The prevalence and significance of gestational cannabis use at an Australian tertiary hospital.

BACKGROUND: Cannabis is one of the most common non-prescribed psychoactive substances used in pregnancy. The prevalence of gestational cannabis use is increasing. AIM: The aim was to examine the prevalence of gestational cannabis use and associated pregnancy and neonate outcomes. MATERIALS AND METHODS: A retrospective observational study involving pregnant women delivering in 2019 was conducted at a tertiary hospital in Perth, Western Australia. Gestational cannabis and other substance use records were based on maternal self-report. Pregnancy outcomes included neonatal gestational age, birthweight, birth length, head circumference, resuscitation measures, special care nursery admission, 5-min Apgar score and initial neonatal feeding method. RESULTS: Among 3104 pregnant women (mean age: 31 years), gestational cannabis use was reported by 1.6% (n = 50). Cannabis users were younger, more likely to use other substances and experience mental illness or domestic violence compared with non-users. Neonates born to cannabis users had a lower mean gestational age, birthweight and birth length compared to those born to non-cannabis users. Gestational cannabis use (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.6-6.7) and tobacco smoking (OR 2.2, 95% CI 1.5-3.6) were associated with increased odds of a low-birthweight neonate. Combined cannabis and tobacco use during pregnancy further increased the likelihood of low birthweight (LBW, adjusted OR 3.9, 95% CI 1.6-9.3). Multivariate logistic regression analysis adjusted for maternal sociodemographical characteristics, mental illness, alcohol, tobacco and other substance use demonstrated gestational cannabis use to be independently associated with LBW (OR 2.3, 95% CI 1.1-5.2). CONCLUSION: Gestational cannabis use was independently associated with low birthweight, synergistically affected by tobacco smoking.

Does a high dietary intake of resistant starch affect glycaemic control and alter the gut microbiome in women with gestational diabetes? A randomised control trial protocol.

BACKGROUND: Gestational Diabetes Mellitus (GDM) is prevalent with lasting health implications for the mother and offspring. Medical nutrition therapy is the foundation of GDM management yet achieving optimal glycaemic control often requires treatment with medications, like insulin. New dietary strategies to improve GDM management and outcomes are required. Gut dysbiosis is a feature of GDM pregnancies, therefore, dietary manipulation of the gut microbiota may offer a new avenue for management. Resistant starch is a fermentable dietary fibre known to alter the gut microbiota and enhance production of short-chain fatty acids. Evidence suggests that short-chain fatty acids improve glycaemia via multiple mechanisms, however, this has not been evaluated in GDM. METHODS: An open-label, parallel-group design study will investigate whether a high dietary resistant starch intake or resistant starch supplement improves glycaemic control and changes the gut microbiome compared with standard dietary advice in women with newly diagnosed GDM. Ninety women will be randomised to one of three groups - standard dietary treatment for GDM (Control), a high resistant starch diet or a high resistant starch diet plus a 16 g resistant starch supplement. Measurements taken at Baseline (24 to 30-weeks' gestation), Day 10 and Day 56 (approximately 36 weeks' gestation) will include fasting plasma glucose levels, microbial composition and short-chain fatty acid concentrations in stool, 3-day dietary intake records and bowel symptoms questionnaires. One-week post-natal data collection will include microbial composition and short-chain fatty acid concentrations of maternal and neonatal stools, microbial composition of breastmilk, birthweight, maternal and neonatal outcomes. Mixed model analysis of variance will assess change in glycaemia and permutation-based multivariate analysis of variance will assess changes in microbial composition within and between intervention groups. Distance-based linear modelling will identify correlation between change in stool microbiota, short-chain fatty acids and measures of glycaemia. DISCUSSION: To improve outcomes for GDM dyads, evaluation of a high dietary intake of resistant starch to improve glycaemia through the gut microbiome needs to be established. This will expand the dietary interventions available to manage GDM without medication. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry, ACTRN12620000968976p . Registered 28 September 2020.

Continuous pulse oximetry during skin-to-skin care: An Australian initiative to prevent sudden unexpected postnatal collapse.

