Perceptions of European medical staff on the facilitators and barriers to physical closeness between parents and infants in neonatal units.

AIM: Studies have provided insights into factors that may facilitate or inhibit parent-infant closeness in neonatal units, but none have specifically focused on the perspectives of senior neonatal staff. The aim of this study was to explore perceptions and experiences of consultant neonatologists and senior nurses in five European countries with regard to these issues. METHODS: Six small group discussions and three-one-to-one interviews were conducted with 16 consultant neonatologists and senior nurses representing nine neonatal units from Estonia, Finland, Norway, Spain and Sweden. The interviews explored facilitators and barriers to parent-infant closeness and implications for policy and practice, and thematic analysis was undertaken. RESULTS: Participants highlighted how a humanising care agenda that enabled parent-infant closeness was an aspiration, but pointed out that neonatal units were at different stages in achieving this. The facilitators and barriers to physical closeness included socio-economic factors, cultural norms, the designs of neonatal units, resource issues, leadership, staff attitudes and practices and relationships between staff and parents. CONCLUSION: Various factors affected parent-infant closeness in neonatal units in European countries. There needs to be the political motivation, appropriate policy planning, legislation and resource allocation to increase measures that support closeness agendas in neonatal units.

Predicting death or extended length of stay in infants with congenital diaphragmatic hernia.

OBJECTIVE: To predict mortality or length of stay (LOS) >109 days (90th percentile) among infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN: We conducted a retrospective analysis using the Children's Hospital Neonatal Database during 2010 to 2014. Infants born >34 weeks gestation with CDH admitted at 22 participating regional neonatal intensive care units were included; patients who were repaired or were at home before admission were excluded. The primary outcome was death before discharge or LOS >109 days. Factors associated with this outcome were used to develop a multivariable equation using 80% of the cohort. Validation was performed in the remaining 20% of infants. RESULTS: The median gestation and age at referral in this cohort (n=677) were 38 weeks and 6 h, respectively. The primary outcome occurred in 242 (35.7%) infants, and was distributed between mortality (n=180, 27%) and LOS >109 days (n=66, 10%). Regression analyses showed that small for gestational age (odds ratio (OR) 2.5, P=0.008), presence of major birth anomalies (OR 5.9, P<0.0001), 5- min Apgar score ⩽3 (OR 7.0, P=0.0002), gradient of acidosis at the time of referral (P<0.001), the receipt of extracorporeal support (OR 8.4, P<0.0001) and bloodstream infections (OR 2.2, P=0.004) were independently associated with death or LOS >109 days. This model performed well in the validation cohort (area under curve (AUC)=0.856, goodness-of-fit (GF) χ(2), P=0.16) and acted similarly even after omitting extracorporeal support (AUC=0.82, GF χ(2), P=0.05). CONCLUSIONS: Six variables predicted death or LOS ⩾109 days in this large, contemporary cohort with CDH. These results can assist in risk adjustment for comparative benchmarking and for counseling affected families.

The relationship between zinc intake and growth in children aged 1-8 years: a systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: It is estimated that zinc deficiency affects 17% of the world's population, and because of periods of rapid growth children are at an increased risk of deficiency, which may lead to stunting. This paper presents a systematic review and meta-analysis of the randomised controlled trials (RCTs) that assess zinc intake and growth in children aged 1-8 years. This review is part of a larger systematic review by the European Micronutrient Recommendations Aligned Network of Excellence that aims to harmonise the approach to setting micronutrient requirements for optimal health in European populations (www.eurreca.org). SUBJECT/METHODS: Searches were performed of literature published up to and including December 2013 using MEDLINE, Embase and the Cochrane Library databases. Included studies were RCTs in apparently healthy child populations aged from 1 to 8 years that supplied zinc supplements either as capsules or as part of a fortified meal. Pooled meta-analyses were performed when appropriate. RESULTS: Nine studies met the inclusion criteria. We found no significant effect of zinc supplementation of between 2 weeks and 12 months duration on weight gain, height for age, weight for age, length for age, weight for height (WHZ) or WHZ scores in children aged 1-8 years. CONCLUSIONS: Many of the children in the included studies were already stunted and may have been suffering from multiple micronutrient deficiencies, and therefore zinc supplementation alone may have only a limited effect on growth.

