Framework for considering abnormal heart rate characteristics and other signs of sepsis in very low birth weight infants

Objective: A heart rate characteristics index (HeRO score), incorporating low variability and superimposed decelerations, was developed as a sepsis risk indicator for preterm infants in the NICU. A rise in the risk score should prompt consideration of other clinical changes that may be signs of sepsis to decide whether a workup and antibiotics are indicated. We aimed to develop a framework to systematically consider signs potentially indicating sepsis in very low birth weight (VLBW) infants. Study Design We developed easy-recall acronyms for ten signs of sepsis in VLBWs. Over 12 months in a level IV NICU, Neonatology Fellows completed a brief survey after each shift to document changes prompting sepsis work-ups. We analyzed associations between survey data, hourly HRC data, and the diagnosis of the work-up, grouped as culture-positive sepsis (CXSEP, positive blood or urine culture), clinical sepsis (CLINSEP, negative cultures treated with antibiotics ≥5 days), or sepsis ruled out (SRO, negative cultures, <3 days antibiotics). Results We analyzed 93 sepsis work-ups in 48 VLBW infants (35 CXSEP, 20 CLINSEP, 38 SRO). The most frequently cited changes prompting the work-ups were heart rate patterns and respiratory deterioration, which were common in all three categories. Low blood pressure and poor perfusion were uncommonly cited but were more likely to be associated with CXSEP than the other signs. A rise in the HeRO score ≥1 from 0-12h before the blood culture compared to 12-72h prior occurred in 31% of work-ups diagnosed as CXSEP, 16% CLINSEP, and 31% SRO. Conclusion The HeRO score can alert clinicians to VLBW infants at high or increasing risk for a sepsis-like illness, but HRC patterns are highly variable in individual babies. The easy-recall NeoSEP-10 framework can assist clinicians in considering other clinical changes when making decisions about sepsis work-ups and the duration of antibiotics.

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Early Vital Sign Differences in Very Low Birth Weight Infants with Severe Intraventricular Hemorrhage

American Journal of Perinatology ◽

10.1055/s-0041-1733955 ◽

2021 ◽

Author(s):

Santina A. Zanelli ◽

Maryam Abubakar ◽

Robert Andris ◽

Kavita Patwardhan ◽

Karen D. Fairchild ◽

...

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Vital Sign ◽

Intraventricular Hemorrhage ◽

Neonatal Intensive Care ◽

Very Low Birth Weight ◽

Cranial Ultrasound ◽

Low Birth Weight Infants ◽

Vlbw Infants ◽

Arterial Blood

Objective Severe intraventricular hemorrhage (sIVH, grades 3 and 4) is a serious complication for very low birth weight (VLBW) infants and is often clinically silent requiring screening cranial ultrasound (cUS) for detection. Abnormal vital sign (VS) patterns might serve as biomarkers to identify risk or occurrence of sIVH. Study Design This retrospective study was conducted in VLBW infants admitted to two level-IV neonatal intensive care units (NICUs) between January 2009 and December 2018. Inclusion criteria were: birth weight <1.5 kg and gestational age (GA) <32 weeks, at least 12 hours of systemic oxygen saturation from pulse oximetry (SpO2) data over the first 24 hours and cUS imaging. Infants were categorized as early sIVH (sIVH identified in the first 48 hours), late sIVH (sIVH identified after 48 hours and normal imaging in the first 48 hours), and no IVH. Infants with grades 1 and 2 or unknown timing IVH were excluded. Mean heart rate (HR), SpO2, mean arterial blood pressure (MABP), number of episodes of bradycardia (HR < 100 bpm), and desaturation (SpO2 < 80%) were compared. Results A total of 639 infants (mean: 27 weeks' gestation) were included (567 no IVH, 34 early sIVH, and 37 late sIVH). In the first 48 hours, those with sIVH had significantly higher HR compared with those with no IVH. Infants with sIVH also had lower mean SpO2 and MABP and more desaturations <80%. No significant differences in VS patterns were identified in early versus late sIVH. Logistic regression identified higher HR and greater number of desaturations <80% as independently associated with sIVH. Conclusion VLBW infants who develop sIVH demonstrate VS differences with significantly lower SpO2 and higher mean HR over the first 48 hours after birth compared with VLBW infants with no IVH. Abnormalities in early VS patterns may be a useful biomarker for sIVH. Whether VS abnormalities predict or simply reflect sIVH remains to be determined. Key Points

