Exposure to repeat doses of antenatal glucocorticoids is associated with altered cardiovascular status after birth.

OBJECTIVE: To determine if exposure to more than one course of antenatal glucocorticoids is associated with changes in infant blood pressure and myocardial wall thickness in the first month after birth. DESIGN: Prospective cohort study. SETTING: Tertiary neonatal intensive care unit. PARTICIPANTS: Mothers who were eligible for but declined to enter a randomised trial of repeated doses of antenatal glucocorticoids (ACTORDS)-that is, who had a singleton, twin, or triplet pregnancy at <32 weeks gestation, had received an initial course of glucocorticoids seven or more days previously, and were considered to be at continued risk of preterm birth. MAIN OUTCOME MEASURES: Blood pressure daily for the first week then weekly until 4 weeks of age. End diastolic interventricular septal and left ventricular posterior wall (EDIVS and EDLVPW) thickness at 48-72 hours after birth. RESULTS: Thirty seven women were enrolled and delivered 50 infants. Thirty mothers (39 infants) were exposed to one course of glucocorticoids, and seven mothers (11 infants) to more than one course. Blood pressures were higher in the first week after birth in infants exposed to multiple courses of glucocorticoids, and in infants with a latency between last exposure and delivery of less than seven days. Systolic blood pressure on day 1 was >2SD above published normal ranges in 67% of babies exposed to multiple courses and 24% of babies exposed to a single course of glucocorticoids (p = 0.04). There was no difference between groups in thickness of the EDIVS or EDLVPW. However, 44/50 (88%) babies had EDIVS and 49/50 (98%) babies had EDLVPW thickness >2 SD above the expected mean for birth weight and gestation. EDIVS but not EDLVPW thickness increased with increasing latency (mean 0.02 mm/day, p = 0.03). CONCLUSION: Future randomised trials should assess the long term effects of exposure to antenatal glucocorticoids, particularly multiple courses, on the cardiovascular status of the infant.

Can methadone concentrations predict the severity of withdrawal in infants at risk of neonatal abstinence syndrome?

AIM: To assess the usefulness of cord and serum methadone concentrations at 2 days of age in predicting the severity of neonatal abstinence syndrome (NAS) in infants whose mothers received methadone during pregnancy. METHODS: After informed consent, infants were enrolled if they were delivered at 35 weeks gestation or greater. Relevant information was collected from maternal notes. A sample of cord blood was taken at delivery, with a follow up sample at 48 hours of age. The samples were analysed in batches, and the results were unavailable to the attending clinical staff. Infants were treated for NAS on clinical grounds according to a standardised scoring system. RESULTS: Twenty five of 36 eligible infants over the 21 month period of the study were enrolled. Of these, 12 required treatment for NAS. Maternal methadone dose did not predict the need for treatment. However, infants who required treatment had significantly lower methadone concentrations in cord blood than the group who did not receive treatment (31 v 88 ng/ml respectively; p = 0.029). Paired blood samples for methadone concentrations were available for 17 infants. All but one of the 12 infants who required treatment had undetectable concentrations of methadone in the postnatal sample, whereas the median postnatal methadone concentration in untreated infants was 23 ng/ml (p = 0.002). CONCLUSIONS: Methadone concentrations taken from cord blood may identify infants at greater risk of neonatal withdrawal and therefore requiring treatment.

Multicomponent fortified human milk for promoting growth in preterm infants.

