The transition from tube feeding to oral feeding algorithm in preterm infants: case-control study.

BACKGROUND: Oral feeding is a complex sensorimotor process influenced by many variables, making it challenging for healthcare providers to introduce and manage it. Feeding practice guided by tradition or a trial-and-error approach may be inconsistent and potentially delay the progression of oral feeding skills. AIM: To apply a new feeding approach that assesses early oral feeding independence skills of preterm infants in the neonatal intensive care unit (NICU). To prove its effectiveness, compare two approaches of oral feeding progression based on clinical outcomes in preterm infants, the traditional approach used in the NICU of Mansoura University Children Hospital (MUCH) versus the newly applied approach. METHODS: A quasi-experimental, exploratory, and analytical design was employed using two groups, control and intervention groups, with 40 infants for the first group and 41 infants for the second one. The first group (the control) was done first and included observation of the standard practice in the NICU of MUCH for preterm oral feeding, in which oral feeding was dependent on post-menstrual age (PMA) and weight for four months. The second group (the intervention) included early progression to oral feeding depending on early assessment of Oral Feeding Skills (OFS) and early supportive intervention and/or feeding therapy if needed using the newly developed scoring system, the Mansoura Early Feeding Skills Assessment "MEFSA" for the other four months. Infants in both groups were studied from the day of admission till discharge. RESULTS: In addition to age and weight criteria, other indicators for oral feeding readiness and oral motor skills were respected, such as oral feeding readiness cues, feeding practice, feeding maintenance, and feeding techniques. By following this approach, preterm infants achieved earlier start oral feeding (SOF) and full oral feeding (FOF) and were discharged with shorter periods of tube feeding. Infants gained weight without increasing their workload to the NICU team. CONCLUSION: The newly applied approach proved to be a successful bedside scoring system scale for assessing preterm infants' early oral feeding independence skills in the NICU. It offers an early individualized experience of oral feeding without clinical complications.

Lung and diaphragm ultrasound as predictors of successful weaning from nasal continuous positive airway pressure in preterm infants.

OBJECTIVE: Assessment of the utility of lung and diaphragm ultrasound in the prediction of successful weaning from nasal continuous positive airway pressure (NCPAP) in preterm infants. STUDY DESIGN: This prospective cohort study was conducted on preterm infants who were considered ready for weaning off NCPAP. Lung and diaphragm ultrasound were performed just before and 3 h after weaning off NCPAP. The primary outcome was to evaluate the accuracy of lung ultrasound (LUS) in predicting successful weaning from NCPAP. RESULTS: Out of 65 enrolled preterm infants, 30 (46.2%) were successfully weaned from NCPAP to room air. The successful weaning group had higher gestational ages, lower incidences of previous invasive mechanical ventilation, and treated hemodynamically significant patent ductus arteriosus before the trial weaning. A LUS score of ≤6, measured before discontinuation of NCPAP, exhibited a predictive sensitivity of 80% and specificity of 75% for successful weaning (Area under the curve (AUC) = 0.865, ≤.001). When the LUS score was assessed 3 h after weaning from NCPAP, a cutoff point of ≤7 predicted successful weaning with a sensitivity and specificity of 90% and 60% respectively (AUC = 0.838, p ≤ .001). The diaphragmatic thickness fraction (DTF) was significantly lower in the successful weaning group. After adjustment for various factors, LUS score remained the only independent predictor of successful weaning. CONCLUSION: LUS score before weaning from NCPAP has a good sensitivity and specificity for predicting successful weaning from NCPAP in preterm infants. Diaphragmatic excursion and DTF were not good predictors.

Developing the Mansoura Early Feeding Skills Assessment Scale for Preterm Infants.

Purpose: This study aimed to develop a new bedside scoring system scale that assesses preterm infants' oral feeding skills (OFS) in the neonatal intensive care unit (NICU). Methods: A literature review and critical appraisal of available oral feeding assessment tools/scores were performed. Subsequently, we developed the "Mansoura Early Feeding Skills Assessment" (MEFSA) scale, an 85-item observational measure of oral feeding skills with three main sections. Forty-one preterm infants who did not receive oral feeding but were clinically stable enough to initiate oral feeding were included in the study. Next, we applied and interpreted the MEFSA to describe and score their feeding skills. Results: Applying the MEFSA resulted in a smooth feeding transition, early start of oral feeding, full oral feeding, and discharge with a shorter period of tube feeding in preterm infants. Conclusion: The MEFSA is a successful bedside scoring system that assesses the OFS of preterm infants in the NICU.

Intracranial haemorrhage associated with Vitamin K deficiency in Egyptian infants.

