Cytomegalovirus infection in a neonatal intensive care unit. Subsequent morbidity and mortality of seropositive infants

In a study of blood transfusion and cytomegalovirus (CMV) infection in 385 infants, 5 (8%) of 60 seropositive infants with birthweights less than or equal to 1250 g acquired CMV. Four infants had become seronegative by the time of viral excretion and demonstrated significant morbidity with one death. Morbidity included variant (atypical) lymphocytosis, thrombocytopenia, Staphylococcal epidermidis and Candida parapsilosis infections, and respiratory deterioration. Interestingly, the infant who exhibited only minimal morbidity was seropositive at the time of viral excretion. CMV seropositivity at birth may not protect low birthweight (LBW) infants from the morbidity and mortality associated with CMV infection.     

Distribution of congenital anomalies in a neonatal intensive care unit in Turkey

Abstract

Background: Congenital anomalies are one of the important reasons of mortality and morbidity in newborns. The aim of this study is to determine the incidence, distribution and the mortality of the congenital anomalies in a single neonatal intensive care unit (NICU) from Turkey.

Method: A retrospective analysis was performed between 2005 and 2012 in NICU using a computerized database. Variables including the type of anomaly, antenatal and postnatal history, gestational age, birth weight, consanguinity and other demographic, clinical and related laboratory variables were extracted from the computerized database using ICD-10 codes. Congenital anomalies were classified according to involved organ systems and also classified as single and multiple anomalies.

Results: A total of 1024 newborns with congenital anomaly (CA) (13.7%) were identified among the 7450 hospitalized newborns in NICU. The most affected system was the cardiovascular system (68.8%). Most of the anomalies (67.1%) were single anomalies. Of all, 59.4% had single major, 7.7% had single minor, 9% had single major plus single minor, 18.4% had multiple major and 2% had multiple minor anomalies. On the other hand, 96.3, 1.9, 0.1 and 1.7% of the newborns had malformation, deformation, disruption and dysplasia, respectively. Chromosomal analysis was only performed 24.8% of the newborns with CA and among them, 65.3% of these were in normal limits. The most frequently detected chromosomal abnormality was trisomy 21. Overall, mortality rate was 15.5% among the newborns with CA.

Conclusion: In conclusion, the most common and mortal CA was cardio-vascular malformations in our hospital. The overall prevalence of cardio-vascular malformations among the newborn was higher than previously reported studies in Turkey. Further, studies with larger sample size are needed to determine CA in Turkey.     

Congenital Cytomegalovirus and Hearing Loss

Congenital cytomegalovirus (cCMV) is the most common cause of nongenetic, sensorineural hearing loss and neurodevelopmental disorders in newborns, infants, and children. Current cCMV screening procedures for pregnant women and newborns are not standardized, which may be attributed to the lack of knowledge about the consequences of infection among clinicians and the general public and the lack of effective treatments. The purpose of this article is to provide a review and update on cCMV infection epidemiology, diagnostic tests, clinical manifestations, prevention, treatment, and nursing implications. Hearing loss is emphasized because this is a common sequela of cCMV infection for which diagnostic modalities and treatments are available.     

Big infants in the neonatal intensive care unit

OBJECTIVE: This study was undertaken to identify risk factors for prolonged neonatal intensive care unit (NICU) stay in macrosomic (> or = 4000 g) neonates. STUDY DESIGN: A population-based case-control study in which 799 cases of macrosomic neonates with a prolonged NICU stay were compared with macrosomic neonates without a prolonged stay (n = 1598). RESULTS: Significant risk factors included: 5-minute Apgar score less than 7: odds ratio (OR) = 43.1; fetal distress: OR = 3.0; birth length less than 20 inches: OR = 2.2; birth weight more than 5000 g: OR = 2.6; maternal diabetes: OR = 3.0; gestational age 37 to 38 weeks: OR = 2.2; cephalopelvic disproportion: OR = 2.5; primary cesarean: OR = 2.6; forceps/vacuum: OR = 1.7. No significant association was seen with labor induction/augmentation or dysfunctional/prolonged labor. CONCLUSION: Prolonged stay in macrosomic neonates was related to fetal distress measures and less to factors related to prolonged labor. Attention to intrapartum fetal status during labor with suspected macrosomia appears to be especially warranted.     

Prophylactic fluconazole in very low birth weight infants admitted to neonatal intensive care unit: randomized controlled trial

Objective: To evaluate the effect of fluconazole prophylaxis on invasive fungal infection (IFI) in very low birth weight (VLBW) infants in the Neonatal Intensive Care Unit (NICU).

