Genetic counselling considerations with genetic/genomic testing in Neonatal and Pediatric Intensive Care Units: A scoping review.

Genetic and genomic technologies can effectively diagnose numerous genetic disorders. Patients benefit when genetic counselling accompanies genetic testing and international guidelines recommend pre- and post-test genetic counselling with genome-wide sequencing. However, there is a gap in knowledge regarding the unique genetic counselling considerations with different types of genetic testing in the Neonatal Intensive Care Unit (NICU) and the Pediatric Intensive Care Unit (PICU). This scoping review was conducted to identify the gaps in care with respect to genetic counselling for infants/pediatric patients undergoing genetic and genomic testing in NICUs and PICUs and understand areas in need of improvement in order to optimize clinical care for patients, caregivers, and healthcare providers. Five databases (MEDLINE [Ovid], Embase [Ovid], PsycINFO [Ebsco], CENTRAL [Ovid], and CINHAL [Ebsco]) and grey literature were searched. A total of 170 studies were included and used for data extraction and analysis. This scoping review includes descriptive analysis, followed by a narrative account of the extracted data. Results were divided into three groups: pre-test, post-test, and comprehensive (both pre- and post-test) genetic counselling considerations based on indication for testing. More studies were conducted in the NICU than the PICU. Comprehensive genetic counselling was discussed in only 31% of all the included studies demonstrating the need for both pre-test and post-test genetic counselling for different clinical indications in addition to the need to account for different cultural aspects based on ethnicity and geographic factors.

The effect of rapid exome sequencing on downstream health care utilization for infants with suspected genetic disorders in an intensive care unit.

PURPOSE: This study aimed to compare downstream utilization of medical services among critically ill infants admitted to intensive care units who received rapid exome sequencing (ES) and those who followed alternative diagnostic testing pathways. METHODS: Using propensity score-weighted regression models including sex, age at admission, and severity indicators, we compared a group of 47 infants who underwent rapid ES with a group of 211 infants who did not receive rapid ES. Utilization and cost indicators were compared between cohorts using negative binomial models for utilization and two-part models for costs. RESULTS: After controlling for patients' sociodemographic and clinical characteristics, we found no statistically significant difference in outpatient visits, hospitalizations, intensive care unit or total length of stay, or length of stay-associated costs between the cohorts at 12- or 26-month follow-up. Similarly, there was no evidence of higher utilization or costs by the ES group when infants who died were removed from the analysis. CONCLUSION: When examining utilization during and beyond the diagnostic trajectory, there is no evidence that ES changes frequency of outpatient visits or use of in-hospital resources in critically ill infants with suspected genetic disorders.

What is stopping us? An implementation science study of kangaroo care in British Columbia's neonatal intensive care units.

BACKGROUND: The goal of the Neonatal Intensive Care Unit (NICU) is to provide optimal care for preterm and sick infants while supporting their growth and development. The NICU environment can be stressful for preterm infants and often cannot adequately support their neurodevelopmental needs. Kangaroo Care (KC) is an evidence-based developmental care strategy that has been shown to be associated with improved short and long term neurodevelopmental outcomes for preterm infants. Despite evidence for best practice, uptake of the practice of KC in resource supported settings remains low. The aim of this study was to identify and describe healthcare providers' perspectives on the barriers and enablers of implementing KC. METHODS: This qualitative study was set in 11 NICUs in British Columbia, Canada, ranging in size from 6 to 70 beds, with mixed levels of care from the less acute up to the most complex acute neonatal care. A total of 35 semi-structured healthcare provider interviews were conducted to understand their experiences providing KC in the NICU. Data were coded and emerging themes were identified. The Consolidated Framework for Implementation Research (CFIR) guided our research methods. RESULTS: Four overarching themes were identified as barriers and enablers to KC by healthcare providers in their particular setting: 1) the NICU physical environment; 2) healthcare provider beliefs about KC; 3) clinical practice variation; and 4) parent presence. Depending on the specific features of a given site these factors functioned as an enabler or barrier to practicing KC. CONCLUSIONS: A 'one size fits all' approach cannot be identified to guide Kangaroo Care implementation as it is a complex intervention and each NICU presents unique barriers and enablers to its uptake. Support for improving parental presence, shifting healthcare provider beliefs, identifying creative solutions to NICU design and space constraints, and the development of a provincial guideline for KC in NICUs may together provide the impetus to change practice and reduce barriers to KC for healthcare providers, families, and administrators at local and system levels.

