Slow versus fast enteral feed advancement in very low birth weight infants: a randomized control trial

OBJECTIVE: To evaluate the tolerance of rapid advancement of enteral feeds in VLBW babies. SETTING: Tertiary teaching hospital. DESIGN: Randomized controlled trial. METHODS: All stable neonates with birth weight less than 1250 grams were included in the study. The primary outcome variable was the time taken to achieve full enteral feeds (defined as 180 ml/kg/day). The secondary outcome variables were incidence of Necrotizing enterocolitis (NNEC) and incidence of apnea. At 48 hours, the infants were randomized into the slow advancement group (enteral feeds advanced by increments of 15 ml/kg/day) or fast advancement group (enteral feeds advanced by increments of 30 ml/kg/day). The monitoring during feeding included daily weight record, two hourly abdominal girth charting, gastric aspirates, apnea, time taken to reach full enteral feedings and for NNEC. RESULTS: There were 53 infants who were enrolled for the study (27 in the fast advancement group and 26 in the slow advancement group). In the fast advancement group, 20 percent completed the trial; whereas 14 (53.8 percent;) in the slow advancement group completed the study. The two groups were comparable for birth weights, gestational age, sex, intrauterine growth status, Apgar and CRIB scores. The infants in the fast group reached full enteral intake of 180 ml/kg/day significantly earlier (10 +/- 1.8 days) than in the slow group (14.8 +/- 1.5 days). The two groups were comparable for episodes of feed intolerance, apnea, NNEC. Infants in the fast group regained birth weight significantly earlier (median 18 days) than in the slow advancement group (median 23 days). CONCLUSIONS: Stable VLBW neonates can tolerate rapid advancements of enteral feeding without increased risk of adverse effects.     

Promoting shorter duration of ventilator treatment decreases the number of painful procedures in preterm infants

Aim:  To investigate whether promoting shorter ventilator treatment decreases the number of painful procedures and the use of analgesics in preterm infants.
Methods:  Retrospective patient chart review of all preterm infants in one Neonatal Intensive Care Unit (NICU) was carried out in 2000 (n = 240) and 2005 (n = 206). Between these cohorts, early nasal continuous positive airway pressure (nCPAP) application and early extubation policy were introduced.
Results:  Fewer infants were intubated (22 vs. 32%, p = 0.03), the duration of ventilator treatment decreased (6.7 SD 11.3 vs. 9.0 SD 11.1 days, p < 0.001) and nCPAP treatment became more common (41 vs. 25%, p < 0.001) in 2005 than in 2000. Similarly, the infants' exposure to painful procedures did not decrease significantly (61.9 SD 98.5 vs. 67.1 SD 104.3 procedures, p = 0.32) but the procedures related to respiratory support were fewer (45.2 SD 79.5 vs. 68.9 SD 91.1 procedures, p < 0.001) in 2005 than in 2000. In addition, the amount of pain medication used was significantly lower in 2005 than in 2000. One day on a ventilator included more painful procedures than a day on nCPAP (11.2 95% CI: 11.0–11.5 vs. 4.2 95% CI: 4.1–4.4 procedures, p < 0.001) during both study years.
Conclusion:  Early nCPAP and early extubation policies were successfully implemented in an NICU resulting in less invasive respiratory support. This was associated with fewer painful procedures and less pain medication in the preterm infants who required respiratory support. Despite this positive effect, the number of painful procedures in all preterm infants stayed at the same level. Our results provide further support for the use of nCPAP in preterm infants.     

Erythromycin fails to improve feeding outcome in feeding-intolerant preterm infants

OBJECTIVE: Approximately half of extremely low birth weight infants have feeding intolerance, which delays their achievement of full enteral feedings. Erythromycin, a motilin receptor agonist, triggers migrating motor complexes and accelerates gastric emptying in adults with feeding intolerance. Few studies have assessed the efficacy of this drug in preterm infants with established feeding intolerance. This study was designed to assess the efficacy of erythromycin in feeding-intolerant infants, as measured by gastric emptying, maturation of gastrointestinal motor patterns, and time to achieve full enteral feedings. METHODS: Subjects were 27 preterm infants who were admitted to the neonatal intensive care unit and who did not achieve full enteral feeding volumes (150 mL/kg/day) within 8 days of the initiation of feedings. In a controlled, randomized, double-blinded clinical trial, infants received intragastric erythromycin or placebo for 8 days without crossover. At study entry, the authors recorded motor activity in the antrum and the duodenum during fasting, in response to intragastric erythromycin (1.5 mg/kg) or placebo, and in response to feeding. Gastric emptying at 20 minutes and transit time from duodenum to anus were determined. Each infant then received erythromycin or placebo for 8 days, and feeding characteristics were prospectively tracked. RESULTS: Gastric emptying and characteristics of antroduodenal motor contractions were similar in the two groups, as were the transit times from duodenum to anus. Feeding outcomes were comparable in the two groups. CONCLUSION: Intragastric erythromycin does not improve feeding tolerance in preterm infants with established feeding intolerance because it fails to improve gastrointestinal function in the short or long term.     