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Beneficial Effects of Probiotic Treatment on Gut Microbiota in Very Low Birth Weight Infants

Gastroenterology Research and Practice ◽

10.1155/2019/3682836 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7

Author(s):

Yue-feng Li ◽

Chuan-rui Zhu ◽

Xue-lei Gong ◽

Hui-ling Li ◽

Li-kuan Xiong ◽

...

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Gut Microbiota ◽

Very Low Birth Weight ◽

Secondary Outcome ◽

Rrna Gene ◽

Low Birth Weight Infants ◽

Microbial Composition ◽

Vlbw Infants ◽

Probiotic Treatment

The very low birth weight (VLBW) infant is at great risk for marked dysbiosis of the gut microbiota. In the present study, a total of 36 VLBW infants were randomly divided into two groups, who were treated with combined probiotics and placebo, and 72 fecal specimens on days 14 and 28 of life were collected from them. Finally, 32 fecal specimens extracted from 16 preterm VLBW infants were qualified and analyzed using 16S rRNA gene sequencing. The primary outcome was to evaluate the change of gut microbiota in VLBW infants after combined probiotic supplement. The secondary outcome was to analyze the correlation gut microbial composition and levels of cytokines. We found that probiotic treatment, but not placebo, decreased the α-diversity of gut microbiota in VLBW infants. At the phylum level, probiotic treatment strongly increased the abundance of Firmicutes, whereas that of Proteobacteria was significantly reduced. At the family level, Streptococcaceae and Lactobacillaceae became prevalent after probiotic treatment, while the relative abundance of Enterobacteriaceae was reduced in the meantime. Most notably, significant correlations were observed between Lactobacillaceae abundance and serum cytokine levels. Further studies are required to shed more light on the characteristics of gut microbiota of VLBW neonates. And the modulation of microbiota should be considered to improve the survival rate of VLBW infants.

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Pre-discharge growth pattern of very low birth weight infants (VLBW): A 5 year single center experience

Journal of Neonatal-Perinatal Medicine ◽

10.3233/npm-200592 ◽

2020 ◽

pp. 1-6

Author(s):

S.H. Elbeely ◽

M.A. AlQurashi

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Gestational Age ◽

Growth Pattern ◽

Very Low Birth Weight ◽

Single Center ◽

Low Birth Weight Infants ◽

Cross Sectional ◽

Vlbw Infants ◽

The Mean

BACKGROUND: Very low birth weight infants born prematurely are at greater risk for growth delays that lead to Ex-utero Growth Restriction (EUGR) during vulnerable periods of organ structural and functional development. There is considerable evidence that early growth failure has adverse effects on long term neurodevelopment in children which often persists into adulthood. METHODS: This is a single-center cross-sectional study on live newborn infants with birth weight ranges from 500 to 1500 grams (VLBW) and gestational age (GA) between 24–32 weeks who were admitted to NICU at KAMC-Jeddah over a 5 year period (2009–2013). This study aims to evaluate predischarge growth pattern of VLBW infants in terms of weight, head circumference (HC) and length and to identify important variables that have influenced such growth pattern. RESULTS: Of the 135 infants included in the final analysis, 68 (50.4%) were male and 67 (49.6%) were female and the mean gestational age was 28.83±2.064 weeks and the mean birth weight 1166.74±256 grams. Ninety-two infants (68%) had discharge weight at ≤10th percentile and forty four (32%) had their weight >10th percentile. HC was the lowest affected among the anthropometric measurements with 42% ≤10th percentile. In terms of linear growth, 62% had their length ≤10th percentile. Amongst infants born ≤750 grams, 71% and 70% had HC and height at ≤10th percentile respectively, at the time of discharge. BPD was significantly associated with EUGR (p = 0.026). CONCLUSIONS: This study demonstrates that almost 2/3rd of VLBW infants born at KAMC-Jeddah with birth weight ≤750 grams were discharged home with EUGR as demonstrated by their weight, length, and HC ≤10th percentile. BPD was found to be significantly associated with EUGR amongst post-natal factors influencing EUGR.