Rapid genome-wide sequencing in a neonatal intensive care unit: A retrospective qualitative exploration of parental experiences.

Genome-wide sequencing (GWS) is increasingly being used in neonatal intensive care units. While studies have explored its clinical utility, little is known about parental experiences with this testing post-return of results. We conducted a qualitative study, using an interpretive description framework and thematic analysis, to gain further insight into parents' perceptions of the value and utility of GWS for their infant. We sought to explore whether parents' perceptions differ if their child received a diagnosis or not, and whether their child is living or deceased. Semi-structured, telephone interviews were conducted with parents of infants who had rapid exome sequencing while in the neonatal intensive care unit at BC Women's Hospital in Vancouver, Canada. Interviews addressed perceived benefits and harms of GWS and included an evaluation of decisional regret. Parents of 27 probands were approached and 14 (52%; 13 mothers and 1 father) participated in interviews. On average, 26 months had elapsed from the time of results to the interview. Six themes were identified. Firstly, parents had a positive regard for GWS. The results of GWS helped provide context for their child's admission to the NICU, and all parents experienced relief following receiving the results. A diagnosis by GWS enabled parents to picture the future, form connections with other parents, and coordinate their child's care. Lastly, some parents experienced discomfort with the concept of a genetic diagnosis, and interestingly felt lack of a genomic diagnosis indicated a reduced severity of their infant's condition. Decisional regret post-results was found to be low. Our results highlight how parents cope with the results of GWS and suggest that a genetic counselor can have an important role in helping families understand and adjust to these results in the neonatal intensive care unit.

Are there alternatives to over-the-counter diabetes-care glucose-gels for transitional neonatal hypoglycemia?

Transitional neonatal hypoglycemia is common in at-risk well newborns, requires immediate attention, interferes with breastfeeding, and frequently results in separation of mothers from their babies. Breastfeeding shortly after birth and screening at-risk newborns at 2 hours of age is standard practice in Canada. In the Sugar Babies Trial, a custom-made 40% glucose-gel massaged to the buccal mucosa in at-risk infants decreased intravenous glucose treatment, but not neonatal intensive care unit admission. It increased the rate of full breastfeeding after discharge but experts suggest that additional evidence is needed. Further, commercially available neonatal glucose-gels do not exist, so practitioners around the world have started using diabetes-care products, which do not meet standards for use in newborns. Here, we provide a condensed summary of the topic and of management alternatives.

RAPIDOMICS: rapid genome-wide sequencing in a neonatal intensive care unit-successes and challenges.

Genetic disorders are one of the leading causes of infant mortality and are frequent in neonatal intensive care units (NICUs). Rapid genome-wide sequencing (GWS; whole genome or exome sequencing (ES)), due to its diagnostic capabilities and immediate impacts on medical management, is becoming an appealing testing option in the NICU setting. RAPIDOMICS was a trio-based rapid ES pilot study of 25 babies with suspected genetic disorders in the BC Women's Hospital NICU. ES and bioinformatic analysis were performed after careful patient ascertainment. Trio analysis was performed using an in-house pipeline reporting variants in known disease-causing genes. Variants interpreted by the research team as definitely or possibly causal of the infant's phenotype were Sanger validated in a clinical laboratory. The average time to preliminary diagnosis was 7.2 days. Sanger validation was pursued in 15 patients for 13 autosomal dominant and 2 autosomal recessive disorders, with an overall diagnostic rate (partial or complete) of 60%.Conclusion: In total, 72% of patients enrolled had a genomic diagnosis achieved through ES, multi-gene panel testing or chromosomal microarray analysis. Among these, there was an 83% rate of significant and immediate impact on medical decision-making directly related to new knowledge of the diagnosis. Health service implementation challenges and successes are discussed. What is Known: • Rapid genome-wide sequencing in the neonatal intensive care setting has a greater diagnostic hit rate and impact on medical management than conventional genetic testing. However, the impact of consultation with genetics and patient ascertainment requires further investigation. What is New: • This study demonstrates the importance of genetic consultation and careful patient selection prior to pursuing exome sequencing (ES). • In total, 15/25 (60%) patients achieved a diagnosis through ES and 18/25 (72%) through ES, multi-gene panel testing or chromosomal microarray analysis with 83% of those having immediate effects on medical management.

