Exclusive breastfeeding among women with type 1 and type 2 diabetes mellitus.

OBJECTIVE: To compare exclusive breastfeeding (BF) and BF initiation among 185 women with Type 1 and 212 women with Type 2 pregestational diabetes who intended exclusive or partial BF and delivered at ≥34 weeks of gestation. METHODS: Retrospective cohort study. At discharge, exclusive BF is direct BF or BF complemented with expressed breast milk. BF initiation is defined by exclusive or partial BF. RESULTS: Type 1 and Type 2 groups were similar in prior BF experience (69 vs 67%) but were different in intention to BF exclusively (92 vs 78%) and partially (8 vs 22%). Women in the Type 1 group were younger (median age 30 vs 33y), likely to be primiparous (47 vs 25%), have a lower median BMI (32 vs 36 kg/m2) and deliver by primary cesarean (37 vs 26%). Infants born to Type 1 women were more likely to be admitted to the NICU (44 vs 18%) and to have hypoglycemia (59 vs 41%). At discharge, exclusive BF among Type 1 was higher (34 vs 23%), partial BF was similar (47 vs 46%) while FF (formula feeding) was lower (19 vs 31%) than in the Type 2 group. BF initiation occurred in 81% of Type 1 and 69% of Type 2 women. CONCLUSION: Intention to BF exclusively was higher in Type 1 women compared to Type 2. At discharge, exclusive BF and BF initiation were lower and FF higher in the Type 2 group highlighting the need for different strategies if lactation in this special population is to be improved.

Impact of excessive gestational weight gain on exclusive breastfeeding among women with Type 1 and Type 2 diabetes and obesity.

BACKGROUND: Pregestational diabetes, obesity and gestational weight gain (GWG) are associated with adverse perinatal outcomes, however, the influence of excessive GWG on lactation at discharge is less known. Our aim is to evaluate the impact of excessive GWG using the LifeCycle project guidelines on exclusive breastfeeding (EBF) and any BF rates at discharge among 171 women with Type 1 and 294 Type 2 diabetes and obesity who intended to BF. METHODS AND FINDINGS: Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). GWG was categorized as adequate, inadequate or excessive according to the 2019 LifeCycle Project guidelines. Women with Type 1 were younger (30 vs 33y), primiparous (51 vs 32%), delivered earlier (37 vs 38w) than women with Type 2 andwere different in grade 1 (40 vs 26%), grade 3 obesity (19 vs 49%) and median GWG (15 vs 11kg). Of all 465 women with Type 1 and Type 2 combined, 365 (78%) who had excessive GWG and 100 (22%) who had non-excessive GWG showed similar EBF (27 vs 25%) and any BF (72 vs 72%) rates. Regression analysis showed that after adjusting for potential confounders excessive GWG was not a predictor of EBF or any BF at discharge. CONCLUSION: Type 1 and Type 2 diabetes, obesity and excessive GWG are associated with low EBF, however, excessive GWG is not an independent predictor of low EBF or any BF at discharge.

Use of polyethylene bags in extremely low birth weight infant resuscitation for the prevention of hypothermia.

OBJECTIVE: To compare the clinical responses of extremely low birth weight (ELBW) infants resuscitated in polyethylene bags with ELBW infants who were resuscitated using traditional temperature control measures. STUDY DESIGN: Retrospective cohort investigation of 70 ELBW infants who were resuscitated using polyethylene bags (study) and 70 ELBW infants (control) resuscitated without polyethylene bags matched by birth weight, gestational age and gender. RESULTS: Infants in the study and control groups were comparable demographically and in obstetric risk factors. Study and control infants were similar in birth weight, gestational age and low 5-minute Apgar score. Axillary temperature on admission to the neonatal intensive care unit (NICU) and at 1 hour was greater in the study group as compared with controls. The incidence of grade III-IV intraventricular hemorrhage and periventricular leukomalacia (PVL) combined was decreased in the study group as compared with controls. Other neonatal comorbidities were not different. CONCLUSION: Resuscitation of ELBW infants in polyethylene bags led to higher skin temperature on admission to the NICU and at 1 hour of life. These infants were less likely to develop grade 3-4 PVL than infants resuscitated using traditional temperature control measures. No deleterious clinical effects were observed in infants resuscitated using polyethylene bags.

High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome.

