Early blood glucose screening in asymptomatic high-risk neonates.

OBJECTIVES: Detecting and treating severe hypoglycemia promptly after birth is crucial due to its association with adverse long-term neurodevelopmental outcomes. However, limited data are available on the optimal timing of glucose screening in asymptomatic high-risk neonates prone to hypoglycemia. Risk factors associated with asymptomatic high-risk neonates include late prematurity ≥35 and <37 weeks gestation (LPT), small-for-gestational-age (SGA), large-for-gestational-age (LGA), and infant-of-a-diabetic mother (IDM). This study aims to determine the incidence and the impact of individual risk factors on early hypoglycemia (defined as blood glucose ≤25 mg/dL in the initial hour after birth) in asymptomatic high-risk neonates. METHODS: All asymptomatic high-risk neonates ≥35 weeks gestation underwent early blood glucose screening within the first hour after birth (n=1,690). A 2-year retrospective analysis was conducted to assess the incidence of early neonatal hypoglycemia in this cohort and its association with hypoglycemia risk factors. RESULTS: Out of the 9,919 births, 1,690 neonates (17 %) had risk factors for neonatal hypoglycemia, prompting screening within the first hour after birth. Incidence rates for blood glucose ≤25 mg/dL and ≤15 mg/dL were 3.1 and 0.89 %, respectively. Of concern, approximately 0.5 % of all asymptomatic at-risk neonates had a blood glucose value of ≤10 mg/dL. LPT and LGA were the risk factors significantly associated with early neonatal hypoglycemia. CONCLUSIONS: Asymptomatic high-risk neonates, particularly LPT and LGA neonates, may develop early severe neonatal hypoglycemia identified by blood glucose screening in the first hour of life. Additional investigation is necessary to establish protocols for screening and managing asymptomatic high-risk neonates.

From Warm to Cold: Feeding Cold Milk in Preterm Infants with Uncoordinated Oral Feeding Patterns.

Objective: Premature infants frequently face feeding challenges due to disrupted coordination of sucking, swallowing, and breathing, increasing their risk of dysphagia. There are few effective treatment options available for these infants. In adults experiencing dysphagia, consuming cold foods or liquids can be an effective strategy. This method stimulates the sensory receptors in the pharyngeal mucosa, promoting safer and more effective swallowing. We have previously demonstrated that short-duration feeding (5 swallows) with cold liquid significantly reduces dysphagia in preterm infants; however, the impact of extended cold milk feeding remains unexplored. This study aims to assess the safety of cold milk feedings in preterm infants diagnosed with uncoordinated feeding patterns and its effect on feeding performance. Study Design: Preterm infants with uncoordinated feeding patterns (n=26) were randomized to be fed milk at either room or cold temperatures using an experimental, randomized crossover design. We monitored axillary and gastric content temperatures, mesenteric blood flow, and feeding performance. Result: The findings suggest that preterm infants can safely tolerate cold milk without any clinically significant changes in temperature or mesenteric blood flow, and it may enhance certain aspects of feeding performance. Conclusion: These results suggest that cold milk feeding could be a safe therapeutic option for preterm infants. These results highlight the potential for further comprehensive studies to explore the use of cold milk as an effective therapeutic approach for addressing feeding and swallowing difficulties in preterm infants. Registered at clinicaltrials.org #NCT04421482.

Respiratory management in the premature neonate.

INTRODUCTION: Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes. AREAS COVERED: Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed. EXPERT OPINION: Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.

Pneumothorax in Neonates Born to COVID-19-Positive Mothers: Fact or Fortuity?

Neonates born to mothers with coronavirus disease 2019 (COVID-19) have been largely asymptomatic based on initial reports. All neonates born to mothers with COVID-19 have tested negative for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in our institution (published data as of April 12, 2020). As novel presentations of COVID-19, such as multisystem inflammatory syndrome in children are being increasingly reported, we raise the possibility of increased incidence of pneumothorax in neonates born to SARS-CoV-2-positive mothers. Two recently described neonates with COVID-19 infection were noted to have pneumothoraces. We describe two SARS-CoV-2-negative neonates born to COVID-19-positive mothers at 38 and 33 weeks, respectively, admitted to our neonatal intensive care unit for respiratory distress and subsequently developed pneumothoraces. As diverse clinical presentations in various age groups are being described, it becomes difficult to differentiate the increased incidence of complications related to an underlying illness, from COVID-19-related illness. It remains to be seen if neonates with in utero exposure to SARS-CoV-2 have an elevated inflammatory response with pneumonitis and exaggerated lung disease, similar to adult COVID-19 patients, due to in utero exposure.

