An Observational Time Study of Neonatal Intensive Care Unit Multidisciplinary Rounds.

OBJECTIVE: In this observational study, we aimed to describe the rounding structure in a high acuity neonatal intensive care unit (NICU) to identify potential barriers to efficient multidisciplinary rounds. STUDY DESIGN: We observed daily medical rounds (January-December 2018) on the resident teaching service in a 46-bed academic level IV NICU. Daily census, duration of rounds, and causes for rounding delays were recorded. During a subset of the study period, additional data were collected describing the time spent on specific activities and the room-to-room pathway followed by the rounding team. Descriptive statistics were used to summarize the census, total rounding time, time spent on each activity, and rounding time by day of the week and by attending. RESULTS: A total of 208 rounding days were observed. During the study period, the teaching service mean daily census was 17 patients and total rounding time (mean ± standard deviation) was 136 ± 31 minutes. Mean rounding time and time/patient varied between the nine attendings (total time range 109 minutes to 169 minutes, time/patient range 6.4 minutes/patient to 10.0 minutes/patient). In total, 91% of rounding time focused on patient care, teaching, and discussions with parents, while 9% of the time was spent deciding which patient to see next, moving between rooms, and waiting for members of the team to be ready to start rounds. CONCLUSION: On average, the medical team spent over 2 hours per day making multisciplinary rounds in the NICU with substantial variation between attending providers. While most time was spent on patient care, teaching, and talking with parents, we identified opportunities to improve rounding efficiency. KEY POINTS: · The structure of rounds in a NICU was observed to identify the potential barriers to efficiency.. · There are limited data on MDR processes in the NICU.. · In total, 9% of time was spent on patient care activities during daily rounds..

Impact of maternal overweight and obesity on milk composition and infant growth.

Overweight and obesity (OW/OB) impact half of the pregnancies in the United States and can have negative consequences for offspring health. Studies are limited on human milk alterations in the context of maternal obesity. Alterations in milk are hypothesized to impact offspring development during the critical period of lactation. We aimed to evaluate the relationships between mothers with OW/OB (body mass index [BMI] ≥25 kg/m2 ), infant growth, and selected milk nutrients. We recruited mother-infant dyads with pre-pregnancy OW/OB and normal weight status. The primary study included 52 dyads with infant growth measures through 6 months. Thirty-two dyads provided milk at 2 weeks, which was analysed for macronutrients, long-chain fatty acids, and insulin. We used multivariable linear regression to examine the association of maternal weight status with infant growth, maternal weight status with milk components, and milk components with infant growth. Mothers with OW/OB had infants with higher weight-for-length (WFL) and BMI Z-scores at birth. Mothers with OW/OB had higher milk insulin and dihomo-gamma-linolenic, adrenic, and palmitic acids and reduced conjugated linoleic and oleic acids. N6 long-chain polyunsaturated fatty acid (LC-PUFA)-driven factor 1 was associated with higher WFL, lower length-for-age (LFA), and lower head circumference-for-age Z-scores change from 2 weeks to 2 months in human milk-fed infants, whereas N6 LC-PUFA-driven factor 5 was associated with lower LFA Z-score change. Human milk composition is associated with maternal pre-pregnancy weight status and composition may be a contributing factor to early infant growth trajectory.

Lactational programming of glucose homeostasis: a window of opportunity.

The window of lactation is a critical period during which nutritional and environmental exposures impact lifelong metabolic disease risk. Significant organ and tissue development, organ expansion and maturation of cellular functions occur during the lactation period, making this a vulnerable time during which transient insults can have lasting effects. This review will cover current literature on factors influencing lactational programming such as milk composition, maternal health status and environmental endocrine disruptors. The underlying mechanisms that have the potential to contribute to lactational programming of glucose homeostasis will also be addressed, as well as potential interventions to reduce offspring metabolic disease risk.

Chorioamnionitis-exposure alters serum cytokine trends in premature neonates.

