Infant Essential Fatty Acid Status Is Not Associated With Postoperative Wound Complication Severity.

BACKGROUND: Neonates are susceptible to postoperative wound complications (POWCs), as prematurity, hypoxia, steroid use, immunosuppression, and malnutrition are all common comorbidities. Critically ill infants, dependent on parenteral nutrition, are at even further risk of developing essential fatty acid deficiency (EFAD). We hypothesized that POWC severity and EFAD were associated because of increased susceptibility to infections and impaired wound healing seen with EFAD. METHODS: Institutional review board-approved (OUHSC10554), retrospective review from our academic Level IV Neonatal Intensive Care Unit. Infants aged <1 y who underwent a fascial-compromising gastrointestinal surgery from June 1, 2015, to March 15, 2019, and who had essential fatty acids (EFAs) measured ±2 wk from surgery were included. Three blinded investigators independently categorized POWC using the World Union of Wound Healing Society Surgical Wound Grading System. Infants were categorized into three groups: no POWC, POWC Grades 1 and 2 (superficial tissue nonintegrity), and POWC Grades 3 and 4 (deep tissue nonintegrity and complete dehiscence). EFA status and other possible POWC-associated factors were analyzed to determine any association with wound severity. RESULTS: Fifty infants met the inclusion criteria. Half (25/50) had no POWC, 30% (15/50) had Grade 1 or 2, and 20% (10/50) had Grade 3 or 4. We found no association between EFAD and POWC severity. CONCLUSIONS: In our cohort, EFA status did not predict POWC severity. At this time, we cannot suggest delaying elective surgical procedures to correct EFAD as an approach to preventing POWC.

Resources Recommended for the Care of Pediatric Patients in Hospitals.

It is crucial that all children are provided with high-quality and safe health care. Pediatric inpatient needs are unique in regard to policies, equipment, facilities, and personnel. The intent of this clinical report is to provide recommendations for the resources necessary to provide high-quality and safe pediatric inpatient medical care.

Enhanced Protein Diet for Preterm Infants: A Prospective, Randomized, Double-blind, Controlled Trial.

OBJECTIVE: To evaluate dietary protein's effect on fat accretion and weight gain in hospitalized preterm infants. METHODS: Prospective, randomized, double-blind, controlled trial of 36 infants born at <32 weeks, hospitalized in a tertiary neonatal intensive care unit. After achieving full enteral volume, infants were randomized to either an enhanced protein diet (EPD) (protein-energy ratio [PER] 4 g/100 calories) or a standard protein diet (SPD) (PER 3 g/100 calories). Macronutrients were calculated using published values for formula, donor milk bank analysis, or weekly analysis of a 24-hour pooled maternal milk sample. Human milk fortifier and/or liquid protein were used to achieve the target PER until discharge or a maximum of 4 weeks. Body composition was measured weekly using air displacement plethysmography. The principal outcomes, rates of weight gain and fat accretion, were compared between groups in linear mixed models. RESULTS: Thirty-three infants received approximately 17 days of the study diet. Relative weight gain was 21.6 g ·â€Škg ·â€Šday (95% confidence interval [CI] 19.5-23.8) for the EPD group (n = 16) versus 19.1 g ·â€Škg ·â€Šday (95% CI 17.0-21.2) for the SPD group (n = 17), P = 0.095. Baseline percent fat mass (FM) in the EPD group was 5.15% (95% CI 3.58%-6.72%) compared with 7.29% (95% CI 5.73%-8.84%) in the SPD group, P = 0.0517. Percent FM increased 0.398%/day (95% CI 0.308-0.488) for the EPD group versus 0.284%/day (95% CI 0.190-0.379) for the SPD group (P = 0.0878). CONCLUSIONS: Preterm infants with a lower baseline FM percentage who received an EPD demonstrated a more pronounced catch-up percentage of fat accretion.

THE OPIOID-EXPOSED NEONATE: A REVIEW OF THE OKLAHOMA EXPERIENCE.