Outcomes of Neonates With Complex Medical Needs.

BACKGROUND: Children with complex medical needs (CMN) are high healthcare resource utilizers, have varying underlying diagnoses, and experience repeated hospitalizations. Outcomes on neonatal intensive care (NICU) patients with CMN are unknown. PURPOSE: The primary aim is to describe the clinical profile, resource use, prevalence, and both in-hospital and postdischarge outcomes of neonates with CMN. The secondary aim is to assess the feasibility of sustaining the use of the neonatal complex care team (NCCT). METHODS: A retrospective cohort study was conducted after implementing a new model of care for neonates with CMN in the NICU. All neonates born between January 2013 and December 2016 and who met the criteria for CMN and were cared for by the NCCT were included. RESULTS: One hundred forty-seven neonates with a mean (standard deviation) gestational age of 34 (5) weeks were included. The major underlying diagnoses were genetic/chromosomal abnormalities (48%), extreme prematurity (26%), neurological abnormality (12%), and congenital anomalies (11%). Interventions received included mechanical ventilation (69%), parenteral nutrition (68%), and technology dependency at discharge (91%). Mortality was 3% before discharge and 17% after discharge. Postdischarge hospital attendances included emergency department visits (44%) and inpatient admissions (58%), which involved pediatric intensive care unit admissions (26%). IMPLICATIONS FOR PRACTICE: Neonates with CMN have multiple comorbidities, high resource needs, significant postdischarge mortality, and rehospitalization rates. These cohorts of NICU patients can be identified early during their NICU course and serve as targets for implementing innovative care models to meet their unique needs. IMPLICATIONS FOR RESEARCH: Future studies should explore the feasibility of implementing innovative care models and their potential impact on patient outcomes and cost-effectiveness.

Dextrose gels for neonatal transitional hypoglycemia: What are we giving our babies?

Transitional hypoglycemia is common in at-risk newborns, frequently resulting in therapeutic interference with bonding and breastfeeding; 40% dextrose gel massaged to the buccal mucosa has been shown to decrease hypoglycemia <2.6 mmol/L and NICU admissions. However, in the absence of a newborn-specific product, over-the-counter diabetes-care products with poorly documented composition are being used for neonates. We analyzed the carbohydrate content, and compared composition of the two commercially available gels in Canada, Dex4 and Insta-Glucose. We found that the glucose concentrations were significantly different from the expected 40% glucose, and that they contain artificial colorants, flavours and preservatives. In addition, we observed inconsistent concentration differences within each tube when aliquotes from the top, middle, or bottom were measured. There is a need for a custom made neonatal dextrose gel dispensed in unit dose vials, with a standardized concentration of glucose, and without chemical substances one would generally not recommend administering to newly born infants.

Hypoglycemia in unmonitored full-term newborns-a surveillance study.

