Partial Enteral Discharge Programs for High-risk Infants

Premature infants or infants born with complex medical problems are at increased risk of having delayed or dysfunctional oral feeding ability. These patients typically require assisted enteral nutrition in the form of a nasogastric tube (NGT) during their NICU hospitalization. Historically, once these infants overcame their initial reason(s) for admission, they were discharged from the NICU only after achieving full oral feedings or placement of a gastrostomy tube. Recent programs show that these infants can be successfully discharged from the hospital with partial NGT or gastrostomy tube feedings with the assistance of targeted predischarge education and outpatient support. Caregiver opinions have also been reported as satisfactory or higher with this approach. In this review, we discuss the current literature and outcomes in infants who are discharged with an NGT and provide evidence for safe practices, both during the NICU hospitalization, as well as in the outpatient setting.

Use of Neuromuscular Electrical Stimulationfor Swallowing Habilitation in High-Risk Infants: A Survey of Clinical Practice

Purpose: The purpose of this clinical focus article was to identify clinical practice patterns of speech-language pathologists (SLPs) who use neuromuscular electrical stimulation (NMES) with the high-risk infants, specifically, the modality treatment parameters and physiological rationale. Method: An online survey was disseminated to query use of NMES by licensed SLPs who routinely address swallowing habilitation in high-risk infants. Results: Eleven of the 40 practicing SLPs who completed the survey indicated they have used NMES on neonates and infants. Most survey respondents reported not using NMES with infants. Of the SLPs who used this modality, over half reported they relied on clinical judgment for determination of NMES dose, frequency of treatments, electrode placement, and discharge determination. While SLPs acknowledged that little empirical evidence is available, those who used this modality indicated that the American Speech-Language-Hearing Association should support this modality in infants. Conclusions: Reliance on clinical judgment, as indicated by SLPs who use NMES on high-risk infants, is not consistent with the evidence-based practice triad, which encourages the use of high-quality peer-reviewed published evidence to inform clinical decision-making. Additional basic and applied research is needed to support use of NMES as a therapeutic modality in infants.

Dietary exposures and allergy prevention in high-risk infants

Infants at high risk for developing a food allergy have either an atopic condition (such as eczema) themselves or an immediate family member with such a condition. Breastfeeding should be promoted and supported regardless of issues pertaining to food allergy prevention, but for infants whose mothers cannot or choose not to breastfeed, using a specific formula (i.e., hydrolyzed formula) is not recommended to prevent food allergies. When cow’s milk protein formula has been introduced in an infant’s diet, make sure that regular ingestion (as little as 10 mL daily) is maintained to prevent loss of tolerance. For high-risk infants, there is compelling evidence that introducing allergenic foods early—at around 6 months, but not before 4 months of age—can prevent common food allergies, and allergies to peanut and egg in particular. Once an allergenic food has been introduced, regular ingestion (e.g., a few times a week) is important to maintain tolerance. Common allergenic foods can be introduced without pausing for days between new foods, and the risk for a severe reaction at first exposure in infancy is extremely low. Pre-emptive in-office screening before introducing allergenic foods is not recommended. No recommendations can be made at this time about the role of maternal dietary modification during pregnancy or lactation, or about supplementing with vitamin D, omega 3, or pre- or probiotics as means to prevent food allergy.

1424. Short-Course Antibiotic Therapy for Urinary Tract Infection (UTI) in the NICU: It’s Safe and Effective!

Background Antibiotic overuse in the neonatal intensive care unit (NICU) has been associated with adverse patient outcomes such as necrotizing enterocolitis (NEC), late-onset sepsis, invasive candidiasis, bronchopulmonary dysplasia, neurodevelopmental impairment, and death. On 11/2020 at Nationwide Children’s Hospital, Columbus, OH, the Neonatal Antimicrobial Stewardship Program Committee recommended 5 days of antibiotic therapy with a subsequent antibiotic “timeout” for uncomplicated UTI without bacteremia as part of ongoing efforts to reduce antibiotic exposure among high risk infants in 7 Level 2/3/4 NICUs. Methods Retrospective review of all infants who received antimicrobial therapy for UTI after implementation of a UTI Diagnosis and Management Protocol. Twice weekly NEO-ASP meetings provided prospective audit and feedback to neonatologists on appropriate antibiotic therapy and duration. Pertinent clinical, laboratory, and outcome data were obtained from the infants’ electronic health record. Safety measure evaluated include recurrence of infection with the same previously identified pathogen in the fourteen days after discontinuation of antibiotic therapy and mortality. Results Since implementation of the UTI protocol, 28 infants (median gestational age, 28 wk [IQR, 26-30 wk; median birth weight, 1203 g [IQR, 731-1801 g]) received antimicrobial therapy for treatment of a UTI at a median age of 50 days (IQR, 28-69 days). The most frequent pathogens were E. coli (n=8), K. pneumoniae (n=5), and Enterobacter spp. (n=4). Median duration of antibiotic therapy was 6 calendar days (IQR, 5-6 days). Only 1 (4%) infant had antibiotic therapy restarted within 14 days of discontinuation of initial therapy; infant had fever but blood, urine, and CSF cultures were sterile and antibiotic therapy was discontinued after 48 hours. One (4%) infant (23 wk gestational age) died at 6 weeks of age from NEC totalis not related to the previous UTI. 22 (81%) infants have been discharged home while 6 remain in the NICU. Conclusion Our preliminary data suggests that short course antibiotic therapy (with a timeout) < ![if !supportAnnotations] >[SP1]< ![endif] > for uncomplicated UTIs in the NICU is an effective and safe therapy that ultimately may lead to less antibiotic exposure among high risk infants. Disclosures All Authors: No reported disclosures