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Oropharyngeal Administration of Colostrum Increases Salivary Secretory IgA Levels in Very Low-Birth-Weight Infants

American Journal of Perinatology ◽

10.1055/s-0037-1603655 ◽

2017 ◽

Vol 34 (14) ◽

pp. 1389-1395 ◽

Cited By ~ 18

Author(s):

Coleen Greecher ◽

Kim Doheny ◽

Kristen Glass

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Very Low Birth Weight ◽

Late Onset ◽

Multicenter Trial ◽

Secretory Iga ◽

Control Group ◽

Low Birth Weight Infants ◽

Vlbw Infants ◽

Late Onset Sepsis

Aim Oropharyngeal administration of colostrum (OAC) has been proposed to provide mother's early milk to very low-birth-weight (VLBW) infants in the first few days of life. The aim of this study was to test the hypothesis that OAC would increase salivary secretory IgA (SsIgA). Patients and Methods Overall, 30 VLBW infants randomized to receive OAC or sterile water had salivary sampling for SsIgA on the day of life (DOL) 2, 7, and 14. The incidence of late-onset sepsis (LOS) and necrotizing enterocolitis (NEC) was determined prospectively. Within and between-group comparisons were made by paired and independent samples t-tests. Results Baseline characteristics were similar between groups. SsIgA was higher in OAC versus the control group (p < 0.05) on DOL 7, but not subsequently on DOL 14. There was no difference in LOS or NEC. Conclusion OAC increased SsIgA at DOL 7. A large, multicenter trial is needed to determine if OAC decreases LOS or NEC in VLBW infants.

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Incidence of bronchopulmonary dysplasia and mortality of very low birth weight infants in Vojvodina

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh171227075v ◽

2020 ◽

Vol 148 (1-2) ◽

pp. 52-57

Author(s):

Gordana Vilotijevic-Dautovic ◽

Aleksandra Doronjski ◽

Gordana Vijatov-Djuric ◽

Milena Bjelica

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Bronchopulmonary Dysplasia ◽

Very Low Birth Weight ◽

Developed Countries ◽

Supplemental Oxygen ◽

Low Birth Weight Infants ◽

Vlbw Infants ◽

Original Definition ◽

Overall Mortality

Introduction/Objective. The incidence of bronchopulmonary dysplasia (BPD) varies depending on the prematurity rate, definition, and therapy that are applied at a certain center. The average incidence of BPD for very low birth weight infants (VLBW) in developed countries ranges 4?53%. The mortality of VLBW infants is high and represents 50% of the total neonatal and infant mortality. In recent years, the survival limits are shifted towards lower gestations. The aim of our study was to determine the incidence and severity of BPD in VLBW infants in Vojvodina and the overall mortality. Methods. This retrospective study was conducted from January 2006 to December 2011 and included 504 infants with birth weight < 1,500 g. Results. In the total premature infants? population, 82.3% survived by the gestational age of 36 weeks. According to the original definition of BPD, as supplemental oxygen use at 28 days of life, BPD had 45.4% of infants. According to the severity based definition 19.4% had mild BPD, 19.8% moderate BPD and 6.5% severe BPD. If BPD is observed as supplemental oxygen use at 36 weeks postmenstrual age, BPD had 26% of infants. Conclusion. The overall mortality and incidence of BPD in our study are comparable to those in some developed countries and lower compared to underdeveloped countries.

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Protein Enrichment of Donor Breast Milk and Impact on Growth in Very Low Birth Weight Infants

Nutrients ◽

10.3390/nu13082869 ◽

2021 ◽

Vol 13 (8) ◽

pp. 2869

Author(s):

Ting Ting Fu ◽

Heather C. Kaplan ◽

Trayce Fields ◽

Alonzo T. Folger ◽

Katelyn Gordon ◽

...