Effect of early low-volume enteral substrate on subsequent feeding tolerance in very low birth weight infants

To determine the effect of small enteral feedings on small bowel function, 46 infants with birth weight less than 1500 g, selected on the basis of risk factors for feeding intolerance, were assigned randomly to one of two feeding groups. Group 1 received low-volume enteral feeds (12 ml/kg/day) in addition to parenteral alimentation for 10 days beginning on day 8 of life; group 2 received parenteral alimentation alone until day 18 of life. After this trial period feedings were increased by 15 ml/kg/day in all infants. Four infants (9%) developed necrotizing enterocolitis (one prior to any feeds, two in group 1, and one in group 2); two others were dropped from the study for reasons unrelated to feeding. The remaining 18 infants in group 1 had improved feeding tolerance compared with the 22 in group 2, as manifested by fewer days that gastric residuum totalled more than 10% of feedings (1.3 +/- 0.5 days vs 3.2 +/- 0.6 days, respectively, p less than 0.05) and fewer days that feedings were discontinued because of feeding intolerance (2.7 +/- 0.8 days vs 5.5 +/- 0.9 days, respectively, p less than 0.05). Consequently, 17 of 18 (94%) infants who had received the early low-volume enteral feedings achieved an enteral intake of 120 kcal/kg/day by 6 weeks of life, whereas only 14 of 22 (64%) infants in the delayed feeding group reached this intake (p less than 0.05). Peak total serum bilirubin concentrations were comparable in the two groups. The initiation of hypocaloric enteral substrate as an adjunct to parenteral nutrition improved subsequent feeding tolerance in sick infants with very low birth weight.     

Establishing enteral feeding in preterm infants with feeding intolerance: a randomized controlled study of low-dose erythromycin

OBJECTIVE: A prospective, double-blind, randomized, controlled trial was conducted to evaluate the effect of low-dose erythromycin on the time taken to attain full enteral feedings in preterm infants with very low birth weight and feeding intolerance. METHODS: Two groups of preterm infants (birth weight 相似文献   

Early feeding advancement in very low-birth-weight infants with intrauterine growth retardation and increased umbilical artery resistance

BACKGROUND: To investigate whether intrauterine growth retardation (birth weight <10th percentile), increased umbilical artery resistance (resistance index >90th percentile measured by Doppler velocimetry), or brain sparing (increased umbilical artery resistance and decreased middle cerebral artery resistance index <5th percentile) were associated with early feeding intolerance in very low-birth-weight (VLBW, <1,500 g) infants. METHODS: From July 1999 to December 2000, 124 inborn VLBW infants were enrolled in a prospective trial evaluating early enteral nutrition after a standardized feeding protocol (daily feeding advancement, 16 mL/kg birth weight). Feeding tolerance was assessed as the age at which full enteral feeds (150 mL/kg daily) were achieved. Data are shown as median, 25th, and 75th percentiles. RESULTS: Full enteral feeds were achieved at 15 days (range, 12-21 days) of age for all infants. Intrauterine growth retardation (full enteral feeding achieved at 14 days; range, 12-21 days), increased umbilical artery resistance (full enteral feeding achieved at 14 days; range, 11-16 days), and brain sparing (full enteral feeding achieved at 15 days; range, 14-20 days) were not associated with early feeding intolerance. CONCLUSION: Very low-birth-weight infants with intrauterine growth retardation, increased umbilical artery resistance, and brain sparing tolerated enteral feeding as well as appropriate-for-gestational-age VLBW infants.     