Endogenous and social factors influencing infant vocalizations as fitness signals

This dissertation evaluated the role of social and endogenous prelinguistic vocalizations as vocal fitness signals in human development. It consists of three studies. The first investigated the saliency of infant vocal imitation using listener judgments regarding the degree of imitativeness in parent-infant vocal turn pairs. Participating listeners demonstrated moderate to high intra- and inter-rater agreement, suggesting vocal imitation has the potential to be used as a signal of fitness to caregivers in early development. The work also showed that vocal imitation in infancy is rare. The second study sought to quantify the extent to which infants produce vocalizations socially (directed to a caregiver) vs endogenously (not directed to a caregiver) in laboratory settings where parents either attempted to engage them or talked with another adult. The infants produced three times as many vocalizations endogenously as socially in both settings. High rates of endogenously produced sounds may result from evolutionary pressures to signal wellness to caregivers through vocalization. Extensive independent vocal play may offer infants the opportunity to explore sensorimotor characteristics of the vocal system and provide the raw material that parents can use in face-to-face interactions. The third study examined social and endogenous motivations in the emergence of advanced vocal forms. Specifically, it compared canonical babbling ratios of infants at low- and high-risk for autism across high and low levels of both vocal turn-taking and vocal play. Both groups showed a tendency to produce more canonical babbling during high turn-taking and high vocal play. The findings highlight a potentially robust internal social motivation for vocalization, even in the presence of likely social-cognitive differences such as risk for autism. High rates of endogenously produced canonical syllables in high-risk infants support the idea of robust evolutionary pressures for infants to signal fitness through vocalization. Furthermore, differences in vocal production across settings can inform our understanding of the importance of both vocal interaction and independent infant exploration of vocalization. This dissertation offers perspective on the ways in which social and endogenous factors reveal natural selection pressures on fitness signaling in the human infant.

119 Communicating Sensitive Information - An Exploration of Parental Perspectives on Prognostication of High Risk Infants

Primary Subject area Neonatal-Perinatal Medicine Background Preterm infants are at high risk of experiencing a range of impairments that may contribute to long-term challenges such as neurocognitive deficits. Physicians are often expected to give an outlook on future developmental outcomes of high-risk infants, often before sufficient time has elapsed to observe whether that particular child will demonstrate neurologic recovery from the initial injury. Clinicians often struggle with communicating this information, especially a poor prognosis, because of the worry about how these conversations affect families and their future expectations of the child. Objectives Our aim was to capture parents' retrospective perceptions of how their infant’s prognosis was communicated to them during their NICU stay. Design/Methods Semi-structured interviews were conducted over the phone with parents of former preterm infants with a birthweight below 1500 grams or parents of term infants who have sustained HIE requiring cooling. Parents were invited to participate when their child was between 12-36 months old at the time of the interview, so that parents would be able to have a sense of their child’s development and possible impairments. The data was analyzed thematically, with particular focus around the discourse of communication and prognostication. Results Twenty-three interviews were conducted: 20 with the biological mother, two with both biological parents, and one with the biological father. The average length of the interviews was 30 minutes. The main themes that recurred in the interviews included parental loss of control, needing to prepare for the unexpected, the value of shared decision making between the health care practitioners and parents, recognition and conveyance of uncertainty by the physician, and the importance of celebrating the present. Above all, a recurring theme mentioned by the majority of interviewees was the power of hope. While wanting to receive transparent and honest updates, parents felt strongly that giving them realistic hope was of utmost importance. Conclusion Although clinicians often feel pressured to deliver answers, parents found it helpful when clinicians acknowledged and explained the uncertainty that surrounds prognostication. While healthcare providers may feel the need to prepare parents for the worst, the importance of balancing this information with hope and positivity is what families remember and value years after the prognosis was given.