AIM: To examine the use of continuous pulse oximetry monitoring (CPOM) of newborns as a non-invasive and non-intrusive standard of care for promoting early and safe skin-to-skin contact between mothers and newborns immediately after birth and to gather acceptability feedback from midwifery staff and mothers. METHODS: All babies receiving skin-to-skin contact (SSC) had continuous pulse oximetry monitoring (CPOM) for the first-hour postbirth. Staff were trained with education sessions before implementation. Midwives and mothers were surveyed post-implementation and again after distribution of an education brochure regarding CPOM. RESULTS: Seventy per cent of midwives and 66% of mothers responded to the survey. The majority of midwives received the practice positively and felt reassured by the use of CPOM in the immediate postpartum period. The survey identified gaps in maternal knowledge of the risk and benefits of SSC which improved significantly after the distribution of the educational brochure (P = .01). CONCLUSION: Continuous pulse oximetry monitoring with a compact monitor in the first-hour postbirth is a simple, non-invasive and innovative approach to enhance safe skin-to-skin care by improving vigilance of newborns. Our study confirmed the acceptance of such approach by midwives and mothers in our population.

Effect of obesity on neonatal hypoglycaemia in mothers with gestational diabetes: A comparative study.

BACKGROUND: Rates of pre-gestational obesity and gestational diabetes mellitus (GDM) are increasing in Australia. While both are established risk factors for neonatal hypoglycaemia, the additive effect of both risks on neonatal hypoglycaemia is not well understood. AIMS: To determine the influence of obesity on neonatal hypoglycaemia among infants born to GDM mothers. The authors hypothesise the presence of a greater frequency and severity of neonatal hypoglycaemia in infants born to obese GDM women. MATERIALS AND METHODS: A cohort of 471 singleton GDM pregnancies was retrospectively studied. Women were divided into obese (body mass index (BMI) ≥ 30 kg/m2 ) and not-obese (BMI < 30 kg/m2 ) groups according to self-reported pre-pregnancy weight. Perinatal outcomes and details of hypoglycaemic episodes were obtained by reviewing medical records. RESULTS: Twenty-five percent (104/410) of the GDM mothers were obese, while 36% (146/410) exceeded pregnancy weight gain recommendations. GDM and obesity resulted in a greater frequency of neonatal hypoglycaemia as compared to women with GDM alone (obese 44%, not obese 34%, P = 0.046). Obesity increased the likelihood of having multiple hypoglycaemic episodes (P = 0.022). Excess weight gain increased the likelihood of the neonate requiring intravenous dextrose (P = 0.0012). No differences were found in the likelihood of nursery admissions or lowest plasma glucose levels. CONCLUSIONS: Pre-pregnancy obesity and weight gain during pregnancy above the recommended limits increased the likelihood of neonatal hypoglycaemia among infants of GDM mothers. Further studies with larger cohorts are warranted to confirm our findings.

Eligibility criteria for therapeutic hypothermia: From trials to clinical practice.

AIM: Whole body therapeutic hypothermia (TH) for hypoxic ischaemic encephalopathy was introduced into clinical practice in New South Wales (NSW) and Australian Capital Territory in 2007. State-wide policy adopting the eligibility criteria and practice based on trial-designs was published in 2009. METHODS: The study was conducted by retrospectively reviewing medical records of all TH infants born between 2007 and 2011 in NSW and Australian Capital Territory to examine if eligibility criteria (assessed against evidence-based policy directives) were met. RESULTS: A total of 207 infants received TH, 104 (50%) did not meet the eligibility criteria defined in NSW policy directive. Over the 5-year period, the proportion of infants meeting the eligibility criteria did not change. Seventy percent of infants (73 out of 104) not meeting eligibility criteria did not fulfil the criteria for 'evidence of asphyxia', although half of them met 'moderate or severe encephalopathy criterion'. Adverse events (hypotension, coagulopathy and arrhythmia), were more common in the 'criteria met' group than the 'criteria not met' group (89 vs. 71%, P = 0.001). Similar proportions of infants had TH discontinued before 72 h (criteria met: 32 (31%) vs. criteria not met: 27(26%)). Most frequent reason for early cessation was 'palliation' (19/32, 59%) in criteria met and 'clinical improvement' (16/27, 59%) in criteria not met group. CONCLUSIONS: Many TH infants were treated based on clinician judgement, though not meeting the trial-design policy criteria. Early TH cessation (<72 h) was common. Future studies are warranted on long-term neurodevelopmental outcomes for all infants receiving TH particularly those with early cessation of therapy.

Cardiac sonography by the neonatologist: clinical usefulness and educational perspective.