BACKGROUND AND OBJECTIVES: Hypoglycemia monitoring is not recommended for most full-term newborns. We wished to determine the incidence, presentation and case characteristics of hypoglycemia in low-risk newborns. METHODS: With the assistance of the Canadian Paediatric Surveillance Program, we conducted a national study of severe hypoglycemia in apparently low-risk full-term newborns. Paediatricians who reported a case were sent a detailed questionnaire and the data were analyzed. RESULTS: All 93 confirmed cases were singletons, 56% were first-borns and 65% were male. An 8% rate of First Nations cases was twofold the population rate. Maternal hypertension rate was 23%, fourfold the general pregnancy rate. Maternal obesity was double the general pregnancy rate at 23%. Concerning signs or feeding issues were noted in 98% at the time of diagnosis. Median time to diagnosis was 4.1 hours. Mean blood glucose at intravenous (IV) start was 1.4 ± 0.5 hours (SD). Seventy-eight per cent had at least one of four potential stress indicators and were more likely to have early diagnosis (P=0.03). Major signs were present in 20%. Those cases presented later and had lower glucose levels (median=0.8 mmol/L versus 1.6 mmol/L, [P<0.001). Twenty-five per cent of cases had birth weight less than the 10th centile. Neurodevelopmental concern was reported in 20%. Of the 13 cases which had brain magnetic resonance imaging, 11 were abnormal. CONCLUSION: Hypoglycemia in unmonitored newborns is uncommon but is associated with significant morbidity. We provide a range of clues to help identify these newborns soon after birth. Widespread adoption of norm-based standards to identify small-for-gestational age infants is supported.

Preferential cephalic redistribution of left ventricular cardiac output during therapeutic hypothermia for perinatal hypoxic-ischemic encephalopathy.

OBJECTIVE: To determine the relationship between left ventricular cardiac output (LVCO), superior vena cava (SVC) flow, and brain injury during whole-body therapeutic hypothermia. STUDY DESIGN: Sixteen newborns with moderate or severe hypoxic-ischemic encephalopathy were studied using echocardiography during and immediately after therapeutic hypothermia. Measures were also compared with 12 healthy newborns of similar postnatal age. Newborns undergoing therapeutic hypothermia also had cerebral magnetic resonance imaging as part of routine clinical care on postnatal day 3-4. RESULTS: LVCO was markedly reduced (mean ± SD 126 ± 38 mL/kg/min) during therapeutic hypothermia, whereas SVC flow was maintained within expected normal values (88 ± 27 mL/kg/min) such that SVC flow represented 70% of the LVCO. The reduction in LVCO during therapeutic hypothermia was mainly accounted by a reduction in heart rate (99 ± 13 vs 123 ± 17 beats/min; P < .001) compared with immediately postwarming in the context of myocardial dysfunction. Neonates with brain injury on magnetic resonance imaging had higher SVC flow prerewarming, compared with newborns without brain injury (P = .013). CONCLUSION: Newborns with perinatal hypoxic-ischemic encephalopathy showed a preferential systemic-to-cerebral redistribution of cardiac blood flow during whole-body therapeutic hypothermia, which may reflect a lack of cerebral vascular adaptation in newborns with more severe brain injury.

Reduction of central line-associated bloodstream infection rates in a neonatal intensive care unit after implementation of a multidisciplinary evidence-based quality improvement collaborative: A four-year surveillance.

BACKGROUND: The use of central venous catheters has permitted lifesaving treatment for critically ill neonates; however, the attributable mortality rate for central line-associated bloodstream infections (CLABSIs) has been estimated to be between 4% and 20%. In 2006/2007, the authors' neonatal intensive care unit (NICU) had a CLABSI rate that was nearly twofold higher than that reported by other Canadian NICUs. OBJECTIVE: To implement a quality improvement collaborative to reduce the incidence of neonatal CLABSI. METHODS: A retrospective observational study was performed to compare CLABSI in neonates admitted to the authors' level III NICU between August 2007 and March 2011. The entire study period was divided into four time periods to evaluate secular trends. A comprehensive catheter-related bloodstream infection prevention initiative was implemented in August 2007. The initiatives included staff education, standardization of skin preparation protocol, introduction of new antiseptic agents, implementation of central catheter insertion and maintenance checklists, reinforcement of the use of maximal sterile barrier precautions, and revision of the central catheter configuration and maintenance protocols. RESULTS: The median CLABSI rate of 7.9 per 1000 catheter days at the beginning of the study (period 1 [August 2007 to June 2008]) gradually decreased over the entire study period (P=0.034): period 2 (July 2008 to May 2009), 3.3 per 1000 catheter days; period 3 (June 2009 to April 2010), 2.6 per 1000 catheter days; and period 4 (May 2010 to March 2011), 2.2 per 1000 catheter days. CONCLUSION: A multidisciplinary evidence-based quality improvement collaborative resulted in a significant reduction in the CLABSI rate. Continuous quality improvement measures are required to reduce catheter-related bloodstream infections among low-birth-weight infants.