OBJECTIVE: The purpose of this study was to examine high-dose methadone in pregnant women and its effect on the duration of neonatal abstinence syndrome. STUDY DESIGN: This was a retrospective chart review of 68 neonates and their mothers who received methadone therapy during pregnancy. The last dosage of maternal methadone just before delivery and the length of treatment for neonatal abstinence syndrome were examined with an analysis of variance model. RESULTS: When the data were analyzed for methadone dosages as a continuous variable, each 1-mg increase in the last maternal methadone dosage before delivery was associated with an additional 0.18 days of infant treatment for neonatal abstinence syndrome (P < .001; 95% CI, 0.112-0.255). In other words, every increase of 5.5 mg of methadone in the mother was associated statistically with 1 additional day of neonatal abstinence syndrome treatment for the infant. Gestational age at delivery and birthweight were not statistically significant. CONCLUSION: Higher doses of maternal methadone were associated with an increase in diagnosis and longer duration of neonatal abstinence syndrome.

Use of recombinant human erythropoietin and risk of severe retinopathy in extremely low-birth-weight infants.

STUDY OBJECTIVES: To evaluate the frequency and severity of retinopathy of prematurity in extremely low-birth-weight (ELBW) infants who received recombinant human erythropoietin (rHuEPO), and to compare the frequency of blood cell transfusions these infants required with a matched control group who did not receive rHuEPO. DESIGN: Retrospective cohort analysis. SETTING: Level III neonatal intensive care unit in a large academic medical center. PATIENTS: One hundred thirty-eight ELBW infants who received rHuEPO and 138 ELBW infants who did not (control group) but who were matched by birth weight, gestational age, sex, and year of birth and who survived to the first ophthalmologic examination. MEASUREMENTS AND MAIN RESULTS: The rHuEPO was started before the 8th day of life in 115 (83%) of the 138 infants. Stages III-V retinopathy of prematurity occurred with similar frequency in both groups of infants (rHuEPO group 19% [26 infants] vs control group 20% [27 infants], p>0.05). Infants in the rHuEPO group received fewer transfusions on average during their hospitalization compared with those in the control group (4.2 vs 6.1 transfusions, p<0.01). CONCLUSION: Use of rHuEPO for prevention or treatment of anemia of prematurity in ELBW infants does not increase the frequency of severe retinopathy of prematurity and reduces the number of transfusions.

Mean arterial pressure in concordant and discordant triplets during the first week of life.

OBJECTIVE: To retrospectively determine mean arterial pressure (MAP) for stable concordant and discordant triplets during the first 7 days of life. BACKGROUND: Morbidity and mortality for prematurely born triplets is high, therefore, MAP monitoring during the first day of life is important for their clinical management. MAP reference values for special populations such as triplets have not been published. Recently, we reported that in stable discordant twins MAP values during the first day of life were significantly lower in the smaller than in their larger siblings. Comparable information for triplets is not available. DESIGN: Retrospective cohort study. METHODS: We studied 30 sets of concordant and 29 sets of discordant (birth weight difference > or =20%) consecutively born triplets. Stable patients were defined as those having umbilical cord hemoglobin > or =13 g/dl, normal blood gases, who were never treated for hypotension, and survived at least 7 days. MAP (torr) were measured by oscillometry in 3410, and by transducer via an umbilical arterial catheter in 1251 instances. RESULTS: Concordant and discordant triplets were similar in demographics, history of preterm labor (63 and 63%), chorioamnionitis (10 and 10%), pre-eclampsia (53 and 48%), cesarean delivery (100 and 100%), antenatal steroids (77 and 73%), cord hemoglobin (16 and 16 g/dl), combined triplets birth weight (4922 and 4732 g), gestational age (32 and 33 weeks), normal head ultrasounds or Grade I intracranial hemorrhage (96 and 100%) and neonatal mortality (2 and 1%), but were different in the number of infants requiring mechanical ventilation (57 and 31%). A total of 80 (89%) concordant triplets and 77 (88%) discordant triplets were stable according to our definition. Concordant stable triplets, whether small, medium or large, had similar MAP at birth. Their MAP values increased noticeably from birth to 24 hours and more subtlely to 7 days. Triplets of < or =32 weeks GA had lower MAP throughout than those of > or =33 weeks GA. Discordant stable triplets were divided into 27 small (1382 g), 26 medium (1683 g) and 27 large (1969 g); during the first 24 hours, medium and smaller triplets had MAP values that were lower than those of their larger siblings. From the second to the seventh day of life, all MAP values and trends were similar. Among discordant triplets, 86% of the smallest, 13% of the medium and 13% of the largest infants had asymmetrical intrauterine growth restriction. CONCLUSION: In stable concordant and stable discordant triplets, MAP correlates with birth weight, gestational age and postnatal age. MAP values increase noticeably during the first 24 hours and more subtlely during the next 7 days. Concordant or discordant, small, medium, and large triplets have similar MAP values and trends to that of their siblings. Small and medium discordant triplets have lower MAP values during the first day of life than their larger siblings but by the second day there MAP trends and values were no longer different.