AIM: Intracranial haemorrhage (ICH) in infancy is a rare life-threatening event. The aim of this review is to highlight the association of ICH and potentially preventable vitamin K deficiency and to describe risk factors, presentation and outcome. METHODS: Original published data on ICH related to vitamin K deficiency during 2008-2012 were extracted from records of participating centres in Egypt (Cairo and Delta region). Full data on 70 infants (0-24 weeks) have been reported in three publications. RESULTS: The first study involved premature infants where ICH was potentially preventable with administration of parenteral vitamin K prophylactic doses to mothers ahead of imminent preterm delivery. The other 2 studies involved term newborns and infants. ICH due to early or classic vitamin K deficiency was reported in nine patients while 44 were due to late vitamin K deficiency. Main risk factors for late onset were exclusive breastfeeding, persistent diarrhoea and/or prolonged antibiotic therapy. CONCLUSION: Vitamin K deficiency bleeding is a relatively frequent problem underlying ICH in infancy. Prophylactic vitamin K to mothers when anticipating preterm labour or a vitamin K boost in exclusively breast-fed infants with prolonged antibiotic usage and, or, persistent diarrhoea might have an impact on prevention and outcome.

Effect of tactile/kinesthetic massage therapy on growth and body composition of preterm infants.

Massage therapy (MT) improves growth parameters in preterm infants. The growth of lean mass rather than fat mass has been associated with better long-term outcomes. We aimed to study the effect of tactile/kinesthetic MT on growth and body composition parameters in preterm infants. Preterm (< 32 weeks gestation) infants were randomly assigned at corrected gestational age of 35 weeks to receive 3 consecutive, 15-min, sessions of MT over 5 days or routine care. Primary outcome was mean daily weight gain. Secondary outcomes included anthropometric measurements and body composition parameters assessed by dual X-ray absorptiometry (DXA) scan. Out of 218 infants screened, 86 were eligible and 60 infants (30 in each group) were recruited after parental consent. MT was associated with significant increase in daily weight gain [19.3 (10-34.3) versus 6.2 (2.5-18.4) g/day, p = 0.01] and growth velocity [12.5 (6-21) versus 3.6 (1.6-12.6) g/kg/d, p = 0.01] compared with routine care. Infants on MT showed significant increase in total body mass, fat mass (total/legs), lean mass (total/arms/legs/trunk), and bone mineral density (arms/legs/trunk) values compared with routine care group. In conclusions, MT improves growth quality as evident by increased total and regional lean masses, increased bone mineral density, and peripheral rather than central fat distribution. What is known on this subject? • Massage therapy (MT) for preterm infants leads to achievement of faster independent oral feeding, increased weight gain, less stress, less response to pain, less occurrence of sepsis, and shorter hospital stay. • Growth of lean mass rather than fat mass has been associated with better long-term outcomes. What this study adds? • Tactile/kinesthetic massage therapy in preterm infant is associated with improved growth parameters and anthropometric measures. • Tactile/kinesthetic massage therapy increased total body mass, fat mass (total/legs), lean mass (total/arms/legs/trunk), and bone mineral density (arms/legs/trunk) values.

Sonographic evaluation of diaphragmatic thickness and excursion as a predictor for successful extubation in mechanically ventilated preterm infants.

Sonographic assessment of diaphragmatic thickness and excursion has been found to be an accurate tool in predicting successful extubation of adult patients from invasive mechanical ventilation. We aimed to evaluate the accuracy of sonographic assessment of diaphragmatic thickness and excursion in predicting successful extubation of preterm infants from invasive conventional mechanical ventilation. Preterm infants less than 32 weeks gestation who required invasive conventional mechanical ventilation were evaluated by diaphragmatic sonography within 1 h of their planned extubation. Infants were classified into successful or failed extubation groups based on their ability to stay off invasive mechanical ventilation for 72 h after extubation. Inspiratory and expiratory thickness plus excursion of the right and left hemidiaphragm as well as diaphragmatic thickening fraction (DTF) measures were compared between groups. We included 43 eligible infants, of whom 34 infants succeeded and 9 infants failed extubation. Infants in the successful extubation group had a significantly higher expiratory thickness of the right and left hemidiaphragm, excursion of the right and left hemidiaphragm, inspiratory thickness of the left hemidiaphragm, and DTF of the left hemidiaphragm compared with infants who failed extubation. The receiver-operating characteristic curves showed that excursion of the right and left hemidiaphragm has the highest significant accuracy in predicting successful extubation of preterm infants among all diaphragmatic parameters (AUC is 0.98 and 0.96, respectively; p value < 0.001 for both).Conclusion: We conclude that diaphragmatic excursion is a useful indicator for successful extubation of preterm infants from mechanical ventilation. What is Known: • Invasive mechanical ventilation induces ventilator induced diaphragmatic dysfunction (VIDD) particularly when used for long time. • Assessment of diaphragmatic dimensions and functional activity has been a valuable tool in predicting successful extubation of adult patients from invasive mechanical ventilation. What is New: • Sonographic assessment of diaphragmatic dimensions can be used to predict successful extubation of preterm infants from mechanical ventilation. • Sonographic assessment of diaphragmatic excursion shows the highest sensitivity and specificity in predicting successful extubation of preterm infants.