Keyword(s):

Birth Weight ◽

Breast Milk ◽

Low Birth Weight ◽

Very Low Birth Weight ◽

Average Weight ◽

Protein Enrichment ◽

Z Score ◽

Low Birth Weight Infants ◽

Poor Growth ◽

Vlbw Infants

Protein content is often inadequate in donor breast milk (DBM), resulting in poor growth. The use of protein-enriched target-pooled DBM (DBM+) has not been examined. We compared three cohorts of very low birth weight (VLBW) infants, born ≤ 1500 g: DBM cohort receiving > 1-week target-pooled DBM (20 kcal/oz), MBM cohort receiving ≤ 1-week DBM, and DBM+ cohort receiving > 1-week DBM+. Infants followed a standardized feeding regimen with additional fortification per clinical discretion. Growth velocities and z-scores were calculated for the first 4 weeks (n = 69 for DBM, 71 for MBM, 70 for DBM+) and at 36 weeks post-menstrual age (n = 58, 64, 59, respectively). In total, 60.8% MBM infants received fortification >24 kcal/oz in the first 30 days vs. 78.3% DBM and 77.1% DBM+. Adjusting for SGA, length velocity was greater with DBM+ than DBM in week 1. Average weight velocity and z-score change were improved with MBM compared to DBM and DBM+, but length z-score decreased similarly across all groups. Incidences of NEC and feeding intolerance were unchanged between eras. Thus, baseline protein enrichment appears safe in stable VLBW infants. Weight gain is greatest with MBM. Linear growth comparable to MBM is achievable with DBM+, though the overall length trajectory remains suboptimal.

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Changes in Intubation Rates and Outcome of Very Low Birth Weight Infants: A Population-based Study

PEDIATRICS ◽

10.1542/peds.98.1.24 ◽

1996 ◽

Vol 98 (1) ◽

pp. 24-27 ◽

Cited By ~ 7

Author(s):

Christian F. Poets ◽

Brigitte Sens

Keyword(s):

Quality Assurance ◽

Birth Weight ◽

Low Birth Weight ◽

Very Low Birth Weight ◽

Controlled Trial ◽

Population Based ◽

Quality Assurance Program ◽

Low Birth Weight Infants ◽

Vlbw Infants ◽

Selective Approach

Objective. There have been indications of a recent decrease in intubation rates of very low birth weight (VLBW) infants in Germany. We wanted to quantify this decrease and analyze its effect on clinical outcome. Methods. Population-based data on the treatment and outcome at hospital discharge from a statewide quality assurance program were analyzed for 2001 VLBW infants (500 to 1499 g) born from 1992 to 1994 in Lower Saxony, North Germany. Results. The proportion of patients not intubated and mechanically ventilated increased from 7% to 14% in infants less than 1000 g and from 28% to 44% in those greater than or equal to 1000 g (P < .02 and < .01, respectively). This increase was not associated with any significant increase in adverse outcome such as death, intraventricular hemorrhage, periventricular leucomalacia, or bronchopulmonary dysplasia (BPD). Instead, there was an increase in the proportion of infants less than 1000 g who survived without BPD (from 38% in 1992 to 48% in 1994; P > .05) and a decrease in the proportion of infants greater than or equal to 1000 g in whom BPD developed (from 14% to 9%; P < .05). Conclusions. The data from a statewide quality assurance program show a significant reduction in the aggressiveness of the treatment of VLBW infants, which was not associated with an increased mortality or morbidity. This observational study, however, cannot define whether a more selective approach to the intubation of VLBW infants will ultimately result in a better outcome. A randomized, controlled trial would be required to answer this clinically important question.