HISTORIQUE: Le recours aux cathéters veineux centraux permet de prodiguer des traitements salutaires aux nouveau-nés gravement malades. Toutefois, on évalue de 4 % à 20 % le taux de mortalité attribué aux infections sanguines associées à un cathéter central (ISACC). En 2006­2007, à l'unité de soins intensifs néonatals (USIN) des auteurs, le taux d'ISACC était près de deux fois plus élevé que celui déclaré par les autres USIN canadiennes. OBJECTIF: Adopter une collaboration visant l'amélioration de la qualité pour réduire l'incidence d'ISACC néonatales. MÉTHODOLOGIE: La présente étude rétrospective d'observation visait à comparer les ISACC chez les nouveau-nés admis à l'USIN de niveau III des auteurs entre août 2007 et mars 2011. Les auteurs ont divisé l'étude en quatre périodes pour évaluer les tendances séculaires. Une initiative complète de prévention des infections sanguines associées au cathéter a été adoptée en août 2007. Elle incluait la formation du personnel, la standardisation du protocole de préparation de la peau, l'introduction de nouveaux antiseptiques, l'adoption d'aide-mémoire sur l'insertion et l'entretien du cathéter central, le renforcement des précautions maximales entourant la barrière stérile et la révision des protocoles de configuration et d'entretien du cathéter central. RÉSULTATS: Le taux médian d'ISACC de 7,9 sur 1 000 jours-cathéter en début d'étude (période 1 [août 2007 à juin 2008]) a fléchi graduellement jusqu'à la fin de l'étude (P=0,034) : période 2 (juillet 2008 à mai 2009), 3,3 sur 1 000 jours-cathéter; période 3 (juin 2009 à avril 2010), 2,6 sur 1 000 jours-cathéter; et période 4 (mai 2010 à mars 2011), 2,2 sur 1 000 jours-cathéter. CONCLUSION: Une collaboration multidisciplinaire visant l'amélioration de la qualité fondée sur des données probantes a réduit considérablement les ISACC. Des mesures continues d'amélioration de la qualité s'imposent pour réduire les infections sanguines associées au cathéter chez les nourrissons de petit poids à la naissance.

Umbilical Venous Catheter Position: The Value of Acquiring a Lateral in Addition to a Frontal Chest Radiograph.

Introduction Umbilical venous catheters (UVCs) are standardly used for central venous access in acutely sick neonates. Complications associated with UVCs include thrombosis, infection, diffuse intravascular coagulopathy, arrhythmia, tamponade, and liver injury, many of which are related to misplacement of the catheters. Therefore, this study aimed to institute a policy of obtaining lateral and frontal radiographs to improve the determination of the UVC position. Methods We retrospectively reviewed UVC placement from 132 radiographs. We compared interpretations by different reviewers of frontal versus frontal and lateral chest radiographs for the most accurate determination of the UVC position. The reviewers completed questionnaires indicating their assessment of the catheter tip position, as well as the appropriate catheter manipulation required for optimal positioning. Their assessment was derived from frontal chest radiographs followed by frontal plus lateral view radiographs a week later. Results The reviewers (junior neonatology fellow, senior neonatology fellow, pediatric radiology fellow, and senior pediatric radiologist) revised their assessment with regard to the UVC positioning between frontal and frontal plus lateral radiographs in 24.6%, 22.7%, 19.6%, and 15.9% of cases, respectively, and indicated that the lateral view was helpful in 18%, 13.6%, 19.6%, and 31% of the cases, respectively. UVCs were placed appropriately at the first attempt in only 13.6% of the cases. Conclusion Correct initial placement of a UVC is uncommon. A lateral radiograph is beneficial in determining the UVC position. Hence, we suggest the inclusion of a lateral view along with the frontal chest radiograph for the evaluation of the UVC position if real-time ultrasound cannot be performed before UVC usage.

