Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants

BACKGROUND: We report a statewide quality improvement initiative aimed to decrease the incidence of extrauterine growth restriction among very low birth weight infants cared for in Tennessee NICUs. METHODS: The cohort consisted of infants born appropriate for gestational age between May 2016 and December 2018 from 9 NICUs across Tennessee. The infants were 23 to 32 weeks gestation and 500 to 1499 g birth weight. The process measures were the hours of life (HOL) when parenteral protein and intravenous lipid emulsion were initiated, the number of days to first enteral feeding, and attainment of full enteral caloric intake (110–130 kcal/kg per day). The primary outcome was extrauterine growth restriction, defined as weight <10th percentile for weight at 36 weeks postmenstrual age. Statistical process control charts and the Shewhart control rules were used to find special cause variation. RESULTS: Although special cause variation was not indicated in the primary outcome measure, it was indicated for the reduction in specific process measures: HOL when parenteral protein was initiated, HOL when intravenous lipid emulsion was initiated, and the number of days to attainment of full enteral caloric intake (among the hospitals considered regional perinatal centers). CONCLUSIONS: A statewide quality improvement initiative led to earlier initiation of parenteral and enteral nutrition and improved awareness of the importance of postnatal nutrition.

The Survival Rate of Extremely Low Birth Weight Infants Improved in Guangdong Province, China

Background With the increase in extremely low birth weight (ELBW) infants, their outcomes received special attention. However, in China, studies of the outcomes of ELBW infants are rare. Methods The hospitalized records of ELBW infants discharged from twenty-six neonatal intensive care units were reviewed and analyzed. Results A total of 2575 ELBW infants were enrolled and the overall survival rate was 55.11%. From 2008 to 2017, the number of ELBW infants increased rapidly from 91 to 466, and the survival rate improved steadily from 41.76–62.02%. The survival rate rose with increasing BW, the ascending level of regional economic development and specialist hospitals. The incidence of complications was neonatal respiratory distress syndrome (85.2%), bronchopulmonary dysplasia (63.7%), retinopathy of prematurity (39.3%), intraventricular hemorrhage (29.4%), necrotizing enterocolitis (12.0%), and periventricular leukomalacia (8.0%). Among the 1156 nonsurvivors, 90.0% of infants died during the neonatal period (≤ 28 days), and the other died after the neonatal period. A total of 768 ELBW infants died after medical care withdrawal, with economic factors and expected outcome being important causes. Conclusion The number of ELBW infants is increasing in China, and the overall survival rate is still low but is improving steadily.

Nutritional Factors Associated with Late-Onset Sepsis in Very Low Birth Weight Newborns

Background: Delayed onset of minimal enteral nutrition compromises the immune response of preterm infants, increasing the risk of colonization and clinical complications (e.g., late-onset sepsis). This study aimed to analyze associations between late-onset sepsis in very low birth weight infants (<1500 g) and days of parenteral nutrition, days to reach full enteral nutrition, and maternal and nutritional factors. Methods: A cross-sectional study was carried out with very low birth weight infants admitted to a neonatal intensive care unit (NICU) of a reference maternity hospital of high-risk deliveries. Data regarding days of parenteral nutrition, days to reach full enteral nutrition, fasting days, extrauterine growth restriction, and NICU length of stay were extracted from online medical records. Late-onset sepsis was diagnosed (clinical or laboratory) after 48 h of life. Chi-squared, Mann–Whitney tests, and binary logistic regression were applied. Results: A total of 97 preterm infants were included. Of those, 75 presented late-onset sepsis with clinical (n = 40) or laboratory (n = 35) diagnosis. Maternal urinary tract infection, prolonged parenteral nutrition (>14 days), and extrauterine growth restriction presented 4.24-fold, 4.86-fold, and 4.90-fold higher chance of late-onset sepsis, respectively. Conclusion: Very low birth weight infants with late-onset sepsis had prolonged parenteral nutrition and took longer to reach full enteral nutrition. They also presented a higher prevalence of extrauterine growth restriction than infants without late-onset sepsis.

Extended Interval Aminoglycoside Treatment for Klebsiella Pneumoniae Endocarditis in an Extremely Low Birth Weight Neonate

Infective endocarditis (IE) in neonates is associated with high mortality and incidence has been increasing over the past two decades. The majority of very low birth weight infants will be treated with at least one nephrotoxic medication during their hospital course. Over one-quarter of very low birth weight neonates exposed to gentamicin may develop acute kidney injury (AKI); this is particularly worrisome as AKI is an independent factor associated with increased neonatal mortality and increased length of stay. AKI during periods of neonatal nephrogenesis, which continues until 34–36 weeks postmenstrual age, may also have serious effects on the long-term nephron development which subsequently puts infants at risk of chronic kidney disease. Extended interval (EI) aminoglycoside (AMG) dosing has been used for decades in adult populations and has proven to reduce AKI while being at least as effective as traditional dosing, although there is limited published research for using an EI AMG in endocarditis in adults or pediatric patients. We describe an extremely low birth weight neonate, born preterm at 24 weeks gestation treated for Klebsiella pneumoniae IE that required AMG therapy who also had concurrent AKI. We utilized EI AMG combination therapy for treatment of Klebsiella pneumoniae endocarditis with good outcome and encourage others to report their experiences to improve our knowledge of EI AMG in this population.