Monochorionic diamniotic infants without twin-to-twin transfusion syndrome.

BACKGROUND: Monochorionic-diamniotic twins (MoDi) occur in 0.3% of all pregnancies. Twin-to-twin transfusion syndrome (TTS) that occurs in 20% of MoDi pregnancies is associated with high perinatal morbidity and mortality. MoDi twins without TTS are more frequent (80%) but have been scarcely reported. OBJECTIVE: To study perinatal morbidity and mortality of 74 MoDi twin sets without TTS and to compare it to that of 38 sets of MoDi twins with TTS. METHODS: Chorionicity was determined by gender and placental examination. Gestational age (GA) was set by sonography and pediatric examination. TTS was diagnosed clinically and by sonography, discordance was defined by twins birth weight difference > or =20%, and fetal growth restriction was determined by using a twin-specific nomogram. RESULTS: MoDi twin pregnancies without and with TTS were similar in demographics, live births, history of preeclampsia, fetal distress and cesarean delivery. They were different (p<0.01) in discordant pregnancies (36 and 79%), GA at delivery (32 and 29 weeks) intrauterine growth restriction (39 and 89%) and neonatal mortality (12 and 36%). Concordant (47 sets) and discordant (27 sets) MoDi twins without TTS were clinically similar. CONCLUSIONS: MoDi twins without TTS have high rates of birth weight discordance, fetal growth restriction, fetal distress, prematurity and cesarean delivery. Although their perinatal mortality is low, the reported occurrence and the short- and long-term impacts of fetal and neonatal morbidities warrants attention.

Breastfeeding initiation among macrosomic infants born to obese nondiabetic mothers.

BACKGROUND: Women who are overweight or obese are at risk for maternal and neonatal medical complications, including macrosomia (birth weight ≥4,000 g), that may contribute to breastfeeding initiation failure. This study examined factors associated with breastfeeding initiation among obese women without diabetes who delivered macrosomic infants. STUDY DESIGN AND METHODS: A retrospective chart review was conducted from 2008 to 2011. Based on prepregnancy body mass index (in kg/m(2)), women were classified as normal (18-24.9), overweight (25-29.9), obese (30-34.9), very obese (35-39.9), and extremely obese (≥40). Intention to breastfeed was ascertained prenatally, and breastfeeding initiation was defined if at discharge ≥50% of the infant feedings were breastmilk. RESULTS: Twenty-nine percent of the population was overweight, 23% obese, 14% very obese, and 12% extremely obese. Intention to breastfeed was similar among normal-weight, overweight, obese, and very obese women but was significantly lower for those who were extremely obese (p<0.05). Breastfeeding initiation was 75% for normal-weight, 72% for overweight, 71% for obese, 66% for very obese, and 53% for extremely obese women (p<0.05). Among women who intended to breastfeed, breastfeeding initiation was uniformly high: 94% for normal-weight, 93% for overweight, 95% for obese, 92% for very obese, and 87% for extremely obese women. CONCLUSIONS: Intention to breastfeed as well as breastfeeding initiation was significantly lower for extremely obese women. Lack of intention to breastfeed declared during the antepartum period by extremely obese women highlights a need as well as an opportunity for intervention.

Trends in breastfeeding initiation, continuation, and exclusivity by maternal prepregnancy weight: 2004-2011.

OBJECTIVE: To examine trends in breastfeeding initiation, continuation, and exclusivity by prepregnancy weight from 2004 to 2011 and the associations between these outcomes and prepregnancy weight. METHODS: Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System, a survey of women with a recent live birth from 34 states and New York City, were used. Trends in breastfeeding initiation, continuation, and exclusivity at 12 weeks postpartum were evaluated by prepregnancy BMI. Logistic regression was used to identify the association between prepregnancy BMI and the breastfeeding outcomes. RESULTS: Among 244,196 women, with increasing BMI, a decreasing number of women initiated, continued, and breastfed exclusively. From 2004 to 2011, the rates of breastfeeding initiation increased significantly for women of all weight classes (P < 0.01), and the disparity between normal-weight women and women with obesity class III narrowed. Among all women, breastfeeding continuation increased significantly for women of almost all weight classes (P < 0.01), although the disparity between normal-weight women and women with obesity class III worsened. From 2009 to 2011, among all women, exclusive breastfeeding increased significantly among women with normal and overweight BMI (P < 0.01) but decreased among obese class III; the disparity between women with normal and obese class III BMI worsened. CONCLUSIONS: Our results highlight the need for more concentrated efforts on breastfeeding continuation and exclusivity, particularly for women with obesity.

Duration of empiric antibiotics for suspected early-onset sepsis in extremely low birth weight infants.

