Evaluation of Implementation of Early-Onset Sepsis Calculator in Newborns in Israel.

OBJECTIVE: To evaluate the recommendations based on the early-onset sepsis (EOS) calculator in the first 2 years of its implementation in Israel. STUDY DESIGN: Prospective 2-year surveillance of a cohort of infants born at gestational age of ≥34 weeks in Bnai Zion Medical Center, who were evaluated using the EOS calculator because of peripartum risk factors. RESULTS: We evaluate 1146 newborns with peripartum risk factors using the EOS calculator. The percentage of infants who had laboratory evaluation decreased to 4.6%, and the EOS calculator recommended empiric antibiotic therapy in only 2.2%. During the study period, there were 4 early-onset infections (EOS incidence of 0.6 in 1000 live births). Three had group B streptococcus (GBS) and one had Escherichia coli infection. Only 2 of these infants had perinatal risk factors and the EOS calculator identified them and recommended laboratory evaluation and empiric antibiotics. However, 2 infants with GBS EOS had no perinatal risk factors or clinical symptoms at delivery, and were discovered clinically at older ages. CONCLUSIONS: The Israeli EOS calculator-based guidelines seem to be appropriate and are associated with less laboratory evaluations, and little use of empiric antibiotics. Concerns are related to the current recommendation of no GBS universal screening in Israel, and the inability of the calculator-based approach to identify GBS EOS in infants born to mothers with unknown GBS who have no peripartum risk factors before presentation of clinical symptoms.

Oxygenation Instability Assessed by Oxygen Saturation Histograms during Supine vs Prone Position in Very Low Birthweight Infants Receiving Noninvasive Respiratory Support.

OBJECTIVE: To evaluate the effect of prone vs supine position on the oxygenation instability among very low birth weight (VLBW) infants receiving noninvasive respiratory support, as assessed by the average oxygen saturation (SpO2) histograms. STUDY DESIGN: Sixty-nine histograms from 23 VLBW infants were studied prospectively. Each infant was studied during 3 consecutive 3-hour periods of alternating positions; 12 infants started the study while prone and 11 infants started supine, by random order. Histogram classification system was used to quantify oxygenation stability and time spent in different SpO2 ranges. RESULTS: The fraction of inspired oxygen values were similar in both positions. Unstable histograms were more common in supine vs prone position (20/34 [59%] vs 10/35 [29%]; P = .02, respectively). Analyzing oxygenation stability as per position change revealed that a change from prone to supine increased oxygenation instability, and supine to prone decreased instability (P = .02). In the supine vs prone position, percent of time spent in SpO2 ≤80% and <90% was higher (5.0 ± 4.2 vs 2.4 ± 3.4 [P < .001] and 24.1 ± 13.7 vs 13.2 ± 10.0 [P < .001], respectively), and percent of time in SpO2 >94% was lower (39.7 ± 26.0 vs 52.4 ± 23.4 [P = .04]). CONCLUSIONS: Prone positioning decreased oxygenation instability and resulted in higher oxygenation among VLBW premature infants on noninvasive respiratory support. SpO2 histograms allow easy bedside assessment of oxygenation instability, and quantification of the time spent at different SpO2 ranges.

The Impact of Routine Evaluation of Gastric Residual Volumes on the Time to Achieve Full Enteral Feeding in Preterm Infants.

OBJECTIVE: To evaluate the time to full enteral feedings in preterm infants after a practice change from routine evaluation of gastric residual volume before each feeding to selective evaluation of gastric residual volume , and to evaluate the impact of this change on the incidence of necrotizing enterocolitis (NEC). STUDY DESIGN: Data were collected on all gavage-fed infants born at ≤34 weeks gestational age (GA) for 2 years before (n = 239) and 2 years after the change (n = 233). RESULTS: The median GA was 32.0 (IQR: 29.7-33.0) weeks before and 32.4 (30.4-33.4) weeks after the change (P = .02). Compared with historic controls, infants with selective evaluations of gastric residual volumes weaned from parenteral nutrition 1 day earlier (P < .001) and achieved full enteral feedings (150 cc/kg/day) 1 day earlier (P = .002). The time to full oral feedings and lengths of stay were similar. The rate of NEC (stage ≥ 2) was 1.7% in the selective gastric residual volume evaluation group compared with 3.3% in the historic control group (P = .4). Multiple regression analyses showed that the strongest predictor of time to full enteral feedings was GA. Routine evaluation of gastric residual volume and increasing time on noninvasive ventilation both prolonged the attainment of full enteral feedings. Findings were consistent in the subgroup with birth weights of <1500 g. Increased weight at discharge was most strongly associated with advancing postmenstrual, age but avoidance of routine evaluations of gastric residual volume also was a significant factor. CONCLUSIONS: Avoiding routine evaluation of gastric residual volume before every feeding was associated with earlier attainment of full enteral feedings without increasing risk for NEC.