BACKGROUND: For term infants, human milk provides adequate nutrition to facilitate growth, as well as potential beneficial effects on immunity and the maternal-infant emotional state. However, the role of human milk in premature infants is less well defined as it contains insufficient quantities of some nutrients to meet the estimated needs of the infant. Observational studies have suggested that infants fed formula have a higher rate of growth than infants who are breast fed. However, there are potential short term and long term benefits from human milk. Commercially-produced multicomponent fortifiers provide additional nutrients to supplement human milk (in the form of protein, calcium, phosphate, and carbohydrate, as well as vitamins and trace minerals). OBJECTIVES: The main objective was to determine if addition of multicomponent nutritional supplements to human milk leads to improved growth, bone metabolism and neurodevelopmental outcomes without significant adverse effects in premature infants. SEARCH STRATEGY: Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 3003), MEDLINE (searched August 29, 2003), previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language. SELECTION CRITERIA: All trials utilising random or quasi-random allocation to supplementation of human milk with multiple nutrients or no supplementation in premature infants within a nursery setting were eligible. DATA COLLECTION AND ANALYSIS: Data were extracted using the standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference. MAIN RESULTS: Supplementation of human milk with multicomponent fortifiers is associated with short term increases in weight gain, linear and head growth. There is no effect on serum alkaline phosphatase levels; it is not clear if there is an effect on bone mineral content. Nitrogen retention and blood urea levels appear to be increased. There are insufficient data to evaluate long term neurodevelopmental and growth outcomes, although there appears to be no effect on growth beyond one year of life. Use of multicomponent fortifiers does not appear to be associated with adverse effects, although the total number of infants studied and the large amount of missing data reduces confidence in this conclusion. Blood urea levels are increased and blood pH levels minimally decreased, but the clinical significance of this is uncertain. REVIEWER'S CONCLUSIONS: Multicomponent fortification of human milk is associated with short-term improvements in weight gain, linear and head growth. Despite the absence of evidence of long-term benefit and insufficient evidence to be reassured that there are no deleterious effects, it is unlikely that further studies evaluating fortification of human milk versus no supplementation will be performed. Further research should be directed toward comparisons between different proprietary preparations and evaluating both short-term and long-term outcomes in search of the "optimal" composition of fortifiers.

Carbohydrate supplementation of human milk to promote growth in preterm infants.

BACKGROUND: This section is under preparation and will be included in the next issue. OBJECTIVES: The main objective was to determine if addition of carbohydrate supplements to human milk leads to improved growth and neurodevelopmental outcomes without significant adverse effects in preterm infants. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group was used. This includes searches of the Oxford Database of Perinatal Trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language. SELECTION CRITERIA: All trials utilising random or quasi-random allocation evaluating the supplementation of human milk with carbohydrate in preterm infants within a nursery setting were eligible. DATA COLLECTION AND ANALYSIS: Not applicable. MAIN RESULTS: No eligible trials were found. REVIEWER'S CONCLUSIONS: There are no studies which have specifically evaluated the addition of carbohydrate alone for the purpose of improving growth and neurodevelopmental outcomes. No recommendations for practice can be made. Research should be directed towards comparison of different quantities and types of carbohydrate in multicomponent fortifiers containing protein and minerals, specifically evaluating short-term growth and long-term growth and neurodevelopmental outcomes.

Fat supplementation of human milk for promoting growth in preterm infants.

BACKGROUND: For term infants, human milk provides adequate nutrition to facilitate growth, as well as potential beneficial effects on immunity and the maternal-infant emotional state. However, the role of human milk in premature infants is less well defined as it contains insufficient quantities of some nutrients to meet the estimated needs of the infant. There are potential short term and long term benefits from human milk, although observational studies have suggested that infants fed formula have a higher rate of growth than infants who are breast fed. OBJECTIVES: The main objective is to determine if addition of supplemental fat to human milk leads to improved growth and neurodevelopmental outcomes without significant adverse effects in preterm infants. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Collaborative Review Group was used. This includes searches of the Oxford Database of Perinatal Trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language. SELECTION CRITERIA: All trials utilizing random or quasi-random allocation to supplementation of human milk with fat or no supplementation in preterm infants within a hospital were eligible. DATA COLLECTION AND ANALYSIS: Data were extracted using the standard methods of the Cochrane Neonatal Collaborative Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference. MAIN RESULTS: Results are available for only one small study evaluating the effects of fat supplementation. There are insufficient data to evaluate short term or long term growth outcomes and neurodevelopmental outcomes. There are insufficient data to comment on potential adverse effects. REVIEWER'S CONCLUSIONS: There is insufficient evidence to make recommendations for practice. Further research should evaluate the practice of supplementation of human milk with fat. This may best be done in the context of the development of multicomponent fortifiers. Both short term growth outcomes and long term growth and neurodevelopmental outcomes should be evaluated. Adverse effects should be evaluated.