OBJECTIVES: To study multicenter antibiotic practices for suspected early-onset sepsis (EOS) with negative blood cultures (NegBCs) and to identify opportunities for reduction of antimicrobial exposure. DESIGN: Retrospective study. SETTING: Thirty academic hospitals (University HealthSystem Consortium) located in 24 states. METHODS: Data were from a survey of 790 extremely low birth weight (ELBW) infants. Total antibiotic exposures (antibiotic-days per patient) were calculated. RESULTS: On admission to the NICU, 94% of 790 ELBW infants had BCs performed and empiric antibiotics initiated. When PosBC and NegBC infants were compared, 47 patients with PosBCs were similar to 695 with NegBCs in birth weight, gestational age (GA), and mortality. Patients with suspected EOS but NegBCs given ampicillin/aminoglycosides were grouped by length of administration and GA. For GA of 26 weeks or younger, 170 infants given a short (< or = 3 days) and 157 given a long (> or = 7 days) course were similar regarding birth weight, mortality, antepartum history, and CRIB scores, but were different (P < .01) in number receiving a third antimicrobial (3% and 17%) and antibiotic-days (23 and 38). For GA of 27 weeks or older, 113 infants given a short and 77 given a long course differed (P < .01) in number receiving a third antimicrobial (2% and 23%) and antibiotic-days (19 and 30). CONCLUSIONS: Most suspected EOS infants with NegBCs are given antibiotics, but no antepartum historical risk factors or neonatal clinical signs explained prolonged administration. Discontinuing empiric antibiotics when BCs are negative in asymptomatic ELBW infants can reduce antimicrobial exposure without compromising clinical outcome.

Enteric gram-negative bacilli bloodstream infections: 17 years' experience in a neonatal intensive care unit.

OBJECTIVE: To assess the occurrence of enteric gram-negative bacilli (EGNB) bloodstream infections (BSI) in a neonatal intensive care setting during a 17-year period in which a consistent antibiotic treatment program was in place. To document infections, outbreaks, or epidemics, emergence of antibiotic resistance, clinical correlates, and outcomes of the most prevalent EGNB (Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae). METHODS: This study analyzed demographic, clinical, and bacteriologic information from 360 infants born 1986-2002 who developed 633 blood culture-proven BSI. A total of 121 EGNB were isolated (E coli, K pneumoniae, and E cloacae). Early-onset BSI were discovered within 48 hours from birth, and late-onset BSI were those that occurred thereafter. Suspected early-onset BSI were treated with ampicillin and gentamicin, suspected late-onset BSI with vancomycin and gentamicin. Antibiotics were changed on the basis of organism antimicrobial susceptibility. RESULTS: Early-onset BSI were noted in 52 of 21,336 (244/100,000) live births (1986-1991), 40 of 20,402 (196/100,000) live births (1992-1997), and 25 of 17,926 (139/100,000) live births (1998-2002). Of these cases, 39 were caused by E coli and 4 by K pneumoniae. Antibiograms for E coli isolated during the last 5 years of the study showed an increase in antibiotic resistance that coincided with obstetric group B streptococcus antepartum antibiotic prophylaxis. Group B streptococcus declined from 41 to 4 cases from the first to the last period. Late-onset BSI increased from 111 to 230 cases from the first to the second 6-year study period and declined modestly (171 cases) during the last. Fifteen percent (78 cases) of late-onset BSI were caused by EGNB, 5% by other gram-negative bacilli, 67% primarily by coagulase-negative staphylococcus, and 13% by fungus. Nonspecific clinical and hematologic signs of late-onset BSI were similar across EGNB species, but necrotizing enterocolitis was often associated with E coli, whereas pneumonia and prolonged thrombocytopenia characterized K pneumoniae infections. No outbreaks or epidemics were observed, and strains of EGNB with evidence of extended spectrum beta-lactamase production were never isolated. CONCLUSION: Antepartum antibiotic prophylaxis may have increased antibiotic resistance in E coli isolates from early-onset BSI but has dramatically decreased group B streptococcus infections. Late-onset BSI caused by EGNB increased, but without changes in antibiotic susceptibility. In spite of medical advances, E coli, K pneumoniae, and E cloacae remain responsible for significant morbidity and mortality, especially in very low birth weight infants.

Surveillance of ventilator-associated pneumonia in very-low-birth-weight infants.

