Optimal periods of exclusive breastfeeding associated with any breastfeeding duration through one year.

OBJECTIVE: To quantify optimal minimum durations of exclusive breastfeeding associated with maintenance of any breastfeeding at 15 time points during the first year of life. STUDY DESIGN: Mothers (n = 1189) from the prospective Infant Feeding Practices Study II cohort who initiated exclusive breastfeeding with healthy term infants were included. In a 80:20 split-sample validation study, receiver operating characteristic curves estimated optimal minimum durations of exclusive breastfeeding needed to predict maintenance of any breastfeeding at 15 time points during the first year (n = 951). Logistic regression estimated the predictive performance of the identified thresholds adjusted for maternal age, race, education, parity, support system, and return-to-work status. Results were validated in the remaining 20% (n = 238). RESULTS: Optimal minimum durations ranged from 4.0-17.1 weeks of exclusive breastfeeding associated with maintenance of any breastfeeding at 15 time points. All estimated threshold durations were statistically significant after adjustment. CONCLUSIONS: Using a methodological approach unique to breastfeeding duration research, the authors report optimal durations of exclusive breastfeeding associated with duration of any breastfeeding at time points throughout the first year. Perinatal clinicians, pediatricians, lactation professionals, policymakers, researchers, and families might apply these findings to achieve desirable collective breastfeeding duration outcomes.

Independent predictors of human milk receipt at neonatal intensive care unit discharge.

OBJECTIVE: The aim of this study is to construct a predictive model for very low birth weight (VLBW) infants' receipt of mother's own milk within 24 hours before neonatal intensive care unit (NICU) discharge. STUDY DESIGN: Vermont Oxford Network (VON) clinical data were analyzed retrospectively for VLBW infants admitted between 2002 and 2012 at an inner city, level IV NICU with a well-established lactation program. Bivariate analyses compared infant characteristics between recipients and nonrecipients of human milk before 24 hours of NICU discharge. Independent predictors identified in the bivariate analyses (p ≤ 0.05), were eligible for inclusion into a multivariable logistic regression model. RESULTS: We observed a 60.4% human milk feeding rate at NICU discharge. Multiple independent maternal (black race and Hispanic ethnicity) and clinical factors (need for mechanical ventilation, patent ductus arteriosus, late-onset sepsis, or discharge to home on a cardiorespiratory monitor) positively predicted the outcome. CONCLUSIONS: Our results were inconsistent with previous studies and suggest that a strong NICU lactation program in combination with a community-based peer counselor program may increase rates of human milk receipt among VLBW infants born to black/Hispanic mothers and those with more complicated neonatal courses.

Perinatal and neonatal outcomes of triplet gestations based on placental chorionicity.

The purpose of our study was to evaluate perinatal and neonatal outcomes in triplet gestations in relation to placental chorionicity. We hypothesized that triplets containing a monochorionic pair (dichorionic triamniotic) would have increased morbidity compared with triplets without a monochorionic pair (trichorionic triamniotic). We retrospectively analyzed all triplet sets > or =20 weeks delivering at our institutions from January 1995 through April 2007. Data were collected via perinatal and neonatal databases, chart review, and placental pathology. Individuals in dichorionic triamniotic triplet sets (N = 75), when compared with trichorionic triamniotic triplets (N = 309), were more likely to have a lower mean birth weight (P < 0.001) and lower gestational age at delivery (P < 0.001), spend more days in the neonatal intensive care unit (P = 0.045), have culture-proven sepsis (P = 0.02), and require intubation (P = 0.05). Multivariate analysis demonstrated that dichorionicity is not an independent cause of morbidity, but results in earlier delivery and lower birth weight. Dichorionic triamniotic triplets are at increased risk for earlier deliveries and lower birth weight at delivery compared with trichorionic triamniotic triplets.

Variability of Criteria for Pasteurized Donor Human Milk Use: A Survey of U.S. Neonatal Intensive Care Unit Medical Directors.