Impact of Continuous Capnography in Ventilated Neonates: A Randomized, Multicenter Study.

OBJECTIVE: To compare the time spent within a predefined safe range of CO2 (30-60 mmHg) during conventional ventilation between infants who were monitored with distal end-tidal CO2 (dETCO2, or capnography) and those who were not. STUDY DESIGN: For this randomized, controlled multicenter study, ventilated infants with a double-lumen endotracheal tube were randomized to 1 of 2 groups: the open (monitored) group, in which data from the capnograph were recorded, displayed to the medical team, and used for patient care, and the masked group, in which data from the capnograph were recorded. However, the measurements were masked and not available for patient care. dETCO2 was compared with PaCO2 measurements recorded for patient care. RESULTS: Fifty-five infants (25 open, 30 masked) participated in the study (median gestational age, 28.6 weeks; range, 23.5-39.0 weeks). The 2 groups were comparable. dETCO2 was in good correlation (r = 0.73; P < .001) and adequate agreement (mean ± SD of the difference, 3.0 ± 8.5 mmHg) with PaCO2. Compared with infants in the masked group, those in the monitored group had significantly (P = .03) less time with an unsafe dETCO2 level (high: 3.8% vs 8.8% or low: 3.8% vs 8.9%). The prevalence of intraventricular hemorrhage or periventricular leukomalacia rate was lower in the monitored group (P = .02) and was significantly (P < .05) associated with the independent factors dETCO2 monitoring and gestational age. CONCLUSION: Continuous dETCO2 monitoring improved control of CO2 levels within a safe range during conventional ventilation in a neonatal intensive care unit. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01572272.

Intravenous fluids versus gastric-tube feeding in hospitalized infants with viral bronchiolitis: a randomized, prospective pilot study.

The American Academy of Pediatrics recommends intravenous fluids for infants with bronchiolitis who are unable to sustain oral feedings. Our randomized, prospective pilot study shows that gastric tube feeding (in 31 infants) is feasible and demonstrated comparable clinical outcomes with intravenous fluids (in 20 infants) among hospitalized infants ≤6 months of age with moderate bronchiolitis.

Glucose-6-phosphate dehydrogenase deficiency and borderline deficiency: association with neonatal hyperbilirubinemia.

OBJECTIVE: To characterize the occurrence of glucose-6-phosphate dehydrogenase (G6PD) deficiency and its association with neonatal hyperbilirubinemia. STUDY DESIGN: This study involved an evaluation of G6PD data for 2656 newborns from a universal newborn screening program. RESULTS: Mean G6PD activity was 14.2 ± 3.3 U/g Hb. Some 2.71% of the newborns were G6PD-deficient, and 1.77% had borderline G6PD activity, with male and female predominance, respectively. G6PD deficiency was more prevalent in newborns of Sephardic Jew and Muslim Arab backgrounds. The infants with G6PD deficiency had higher bilirubin levels at the time of discharge from the nursery. Infants with low and borderline G6PD activity were more likely to require phototherapy (22.2% and 25.5%, respectively, vs 7.6% of infants with normal G6PD activity; P < .005) and to have more referrals for exacerbation of jaundice (15.3% and 14.9%, respectively, vs 6.1%; P < .005). Mean G6PD activity was higher in preterm infants born at 27-34 weeks gestational age compared with those born later (16.3 ± 1.8 U/g Hb vs 14.8 ± 2.0 U/g Hb). Based on sex distribution and theoretical genetic calculations for the rate of heterozygous females, we propose that the range of borderline G6PD activity should be 2-10 U/g Hb rather than the currently accepted range of 2-7 U/g Hb. CONCLUSIONS: There is association between G6PD deficiency and significant neonatal hyperbilirubinemia. Increased risk is also associated with borderline G6PD activity. The suggested new range for borderline G6PD activity should enhance the identification of females at risk. G6PD activity is higher in preterm infants.