BACKGROUND: Surveillance of ventilator-associated pneumonia (VAP) is an essential part of quality patient care. Very-low-birth-weight (VLBW) infants, many with tracheal microbial colonization and bronchopulmonary dysplasia (BPD), comprise a difficult group in whom to make a diagnosis of pneumonia with the Centers for Disease Control and Prevention (CDC) criteria for infants younger than 1 year. OBJECTIVE: Our objective was to retrospectively compare VAP surveillance diagnoses made by the hospital infection control practitioner (ICP) with those made by a panel of experts with the same clinical and laboratory evidence and supportive radiologic data. A secondary objective was to compare radiologic diagnosis of pneumonia made by the general hospital radiologists, by the panel of experts, and by a pediatric radiologist from another hospital. STUDY POPULATION: Thirty-seven VLBW infants identified as at risk for VAP by the ICP on the basis of a positive bacterial tracheal culture and the application of CDC criteria for the definition of pneumonia were studied. METHODS: Clinical and laboratory evidence and routine radiologic reports made by the general radiologist were reviewed independently by a panel of experts composed of 3 experienced neonatologists. Chest x-rays from the day before, day of, and day after the surveillance date were reviewed separately by the 3 neonatologists and also by a pediatric radiologist. RESULTS: After inter-reader reliability was found satisfactory (kappa's coefficient, 0.47-0.75; P <.05), the panel of neonatologists determined that the 37 VLBW infants represented 4 distinct clinical categories. Group 1 comprised 12 airway-colonized infants, aged 14 to 30 days, who on the surveillance date, albeit intubated, were asymptomatic, not treated with antibiotics, and survived. Group 2 comprised 11 airway-colonized infants, aged 7 to 42 days, who presented with equivocal clinical, laboratory, or radiologic signs of VAP and survived. Group 3 comprised 7 airway-colonized infants, aged 14 to 21 days, who were acutely ill (3 died) and had clinical and laboratory evidence of nosocomial bloodstream infection (BSI) but no radiologic signs of pneumonia. Group 4 comprised 7 infants, aged 14 to 28 days, who were acutely ill (4 died) and had clinical and laboratory evidence of infection and radiologic changes consistent with VAP. Radiologic Findings: General radiologists, neonatologists, and the pediatric radiologist agreed that none of the asymptomatic airway-colonized infants (Group 1) had VAP. General radiologists reported signs suggestive of pneumonia in 8 of 11 infants (Group 2), a finding not corroborated by the others. Everybody agreed on the absence of radiologic pneumonia in 6 of 7 patients with nosocomial BSI (Group 3) and on the presence of signs consistent with pneumonia in the remaining 7 infants (Group 4). CONCLUSION: Surveillance diagnosis of VAP in VLBW infants is difficult because current CDC definitions are not specific for this population. Isolated positive tracheal culture alone does not distinguish between bacterial colonization and respiratory infection. Clinical and laboratory signs of VAP, mostly nonspecific, can be found in other conditions such as bronchopulmonary dysplasia and nosocomial BSI. Routine radiologic reports suggestive of pneumonia in airway-colonized infants without definitive clinical and laboratory evidence of infection could be misleading. To improve accuracy, surveillance diagnosis of VAP in special populations such as VLBW infants should be reformulated; meanwhile, ICPs should seek consultation with experienced clinicians for interpretation of data.

Mean arterial pressure in extremely low birth weight concordant and discordant twins during the first day of life.

OBJECTIVE: To determine mean arterial pressure (MAP) values during the first 24 hours for stable concordant and discordant extremely low birth weight (ELBW) twins and to ascertain its association with perinatal factors. BACKGROUND: In ELBW infants, whether singletons or concordant or discordant twins, hypotension is diagnosed by nonspecific clinical signs together with reference arterial pressure values extrapolated from regression models or from scarce actual observations. DESIGN: Retrospective cohort study. METHODS: We studied 26 sets of concordant and 29 sets of discordant twins, one of whom in each set weighed < or = 800 g at birth. Infants with umbilical cord hemoglobin > or = 14 g/dl and who, although mechanically ventilated, had normal acid-base balance, no patent ductus arteriosus, had not received indomethacin, steroids, muscle relaxants, narcotics, were never treated for hypotension, and survived at least 7 days were considered stable. Arterial pressures were determined by oscillometry (OBP) and direct transducer readings using an umbilical line (MAP). All admission and 10 % of the subsequent readings were measured by OBP; the remaining were measured by MAP. RESULTS: Concordant and discordant twins were similar in demographics, history of chorioamnionitis, preeclampsia, antepartum steroids, cesarean delivery, and neonatal morbidity, but were different in mean birth weight (700 and 789 g), and gestational age (GA) (25 and 27 weeks). Forty-four (82%) of all concordant and 14 (26%) of 58 discordant twins were treated empirically for hypotension. Head ultrasounds were normal or showed Grade I/II in 74% concordant, 81% discordant, and 80% discordant infants with twin-to-twin transfusion syndrome (TTTX). Neonatal mortality was 46%, 45%, and 47%, respectively. There were 14 stable concordant and 22 stable discordant. Their MAPs were different at 1 hour (29 and 34 Torr), 3 hours (29 and 35 Torr), 6 hours (30 and 37 Torr), 12 hours (31 and 36 Torr), 18 hours (33 and 35 Torr), and 24 hours (34 and 36 Torr), respectively. Twenty-six small and 26 large concordant infants had similar MAP from the 1st (27 and 28 Torr) to the 24th hour of life (43 and 43 Torr). Concordant males (often not stable) had lower MAP than concordant females. Seventeen small discordant twins had lower MAP from 1 to 24 hours (28 and 33 Torr) than 17 large discordant twins without TTTX (32 and 38 Torr). Small discordant twins with (donors) and without TTTX had similar trends and MAP values. Large discordant twins with TTTX (recipient) had the highest MAP from birth to 24 hours than any other subgroup of infants and, unlike the others, the MAP trend decreased over time. MAP correlated with GA but not with very low birth weight (< or = 750 g), although with the same GA, those with higher birth weights had higher MAP, and at the same birth weight younger GA twins had lower MAP values. CONCLUSION: MAP increases from birth to 24 hours in all concordant and discordant twins regardless of condition (stable or unstable), birth weight (large or small) or GA. Recipient TTTX twins had higher MAP throughout but, unlike the other twins, it declined over 24 hours. Small discordant and donor TTTX infants should be considered intrauterine growth restricted and are expected to have MAP commensurable to their GA and not to their birth weight.

