Stopping Parenteral Nutrition for 3 Hours Reduces False Positives in Newborn Screening.

OBJECTIVE: To evaluate effects of holding parenteral nutrition (PN) for 3 hours prior to newborn screening (NBS) on false-positive NBS rate for amino acids (AAs) in very low birth weight (VLBW) infants (birth weight <1500 g). STUDY DESIGN: We analyzed data from 12 567 consecutive births in 1 hospital between May 2010 and June 2013. VLBW infants were stratified into 3 groups: (1) infants without PN before NBS (no-PN group); (2) infants with early PN running at the time of NBS (early-PN group); and (3) infants with early-PN that were temporarily replaced by dextrose-containing intravenous fluid 3 hours prior to NBS (stop-PN group). We compared the false-positive rate for AA and cost effectiveness between the groups. RESULTS: The false-positive rate for AA among 413 VLBW infants was significantly higher than infants with birth weight >1500 g (7.62% vs 0.05%; P < .001). There were no false-positive results for AA in the no-PN group. The false-positive rate for AA in the stop-PN group (2/65) was significantly lower than the early-PN group (29/245) (3.1% vs 11.8%; P = .037). The stop-PN group was more cost effective than early-PN group, saving $17.27 per infant screened ($5.53 vs $22.80) or $192.54 for each false-positive result for AA averted. Further reductions in inconclusive samples were also noted. CONCLUSIONS: VLBW and early-PN are significant factors for false-positive results for AA. Holding PN containing AAs for 3 hours before NBS collection is a practical and cost-effective method to significantly reduce the false-positive rate for AA in VLBW infants.

Adult and child automated immature granulocyte norms are inappropriate for evaluating early-onset sepsis in newborns.

AIM: Automated haematology analysers are increasingly being used. Normal ranges for automated immature granulocyte counts (IG%) are described in adults and children as <1%, but are not reported for newborns, who often have complete blood count with differential in evaluation for early-onset sepsis. Therefore, this study aimed to describe IG% during the first 48 hours of life (HOL) in newborns and determine the clinical factors affecting IG%. METHODS: We carried out retrospective chart reviews for newborns ≥35 weeks gestational age with one or more complete blood count with differential in the first 48 HOL. Clinical history and automated haematology results were reviewed. RESULTS: Forty-seven of 215 subjects had two or more complete blood counts within 48 h. In the first 48 HOL, IG% ranged from 0 to 8.4% (95th percentile 5.2%). At <12 h, 70% of samples had IG% >1%. IG% appears to decrease over time. Earlier hour of life and higher birth weight were independently associated with higher IG%. CONCLUSION: Immature granulocyte counts in newborns appeared to be higher than reported for other age groups. Use of adult and child norms for IG% would not be appropriate for newborns being evaluated for early-onset sepsis.

Efficacy of recombinant erythropoietin for the late treatment of anemia of prematurity in a level IV neonatal intensive care unit: a retrospective single-center cohort study.

OBJECTIVE: To describe the population to which we administered recombinant erythropoietin and to determine the effectiveness of this treatment as quantified by the change in hematocrit. STUDY DESIGN: This retrospective chart review study included infants who received erythropoietin for the treatment of anemia of prematurity. RESULTS: There were 132 infants representing 162 unique treatment courses included in the study. The average duration of therapy was 9 days (±7) and 6 doses (±2). The average change in hematocrit (Hct) was 6.2% (SD 3.9%, p < 0.001). Rise in Hct was associated with a higher number of rEPO doses (p < 0.001) and higher postmenstrual age (p < 0.001). In our small cohort we did not find an association between the number of rEPO doses and retinopathy of prematurity (ROP) requiring treatment. CONCLUSION: Erythropoietin is safe and effective at treating anemia of prematurity as evidenced by a clinically and statistically significant increase in Hct from baseline.

Evaluation of Intravenous Immunoglobulin Administration for Hyperbilirubinemia in Newborn Infants with Hemolytic Disease.