Methods: VLBW infants receiving antibiotics for more than 3 days were randomized to receive either fluconazole (6?mg/kg) or placebo, every other day for 7 days followed by everyday till day 28 or discharge whichever was earlier. The primary outcome was IFI, and secondary outcome was fungal attributable mortality and all-cause mortality.

Results: The incidence of IFI was significantly lower (21%) in the fluconazole group compared to the control group (43.2%, 95%CI 0.09–0.37, p?<?0.05). The ARR (absolute risk reduction) was 22.2% and the NNT (number needed to treat) was 5. Fungal attributable mortality was also lower in the fluconazole group (2.6% versus 18.9%, 95%CI 0.003–0.52, p?<?0.05).

Conclusion: In VLBW neonates on the NICU, use of fluconazole prophylaxis decreases IFI and fungal attributable mortality.     

新生儿重症监护病房患儿耐亚胺培南铜绿假单胞菌感染的危险因素

目的 探讨新生儿重症监护病房患儿耐亚胺培南铜绿假单胞菌(imipenem-resistant Pseudomonas aeruginosa,IRPA)感染的危险因素. 方法 收集广东省妇幼保健院新生儿重症监护病房2008年1月1日至2011年12月31日188例经病原学检查确认铜绿假单胞菌感染患儿的临床资料,将患儿分为耐亚胺培南铜绿假单胞菌感染组(IRPA组)73例和亚胺培南敏感铜绿假单胞菌(imipenem-sensitive Pseudomonas aeruginosa,ISPA)感染组(ISPA组)115例.统计分析采用t检验或非参数检验、x2检验、单因素及多因素Logistic回归分析等方法. 结果 单因素分析发现,IRPA 组与ISPA组比较,胎龄较小[(34.0±3.5)周与(35.6±2.8)周,t=3.413,P＜0.01],出生体重较低[(1848.1±276.4)g与(2110.7±345.6)g,t=5.472,P＜0.01)];胎龄≤32周、出生体重＜1500 g、小于胎龄儿、分离出铜绿假单胞菌前2周内应用过亚胺培南、三代头孢菌素类抗菌药物治疗以及接受过机械通气、深部动静脉置管的比例高[67.1％(49/73)与45.2％(52/115)、73.9％(54/73)与33.0％(38/115)、68.5％(50/73)与29.6％(34/115)、72.6％(53/73)与27.0％(31/115)、65.8％(48/73)与33.0％(38/115)、78.1％(57/73)与61.7％(71/115)、83.6％(61/73)与65.2％(75/115)],差异均有统计学意义(P均＜0.05或0.01).多因素Logistic回归分析发现分离出铜绿假单胞菌前2周内应用过亚胺培南治疗是IRPA感染的独立危险因素(OR=6.409,95％CI:1.926～21.333,P=0.002).结论 新生儿重症监护病房患儿发生IRPA感染与其胎龄及出生体重相关,曾经使用亚胺培南治疗为独立危险因素.     

Opioid analgesia for infants in the neonatal intensive care unit

There is an ethical obligation to relieve the pain and suffering in newborn infants. Opioids have been demonstrated to blunt the physiologic effects of pain and may prevent some of the clinical consequences of unmanaged pain. There are sufficient data to recommend the clinical use of opioid analgesics for the treatment of pain in the neonate. Neonates exposed to opioid analgesics can experience adverse effects. Adverse effects can be minimized by the use of various drug administration techniques and close monitoring. Further research is needed to determine how to optimize their effects. Data on the long-term effects of neonatal opioid exposure are warranted.     

Oral care in a neonatal intensive care unit

Objective: Compare the oral colonization profile of premature infants admitted at NICU before and after doing oral care routine with sterile water versus no intervention.

Methods: It was a randomized clinical trial composed of 37 premature infants admitted at the Neonatal Intensive Care Unit (NICU) with a birth weight (BW) <1500?g. They were distributed in two groups: the study group (SG) with 15 patients who received an oral hygiene with sterile water; and a control group (CG) (no intervention) formed by 22 patients. Primary outcome was oral colonization profile before and after doing oral care.

Result: In the study group, the number of patients colonized by the Gram-positive bacteria at the beginning of the study was 53% versus 40% at the end (p=0.10). For Gram negative, 40% at the study’s beginning versus 60% at the end (p=0.18). In the control group, the number of colonized patients for the Gram-positive bacteria at the onset of the study was 54.5% versus 32% patients at the end (p=0.24). For Gram negative, 32% patients at the start of the study versus 77% at the end (p?=?0.003).

Conclusion: There is a significant increase of the Gram-negative flora in those patients without oral care.     

Exchange transfusion for neonatal hyperbilirubinemia: an 8-year single center experience at a tertiary neonatal intensive care unit in Turkey

Objective: The aim of present study was to evaluate the indications and the complications associated with neonatal exchange transfusion (ET) performed for hyperbilirubinemia.