Effectiveness of a neonatal intensive care unit-specific antimicrobial stewardship program: A ten-year review.

OBJECTIVE: To evaluate the change in consumption of specific antibiotics in a neonatal intensive care unit after the implementation of an antimicrobial stewardship program (ASP). DESIGN: Retrospective cohort study between January 1, 2010, and December 31,2019. SETTING: The neonatal intensive care unit at British Columbia Women's Hospital (Vancouver Canada), a tertiary-care center. PATIENTS: Admitted neonates prescribed antibiotics. METHODS: We implemented an ASP with an early implementation phase starting in January 2014 (period 2) and a later phase starting in January 2017 (period 3). Patient demographics were collected, including birth weight, gestational age, history of necrotizing enterocolitis (NEC), and surgical operations from existing databases. Interrupted time-series analysis was used, and comparison of antibiotic days of therapy (DOT) averages were conducted across the preimplementation period (period 1), period 2, and period 3 regarding total patients and subgroups. RESULTS: We identified 4,512 infants. There was a significant decrease in DOT from 472 (95% confidence interval [CI], 431-517) in period 1 to 405 (95% CI, 367-446) in period 2 to 313 (95% CI, 280-350) in period 3. We detected a significant decrease in the use of ampicillin, aminoglycosides, cloxacillin, and linezolid but not in vancomycin or cefotaxime. Subgroup analyses of infants <1,500 g and those without NEC or surgery showed decreases in the use of cloxacillin, aminoglycosides, and linezolid. CONCLUSIONS: The implementation of an ASP was associated with a significant decrease in the overall DOT and use of certain antibiotics. This study presents important targets for ongoing ASP work.

Targeted neonatal echocardiography for patent ductus arteriosus in neonates reduces the surgical ligation rate without affecting healthcare outcomes.

Background: Surgical ligation of patent ductus arteriosus (PDA) can be associated with long-term morbidity and adverse outcomes in neonates. Targeted neonatal echocardiography (TNE) has been increasingly used to improve the hemodynamic management. We aimed to evaluate the preoperative assessment impacts of the hemodynamic significance of PDA using TNE on PDA ligation rates and neonatal outcomes. Methods: This observational study included preterm infants who underwent PDA ligation during two epochs (Epoch I: January 2013 to December 2014; Epoch II: January 2015 to June 2016). During Epoch II, a comprehensive TNE assessment was performed preoperatively to evaluate the hemodynamic significance of PDA. Primary outcome was the incidence of PDA ligation. Secondary outcomes included the incidence of postoperative cardiorespiratory instabilities, individual morbidities, and the composite outcome of death. Results: A total of 69 neonates underwent PDA ligation. No difference in baseline demographics was found between the epochs. The incidence of PDA ligation in very low birth weight (VLBW) infants was lower during Epoch II than Epoch I [7.5% vs. 14.6%, rate ratio =0.51 (95% confidence interval =0.30-0.88)]. No differences were observed between epochs in the proportion of VLBW infants who developed post-operative hypotension or oxygenation failure. The composite outcome of death or major morbidity did not significantly differ between Epoch I and Epoch II (91.1% vs. 94.1%, P=1.000). Conclusions: Incorporating TNE into a standardized hemodynamic assessment program, we demonstrated a 49% reduction in PDA ligation rate without any increase in postoperative cardiopulmonary instability or short-term neonatal morbidities in a cohort of VLBW infants.

Improving Efficiency of Multidisciplinary Bedside Rounds in the NICU: A Single Centre QI Project.