A double-blind placebo-controlled study on prophylactic use of cisapride on feed intolerance and gastric emptying in preterm neonates

OBJECTIVE: To evaluate whether prophylactic use of cisapride will reduce the incidence of feed intolerance and gastro-esophageal reflux, and improve gastric emptying in early neonatal period in preterm babies. DESIGN: Double blind randomized controlled trial. SETTING: Hospital based. SUBJECTS: Forty nine preterm babies between 29-34 weeks of gestation were administered either cisapride or placebo. METHODS: Babies were enrolled in the study once they reached 30 ml/kg/day of enteral feeding or when 25% of total fluid intake was received through the enteral route. Those with sepsis, congenital malformations and on aminophylline were excluded. The subjects were randomized to receive either cisapride or placebo in a dose of 0.2 mg/kg/dose every 8 hourly for 14 days or till discharge. During the study period babies were observed for clinical signs of feed intolerance as judged by increase in abdominal girth, increased prefeed gastric residuals or vomiting. Gastro-esophageal reflux and gastric emptying time was assessed by Technetium phytate scan on day 7 +/- 1. RESULTS: Feed intolerance was noticed in 59% of study and 41% of control population. No significant difference was noticed in the two groups in the total number of episodes of feed intolerance (1.54 +/- 2.4 vs 1.18 +/- 1.6). Nearly 50% of babies in each group had gastro-esophageal reflux. Gastric emptying time (mean (SD) and median) was found to be comparable (p = 0.70) in those on drug and placebo (58.1 (32.2 min) 48.8 min) vs (53.8 (34.6 min) 43.4 min). CONCLUSION: Cisapride does not reduce the incidence of feed intolerance, gastro-esophageal reflux and does not improve gastric emptying in normal preterm neonates.     

The addition of rosiglitazone to insulin in adolescents with type 1 diabetes and poor glycaemic control: a randomized-controlled trial

Objective:  To evaluate the effect of rosiglitazone, an insulin sensitizer, on glycaemic control and insulin resistance in adolescents with type 1 diabetes mellitus (T1DM)
Research design and methods:  Randomized, double-blind, placebo-controlled crossover trial of rosiglitazone (4 mg twice daily) vs. placebo (24 wk each, with a 4 wk washout period). Entry criteria were diabetes duration >1 yr, age 10–18 yr, puberty (≥Tanner breast stage 2 or testicular volume >4 mL), insulin dose ≥1.1 units/kg/day, and haemoglobin A1c (HbA1c) >8%. Responses to rosiglitazone were compared with placebo using paired t -tests.
Results:  Of 36 adolescents recruited (17 males), 28 completed the trial. At baseline, age was 13.6 ± 1.8 yr, HbA1c 8.9 ± 0.96%, body mass index standard deviation scores (BMI-SDS) 0.94 ± 0.74 and insulin dose 1.5 ± 0.3 units/kg/day. Compared with placebo, rosiglitazone resulted in decreased insulin dose (5.8% decrease vs. 9.4% increase, p = 0.02), increased serum adiponectin (84.8% increase vs. 26.0% decrease, p < 0.01), increased cholesterol (+0.5 mmol/L vs. no change, p = 0.02), but no significant change in HbA1c (−0.3 vs. −0.1, p = 0.57) or BMI-SDS (0.08 vs. 0.04, p = 0.31). Insulin sensitivity was highly variable in the seven subjects who consented to euglycaemic hyperinsulinaemic clamps. There were no major adverse effects attributable to rosiglitazone.
Conclusion:  The addition of rosiglitazone to insulin did not improve HbA1c in this group of normal weight adolescents with T1DM.     

Effects of formula supplementation in breast-fed infants with failure to thrive

Background:  The aim of the present study was to assess whether formula supplementation of infants with failure to thrive can improve underweight without jeopardizing breast-feeding.
Methods:  In a prospective intervention study 31 term exclusively breast-fed infants were studied, who were admitted to hospital at an age of 28–99 days with failure to thrive (≤40% expected weight gain for age and/or bodyweight ≤10th percentile for age) without underlying disease. Infant formula was offered ad libitum after each breast-feeding, while continued breast-feeding was supported.
Results:  Energy intake per day increased from 352 ± 111 kJ/kg (mean ± SD) at study start to 587 ± 115 kJ/kg ( P  < 0.001, days 1–3 of supplementation) and 501 ± 99 kJ/kg (days 29–31; P  < 0.001 vs study entry). Twenty-five infants continued to be partially ( n  = 21) or fully ( n  = 4) breast-fed. Human milk intake decreased from 476 ± 163 g/day (study days 1–3) to 349 ± 285 g/day (study days 29–31; P  < 0.01). The contribution of breast milk to total milk intake decreased from 100% to 42 ± 35% ( P  < 0.001). Supplementation over 31 days led to increased weight (0.98 [0.70], standard deviation scores [SDS]), length (+0.40 [0.41] SDS) and head circumference (+0.59 [0.93] SDS).
Conclusions:  One month of formula supplementation successfully improved growth in 72% of infants with failure to thrive on human milk feeding. Breast-feeding was maintained in 81% of infants.     

