Milk Flow Rates From Bottle Nipples: What We Know and Why It Matters

Feeding difficulties are common in infants hospitalized in the NICU and can be a challenge to manage. The purpose of this article is to explain how and why the flow rate from the bottle nipple affects physiologic stability in infants and to describe the current evidence available on the flow rates of nipples used in the hospital and after discharge. Study results have indicated that flow rate varies widely among different types of nipples. Within the same type of nipple, there can be significant variability in flow from one nipple to another. Other factors, such as type of infant formula and thickening, also affect flow. Altering the flow rate of the bottle nipple is a relatively simple intervention that may support safe oral feeding.     

Assessing the flow rate of different bottles and teats for neonates with feeding difficulties: An Australian context

AimsTo compare flow rates for Australian bottle/teat systems marketed as ‘slow’ or ‘extra-slow’ flow, and to examine flow consistency within each teat type.MethodsEstablished assessment methods were used to test 27 types of teats. Fifteen teats of each type were tested by measuring the amount of infant formula extracted in 1-min by a breast pump system. Teats were compared within ‘slow’ and ‘extra-slow’ categories, a coefficient of variation was calculated for each teat type, and a cluster analysis was performed to group teats with similar flow.ResultsThere was significant variability observed between teats in the same 'slow' and 'extra-slow' categories, and sometimes between teat brands. Cluster analysis revealed 5 clusters. Many teats were considered to have moderate to high variability in flow rate.ConclusionsThis study provides information regarding Australian bottle/teat systems. This is of relevance to those who support the neonatal bottle-feeding journey, particularly with premature or medically complex neonates.     

Nipple confusion, alternative feeding methods, and breast-feeding supplementation: State of the science

Mothers of preterm and term infants frequently experience breast-feeding problems that make it necessary for them to use supplemental or complementary feedings. Although bottle feeding is used most frequently, alternatives to bottle feeding are frequently recommended to avoid nipple confusion. This report reviews the evidence of a relationship between exposure to artificial nipples and the development of nipple confusion. It also examines the effects of alternative feeding methods such as cup feeding, finger feeding, spoon feeding and gavage feeding on physiological responses of infants and long-term breast-feeding outcomes. This report recommends further research before alternatives to bottle feeding are routinely implemented. Copyright © 2001 by W.B. Saunders Company     

超声诊断乳头疾病

目的 探讨超声诊断和鉴别诊断女性乳头疾病的价值.方法 回顾性分析25例超声首诊乳头异常患者,其中16例经病理证实,4例经随访证实,5例为临床诊断,分析不同乳头疾病的超声特征.结果 16例中,乳头佩吉特病9例,均经病理证实,包括混合型6例、单纯型3例,超声诊断准确率88.89％(8/9);乳头炎症6例,2例经手术活检证实...     

Accuracy of Intravenous Infusion Flow Regulators in the Prehospital Environment

Objective: To assess the accuracy of multiple Intravenous Infusion Flow Regulators (IIFRs) at infusion rates and hanging heights common to the prehospital setting. Methods: Five different manufacturer's IIFRs were tested over a range of infusion rates while hanging at heights equivalent to the gurney pole, ambulance ceiling hook, and manufacturer's recommended height (if available). Each IIFR was run over a 15-minute period at each infusion rate and height three times. Drip effluent was collected and measured for comparison of volumes. Intra- and inter-device accuracy at different infusion rates and heights was calculated. Results: All devices deviated from the expected infusion volume regardless of infusion rate or height. There was inter-device variability across all IIFRs with some having reproducible though inaccurate volumes. Volumes were consistently below expected at lower heights and above expected at increased heights. Manufacturer recommended height guidelines provided slight improvements in accuracy. Conclusions: Significant deviations from expected IIFR volume were observed across all devices, flow rates, and heights in a static, laboratory environment. These findings would lend caution to the use of IIFRs as they could lead to inaccurate medication dosing (both over- or under-dosing) in the prehospital environment.     

Mechanical factors affecting nebulized albuterol aerosol particle sizes for asthma drug delivery

Background

Nebulized particles must have diameters between 1 to 5 μm (optimal particle size range [OPSR]) to be deposited in the lower respiratory tract. The purpose of this study is to determine factors that affect the particle size distributions of nebulized albuterol.

