Breastmilk use in preterm infants <29 weeks' gestational age in Australia, New Zealand and Singapore.

AIMS: To describe the prevalence of use of breastmilk and explore demographic characteristics and clinical outcomes associated with breastmilk provision in infants born <29 weeks' gestational age in Australia, New Zealand and Singapore. METHODS: This is a secondary analysis of data from a randomised controlled trial, which enrolled 1273 infants in 13 neonatal units across Australia, New Zealand and Singapore from 2012 to 2015. Infants were classified as formula-fed, donor milk-fed or mother's milk-fed at their first enteral feed and separately, at hospital discharge. RESULTS: The percentage of infants receiving mother's own milk differed between centres both at first feed (79% to 100%), and at hospital discharge (47.1% to 71.6%). Aboriginal, Torres Strait Islander and Southeast Asian heritage, drug use and smoking were associated with lower rates of fully breastmilk feeding at hospital discharge. There was no significant difference in growth outcomes, length of stay and feeding tolerance between feeding groups. CONCLUSIONS: Achieving high breastmilk feeding rates at hospital discharge for all preterm infants born <29 weeks' gestational age at hospital discharge is possible; however, targeted support for mothers who are Indigenous, Southeast Asian and/or using recreational drugs and/or smoking and/or experiencing social disadvantage may be needed. A better understanding and shared knowledge of practice variations within neonatal units with high breastfeeding rates could improve breastmilk access and equity for preterm infants. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY: ACTRN12612000503820.

Can 3-dimensional cranial ultrasound be used to successfully reconstruct a 2-dimensional image without compromising on image quality in a neonatal population?

BACKGROUND: Cranial ultrasound is frequently performed in neonatal intensive care units and acquiring 2-dimensional (D) images requires significant training. Three-D ultrasound images can be acquired semi-automatically. OBJECTIVE: This proof-of-concept study aimed to demonstrate that 3-D study image quality compares well with 2-D. If this is successful, 3-D images could be acquired in remote areas and read remotely by experts. MATERIALS AND METHODS: This was a prospective study of 20 neonates, who underwent both routine 2-D and 3-D cranial ultrasounds. Images were reconstructed into standard views extracted from the 3-D volume and evaluated by three radiologists blinded to the acquisition method. The radiologists assessed for the presence of anatomical landmarks and overall image quality. RESULTS: More anatomical structures were identified in the 3-D studies (P<0.01). There was a trend that 3-D ultrasound demonstrated better image quality in the coronal plane, and 2-D in the sagittal plane, only reaching statistical significance for two coronal views and two sagittal views. CONCLUSION: Overall, this study has demonstrated that 3-D cranial ultrasound performs similarly to 2-D and could be implemented into neonatal practice.

Diagnostic Utility of Whole Genome Sequencing After Negative Karyotyping/Chromosomal Microarray in Infants Born With Multiple Congenital Anomalies.

BACKGROUND: Achieving a definitive genetic diagnosis of unexplained multiple congenital anomalies (MCAs) in neonatal intensive care units (NICUs) infants is challenging because of the limited diagnostic capabilities of conventional genetic tests. Although the implementation of whole genome sequencing (WGS) has commenced for diagnosing MCAs, due to constraints in resources and faculty, many NICUs continue to utilize chromosomal microarray (CMA) and/or karyotyping as the initial diagnostic approach. We aimed to evaluate the diagnostic efficacy of WGS in infants with MCAs who have received negative results from karyotyping and/or CMA. METHODS: In this prospective study, we enrolled 80 infants with MCAs who were admitted to a NICU at a single center and had received negative results from CMA and/or karyotyping. The phenotypic characteristics were classified according to the International Classification of Diseases and the Human Phenotype Ontology. We assessed the diagnostic yield of trio-WGS in infants with normal chromosomal result and explored the process of diagnosing by analyzing both phenotype and genotype. Also, we compared the phenotype and clinical outcomes between the groups diagnosed with WGS and the undiagnosed group. RESULTS: The diagnostic yield of WGS was 26% (21/80), of which 76% were novel variants. There was a higher diagnostic yield in cases of craniofacial abnormalities, including those of the eye and ear, and a lower diagnostic yield in cases of gastrointestinal and genitourinary abnormalities. In addition, higher rates of rehabilitation therapy and gastrostomy were observed in WGS-diagnosed infants than in undiagnosed infants. CONCLUSION: This prospective cohort study assessed the usefulness of trio-WGS following chromosomal analysis for diagnosing MCAs in the NICU and revealed improvements in the diagnostic yield and clinical utility of WGS.

