Unveiling the paradoxes of implementing post graduate competency based medical education programs.

PURPOSE: Competency-based medical education (CBME) has gained prominence as an innovative model for post-graduate medical education, yet its implementation poses significant challenges, especially with regard to its sustainability. Drawing on paradox theory, we suggest that revealing the paradoxes underlying these challenges may contribute to our understanding of post graduate competency-based medical education (PGCBME) implementation processes and serve as a first-step in enhancing better implementation. Thus, the purpose of the current study is to identify the paradoxes associated with PGCBME implementation. METHOD: A qualitative study was conducted, as part of a larger action research, using in-depth semi-structured interviews with fellows and educators in eight Neonatal wards. RESULTS: Analysis revealed that the PGCBME program examined in this study involves three different levels of standardization, each serving as one side of paradoxical tensions; (1) a paradox between the need for standardized assessment tools and for free-flow flexible assessment tools, (2) a paradox between the need for a standardized implementation process across all wards and the need for unique implementation protocols in each ward; and 3) a paradox between the need for a standardized meaning of competency proficiency and the need for flexible and personal competency achievement indicators. CONCLUSIONS: Implementing PGCBME programs involves many challenges, some of which are paradoxical, i.e. two contradictory challenges in which solving one challenge exacerbates another. Revealing these paradoxes is important in navigating them successfully.

Preterm infants with severe brain injury demonstrate unstable physiological responses during maternal singing with music therapy: a randomized controlled study.

Preterm infants with severe brain injury are at high risk for poor outcomes and, therefore, may benefit from developmental care modalities such as music therapy (MT). In this prospective, randomized intervention, preterm infants with severe brain injury (grade 3 or 4 intraventricular hemorrhage or periventricular leukomalacia) who underwent skin-to-skin contact (SSC) with or without maternal singing during MT were evaluated for physiological responses, including autonomic nervous system stability (low frequency (LF)/high frequency (HF) power), heart rate, respiratory rate, oxygen saturation, and behavioral state. Maternal anxiety state and physiological data were also evaluated. A total of 35 preterm infants with severe brain injuries were included in the study analysis. Higher mean ± standard deviation (SD) LF/HF ratio (1.8 ± 0.7 vs. 1.1 ± 0.25, p = 0.01), higher mean ± SD heart rate (145 ± 15 vs. 132 ± 12 beats per minute, p = 0.04), higher median (interquartile range) infant behavioral state (NIDCAP manual for naturalistic observation and the Brazelton Neonatal Behavioral Assessment) score (3 (2-5) vs. 1 (1-3), p = 0.03), and higher mean ± SD maternal anxiety (state-trait anxiety inventory) score (39.1 ± 10.4 vs. 31.5 ± 7.3, p = 0.04) were documented in SSC combined with maternal singing during MT, as compared to SSC alone.Conclusion: Maternal singing during MT for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. A unique MT intervention should be designed for preterm infants with severe brain injury and their mothers. What is Known: • Preterm infants with severe brain injury are at high risk for poor outcomes. • Music therapy benefits brain development of preterm infants without severe brain injury, however it is unknown whether maternal singing during music therapy for preterm infants with severe brain injury is beneficial. What is New: • Maternal singing during music therapy for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. • A unique music therapy intervention should be designed for preterm infants with severe brain injury and their mothers.

[UMBILICAL CORD CORTISOL LEVELS DO NOT CORRELATE WITH 17-HYDROXYPROGESTERONE LEVELS IN THE NEWBORN SCREENING TEST].

BACKGROUND: Cortisol is a stress response marker. During pregnancy and delivery, cortisol levels are elevated, especially in complicated deliveries. Blood cortisol levels can increase 17-hydroxyprogesterone (17-OHP) levels in the mother during delivery, however this effect was not elucidate in newborn infants. OBJECTIVES: To investigate whether there is a correlation between umbilical cord cortisol and 17-OHP levels in the newborn, leading to false results in the newborn screening tests. METHODS: Umbilical cord cortisol levels together with maternal delivery data were analyzed at Meir Medical Center during 2015-2016. The newborn screening test was performed in all newborns at 36 to 72 hours after birth, and data on 17-OHP levels were recorded. A correlation between mode of delivery, umbilical cord cortisol level and 17-OH- P levels of the newborn screening tests was conducted. RESULTS: A total of 122 newborn infants were included in the study. The mean cord cortisol levels were 12.3±4.1 mcg/dL. Vacuum extraction deliveries were associated with the higher cord cortisol level compared to unplanned cesarean section deliveries, planned cesarean sections and vaginal deliveries (all p<0.03). Unplanned cesarean sections had higher umbilical cord cortisol levels compared to planned cesarean section and vaginal delivery ( all p<0.05). All infants had 17-OHP levels within normal limits (<35 nM), with no correlation to umbilical cord cortisol levels (r=0.012, p=0.26). CONCLUSIONS: Vacuum extraction deliveries are associated with the highest cord cortisol level compared to unplanned cesarean section deliveries and to vaginal deliveries, however, these levels are not associated with high levels of 17-OHP of the newborn screening test. Therefore, our data does not support the hypothesis that stressful deliveries are associated with high false positive 17-OHP levels in the newborn screening test.

Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible.

PURPOSE: Appendectomy versus conservative antibiotic treatment (CAT) for children with acute uncomplicated appendicitis (AUA) remains unresolved, with concerns regarding the practicality of CAT. We analyzed our center's experience with CAT for AUA, using a protocol with strict inclusion, exclusion and treatment criteria. METHODS: Non-randomized, prospective cohort study included all children admitted betwee 2014 and 2016, with clinical and laboratory tests suspicious for AUA. Data collected included clinical signs and symptoms; laboratory, ultrasound and pathology results. Follow-up was conducted through clinic visits, telephone conversations and national registry analysis. RESULTS: Included in CAT: 362 children, 19 underwent appendectomy within 1-2 days. Overall, 75 were readmitted for recurrent acute appendicitis during 22 months (6-43) follow-up. Thirty were treated successfully with antibiotics a second time. The remaining 45 had appendectomy. Overall, 86.8% underwent CAT with no surgery. Histology of all recurrent AUA revealed no perforations. CONCLUSION: We confirm the feasibility of conservative management of AUA in children. A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile. CAT does not compete with surgery or render appendectomy unnecessary. It is a safe alternative to surgery in selected cases.

Conservative treatment in uncomplicated acute appendicitis: reassessment of practice safety.

The success rate of conservative treatment for children with uncomplicated appendicitis was prospectively evaluated among 197 children. All who received intravenous antibiotics for 3-5 days, and if symptoms resolved, were discharged home on oral antibiotics for 5 days. Failure rate, symptoms, laboratory signs, and sonographic findings were evaluated for prognostic markers of treatment failure. Children were followed for 18 months. The success rate of conservative treatment was 87%, with shorter hospital stays compared to children who eventually needed surgery (72 [60-84] vs. 84 h [72-126], P = 0.001). Vomiting and/or nausea and intraluminal fluid on sonography were the only prognostic signs of failed treatment (P = 0.028 and P = 0.0001, respectively). After multi-regression analysis, intraluminal fluid was the only prognostic sign for failed treatment (odds ratio = 10.2; 95% CI 3.3-31.8, P = 0.001). Patients who failed conservative treatment were successfully operated without significant morbidity. Pathology findings were compatible with acute or subacute inflammation in 94% of operated AA, with no perforated appendices. CONCLUSION: When applying rigorous criteria for children with uncomplicated appendicitis, a high success rate can be achieved with conservative treatment. Those who fail conservative treatment have a benign medical course without serious complications. Intraluminal fluid may increase risk for conservative treatment failure. What is Known: • Conservative treatment in uncomplicated acute appendicitis is a reasonable alternative to appendectomy. What is New: • Using rigorous criteria for conservative treatment in uncomplicated acute appendicitis is safe and feasible. • Intraluminal fluid should be considered a contraindication to conservative treatment.

The Role of Exercise in Prevention and Treatment of Osteopenia of Prematurity: An Update.

Premature infants have an increased risk of osteopenia due to limited bone mass accretion in utero and a greater need for bone nutrients. Until recently, most efforts to prevent osteopenia of prematurity focused on nutritional changes. Recent studies indicate that passive range-of-motion exercise of the extremities may lead to beneficial effects on body weight, increased bone mineralization, increased bone formation markers and leptin levels, and attenuation of the natural postnatal decline in bone speed of sound. These results suggest that exercise may play an important role in the prevention and treatment of osteopenia of prematurity. This review summarizes our current knowledge on the role of exercise in the prevention and treatment of osteopenia of prematurity.