INTRODUCTION: Inconsistent workflow, communication, and role clarity generate inefficiencies during bedside rounds in a neonatal intensive care unit. These inefficiencies compromise the time needed for essential activities and result in reduced staff and family satisfaction. This study's primary aim was to reduce the mean duration of bedside rounds by 25% within 3 months by redesigning the rounding processes and applying QI principles. The secondary aims were to improve staff and family experience. METHODS: We conducted this work in an academic 50-bed neonatal intensive care unit involving 350 staff members. The change interventions included: (i) reinforcing essential value-added activities like standardizing rounding time, the sequencing of patients rounded, sequencing each team member rounding presentations, team preparation, bedside presentation content, and time management; (ii) reducing non-value-added activities; and (iii) moving value-added nonessential activities outside of the rounds. RESULTS: The mean duration of rounds decreased from 229 minutes in the pre-implementation to 132 minutes in the postimplementation phase. The proportion of staff showing satisfaction regarding various components of the rounds increased from 5% to 60%, and perceived staff involvement during the rounds increased from 70% to 77%. Ninety-three percent of family experience survey respondents expressed satisfaction at being invited for bedside reporting and being involved in decision-making or care planning. The staff did not report any adverse events related to the new rounds process. CONCLUSION: Redesigning bedside rounds improved staff engagement and workflow, resulting in efficient rounds and better staff experience.

Corrected fortification approach improves the protein and energy content of preterm human milk compared with standard fixed-dose fortification.

OBJECTIVE: To evaluate whether a pragmatic corrected fortification (CF) model achieves recommended target protein and calorie content of human milk (HM) for preterm infants when compared with standard fixed-dose fortification (SF). DESIGN: In this prospective non-interventional study, we enrolled mothers of infants with birth weight ≤1500 g fed exclusive HM. Infants with chromosomal or intestinal disorders were excluded. A total of 405 HM samples from 29 mothers and 45 donor milk samples were analysed for macronutrient content using a real-time HM analyser. A stepwise CF model was derived based on published data on HM calorie and protein content corrected for lactation stage and milk type. We applied both models to the measured protein and calorie content for all HM samples and compared the proportion of samples achieving target nutrient requirement in each group. RESULTS: Target protein and calorie content of feed was achieved in 68% of HM samples with CF, compared with 5% samples with SF model (p<0.0001). For mother's own milk, none of the samples met the target macronutrient range with SF fortification during later lactation periods (≥week 5). With SF, over 40% of infants had poor growth (decline in weight z-score ≥0.8 SD) by 8 weeks. The final feed osmolality was acceptable for all fortification steps of the CF model. CONCLUSION: The proposed CF model significantly improved the final protein and calorie content of HM with acceptable osmolality. It provides a proactive option to improve nutrient intake in premature infants.

Pathogenesis and Management of Indirect Hyperbilirubinemia in Preterm Neonates Less Than 35 Weeks: Moving Toward a Standardized Approach.

Premature infants have a higher incidence of indirect hyperbilirubinemia than term infants. Management of neonatal indirect hyperbilirubinemia in late preterm and term neonates has been well addressed by recognized, consensus-based guidelines. However, the extension of these guidelines to the preterm population has been an area of uncertainty because of limited evidence. This leads to variation in clinical practice and lack of recognition of the spectrum of bilirubin-induced neurologic dysfunction (BIND) in this population. Preterm infants are metabolically immature and at higher risk for BIND at lower bilirubin levels than their term counterparts. Early use of phototherapy to eliminate BIND and minimize the need for exchange transfusion is the goal of treatment in premature neonates. Although considered relatively safe, phototherapy does have side effects, and some NICUs tend to overuse phototherapy. In this review, we describe the epidemiology and pathophysiology of BIND in preterm neonates, and discuss our approach to standardized management of indirect hyperbilirubinemia in the vulnerable preterm population. The proposed treatment charts suggest early use of phototherapy in preterm neonates with the aim of reducing exposure to high irradiance levels, minimizing the need for exchange transfusions, and preventing BIND. The charts are pragmatic and have additional curves for stopping phototherapy and escalating its intensity. Having a standardized approach would support future research and quality improvement initiatives that examine dose and duration of phototherapy exposure with relation to outcomes.