Multicomponent fortified human milk for promoting growth in preterm infants.

BACKGROUND: For term infants, human milk provides adequate nutrition to facilitate growth, as well as potential beneficial effects on immunity and the maternal-infant emotional state. However, the role of human milk in premature infants is less well defined as it contains insufficient quantities of some nutrients to meet the estimated needs of the infant. There are potential short term and long term benefits from human milk, although observational studies have suggested that infants fed formula have a higher rate of growth than infants who are breast fed. Commercially-produced multicomponent fortifiers provide additional nutrients to human milk (in the form of protein, calcium, phosphate, and carbohydrate, as well as vitamins and trace minerals). OBJECTIVES: The main objective was to determine if addition of multiple dietary supplements to human milk leads to improved growth, bone metabolism and neurodevelopmental outcomes without significant adverse effects in premature infants. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group was used. This includes searches of the Oxford Database of Perinatal Trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language. SELECTION CRITERIA: All trials utilising random or quasi-random allocation to supplementation of human milk with multiple nutrients or no supplementation in premature infants within a nursery setting were eligible. DATA COLLECTION AND ANALYSIS: Data were extracted using the standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference. MAIN RESULTS: Supplementation of human milk with multicomponent fortifiers is associated with short term increases in weight gain, linear and head growth. There is no effect on serum alkaline phosphatase levels. Bone mineral content and nitrogen retention appear to be increased. There are insufficient data to evaluate long term neurodevelopmental and growth outcomes. Adverse effects of fortification do not appear to be significantly increased, although the total number of infants studied and the unavailability of results for some infants randomized and subsequently withdrawn reduces confidence in this conclusion. Blood urea levels are increased and blood pH levels minimally decreased, but the significance of this is uncertain. REVIEWER'S CONCLUSIONS: Multicomponent fortification of human milk is associated with short-term improvements in weight gain, linear and head growth. Despite the absence of evidence of long-term benefit and insufficient evidence to be reassured that there are no deleterious effects, it is unlikely that further studies evaluating fortification of human milk versus no supplementation will be performed. Further research should be directed toward comparisons between different proprietary preparations and evaluating both short-term and long-term outcomes in search of the "optimal" composition of fortifiers.

Protein supplementation of human milk for promoting growth in preterm infants.

BACKGROUND: For term infants, human milk provides adequate nutrition to facilitate growth, as well as potential beneficial effects on immunity and the maternal-infant emotional state. However, the role of human milk in preterm infants is less well defined as it contains insufficient quantities of some nutrients to meet the estimated needs of the infant. Preterm infants require higher protein intakes than term infants to attain adequate growth rates, and have relatively higher protein turnover rates. Inadequate protein intakes may be partly responsible for low serum albumin and blood urea concentrations in preterm infants. OBJECTIVES: The main objective was to determine if addition of protein to human milk leads to improved growth and neurodevelopmental outcomes without significant adverse effects in preterm infants. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used. This includes searches of the Oxford Database of Perinatal Trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, and journal handsearching mainly in the English language. SELECTION CRITERIA: All trials utilizing random or quasi-random allocation to supplementation of human milk with protein or no supplementation in preterm infants who remained in hospital were eligible. DATA COLLECTION AND ANALYSIS: Data were extracting using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference. MAIN RESULTS: Protein supplementation of human milk results in increases in short term weight gain (WMD 3.6 g/kg/day, 95% CI 2.4 to 4.8 g/kg/day), linear growth (WMD 0.28 cm/week, 95% CI 0.18 to 0.38 cm/week) and head growth (WMD 0.15 cm/week, 95% CI 0.06 to 0.23 cm/week). There are insufficient data to evaluate long term neurodevelopmental and growth outcomes. There are too few infants studied to be certain that adverse effects of protein supplementation are not increased. Blood urea levels are increased (WMD 1.0 mmol/l, 95% CI 0.8 to 1.2 mmol/l). REVIEWER'S CONCLUSIONS: Protein supplementation of human milk in relatively well preterm infants results in increases in short term weight gain, linear and head growth. Urea levels are increased, which may reflect adequate rather than excessive dietary protein intake. Further research should be directed towards the evaluation of specific levels of protein intake in preterm infants and the clinical effects of supplementation with protein, including long term growth and neurodevelopmental outcomes. This may best be done in the context of refinement of available multicomponent fortifier preparations.