Applied pharmacokinetics to improve pharmacotherapy in neonatal and paediatric intensive care units: focus on correct dose selection.

Drug dosing and exposure throughout childhood are constantly affected by maturational changes like weight, age or body surface area. In neonatal and paediatric intensive care units (NICU and PICU, respectively), drug dosing and exposure are further impacted by non-maturational changes. These changes are related to factors such as sepsis, cardiac failure, acute kidney injury, extracorporeal circuits or drug-drug interactions (DDIs) resulting from polypharmacy.This potentially complex situation may alter drug pharmacokinetics to result in greater-than-usual intrapatient and interpatient drug exposure variability. These effects may call for individual dosage adjustments. Dosage adjustments may apply to both loading doses or maintenance doses, which should be used as appropriate, depending on the specific characteristics of a given drug. Phenobarbital and vancomycin dosing are hereby used as illustrations.To optimise dose selection in NICU/PICU settings, we suggest to consider therapeutic drug monitoring integrated in model-informed precision dosing, and to familiarise oneself with existing paediatric drug formularies as well as DDI databases/search engines. Paediatric clinical pharmacologists and pharmacists can hereby guide clinicians with no prior experience on how to properly apply these data sources to day-to-day practice in individual patients or specific subpopulations of NICU or PICU patients.

How to perform and interpret a middle cerebral artery transcranial Doppler examination in children at risk of brain injury.

Transcranial Doppler (TCD) ultrasound is a non-invasive neuromonitoring technique that falls under the umbrella of point-of-care ultrasound. In this article, we provide a primer to encourage clinicians to perform TCD examinations and to aid them with accurately interpreting the scans. We focus on the middle cerebral artery waveforms and use traumatic brain injury as a model for brain insult.

Characterisation of parathyroid hormone concentration in extremely preterm or very low birthweight infants in routine clinical screening for metabolic bone disease: A service evaluation cohort study.

AIM: To characterise parathyroid hormone (PTH) concentrations in infants at high risk for metabolic bone disease, in order to assist clinical decisions around the use of PTH for screening. METHODS: Infants born under 28 weeks' postmenstrual age or with birthweight under 1.5 kg in a tertiary neonatal unit in the UK were included. Clinical guidance was to assess PTH concentration in the first 3 weeks after birth. Clinical information was extracted from prospective records. RESULTS: Sixty-four infants had mean birth gestation of 26 weeks and birthweight of 882 g. Median PTH (sent on median day 18 of life) was 9.2 pmol/L (interquartile range 5.3-17 pmol/L). Sixty-seven per cent of infants had a PTH greater than 7 pmol/L. For 22% of the infants, raised PTH was not accompanied by abnormal phosphate or alkaline phosphatase. Eighty-nine per cent of infants tested were insufficient or deficient for 25-hydroxyvitamin D. CONCLUSIONS: Universal screening highlights the high frequency of high PTH in this high-risk population, implying a need for calcium supplementation. A considerable number of infants would not be identified as showing potential signs of metabolic bone disease if the assessment excludes the use of PTH. The high level of 25-hydroxyvitamin D deficiency may be a confounder.

Quality of Life of Mothers and Fathers 4 to 6 Months After Birth: The Effect of a Very Preterm Delivery.

OBJECTIVES: The sparse literature on the effect of a preterm delivery on parents' quality of life (QoL) yields inconsistent results, restricting their analysis to mothers. The present study aimed to assess the effect of a very preterm delivery on parents' gender-specific perception of QoL, 4 to 6 months after birth. METHODS: A total of 117 parents of very preterm infants hospitalized at birth in a level III Neonatal Intensive Care Unit, and 214 parents of never hospitalized full-term infants born in a public maternity, both located in the North of Portugal, participated in the study, 4 to 6 months after delivery (November 2013-June 2015). The Portuguese version of the World Health Organization Quality of Life - BREF Inventory was applied and scores were transformed to reflect a 0 to 100 scale. RESULTS: The mean [standard deviation (SD)] of overall QoL ranged between 72.1 (13.3) among mothers of full-term infants and 74.6 (12.5) among mothers of very preterm infants. The perception of QoL was not significantly different among parents of very preterm and full-term infants, according to gender. The highest scores were observed in the psychological and physical dimensions, for both mothers and fathers. CONCLUSIONS FOR PRACTICE: The lack of differences on the perception of QoL among mothers and fathers of very preterm and full-term infants, highlights the need to deeply understand and explore the influence of accommodation mechanisms, the extended family/community and health policies on parental QoL trajectories.