Implementation of a protocol-based strategy for weaning nasal high flow therapy in preterm infants.

OBJECTIVE: We compared protocolized weaning versus nonprotocolized weaning practice from nasal high flow therapy (nHFT) in preterm infants. STUDY DESIGN: A before-and- after observational study. METHODS: The study was conducted in three phases; Phase 1: infants were weaned according to usual practice for 6 months (nonprotocolized), Phase 2: education and training physicians and nursing staff for the protocol for 1 month, and Phase 3: protocol of weaning from nHFT was applied for the following 6 months with specified criteria for readiness to wean, weaning failure and weaning technique. The primary outcome was failure to wean off nHFT. RESULTS: One hundred and four preterm infants were enrolled, 51 preterm infants in the protocol group and 53 in the nonprotocol group. The groups were similar in demographic and clinical characteristics at baseline. There were significantly lower number of patients who failed weaning from nHFT in the protocol group compared to nonprotocol group (4 [7.8%] versus 15 [28.3%], p = .007]. There was shorter time to reach full enteral feeding in the protocol group compared with nonprotocol group (p = .03). There were no significant differences between groups regarding other outcomes including total durations of respiratory support, nHFT and oxygen therapy, duration of nHFT after decision of weaning, and neonatal mortality and morbidity. CONCLUSION: Implementation of a standardized protocol for weaning from nHFT in preterm infants reduced weaning failure and reduced the time to full feeds. Larger trials are recommended to detect the impact of weaning protocols on other outcomes.

Mediators in Preterm Infants With Late-onset Sepsis: A Randomized Controlled Trial.

OBJECTIVE: To evaluate biochemical and clinical effects of 2 different doses of vitamin D supplementation in preterm infants with late-onset sepsis (LOS). STUDY DESIGN: A double blinded randomized controlled stratified trial included preterm infants with gestational age (GA) ≥28 weeks with LOS. Subjects were randomly assigned to receive 400 or 800 IU/day of vitamin D3. Serum concentrations of 25(OH)D, TNF-α, and IL-6 were measured at enrollment, 7 days after vitamin D supplementation, and at 40 weeks of postmenstrual age (PMA). Short-term outcomes and growth parameters were assessed. RESULTS: A total of 50 infants were enrolled, 25 in each group. Seventy-six percentage of enrolled infants were vitamin D-deficient at enrollment in both groups whereas only one infant in the 400 IU and none in the 800 IU group remained deficient at 40 week's PMA; vitamin D concentrations at 40 weeks PMA were 54.8 ±â€Š35.1 and 67.4 ±â€Š37.1 ng/mL, respectively, P = 0.01). None of the infants enrolled in the study had signs of vitamin D toxicity. Serum pro-inflammatory cytokines IL-6 and TNF- α concentrations decreased at 1 week and at discharge in both groups without differences between groups. The 2 groups did not differ in anthropometric measurements, duration of oxygen and respiratory support, duration of antimicrobial use, length of hospital stay, and mortality. CONCLUSIONS: A dose of 400 IU of vitamin D was adequate to treat vitamin D deficiency in the majority of premature infants with LOS. The 2 dosing regimens did not differ in clinical or biochemical changes.

Comparative Study of the Effects of Continuous Positive Airway Pressure and Nasal High-Flow Therapy on Diaphragmatic Dimensions in Preterm Infants.