Methods

We used a sophisticated laser diffraction machine to measure aerosol particle size distributions. We compared the percentage of particles in the OPSR at different flow rates through single-use disposable (SUD) and semipermanent nebulizers at different flow rates under different conditions.

Results

The SUD nebulizer produced OPSR percentages of 16%, 28%, 40%, 50%, 56%, and 62% at 3, 4, 5, 6, 7, and 8 Liters per minute (Lpm), respectively. The semipermanent nebulizer, however, produced OPSR percentages of 57%, 57%, 60%, and 64% at 3, 4, 5, and 6 Lpm, respectively. The home pump produced a gas flow rate of 5.2 Lpm through the SUD nebulizer and 4.2 Lpm through the semipermanent nebulizer. Single-use disposable nebulizer performance did not degrade with use up to 150 nebulizations. Optimal particle size range percentages did not change significantly with large or small nebulization volumes.

Conclusion

Single-use disposable nebulizers do not degrade with use, but their performance is highly dependent on gas flow rates. At the flow rate achieved by the home pump, the semipermanent nebulizer performs better than the SUD nebulizer.     

The accuracy of state NCLEX-RN© passing standards for nursing programs

BackgroundNursing education programs in every state must meet specified NCLEX pass rate standards in order to maintain licensure and accreditation. These standards are a source of great anxiety for educators and students. There is wide variety of pass rate standards among the states. In addition, individual nursing program pass rates vary substantially from one year to the next.ObjectivesPass rate variation suggests the need for scrutiny of the accuracy of applying state pass rates as a standard for evaluating nursing education program. This study considers the implications of such variation.DesignThe study computes 95% confidence intervals for nursing program pass rates from 2010 to 2014 to determine whether programs that failed to meet pass rate standards may have done so by accident and whether programs that met pass rate standards may have done so by accident.DataThe study data includes statutes and regulations that establish pass rate standards and NCLEX pass rates for 1792 nursing programs reflected in reports provided by state nursing boards.FindingsAlmost 20% of nursing education programs violated the state pass rate standard at least once between 2010 and 2014. Among the programs that failed to meet pass rate standards, 28.4% had a 95% confidence interval that extended above the pass rate standard. A determination that these programs did not meet pass rate standards could well be erroneous. Approximately 17.4% of programs that met pass rate standards had confidence intervals that went below the pass rate standard. A finding that these programs complied with state pass rate standards might also be erroneous.ConclusionsApplication of confidence intervals to nursing program pass rates suggests that use of pass rate standards to evaluate nursing program quality may not be appropriate. This suggests the need to rethink application of state pass rate standards when evaluating nursing education programs.     

Effects of single-hole and cross-cut nipple units on feeding efficiency and physiological parameters in premature infants

The purpose of this study was to compare the amount of total milk intake, feeding time, sucking efficiency, heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2) of premature infants when fed with either signal-hole or cross-cut nipple units. Twenty stable infants admitted to a level II nursery in a tertiary care center with gestational ages averaging 32.2+/-3.2 wks were enrolled. Subjects had an average postmenstrual age of 34.1+/-1.6 wks, and average body weight of 1996+/-112 gm. A crossover design was used and infants were observed for two consecutive meals separated by a four-hour interval. They were bottle fed with equal feeding amounts using a single-hole and cross-cut nipple administered in random order. Results showed that infants fed with single-hole nipple units took more milk (57.5+/-8.3 ml vs. 51.6+/-9.5 ml, p=.011), had a shorter feeding time per meal (11.5+/-4.9 min vs. 20.9+/-5.0 min, p<.001), and sucked more efficiently (5.8+/-2.5 ml/min vs. 2.7+/-1.0 ml/min, p<.001) compared to those fed through cross-cut nipples. Infants using cross-cut nipple units had a higher RR (44.4+/-4.6 breaths/minutes vs. 40.8+/-4.9 breaths/minutes, p=.002) and SpO2 (96.1+/-1.4% vs. 94.6+/-3.2%, p=.044) than those using single-hole nipples. Oxygen desaturation (SpO2<90% and lasting for longer than 20 sec) and bradycardia were not recorded in either group of infants during feeding. Compared to using cross-cut nipple units, premature infants using single-hole nipple units take more milk and tend to tolerate feedings better. A single-hole nipple may be a choice for physiologically stable bottle-fed premature infants.     

