Retinopathy of prematurity screening at ≥30 weeks: urinary NTpro-BNP performance.

AIM: Urinary N-terminal B-type natriuretic peptide NTproBNP levels are associated with the development of retinopathy of prematurity (ROP) in infants <30 weeks of gestation. The incidence of ROP in more mature infants who meet other ROP screening criteria is very low. We therefore aimed to test whether urinary NTproBNP predicted ROP development in these infants. METHODS: Prospective observational study in 151 UK infants ≥30 + 0 weeks of gestation but also <32 weeks of gestation and/or <1501 g, to test the hypothesis that urinary NTproBNP levels on day of life (DOL) 14 and 28 were able to predict ROP development. RESULTS: Urinary NTproBNP concentrations on day 14 and day 28 of life did not differ between infants with and without ROP (medians 144 vs 128 mcg/mL, respectively, p = 0.86 on DOL 14 and medians 117 vs 94 mcg/mL, respectively, p = 0.64 on DOL28). CONCLUSION: The association previously shown for infants <30 completed weeks between urinary NTproBNP and the development of ROP was not seen in more mature infants. Urinary NTproBNP does not appear helpful in rationalising direct ophthalmoscopic screening for ROP in more mature infants, and may suggest a difference in pathophysiology of ROP in this population.

Health professionals' perspectives on bereavement following loss from a twin pregnancy: a qualitative study.

OBJECTIVE: To provide an in-depth understanding of the perspectives of health professionals caring for parents who have lost a baby from a twin pregnancy, either during pregnancy or in the neonatal period. STUDY DESIGN: A qualitative study involving semi-structured interviews. Twenty-six health professionals were interviewed from maternity and neonatal departments in one hospital. Data were analyzed using a generative thematic approach. RESULTS: Three main themes were identified from the data: health professionals' lack of confidence in their interactions with bereaved parents; their desire to learn more about bereavement; and a consideration of sensitive health-care practices for bereaved parents. CONCLUSIONS: Health professionals acknowledged that parents who experience the loss of a twin have specific needs, some of which can be addressed by relatively small changes to clinical practices and behaviors. They felt, however, that they needed education about bereavement in order to react more effectively to bereaved parents' needs.

The preterm gut microbiota: changes associated with necrotizing enterocolitis and infection.

AIM: To describe gut colonization in preterm infants using standard culture and 16S gene rRNA profiling, exploring differences in healthy infants and those who developed NEC/late onset sepsis (LOS). METHODS: Ninety-nine stools from 38 infants of median 27-week gestation were cultured; 44 stools from 27 infants had their microbial profiles determined by 16S. Ordination analyses explored effects of patient variables on gut communities. RESULTS: Standard microbiological culture identified a mean of two organisms (range 0-7), DGGE 12 (range 3-18) per patient. Enterococcus faecalis and coagulase negative staphylococci (CONS) were most common by culture (40% and 39% of specimens). Meconium was not sterile. No fungi were cultured. Bacterial community structures in infants with NEC and LOS differed from healthy infants. Infants who developed NEC carried more CONS (45% vs 30%) and less Enterococcus faecalis (31% vs 57%). 16S identified Enterobacter and Staphylococcus presence associated with NEC/LOS, respectively. CONCLUSIONS: Important differences were found in the gut microbiota of preterm infants who develop NEC/LOS. The relationship of these changes to current practices in neonatal intensive care requires further exploration.

Epigenetics and child health: basic principles.

Epigenetic mechanisms are believed to play an important role in disease, development and ageing with early life representing a window of particular epigenomic plasticity. The knowledge upon which these claims are based is beginning to expand. This review summarises evidence pointing to the determinants of epigenetic patterns, their juxtaposition at the interface of the environment, their influence on gene function and the relevance of this information to child health.

Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition.

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infant's own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

Palivizumab for preterm infants. Is it worth it?

Respiratory syncytial virus infection is an important cause of morbidity. Although palivizumab prophylaxis is widely used, it is uncertain whether the cost is justified. A systematic review was therefore performed of the safety, efficacy, and the likely cost effectiveness of prophylaxis for preterm infants in the United Kingdom using a standard search strategy. The only randomised controlled trial identified showed a reduction in hospital admission but no benefit on more serious outcomes. None of the United Kingdom cost studies showed economic benefit for palivizumab prophylaxis. New treatments are rarely cost effective, and, in the absence of a comprehensive economic assessment, continued use for high risk infants may appear justified.

Towards safer neonatal transfer: the importance of critical incident review.

BACKGROUND: Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group. AIMS: To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants. METHODS: Critical incidents over an eight year period are reported from a single neonatal transfer service before and after major service changes were made. The changes were instigated as part of ongoing critical incident reviews. RESULTS: Changes made as a result of critical incident review significantly reduced the number of incidents contributed to by poor preparation, transport equipment or clinical problems, ambulance delays, and ambulance equipment failure. CONCLUSIONS: The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants.

Foot length, an accurate predictor of nasotracheal tube length in neonates.