The effects of lactulose supplementation to enteral feedings in premature infants: a pilot study.

OBJECTIVE: To assess the safety and prebiotic effects of lactulose in preterm infants. STUDY DESIGN: This was a prospective, double-blinded, placebo-controlled, single-center study in 23- to 34-weeks premature infants. The study group received 1% lactulose, and control infants received 1% dextrose in all feeds (human milk or formula). RESULTS: Twenty-eight infants participated (15 lactulose, 13 placebo). Small doses of lactulose appeared to be safe and did not cause diarrhea. Premature infants on lactulose had more Lactobacilli-positive stool cultures that appeared earlier with larger number of colonies. The lactulose group tended to have less intolerance to enteral feedings, to reach full oral feeds earlier, and to be discharged home earlier. They also tended to have fewer episodes of late-onset sepsis, lower Bell stage necrotizing enterocolitis, and their nutritional laboratory indices were better, especially calcium and total protein. CONCLUSIONS: This pilot study supports the safety of supplementing preterm infants' feeds with low doses of lactulose. It also demonstrated trends that may suggest positive prebiotic effects.

Is visual assessment of jaundice reliable as a screening tool to detect significant neonatal hyperbilirubinemia?

OBJECTIVE: To assess the reliability of visual assessment of bilirubin levels (BiliEye) in newborns as a screening tool to detect significant neonatal hyperbilirubinemia. STUDY DESIGN: 5 neonatologists and 17 nurses estimated 3,532 BiliEye in 1,129 term and late preterm (> or = 35 weeks) infants before discharge from the nursery, at 62 +/- 24 hours. Total serum bilirubin (TSB) levels were measured concomitantly. RESULTS: Mean TSB and BiliEye were 6.7 +/- 2.9 mg/dL (range, 0.4-18.2 mg/dL) and 6.6 +/- 3.2 mg/dL (range, 0.0-17.2 mg/dL), respectively, with good correlation (Pearson's r = 0.752, P < .0001), but other measures of agreement were poor. 61.5% of the 109 babies with TSB levels in high-risk zones were clinically misclassified. The area under curve (AUC) of the receiver-operating characteristics plotted for these high-risk zones was 0.825, but became low for early discharge (< or = 36 hours; AUC = 0.638) and late preterm (35-37 weeks; AUC = 0.613). There was significant interobserver variation (low weighted kappa, 0.363). CONCLUSIONS: Although there was good correlation between BiliEye and actual TSB level, visual assessment was unreliable as a screening tool to detect significant neonatal hyperbilirubinemia before discharge. Babies with TSB levels within high-risk zones may be clinically misdiagnosed as low-risk, resulting in inadequate follow-up.

Nasal intermittent mandatory ventilation versus nasal continuous positive airway pressure for respiratory distress syndrome: a randomized, controlled, prospective study.

OBJECTIVE: To evaluate whether nasal intermittent mandatory ventilation (NIMV) compared with nasal continuous positive airway pressure (NCPAP) would decrease the requirement for endotracheal ventilation in the treatment of respiratory distress syndrome (RDS) in preterm infants <35 weeks. STUDY DESIGN: Randomized, controlled, prospective, single-center study. Forty-one infants were randomized to NCPAP and 43 comparable infants to NIMV (birth weight 1533 +/- 603 vs 1616 +/- 494 g, gestational age 30.6 +/- 3.0 vs 31.1 +/- 2.3 weeks, P = .5, respectively). RESULTS: Infants treated with NIMV and with NCPAP had comparable cardio-respiratory status at study entry. In the total cohort, infants treated initially with NIMV needed less endotracheal ventilation than infants treated with NCPAP (25% vs 49%, P < .05) with a similar trend in infants <1500 g; 31% vs 62%, P =. 06). When controlling for weight and gestational age, NIMV was more successful in preventing endotracheal ventilation (P < .05). Infants treated with NIMV had a decreased incidence of bronchopulmonary dysplasia (BPD) compared with those treated with NCPAP (2% vs 17%, P <. 05, in the total cohort and 5% vs 33%, P <. 05, for infants <1500 g). CONCLUSIONS: NIMV compared with NCPAP decreased the requirement for endotracheal ventilation in premature infants with RDS. This was associated with a decreased incidence of BPD.