Postponing or eliminating red blood cell transfusions of very low birth weight neonates by obtaining all baseline laboratory blood tests from otherwise discarded fetal blood in the placenta.

BACKGROUND: Safely reducing the proportion of very low birth weight neonates (<1500 g) that receive a red blood cell (RBC) transfusion would be an advance in transfusion practice. STUDY DESIGN AND METHODS: We performed a prospective, single-centered, case-control, feasibility analysis, preparatory to designing a definitive trial. Specifically, we sought to determine whether we could obtain all baseline neonatal intensive care unit blood tests from the placenta, after placental delivery, thereby initially drawing no blood from the neonate. RESULTS: Ten cases where all baseline blood tests were drawn from the placenta, and 10 controls where all tests were drawn from the neonate, were closely matched for birth weight, gestational age, sex, and race. Early cord clamping was used for all 20. Over the first 18 hours the hemoglobin increased in nine cases versus two controls (p = 0.005). During the first 72 hours one case versus five controls qualified for and received an RBC transfusion. In the first week the cases received four transfusions and the controls received 16 (p = 0.02). None of the cases had an intraventricular hemorrhage (IVH) but four of the controls had a Grade 1 and two had a Grade 3 (p = 0.01). CONCLUSION: We speculate that this method is feasible and generally postpones the first RBC transfusion until beyond the period of peak vulnerability to IVH.

Lansoprazole, ranitidine, and metoclopramide: comparison of practice patterns at 4 level III NICUs within one healthcare system.

PURPOSE: Evidence is needed to guide NICU use of lansoprazole (Prevacid), ranitidine (Zantac), and metoclopramide (Reglan). As a step toward that goal, we conducted a historic cohort analysis of all patients who received any of these medications in 4 Intermountain Healthcare NICUs during the year 2006. SUBJECTS: Data were obtained from all patients admitted between January 1 and December 31, 2006, to any of 4 Intermountain Healthcare NICUs. DESIGN: This was a retrospective descriptive design. METHODS: Data were obtained from electronic pharmacy records and electronic medical records. The NICUs involved were blinded and included McKay-Dee Hospital Center, Ogden, Utah; LDS Hospital, Salt Lake City, Utah; Utah Valley Regional Medical Center, Provo, Utah; and Dixie Regional Medical Center, St George, Utah. RESULTS: Although the demographics of the patients at the 4 centers were similar, significant differences were seen among the centers in drug use patterns. Lansoprazole use ranged from a high of 17% of patients in one center to a low of 7% of patients in another. Ranitidine use ranged from 9% in one center to 1% in another. Metoclopramide use ranged from 9% of patients in one center to <1% in another. CONCLUSIONS: The extreme variability among the centers in use patterns of these 3 medications suggests lack of an adequate evidence base to guide practice and indicates that case controlled studies or random controlled trials are needed to devise a consistent evidence-based approach.

An unusual case of severe neonatal thrombocytopenia.

Neonatal alloimmune thrombocytopenia (NAIT) occurs when maternal antibodies are directed against antigens on fetal and paternal but not maternal platelets. Most cases of NAIT arise when platelets of the father (and the fetus) express the human platelet antigen (HPA)1a and the mother's platelets expresses HPA-1b. A female patient presented with congenital severe thrombocytopenia and received 4 platelet transfusions, on days 2, 7, 16, and 28. This appeared to be a case of NAIT; however, extensive serologic evaluation by 2 reference laboratories failed to reveal the offending platelet antigen. Consistent with NAIT, the condition resolved by 6 weeks of age. By patient day of life 42, the platelet count had increased without additional need for transfusions, and by 16 weeks, the patient had a completely normal platelet count of 437,000/microL. The patient's platelet count remains normal at a 2-year follow-up. This case is reported as an instructive atypical case of NAIT, in which the relevant platelet antigen could not be identified.

A phase 1 trial testing an enteral solution patterned after human amniotic fluid to treat feeding intolerance.

OBJECTIVE: Feeding intolerance is a common problem in neonates; in some cases it may be related to atrophic changes in the small bowel mucosa. In these infants, feeding tolerance might improve after oral administration of enterocyte growth factors in a sterile, isotonic, noncaloric solution patterned after human amniotic fluid. STUDY DESIGN: Ten infants who met the study criteria for feeding intolerance were enrolled in this pilot trial. The test solution was administered, 2.5 mL/kg every 3 hours, until 80 mL/kg/day of milk feedings were tolerated, or for a maximum of 7 days. When milk feedings were prescribed, they were mixed with the test solution. Volumes of milk feedings were increased in amounts determined by the attending neonatologist and neonatal nurse practitioner. The outcome was the net average enteral kilocalories per kilogram of body weight per day (kcal/kg/day) for 3 periods: (1) the 3 days before the test treatment was begun, (2) the days the test treatment was administered, and (3) the 7 days following cessation of the test treatment. RESULTS: At study entry the infants' chronological ages ranged from 3 to 65 days. All infants tolerated the test solution, which was given for a mean of 5 days (range 3 to 7 days). During that period, the infants received more enteral calories (mean 18 kcal/kg/day, range 1 to 32) than during the preceding 3 day period (mean 3 kcal/kg/day, range 0 to 7, P < 0.05). During the 7 days following the test treatment the infants received 87 enteral kcal/kg/day (range 11 to 109, P < 0.02 compared to the treatment period). CONCLUSIONS: In this Phase 1 pilot trial, 10 heterogeneous infants in the neonatal intensive care unit with feeding intolerance had a significant increase in milk feedings after treatment with a sterile, isotonic, noncaloric solution patterned after human amniotic fluid.