Mean arterial pressure in very low birth weight (801 to 1500 g) concordant and discordant twins during the first day of life.

OBJECTIVE: To determine retrospectively mean arterial pressure (MAP) for stable and unstable concordant and discordant very low birth weight (VLBW: 801 to 1500 g) twins during the first 24 hours of life. BACKGROUND: Morbidity and mortality are much higher for extremely low birth weight (ELBW < or =800 g) than for VLBW twins. Recently, we reported MAP trends and reference values in concordant and discordant ELBW twins. No comparable information is available for VLBW infants. DESIGN: Retrospective cohort study. METHODS: We studied 48 sets of concordant and 40 sets of discordant (birth weight difference > or =20%) consecutively born VLBW twins. Stable patients were defined as having umbilical cord hemoglobin > or =14 g/dl, nonacidotic blood gases, never treated for hypotension and survived at least 7 days. MAPs (Torr) were measured by oscillometry in 3163 and by transducer via umbilical artery in 2028 instances. RESULTS: Concordant and discordant twins were similar in demographics, history of twin-twin transfusion (TTTX), antenatal steroids, chorioamnionitis, pre-eclampsia, cesarean delivery, cord hemoglobin, normal head ultrasounds or I to II intracranial hemorrhage (97 and 99%) and neonatal mortality (4 and 5%), but were different in incidence of preterm labor (83 and 58%), birth weight (1227 and 1509 g) and gestational age (GA) (30 and 32 weeks). In all, 66 (69%) concordant twins and 61 (76%) discordant twins were stable. Stable concordant twins, whether small or large, had comparable MAP on admission that increased to 24 hours. Twins of < or =32 weeks GA had lower MAP throughout than those of > or =33 weeks GA. Although their mean birth weights were similar (1262 and 1274 g), 23 stable concordant males had significantly higher MAP than 43 concordant females. Stable discordant twins were divided into 31 small (1241 g) and 30 large (1845 g); their MAPs were different (p<0.05): 35 and 39 (admission), 35 and 39 (1 hour), 36 and 46 (6 hours), 38 and 41 (12 hours), 40 and 41 (18 hours) and 42 and 42 (24 hours) Torr. In all, 88% of small discordant twins were IUGR and 91% of large discordant twins had normal growth. TTTX syndrome occurred in 12 monochorionic sets. Nine of 12 donors were IUGR while 10 of 12 recipients had normal growth. Four of 12 donors had grades III to IV intracranial hemorrhage, eight donors and all 12 recipients had normal ultrasounds. Although their cord hemoglobin levels were similar, donor and recipient MAPs were higher than in any other group and, opposite to concordant and discordant twins, their values decreased from birth to 24 hours. CONCLUSION: In stable concordant, stable discordant, and small and large discordant twins, MAP correlates with birth weight, GA and postnatal age, and increases during the first 24 hours. In recipient and donor twin-twin transfusion infants, MAP is higher throughout and declines over time.

Impact of computerized physician order entry on clinical practice in a newborn intensive care unit.