OBJECTIVE: Nasal continuous positive airway pressure (nCPAP) and nasal high-flow therapy (nHFT) are the most common forms of noninvasive respiratory support in preterm infants. We conducted this study to compare effects of nCPAP and nHFT on diaphragmatic dimensions as assessed by bedside ultrasonography in preterm infants. STUDY DESIGN: A prospective, randomized crossover study comprised 24 preterm infants. Group 1 (n = 12): started on nCPAP for 60 minutes and then switched to nHFT for 60 minutes. Group 2 (n = 12): started on nHFT for 60 minutes then switched to nCPAP for 60 minutes. Ultrasonographic assessment of diaphragmatic dimensions was performed at the end of each epoch. RESULTS: There were no statistically significant differences in diaphragmatic dimensions at the end of each epoch of nCPAP or nHFT. The diaphragm thickening fraction (DTF) was not significantly different with either nCPAP or nHFT [23.4 (13.7-28.0) versus 23.4 (11.2-31.6), p = 0.57]. No significant differences were found regarding heart rate, respiratory rate, Silverman-Anderson scores, and SpO2 on nCPAP and nHFT. All infants enrolled tolerated the crossover maneuver. CONCLUSION: Stable preterm infants (30.3 ± 2.2 weeks' gestation) with mild respiratory dysfunction show comparable effects on diaphragm thickness and excursion during relatively brief periods of support on nCPAP or nHFT. CLINICAL TRIAL REGISTRATION: Registry name: Clinical Trials.gov. Registration number: NCT02421328. Web link to study on registry: https://clinicaltrials.gov/ct2/show/NCT02421328.

Study of platelet activation, hypercoagulable state, and the association with pulmonary hypertension in children with ß-thalassemia.

BACKGROUND: The increased survival rate of thalassemic patients has led to unmasking of management related complications which were infrequently encountered. OBJECTIVE: Study the increased coagulation and platelet activation in children with ß-thalassemia, to analyze the factors that lead to such hypercoagulable state and to study pulmonary hypertension (PH) in conjunction with platelet activation and hypercoagulable state in children with ß-thalassemia. METHODS: 36 Egyptian children with ß-thalassemia with a mean age of 9.9years (±4.7 SD). In addition, 20 healthy Egyptian children matched for age and sex were enrolled as a control group. Both were subjected to clinical and laboratory assessments. Echocardiography was done to the patient group and PH was diagnosed based on calculated mean pulmonary artery pressure [MPAP] >25mmHg. RESULTS: We found that, mean±SD serum P-selectin level (platelet activator marker) was significantly higher in thalassemic patients (2337±566pg/ml) in comparison to controls (1467±247pg/ml) (P<0.001). Mean serum protein-C and antithrombin-III levels were significantly lower in thalassemic patients (1.2±1.3µg/ml, 27.3±7.5mg/dl) in comparison to controls (2.3±1.3µg/ml, 35.1±4.1mg/dl) (P=0.003 and <0.001) respectively. PH was detected in 17 (47.2%) patients and it was significantly associated with splenectomy (P=0.01) and non-transfusion dependent thalassemia (NTDT) (P=0.04). PH was positively correlated with serum levels of P-selectin (r=0.38, P=0.02), fibrinogen (r=0.41, P=0.01) and negatively correlated with serum protein-C level (r=-0.48, P=0.003). CONCLUSION: A chronic hypercoagulable state and platelet activation is present in children with ß-thalassemia. Splenectomy and transfusion infrequency are the main risk factors noted to be associated with such hypercoagulable state and platelet activation and consequently the PH among our thalassemic patients.

Language and cognitive outcome for high-risk neonates at the age of 2-3 years - experience from an Arab Country.

AIM: To investigate the effect of different neonatal risk factors on different language parameters as well as cognitive abilities among Arabic speaking Egyptian children at the age of two to three years of life and to find out which risk factor(s) had the greatest impact on language and cognitive abilities. METHODS: This retrospective cohort study was conducted on 103 children with age range of 2-3 years (median age 31 mo). They were 62 males and 41 females who were exposed to different high-risk factors in the perinatal period, with exclusion of metabolic disorders, sepsis/meningitis, congenital anomalies and chromosomal aberrations. The studied children were subjected to a protocol of language assessment that included history taking, clinical and neurological examination, audiological evaluation, assessment of language using modified preschool language scale-4, IQ and mental age assessment and assessment of social age. RESULTS: The studied children had a median gestational age of 37 wk, median birth weight of 2.5 kg. The distribution of the high-risk factors in the affected children were prematurity in 25 children, respiratory distress syndrome in 25 children, hypoxic-ischemic encephalopathy in 15 children, hyperbilirubinemia in 10 children, hypoglycemia in 13 children, mixed risk factors in 15 children. The results revealed that high-risk neonatal complications were associated with impairment of different language parameters and cognitive abilities (P < 0.05). The presence of prematurity, in relation to other risk factors, increases the risk of language and cognitive delay significantly by 3.9 fold. CONCLUSION: Arabic-speaking children aged 2-3 years who were exposed to high-risk conditions in the perinatal period are likely to exhibit delays in the development of language and impairments in cognitive abilities. The most significant risk factor associated with language and cognitive impairments was prematurity.