Short-term outcomes after perinatal hypoxic ischemic encephalopathy: a report from the Children's Hospitals Neonatal Consortium HIE focus group.

OBJECTIVE: To characterize infants affected with perinatal hypoxic ischemic encephalopathy (HIE) who were referred to regional neonatal intensive care units (NICUs) and their related short-term outcomes. STUDY DESIGN: This is a descriptive study evaluating the data collected prospectively in the Children's Hospital Neonatal Database, comprised of 27 regional NICUs within their associated children's hospitals. A consecutive sample of 945 referred infants born ⩾36 weeks' gestation with perinatal HIE in the first 3 days of life over approximately 3 years (2010-July 2013) were included. Maternal and infant characteristics are described. Short-term outcomes were evaluated including medical comorbidities, mortality and status of survivors at discharge. RESULT: High relative frequencies of maternal predisposing conditions, cesarean and operative vaginal deliveries were observed. Low Apgar scores, profound metabolic acidosis, extensive resuscitation in the delivery room, clinical and electroencephalographic (EEG) seizures, abnormal EEG background and brain imaging directly correlated with the severity of HIE. Therapeutic hypothermia was provided to 85% of infants, 15% of whom were classified as having mild HIE. Electrographic seizures were observed in 26% of the infants. Rates of complications and morbidities were similar to those reported in prior clinical trials and overall mortality was 15%. CONCLUSION: Within this large contemporary cohort of newborns with perinatal HIE, the application of therapeutic hypothermia and associated neurodiagnostic studies appear to have expanded relative to reported clinical trials. Although seizure incidence and mortality were lower compared with those reported in the trials, it is unclear whether this represented improved outcomes or therapeutic drift with the treatment of milder disease.

Clinical predictability of intraventricular hemorrhage in preterm infants.

Ninety-eight infants of less than 35 weeks' gestation, consecutively admitted to a regional neonatal intensive care unit, were followed prior to computerized tomography (CT) scan for clinical signs of subependymal and/or intraventricular hemorrhage. The presence or absence of intracerebral hemorrhage was confirmed by CT scan in all patients, and the severity of hemorrhage was quantitated as mild, moderate, or marked. Thirty-seven out of 98 infants (38%) demonstrated intracerebral hemorrhage on CT scan; 20 of 37 (54%) were predicted clinically. Clinical predictability was related to severity of hemorrhage as quantitated by CT scan. Clinical signs that were found helpful in predicting subependymal and/or intraventricular hemorrhage were fall in hematocrit, failure of rise in hematocrit with transfusion of packed red blood cells, tight fontanel, decrease in spontaneous activity, decreased tone, abnormal eye signs, and seizures.

Intraventricular hemorrhage and high-frequency ventilation: a meta-analysis of prospective clinical trials.

OBJECTIVE: The association between high-frequency ventilation (HFV) and intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL) has been debated. PURPOSE: To determine if premature neonates treated with HFV are at greater risk for developing IVH and/or PVL than neonates treated with conventional ventilation, we completed a meta-analysis of all prospective randomized control trials comparing HFV and conventional ventilation in the management of respiratory distress syndrome. METHODS: The meta-analysis included nine studies comparing HFV and conventional ventilation in the management of preterm neonates. To summarize the data, we calculated the difference in absolute risk for IVH and PVL between neonates treated with HFV and those treated with standard ventilation. These differences were combined to determine an overall difference in the absolute risk and its confidence interval. We examined the effect of estimated gestational age, birth weight, surfactant, and age at study entry on the results. Because one trial (HIFI study) was much larger than the other studies, it dominated the analysis, so we evaluated the data with and without including data from the HIFI trial. RESULTS: The occurrences of IVH and PVL ranged from 14% to 47% and 5% to 16%, respectively. This variation may be explained by the difference in the populations of neonates treated. The meta-analysis showed that use of HFV was associated with an increased risk of PVL (odds ratio = 1.7 with a confidence interval of 1.06 to 2.74), but not IVH or severe (> or = grade 3) IVH. When the results of the HIFI study were excluded, there were no differences between HFV and conventional ventilation in the occurrence of IVH or PVL. CONCLUSIONS: The association between HFV and adverse neurologic outcomes is primarily influenced by the results of the HIFI trial. Meta-analysis of more recent studies does not confirm the findings of the HIFI trial and suggests that HFV is not associated with increased occurrence of IVH or PVL.