Correlation of troponin I with perinatal and neonatal outcomes in neonates with respiratory distress

Background:   The specific aims of the present study were to evaluate the associations between cardiac troponin I (Tn I) and perinatal events and whether Tn I serves as a predictor to evaluate neonatal outcomes.
Methods:   Tn I level was assessed in sick neonates with respiratory distress within 12 h after birth. Apgar scores, acidosis, ventilator or oxygen requirement, hospital days and placenta clues were recorded. A total of 80 sick neonates were enrolled (54 preterm and 26 full-term neonates) delivered at Shin-Kong Wu Ho-Su Memorial Hospital between July 2003 and December 2004.
Results:   There was a significant negative correlation between Apgar scores at 1 min and 5 min ( r =−0.383, P = 0.001; r =−0.500, P < 0.001), acidosis ( r =−0.309, P = 0.006), base excess ( r =−0.332, P = 0.003) and Tn I. The subjects were divided into two groups using the median level of 0.028 ng/mL as a cut-off. There were significantly fewer neonates with high Apgar score (>7 at 5 min; 27/40, 69.2% vs 38/40, 97.4%; P = 0.001) in the higher Tn I group (≥0.028 ng/mL). Lower pH (7.4 ± 0.10 vs 7.3 ± 0.1, P = 0.011), lower base excess (−1.0 ± 4.3 vs −4.4 ± 5.1, P = 0.003) and less placental weight (548.8 ± 195.36 g vs 396.56 ± 154.30 g, P = 0.019) were also seen in the higher Tn I group.
Conclusion:   Tn I may play a role in the assessment of perinatal outcomes but is not a precise predictor of neonatal outcomes. Tn I level of 0.028 ng/mL is also suggested as a predictor of severity of perinatal outcomes in neonates with respiratory distress.     

Effect of early feeding on maturation of the preterm infant''s small intestine

To determine the response of the preterm infant's intestine to entire feedings at different postnatal ages, we recorded results of manometry of the gastroduodenum and determined fasting plasma concentrations of gastrin, gastric inhibitory peptide, neurotensin, and peptide YY three times in each of two groups: 27 preterm infants were randomly assigned to receive hypocaloric enteral nutrition on postnatal days 3 to 5 (early feeding) or on days 10 to 14 (late feeding). Initial observations (study 1) were performed by the fifth postnatal day; study 2 was performed on days 10 to 14, and study 3 on days 24 to 28. Early-fed infants received hypocaloric feedings immediately after study 1; late-fed infants did not receive enteral feedings until the completion of study 2. Although motor activity and fasting gastrointestinal peptide concentrations did not differ between groups at study 1, at study 2 early-fed infants had significantly more mature motor patterns than did babies not being fed. Early-fed infants also had significantly higher plasma concentrations of gastrin and gastric inhibitory peptide than did late-fed infants; neurotensin and peptide YY values were similar in both groups. By the time of study 3, when late-fed infants had also received enteral feedings, gut development was not different in the two groups. However, early-fed infants were able to tolerate full oral nutrition sooner, had fewer days of feeding intolerance, and had shorter hospital stays. Thus the provision of early hypocaloric nutrition was associated with earlier nutrition of preterm infants' intestinal function and resulted in improved feeding tolerance. These findings support the use of early feedings in preterm infants.     