Calcium and phosphorus supplementation of human milk for preterm infants.

BACKGROUND: Preterm infants are born with low skeletal stores of calcium and phosphorus. Preterm human milk provides insufficient calcium and phosphorus to meet their estimated needs. OBJECTIVES: To determine if addition of calcium and phosphorus supplements to human milk leads to improved growth and bone metabolism without significant adverse effects in preterm infants. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group (NRG) was used. This includes searches of the Oxford Database of Perinatal Trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language. SELECTION CRITERIA: All trials utilizing random or quasi-random allocation to supplementation of human milk with calcium and/or phosphorus or no supplementation in preterm infants within a hospital were eligible. DATA COLLECTION AND ANALYSIS: Data were extracted using the standard methods of the Cochrane NRG, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference. MAIN RESULTS: No studies which met selection criteria were identified. Excluded studies that were identified included minerals as one component of a multicomponent fortifier or reported only non-clinical outcomes (for example, urinary excretion of calcium). Two studies were excluded because of methodological concerns. REVIEWER'S CONCLUSIONS: There are no randomized controlled data evaluating clinical outcomes of calcium and phosphorus supplementation of human milk for preterm infants on which to base practice recommendations. Further trials should assess the clinical benefits and potential adverse effects of supplementation of human milk with minerals. This may best be done in the context of manipulation of the composition of human milk fortifiers containing multiple nutrients (carbohydrate, protein, and minerals).

Delay of catch-up growth in very low birthweight infants.

AIM: To determine if appropriate for gestational age, very low birth weight infants demonstrate catch-up growth. METHODS: The notes of 74 appropriate for gestational age, very low birth weight infants were reviewed and anthropometric measures converted into standard deviation scores (Z-scores). The growth of "well" infants was compared with that of "unwell" infants (those who developed necrotising enterocolitis, bronchopulmonary dysplasia or were not feeding at one week of age). RESULTS: All infants showed reduced weight (p<0.001) and head circumference (p<0.01) Z-scores at one week of age. This persisted until 35 weeks postmenstrual age in both groups, by which time length Z-scores had also reduced. The well group had regained birth Z-scores for all measurements by three months post-term. However the unwell group still had significantly lower weight (p<0.01) and length (p<0.05) Z-scores at three months. CONCLUSIONS: Well very low birth weight infants regained their birth percentiles by three months post-term. In infants with significant neonatal illness, this recovery was delayed.

Relationship between blood pressure and blood flow in newborn preterm infants.