OBJECTIVES: Determine if chronologic age and/or chorioamnionitis exposure alter normal serum cytokine and chemokine levels in uninfected preterm neonates during their initial NICU stay. STUDY DESIGN: A 7-plex immunoassay measured levels of serum IL-1ß, IL-6, IL-8, IL-10, TNF-α, CCL2, and CCL3 longitudinally from chorioamnionitis-exposed and unexposed preterm neonates under 33 weeks' gestation. RESULTS: Chorioamnionitis-exposed and unexposed preterm neonates demonstrated differences in the trends of IL-1ß, IL-6, IL-8, IL-10, TNF-α, and CCL2 over the first month of life. The unexposed neonates demonstrated elevated levels of these inflammatory markers in the first two weeks of life with a decrease by the third week of life, while the chorioamnionitis-exposed neonates demonstrated differences over time without a predictable pattern. Chorioamnionitis-exposed and unexposed neonates demonstrated altered IL-10 and TNF-α trajectories over the first twelve weeks of life. CONCLUSION: Chorioamnionitis induces a state of immune dysregulation in preterm neonates that persists beyond the immediate neonatal period.

Bioactive compounds in mothers milk affecting offspring outcomes: A narrative review.

BACKGROUND: Compared to the exhaustive study of transgenerational programming of obesity and diabetes through exposures in the prenatal period, postnatal programming mechanisms are understudied, including the potential role of breast milk composition linking maternal metabolic status (body mass index and diabetes) and offspring growth, metabolic health and future disease risk. METHODS: This narrative review will principally focus on four emergent bioactive compounds [microRNA's (miRNA), lipokines/signalling lipids, small molecules/metabolites and fructose] that, until recently were not known to exist in breast milk. The objective of this narrative review is to integrate evidence across multiple fields of study that demonstrate the importance of these compositional elements of breast milk during lactation and the subsequent effect of breast milk components on the health of the infant. RESULTS: Current knowledge on the presence of miRNA's, lipokines/signalling lipids, small molecules/metabolites and fructose in breast milk and their associations with infant outcomes is compelling, but far from resolved. Two themes emerge: (1) maternal metabolic phenotypes are associated with these bioactives and (2) though existing in milk at low concentrations, they are also associated with offspring growth and body composition. CONCLUSION: Breast milk research is gaining momentum though we must remain focused on understanding how non-nutritive bioactive components are affected by the maternal phenotype, how they subsequently impact infant outcomes. Though early, there is evidence to suggest fructose is associated with fat mass in the 1st months of life whereas 12,13 diHOME (brown fat activator) and betaine are negatively associated with early adiposity and growth.

An Alternative to Mother's Own Milk: Maternal Awareness of Donor Human Milk and Milk Banks.

BACKGROUND: The use of donor human milk is rising. Maternal awareness of donor human milk use, milk donation, and milk banks has not been well described in the United States. RESEARCH AIMS: To explore maternal experience, knowledge, and attitudes regarding donor human milk use and milk donation. We also assessed counseling by medical providers about donor human milk use and donation. METHODS: A cross-sectional prospective survey design was used in this study. We anonymously surveyed mothers (N = 73) attending the 1 to 2-week well newborn appointment. Analyses were completed using one-way ANOVA and logistic regression. RESULTS: Participants' infants primarily received their own mother's milk (87%, n = 61). No infants received donor human milk, but 4% (n = 3) of participants donated milk. The majority of participants had positive responses to attitudinal statements about donor milk. When presented with a hypothetical scenario, participants chose formula (89%, n = 59) over donor human milk (11%, n = 7) for their infant. Moreover, if donor human milk was the only option available, they chose donor human milk from a relative or friend (60%, n = 40) over a milk bank (40%, n = 26). Medical providers had discussed donor human milk use or donation with 4% (n = 3) of participants. CONCLUSIONS: The majority of participants previously had minimal experience using donor human milk and limited knowledge regarding donor human milk and milk banks. According to participants, medical providers did not routinely discuss milk donation and the role of donor human milk with families.

Congenital Cytomegalovirus Infection Presenting with Hyperbilirubinemia and Splenomegaly in a Term Infant with Trisomy 21.

Congenital cytomegalovirus infection (cCMV) is very common, yet the presentation can be varied, making the diagnosis challenging. However, early diagnosis for treatment with medication in symptomatic cases within the first month of life is critical. Hyperbilirubinemia and splenomegaly are less common manifestations at birth and may be overlooked in the setting of other symptoms, especially in a critically ill neonate. We present a case of a term infant with trisomy 21 who presented with isolated hyperbilirubinemia and splenomegaly and was later diagnosed with congenital CMV.

Breast Milk Iodine Concentration Is Associated with Infant Growth, Independent of Maternal Weight.