Intraventricular hemorrhage: a prospective evaluation of etiopathogenesis.

In a study population of 151 newborn infants less than 35 weeks gestation, who required intensive care for more than 24 hours, clinical and biochemical factors associated with the presence of intraventricular hemorrhage (IVH) were prospectively evaluated. The diagnosis of IVH was confirmed by computed tomography, ventricular tap, or autopsy. Alveolar rupture was highly correlated with the presence of IVH. Other factors associated with IVH were: hypoxemia, hypercarbia, mechanical ventilation, peak inflation presser > 25 cm H2O, inspiratory to expiratory ratio > 1:1, patent ductus arteriosus, bicarbonate administration after the first day of life, volume expansion in the first day of life, hypotension, stages III and IV hyaline membrane disease, and intrauterine growth retardation. Early bicarbonate administration (first day), sodium administration > 8 mEq/kg/day, acidosis and birth weight less than or equal to 1,200 gm were associated with IVH only in the infants who died with IVH. Factors not associated with IVH were Apgar less than or equal to 5 at one and five minutes, birth weight, gestational age, male sex, osmolality greater than or equal to 300, serum sodium greater than or equal to 150, hypothermia, continuous distending pressure > 6 cm H2O, positive end-expiratory pressure > 5 cm H2O, outborn birth, obstetric trauma, or coagulopathy. Certain therapeutic interventions may lead to an increase incidence of intracerebral hemorrhage in the high-risk preterm infant.

Relationship between pressure passivity and subependymal/intraventricular hemorrhage as assessed by pulsed Doppler ultrasound.

A prospective study was undertaken using a range-gated, pulsed Doppler velocimeter to study flowpressure relationships in the anterior cerebral artery. Serial velocity and pressure studies were performed with each infant serving as his or her own control. The hypothesis tested was that ill preterm infants sustaining subependymal/intraventricular hemorrhage would have absent autoregulation. The hypothesis has been tested in 88 studies on 32 infants. Of 32 infants studied, 15 were judged to be pressure passive; nine of these children bled. The other 17 infants were not pressure passive; eight of these children bled (P greater than .05). From these studies, it may be concluded that the pressure passive state is not the final common link in the genesis of subependymal/intravertricular hemorrhage. Pulsed Doppler ultrasound may provide an extremely useful noninvasive technique for studying both the arterial and venous sides of the cerebral circulation.

The complete spectrum of neurocristopathy in an infant with congenital hypoventilation, Hirschsprung's disease, and neuroblastoma.

Neuroblastoma, Hirschsprung's disease, and central hypoventilation (Ondine's curse) are considered aberrations of neural crest cell growth, migration, or differentiation, and as such are considered to be under the general heading of neurocristopathy. Their combined occurrence in a newborn infant presenting with total colonic aganglionosis, central hypoventilation, and multifocal neuroblastoma had not been reported previously. A 2.3-kg white full-term girl required endotracheal intubation because of persistent apnea in the first hours of life. She had progressive abdominal distension and failure to pass meconium; a barium enema was performed, which showed microcolon with meconium pellets at the distal ileum. During laparotomy the distal ileum was found to be obstructed with inspissated meconium; an ileostomy and appendectomy were performed. The resected specimens were aganglionic. An additional 20 cm of aganglionic ileum was removed, and a normally innervated ileostomy was constructed. Numerous attempts at extubation failed because of apnea. The results of an extensive apnea workup, including electroencephalogram, magnetic resonance imaging (MRI), bronchoscopy, and pH probe study, were normal. Sleep studies showed congenital central hypoventilation syndrome, and the patient underwent a tracheostomy. At 3 months, an abdominal ultrasound examination performed within a septic workup showed a right suprarenal mass extending across the midline. Thoracic and abdominal MRI scans showed large bilateral adrenal and posterior mediastinal masses. The serum catecholamines and ferritin level were markedly elevated, suggestive of neuroblastoma. In light of the child's multiple problems, the family chose to forgo further workup (including a tissue biopsy) and therapy. In the following 2 months her tumor load rapidly progressed, and she died of respiratory insufficiency.(ABSTRACT TRUNCATED AT 250 WORDS)