Methods: This study included overall 306 neonates who underwent ET between 2005 and 2012. The demographic characteristics of patients, causes of jaundice and adverse events occurred during or within 1 week after ET were recorded from their medical files. Those newborns that underwent ET were classified as either “otherwise healthy” or “sick” group.

Results: Of the 306 patients who underwent ET, 244 were otherwise healthy and had no medical problems other than jaundice. The remaining 62 patients were classified as sick that had medical problems other than jaundice ranging from mild to severe. The mean gestational age was 37.6?±?2.5 weeks and the mean peak total bilirubin levels was 25.8?±?6.6?mg/dl. The mean age at presentation was 5.4?±?3.8?d for all infants. The most common cause of hyperbilirubinemia was ABO isoimmunization (27.8%). None of newborns died secondary to ET. Three infants had had necrotizing enterocolitis, and also three infants had had acute renal failure. The most common encountered complications of ET procedure were hyperglycemia (56.5%), hypocalcaemia (22.5%) and thrombocytopenia (16%).

Conclusions: Our data showed that ABO isoimmunization was the most common cause of hyperbilirubinemia. Even mortality was not seen, very rare but major gastrointestinal and renal complications were associated with ET. The majority of adverse events associated with ET were laboratory abnormalities mainly hyperglycemia, hypocalcaemia and thrombocytopenia which were asymptomatic and treatable.     

Outbreak investigation in a neonatal intensive care unit

Outbreaks of healthcare-acquired infection can be devastating in neonatal intensive care units. Neonates are especially susceptible hosts because of prematurity of organ systems, low birth weight, and the use of invasive devices. This article outlines methodologies for infection surveillance and recognition of outbreak events. Principles of infection control in the neonatal intensive care unit are reviewed in reference to an outbreak setting, and a multidisciplinary team approach to developing a plan of action to halt the outbreak and find the source is discussed. Epidemiologic methods for determining the geographical extent and timeline of an outbreak, potential reservoirs or a common source of infection are reviewed.     

Maternal production of milk for infants in the neonatal intensive care unit

Mother's own milk (MOM) feeding is a cost-effective strategy to reduce risks of comorbidities associated with prematurity and improve long-term health of infants hospitalized in the Neonatal Intensive Care Unit (NICU). Significant racial and socioeconomic disparities exist in MOM provision in the NICU, highlighting the importance of developing strategies to reduce these disparities. Mothers of infants in the NICU experience many health concerns which may negatively impact lactation physiology. Objective measures of lactation physiology are limited but may assist in identifying mothers at particular risk. Several strategies to assist mothers of hospitalized infants are essential, including maternal education, qualified lactation professionals, early and frequent milk expression with a hospital-grade double electric breast pump, and providing support for transitioning to direct breastfeeding prior to discharge from the NICU.     

Evidence-based design for infants and staff in the neonatal intensive care unit

Conscientious architects are becoming increasingly aware of the impact of design decisions on the sensory environment of the neonatal intensive care unit (NICU). This article addresses the relevance of theories of environmental psychology to NICU design. Design research on infants and staff in NICUs is summarized, and future research directions are identified.     

Infants with congenital anomalies admitted to neonatal intensive care units

The objective of this study was to describe the congenital anomalies in 17 Canadian neonatal intensive care units (NICUs) and their impact on mortality, morbidity, and resource utilization. This study was performed using a database analysis of 19,507 consecutive admissions. Results show that 13.7% of admissions had one or more anomalies. There was wide variation in incidence between NICUs (4.4 to 36.6%). Congenital anomalies were associated with increased severity of illness, and higher mortality, morbidity, and resource use. Inclusion of congenital anomalies improves mortality prediction in regression analyses models. Congenital anomalies have a significant impact on NICU outcomes and resource use.     

Body temperatures of very low birth weight infants on admission to a neonatal intensive care unit

Objective: Hypothermia occurs frequently in the first minutes after birth in preterm infants. Hyperthermia also occurs, often as a consequence of efforts to provide thermal support. Both hypothermia and hyperthermia are potentially harmful. Our objective was to examine the distribution of admission temperatures of very low birth weight (VLBW) infants, the effect of gestational age on admission temperatures, and the time required for correction of low temperatures.

Methods: Admission axillary temperatures were retrieved from the medical records for all VLBW infants born in our hospital during a 5-year period. The temperatures were classified as severe (<35.0?°C), moderate (35.0–35.9?°C), or mild (36.0–36.4?°C) hypothermia, normothermia (36.5–37.4?°C), or hyperthermia (≥37.5?°C). The relationship between gestational age and admission temperature was examined. In addition, we analyzed the time required for normalization of low temperatures.