Development of a novel controllable,multidirectional, reusable metallic port with a wide working space

Abstract

Background: Endoscopic surgery is currently a standard procedure in many countries. Furthermore, conventional four-port laparoscopic cholecystectomy is developing into a single-port procedure. However, in many developing countries, disposable medical products are expensive and adequate medical waste disposable facilities are absent. Advanced medical treatments such as laparoscopic or single-port surgeries are not readily available in many areas of developing countries, and there are often no other sterilization methods besides autoclaving. Moreover, existing reusable metallic ports are impractical and are thus not widely used. Material and methods: We developed a novel controllable, multidirectional single-port device that can be autoclaved, and with a wide working space, which was employed in five patients. Results: In all patients, laparoscopic cholecystectomy was accomplished without complications. Conclusion: Our device facilitates single-port surgery in areas of the world with limited sterilization methods and offers a novel alternative to conventional tools for creating a smaller incision, decrease postoperative pain, and improve cosmesis. This novel device can also lower the cost of medical treatment and offers a promising tool for major surgeries requiring a wide working space.     

The effect of music-reinforced nonnutritive sucking on feeding rate of premature infants

Premature infants are fed by gavage tube before 34 weeks adjusted gestational age and when nipple feeding results in detrimental changes in respiration and heart rate. Nipple feeding skill must be developed and correlates with length of hospitalization and neurobehavioral development. This study provided music reinforcement for nonnutritive sucking and assessed nipple feeding rates pre- and posttreatment for 32 infants referred as poor feeders. A pacifier fitted with a pressure transducer activated 10 seconds of recorded music in a one-trial, 15-minute intervention given to experimental infants (n = 16) 30 to 60 minutes before the late afternoon bottle feeding. Feeding rates were collected for bottle feedings pre- and postintervention and for a similar interval for a no-contact control group (n = 16). Results showed that the intervention significantly increased feeding rates. Music functioned as reinforcement and the sucking behavior transferred from a nonnutritive to a nutritive event.     

乳腺癌保乳手术保留乳头塑型对乳房外形的影响

【目的】探讨乳腺癌手术患者保持乳头外形重塑对乳房外形的影响。【方法】选择本院乳腺癌实行保乳手术患者28例,评估术后乳头塑型的美观效果,从双乳头水平、双乳头距同侧腋前线垂直距离、瘢痕对乳房外观的影响、乳头外观对保留乳房外形的重塑效果评价及对乳房外形的影响因素进行分析。【结果】术后切口达一期愈合24例,占85．71％,优良率为78．57％（22／28）;乳房外形未达理想标准者6例,占21．43％,其中切口瘢痕致乳房畸形3例,占10．71％,乳头不自然挺立、乳头歪斜及两侧乳头水平高度存在差距各1例,各占3．57％（1／28）。多因素非条件Logistic回归分析结果显示：切除乳腺组织的量、手术切口的设计、术中皮瓣的厚薄、术后切口包扎松紧度与术后乳头塑型影响因素显著相关。【结论】乳腺癌保乳手术乳头外形重塑是影响手术成功满意率的重要因素,术中保留乳腺组织的切除量、术前手术切口的设计、术后切口包扎、术中应瓣的犀薄与术后乳房外形影响因素显著相关。     

Bacterial detection in apheresis platelets: blood systems experience with a two-bottle and one-bottle culture system

BACKGROUND: United Blood Services (UBS) began bacterial testing of platelets (PLTs) using one‐bottle cultures in September 2003. Collection of 7‐day PLTs using two‐bottle cultures began in April 2006. This study compares our experience using both systems. STUDY DESIGN AND METHODS: PLTs from 13 UBS regional centers cultured from September 1, 2003, to September 1, 2007, were included in the analysis. Positive‐signal bottles from a commercially available microbial detection system (BacT/ALERT, bioMérieux) were sent, with corresponding PLTs if available, for confirmatory testing using plate culture media. AABB definitions were used with modifications. RESULTS: A total of 51,265 7‐day PLT collections and 191,521 5‐day PLT collections were tested with bacterial cultures. The overall true‐positive (TP) rate for the two‐bottle system (1:8544) was comparable to the TP rate with the previous one‐bottle system (1:6344). In three of six yield cases, only the anaerobic bottle was positive (two cases of Group D Streptococci, one case of Corynebacterium spp.). The false‐positive (FP) and indeterminate (IND) rates in the anaerobic bottle (1:1767 and 1:1830, respectively) were significantly higher than those in the aerobic bottle (1:6408 and 1:17,088, respectively; p < 0.001). One confirmed transfusion‐related septic reaction, classified as a late TP after investigation, was reported out of 242,786 tested PLT donations. CONCLUSION: The rate of TP cases by the two‐bottle system was not increased over the one‐bottle system, although anaerobic‐bottle‐only positive cases were detected. FP and IND rates were increased in the two‐bottle system, attributable to the anaerobic bottle. Observation of only one documented transfusion‐related septic reaction in 4 years of bacterial screening at UBS is reassuring, although limitations in passive surveillance and higher rates of reactions reported by others indicate the need for continued vigilance.     