The Effect of Assisted Exercise Frequency on Bone Strength in Very Low Birth Weight Preterm Infants: A Randomized Control Trial.

We aimed to assess whether a twice daily assisted exercise interventional program will have a greater effect on bone strength compared to a once daily intervention or no intervention in very low birth weight (VLBW) preterm infants. Thirty-four very VLBW preterm infants (mean BW 1217 ± 55 g and mean gestational age 28.6 ± 1.1 weeks) were randomly assigned into one of three study groups: twice daily interventions (n = 13), a once daily intervention (n = 11), and no intervention (control, n = 10). The intervention was initiated at a mean of 8 ± 2.4 days of life and continued for 4 weeks. It included passive extension and flexion range-of-motion exercise of the upper and lower extremities. Bone strength was measured at enrollment and after 2 and 4 weeks using quantitative ultrasound of tibial bone speed of sound (SOS, Sunlight Omnisense™). At enrollment, the mean bone SOS was comparable between the twice daily interventions, once daily intervention and control groups (2918 ± 78, 2943 ± 119, and 2910 ± 48 m/s, respectively). As expected, the bone SOS declined in all groups during the study period (-23.6 ± 24, -68.8 ± 28, and -115.8 ± 30 m/s, respectively, p < 0.05), with a significantly attenuated decrease in bone strength in the twice daily intervention group (p = 0.03). A twice daily intervention program of assisted range-of-motion exercise attenuates the decrease in bone strength and may decrease the risk of osteopenia and future fractures in VLBW preterm infants.

Association between neonatal morbidities and head growth from birth until discharge in very-low-birthweight infants born preterm: a population-based study.

AIM: To evaluate the possible association between major neonatal morbidities and poor head growth from birth to discharge home in very-low-birthweight (VLBW) infants born preterm. METHOD: Population-based observational study comprising 12 992 infants (6340 male, 6652 female) of 24 to 32 weeks' gestation, and birthweight ≤1500g. Severe head growth failure (HGF) was defined as a decrease in head circumference z-score >2 z-scores, and moderate HGF as a decrease of 1 to 2 z-scores. Multinomial logistic regression analysis was applied to determine morbidities associated with HGF. RESULTS: Severe HGF occurred in 4.5% and moderate HGF in 20.9% of infants. Each unit increase in head circumference z-score at birth was associated with increased odds for severe and moderate HGF (odds ratios [OR] 5.29, 95% confidence intervals [CI] 4.67-6.00, and OR 2.38, 95% CI 2.23-2.54 respectively). Both severe and moderate HGF were associated with respiratory distress syndrome (OR 2.03, 95% CI 1.58-2.62, and OR 1.66, 95% CI 1.48-1.85 respectively); bronchopulmonary dysplasia (OR 3.38, 95% CI 2.33-4.91, and OR 1.87, 95% CI 1.52-2.30 respectively); necrotizing enterocolitis (OR 2.89, 95% CI 2.04-4.09, and OR 1.72, 95% CI 1.38-2.16 respectively), and sepsis (OR 2.06, 95% CI 1.69-2.50, and OR 1.38, 95% CI 1.24-1.53 respectively). INTERPRETATION: Major neonatal morbidities were associated with HGF in VLBW infants born preterm. Identification of whether this is a direct effect of these morbidities or mediated through nutritional or growth factors may enable interventions to improve postnatal head growth of infants born preterm.

Iron homeostasis after blood transfusion in stable preterm infants - an observational study.

AIM: To evaluate the short-term effects of blood transfusion on iron status [hemoglobin, ferritin, soluble transferrin receptor (sTfR), and reticulocyte count], hepcidin, and erythropoietin in stable preterm infants. METHOD: Sixty-three preterm infants treated with red blood cell transfusions (RBCTs) were included. Venous blood samples were collected before and within 24 h after each transfusion. RESULTS: Hemoglobin concentration increased after RBCT (7.2±1.2 g/dL vs. 13.7±2.3 g/dL, P=0.02), as well as ferritin [131 (63-110.4) ng/mL vs. 211 (125.7-299.2) ng/mL, P=0.05); reticulocyte count decreased. sTfR did not change. Hepcidin serum levels increased from 37.5 (21.3-84.7) ng/mL to 72.6 (31.3-126.2) ng/mL, (P=0.04) and erythropoietin decreased (48±19 pg/mL vs. 29±17 pg/mL, P=0.06) after RBCT. A positive linear correlation was found (R2=0.76, P=0.0001) between hepcidin and ferritin levels of post-minus-pre RBCT. Hepcidin levels increased significantly in preterm infants who received RBCT after 1 month of age compared to those who received RBCT at <1 month (P=0.03). No correlation was found between gestational age, weight appropriate for age, or length of blood storage and hepcidin levels. CONCLUSION: Preterm infants can control iron levels by regulating hepcidin and decreasing erythropoietin. This ability varies with postnatal age.