BACKGROUND: Arterial blood pressure remains the most frequently monitored indicator of neonatal circulatory status. However, studies of systemic perfusion in neonates have often shown only weakly positive associations with blood pressure. OBJECTIVES: To examine the relationship between invasively monitored arterial blood pressure and four measurements of systemic perfusion: left and right ventricular outputs, superior vena caval (SVC) flow and descending aortic (DAo) flow. DESIGN: Echocardiographic assessments of perfusion were performed four times in the first 48 h of postnatal life in a cohort of 34 preterm (<30 weeks) infants. Arterial blood pressure was monitored invasively over the exact duration of the echocardiogram. RESULTS: In the first 48 h of postnatal life there was no evidence of a positive association between blood pressure and volume of blood flow in any of the four vessels studied. At 5 h postnatal age there was a weak but significant inverse correlation between volume of SVC flow and arterial blood pressure (p = 0.04). A similar but non-significant trend was seen at 12 h postnatal age. CONCLUSIONS: Infants with reduced systemic perfusion tend to have normal or high blood pressure in the first hours of life, suggesting that a high systemic vascular resistance may lead to reduced blood flow. Low blood pressure does not correlate with poor perfusion in the first 48 h of postnatal life in sick preterm infants.

Echocardiographic assessment of blood flow volume in the superior vena cava and descending aorta in the newborn infant.

BACKGROUND: Clinical methods of assessing adequacy of the circulation are poor predictors of volume of blood flow in the newborn preterm. Doppler echocardiography can be used to assess perfusion at various sites in the circulation. OBJECTIVE: To assess repeatability of measurement of volume of superior vena caval (SVC) and descending aortic (DAo) flow. DESIGN: SVC and DAo flow volume were assessed four times in the first 48 h of postnatal life in a cohort of preterm (<31 weeks) infants. Within-observer and between-observer repeatability was assessed in a subgroup of preterm infants. Normative values were derived from 14 preterm infants who required <48 h respiratory support and 13 healthy term infants. RESULTS: Within-observer repeatability coefficient was 30 ml/kg/min for quantification of SVC flow, and 2.2 cm for DAo stroke distance. Measurement of DAo diameter had poor repeatability. Between-observer repeatability appeared poorer than within-observer repeatability. The fifth centile for volume of SVC flow in healthy preterm infants was 55 ml/kg/min and 4.5 cm for DAo stroke distance. CONCLUSIONS: Echocardiographic assessments of volume of SVC flow and velocity of DAo flow have similar within-observer repeatability to other neonatal haemodynamic measurements. Between-observer repeatability for both measurements was poor, reflecting the difficulty of standardising these novel techniques. In this small cohort of preterm infants, SVC flow volume <55 ml/kg/min and DAo stroke distance <4.5 cm represented low or borderline systemic perfusion in the first 48 h of postnatal life.

Who's got what? A benchmarking exercise for tertiary neonatal units.

OBJECTIVES: To determine the current facilities available in level-3 neonatal units (NNU) in Australia and New Zealand to assist with establishment of standards for new NNU design. BACKGROUND: Many current NNU in Australia and New Zealand are planning new or redesigning existing facilities. There are no adequate local standards for NNU design available which reflect changing neonatal practices. METHODS: All level-3 neonatal units belonging to the Australia and New Zealand Neonatal Network (ANZNN) were invited to respond to a survey on NNU facilities. Questions were based around obtaining information on whether the NNU were planning to build or redesign the space and clinical facilities available in their existing facilities and what support and family spaces were provided. RESULTS: Twenty-six (six in New Zealand and 20 in Australia) of the 29 tertiary NNU in the ANZNN responded the survey. The oldest facility was built in 1960, with the most recent NNU being commissioned in 2003. Of the 26 responders, 18 indicated that they were planning to rebuild or renovate, with 13 anticipating completion within 6 years. The median floor area for existing level-3 cots was 11.1 m(2) (range 5.5-18.0 m(2)) and 5.8 m(2) (range 2.3-15.6 m(2)) for level-2 cots, respectively. Most units responded that storage space was insufficient (median 1.5 m(2) per cot, range 0.4-3.3 m(2) per cot). Most units had facilities for parents including a family lounge and parent overnight rooms, although 16 units indicated that they needed more overnight rooming in facilities. Noise levels in level-3 areas were described as being 'generally' or 'mostly noisy' in 14 of 25 responses, but noise levels in level-2 areas were less in the majority of responses. Privacy was cited as an issue for 80% of responding NNU with comments directed at either the layout or space constraints interfering with confidentiality or interactions with families. CONCLUSIONS: The majority of NNU have inadequate space and environmental control. The lack of space particularly impacts on infection control aspects, parental privacy and participation and staff satisfaction. Level-2 areas, where parent participation in the care of infants is often greater, should receive as much attention as higher technology level-3 areas. Furthermore, work should be undertaken to develop appropriate local recommendations for NNU design which are acknowledged by local government agencies and professional bodies and take into account the changes in neonatal care practices, integration of family in the care of infants and the needs of the staff.