Effect of Kangaroo Mother Care on Maternal Anxiety and Depression States at the Neonatal ICU: A Prospective Cohort Study

Objectives. To determine the effect of kangaroo mother care (KMC) on anxiety and depression of mothers of low-birth-weight neonates during the immediate newborn period. Method. Eligible participants were mothers of low-birth-weight infants (birth weight ≤2500 grams) admitted at a tertiary hospital's neonatal intensive care unit. Mothers were instructed on providing KMC daily to their infants during the study period (first seven days of life). Main Outcome Measure(s). The primary study outcome was the effect of KMC in improving maternal anxiety and depression scores in the immediate postpartum period using the locally validated Hospital Anxiety and Depression Scale-Pilipino (HADS/HADS-P). Results. A total of 171 mothers were enrolled in the study. Only 79 mothers provided KMC, and the rest (92) did not provide KMC. The anxiety and depression scores improved significantly from day 1 to 7 postpartum in both groups (p<0.05). Frequency of mothers categorized as having severe anxiety significantly decreased over time whether they provided KMC or not (KMC: 40.5%, 13.9%, 7.6% at Day 1 and 7 postpartum and day of discharge; No KMC: 35.9% and 27.2% at Day 1 and Day 7 postpartum). There was a significant reduction in the percentage of mothers categorized in the depressed group from Day 1 to Day 7 postpartum, among those who rendered KMC compared with those who did not (KMC: 7.6%, 2.5%, 0% at Day 1 and 7 postpartum and at the day of discharge vs. No KMC: 7.6% and 10.9% at Day 1 and 7 postpartum). There were no significant differences in the anxiety and depression scores at any period between mothers who rendered KMC > 6 hours and KMC ≤ 6 hours/day. Conclusion. Anxiety and depression scores significantly decreased over time in both mothers who rendered and did not render KMC to their infants. However, there was a significant reduction in the percentage of mothers categorized as having severe depression over time among those who rendered KMC compared to those who did not. Other factors aside from KMC may affect the maternal anxiety and depression states, such as instability of the infant.

Effectiveness of Kangaroo Mother Care in Intubated Preterm Neonates 28 to 36 Weeks Gestational Age, Weighing 600 to 2000 Grams at Birth: A Randomized Controlled Trial

Background. Kangaroo Mother Care (KMC) is the standard of care for stable low birth weight infants. Provision of KMC to intubated preterm infants may also be beneficial, but strong evidence is still lacking. Objective. To determine the effectiveness of KMC in decreasing mortality among intubated preterm neonates. Study Design. This is a non-blinded, parallel, non-inferiority randomized controlled trial. Methodology. All intubated, preterm admissions, 28-36 weeks gestation, weighing 600-2000 grams, with respiratory distress were included. They were randomized to the intervention group who received KMC for 2-4 hours daily while intubated and the control group who received care inside an incubator. Participants’ physiologic status – before, during, and after the intervention – was recorded. The primary outcome was mortality. Secondary outcomes included comorbidities, days intubated, and hospital stay. Results. There was a total of 32 patients. The risk of dying in the KMC group (n=16) was significantly reduced by 78% (RR 0.22; 95% CI 0.06 - 0.87 p=0.009). The KMC patients were also less likely to have hypothermia, nosocomial pneumonia, NEC, and late-onset neonatal sepsis (p<0.05). The KMC group had higher blood sugar levels (110 vs. 58, p=0.001) and required fewer days of intubation (3.5 vs.1.5 days, p<0.000) compared to the control group. There was no difference in the duration of the hospital stay. Conclusion. KMC is effective in decreasing mortality among intubated preterm neonates. Other comorbidities and days of intubation were also reduced.

Effect of Community-Initiated Kangaroo Mother Care on Fecal Biomarkers of Gut Function in Low Birth Weight Infants in North India: A Randomized Clinical Trial

This individually randomized trial was conducted to estimate the effect of promoting community-initiated Kangaroo Mother Care (ciKMC) in low birth weight (LBW) infants on gut inflammation and permeability. Participants included 200 stable LBW infants (weighing 1,500–2,250 g) in North India enrolled between May and October 2017. The ciKMC intervention included promotion and support of continuous skin-to-skin contact and exclusive breastfeeding through home visits. The mothers in the intervention arm were supported to practice ciKMC until 28 days after birth, i.e., the neonatal period, or till the baby wriggled out of KMC position, if earlier. Infant stool specimens were collected during the first week of birth, and within 1 week after end of the neonatal period. Concentrations of fecal neopterin (nmol/L), myeloperoxidase (ng/mL), and alpha-1-antitrypsin (μg/mL) were determined using ELISA, and composite enteric enteropathy (EE) score at the end of the neonatal period was calculated by principal component analysis. We did not find any substantial difference in means between the ciKMC and control arm infants in the log-transformed values of neopterin (0.03; 95% CI −0.15 to 0.21), myeloperoxidase (0.28; 95% CI −0.05 to 0.61) and alpha-1-antitrypsin (0.02; 95% CI −0.30 to 0.34). The mean (SD) composite EE score was 13.6 (7.5) in the ciKMC and 12.4 (8.3) in the control arm infants, and the adjusted difference in means was negligible, 0.4 (95% CI −1.8 to 2.7). Our findings suggest that the promotion of ciKMC did not affect gut inflammation and permeability in our target population of LBW infants in North India.

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.