Falling by the wayside: a phenomenological exploration of perceived breast-milk inadequacy in lactating women.

OBJECTIVE: To provide insight into the lived experience of breast feeding, in primiparous women. The main focus was upon women's perceptions related to the adequacy of their breast milk, for the purpose of exclusively nourishing their babies. DESIGN: A longitudinal, phenomenological study involving in-depth, interactive interviews, conducted at 6, 12 and 18 weeks following the birth of the women's babies. PARTICIPANTS AND SETTING: A convenience sample of ten primiparous women were recruited prior to discharge from a maternity unit, in the north of England, in 1998. FINDINGS: Two groups of participants emerged, three who became increasingly confident and empowered by breast feeding and the remaining seven whose confidence progressively diminished, with six of them expressing concern that their breast milk was inadequate. Four major themes related to the participants' perceptions emerged from the analysis: the quest to quantify and visualise breast milk; anxiety regarding the adequacy of their diet; breast feeding as a challenging journey, with most feeling that they had 'fallen by the wayside' (this related partly to inadequate and conflicting advice given by health professionals); and finally, unmet needs for support, nurturing and replenishment in return for 'giving out'. CONCLUSION: Perceived breast-milk inadequacy is underpinned by a complex and synergistic interaction between socio-cultural influences, feeding management, the baby's behaviour, lactation physiology and the woman's psychological state. IMPLICATIONS: Education of midwives and health visitors is required in relation to the needs of breast-feeding mothers within a Western industrialised society. Strong social policy is vital in the UK, to initiate socio-cultural changes, which would enable women who commence breast feeding to perceive it as an empowering and fulfilling experience and not one of 'falling by the wayside'.

An evaluation of skills acquisition on the WHO/UNICEF Breastfeeding Management Course using the pre-validated Breastfeeding Support Skills Tool (BeSST).

OBJECTIVE: To test the hypothesis that midwives who had completed the 20-hour WHO/UNICEF Breastfeeding Management Course would score significantly higher on a validated, quantitative measure of breast-feeding support skills, the Breastfeeding Support Skills Tool (BeSST), than a control group of midwives who had not undertaken the course. DESIGN: Breast feeding support skills were assessed using a between-subjects design conducted in midwives who had not attended the course and at two weeks following the 20 hour course. PARTICIPANTS AND SETTING: Two groups, consisting of 13 pre- and 15 post-course midwives, were compared. The research was carried out at four hospital sites in the UK, three of which had undertaken the 20 hour course and one which had not adopted the course. FINDINGS: Scores on the BeSST were significantly higher in the post-course group (mean = 29.9) than in the pre-course group (mean = 19.8), t (23.39) = 2.94, P < 0.01. KEY CONCLUSIONS: It is clear that breast-feeding support skills, as demonstrated by the BeSST, are significantly improved two weeks following the 20-hour WHO/UNICEF Breastfeeding Management Course. IMPLICATIONS FOR PRACTICE: By demonstrating the effectiveness of the 20-hour course in teaching breast-feeding support skills, additional hospitals may be encouraged to adopt the course and thereby contribute further to the advancement of optimum breast-feeding practices. Furthermore, this approach to assessment may be transferred to other areas of midwifery practice enabling the effective evaluation of courses and assessment of student learning.

A critical analysis of the content of the tools that measure breast-feeding interaction.