Managing "healthy" late preterm infants

Background:  Late preterm infants are often managed in nursery rooms despite the risks associated with prematurity. The objective of this study was to determine the risks facing late preterm infants admitted to nursery rooms and to establish a management strategy.
Methods:  A total of 210 late preterm infants and 2648 mature infants were assessed. Infants born at 35 and 36 weeks' gestation weighing ≥2000 grams admitted to a nursery room and not requiring medical intervention at birth were of particular interest. The admission rates to the neonatal intensive care unit were evaluated according to the chart review.
Results:  Infants born at 35 and 36 weeks' gestation weighing ≥2000 grams had significantly higher admission rates than term infants at birth (Cochran–Mantel–Haenszel test, P < 0.001; common risk ratio, 4.27; 95% confidence interval, 2.41–7.55) and after birth ( P < 0.001; common risk ratio, 3.57; 95% confidence interval, 2.40–5.33). More than 80% of admissions from the nursery room to the neonatal intensive care unit after birth were due to apnea or hypoglycemia in neonates born at 35 and 36 weeks' gestation. The admission rates due to apnea increased with decreasing gestational age. The admission rates due to hypoglycemia with no cause other than prematurity accounted for 24.3% of admissions for those born at 35 weeks' gestation and 14.1% of admissions for those born at 36 weeks' gestation; hypoglycemia due to other causes accounted for fewer admissions.
Conclusion:  The management strategy for late preterm infants should be individualized, based on apnea and hypoglycemia. The respiratory state of late preterm infants should be monitored for at least 2 days, and they should be screened for hypoglycemia on postnatal day 0.     

Early feeding after necrotizing enterocolitis in preterm infants

OBJECTIVE: To report our experience with an early initiation of enteral feedings after necrotizing enterocolitis (NEC). STUDY DESIGN: Over a 4-year period, all inborn infants with NEC Bell stage II or greater received enteral feedings, increased by 20 mL/kg/d, once no portal vein gas had been detected on ultrasound for 3 consecutive days (group 1). Infants were compared with a historic comparison group (group 2). RESULTS: Necrotizing enterocolitis rates were 5% (26/523) in the early feeding group and 4% (18/436) in the comparison group. One early feeding infant and two comparison group infants died of NEC, whereas two and one, respectively, had recurrent NEC. Enteral feedings were restarted at a median of 4 days (range, 3-14) versus 10 days (range, 8-22) after onset of NEC. Early feeding was associated with shorter time to reach full enteral feedings (10 days [range, 7-31] vs 19 days [range, 9-76], P<.001), a reduced duration of central venous access (13.5 days [range, 8-24] vs 26.0 days [range, 8-39], P<.01), less catheter-related septicemia (18% vs 29%, P<.01), and a shorter duration of hospital stay (63 days [range, 28-133] vs 69 days [range, 36-150], P<.05). CONCLUSION: Early enteral feeding after NEC was associated with significant benefits and no apparent adverse effects. This study was underpowered, however, to exclude a higher NEC recurrence risk potentially associated with this change in practice.     

Physical activity and overweight in children and adolescents using intensified insulin treatment

Aim:  To describe physical activity and inactivity and parameters associated with overweight in a population-based study of children and adolescents on intensive insulin treatment.
Methods:  Physical activity and inactivity were evaluated in 723 type 1 diabetic subjects, 240 children aged 6–10 yr and 483 adolescents aged 11–19 yr, using a questionnaire that can estimate total amount of time spent on inactivity and light, moderate and vigorous activity.
Results:  Overall, 54% of the participants do not fulfil the international recommendations of 60 min of moderate-to-vigorous activity per day. Girls are less active than boys in childhood (70 vs. 88 min/d, p = 0.01) and in adolescence (47 vs. 57 min/d, p = 0.02). Furthermore, this study shows that those who are more active are also those who seldom skip meals (p < 0.001). Forty-three percent of the participants watch TV for more than 2 h a day, and TV viewing was found to be related to overweight in children and adolescents with type 1 diabetes [OR: 2.5 (1.40–4.54), p = 0.002]. No statistical differences in physical activity were noted between the different intensified insulin regimens. Patients wearing insulin pumps were not less active.
Conclusion:  To increase physical activity to recommended level and limit TV viewing should be an important issue in education of all children and adolescents with type 1 diabetes, independent of insulin regimen.     

Birth asphyxia alters neonatal intestinal motility in term neonates.