Non-Invasive Ventilatory Strategies to Decrease Bronchopulmonary Dysplasia-Where Are We in 2021?

Recent advances in neonatology have led to the increased survival of extremely low-birth weight infants. However, the incidence of bronchopulmonary dysplasia (BPD) has not improved proportionally, partly due to increased survival of extremely premature infants born at the late-canalicular stage of lung development. Due to minimal surfactant production at this stage, these infants are at risk for severe respiratory distress syndrome, needing prolonged ventilation. While the etiology of BPD is multifactorial with antenatal, postnatal, and genetic factors playing a role, ventilator-induced lung injury is a major, potentially modifiable, risk factor implicated in its causation. Infants with BPD are at a higher risk of developing complications including sepsis, pulmonary arterial hypertension, respiratory failure, and death. Long-term problems include increased risk of hospital readmissions, respiratory infections, and asthma-like symptoms during infancy and childhood. Survivors who have BPD are also at increased risk of poor neurodevelopmental outcomes. While the ultimate solution for avoiding BPD lies in the prevention of preterm births, strategies to decrease its incidence are the need of the hour. It is time to focus on gentler modes of ventilation and the use of less invasive surfactant administration techniques to mitigate lung injury, thereby potentially decreasing the burden of BPD. In this article, we discuss the use of non-invasive ventilation in premature infants, with an emphasis on studies showing an effect on BPD with different modes of non-invasive ventilation. Practical considerations in the use of nasal intermittent positive pressure ventilation are also discussed, considering the significant heterogeneity in clinical practices and management strategies in its use.

Simultaneous Videofluoroscopy and Endoscopy for Dysphagia Evaluation in Preterm Infants-A Pilot Study.

Introduction: The assessment of dysphagia in preterm infants has been limited to clinical bedside evaluation followed by videofluoroscopic swallow study (VFSS) in selected patients. Recently, fiberoptic endoscopic evaluation of swallowing (FEES) is being described more in literature for preterm infants. However, it is unclear if one test has a better diagnostic utility than the other in this population. Furthermore, it is also unclear if performing FEES and VFSS simultaneously will increase the sensitivity and specificity of detecting dysphagia compared to either test performed independently. Objectives: The primary objective of this study is to evaluate the feasibility of performing VFSS and FEES simultaneously in preterm infants. Our secondary objective is to determine whether simultaneously performed VFSS-FEES improves the diagnostic ability in detecting dysphagia in preterm infants compared to either test done separately. Methods: In this pilot study, we describe the process involved in performing simultaneous VFSS-FEES in five preterm infants (postmenstrual age ≥36 weeks) with dysphagia. A total of 26 linked VFSS-FEES swallows were analyzed, where the same bolus during the same swallow was compared using simultaneous fluoroscopy and endoscopy. The sensitivity and specificity of detecting penetration and aspiration were evaluated in simultaneous VFSS-FEES compared with each test done independently. Results: Our results demonstrated that performing simultaneous VFSS-FEES is feasible in preterm infants with dysphagia. All patients tolerated the procedures well without any complications. Our pilot study in these five symptomatic preterm infants demonstrated a low incidence of aspiration but a high incidence of penetration. Simultaneous VFSS-FEES (26 linked swallows) improved the ability to detect penetration compared to each test done separately. Conclusion: To our knowledge, this study is the first to demonstrate the feasibility of performing VFSS and FEES simultaneously in symptomatic preterm infants with dysphagia resulting in potentially higher diagnostic yield than either procedure done separately.

Neonatal Coronavirus 2019 (COVID-19) Infection: A Case Report and Review of Literature.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a global pandemic affecting 213 countries as of April 26, 2020. Although this disease is affecting all age groups, infants and children seem to be at a lower risk of severe infection, for reasons unknown at this time. We report a case of neonatal infection in New York, United States, and provide a review of the published cases. A 22-day-old, previously healthy, full-term neonate was hospitalized after presenting with a one-day history of fever and poor feeding. Routine neonatal sepsis evaluation was negative. SARS-CoV-2 polymerase chain reaction (PCR) testing was obtained, given rampant community transmission, which returned positive. There were no other laboratory or radiographic abnormalities. The infant recovered completely and was discharged home in two days once his feeding improved. The family was advised to self-quarantine to prevent the transmission of COVID-19. We believe that the mode of transmission was horizontal spread from his caregivers. This case highlights the milder presentation of COVID-19 in otherwise healthy, full-term neonates. COVID-19 must be considered in the evaluation of a febrile infant. Infants and children may play an important role in the transmission of COVID-19 in the community. Hence, with an understanding of the transmission patterns, parents and caregivers would be better equipped to limit the spread of the virus and protect the more vulnerable population.

The effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants.

OBJECTIVE: To determine whether delaying oral feeding until coming off NCPAP will alter feeding and respiratory-related morbidities in preterm infants. DESIGN: In this retrospective pre-post analysis, outcomes were compared in two preterm infant groups (≤32 weeks gestation). Infants in Group 1 were orally fed while on NCPAP, while infants in Group 2 were only allowed oral feedings after ceasing NCPAP. RESULTS: Although infants in Group 2 started feeds at a later postmenstrual age (PMA), they reached full oral feeding at a similar PMA compared with Group 1. Interestingly, there was a positive correlation between the duration of oral feeding while on NCPAP and the time spent on respiratory support in Group 1. CONCLUSIONS: Delayed oral feeding until ceasing NCPAP did not contribute to feeding-related morbidities. We recommend caution when initiating oral feedings in preterm infants on NCPAP without evaluating the safety of the infants and their readiness for oral feedings.

Induction of labor and early-onset Sepsis guidelines: impact on NICU admissions in Erie County, NY.

BACKGROUND: Elective delivery prior to term gestation is associated with adverse neonatal outcomes. The impact of American College of Obstetricians and Gynecologists (ACOG) guidelines recommending against induction of labor (IOL) < 39 weeks' postmenstrual age (PMA) on the frequency of early-term births and NICU admissions in Erie County, NY was evaluated in this study. METHODS: This is a population-based retrospective comparison of all live births and NICU admissions in Erie County, NY between pre-and post-ACOG IOL guideline epochs (2005-2008 vs. 2011-2014). Information on early-term, full/late/post-term births and NICU admissions was obtained. A detailed chart analysis of indications for admission to the Regional Perinatal Center was performed. RESULTS: During the 2005-2008 epoch, early-term births constituted 27% (11,968/44,617) of live births. The NICU admission rate was higher for early-term births (1134/11968 = 9.5%) compared to full/late/post-term (1493/27541 = 5.4%).In the 2011-2014 epoch, early-term births decreased to 23% (10,286/44,575) of live births. However, NICU admissions for early-term (1072/10286 = 10.4%) and full/late/post-term births (1892/29508 = 6.4%) did not decrease partly due to asymptomatic infants exposed to maternal chorioamnionitis admitted for empiric antibiotic therapy as per revised early-onset sepsis guidelines. CONCLUSIONS: ACOG recommendations against elective IOL or cesarean delivery < 39 weeks PMA were rapidly translated to clinical practice and decreased early-term births in Erie County, NY. This decrease did not translate to reduced NICU admissions partly due to increased NICU admissions for empiric antibiotic therapy.

Reduction in Central Line-Associated Bloodstream Infection Rates After Implementations of Infection Control Measures at a Level 3 Neonatal Intensive Care Unit.

Advances in neonatology led to survival of micro-preemies, who need central lines. Central line-associated bloodstream infection (CLABSI) causes prolonged hospitalization, morbidities, and mortality. Health care team education decreases CLABSIs. The objective was to decrease CLABSIs using evidence-based measures. The retrospective review compared CLABSI incidence during and after changes in catheter care. In April 2011, intravenous (IV) tubing changed from Interlink to Clearlink; IV tubing changing interval increased from 24 to 72 hours. CLABSIs increased. The following measures were implemented: July 2011, reeducation of neonatal intensive care staff on Clearlink; August 2011, IV tubing changing interval returned to 24 hours; September 2011, changed from Clearlink back to Interlink; November 2011, review of entire IV process and in-service on hand hygiene; December 2011, competencies on IV access for all nurses. CLABSIs were compared during and after interventions. Means were compared using the t test and ratios using the χ2 test; P <.05. CLABSIs decreased from 4.4/1000 to 0/1000 catheter-days; P < .05. Evidence-based interventions reduced CLABSIs.

Caffeine is associated with improved alveolarization and angiogenesis in male mice following hyperoxia induced lung injury.