Neonatal abstinence syndrome from opioids (NAS-O) is a multisystem disorder resulting in neurological and gastrointestinal symptoms from the abrupt discontinuation of chronic fetal exposure to opioids. Increasing opioid use during pregnancy has led to a five-fold increase in NAS-O nationally over the past decade. Several knowledge gaps in our experiences with opioid-exposed neonates have been identified: 1) universal maternal screening; 2) diagnostic tools for newborn abstinence syndrome; 3) optimal treatment protocols; and 4) long-term neurodevelopmental effects of fetal opioid exposure. This review article gives a broad overview of the issues associated with screening, diagnosis, and management of opioid exposure in newborns as well as the issues with collecting accurate outcomes data to monitor efforts aimed at curbing opioid exposure in children and NAS-O. Data specific to Oklahoma is provided, when available.

Electronic Alerts Improve Immunization Rates in Two-month-old Premature Infants Hospitalized in the Neonatal Intensive Care Unit.

OBJECTIVE: To determine if an electronic alert improves 2 month immunization rates in infants remaining hospitalized in the neonatal intensive care unit. METHODS: Institutional Review Board-approved retrospective chart review of 261 infants with birth weights <2 kg and still hospitalized at ≥ 58 days. Charts were reviewed between 2009 and 2013, before and after the 2011 electronic alert was instituted in the electronic medical record from days 56 to 67 to remind providers that immunizations were due. Order and administration dates of two-month vaccine components (Diphtheria, Haemophilus influenza B, Hepatitis B, Pertussis, Pneumococcal, Polio, Tetanus) were determined, and infants were considered fully immunized, partially immunized, or unimmunized by day 90 or discharge, whichever came first. RESULTS: After the alert, the timing of vaccine orders decreased from day 67 to day 61 (p<0.0001) and vaccine administration decreased from day 71 to day 64 (p<0.0001). Missing vaccine orders decreased from 14% [17/121] to 3% [4/140] (p=0.001) with missing administrations decreasing from 21% [26/121] to 4% [6/140] (p<0.0001). Fully immunized rates increased from 71% [86/121] to 94% [132/140] (p<0.0001). CONCLUSIONS: A significant improvement in immunization rates in two-month-old infants in the neonatal intensive care unit occurred by 90 days after implementing an alert in the electronic medical record.

Weekly and consecutive day neonatal intubation training: comparable on a pediatrics clerkship.

PURPOSE: To determine whether medical student intubation proficiency with a neonatal mannequin differs according to weekly or consecutive day practice sessions during a six-week pediatric clerkship. METHOD: From July 2010 through June 2011, the authors prospectively randomized 110 third-year medical students into three neonatal intubation practice groups: standard (control; no practice sessions), weekly (practice once/week for four consecutive weeks), or consecutive day (practice once/day for four consecutive days). At baseline, students performed intubation during individual sessions using a neonatal mannequin (SimNewB). Two reviewers, blinded to practice group, viewed videotapes of intubations and independently scored students on equipment selection, procedural skill steps, length of intubation attempts (in seconds), and the number of attempts (up to three) needed for a successful intubation. Videotaped individual final assessment intubation sessions during week six were evaluated in the same manner. RESULTS: Students in the weekly and consecutive day practice groups performed better at the final assessment on all variables than students in the standard group (P < .001), but over six weeks, the authors detected no differences between the two distributed practice formats for any outcomes of interest. CONCLUSIONS: Practice improved all aspects of neonatal intubation performance, including choosing the correct equipment, properly performing the skill steps, length of time to successful intubation, and success rate, for novice health care providers in a simulation setting. Over six weeks, neither practice format proved superior, but it remains unclear whether one format is superior for learning and skill retention over the long term or in actual practice.

Association of fentanyl with neurodevelopmental outcomes in very-low-birth-weight infants.