BACKGROUND: Use of donor human milk (DHM) is increasing, but criteria for its use are not well defined. MATERIALS AND METHODS: We conducted a 34-question Internet-based survey of medical directors of U.S. level 3 and level 4 neonatal intensive care units (NICUs), with the goal of describing specifics of policies developed to guide DHM use in U.S. NICUs. Respondents reported NICU characteristics and details of policies concerning DHM use. Policy-specified criteria for DHM use, if any, were described. Bivariate and multivariate analyses were used to identify NICU characteristics associated with DHM use. RESULTS: Respondents returned 153 (33%) surveys, with use of DHM reported by 91 (59%). Donor human milk use was more likely with more than 100 annual admissions <1500 g at birth (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.7) and with Vermont-Oxford Network participants (OR, 4.6; 95% CI, 1.8-11.6). Among 72 NICUs reporting a written policy, criteria for providing DHM required birth weights varying from <1000 to <1800 g and/or gestational ages from <28 to <34 completed weeks, but criteria were reportedly waived in many circumstances. Policies regarding duration of DHM therapy were similarly varied. CONCLUSIONS: Criteria for initiating and continuing DHM vary widely among U.S. level 3 and level 4 NICUs. Donor human milk use is more frequent in NICUs with many very low-birth-weight admissions and among Vermont-Oxford Network participants. Further research is needed to define short- and long-term outcomes and cost benefits of DHM use in subgroups of NICU patients, particularly for uses other than necrotizing enterocolitis prevention.

Have the year 2000 neonatal resuscitation program guidelines changed the delivery room management or outcome of meconium-stained infants?

OBJECTIVE: To study the impact of neonatal resuscitation program (NRP) guidelines on delivery room (DR) management of infants born through meconium-stained amniotic fluid (MSAF). STUDY DESIGN: A retrospective study of all term (>or=37 weeks) infants born through MSAF was performed. Patients were divided into two periods: pre year 2000 NRP and post year 2000 NRP. Meconium consistency, APGAR scores and intubation (INT) for suctioning and respiratory outcome were recorded. Groups were analyzed using chi (2) tests and stepwise logistic regression. RESULTS: The incidence of MSAF remained constant in period 1 (13.6%) and period 2 (13.1%) while the proportion of infants intubated fell from 67 to 41% (p<0.001). The incidence of meconium aspiration and nonspecific respiratory distress did not differ between groups. CONCLUSIONS: Since the implementation of year 2000 NRP guidelines, the rate of DR INT for tracheal suctioning has fallen significantly without a change in overall respiratory complications. Results of this study support the efficacy of year 2000 NRP recommendations.

Prothrombotic risk factors in infants of diabetic mothers.

BACKGROUND: Infants of diabetic mothers (IDMs) are at an increased risk for thromboembolic disease. The mechanism(s) to explain this association is unclear. We hypothesized that the pathophysiology of thrombosis in IDMs is multifactorial and likely involves interactions among genetic and acquired factors affecting the procoagulant, anticoagulant and fibrinolytic pathways. OBJECTIVE: To compare the prevalence of common prothrombotic risk factors in a cohort of IDMs to a matched control group. PATIENTS/METHODS: Full-term infants born to mothers with diet controlled (A1-IDM) (N=17), insulin requiring diabetes (ID-IDM) (N=20) and healthy term infants (controls) (N=20) matched for mode of delivery had cord blood collected at delivery. Samples were analyzed for the following: factor V Leiden (FVL), prothrombin 20210A (P20210A), methylenetetrahydrofolate reductase C677 T (MTHFR), Factor VIII (FVIII), Protein C (PC), Lipoprotein(a) (Lp(a)) and plasminogen activator inhibitor-1 (PAI-1). RESULTS: None of the infants had a clinically apparent thrombotic event. IDM mothers and their infants were clinically similar to controls except for a higher prevalence of hypoglycemia (30 vs 0%; p=0.005). There was no significant difference in the prevalence of the common genetic risk factors (FVL, P20210A, MTHFR) FVIII, or PAI-1 levels. Elevated Lp(a) levels were seen more frequently in IDMs than Controls (40 vs 20%) but this difference was not statistically significant. The PC activity (%) was significantly decreased in the IDM group compared to controls, 35+/-12 vs 44+/-9 (p<0.005). A1-IDM had lower PC activity compared to ID-IDM (p=0.05) and controls (p=0.001). CONCLUSIONS: PC deficiency is likely one mechanism to explain thrombosis in IDMs.