OBJECTIVES: Clinicians are increasingly using cardiac sonography in clinical practice. The objectives of this study were to assess the current state of clinician-performed cardiac sonography practice in the Australia-New Zealand region, with particular reference to the scope of clinical practice and type of training offered. METHODS: A prospective cross-sectional survey was conducted, and an electronic Web-based questionnaire was e-mailed to neonatologists and advanced trainees in the region. Information was collected on respondents (demographics, clinician-performed cardiac sonography experience, and opinions), equipment use, and training frameworks. Main outcome measures ascertained were clinical use and educational perspectives. RESULTS: The overall survey response rate was 64% (113 of 176). Eighty-five percent of respondents reported that clinician-performed cardiac sonography was performed in their units, most commonly to use the physiologic information obtained in conjunction with clinical information to refine decision making. The most common clinical indication was evaluation of a hemodynamically relevant ductus arteriosus. A dedicated echocardiographic machine was available to 80% of respondents. Most respondents reported "self-directed" learning as the most common method of training. More than 85% of respondents reported having access to either on-site or off-site pediatric cardiology services. CONCLUSIONS: Widespread availability and use of clinician-performed cardiac sonography in units across the Australia-New Zealand region was noted. The need for a structured training program was identified.

Reduced cardiac output and its correlation with coronary blood flow and troponin in asphyxiated infants treated with therapeutic hypothermia.

Perinatal asphyxia can lead to multi-organ insult which includes cardiovascular dysfunction. The objective was to study the relationship between cardiac function, perfusion and troponin. Unit database was accessed to identify infants with perinatal asphyxia over the last 2 years. Information from medical records and archived echocardiographic images was retrieved. Comparisons for echocardiographic information were made with healthy term infants. Seventeen infants with perinatal asphyxia were identified, of which three were excluded (one-33 weeks gestation, two-coagulopathy and pulmonary hypertension); 14 infants received therapeutic hypothermia. Median (range) gestation and birthweight were 39 (37-42) weeks and 3,550 (2,380-3,992) g respectively. Mean (S.D.) rectal temperature and time of echocardiogram were 33.5 ± 0.5 °C and median (range) 7.7 h [3-10] respectively. Majority of infants had low biventricular outputs. Median (range) SVC flow was 29.8 ml/kg/min (13-96.2). Median (range) troponin was 0.77 µg/L (0.17-2.6); normal ≤ 0.08 µg/L. Markedly low coronary flows (diastolic VTI median (range) 2.1 (1.3-2.9) cm were noted compared to controls. Coronary flow had a significantly positive correlation with left ventricular output. Higher troponin levels were associated with lower aortic stroke velocity. A close association between cardiac output, perfusion and troponin was noted. A dichotomy between blood pressure and flow parameters was noted, indicating the wide variation in vascular resistance in these infants. Biventricular output, coronary and SVC flows were significantly higher in the control population. In conclusion, inter-variable relationship between cardiac output, coronary flow and troponin is an important addition to the understanding of cardiovascular impact of perinatal asphyxia.

"Mild'' Hypoxic-Ischaemic Encephalopathy and Therapeutic Hypothermia: A Survey of Clinical Practice and Opinion from 35 Countries.

INTRODUCTION: We aimed to determine global professional opinion and practice for the use of therapeutic hypothermia (TH) for treating infants with mild hypoxic-ischaemic encephalopathy (HIE). METHODS: A web-based survey (REDCap) was distributed via emails, social networking sites, and professional groups from October 2020 to February 2021 to neonatal clinicians in 35 countries. RESULTS: A total of 484 responses were obtained from 35 countries and categorized into low/middle-income (43%, LMIC) or high-income (57%, HIC) countries. Of the 484 respondents, 53% would provide TH in mild HIE on case-to-case basis and only 25% would never cool. Clinicians from LMIC were more likely to routinely offer TH in mild HIE (25% v HIC 16%, p < 0.05), have a unit protocol for providing TH (50% v HIC 26%, p < 0.05), use adjunctive tools, e.g., aEEG (49% v HIC 32%, p < 0.001), conduct an MRI post TH (48% v HIC 40%, p < 0.05) and less likely to use neurological examinations as a HIE severity grading tool (80% v HIC 95%, p < 0.001). The majority of respondents (91%) would support a randomized controlled trial that was sufficiently large to examine neurodevelopmental outcomes in mild HIE after TH. CONCLUSIONS: This is the first survey of global opinion for TH in mild HIE. The overwhelming majority of professionals would consider "cooling" an infant with mild HIE, but LMIC respondents were more likely to routinely cool infants with mild HIE and use adjunctive tools for diagnosis and follow-up. There is wide practice heterogeneity and a sufficiently large RCT designed to examine neurodevelopmental outcomes, is urgently needed and widely supported.

Sepsis calculator for neonatal early onset sepsis - a systematic review and meta-analysis.