OBJECTIVE: To undertake a critical analysis of the content of six tools, which have been designed to evaluate the breast-feeding interaction. DESIGN: The tools are viewed as discourses and are examined in terms of the insight they give into the assumptions about and attitudes towards breast-feeding inherent in the authors who have produced them. FINDINGS: The findings indicate that there is little agreement between the existing breast-feeding assessment tools as to how to measure a successful breast feed and that the tools appear to place insufficient reliance upon the research evidence related to lactation. KEY CONCLUSIONS: The lack of commonality between evaluation tools appears to reflect a prevailing inconsistency in the advice given by health workers to breast-feeding mothers. Reports of their unreliability may be indicative of the problems inherent when attempting to impose a biomedical model upon an intrinsically natural interaction. IMPLICATIONS FOR PRACTICE: It is suggested that, if evaluations of the breast-feeding interaction are to be useful, a tool which places greater emphasis on the research evidence is called for. Otherwise, given the limitations of such tools, their use may actively hinder the establishment of successful breast feeding.

Extracorporeal membrane oxygenation service at Egleston: two years' experience.

Extracorporeal membrane oxygenation (ECMO) is a perfusion support procedure that has been used to treat more than 7,000 patients with life threatening cardiac and/or respiratory failure. After 6 months of training and preparation, an ECMO service was opened on January 2, 1991, in Egleston Children's Hospital at Emory University. During the first 2 years, 96 neonatal, 31 pediatric, and 8 cardiac patients have been referred for possible ECMO. Of these 135 patients, 21 had disqualifying conditions. Sixty-four were considered candidates for ECMO but were able to be supported using less invasive therapies; only one of these died. Fifty patients were treated with ECMO of whom 39 survived (78%). Survival rates for neonatal, pediatric, and cardiac cases as separate groups as well as for each diagnostic category within these groups compare favorably with those reported by the international ELSO Registry. Notable in this series is the fact that 26/35 neonatal patients and 7/10 pediatric patients were successfully supported using venovenous (VV) rather than venoarterial (VA) perfusion, with the major indication for venoarterial ECMO being inability to introduce the 14F venovenous catheter into the patient's internal jugular vein. No patient initially managed with VV ECMO required conversion to VA. It is anticipated that avoidance of carotid ligation along with other innovations, such as the impending commercial availability of heparin-coated ECMO circuits, will make ECMO a highly attractive and appropriate therapy for an increasing number of high risk neonatal and pediatric patients in our state and region.

The Children's Hospitals Neonatal Database: an overview of patient complexity, outcomes and variation in care.

The Children's Hospitals Neonatal Consortium is a multicenter collaboration of leaders from 27 regional neonatal intensive care units (NICUs) who partnered with the Children's Hospital Association to develop the Children's Hospitals Neonatal Database (CHND), launched in 2010. The purpose of this report is to provide a first summary of the population of infants cared for in these NICUs, including representative diagnoses and short-term outcomes, as well as to characterize the participating NICUs and institutions. During the first 2 1/2 years of data collection, 40910 infants were eligible. Few were born inside these hospitals (2.8%) and the median gestational age at birth was 36 weeks. Surgical intervention (32%) was common; however, mortality (5.6%) was infrequent. Initial queries into diagnosis-specific inter-center variation in care practices and short-term outcomes, including length of stay, showed striking differences. The CHND provides a contemporary, national benchmark of short-term outcomes for infants with uncommon neonatal illnesses. These data will be valuable in counseling families and for conducting observational studies, clinical trials and collaborative quality improvement initiatives.

Predicting death or tracheostomy placement in infants with severe bronchopulmonary dysplasia.