Can nitroglycerine ointment facilitate newborn heelstick blood collection? A randomized controlled trial.

UNLABELLED: Newborn heelstick blood collection can be a painful procedure in part because of the time required to obtain sufficient quantity of blood. No previous studies have determined whether local vasodilatation using topical nitroglycerine ointment (NGO) would facilitate heelstick blood collection. OBJECTIVE: To determine if the topical application of NGO would reduce the time needed to collect the required amount of blood for newborn metabolic screening and, in turn, reduce the pain/distress of the procedure. STUDY DESIGN: In a randomized, prospective, placebo controlled and blinded fashion, term newborns in a well nursery received either topical nitroglycerine or placebo ointment 10 minutes prior to heelstick. Total time and number of heelsticks required to complete the collection were measured along with crying time, heart rate and blood pressure. RESULTS: In all, 50 were studied, 25 in each group. There was no statistical difference between groups in collection time, crying time or number of heelsticks required for completion. Heart rate increased significantly and equally in both groups. Blood pressures were unchanged. CONCLUSIONS: Topical NGO did not facilitate heelstick blood collection or reduce the pain/distress of the procedure.

Donor human milk bank data collection in north america: an assessment of current status and future needs.

BACKGROUND: The Human Milk Banking Association of North America (HMBANA) is a nonprofit association that standardizes and facilitates the establishment and operation of donor human milk (DHM) banks in North America. Each HMBANA milk bank in the network collects data on the DHM it receives and distributes, but a centralized data repository does not yet exist. In 2010, the Food and Drug Administration recognized the need to collect and disseminate systematic, standardized DHM bank data and suggested that HMBANA develop a DHM data repository. OBJECTIVES: This study aimed to describe data currently collected by HMBANA DHM banks and evaluate feasibility and interest in participating in a centralized data repository. METHODS: We conducted phone interviews with individuals in different HMBANA milk banks and summarized descriptive statistics. RESULTS: Eight of 13 (61.5%) sites consented to participate. All respondents collected donor demographics, and half (50%; n = 4) rescreened donors after 6 months of continued donation. The definition of preterm milk varied between DHM banks (≤ 32 to ≤ 40 weeks). The specific computer program used to house the data also differed. Half (50%; n = 4) indicated that they would consider participation in a centralized repository. CONCLUSIONS: Without standardized data across all HMBANA sites, the creation of a centralized data repository is not yet feasible. Lack of standardization and transparency may deter implementation of donor milk programs in the neonatal intensive care unit setting and hinder benchmarking, research, and quality improvement initiatives.

The Effect of a Donor Milk Policy on the Diet of Very Low Birth Weight Infants.

BACKGROUND: Use of donor milk (DM) to supplement mother's own milk (MOM) in the neonatal intensive care unit (NICU) is steadily increasing based on health and developmental benefits to premature infants. A paucity of data exists documenting the effect of DM use on the diet of very low birth weight (VLBW) infants related to the implementation of a DM policy. OBJECTIVE: This study aimed to compare VLBW enteral intake type in the first 28 days of life before versus after establishing a DM policy. METHODS: This single-center pre-post prospective cohort study included all inborn infants ≤ 1500 grams in a level 4 NICU remaining hospitalized at 28 days and admitted either before (pre-DM period, October 2009-March 2010) or after (DM period, October 2010-September 2012) implementing a DM policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and daily volume of enteral intake as MOM, DM, and formula. The proportion of enteral feeds from these sources during the first 28 days of life was compared pre-DM versus DM. RESULTS: Compared to pre-DM baseline, formula exposure was significantly decreased, and human milk exposure and proportion of diet as human milk increased. The proportion of infants fed exclusively human milk increased. Exposure to and proportion of diet as MOM was unchanged. Infants were fed earlier in the DM period. CONCLUSION: Establishment of a DM policy was associated with reduced exposure to formula, promoting an exclusively human milk diet, with earlier initiation of feeds and no decrease in use of MOM.