BACKGROUND: Over investigation and overuse of empirical antibiotics is a concern in management of neonatal early onset sepsis (EOS) using the Centers for Disease Control and Prevention guidelines. "Sepsis calculator" is a risk-based prediction model for managing neonates at risk of EOS. OBJECTIVE: To compare outcomes of neonatal EOS using of sepsis calculator versus conventional approach. METHODS: A systematic review of randomized controlled trials (RCT) and non-RCTs reporting on outcomes after implementation of sepsis calculator for EOS for neonates >34-week gestation was conducted using the Cochrane methodology. Databases PubMed, CINAHL, Embase, Cochrane Central library and Google Scholar were searched in May 2019. Primary outcomes were antibiotics usage and laboratory tests for managing EOS. Secondary outcomes included hospital admissions and readmissions, blood culture positive EOS and mortality. The level of evidence (LOE) was summarized using the GRADE guidelines. RESULTS: A total of 387 articles were retrieved after initial search. Six high quality non-RCTs fulfilled inclusion criteria. Meta-analysis (random effects model) showed that implementation of sepsis calculator was associated with reduced antibiotic usage [N = 172,385; OR = 0.22 (0.14-0.36); p < .00001; heterogeneity (I2) = 97%, Number needed to treat (NNT): 22], laboratory tests [N = 168,432; OR = 0.14 (0.08-0.27); p < .00001; I2 = 99%, NNT = 8], and admissions to neonatal unit [N = 16,628; OR = 0.24 (0.11-0.51); p = .0002; I2 = 98%, NNT = 7]; LOE: moderate. There was no difference in mortality, culture positive EOS, and readmissions. CONCLUSION: Moderate quality evidence indicates that the implementation of a sepsis calculator was associated with reduced usage of antibiotics, laboratory tests and admission to neonatal unit with no increase in mortality and readmissions.

Association between gestational cannabis exposure and maternal, perinatal, placental, and childhood outcomes.

Globally, the availability and formulations for the administration of cannabis are changing with decriminalization or legalization of recreational use in some jurisdictions, and the prescription of cannabis also occurring. These changes are likely to affect the prevalence of use, including by women of childbearing age. The effects of in utero and infant alcohol and tobacco exposure are well-documented, but the outcomes of cannabis exposure are less certain. The content of delta-9-tetrahydrocannabinol (THC), the psychoactive component of cannabis has progressively increased over several decades. This review explores the limited knowledge surrounding the epidemiology of gestational and postnatal cannabis exposure and implications for the mother-placenta-fetus/neonate triad. We examine cannabis' effects from antenatal and lactation exposure on (a) pregnancy and perinatal outcomes, (b) placental health, and (c) longer term cardiometabolic and neurodevelopmental risks and outcomes. Though definitive outcomes are lacking, gestational cannabis has been associated with increased risk of other substance use during pregnancy; impaired placental blood flow; increased risk of small for gestational age births; and associated complications. Childhood and adolescent outcomes are sparsely assessed, with suggested outcomes including increased risk of depression and attention-deficit hyperactivity disorder. Cardiometabolic implications of gestational cannabis use may include maternal fatty liver, obesity, insulin resistance, and increased risk of gestational diabetes mellitus (GDM), with potential consequences for the fetus. Clinical implications for pediatric practice were explored in a bid to understand any potential risk or impact on child health and development.

Wastage of standardised parenteral nutrition solution - a challenge for neonatal units.

Background: Standardised parental nutrition (PN) has been used in many neonatal intensive care unit (NICU). Easy accessibility, better provision of nutrients, reduced prescription errors and cost savings are some of its benefits. Fixed large volume (e.g. 750-1000 mL) and short expiry limit (48 hrs) along with changing metabolic needs of neonates leads to significant wastage of PN solution. Objective: To evaluate wastage of PN solution in our 22-bedded NICU. Methods: The audit was conducted over 21-month period (July 2015-April 2017). Data on PN use (e.g. type, duration, infused volume, residual after use) was obtained from hospital records. The discarded volume of PN was estimated after subtracting the administered volume based on the rate of infusion from the total volume in the bag. Cumulative "discarded" volume as percentage of the total "supplied" volume was calculated. Results: A total of 305-PN bags (Standardised: Preterm: 222, Term: 83) were used. The estimated total used, discarded, and percentage discarded volumes for standard preterm and term PN were 78.1, 88 L, 53% and 33.5, 49.7 L, and 59.8%, respectively. Conclusions: There was more than 50% wastage of PN solution in our NICU. The estimated cost of this PN wastage was around 21,000 AUD over 21 months. Strategies such as minipack should be explored to prevent such losses.

Dose-Banding of Intravenous Piperacillin-Tazobactam in Pediatric Surgical Inpatients.