BACKGROUND: Existing guidelines for optimal positioning of endotracheal tubes in neonates are based on scanty data and relate to measurements that are either non-linear or poorly reproducible in sick infants. Foot length can be measured simply and rapidly and is related to a number of external body measurements. OBJECTIVES: To evaluate the relation of foot length to nasotracheal length in direct measurements at post mortem examinations, and then compare its clinical relevance with traditional weight based estimates in a randomised controlled trial. METHODS: The dimensions of the upper airway were measured at autopsy in 39 infants with median (range) postmenstrual age and birth weight of 32 (24-43) weeks and 1630 (640-3530) g. The regression equations with 95% prediction intervals were calculated to estimate the optimal nasotracheal length from foot length. In a randomised trial, 59 neonates were nasally intubated according to foot length and body weight based estimates to assess the achievement of "optimal" and "satisfactory" tube placements. RESULTS: In the direct measurements of the airway at autopsy, foot length was a better predictor of nasotracheal distances (r(2) = 0.79) than body weight, gestational age, and head circumference (r(2) = 0.67, 0.58, and 0.60 respectively). Measurement of foot length was easy and highly reproducible. In the randomised controlled trial, there were no significant differences between the foot length and body weight based estimates in the rates of optimal (44% v 56%) and satisfactory (83% v 72%) endotracheal tube placements. CONCLUSIONS: Foot length is a reliable and reproducible predictor of nasotracheal tube length and is at least as accurate as the conventional weight based estimation. This method may be particularly valuable in sick unstable infants.

Feeding preterm infants after hospital discharge: growth and development at 18 months of age.

We have shown that preterm infants fed a preterm formula grow better than those fed a standard term infant formula after hospital discharge. The purpose of this follow-up study was to determine whether improved early growth was associated with later growth and development. Preterm infants (< or =1750 g birth weight, < or =34 wk gestation) were randomized to be fed either a preterm infant formula (discharge to 6 mo corrected age), or a term formula (discharge to 6 mo), or the preterm (discharge to term) and the term formula (term to 6 mo). Anthropometry was performed at 12 wk and 6, 12, and 18 mo. Mental and psychomotor development were assessed using the Bayley Scales of Infant Development II at 18 mo. Differences in growth observed at 12 wk were maintained at 18 mo. At 18 mo, boys fed the preterm formula were 1.0 kg heavier, 2 cm longer, and had a 1.0 cm greater occipitofrontal circumference than boys fed the term formula. Boys fed the preterm formula were also 600 g heavier and 2 cm longer than girls fed the preterm formula. However, no differences were noted in MDI or PDI between boys fed the preterm formula and boys fed the term formula or between the boys fed preterm formula and girls fed the preterm formula. Overall, boys had significantly lower MDI than girls (mean difference, 6.0; p < 0.01), primarily reflecting lower scores in boys fed the term formula. Thus, early diet has long-term effects on growth but not development at 18 mo of age. Sex remains an important confounding variable when assessing growth and developmental outcome in these high-risk infants.

Fetal and neonatal death from maternally acquired infection.

Infection is a potentially preventable cause of perinatal mortality but there is only limited epidemiological information on which to develop prophylactic guidelines. The aim of this study was to determine the population incidence of perinatal death from maternally acquired infection and to describe the responsible organisms and antibiotic sensitivities, and also the associated risk factors. Fetal and neonatal deaths from perinatal infection in the former Northern Health Region, United Kingdom, were identified for the years 1981-96 using data held by the Perinatal Mortality Survey, and the obstetric, paediatric and pathology case notes were reviewed. Maternally acquired bacterial infection of the baby was identified as responsible for 60 pre-delivery deaths and 142 post-delivery deaths among babies of 24 or more weeks gestation at birth between 1981 and 1996. There were 630,206 livebirths and 3,591 registered stillbirths in the survey area during this time. Bacterial infection was also considered the primary cause of death in 64 fetuses where delivery occurred at 20-23 weeks gestation between 1989 and 1996. Although group B streptococcus was the commonest single organism it was only responsible for 30% of all infectious deaths from 24 weeks gestation onwards. Ampicillin resistance was more common in the second half of the study. Infection remains an important cause of perinatal mortality but responsible organisms and antibiotic sensitivities have changed significantly over time. Although 80% of the post-delivery deaths would have received intrapartum antibiotics if current guidelines had been in place, the choice of antibiotics and identification of risk groups requires careful consideration.

High prevalence of anemia after cardiac transplantation in children.

BACKGROUND: Chronic anemia is common in adults after successful cardiac transplantation. However, the prevalence of anemia in children after cardiac transplantation is uncertain. The purpose of this study was to investigate the prevalence and causes of chronic anemia in well children after cardiac transplantation and in particular to define the role, if any, of iron deficiency, which is important and relatively common in normal children. METHODS: Twenty children (ages 7 months to 16 years) who were well 4 months to 6 years after cardiac transplantation were studied. Fourteen children (70%) were anemic and enrolled in a prospective trial of iron supplementation. RESULTS: In the majority of children, serum iron and erythropoietin levels were low, although serum ferritin and zinc protoporphyrin levels tended to be normal or high. Only one child demonstrated a definite response to iron supplementation, although the hemoglobin level remained low. CONCLUSIONS: Anemia is highly prevalent in this population, and, despite the presence of low serum iron and transferrin saturation, anemia is not usually due to iron deficiency. Although the diagnosis of iron deficiency in this group is difficult and must not be missed, inappropriate therapy should be avoided. In the majority of children, there appears to be an anemia of chronic disease which may be secondary to chronic inflammation or an effect of cyclosporine on erythropoietin production.

Natural history of trisomy 18.

It has been suggested that survival in babies with trisomy 18 may be better than previously recognised, and that cardiac surgery may be justified. A population based study spanning seven years in one English health region is presented. The fetal prevalence at 18 weeks was 1 in 4274 and birth prevalence 1 in 8333 live births. Trisomy 18 was detected antenatally in 43% of cases, but almost 90% of those born without a diagnosis were known to be growth retarded in utero. More than 50% of liveborn infants were delivered by caesarean section. The median survival of those born alive was 3 days with no babies living longer than one year. Cardiac malformations were not universal but were present in more than 87% of those for whom there were data. However, in only three cases were cardiac problems implicated in the death of the infants. Cardiac surgery is not likely to improve the survival of infants with trisomy 18 and at present cannot be justified. The most common mode of death was central apnoea.