The experience of fathers whose infants were hospitalized in Neonatal Intensive Care Unit in South Korea: A scoping review.

PROBLEM: The purpose of this scoping review was to map and organize the previous studies conducted among fathers whose infants experienced admission to neonatal intensive care units (NICUs) in South Korea. ELIGIBILITY CRITERIA: A scoping review was conducted based on Arksey and O'Malley using the JBI template. The review was described by PRISMA-ScR. The studies were reviewed through five electronic databases (PubMed, CINAHL, Web of Science, RISS and KMbase) since 1996. Each study was analyzed, extracted, and summarized into the following domains: general characteristics (language, design, data collection methods, intervention, data collection site, and time) and fathers' characteristics (types of fathers, mean age, variables related to the fathers, and measurements). SAMPLE: A total of 290 studies were identified after screening titles and abstracts, and 32 full-text articles were retrieved for eligibility. Finally, 15 articles were included in the review. RESULTS: Four themes were derived after review: paternal stress, paternal attachment, fathers' adaptation, and fathers' support needs. CONCLUSIONS: Infants' hospitalization in NICUs causes stress for fathers but they overcome difficulties and play multiple roles as guardians, caregivers, and decision-makers of their spouses and infants over time. Paternal attachment increases significantly after participating in tactile and educational interventions. Fathers rely on nurses and they want to receive support from nurses. IMPLICATIONS: It is necessary for NICU nurses to understand and support fathers whose infants are hospitalized in NICUs. Medical institutions should provide nursing interventions and education for fathers to relieve their stress, help their adaptation, and improve attachment.

Fifteen-minute consultation: How to approach the initial discussions of dysmorphism with parents.

Approaching discussions and introducing the idea of dysmorphology to parents and families can be perceived as difficult and even daunting by health professionals resulting in uneasiness in how best to initiate important dialogues sensitively and accessibly.Here, we offer a structured approach to the assessment of, and subsequent initial discussion around, dysmorphism and potential syndromic features in babies and children.

Factors associated with 5-min APGAR score, death and survival in neonatal intensive care: a case-control study.

BACKGROUND: The 5-minute APGAR score is clinically used as a screening tool to assess how the newborn has reacted to previous care, remaining relevant for predicting neonatal survival. This study aimed to analyze the determinants of the 5th minute APGAR score, and the factors associated with the death and survival of newborns with low APGAR scores hospitalized in the neonatal intensive care unit (NICU) at a referral public hospital in North Brazil. METHODS: This was a hospital-based retrospective case-control study with 277 medical records. Newborns who presented with a 1-minute APGAR score < 7 followed by a 5-minute APGAR score < 7 were considered cases, while a score ≥ 7 was categorized as controls. Univariate and multivariable logistic regression analyses were used to establish the determinant factors of the low APGAR score and death outcome in this group. Survival curves were obtained using the Kaplan-Meier estimator, and then univariate and multivariate Cox regression was performed. RESULTS: After adjusted analysis, the factor associated with low APGAR scores was vaginal delivery (OR = 3.25, 95%CI = 1.60-6.62, p = 0.001). Birth injury (OR = 0.39, 95%CI = 0.19-0.83, p = 0.014) was associated with upper APGAR scores. No significant independent associations were observed between the variables analyzed and death in the low APGAR score group. The Kaplan-Meier curve showed that individuals who presented Cesarean delivery had a shorter survival time in the ICU. CONCLUSION: In this setting, a 5-minute Apgar score < 7 was associated with the occurrence of vaginal delivery and birth injury with a 5-minute Apgar score ≥ 7. Survival in ICU was lower in newborns that were delivered via cesarean section.

Clinical course of neonatal acute kidney injury: multi-center prospective cohort study.