As an extension of an earlier study showing that manometry can identify preterm newborns at risk for feeding intolerance, the authors investigated whether abnormalities of intestinal motor activity underlie the feeding intolerance seen in asphyxiated newborns. Low-compliance perfusion manometry was recorded within the first postnatal week in 25 term neonates admitted consecutively for respiratory diseases. Eleven of these neonates were identified to have experienced birth asphyxia because three concurrent features were present: 1-minute Apgar score of less than 2; 5-minute Apgar score of less than 4; and recurrent seizures within the first 48 postnatal hours. The remaining 14 neonates, who did not have any of these three characteristics, were considered to be nonasphyxiated control neonates. Motor activity differed in nonasphyxiated and asphyxiated neonates during fasting and feeding. During fasting, asphyxiated neonates had less migrating activity than nonasphyxiated neonates. In addition, episodes of motor quiescence and clustered phasic activity were less well organized in asphyxiated neonates. Both groups of neonates displayed a change in motor activity in response to a feeding infusion; however, the response was initiated significantly sooner in asphyxiated than in control neonates. All of the 11 asphyxiated neonates were intolerant of enteral feedings during the first poststudy week, but no control neonate was feeding intolerant. Six of the asphyxiated neonates were reevaluated 1 to 2 weeks later. During this latter study, motor activity in these asphyxiated neonates was similar to that of nonasphyxiated neonates; 5 of 6 of these neonates subsequently tolerated enteral feedings. It is speculated that changes in motor activity underlie the feeding intolerance that asphyxiated neonates typically exhibit.(ABSTRACT TRUNCATED AT 250 WORDS)     

Late and ultra late onset Streptococcus B meningitis: clinical and bacteriological data over 6 years in France

Background:  Group B Streptococcus (GBS) is one of the leading causes of sepsis and meningitis in newborn. The objective of this study was to describe the characteristics of GBS meningitis in children aged between 7 and 89 days (late onset disease – LOD group) and to compare them with children aged more than 3 months (ultra late onset disease – ULOD group).
Methods: Clinical and biological data were gathered by ACTIV/GPIP (a nationwide active surveillance network). The study population included 242 children hospitalized between 2001 and 2006 for GBS meningitis (220 in the LOD group and 22 in the ULOD group).
Results:  Univariate analysis revealed that gestational age (GA) was significantly lower in the ULOD group as compared with the LOD group (respectively 35.6 weeks vs. 37.9 weeks, p = 0.002). Prevalence of early preterm birth (before the 32nd week GA) was significantly higher in the ULOD group than in the LOD group (32% vs. 7%, p = 0.002). No significant difference was found between the two groups for biological characteristics of lumbar puncture, GBS serotypes, complications and survival rate.
Conclusion: These data suggest that LOD and ULOD would be the same clinical and bacteriological entity, except for prematurity, which seems significantly associated with ULOD.     

Prebiotic oligosaccharides reduce stool viscosity and accelerate gastrointestinal transport in preterm infants

Aim: To investigate whether a mixture of prebiotic non-digestible oligosaccharides (GosFos; referring to galacto- and fructo-oligosaccharides) would improve feeding tolerance in preterm infants on full enteral formula feeding. We hypothesized that GosFos would: (1) reduce stool viscosity and (2) accelerate gastrointestinal transport. Methods: In a placebo-controlled double-blind trial 20 preterm infants on full enteral nutrition (gestational age 27 (24-31) weeks, postnatal age 42 (11-84) days, and weight at study entry 1570 (1080-2300) g were randomly allocated to have their feedings supplemented with either GosFos (1 g/100 mL) or placebo for 14 days. Stool viscosity was measured by high-pressure capillary rheometry. Gastrointestinal transport time was assessed as the time from feeding carmine red to its appearance in the diaper. The hypotheses were tested as a priori ordered hypotheses. Data are shown as median (range). Results: Birth weight, gestational age, postnatal age, and weight at study entry did not differ between groups. GosFos significantly reduced both stool viscosity, as measured by extrusion force (32 (2-67) versus 158 (24-314) N), and gastrointestinal transit time (12 (4-33) versus 26 (5-52) h). No adverse effects were observed.

Conclusion: Formula supplementation with GosFos reduced stool viscosity and accelerated gastrointestinal transport. Further trials are required to investigate whether GosFos facilitates enteral feeding advancement and early enteral nutrition thereby eventually reducing the incidence of catheter-related nosocomial infections and improving long-term outcome.     

Once daily dose gentamicin in neonates — is our dosing correct?