[DEVELOPMENTAL CARE IN THE NEONATAL INTENSIVE CARE UNIT ACCORDING TO NEWBORN INDIVIDUALIZED DEVELOPMENTAL CARE AND ASSESSMENT PROGRAM (NIDCAP)].

During hospitalization in the neonatal intensive care unit (NICU), the brain of the preterm infant undergoes a particularly vulnerable and sensitive period of development. Brain development might be negatively influenced by direct injury as well as by complications of prematurity. Over the past few years, stress has come to be increasingly recognized as a potential risk factor. The NICU environment contains numerous stress factors due to maternal deprivation and over-stimulation, such as light, sound and pain, which conflict with the brain's developmental requirements. Developmental care is a caregiving approach that addresses the early developmental needs of the preterm infant as an integral component of quality neonatal care. NIDCAP (Newborn Individualized Developmental Care and Assessment Program) is a comprehensive program that aims to reduce environmental stress, to support the infant's neuro-behavioral maturation and organization, and to promote early parent-infant relationships. The implementation of developmental care based on NIDCAP principles is a gradual, in-depth systems change process, which affects all aspects of care in the NICU. This review describes the theoretical basis of the NIDCAP approach, summarizes the scientific evidence and addresses some of the implications of the transition from a traditional to a developmental care NICU.

Reduced crying in term infants fed high beta-palmitate formula: a double-blind randomized clinical trial.

BACKGROUND: Beta-palmitate (sn-2 palmitate) mimics human milk fat, enabling easier digestion.Therefore, we hypothesized that infants consuming high beta-palmitate formula would have more frequent, softer stools and reduced crying compared to infants consuming low beta-palmitate formula. METHODS: Formula-fed infants were randomly assigned to receive either (1) formula with high beta-palmitate (HBP, n = 21) or (2) regular formula with a standard vegetable oil mix (LBP, n = 21). A matched group of breastfed infants served as a reference (BF, n = 21). Crying and stool characteristics data were recorded by the parents for 3 days before the 6- and 12-week visits. RESULTS: We found no significant differences in the stool frequency or consistency between the two formula groups. The percentage of crying infants in the LBP group was significantly higher than that in the HBP and BF groups during the evening at 6 weeks (88.2% vs. 56.3% and 55.6%, p < 0.05) and during the afternoon at 12 weeks (91.7% vs. 50.0% and 40%, p < 0.05). The infants fed HBP had significantly shorter crying durations when compared with infants fed LBP formula (14.90 ± 3.85 vs.63.96 ± 21.76 min/day, respectively; p = 0.047). CONCLUSIONS: Our study indicates that consumption of a high beta-palmitate formula affects infant crying patterns during the first weeks of life. Comparable to breastfeeding, it reduced crying duration and frequency, primarily during the afternoon and evening hours, thereby improving the well-being of formula-fed infants and their parents. TRIAL REGISTRATION: NCT00874068.Registration date March 31, 2009.

Maternal singing during kangaroo care led to autonomic stability in preterm infants and reduced maternal anxiety.

AIM: Kangaroo care (KC) and maternal singing benefit preterm infants, and we investigated whether combining these benefitted infants and mothers. METHODS: A prospective randomised, within-subject, crossover, repeated-measures study design was used, with participants acting as their own controls. We evaluated the heart rate variability (HRV) of stable preterm infants receiving KC, with and without maternal singing. This included low frequency (LF), high frequency (HF) and the LF/HF ratio during baseline (10 min), singing or quiet phases (20 min) and recovery (10 min). Physiological parameters, maternal anxiety and the infants' behavioural state were measured. RESULTS: We included 86 stable preterm infants, with a postmenstrual age of 32-36 weeks. A significant change in LF and HF, and lower LF/HF ratio, was observed during KC with maternal singing during the intervention and recovery phases, compared with just KC and baseline (all p-values <0.05). Maternal anxiety was lower during singing than just KC (p = 0.04). No differences in the infants' behavioural states or physiological parameters were found, with or without singing. CONCLUSION: Maternal singing during KC reduces maternal anxiety and leads to autonomic stability in stable preterm infants. This effect is not detected in behavioural state or physiological parameters commonly used to monitor preterm infants.