OBJECTIVE: To study the impact of computerized physician order entry (CPOE) on selected neonatal intensive care unit (NICU) practices. DESIGN: Retrospective review. SETTING: Nursing units in an academic health system where CPOE has been implemented in adult services since 2000 and in the NICU since 2002. STUDY POPULATION: Data from 111 very-low-birth-weight (VLBW) infants born consecutively within 6 months before and 100 VLBW infants born within 6 months after the implementation of CPOE were evaluated. The study is based on pre- and post-CPOE comparisons in medication error rates and on the initiation to completion time intervals for pharmacy orders and radiology procedures. The specific data subsets that were compared included caffeine and gentamicin. Radiology turn-around time (order to image display) for the first chest and abdominal X-ray taken following endotracheal intubation and/or umbilical catheter placement was studied. RESULTS: Statistically significant (p<0.01) reductions were seen in medication turn-around times for the loading dose of caffeine in pre-CPOE (n=41, mean 10.5+/-9.8 SD hours) and post-CPOE (n=48, mean 2.8+/-3.3 SD hours). After CPOE implementation, the percentage of cases during each period where caffeine was administered before 2 and 3 hours increased from 10 to 35% and 12 to 63%, respectively. Accuracy of gentamicin dose at the time of admission for 105 (pre-CPOE) and 92 (post-CPOE) VLBW infants was determined. In the pre-CPOE period, 5% overdosages, 8% underdosages, and 87% correct dosages were identified. In the post-CPOE, no medication errors occurred. Accuracy of gentamicin dosages during hospitalization at the time of suspected late-onset sepsis for 31 pre- and 28 post-CPOE VLBW infants was studied. Gentamicin dose was calculated incorrectly in two of 31 (6%) pre-CPOE infants. No such errors were noted in the post-CPOE period. Radiology response time decreased significantly from the pre-CPOE (n=107, mean 42+/-12 SD minutes) to post-CPOE (n=95, mean 32+/-16 SD minutes). CONCLUSION: The implementation of CPOE in our NICU resulted in a significant reduction in medication turn-around times and medication errors for selected drugs, and a decrease in ancillary service (radiology) response time. In spite of the complexities of medication orders in pediatric populations, commercially available software programs for CPOE can successfully be adjusted to accommodate NICU needs and to beneficially impact clinical practice.

Mean arterial pressures during the first 24 hours of life in < or = 600-gram birth weight infants.

OBJECTIVE: To determine mean arterial pressure values during the first 24 hours for "stable" and "unstable" extremely low birth weight (ELBW) infants and to ascertain its association with perinatal factors. BACKGROUND: In ELBW infants, hypotension is diagnosed by nonspecific clinical signs together with reference arterial pressure values extrapolated from regression models or from scarce actual observations. DESIGN: Retrospective cohort study. METHODS: 101 ELBW (< or = 600 g) infants born in our medical center (1989-2000). Considered stable were 36 infants with umbilical cord hemoglobin > or = 14 g/dl who, although mechanically ventilated, had normal acid-base balance, no patent ductus arteriosus, had not received indomethacin, steroids, muscle relaxants, narcotics, were never treated for hypotension and survived at least 7 days. The remaining 65 infants constituted the unstable group. Arterial pressures were determined by oscillometry (OBP) and direct transducer readings through an umbilical line (MAP). All admission and 10% of the readings were by OBP; the remaining 1877 measurements were by MAP. RESULTS: Stable and unstable infants were similar in birth weight, demographics, history of chorioamnionitis, antepartum steroids, low Apgar scores, administration of epinephrine during resuscitation, and sepsis. Stable infants were different from unstable in gestational age (27+/-2 vs 25+/-2 weeks' gestational age [w GA]), history of preterm labor, preeclampsia, and neonatal mortality (22 vs 68%). Admission OBP (30+/-7 vs 29+/-10 Torr) were similar and 1-hour MAP were different (30+/-6 vs 27+/-7 Torr) between both groups. MAP for stable infants was higher throughout the 24 hours. Greater differences were noted between 3 and 6 hours when 34 of 65 unstable infants were treated for hypotension. Mean MAP and 10 percentile values for stable infants at 1, 3, 6, 12, and 24 hours were 30 (22), 31 (24), 32 (25), 34 (24), and 35 (28) Torr, respectively. MAPs did not correlate with birth weight, but they were lower among 19 stable infants < or = 26 w GA than among 17 stable infants > or = 27 w GA. History of preeclampsia, antenatal steroids, intratracheal epinephrine and cord hemoglobin did not influence MAP. Low 1-minute Apgar score and intracranial hemorrhage were associated with low MAP during the first day. CONCLUSION: There is a wide variation of GA among ELBW infants. MAPs increase with GA and with postnatal age. Shortly after birth, arterial pressures are similar for stable and unstable infants. Failure to increase MAP between 3 and 6 hours of life should create concern. MAP < or = 28 Torr at 3 hours of life is a reasonable, but not absolute, predictor of the need for hypotension treatment.