Acoustic Properties of Axial and Centrifugal Flow Left Ventricular Assist Devices and Prediction of Pump Thrombosis

ObjectiveTo characterize the properties of the audible tones produced by current left ventricular assist device (LVAD) pumps approved for use, and to ascertain if changes in those may be present in the setting of pump thrombosis.Patients and MethodsFrom August 31, 2016, to January 16, 2020, LVAD recipients consented to have surface recordings obtained using a high-fidelity digital stethoscope. Audio data were analyzed using digital recording and editing software to produce an acoustic spectrogram by Fast Fourier transformation.ResultsRecordings were obtained in 53 patient encounters (27 HeartMate II, 19 HeartWare and 7 HeartMate 3). In 12 patients (9 HeartMate II, 3 HeartWare) there was a clinical concern for pump thrombosis. In all patients and pump models, a fundamental frequency was noted, and the second and third harmonics were also clearly detectable. Where thrombosis occurred in the HeartMate II pump, the absolute (normal -46.9 [-57.5,-42.9] dB vs thrombosis -41.4 [-49.8,-26.8] dB; P=.08) and relative (normal 0.72 [0.62, 0.92] vs thrombosis 0.95 [0.86, 1.24]; P=.01) third harmonic frequencies were increased in amplitude. Where paired data were available, an increase in the absolute and relative third harmonic frequencies was observed in all patients. In the case of the HeartWare device, a consistent difference in harmonic amplitudes in the setting of thrombosis could not be identified.ConclusionA consistent pattern of fundamental and harmonic frequencies is common to all LVADs currently approved for use. Alterations in the amplitude of higher order harmonics may signal the onset of pump thrombosis in axial flow LVADs.     

MRI在乳头溢液性疾病中的应用

目的 探讨MRI对乳头溢液性疾病的临床应用价值。方法 对78例临床表现为乳头溢液的患者行乳腺MR检查,观察MRI表现,并将MRI诊断与病理检查结果进行对比,计算MRI的检出率及诊断符合率。结果 病理检查证实的78例患者共89个乳头溢液责任病灶中,MRI共检出86个,检出率为96.63%(86/89)。MRI正确诊断82个病灶,误、漏诊7个,诊断符合率为92.13%(82/89)。结论 利用MRI能够敏感地检出乳头溢液性疾病的责任病灶,并做出较为可靠的病因诊断。     

Y型乳头矫正器的研制及临床应用

目的 探讨凹陷或扁平乳头的有效矫正方法及Y型乳头矫正器的矫正效果.方法 将66例乳头凹陷或乳头扁平的初产妇分为观察组(38例),用自行研制的乳头矫正器进行矫正.对照组(28例)用一次性注射器抽吸矫正.结果 2组在乳头伸展长度、吸乳器每次持续作用时间、产妇舒适度、乳头矫正时间、总使用次数上有显著性差异(p＜0.05).结论 自制的Y型乳头矫正器矫正乳头凹陷和乳头扁平效果优于一次性注射器抽吸矫正.     

相位对比磁共振成像观察颅内基底动脉、上矢状窦和中脑导水管的生理流动模式

目的 相位对比磁共振成像(PC MRI)观察颅内基底动脉(BA)、上矢状窦(SSS)和中脑导水管(AM)的生理流动模式。方法 选取健康志愿者37名,采用PC MRI测量BA、SSS和AM流体的流动模式。观察时相-流速曲线特征,记录舒张期和收缩期的峰值流速及达峰时相点,并计算两峰值时相差率,记录心动周期内每搏流量、净流量。结果 BA呈单向高幅流动,时相-流速曲线为"缓降-速升-缓降"型;SSS呈单向低幅流动,曲线为"缓降-缓升-缓降"型,两波峰时相差率最小;AM脑脊液呈双向振动式流动,呈"缓升-缓降-缓升型",时相差率最大,绝对每搏流量(74.03±33.22)×10^-3 ml,向4脑室净流量为(3.70±2.78)×10^-3 ml。BA心动周期内两流速波峰间时相差率小于SSS、AM(F=26.63,P<0.01)。结论 BA、SSS及AM的生理流动模式不同。脑室系统、脑组织容积在心动周期内发生动态变化。PC MRI时相-流速曲线可直观、准确地观察脑血管、脑脊液的流动模式。     