The primary objective of this research was to evaluate the use of intravenous immunoglobulin (IVIG) in infants with hemolytic disease, to assess compliance with the American Academy of Pediatrics (AAP) guideline recommendations, and to review the data on which the guidelines were based. This retrospective study evaluated all infants in the NICU (neonatal intensive care unit) who received IVIG between January 2018 and December 2020 (n = 71). Total serum bilirubin (TSB) levels surrounding the time of IVIG administration, rate of rise of bilirubin, and direct antiglobulin test (DAT) status were evaluated to determine the appropriateness of IVIG use based on the 2004 AAP recommendations that was current at the time of the study. Fifty-nine infants received IVIG for hyperbilirubinemia. Of them, 80% had an ABO mismatch, 19% had Rh mismatch, and 71% were DAT-positive. Phototherapy was started at an average of 7 h of age, and the first IVIG dose was administered at an average of 13 h of life; nearly 25% received a second IVIG dose. One infant (1.6%) met all three AAP guideline criteria of being DAT-positive, bilirubin within 3 of exchange level, and rising bilirubin despite intensive phototherapy. Twenty-five (42%) babies were DAT positive and met one of the other two criteria. Only 12% (n = 7) had a bilirubin within 3 of exchange level. Most infants who received IVIG for hyperbilirubinemia did not meet the AAP criteria, prompting us to develop an institution-specific IVIG clinical practice guideline. The 2022 AAP guideline was published after our study was completed, but it confirmed our belief that IVIG usage should be more restricted and the criteria more explicit.

Reducing Antacid Use in a Level IV NICU: A QI Project to Reduce Morbidity.

INTRODUCTION: Gastroesophageal reflux is a physiologic occurrence in infants. Clinicians caring for neonates use histamine-2 receptor antagonists (H2As) or proton pump inhibitors (PPIs) for symptomatic reflux, apnea/bradycardia/desaturations, or irritability. Recent studies have shown that there is an increased incidence of infection, fracture, and mortality in neonates who receive antacids. METHODS: A multidisciplinary team aimed to decrease nonindicated antacid use in the NICU by 50% by April 2019. Outcome measures include the median number of inappropriate antacid prescriptions and patient-days on acid-suppressants. Interventions include education regarding use and risks of antacids, development of a list of indications deemed "appropriate" for starting an H2A or PPI, mandatory discussion on rounds when considering antacids, documentation of treatment goal, and indication, and an automatic drop-off in the electronic medical record. RESULTS: Baseline data (June-December 2017) showed 19 prescriptions of H2As or PPIs. Of those, 10 orders were deemed "inappropriate," according to our indicated uses. There were 407 total patient-days of medication-use (median: 51 patient-days). After the implementation of the interventions (October 2018-May 2019), there were 11 prescriptions of antacid medications, 3 of which were deemed "inappropriate." There were 206 total days of medication-use (median: 18.5 patient-days). CONCLUSIONS: A multidisciplinary agreement on indications for antacid use in neonates stimulates discussion and creates more purposeful use. Overall, we successfully decreased nonindicated antacid prescriptions in the NICU. For the next steps, we hope to educate physicians on the risks of antacid use and reduce prescriptions in other areas of the hospital and the outpatient setting.

L1 cell adhesion molecule found in human CSF varies as a function of age.

Differences in the pattern and quantity of high molecular weight isoforms of L1 neural cell adhesion molecule were found between premature and term newborns compared to children and adults. These patterns were disrupted in two patients with neurologic disease.

Relationship of the ventilatory response to hypoxia with neonatal apnea in preterm infants.

OBJECTIVE: Correlate the ventilatory response of preterm infants to hypoxic exposure with incidence of neonatal apnea. Study design Seventeen stable convalescing premature infants underwent bedside cardiorespiratory monitoring of respiration using respiratory inductance plethysmography, heart rate, and oxygen saturation (SaO(2)) for a 12-hour period. These studies were scored for number of apneas > or =15 and > or =20 seconds. Infants then underwent a 3-minute hypoxic exposure. Minute ventilation (V(E)) was calculated for 30-second epochs from the time inspired oxygen reached 15%. Linear regression analysis was used to correlate the change in V(E) normalized for decrease in SaO(2) (DeltaV(E)/DeltaSaO(2)) during the first and third minutes of hypoxic exposure with the number of apneic episodes during the 12-hour study. RESULTS: The majority of infants exhibited an anticipated biphasic ventilatory response to hypoxia. There was a significant positive correlation between DeltaV(E)/DeltaSaO(2) during the first and third minutes of hypoxic exposure and number of apneic episodes > or =15 and > or =20 seconds during the preceding 12 hours. CONCLUSIONS: Preterm infants with a greater number of apneic episodes exhibit an increased ventilatory response to hypoxic exposure, suggesting that apnea of prematurity may be associated with enhanced peripheral chemoreceptor activity.