIONS: Paper neonatal PN order forms offer relatively little CPG. Significant form variation and format reflects the need to standardize neonatal PN design as the neonatal PN design moves from paper to electronic ordering systems.     

A survey of neonatal parenteral nutrition design practices in North Carolina.

BACKGROUND: Parenteral nutrition is an important component of postnatal hospital care for very-low-birth-weight infants (VLBW; birth weight < or =1500 g). Designing and preparing parenteral nutrition for VLBW infants is a complicated process requiring many nutrition decisions and mathematical computations, a process most medical centers have developed independently. The goal of this project was to examine the nutrition design practices and resources of regional neonatal intensive care units (NICUs). METHODS: In depth interviews were conducted with neonatal nutrition health-care providers at eight medium to large NICUs in North Carolina to describe the patient population, the nutrition support staff, nutrition decision-making procedures and resources, the design of parenteral nutrition, and problems with parenteral nutrition design and preparation. RESULTS: The eight centers reported an average of 182 VLBW infant admissions and prepared 4810 parenteral nutrition orders per year. Five centers employed experienced neonatal nutrition staff to offer decision support. Six centers used paper parenteral nutrition order forms, all of which provided some decision guidance such as a recommended ordering dose range. Self-reported medical mistakes included incorrect parenteral nutrition additive dilutions and incorrect supplementation of parenteral nutrition additives. CONCLUSIONS: Most NICUs offered nutrition resource personnel and used paper parenteral nutrition order forms, which offered a wide range of decision guidance. About half the reported medical errors could be addressed using electronic parenteral nutrition design; however, a broader, more general approach to the entire design and administration system would reduce more errors. Last, as development of electronic neonatal nutrition resources in the clinical arena progresses, standards for recording neonatal nutrition content, and evaluating the effect of decision support need to be identified.     

Management of spontaneous congenital chylothorax: oral medium-chain triglycerides versus total parenteral nutrition

The aim of this article is to compare total parenteral nutrition (TPN) with oral medium-chain triglycerides-diets (MCT) in the management of spontaneous congenital chylothorax. We analyzed retrospectively the charts of 6 patients seen in our tertiary care center and of 11 comparable patients from the literature. All neonates were symptomatic at birth; 15 had bilateral chylothorax. In the neonates who received mainly TPN (n = 9), the chylothorax resolved significantly (p < 0.05) earlier (mean 10 days, SE 1) than in the others, who received mainly MCT (n = 8) (mean 23 days, SE 4). The mean chyle loss was not significantly different between the 2 groups. Our results suggest that TPN is more effective than oral MCT in the treatment of spontaneous congenital chylothorax. These results support the data of Peitersen et al, who reported that most of the positive results with MCT were achieved in postoperative chylothorax of the newborn.     

The effect of oxytocin in induced labour on neonatal jaundice.

A prospective study in 180 mothers and babies examined the effects of oxytocin in induced labour on plasma bilirubin levels in cord blood, as well as on the incidence of neonatal jaundice. Raised plasma bilirubin levels in cord blood, probably enhanced by breakdown of fetal red cells, appeared to be a dose dependent effect of oxytocin. Commensurate with this was the finding that a larger proportion of babies in the induced group manifested a greater severity of jaundice.     

Carbohydrate-induced lipogenesis in the human placenta of normal and diabetic pregnancies.

Using in vitro incubation, human placental slices have been shown to synthesize lipid from 14-C fructose, but to a lesser extent than from 14-C glucose. Diabetic placentae did not incorporate more of either sugar into lipid than did placentae from normal pregnancies; nor did insulin in the incubation medium enhance lipogenesis. There was a correlation between the extent of incorporation of 14-C fructose and 14-C glucose into triglyceride, suggesting a linked enzyme system for phosphorylation of the two hexoses.     

Absence of a prenidatory effect of luteinizing hormone releasing hormone (LHRH) in hamsters.

Luteinizing hormone releasing hormone at high doses will terminate gestation in rats during early and midpregancy (ED50 approximately equal to 100 microgram/day) and rabbits during early pregnancy. Early pregnancy in hamsters, in contradistinction, seems refractory to this effect. Administration of LHRH up to massive doses (10 mg/day) over the first 3 or 7 days of pregnancy failed to affect the pregnancies in meaningful fashion. Further, a single injection (100 mg) on day 5 had no effect on pregnancy; this system has been employed for the assay of prostaglandins because hamsters are remarkably sensitive to PG's (PGF2alpha, ED50 approximately equal to 17 microgram, PGE2, ED50 approximately equal to 210 microgram). The absence of response of hamsters to LHRH cannot be interpreted at present.     

The effect of the mode of delivery on neonatal thyroid function.