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Sepsis and Mortality Prediction in Very Low Birth Weight Infants: Analysis of HeRO and nSOFA

American Journal of Perinatology ◽

10.1055/s-0041-1728829 ◽

2021 ◽

Author(s):

Angela C. Zeigler ◽

John E. Ainsworth ◽

Karen D. Fairchild ◽

James L. Wynn ◽

Brynne A. Sullivan

Keyword(s):

Birth Weight ◽

Blood Culture ◽

Low Birth Weight ◽

Very Low Birth Weight ◽

Late Onset ◽

Mortality Prediction ◽

Blood Cultures ◽

Low Birth Weight Infants ◽

Vlbw Infants ◽

Prediction Of Mortality

Objective Scores to predict sepsis or define sepsis severity could improve care for very low birth weight (VLBW) infants. The heart rate characteristics (HRC) index (HeRO score) was developed as an early warning system for late-onset sepsis (LOS), and also rises before necrotizing enterocolitis (NEC). The neonatal sequential organ failure assessment (nSOFA) was developed to predict sepsis-associated mortality using respiratory, hemodynamic, and hematologic data. The aim of this study was to analyze the HRC index and nSOFA near blood cultures in VLBW infants relative to diagnosis and sepsis-associated mortality. Study Design Retrospective, single-center study of VLBW infants from 2011 to 2019. We analyzed HRC index and nSOFA around blood cultures diagnosed as LOS/NEC. In a subgroup of the cohort, we analyzed HRC and nSOFA near the first sepsis-like illness (SLI) or sepsis ruled-out (SRO) compared with LOS/NEC. We compared scores by diagnosis and mortality during treatment. Results We analyzed 179 LOS/NEC, 93 SLI, and 96 SRO blood culture events. In LOS/NEC, the HRC index increased before the blood culture, while nSOFA increased at the time of culture. Both scores were higher in nonsurvivors compared with survivors and in LOS/NEC compared with SRO. The nSOFA 12 hours after the time of blood culture predicted mortality during treatment better than any other time point analyzed (area under the curve 0.91). Conclusion The HRC index provides earlier warning of imminent sepsis, whereas nSOFA after blood culture provides better prediction of mortality. Key Points

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Early Pulse Oximetry Data Improves Prediction of Death and Adverse Outcomes in a Two-Center Cohort of Very Low Birth Weight Infants

American Journal of Perinatology ◽

10.1055/s-0038-1654712 ◽

2018 ◽

Vol 35 (13) ◽

pp. 1331-1338 ◽

Cited By ~ 5

Author(s):

A. Wallman-Stokes ◽

J. Isler ◽

R. Sahni ◽

J. Moorman ◽

K. Fairchild ◽

...

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Pulse Oximetry ◽

Very Low Birth Weight ◽

Late Onset ◽

Adverse Outcomes ◽

Predictive Score ◽

Low Birth Weight Infants ◽

Vlbw Infants ◽

Net Reclassification Improvement

Background We previously showed, in a single-center study, that early heart rate (HR) characteristics predicted later adverse outcomes in very low birth weight (VLBW) infants. We sought to improve predictive models by adding oxygenation data and testing in a second neonatal intensive care unit (NICU). Methods HR and oxygen saturation (SpO2) from the first 12 hours and first 7 days after birth were analyzed for 778 VLBW infants at two NICUs. Using multivariate logistic regression, clinical predictive scores were developed for death, severe intraventricular hemorrhage (sIVH), bronchopulmonary dysplasia (BPD), treated retinopathy of prematurity (tROP), late-onset septicemia (LOS), and necrotizing enterocolitis (NEC). Ten HR-SpO2 measures were analyzed, with first 12 hours data used for predicting death or sIVH and first 7 days for the other outcomes. HR-SpO2 models were combined with clinical models to develop a pulse oximetry predictive score (POPS). Net reclassification improvement (NRI) compared performance of POPS with the clinical predictive score. Results Models using clinical or pulse oximetry variables alone performed well for each outcome. POPS performed better than clinical variables for predicting death, sIVH, and BPD (NRI > 0.5, p < 0.01), but not tROP, LOS, or NEC. Conclusion Analysis of early HR-SpO2 characteristics adds to clinical risk factors to predict later adverse outcomes in VLBW infants.

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