Patterns and predictors of donor human milk non-consent in the neonatal ICU.

BACKGROUND: Previous research has not evaluated predictors of donor human milk (DHM) non-consent status in a neonatal intensive care unit (ICU) setting within the United States. The purpose of this study is to identify and describe maternal and infant factors associated with DHM consent status in a Level IV inner-city neonatal ICU. MATERIALS AND METHODS: Demographics and additional maternal/infant data were stratified by DHM consent and compared with the appropriate parametric/nonparametric hypothesis testing statistic. A predictive multivariable logistic regression model was constructed, adjusted for independent predictors identified in the bivariate analysis (p≤0.2) using a backwards selection process (retention threshold p≤0.1). The adjusted odds ratios generated from the multivariable model identified predictors independently associated with DHM non-consent. RESULTS: Data were analyzed for 113 mother-infant dyads from the first 18 months of a DHM program, with 65 mothers consenting to DHM and 48 not consenting. Race, ethnicity, marital status, education, delivery mode, and presence of a breastfeeding duration goal qualified for inclusion into the multivariable model. Only race and marital status were retained in the final model. In this sample, black race, other race, and being married are all independent predictors for DHM non-consent. CONCLUSIONS: Black race, other race, and marital status statistically predicted DHM non-consent in a Level IV inner-city neonatal ICU. These results are relevant to all neonatal ICUs who use DHM and to those who are developing DHM programs.

Hypospadias and early gestation growth restriction in infants.

OBJECTIVE: There has been a major increase in the incidence of hypospadias in infants in the 1990s, but the risk factors are not known. Although there are scattered reports in the literature regarding the association of low birth weight and hypospadias, this has not been systematically studied. The objective of this study was to determine the association between early gestation intrauterine growth and hypospadias. METHODS: A retrospective review of 13 years of admissions to 2 tertiary care neonatal intensive care units (NICUs) in Connecticut (1987--2000) showed that 112 (1.66%) of 6746 male infants had any degree of hypospadias. Of these, 8 were part of a genetic syndrome and were excluded. A retrospective cohort analysis of these 6738 infants was performed. Infant growth parameters at birth (weight, head circumference, and length) were analyzed along with maternal risk factors known to be associated with changes in fetal growth, including maternal age, race, diagnosis of preeclampsia, gestational diabetes, and maternal use of alcohol or tobacco or substance abuse during pregnancy. RESULTS: The incidence of hypospadias in the NICU population increased 10-fold from 0.4% in 1987 to 4% in the first quarter of 2000. Hypospadias was significantly more common in infants who had uniformly poor intrauterine growth (<10th percentiles) in the various parameters measured: birth weight, length, or head circumference. There were no significant differences in maternal age or race, nor were there differences in the use of alcohol, tobacco, or street drugs by the mother. There were no differences between singletons and multiple-gestation births. However, the frequency of occurrence was significantly higher among first-born infants (1.9%) compared with all other infants (0.9%). CONCLUSIONS: The incidence of hypospadias in our NICU population has increased 10-fold during the 13-year period of study. There was a significant association of hypospadias with poor intrauterine growth. The growth restriction was probably of early gestational cause as there was proportionate involvement of somatic (weight and length) and brain growth (head circumference). The increasing frequency of hypospadias and its association with poor intrauterine growth originating in early gestation suggests that common environmental factor(s) that have an impact on both conditions may be involved.