OBJECTIVE: To estimate the risk of death or tracheostomy placement (D/T) in infants with severe bronchopulmonary dysplasia (sBPD) born < 32 weeks' gestation referred to regional neonatal intensive care units. STUDY DESIGN: We conducted a retrospective cohort study in infants born < 32 weeks' gestation with sBPD in 2010-2011, using the Children's Hospital Neonatal Database. sBPD was defined as the need for FiO2 ⩾ 0.3, nasal cannula support >2 l min(-1) or positive pressure at 36 weeks' post menstrual age. The primary outcome was D/T before discharge. Predictors associated with D/T in bivariable analyses (P < 0.2) were used to develop a multivariable logistic regression equation using 80% of the cohort. This equation was validated in the remaining 20% of infants. RESULT: Of 793 eligible patients, the mean gestational age was 26 weeks' and the median age at referral was 6.4 weeks. D/T occurred in 20% of infants. Multivariable analysis showed that later gestational age at birth, later age at referral along with pulmonary management as the primary reason for referral, mechanical ventilation at the time of referral, clinically diagnosed pulmonary hypertension, systemic corticosteroids after referral and occurrence of a bloodstream infection after referral were each associated with D/T. The model performed well with validation (area under curve 0.86, goodness-of-fit χ(2), P = 0.66). CONCLUSION: Seven clinical variables predicted D/T in this large, contemporary cohort with sBPD. These results can be used to inform clinicians who counsel families of affected infants and to assist in the design of future prospective trials.

Short-term outcomes for preterm infants with surgical necrotizing enterocolitis.

OBJECTIVE: To characterize the population and short-term outcomes in preterm infants with surgical necrotizing enterocolitis (NEC). STUDY DESIGN: Preterm infants with surgical NEC were identified from 27 hospitals over 3 years using the Children's Hospitals Neonatal Database; infants with gastroschisis, volvulus, major congenital heart disease or surgical NEC that resolved prior to referral were excluded. Patient characteristics and pre-discharge morbidities were stratified by gestational age (<28 vs 28(0/7) to 36(6/7) weeks' gestation). RESULT: Of the 753 eligible infants, 60% were born at <28 weeks' gestation. The median age at referral was 14 days; only 2 infants were inborn. Male gender (61%) was overrepresented, whereas antenatal steroid exposure was low (46%). Although only 11% had NEC totalis, hospital mortality (<28 weeks' gestation: 41%; 28(0/7) to 36(6/7) weeks' gestation: 32%, P=0.02), short bowel syndrome (SBS)/intestinal failure (IF) (20% vs 26%, P=0.06) and the composite of mortality or SBS/IF (50% vs 49%, P=0.7) were prevalent. Also, white matter injury (11.7% vs 6.6%, P=0.02) and grade 3 to 4 intraventricular hemorrhages (23% vs 2.7%, P<0.01) were commonly diagnosed. After referral, the median length of hospitalization was longer for survivors (106 days; interquartile range (IQR) 79, 152) relative to non-survivors (2 days; IQR 1,17; P<0.001). These survivors were prescribed parenteral nutrition infrequently after hospital discharge (<28 weeks': 5.2%; 28(0/7) to 36(6/7) weeks': 9.9%, P=0.048). CONCLUSION: After referral for surgical NEC, the short-term outcomes are grave, particularly for infants born <28 weeks' gestation. Although analyses to predict outcomes are urgently needed, these data suggest that affected infants are at a high risk for lengthy hospitalizations and adverse medical and neuro-developmental abnormalities.

Therapeutic interventions and short-term outcomes for infants with severe bronchopulmonary dysplasia born at <32 weeks' gestation.

OBJECTIVE: To characterize the treatments and short-term outcomes in infants with severe bronchopulmonary dysplasia (sBPD) referred to regional neonatal intensive care units. STUDY DESIGN: Infants born <32 weeks' gestation with sBPD were identified using the Children's Hospital Neonatal Database. Descriptive outcomes are reported. RESULT: A total of 867 patients were eligible. On average, infants were born at 26 weeks' gestation and referred 43 days after birth. Infants frequently experienced lung injury (pneumonia: 24.1%; air leak: 9%) and received systemic corticosteroids (61%) and mechanical ventilation (median duration 37 days). Although 91% survived to discharge, the mean post-menstrual age was 47 weeks. Ongoing care such as supplemental oxygen (66%) and tracheostomy (5%) were frequently needed. CONCLUSION: Referred infants with sBPD sustain multiple insults to lung function and development. Because affected infants have no proven, safe or efficacious therapy and endure an exceptional burden of care even after referral, urgent work is required to observe and improve their outcomes.