High Beta-palmitate formula and bone strength in term infants: a randomized, double-blind, controlled trial.

We aimed to compare the effect of 12-week feeding of commercially available infant formulas with different percentages of palmitic acid at sn-2 (beta-palmitate) on anthropometric measures and bone strength of term infants. It was hypothesized that feeding infants with high beta-palmitate (HBP) formula will enhance their bone speed of sound (SOS). Eighty-three infants appropriate for gestational age participated in the study; of these, 58 were formula-fed and 25 breast-fed infants, serving as a reference group. The formula-fed infants were randomly assigned to receive HBP formula (43 % of the palmitic acid is esterified to the middle position of the glycerol backbone, study group; n = 30) or regular formula with low-beta palmitate (LBP, 14 % of the palmitic acid is esterified to the middle position of the glycerol backbone, n = 28). Sixty-six infants completed the 12-week study. Anthropometric and quantitative ultrasound measurements of bone SOS for assessment of bone strength were performed at randomization and at 6 and 12 weeks postnatal age. At randomization, gestational age, birth weight, and bone SOS were comparable between the three groups. At 12 weeks postnatal age, the mean bone SOS of the HBP group was significantly higher than that of the LBP group (2,896 ± 133 vs. 2,825 ± 79 m/s respectively, P = 0.049) and comparable with that of the breast-fed group (2,875 ± 85 m/s). We concluded that infants consuming HBP formula had changes in bone SOS that were comparable to those of infants consuming breast milk and favorable compared to infants consuming LBP formula.

Effect of high ß-palmitate content in infant formula on the intestinal microbiota of term infants.

OBJECTIVES: Palmitic acid (PA) constitutes 17% to 25% of the human milk fatty acids, and ~70% is esterified in the sn-2 position of triglycerides (ß-palmitate). In the sn-2 position, PA is not hydrolyzed and thus is efficiently absorbed. The PA in palm oils, commonly used in infant formulas, is esterified in the sn-1 and sn-3 positions. In these positions, PA is hydrolyzed and forms poorly absorbed calcium complexes. The present study assessed whether high ß-palmitate in infant formulas affects the intestinal flora. METHODS: Thirty-six term infants were enrolled: 14 breast-fed (BF group) and 22 formula-fed infants who were randomly assigned to receive formula containing high ß-palmitate (HBP group, n=14), or low ß-palmitate (LBP group, n=8), where 44% and 14% of the PA was ß-palmitate, respectively. The total amount of PA in the formulas was 19% and 22% in the LBP and HBP groups, respectively. Neither formula contained pre- or probiotics. Stool samples were collected at enrollment and at 6 weeks for the quantification of bacteria. RESULTS: At 6 weeks, the HBP and BF groups had higher Lactobacillus and bifidobacteria counts than the LBP group (P<0.01). The Lactobacillus counts at 6 weeks were not significantly different between the HBP and BF groups. Lactobacillus counts were 1.2×10¹°, 1.2×10¹¹, and 5.6×10¹° CFU/g for LBP, HBP, and BF groups, respectively. Bifidobacteria counts were 5.1×109, 1.2×10¹¹, and 3.9×10¹° CFU/g for LBP, HBP, and BF groups, respectively. CONCLUSIONS: HBP formula beneficially affected infant gut microbiota by increasing the Lactobacillus and bifidobacteria counts in fecal stools.

Ultrasound assessment of endotracheal tube depth in neonates: a prospective feasibility study.

