Evaluation of a lactation support service in a children's hospital neonatal intensive care unit.

Breastfeeding hospitalized infants can be difficult. The authors assessed the effectiveness of an International Board Certified Lactation Consultants (IBCLC) service to increase the proportion of infants given their own mother's milk (OMM) in a children's hospital neonatal intensive care unit (NICU). The charts of 350 randomly selected patients admitted the year before and after implementation of the service in July 1997 were abstracted. Factors significantly associated with infants being given OMM included infant sex, ethnicity, length of NICU stay, and 5-minute Apgar score. After comparison of the periods before and after program implementation, the proportion of NICU infants ever given their OMM was found to have increased from 31% to 47% (P = .002). This increase differed significantly in relation to infants' clinical status and/or management (5-minute Apgar score, length of NICU stay, and age at NICU admission) but not in relation to maternal factors. Mothers with infants in the NICU should have access to lactation counseling.     

Correlation of MRI Brain Injury Findings with Neonatal Clinical Factors in Infants with Congenital Diaphragmatic Hernia

BACKGROUND AND PURPOSE:Infants with congenital diaphragmatic hernia are reported to have evidence of brain MR imaging abnormalities. Our study aimed to identify perinatal clinical factors in infants with congenital diaphragmatic hernia that are associated with evidence of brain injury on MR imaging performed before hospital discharge.MATERIALS AND METHODS:MRIs performed before hospital discharge in infants with congenital diaphragmatic hernia were scored for brain injury by 2 pediatric neuroradiologists. Perinatal variables and clinical variables from the neonatal intensive care unit stay were analyzed for potential associations with brain MR imaging findings.RESULTS:Fifty-three infants with congenital diaphragmatic hernia (31 boys) were included. At least 1 abnormality was seen on MR imaging in 32 infants (60%). The most common MR imaging findings were enlarged extra-axial spaces (36%), intraventricular hemorrhage (23%), ventriculomegaly (19%), white matter injury (17%), and cerebellar hemorrhage (17%). The MR imaging brain injury score was associated with extracorporeal membrane oxygenation (P = .0001), lack of oral feeding at discharge (P = .012), use of inotropes (P = .027), and gastrostomy tube placement before hospital discharge (P = .024). The MR imaging brain injury score was also associated with a large diaphragmatic defect size (P = .011).CONCLUSIONS:Most infants with congenital diaphragmatic hernia have at least 1 abnormality identified on MR imaging of the brain performed before discharge. The main predictors of brain injury in this population are a requirement for extracorporeal membrane oxygenation, large diaphragmatic defect size, and lack of oral feeding at discharge.

Congenital diaphragmatic hernia (CDH), with an incidence of 1 case per 2000 live births, is an anomaly associated with substantial morbidity and mortality.¹ Survivors of CDH are at risk for long-term respiratory, gastrointestinal, nutritional, hearing, and neurologic sequelae, requiring multidisciplinary support, especially during early childhood.¹ Prenatal predictive factors for increased morbidity and mortality include prenatal imaging findings of liver herniation into the chest, lung to head ratio on prenatal sonography, or lung volumes on fetal MR imaging.^2–4 The size of the diaphragmatic defect is another factor that likely plays a major role in morbidity and mortality in infants with congenital diaphragmatic hernia.⁵ However, the association of the defect size with evidence of injury on brain imaging has not been studied, to our knowledge.Long-term neurodevelopmental and neurobehavioral disabilities are reported in up to 70% of infants with congenital diaphragmatic hernia.^6–9 Both brain maturational delays and evidence of brain injury have been reported on imaging.^8,9 There continues to be some controversy about the correlation of neuroimaging abnormalities in CDH with neurologic outcome. In a small cohort of patients with CDH with prenatal and postnatal imaging, Tracy et al⁹ identified an association between brain injury seen on postnatal CT/MR imaging in 4 infants and neurodevelopmental outcome at 1 year. There was no correlation between prenatal factors and neurodevelopmental outcome in this study.⁹ In another study by Danzer et al,¹⁰ postnatal brain MR imaging abnormalities were associated with lower cognitive scores, motor dysfunction, and language deficits.The impact of extracorporeal membrane oxygenation (ECMO) on neonates with CDH requiring ECMO is of clinical relevance. Studies suggest that neonates with CDH who require ECMO have a greater incidence of adverse neurodevelopmental sequelae, though it unclear whether the severity of the illness leading up to ECMO (hypercapnia, hypotension, and so forth) or the ECMO itself should be implicated.^6,11Which clinical factors in the neonatal intensive care unit play a role in brain injury in infants with CDH is yet to be determined.In this study, we have developed a brain injury score to determine whether brain injury seen on predischarge MRI in infants with CDH is associated with diaphragmatic defect size and postnatal clinical factors in the NICU.     