Cardiorespiratory stability during echocardiography in preterm infants.

Blood pressure, heart rate, and oxygen saturation were monitored prospectively during 40 echocardiography recordings on 17 preterm infants (25-29 weeks; 510-1430 g), to examine whether echocardiography can be performed without disturbing cardiorespiratory status in preterm infants. There was no impact on absolute blood pressure. Heart rate increased by a mean of 4 beats per minute, and oxygen saturation decreased by a mean of 1% during echocardiography. While these changes reached statistical significance they are not of clinical significance as they remained well within ranges seen during control rest periods. All readings had greater minute-to-minute variability during echocardiography but differences were small and again remained within physiological ranges.

Variation in identifying neonatal percutaneous central venous line position.

OBJECTIVE: The study objective was to obtain data on interpretation, including intra and interobserver variation and action taken for a given line tip location, for a series of radiographs demonstrating neonatal long lines. METHODS: Nineteen radiographs taken to identify line tip position were digitized and published on an internet site. One film was included twice in order to assess intraobserver variation giving a total of 20 images. Fourteen used radio-opaque contrast and five no contrast. Australian and New Zealand Neonatal Network members and National Women's Hospital NICU staff were invited to participate in the study. For each radiograph, participants were asked to identify if long line tip could be identified, the likely anatomical position and desired action. Interobserver agreement was assessed by the maximum proportion of agreement per radiograph and by the number of different options selected. Intraobserver agreement was assessed by comparing the two reports from the duplicate radiograph. RESULTS: Twenty-seven responses were received. Overall, 50% of the reports stated that the long line tips could be identified. The most commonly reported position was in the right atrium (31%) and most commonly reported action was to pull the line back (53%). The median agreement of whether the line was seen was 68%, agreement on position 62% and agreement on action 86%. On analysis of intraobserver variability, from the identical radiographs, 27% of respondents differed on whether the line tip could be visualized. CONCLUSION: Interobserver and intraobserver reliability was poor when using radiographs to assess long line tips. The major determinant of line repositioning was the perceived location.

Alveolar capillary dysplasia with antenatal anomalies mimicking trisomy 21.

Alveolar capillary dysplasia (ACD) has been described in conjunction with a number of congenital abnormalities. The case reported here was noted in utero to have duodenal atresia and a partial atrioventricular canal defect and a provisional diagnosis of trisomy 21 was considered. A fetal blood sample showed a normal karyotype. The diagnosis of ACD was made at post-mortem following a neonatal death on the tenth day. This case further highlights the range of congenital abnormalities that may be present in cases of ACD that may mimic other conditions, including trisomy 21, on antenatal scan. However, the absence of congenital anomalies, even in the same family, would not exclude the diagnosis of ACD.

Pericardial effusion complicating a percutaneous central venous line in a neonate.

A premature infant developed pericardial effusion four days after the insertion of a 25-gauge silastic percutaneous central venous catheter. The effusion contained parenteral nutrition fluid and resolved rapidly after withdrawal of the catheter. Pericardial effusion is a potential complication of percutaneous, as well as surgically placed, central venous catheters.

Predictors of chronic lung disease in the 'CPAP era'.