BACKGROUND: Opioids are commonly used in the neonatal intensive care unit (NICU). Negative neurodevelopmental effects in the short-term setting have been associated with opioids ; however, long-term studies have been limited. OBJECTIVE: The primary objective was to determine if there is a dose relationship between fentanyl and neurodevelopmental outcomes, as measured by Bayley Scales of Infant and Toddler Development (Bayley-III) composite scores for language, cognition, and motor skills. Secondary objectives included comparison of Bayley-III scores and neurodevelopmental impairment classification based on fentanyl exposure. METHODS: A retrospective evaluation of 147 very-low-birth-weight infants with Bayley-III scores obtained at a chronological age of 6 months to 2 years at clinic follow-up was conducted. Univariate and multivariable linear regression analyses were used to determine if there was a dose-related association between fentanyl and neurodevelopmental outcomes. To evaluate secondary outcomes, patients were divided based on cumulative fentanyl dose ("high-dose" versus "low/no-dose"). RESULTS: The univariate analysis found a statistically significant decrease in cognition (P = .034) and motor skills scores (P = .006). No association was found in the multi-variable regression between fentanyl cumulative dose and Bayley-III scores. There was a significant decrease in the motor skills score between the high-dose versus low/no-dose group, 94 ± 20 versus 102 ± 15, respectively (P = .026); however, no statistical differences were noted for language or cognition scores or neurological impairment classification. CONCLUSIONS: When controlling for other variables, the cumulative fentanyl dose did not correlate with neurodevelopmental outcomes. Further evaluation of benefits and risks of opioids in premature infants are needed.

Increased incidence of parenteral nutrition-associated cholestasis with aminosyn PF compared to trophamine.

OBJECTIVE: To compare the incidence of parenteral nutrition-associated cholestasis (PNAC) between two pediatric parenteral amino-acid formulations, Aminosyn PF (APF) and Trophamine (TA). SETTING: Tertiary newborn intensive-care nursery. SUBJECTS: A total of 661 neonates who received either TA or APF. DESIGN: Retrospective. The incidence of PNAC was determined in three groups: Group I (TA, 8/19/97 to 8/19/98, n=335), Group II (APF, 8/20/98 to 1/28/99, n=157), and Group III (TA, 1/29/99 to 8/1/99, n=169). RESULTS: No PNAC developed in any infant receiving parenteral nutrition (PN) for < 3 weeks. Of 141 patients given PN for > or =21 days, 24 were diagnosed with PNAC: Group I (TA, 10/78, 12.8%), Group II (APF, 9/27, 33.3%), and Group III (TA, 5/36, 13.9%). The incidence of PNAC was significantly higher in infants who received APF (p=0.043). Using logistic regression, only birth weight, duration of PN, and use of APF were significant risk factors for the development of PNAC. Despite an earlier initiation of enteral feedings, APF recipients developed PNAC sooner, had higher peak direct bilirubin levels, and remained jaundiced longer. CONCLUSIONS: The use of APF was temporally associated with a greater than two-fold increase in the incidence of PNAC compared to periods of exclusive TA use. In the absence of significant differences in parenteral nutrient or energy intake in neonates who developed PNAC, we speculate that possible differences between the amino-acid compositions of TA and APF may be responsible for the observed differences in the incidence of PNAC.

Postnatal malnutrition of extremely low birth-weight infants with catch-up growth postdischarge.

OBJECTIVE: To assess nutritional intakes and subsequent growth of extremely low birth-weight (BW) infants. STUDY DESIGN: Chart review of 69 extremely low BW infants stratified into two groups by BW: < or =750 g (group 1; n=27) or 751 to 1000 g (group 2; n=42). Dietary intakes, weights, and head circumferences (HC) were collected through discharge and at 1 month postdischarge. The differences between goals and intakes were calculated weekly during hospitalization. Descriptive comparisons were made between growth parameters at birth, discharge, and follow-up. RESULTS: Total energy and protein deficits were inversely related to BW. Both groups exhibited extrauterine growth retardation while hospitalized. After discharge, the rates of weight gain and HC growth increased, leading to some growth recovery at follow-up. CONCLUSIONS: Existing feeding methods resulted in sizeable deficits in energy and protein, particularly for the smallest infants. Changing current practices to limit these deficits is essential to improving postnatal growth.