Results: Overall, 12% of infants were severely hypothermic, 40% moderately hypothermic, 27% mildly hypothermic, 19% normothermic, and 2% hyperthermic. Gestational age was inversely related to hypothermia risk and to the time required for recovery to normothermia.

Conclusion: Admission hypothermia is common among VLBW infants and is affected by gestational age.     

Predictors of needs in mothers with infants in the neonatal intensive care unit

Forty‐six mothers with infants in an urban hospital's neonatal intensive care unit (NICU) were asked to rate the importance of having various needs met in five categories: (1) support (the need for interpersonal emotional support); (2) comfort (the need for personal physical comfort); (3) information (the need to obtain realistic information about the infant); (4) proximity (the need to remain near the infant); and (5) assurance (the need to feel confident about the infant's outcome). Overall, mothers viewed needs in the area of assurance as most important and needs in the area of support as least important to have fulfilled. Multiple regression analyses revealed significant predictive relationships between annual household income and mothers' needs in the area of support, and infant length of stay in the NICU and mothers' information needs. The findings from this study can be used by professionals when interacting with families, as well as during the design and implementation of parent support programs in the NICU.     

Stress and anxiety among mothers of premature infants in a Malaysian neonatal intensive care unit

Objective: This study aims to determine maternal stress and anxiety as perceived by mothers whose premature infants were admitted to the neonatal intensive care unit (NICU) and to identify maternal stress and its relationship with maternal and infant characteristics and anxiety.

Background: Vulnerable premature infants commonly require special care in the NICUs. In most cases, prolonged hospitalization results in stress and anxiety for the mothers.

Methods: A non-probability convenience survey was used in a public hospital, with 180 mothers completing the 26-item Perceived Stress Scale (PSS) and a 40-item State-Trait Anxiety Inventory (STAI).

Results: 56.5% of mothers had high levels of stress, 85.5% of mothers had a high level of state-anxiety and 67.8% of mothers had a high level of trait-anxiety. The stress experienced by these mothers had a significant relationship with anxiety, and was found to be associated with state and trait anxiety levels, but not with maternal and infant characteristics.

Conclusion: Mothers in this setting revealed high levels of stress and anxiety during their premature infants’ NICU admission. An immediate interventional programme focusing on relieving mothers’ anxiety and stress is needed to prevent maternal stress and anxiety at an early stage.     

Planning a developmentally appropriate neonatal intensive care unit

Neonatal intensive care units (NICUs) are now being redesigned in the wake of growing evidence that the physical environment of the NICU has a profound impact on all who live and work there.These new units reflect the universal trend of bringing families directly into the center of the medical care team. More than ever,such projects are bound to change how staff care for babies, how families interact with babies, how staff and families interact with one another, and how staff interact among themselves. When a NICU decides that a more developmentally appropriate environment should be initiated, the question of funding and obtaining other resources inevitably arises. This chapter identifies the essential components that should be included when planning to seek investments in NICU facilities.     

Discharge breastmilk feeding rates in asymptomatic term newborns admitted to the neonatal intensive care unit for maternal chorioamnionitis

Purpose: To compare discharge breastmilk feeding rates among asymptomatic term newborns receiving 48-hour versus >48-hour antibiotics in the neonatal intensive care unit (NICU) and a cohort of well-baby nursery (WBN) newborns.

Materials and methods: This retrospective review included asymptomatic term neonates admitted to the NICU due to maternal chorioamnionitis and a comparison group of WBN neonates between January 2012 and December 2015. Demographic, birth, feeding, and lactation consultant visit data were analyzed in univariate and multivariate models.

Results: Among 272 NICU neonates, 237 (87%) received 48-hour antibiotics versus 35 (13%) who received >48-hour (h) antibiotics; a cohort of 428 WBN neonates was studied for comparison. Exclusive breastmilk feeding was seen in 14% of NICU versus 35% of WBN neonates (p?48?h antibiotics was not associated with altered discharge breastmilk feeding (14 versus 14%; p?=?.89). On multivariate logistic regression analysis among NICU subjects, older maternal age (p?p?=?.02), first-feed breastmilk (p?p?=?.012) were associated with increased discharge breastmilk feeding.

Conclusions: NICU admission for presumed early-onset sepsis due to maternal chorioamnionitis was associated with reduced discharge breastmilk feeding in asymptomatic term neonates, but prolonged antibiotic exposure was not. We speculate that demographic factors, such as maternal age and parity, may aid in focusing lactation consultant efforts to potentially improve NICU exclusive discharge breastmilk feeding rates.