OBJECTIVE: To assess predictors of chronic lung disease (CLD), in infants requiring nasal continuous positive airway pressure (CPAP) support in the first 4 weeks of life. METHODS: A retrospective case note audit of infants of birthweight 1250 g or less was undertaken. RESULTS: Of 290 infants identified, 50% were initially treated with ventilation, 41% with CPAP, 4% required no support, and 5% had care withdrawn. Of infants initially treated with CPAP, 23% subsequently required ventilation. Overall mortality was 19%, with a further 21% of infants developing CLD. For infants requiring CPAP support, requirement for supplementary oxygen at between 10 and 21 days predicted increased risk of CLD, and receiver operating characteristic curves suggest requirement for supplementary oxygen at 14 days to be the most reliable cut-off (area under curve = 0.72). Positive predictive values for future CLD or death for FiO2 .25, .30 and .40 while on CPAP at 14 days were 0.56, 0.61 and 0.76, respectively. CONCLUSIONS: CLD remains prevalent in very low birthweight infants in the CPAP era. Oxygen requirement at 14 days is the strongest predictor of CLD. Infants requiring 30% oxygen or more while on CPAP at 14 days have a 60% risk of subsequent CLD or death.

A randomized trial of enteral feeding volumes in infants born before 30 weeks' gestation.

OBJECTIVE: To compare the effect of two volumes of enteral feeds on postnatal growth in infants born before 30 weeks gestation. METHODOLOGY: Fifty-four infants, less than 30 weeks gestational age, who reached full enteral feeds were randomized to remain on 150 mL/kg per day (150 group) or increase to 200 mL/kg per day (200 group). The primary outcome measure was growth at 35 weeks corrected gestational age (CGA). RESULTS: There were no statistically significant differences in demographic or clinical parameters between the study groups at commencement of the study, although there was a trend for infants in the 150 group to be lighter (895 g vs 1020 g, P = 0.27). Milk intakes were increased in 43% of the infants in the 150 group, whereas 54% of the infants in the 200 group required reduced intakes. Infants in the 200 group had greater daily weight gains (16.7 g/kg per day vs 15.2 g/kg per day, P = 0.047) and at 35 weeks CGA were heavier (2020 g vs 1885 g, P = 0.014) and had a greater arm fat area (282 mm2 vs 218 mm2, P = 0.009). There was no difference in length or head circumference at 35 weeks CGA, and no difference in any growth parameter at 1 year of age. Morbidity was not different between the groups. CONCLUSIONS: The individual milk volume requirements for adequate weight gain without significant adverse effects vary between 150 and 200 mL/kg per day in extremely premature infants. For many infants in both groups, the assigned target volume was not appropriate. Increased milk intakes (and therefore higher caloric and mineral intakes) are associated with increased daily weight gains and a greater weight at 35 weeks CGA. The weight gain may be due to an increase in fat deposition.

The use of renal Doppler ultrasonography to diagnose patent ductus arteriosus in preterm infants.

OBJECTIVE: To prospectively study the diagnostic usefulness of altered renal waveforms in patent ductus arteriosus. METHODS: We studied preterm infants undergoing echocardiography for a suspected patent ductus arteriosus. A spectral Doppler display was acquired for both renal arteries, and a resistive index was obtained. Sensitivity, specificity, and likelihood ratios were calculated using a clinically significant patent ductus arteriosus (>1.5-mm diameter on color Doppler ultrasonography) as the standard of reference. RESULTS: Fifty infants had 78 scans. A significant patent ductus arteriosus was present on 39 scans. When the renal resistive index was greater than 1.0, the likelihood ratio for a significant patent ductus arteriosus was 24.8 (specificity, 97.2%; SD, 3.8%). When the renal resistive index was 1.0 or less, the likelihood ratio for a significant patent ductus arteriosus was 0.2 (sensitivity, 77.2%; SD, 9.4%). CONCLUSIONS: Renal resistive index measurement is a simple investigation that can predict a significant patent ductus arteriosus in patients without congenital heart disease or other causes of diastolic runoff when echocardiography is unavailable.