BACKGROUND: Neonatal acute kidney injury (AKI) has been associated with unfavorable outcomes, including increased mortality. We aimed to describe the clinical course and outcomes during the first 7 days after diagnosis in newborns with AKI in three neonatal intensive care units in Popayán-Colombia. METHODS: Multi-center prospective cohort study conducted between June 2019 and December 2020 in three NICUs after ethical approval. We included newborns between 2 and 28 days of life, first diagnosed with AKI using the KDIGO classification modified for newborns which consider increased serum creatinine values over baseline values as well as urine output over time in hours or both. Patients with chromosomal abnormalities, major kidney malformations, and complex congenital heart disease were excluded. Patients were followed for up to 7 days after diagnosis and the maximum KDIGO stage, recovery of kidney function, need for renal replacement therapy and cumulative incidence of death were evaluated. RESULTS: Over the 18 months of the study, 4132 newborns were admitted to the NICUs, and 93 patients (2.25, 95% CI 1.82-2.75%) developed neonatal AKI. 59.1% of the newborns were premature and there were no differences in severity according to gestational age. During follow-up, the maximum KDIGO was 64.5% for AKI-stage 1, 11.8% for AKI-stage 2, and 23.7% for AKI-stage 3. Kidney function recovery was higher in AKI-stage 1 patients vs. AKI-severe (AKI-stage 2 and 3) (95% vs. 48.5%). Five patients (5.4%) received renal replacement therapy and 15 died (16.1%), four in AKI-stage 1 vs. 11 in AKI-severe (6.7% vs 33.3%). CONCLUSIONS: Newborns admitted to the NICUs can develop AKI regardless of gestational age, and it is more frequent between the second and ninth days of life. More patients whit AKI-stage 1 recover and die less than those in a severe stage.

Neonatal intensive care unit nurse training in identifying ultrasound landmarks in the neonatal mediastinum. Α training program for nurses in North-Eastern Greece.

PURPOSE: To demonstrate methods and landmarks for mediastinum ultrasound as part of ultrasound examination of the lung for nurses. This will be the first step in their education to detect finally the tubes and lines malpositioning in order to distinguish emergency conditions of the lungs in neonates hospitalized in neonatal intensive care units. DESIGN AND METHODS: Theoretical and practical interventions were developed to create a 3-month training program based on similar medical courses. The study was approved by the hospital's ethics committee.The program was performed in the neonatal intensive care unit of a single academic institution. Participating nurse was supervised by a paediatric surgeon and trained in lung ultrasound (a safe method without radiation) by a paediatric radiologist. RESULTS: During the practical period (2 months), the neonatal intensive care unit nurse examined 50 neonates (25 + 6-40 + 4 weeks gestational age; 21 males) separated into two subgroups of 25 neonates each for each training month. In the first month under supervision, the nurse was trained to recognise the aortic arch, the right pulmonary artery, the esophagus, the tracheal air, and the 'sliding lung sign' in the anterior, lateral, and posterolateral aspects of the thoracic cage. In the second month, the nurse recorded the ultrasound examinations. The identified structures were then assessed and graded by the supervising radiologist. The overall estimated success rate (5 landmarks × 25 neonates = 125) was 90.4%. CONCLUSIONS: Although this is the first report of the design of a 'hands-on', lung ultrasound training program for neonatal intensive care unit nurses, our findings demonstrate that it is a safe and useful program for all neonatal intensive care unit nurses because theoverall success rate of the 3-month program was determined by accurate identification of basic anatomical structures (90,4%) by the nurse. PRACTICE IMPLICATIONS: This study describes the first educational training program for NICU nurses designed to recognise basic structures in the neonatal mediastinum. If the program is effective, NICU nurses will be able to identify respiratory emergencies. NICU nurses can inform doctors about emergencies according to tubes and lines malpositioning in a timely manner to avoid negative consequences.

Fifteen-minute consultation: Investigation and management of hypoglycaemia in the term-born infant.

Hypoglycaemia in term infants is very common. Deciding on appropriate investigations and management is often challenging. The aims of this article are to help with understanding when, how and why to investigate symptoms of hypoglycaemia in full-term infants (born ≥37 weeks' gestational age).

Fifteen-minute consultation: When to consider extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a form of organ support which is used for severe, potentially reversible respiratory, cardiac or cardiorespiratory failure. While it is associated with significant risk of intracerebral injury in neonates and children, outcomes can be excellent, and timely referral is associated with improved survival and reduced morbidity. This article provides a concise summary of the technical aspects of ECMO support, indications for referral, complications, outcomes and important considerations for follow-up.

The association between SARS-CoV-2 infection and preterm delivery: a prospective study with a multivariable analysis.