OBJECTIVE: To examine the reliability of a novel ultrasound (US) method for assessment of endotracheal tube (ETT) position in neonates. DESIGN: Prospective, observational, single-centre, feasibility study. SETTING: Level III neonatal intensive care unit. PATIENTS: Term and preterm neonates requiring endotracheal intubation. INTERVENTION: US measurement of the ETT tip to right pulmonary artery (RPA) distance was used to determine ETT position according to one-fourth to three-fourths estimated tracheal length for weight. US demonstration of pleural sliding and diaphragmatic movement was also assessed. Chest radiography (CXR) was performed following each intubation. MAIN OUTCOME MEASURES: Agreement between US assessment of ETT tip position and CXR served as the gold standard. Sensitivity, specificity, positive and negative predictive values for each US method and correlation between ETT tip to RPA distance on US, and ETT tip to carina distance on CXR were assessed. RESULTS: Forty-two US studies were performed on 33 intubated neonates. US evaluation of ETT-RPA distance identified 100% of ETTs positioned correctly: 77% deep and 80% high, demonstrating strong agreement with CXR (kappa=0.822). Sensitivity was 78%, specificity 100%, positive predictive value 100% and negative predictive value 86%. US ETT-RPA distance strongly correlated with CXR ETT-carina distance (r=0.826). No significant agreement was found between CXR and US assessment of pleural sliding and diaphragmatic movement. No adverse events were encountered during US scans. CONCLUSION: US evaluation of ETT-RPA distance demonstrated excellent accuracy for determining ETT position in neonates compared with CXR. More research is needed to support its feasibility in clinical settings.

Regional Splanchnic Oxygenation during Continuous versus Bolus Feeding among Stable Preterm Infants.

INTRODUCTION: There is no agreement regarding the best method for tube-feeding preterm infants. Few studies, to date, have evaluated the influence of different methods of enteral feeding on intestinal oxygenation. The use of near-infrared spectroscopy (NIRS) has permitted the noninvasive measurement of splanchnic regional oxygenation (rSO2S) in different clinical conditions. The aim of this prospective, single-center study was to compare rSO2S during continuous versus bolus feeding among stable preterm infants. METHODS: Twenty-one preterm infants, less than 32 weeks gestation and appropriate for gestational age, were enrolled. All infants were clinically stable and on full tube feedings. Each infant received a bolus feeding initially (20 min duration), and after 3 h, a continuous feeding (5 h duration). Infants were evaluated 30 min before and 30 min after the bolus and continuous feedings. The regional splanchnic saturation (rSO2S) was measured using near-infrared spectroscopy (NIRS) technology and systemic saturation was measured with pulse oximetry. From these measurements, we calculated the splanchnic fractional oxygen extraction ratio (FOES) for each of the four intervals. RESULTS: rSO2S decreased after continuous vs. bolus feeding (p = 0.025), while there was a trend toward decreased SaO2 after bolus feeding (p = 0.055). The FOES, which reflects intestinal oxygen extraction, was not affected by the feeding mode (p = 0.129). DISCUSSION/CONCLUSION: Continuous vs. bolus feeding decreases rSO2S but does not affect oxygen extraction by intestinal tissue; after bolus feeding there was a trend towards decreased systemic saturation.

Vitamin D Levels in Pregnant Women Do Not Affect Neonatal Bone Strength.

Vitamin D plays a key role in regulating calcium and phosphate metabolism. However, whether maternal vitamin D levels affect fetal bone strength is unclear. This study assessed correlations between maternal 25(OH)D status and neonatal bone strength 25(OH)D levels, these were measured in the maternal and infant cord blood of 81 mother−infant dyads. Bone strength was measured using a quantitative ultrasound (QUS) of tibial bone speed of sound (SOS). Maternal vitamin D intake, medical history and lifestyle were evaluated from questionnaires. Maternal 25(OH)D levels were deficient (<25 nmol/L) in 24.7%, insufficient (25−50 nmol/L) in 37% and sufficient (>50 nmol/L) in 38.3%. The maternal and cord blood 25(OH)D levels correlated (r = 0.85, p < 0.001). Cord blood levels (57.9 ± 33.5 nmol/L) were higher than the maternal blood levels (46.3 ± 23.2: p < 0.001). The mean SOS was 3042 ± 130 m/s. The neonatal SOS and 25(OH)D levels were not correlated. The mean bone SOS levels were comparable in the three maternal and cord blood 25(OH)D groups. No correlation was found between the maternal 25(OH)D levels and the neonatal anthropometrics. Although the 25(OH)D levels were higher in Jewish mothers than they were in Muslim mothers (51.1 ± 22.6 nmol/L vs. 24 ± 14.7 nmol/L, respectively: p = 0.002) and in those who took supplemental vitamin D, the bone SOS levels were comparable. In conclusion, maternal vitamin D levels correlate with cord levels but do not affect bone strength or growth parameters.

Sex-Specific Effects of Nutritional Supplements for Infants Born Early or Small: An Individual Participant Data Meta-Analysis (ESSENCE IPD-MA) II: Growth.