Reduction of Inappropriate Antimicrobial Prescriptions in a Tertiary Neonatal Intensive Care Unit After Antimicrobial Stewardship Care Bundle Implementation.

BACKGROUND: Our objective was to evaluate the appropriateness of antibiotic prescriptions in the neonatal intensive care unit using standardized criteria and determine the effects of an antimicrobial stewardship program (ASP) on patterns of antibiotic usage. METHODS: A retrospective audit of antibiotic use from July 2010 to June 2013 was conducted, focusing on prescriptions of vancomycin, cefotaxime, meropenem and linezolid for >3 calendar-days. We evaluated the appropriateness of each course of antibiotic treatment based on the Centers for Disease Control and Prevention 12-Step Guidelines to Prevent Antimicrobial Resistance (steps 4, 6 and 9). An ASP was introduced in August 2014, and the same audit criteria were applied to review antimicrobial use in the subsequent 12 months. RESULTS: In the pre-ASP era, 26.3%, 12.1%, 11.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The most common instance of inappropriate utilization included failure to use narrow-spectrum antimicrobials when appropriate. After the introduction of ASP program, 22.2%, 7.5%, 5.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The numbers of inappropriate antibiotic-days/1000 days of therapy with meropenem, cefotaxime and vancomycin changed from 1.89 to 1.96 [rate ratio (RR), 1.04 (0.70-1.52)], 3.56 to 1.73 [RR, 0.49 (0.33-0.71)] and 2.70 to 1.01 [RR, 0.37 (0.22-0.60)], respectively. In subgroup analysis, very low birth weight infants (birth weight, <1500 g) showed no improvement in the rates of inappropriate antibiotic prescriptions. CONCLUSIONS: In this study, we found that ASP initiatives can be applied in neonatal populations to reduce inappropriate antimicrobial prescriptions, though a different approach may be needed among very low birth weight infants.

Prevalence and clinical impact of methicillin-resistant Staphylococcus aureus colonization among infants at a level III neonatal intensive care unit.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a well-known nosocomial pathogen in neonatal intensive care unit (NICU) patients. Studies on the impact of MRSA colonization on neonatal morbidities are scarce. METHODS: We conducted a 1:3 matched cohort study among infants with and without MRSA colonization, born between January 2010 and June 2014, in a tertiary NICU to review their demographic characteristics and outcomes. RESULTS: During the study period, rates of MRSA colonization and bacteremia were found to be 0.68% and 0.10%, respectively. No differences in demographic characteristics, mortality, and major morbidities were identified among infants with and without MRSA colonization. CONCLUSIONS: We reported a low rate of MRSA colonization in infants admitted to our NICU, without impact on mortality and inhospital morbidity. Further large-scale studies are needed to understand the implications and cost-effectiveness of active MRSA surveillance.

Journey to mother baby care: Implementation of a combined care/couplet model in a Level 2 neonatal intensive care unit.

"Why can't I have my postpartum care in the same room as my baby?" questioned Hilary, a neonatal intensive care unit (NICU) "alumni" parent, during a design event for the new British Columbia's Women's Hospital 70 single family room NICU. This simple yet provocative question was nearly dismissed and the idea of a combined care model lost, since most members of the team thought it was simply "not possible." Hilary did not give up and continued to raise this idea throughout every design event. It was Hilary's fortitude and sharing of her NICU experience that was the inspiration for the MotherBaby Care unit. The voice of one woman has improved the birth experiences of potentially thousands of mothers and their at-risk newborns. By honoring women's voices and values in health care, positive changes that matter to women, infants, and families can be made. Mothers also shared: "I knew what was best for me was to be with my baby," "If I could stand up after my C-section, I would drag my IV pole to be with my baby!", "Teach me how to take care of my premature baby before I am ready to go home!" MotherBaby Care is a combined care or "couplet" care where one NICU nurse provides care for a postpartum mother and her at-risk newborn in the Level 2 NICU. This review describes the journey from innovation and design to the implementation of the MotherBaby Care model.