BACKGROUND: To determine whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the cause of COVID-19 disease) exposure in pregnancy, compared to non-exposure, is associated with infection-related obstetric morbidity. METHODS: We conducted a multicentre prospective study in pregnancy based on a universal antenatal screening program for SARS-CoV-2 infection. Throughout Spain 45 hospitals tested all women at admission on delivery ward using polymerase-chain-reaction (PCR) for COVID-19 since late March 2020. The cohort of positive mothers and the concurrent sample of negative mothers was followed up until 6-weeks post-partum. Multivariable logistic regression analysis, adjusting for known confounding variables, determined the adjusted odds ratio (aOR) with 95% confidence intervals (95% CI) of the association of SARS-CoV-2 infection and obstetric outcomes. MAIN OUTCOME MEASURES: Preterm delivery (primary), premature rupture of membranes and neonatal intensive care unit admissions. RESULTS: Among 1009 screened pregnancies, 246 were SARS-CoV-2 positive. Compared to negative mothers (763 cases), SARS-CoV-2 infection increased the odds of preterm birth (34 vs 51, 13.8% vs 6.7%, aOR 2.12, 95% CI 1.32-3.36, p = 0.002); iatrogenic preterm delivery was more frequent in infected women (4.9% vs 1.3%, p = 0.001), while the occurrence of spontaneous preterm deliveries was statistically similar (6.1% vs 4.7%). An increased risk of premature rupture of membranes at term (39 vs 75, 15.8% vs 9.8%, aOR 1.70, 95% CI 1.11-2.57, p = 0.013) and neonatal intensive care unit admissions (23 vs 18, 9.3% vs 2.4%, aOR 4.62, 95% CI 2.43-8.94, p <  0.001) was also observed in positive mothers. CONCLUSION: This prospective multicentre study demonstrated that pregnant women infected with SARS-CoV-2 have more infection-related obstetric morbidity. This hypothesis merits evaluation of a causal association in further research.

Caring for indigenous families in the neonatal intensive care unit.

Inequitable access to health care, social inequities, and racist and discriminatory care has resulted in the trend toward poorer health outcomes for Indigenous infants and their families when compared to non-Indigenous families in Canada. How Indigenous mothers experience care during an admission of their infant to the Neonatal Intensive Care Unit has implications for future health-seeking behaviors which may influence infant health outcomes. Nurses are well positioned to promote positive health care interactions and improve health outcomes by effectively meeting the needs of Indigenous families. This qualitative study was guided by interpretive description and the Two-Eyed Seeing framework and aimed to understand how Indigenous mothers experience accessing and using the health care system for their infants. Data were collected by way of interviews and a discussion group with self-identifying Indigenous mothers of infants less than two years of age living in Hamilton, Ontario, Canada. Data underwent thematic analysis, identifying nursing strategies to support positive health care interactions and promote the health and wellness of Indigenous infants and their families. Building relationships, providing holistic care, and taking a trauma-informed approach to the involvement of child protection services are three key strategies that nurses can use to positively impact health care experiences for Indigenous families.

What evidence-based strategies have been shown to improve breastfeeding rates in preterm infants?

Breast milk is the preferred form of nutrition for all infants and has been shown to reduce morbidity and improve health outcomes in preterm infants. However, mothers of preterm infants face many challenges initiating and sustaining breastfeeding within the neonatal unit. This scoping review examines evidence-based practices which aim to improve breastfeeding rates in preterm infants at the time of hospital discharge. A literature review identified 17 articles which are included in this review. Supporting evidence was found for the implementation of kangaroo mother care and/or skin-to-skin care, peer counsellors, provision of oropharyngeal colostrum in early infancy and use of donor human milk banks. However, overall it is apparent that high quality research including systematic review and data synthesis in the form of meta-analysis is required in this area to reach sound conclusions regarding recommendations of different interventions. This scoping review provides an important foundation for further research into this area.

Are there interventions that improve breastfeeding and the use of breast milk in late preterm infants?

To answer the clinical question 'Among late preterm infants are there any interventions that improve the rates of breastfeeding and the use of breast milk compared with current practice?'. MEDLINE via Ovid, Embase via Ovid, the Maternity and Infant Care Database and the Cochrane Library were searched for relevant articles. Articles were excluded if they did not discuss specific interventions to improve breastfeeding, for example, if they only commented on factors such as age, race and education. Articles were also excluded if they were not specific to the late preterm infant population. A total of 516 articles were found and screened by title and abstract independently by two reviewers. The full text of 17 articles was independently reviewed. The reference lists of these full-text articles were screened, and 14 abstracts were subsequently reviewed. The final analysis included three studies. There is limited high-quality research evidence for interventions to improve breastfeeding in late preterm infants. In the absence of robust academic research, clinical practice should be guided by clinical expertise and involve a multidisciplinary team, including qualified lactation consultants. While it seems reasonable for hospitals to support interventions that improve breastfeeding in term infants, managing late preterm infants as healthy term infants without additional specialist support may result in high breastfeeding failure rates among late preterm infants.