Neonatal nutritional supplements may improve early growth for infants born small, but effects on long-term growth are unclear and may differ by sex. We assessed the effects of early macronutrient supplements on later growth. We searched databases and clinical trials registers from inception to April 2019. Participant-level data from randomised trials were included if the intention was to increase macronutrient intake to improve growth or development of infants born preterm or small-for-gestational-age. Co-primary outcomes were cognitive impairment and metabolic risk. Supplementation did not alter BMI in childhood (kg/m2: adjusted mean difference (aMD) -0.11[95% CI -0.47, 0.25], p = 0.54; 3 trials, n = 333). Supplementation increased length (cm: aMD 0.37[0.01, 0.72], p = 0.04; 18 trials, n = 2008) and bone mineral content (g: aMD 10.22[0.52, 19.92], p = 0.04; 6 trials, n = 313) in infancy, but not at older ages. There were no differences between supplemented and unsupplemented groups for other outcomes. In subgroup analysis, supplementation increased the height z-score in male toddlers (aMD 0.20[0.02, 0.37], p = 0.03; 10 trials, n = 595) but not in females, and no significant sex interaction was observed (p = 0.21). Macronutrient supplementation for infants born small may not alter BMI in childhood. Supplementation increased growth in infancy, but these effects did not persist in later life. The effects did not differ between boys and girls.

Sex-Specific Effects of Nutritional Supplements for Infants Born Early or Small: An Individual Participant Data Meta-Analysis (ESSENCE IPD-MA) I-Cognitive Function and Metabolic Risk.

Neonatal nutritional supplements are widely used to improve growth and development but may increase risk of later metabolic disease, and effects may differ by sex. We assessed effects of supplements on later development and metabolism. We searched databases and clinical trials registers up to April 2019. Participant-level data from randomised trials were included if the intention was to increase macronutrient intake to improve growth or development of infants born preterm or small-for-gestational-age. Co-primary outcomes were cognitive impairment and metabolic risk. Supplementation did not alter cognitive impairment in toddlers (13 trials, n = 1410; adjusted relative risk (aRR) 0.88 [95% CI 0.68, 1.13]; p = 0.31) or older ages, nor alter metabolic risk beyond 3 years (5 trials, n = 438; aRR 0.94 [0.76, 1.17]; p = 0.59). However, supplementation reduced motor impairment in toddlers (13 trials, n = 1406; aRR 0.76 [0.60, 0.97]; p = 0.03), and improved motor scores overall (13 trials, n = 1406; adjusted mean difference 1.57 [0.14, 2.99]; p = 0.03) and in girls not boys (p = 0.03 for interaction). Supplementation lowered triglyceride concentrations but did not affect other metabolic outcomes (high-density and low-density lipoproteins, cholesterol, fasting glucose, blood pressure, body mass index). Macronutrient supplementation for infants born small may not alter later cognitive function or metabolic risk, but may improve early motor function, especially for girls.

Combining kangaroo care and live harp music therapy in the neonatal intensive care unit setting.

BACKGROUND: Music therapy has been recommended as an adjuvant therapy for both preterm infants and mothers during their stay in the neonatal intensive care unit (NICU), and has been shown to have beneficial effects. OBJECTIVES: To study the usefulness of combining live harp music therapy and kangaroo care (KC) on short-term physiological and behavioral parameters of preterm infants and their mothers in the NICU setting. METHODS: Included in this study were stable infants born between 32 and 37 weeks of gestation, with normal hearing. Mother-infant dyads were randomly assigned to KC and live harp music therapy or to KC alone. Using repeated measures, neonatal and maternal heart rate, oxygen saturation and respiratory rate were recorded along with neonatal behavioral state and maternal anxiety state. Maternal age, ethnicity, education, and love of music were documented. RESULTS: Fifty-two mother-infant dyads were tested. Compared with KC alone, KC and live harp music therapy had a significantly beneficial effect on maternal anxiety score (46.8 +/- 10 vs. 27.7 +/- 7.1, respectively, P < 0.01). Infants' physiological responses and behavior did not differ significantly. No correlation was found between mothers' age, ethnicity, years of education and affinity for music, and anxiety scores (P = 0.2 to 0.5 for all four variables). CONCLUSIONS: KC combined with live harp music therapy is more beneficial in reducing maternal anxiety than KC alone. This combined therapy had no apparent effect on the tested infants' physiological responses or behavioral state.