BACKGROUND: Caffeine therapy for apnea of prematurity reduces the incidence of bronchopulmonary dysplasia (BPD) in premature neonates. Several mechanisms, including improvement in pulmonary mechanics underly beneficial effects of caffeine in BPD. As vascular development promotes alveologenesis, we hypothesized that caffeine might enhance angiogenesis in the lung, promoting lung growth, thereby attenuating BPD. METHODS: C57Bl/6 mice litters were randomized within 12 h of birth to room air (RA) or 95%O2 to receive caffeine (20 mg/kg/day) or placebo for 4 days and recovered in RA for 12wks. The lung mRNA and protein expression for hypoxia-inducible factors (HIF) and angiogenic genes performed on day 5. Lung morphometry and vascular remodeling assessed on inflation fixed lungs at 12wks. RESULTS: Caffeine and hyperoxia in itself upregulate HIF-2α and vascular endothelial growth factor gene expression. Protein expression of HIF-2α and VEGFR1 were higher in hyperoxia/caffeine and angiopoietin-1 lower in hyperoxia. An increase in radial alveolar count, secondary septal count, and septal length with a decrease in mean linear intercept indicate an amelioration of hyperoxic lung injury by caffeine. An increase in vessel surface area and a significant reduction in smooth muscle thickness of the pulmonary arterioles may suggest a beneficial effect of caffeine on vascular remodeling in hyperoxia, especially in male mice. CONCLUSIONS: Postnatal caffeine by modulating angiogenic gene expression early in lung development may restore the pulmonary microvasculature and alveolarization in adult lung.

Surfactant, steroids and non-invasive ventilation in the prevention of BPD.

Bronchopulmonary dysplasia (BPD) is a complex disorder with multiple factors implicated in its etiopathogenesis. Despite the scientific advances in the field of neonatology, the incidence of BPD has remained somewhat constant due to increased survival of extremely premature infants. Surfactant deficiency in the immature lung, exposure to invasive mechanical ventilation leading to volutrauma, barotrauma and lung inflammation are some of the critical contributing factors to the pathogenesis of BPD. Hence, strategies to prevent BPD in the postnatal period revolve around mitigation of this injury and inflammation. This article reviews the progress made in the last 5 years in the development of new preparations of surfactant, use of corticosteroids and non-invasive ventilation in the prevention of BPD. Emerging techniques of surfactant delivery through minimally invasive and non-invasive routes are also discussed.

Reduction in Central Line-Associated Bloodstream Infection Rates After Implementations of Infection Control Measures at a Level 3 Neonatal Intensive Care Unit.

Advances in neonatology led to survival of micro-preemies, who need central lines. Central line-associated bloodstream infection (CLABSI) causes prolonged hospitalization, morbidities, and mortality. Health care team education decreases CLABSIs. The objective was to decrease CLABSIs using evidence-based measures. The retrospective review compared CLABSI incidence during and after changes in catheter care. In April 2011, intravenous (IV) tubing changed from Interlink to Clearlink; IV tubing changing interval increased from 24 to 72 hours. CLABSIs increased. The following measures were implemented: July 2011, reeducation of neonatal intensive care staff on Clearlink; August 2011, IV tubing changing interval returned to 24 hours; September 2011, changed from Clearlink back to Interlink; November 2011, review of entire IV process and in-service on hand hygiene; December 2011, competencies on IV access for all nurses. CLABSIs were compared during and after interventions. Means were compared using the t test and ratios using the χ(2) test; P <.05. CLABSIs decreased from 4.4/1000 to 0/1000 catheter-days; P < .05. Evidence-based interventions reduced CLABSIs.

Type and timing of ventilation in the first postnatal week is associated with bronchopulmonary dysplasia/death.

The type and timing of respiratory support in the first week affecting bronchopulmonary dysplasia (BPD)/death have not been evaluated. We compared outcomes of premature infants on nasal intermittent positive pressure ventilation (NIPPV) or nasal continuous positive airway pressure (NCPAP) to those on endotracheal tube (ETT). We retrospectively reviewed data (1/2004 to 6/2009) of infants ≤ 30 weeks' gestational age (GA) who received NIPPV in the first postnatal week. National Institutes of Health consensus definition was used for BPD. Infants were categorized into three groups based on their being on a particular respiratory support mode for majority of days in the first week. There was no difference in the mean GA and body weight in the three groups: ETT (N = 65; 26.7 weeks; 909 g), NIPPV (N = 66; 27.1 weeks; 948 g), and NCPAP (N = 33; 27.4 weeks; 976 g). Use of surfactant was significantly different. In multivariate analysis, compared with ETT, NIPPV (P < 0.02) and NCPAP (P < 0.01) groups were less likely to have BPD/death. Infants on ETT (N = 97) during 1 to 3 days were more likely to have BPD/death compared with those on NIPPV (N = 38): 67% versus 47% (P = 0.035). Infants on ETT (N = 30) during 4 to 7 days were more likely to have BPD/death compared with those extubated to NIPPV (N = 36): 87 versus 53% (P = 0.003). Extubation to NIPPV or NCPAP in the first postnatal week is associated with decreased probability of BPD/death.