Amplitude-integrated EEG is useful in predicting neurodevelopmental outcome in full-term infants with hypoxic-ischemic encephalopathy: a meta-analysis

Hypoxic ischemic encephalopathy is a common cause of neurological complications resulting in chronic handicapping conditions, such as cerebral palsy. Amplitude-integrated electroencephalography (EEG) has been used in many European countries for more than a decade in the evaluation of infants with hypoxic ischemic encephalopathy but has not been widely used in the United States. The objective of this study was to evaluate the evidence supporting use of amplitude-integrated EEG as a quantitative predictor of neurodevelopmental outcome in full-term infants with hypoxic ischemic encephalopathy. To assess efficacy, the authors performed a meta-analysis of the literature evaluating the use of the amplitude-integrated EEG or cerebral function monitor in full-term infants with hypoxic ischemic encephalopathy and their neurodevelopmental outcome. A total of 8 studies were eligible for the primary meta-analysis. There was an overall sensitivity of 91% (95% CI 87-95) and a negative likelihood ratio of 0.09 (95% CI .06-.15) for amplitude-integrated EEG tracings to accurately predict poor outcome. Amplitude-integrated EEG is a valuable bedside tool for predicting long-term neurodevelopmental outcome in term infants with hypoxic ischemic encephalopathy. This information is useful in structuring communication and care plans for physicians and parents. Early assessment techniques such as amplitude-integrated EEG provide objective means for determining inclusion in clinical studies evaluating therapies for hypoxic ischemic encephalopathy and for predicting which patients are most likely to respond to treatment.     

The large vestibular aqueduct: A new definition based on audiologic and computed tomography correlation

OBJECTIVE: The study goal was to determine the prevalence and clinical significance of a large vestibular aqueduct (LVA) in children with sensorineural hearing loss (SNHL). STUDY DESIGN AND SETTING: We conducted a retrospective review of a pediatric SNHL database. One hundred seven children with SNHL were selected and their radiographic and audiometric studies were evaluated. Radiographic comparisons were made to a group of children without SNHL. RESULTS: A vestibular aqueduct (VA) larger than the 95th percentile of controls was present in 32% of children with SNHL. Progressive SNHL was more likely to occur in ears with an LVA and the rate of progressive hearing loss was greater than in ears without an LVA. The risk of progressive SNHL increased with increasing VA size as determined by logistic regression analysis. CONCLUSIONS: An LVA is defined as one that is >or=2 mm at the operculum and/or >or=1 mm at the midpoint in children with nonsyndromic SNHL. An LVA appears to be more common than previously reported in children with SNHL. A linear relationship is observed between VA width and progressive SNHL. SIGNIFICANCE: The finding of an LVA in children with SNHL provides diagnostic as well as prognostic information.     

Urinary NGAL in premature infants

Premature infants are at unique risk for developing acute kidney injury (AKI) due to incomplete nephrogenesis, early exposure to nephrotoxic medications, and coexisting conditions such as patent ductus arteriosus (PDA) and respiratory distress syndrome (RDS). Unfortunately, laboratory testing for the diagnosis of AKI in this population is problematic because of the physiology of both the placenta and the extra-uterine premature kidney. Recent research has led to the development of promising biomarkers for the early detection of AKI in children but there are no published reports in neonates. Our goal was to determine whether urine neutrophil gelatinase-associated lipocalin (NGAL) was detectable in premature infants and to correlate levels with gestational age, birth weight (BW), or indomethacin exposure. We enrolled 20 infants in four BW groups: 500-750, 751-1000, 1001-1250, and 1251-1500 g. Urine was collected every day for the first 14 d of life. Neonates born at earlier gestational ages and lower BWs had higher urine NGAL levels (p < 0.01). We conclude that urine NGAL is easily obtained in premature infants and that it correlates significantly with both BW and gestational age. The use of urinary NGAL as a biomarker of AKI in premature infants warrants further investigation.