Measurement of Volumetric Flow

Objective. The purpose of this study was to evaluate a 3‐dimensional (3D) sonographic method for the measurement of volumetric flow under conditions of known flow rates and Doppler angles. Methods. A GE/Kretz Voluson 730 system (GE Healthcare, Milwaukee, WI) and RAB2‐5 probe were used to acquire 3D Doppler measurements in a custom flow phantom. Blood‐mimicking fluid circulated by a computer‐controlled pump provided a range of flow velocities (2–15 mL/s). A 6‐axis positioning system maneuvered the ultrasound probe through a range of angles (40°–70° and 110°–140°) with respect to the tube (orthogonal to the tube being 90°). Volume data sets were obtained spanning 29° lateral and 20° elevational angles encompassing the flow tube in a scanning time of less than 10 seconds. Power Doppler data were used to correct for partial volume effects. Results. Using a single angle (110°) with respect to the flow tube, measured and actual volume flow rates were within the 95% confidence interval over the full range of flow rates. At flow rates of 5 and 10 mL/s, the measured volume flow rates were all within ±15% of actual values for the range of angles tested and also stayed within the 95% confidence interval. Conclusions. Direct comparisons of volume flow rates estimated with 3D sonography and known flow rates showed that the method has good accuracy. Subsequent comparisons under pulsatile and in vivo conditions will be needed to verify this performance for clinical applications.     

A new pediatric respiratory monitor that accurately measures imposed work of breathing: A validation study

Objective. A new, microprocessor-controlled respiratory monitor (model CP-100 Pediatric, Bicore Monitoring Systems, Irvine, CA) that measures imposed work of breathing and a variety of respiratory parameters for pediatric patients receiving ventilatory support has recently been developed. To validate its accuracy, measurements obtained using this monitor were compared with those obtained using conventional laboratory equipment.Methods. An in vitro lung model was used to simulate spontaneously breathing pediatric patients ranging from infancy to 10 years of age. Tidal volume, respiratory rate, and peak inspiratory flow rates were simulated in a stepwise manner. Values for imposed work, tidal volume, peak inspiratory flow rate, and change in airway pressure for both methods were compared using regression analysis.Results. The coefficients of determination (r²) describing the relationships of both methods of measuring imposed work, tidal volume, peak inspiratory flow rate, and the change in airway pressure ranged from 0.99 to 1.00, and were highly significant (p<0.001). For all measurements, bias was minimal and precision was calculated.Conclusions. Our data reveal that this pediatric respiratory monitor accurately measures imposed work of breathing, as well as tidal volume, flow rate, and airway pressure. Imposed work of breathing measurements obtained from the monitor may be used to adjust pressure support ventilation, so that the imposed work of the breathing apparatus is reduced to zero and the patient's total work of breathing is thus decreased.     

A Comparative Study of Direct Hemoperfusion and Hemodialysis for the Removal of Glufosinate Ammonium

Abstract

BASTA® is a herbicide containing glufosinate ammonium 18.5% and a surface-active agent. There were six fatalities in 34 cases of glufosinate ammonium poisoning reported by the Japan Poison Information Center. To evaluate efficacy in the removal of glufosinate ammonium from the blood, two bottles were prepared containing 600 mL of heparinized bovine blood with 1 mL or 3 mL of BASTA. Direct hemoperfusion or hemodialysis was performed for two hours at a flow rate of 50 mL/min. The final glufosinate ammonium concentration of the blood bottle containing 1 mL of BASTA decreased to 96.9% of the initial concentration after direct hemoperfusion and to 0.5% after hemodialysis. The final glufosinate ammonium concentration of the bottle containing 3 mL of BASTA decreased to 62.2% after direct hemoperfusion and to 0.9% after hemodialysis. Hemodialysis is more effective than direct hemoperfusion for removal of glufosinate ammonium from blood.