Breast-feeding initiation in women with pregestational diabetes mellitus.

OBJECTIVE: To examine feeding practices and factors associated with breast-feeding initiation (BFI) in women with pregestational diabetes mellitus (PGDM) and their infants. METHODS: In all, 392 PGDM (135 late preterm and 257 term) pregnancies were studied. Infant feeding preference was ascertained on admission. RESULTS: After birth, 166 (42%) of the infants received well-baby care, whereas 226 (58%) were admitted to the newborn intensive care unit (NICU). Hypoglycemia (blood glucose <40 mg/dL), which occurred in 128 (33%) of all infants, did not influence BFI. Of 257 women who intended to BF, 55% initiated BF. Also, 5% of 105 women who intended to feed formula and 13% of the 30 undecided later initiated BF. CONCLUSIONS: The BFI rate for women with PGDM is remarkably low even among those who intended to BF. Factors associated with BFI failure in this population were primiparity, African American race, lower education, smoking, lack of intention to BF, and NICU admission.

Delivery room triage of large for gestational age infants of diabetic mothers.

OBJECTIVE: To review our 4-year experience (2008-2011) with delivery room triage of large for gestational age infants of diabetic mothers. DESIGN/METHODS: Retrospective cohort investigation of 311 large for gestational age infants of diabetic mothers (White's Class A1 (77), A2 (87), B (77), and C-R (70)). RESULTS: Of 311 women, 31% delivered at 34-36 weeks gestational age and 69% at term. While 70% were delivered by cesarean, 30% were vaginal deliveries. A total of 160 asymptomatic infants were triaged from the delivery room to the well baby nursery. Of these, 55 (34%) developed hypoglycemia. In 43 cases, the hypoglycemia was corrected by early feedings; in the remaining 12, intravenous dextrose treatment was required. A total of 151 infants were triaged from the delivery room to the neonatal intensive care unit. Admission diagnoses included respiratory distress (51%), prevention of hypoglycemia (27%), prematurity (21%), and asphyxia (1%). Hypoglycemia affected 66 (44%) of all neonatal intensive care unit infants. CONCLUSION: Safe triage of asymptomatic large for gestational age infants of diabetic mothers from the delivery room to well baby nursery can be accomplished in the majority of cases. Those infants in need of specialized care can be accurately identified and effectively treated in the neonatal intensive care unit setting.

Neonatal outcomes following in utero exposure to buprenorphine/naloxone or methadone.

OBJECTIVES: To study neonatal outcomes following buprenorphine/naloxone and methadone exposure during pregnancy. METHODS: This study is a retrospective review of clinical and demographic information of 58 infants whose mothers were treated with buprenorphine/naloxone and 92 infants whose mothers were treated with methadone for opioid dependence during pregnancy. RESULTS: Gestational age, birth weight, prematurity, admission to neonatal intensive care unit, and length of stay were similar between both groups of infants. Neonatal abstinence syndrome occurred less frequently among infants of mothers treated with buprenorphine/naloxone than those treated with methadone (64% and 80%, respectively, p = 0.03). All infants with neonatal abstinence syndrome were treated postnatally with methadone. There was a trend toward shorter duration of treatment and lower cumulative dosages of methadone among the buprenorphine/naloxone-exposed infants. CONCLUSIONS: No apparent significant adverse neonatal outcomes were detected following treatment with either maintenance medication; however, further prospective research is necessary to examine the safety and efficacy of buprenorphine/naloxone in pregnancy and its effects on the neonate.

Early feeding and neonatal hypoglycemia in infants of diabetic mothers.

OBJECTIVES: To examine the effects of early formula feeding or breast-feeding on hypoglycemia in infants born to 303 A1-A2 and 88 Class B-RF diabetics. METHODS: Infants with hypoglycemia (blood glucose < 40 mg/dL) were breast-fed or formula-fed, and those with recurrences were given intravenous dextrose. RESULTS: Of 293 infants admitted to the well-baby nursery, 87 (30%) had hypoglycemia, corrected by early feeding in 75 (86%), while 12 (14%) required intravenous dextrose. In all, 98 infants were admitted to the newborn intensive care unit for respiratory distress (40%), prematurity (33%) or prevention of hypoglycemia (27%). Although all newborn intensive care unit patients received intravenous dextrose, 22 (22%) had hypoglycemia. Of 109 hypoglycemia episodes, 89 (82%) were single low occurrences. At discharge, 56% of well-baby nursery and 43% of newborn intensive care unit infants initiated breast-feeding. CONCLUSIONS: Hypoglycemia among infants of diabetic mothers can be corrected by early breast-feeding or formula feeding.