BACKGROUND: Antimicrobial doses in children are often prescribed by using an individually calculated dose per weight (e.g., mg/kg) or based on body surface area. Dosing errors are the most commonly reported medication errors in children. A "dose-banding" strategy is frequently used for some over-the-counter drugs to prevent dosing errors. It could also lead to efficiencies by enabling batch preparation of intravenous (IV) medications in hospitals. OBJECTIVES: To evaluate whether use of dose-banding for IV piperacillin-tazobactam results in acceptable dose variation from standard practice of individualized prescription of 100 mg/kg in children. METHODS: We conducted a historically controlled intervention study comparing prescriptions of IV piperacillin-tazobactam before vs. after introduction of dose-banding prescribing guidance for surgical inpatients weighing >5 kg and <16 years of age at the tertiary referral pediatric hospital in Western Australia. RESULTS: Dose-banding of IV piperacillin-tazobactam (with a maximum of 15% departure from the recommended milligram-per-weight dose of 100 mg/kg) resulted in similar overall variation of prescribed dose in comparison to individualized milligram-per-weight (non-dose-banded) prescribing. There was a trend toward fewer prescriptions with large variance (>30% variation from the 100-mg/kg dose) in the dose-banded compared to the non-dose-banded group (1/140 vs. 5/105; p = 0.09). CONCLUSIONS: Our study showed dose-banding of IV piperacillin-tazobactam resulted in acceptable variation when compared to individualized milligram-per-weight dosing in children. Prospectively designed controlled trials are warranted to determine whether dose-banding could reduce medication errors and optimize use of hospital resources. Implications for future practice could include faster batch preparation, shorter checking and dispensing time, and reduction in drug wastage.

Fluid supplementation in hyperbilirubinemia.

OBJECTIVE: To analyze the factors responsible for failure of fluid supplementation in full-term neonates with severe non-hemolytic hyperbilirubinemia. METHODS: The data from two previous randomized controlled trials was used in this study. Full-term (≥37 wks) neonates with severe hyperbilirubinemia (serum total bilirubin 18-25 mg/dL), who received intravenous fluid supplementation in addition to phototherapy were included. Intravenous fluid supplementation was given for 8 h. Those neonates, whose serum bilirubin levels increased by 2 mg/dL or crossed 22 mg/dL, underwent exchange transfusion. The authors compared baseline serum bilirubin, sodium, and osmolality and their changes during study period in neonates who required exchange transfusion (Non-responders) with those who didn't (Responders). RESULTS: The data of 121 neonates was analyzed (non-responders = 17, responders = 104). Both the groups had similar weight loss since birth, baseline serum sodium and osmolality. Mean baseline serum bilirubin [22.5 (1.7) vs 21.6 (1.6) mg/dL, p = 0.04] and cesarean/ instrumental delivery (27.6% vs 20.2%, p = 0.02) were significantly higher in non-responders. With fluid supplementation, serum sodium and osmolality changed similarly in both the groups over 8 h. On multiple regression analysis, only cesarean/instrumental delivery [OR 3.9 (95% CI-1.2, 13.4)] retained independent significance. CONCLUSIONS: Fluid supplementation for severe non-hemolytic hyperbilirubinemia is less likely to be successful in neonates born by cesarean/instrumental delivery as compared to normal vaginal delivery.

A randomized controlled trial of fluid supplementation in term neonates with severe hyperbilirubinemia.

OBJECTIVE: To evaluate the effectiveness of fluid supplementation in decreasing the rate of exchange transfusion and the duration of phototherapy in term neonates with severe nonhemolytic hyperbilirubinemia. STUDY DESIGN: This was a randomized controlled trial conducted in a tertiary care referral unit in northern India. Seventy-four term neonates with severe nonhemolytic hyperbilirubinemia (total serum bilirubin > 18 mg/dL [308 micromol/L] to < 25 mg/dL [427 micromol/L]). The subjects were randomized to an "extra fluids" group (intravenous fluid supplementation for 8 hours and oral supplementation for the duration of phototherapy; n = 37) or a control group (n = 37). RESULTS: At inclusion, 54 infants (73%) had high serum osmolality, including 28 (75%) in the extra fluids group and 26 (70%) in the control group. The proportion of infants who underwent exchange transfusion was lower in the extra fluids group than in the control group: 6 (16%) versus 20 (54%)(P = .001; relative risk = 0.30; 95% confidence interval = 0.14 to 0.66). The duration of phototherapy was also shorter in the extra fluids group: 52 +/- 18 hours versus 73 +/- 31 hours (P = .004). CONCLUSION: Fluid supplementation in term neonates presenting with severe hyperbilirubinemia decreased the rate of exchange transfusion and duration of phototherapy.