BACKGROUND: We aimed to investigate the effect of the mode of delivery and the type of anesthesia on postnatal thyroxine (T4), free T4 (f-T4) and thyroid-stimulating hormone (TSH) in a large number of healthy full-term neonates. METHODS: Serum samples for T4, TSH and f-T4 were drawn from neonates at the time of discharge (postnatal days 1-7) in a pilot thyroid-screening program. Six hundred and thirty-eight neonates were grouped as: vaginal delivery (VD; 332), elective cesarean section (elective C/S; 252) and emergency cesarean section (emergency C/S; 54). The elective C/S group was subdivided into local and general anesthesia groups to investigate the influence of the type of anesthesia used on thyroid function. RESULTS: Mean+/-SD serum T4, TSH and f-T4 levels tended to be higher in the VD group compared to the elective C/S group at almost all time points. However the differences did not reach statistical significance, except for the T4 levels at postnatal day 3 in the VD group, which was higher (195.6+/-37.3 nmol/L) compared to the elective C/S group (160.9+/-34.8 nmol/L) (p < 0.001). The only difference in the anesthesia groups was the slightly higher f-T4 levels from postnatal day 4 in the local anesthesia group compared to the general anesthesia group. CONCLUSIONS: The mode of delivery or type of anesthesia does not have considerable influence on postnatal thyroid functions in the neonates, although minor differences exist. Therefore similar cut-off values can be used for thyroid screening of term newborns regardless of the mode of delivery or type of anesthesia used.     

The effect of labor pain relief medication on neonatal suckling and breastfeeding duration.

We examined the relationship of labor pain relief medications with neonatal suckling and breastfeeding duration in 129 mothers delivering vaginally. Suckling was measured using the Infant Breastfeeding Assessment Tool (IBFAT). Controlling for infant age, birthweight, and gender, infants of unmedicated mothers had higher IBFAT suckling scores than those of medicated mothers (x = 11.1 vs. x = 8.2 respectively, P = .001). IBFAT suckling scores for intravenous and epidural groups were similar (x = 8.5) while those who received a combination of both intravenous and epidural medications were lower (x = 6.4 +/- 2.96, P = .001). Mothers evaluated their breastfeeding similarly to nurse evaluators (Z = 9.39, P = .001). Breastfeeding duration did not differ between unmedicated and medicated groups; however, dyads with low IBFAT scores weaned earlier than those with medium or high scores. Labor pain relief medications diminish early suckling but are not associated with duration of breastfeeding through 6 weeks postpartum.     

Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury

Objective  To compare two postpartum laxative regimens in women who have undergone primary repair of obstetric anal sphincter injury.
Design  Randomised controlled trial.
Setting  National Maternity Hospital, Dublin.
Population  A total of 147 postpartum women who had sustained anal sphincter injury at vaginal birth.
Methods  Women were randomised to receive either lactulose alone thrice daily for the first three postpartum days followed by sufficient lactulose to maintain a soft stool over the following 10 days (lactulose group, n = 77) or the lactulose regimen combined with a sachet of ispaghula husk daily for the first 10 postpartum days (Fybogel™ group, n = 70). All patients kept a diary of bowel habit for the first 10 postpartum days and were invited to return for review at 3 months postpartum.
Main outcome measures  Patient discomfort with first postpartum bowel motion, incidence of postnatal constipation and incontinence and incontinence score in postnatal period.
Results  Pain scores were similar in the two treatment groups; but incontinence in the immediate postnatal period was more frequent with the two preparations compared with lactulose alone (32.86% versus 18.18%, P = 0.03).
Conclusions  This study does not support routine prescribing of a stool-bulking agent in addition to a laxative in the immediate postnatal period for women who have sustained anal sphincter injury at vaginal delivery.     

The effect of hypertension in pregnancy on fetal and neonatal condition

The aim of this prospective study was to determine the effect of hypertension in pregnancy (PH) on fetal and neonatal condition via other mechanisms than retarded intrauterine growth and preterm delivery. Sixty-six preterm and 175 full-term babies born to PH mothers were compared, respectively, with 183 preterm and 220 full-term babies born to non-hypertensive (non-PH) mothers over a 22-month period in 1984-1986. Small-for-gestational-age (SGA) children were examined separately from appropriate-for-gestational-age (AGA) children. Percentages of preterm babies and of both preterm and full-term SGA babies born to hypertensive mothers were twice as great as the percentages of such babies born to non-hypertensive mothers. Hypertension in pregnancy directly increased neonatal morbidity, but the effect was minor. In preterm babies it was related to intrauterine growth retardation and to pre-eclampsia. In full-term babies the effect was unrelated to the severity of hypertension.