In breastfed infants, human milk provides the primary source of iodine to meet demands during this vulnerable period of growth and development. Iodine is a key micronutrient that plays an essential role in hormone synthesis. Despite the importance of iodine, there is limited understanding of the maternal factors that influence milk iodine content and how milk iodine intake during infancy is related to postnatal growth. We examined breast milk samples from near 2 weeks and 2 months post-partum in a mother-infant dyad cohort of mothers with pre-pregnancy weight status defined by body mass index (BMI). Normal (NW, BMI < 25.0 kg/m2) is compared to overweight/obesity (OW/OB, BMI ≥ 25.0 kg/m2). The milk iodine concentration was determined by inductively coupled plasma mass spectrometry. We evaluated the associations between iodine content at 2 weeks and infant anthropometrics over the first year of life using multivariable linear mixed modeling. Iodine concentrations generally decreased from 2 weeks to 2 months. We observed no significant difference in iodine based on maternal weight. A higher iodine concentration at 2 weeks was associated with a larger increase in infant weight-for-age and weight-for-length Z-score change per month from 2 weeks to 1 year. This pilot study shows that early iodine intake may influence infant growth trajectory independent of maternal pre-pregnancy weight status.

Lactational exposure to polychlorinated biphenyls is higher in overweight /obese women and associated with altered infant growth trajectory: A pilot study.

BACKGROUND: Infant exposure to environmental chemicals, such as polychlorinated biphenyls (PCBs), may contribute to developmental programming of long-term metabolic disease risk. PCBs persist given their lipophilicity and long half-lives, allowing them to bio-accumulate in adipose tissue. These compounds can then be excreted into maternal milk resulting in infant exposure. OBJECTIVE: To determine the level of PCBs in milk from mothers with pre-pregnancy overweight and obese (OW/OB) versus normal weight status (NW) and evaluate the association of milk PCB levels with infant growth over the first 6 months of life. METHODS: A pilot study of a subset of milk samples from mothers with NW (pre-pregnancy body mass index (BMI) < 25 kg/m2, n = 11) and OW/OB (pre-pregnancy BMI ≥ 25 kg/m2, n = 8) were examined approximately 2-weeks postpartum. PCB congeners 138 + 163, 132 + 153, 180, and the sum were measured using gas chromatography/mass spectrometry and adjusted for milk fat content. Infant growth was monitored from birth to 6 months for weight-for-age (WFA), length-for-age (LFA), weight-for-length (WFL), head circumference-for-age (HCA), and associations with milk PCB content determined using linear mixed modeling. RESULTS: Total milk fat content did not differ by maternal weight status (p = 0.88). Milk from mothers with OW/OB had significantly higher PCB sum (p = 0.02) and PCB 138 + 163 (p = 0.03). PCB 132 + 153 (ß -0.0008, p = 0.0218), PCB 180 (ß -0.0010, p = 0.0279), and PCB sum (ß -0.0006, p = 0.0138) were negatively associated with HCA Z-score growth to 6 months. PCB 180 was negatively associated with infant WFA (ß -0.0015, p = 0.0058) and WFL Z-score (ß -0.0016, p = 0.0263) to 6 months. There were no associations of PCB sum content with WFL, LFA, WFL Z-score over the first 6 months of life. CONCLUSIONS: Maternal overweight and obesity are associated with higher levels of total PCB congeners (132, 138, 153, 163, 180) in human milk. PCB congeners have negative associations with infant head circumference and weight trajectory over the first 6 months of life.

Oxygen supplementation in the delivery room: T-piece resuscitator cap open or occluded?

OBJECTIVE: Updated neonatal resuscitation guidelines for free-flow oxygen administration with a T-piece resuscitator recommend higher gas flow and an open T-piece cap. We aimed to determine the effect of gas inflow rate and cap occlusion on oxygen delivery through a T-piece resuscitator. STUDY DESIGN: Using a NeoPuff™ T-piece, oxygen inflow was randomly adjusted from 4 to 10 liters per minute (LPM). Gas outflow and oxygen concentration were measured with the T-piece cap open and occluded. Data were analyzed with repeated measures 2-way ANOVA. RESULT: Gas outflow was significantly decreased with the T-piece cap open compared with occluded at each inflow rate (p < 0.001). There was no difference in oxygen concentration of the outflow gas. CONCLUSION: Gas flow from the T-piece is affected by the inflow rate and cap occlusion but oxygen concentration is not. To deliver 5 LPM of free-flow oxygen with the cap open, a minimum of 8 LPM gas inflow is required.