Aim:  The aim of this paper is to study the safety and efficacy (measured by therapeutic level) of once daily gentamicin in neonates ≥32 weeks of gestation and ≤7 days of age.
Setting:  Level II neonatal intensive care unit.
Subjects:  Neonates ≥32 weeks of gestation and ≤7 days of age treated with gentamicin for presumed sepsis.
Methods:  Gentamicin was administered by intravenous injection at 4 mg/kg/day once daily. Peak and trough gentamicin levels were measured at the third dose.
Results:  In neonates with gestational age between 32 and 36 weeks, 14 out of 65 (22%) had trough serum concentration >2 mg/L. Only 39 (60%) had peak and trough levels within the therapeutic range. All babies who had audiometric evaluation (62 out of 65) had normal hearing. Out of the 65 babies, 60 had paired serum creatinine levels estimated and none had evidence of renal dysfunction. Among term neonates, only 2 out of 50 had the trough serum concentration of >2 mg/L. In 38 (76%) of the 50 neonates, the trough serum gentamicin concentration was <2.0 mg/L and the peak level was <10 mg/L. Forty-eight babies had audiometric evaluation which was normal.
Conclusion:  A dose of 4 mg/kg/day produces serum gentamicin levels outside the therapeutic range in two-fifths of neonates between 32 and 36 ± 6 weeks. A single dose of 4 mg/kg/day of gentamicin is appropriate for term babies and probably excessive for 32–36 weeks' neonates.     

Single-centre vs. population-based outcome data of extremely preterm infants at the limits of viability

Aim:  In response to the disappointing outcome data of the population-based EPICure study published in 2000, we compared the outcome of infants 22 0/7 to 25 6/7 weeks of gestational age (GA) in a single tertiary care centre 2000–2004 with that of EPICure.
Methods:  EPICure tools and definitions, including 30 months' Bayley Scales.
Results:  Of 83 infants <26 weeks born alive, more were admitted to intensive care – 82% vs. 68% (p  <  0.0001) – and more infants survived to discharge (57% vs. 26%, p <   0.0001; 69% vs. 39%, p  <  0.01, of those admitted to intensive care). More infants, as a percentage of live births, survived without severe (41%, 34/83 vs. 20%, 233/1185, p <   0.0001) or overall disability (22%, 18/83 vs. 13%, 155/1185, p  =  0.03). However, at the border of viability – GA 23 and 24 weeks – the rate of infants surviving without overall disability was not significantly higher (13%, 6/45 vs. 9%, 56/623).
Conclusion:  In infants <26 weeks of GA, increased rates of survival and survival without disability were observed in a single-centre inborn cohort born 5–8 years later than the EPICure cohort. This did not translate into increased survival without overall disability in infants of 23–24 weeks of GA.     

Basal insulin switch from NPH to glargine in children and adolescents with type 1 diabetes

Background:  Insulin glargine is a long-acting insulin analogue increasingly used instead of neutral protamine Hagedorn (NPH) insulin in young subjects with type 1 diabetes.
Objective:  We evaluated the clinical course of diabetes in children and adolescents who were switched from NPH to insulin glargine.
Methods:  Between August 2003 and November 2004, a total of 76 subjects were switched to glargine in our clinic, treating 340 children with type 1 diabetes. All the subjects had been receiving insulin NPH, and their serum C-peptide levels had been non-detectable for at least 1 yr. Data were collected retrospectively, and 12–18 months after the change, experiences with glargine were inquired using a questionnaire. Seven subjects (9.2%) discontinued glargine before 12 months, and seven refused to participate.
Results:  Data for 62 subjects were analyzed. At the switch (0 months), their mean age was 12.7 yr (range 5.1–17.5), mean duration of diabetes was 6.7 yr (range 1.8–14.3), and mean hemoglobin A1c was (HbA1c) 9.2%. Twelve months later (+12 months), the mean HbA1c remained similar (9.2%), the proportion of long-acting insulin was smaller (47.7 vs. 58.1%; p < 0.001), and the daily insulin dose was lower (0.97 vs. 1.05 IU/kg; p < 0.001). The number of injections was lower at +12 months (17.7% with more than five injections vs. 64.5%; p < 0.001). No differences were seen in weight for height or the number of severe hypoglycemias. Most subjects who continued with glargine for ≥12 months considered glargine better than NPH.
Conclusions:  A switch to insulin glargine retains a similar glycemic control and does not change the number of severe hypoglycemias.