High Frequency Oscillatory Ventilation (HFOV) and Inhaled Nitric Oxide (iNO) Use During Neonatal Emergency Transport - Feasibility and Efficacy in India.

A retrospective study of 24 neonates to evaluate the feasibility and efficacy of high frequency oscillatory ventilation (HFOV) and inhaled nitric oxide (iNO) for transferring critically ill neonates to tertiary neonatal intensive care, who were transported by road ambulance was done. Efficacy was measured by clinical improvement, patient safety was assessed by comparing cardiorespiratory indicators before and after transport, and adverse events during transport. Significant oxygenation improvement was observed in neonates transported with HFOV ± iNO compared to earlier ventilator settings. Pre- and post-transport vital signs were stable, and no transport-related deaths occurred. A substantial rise in median SpO2 was seen after transfer [86 (81, 91) vs. 93 (89, 97) before transport, p <0.001]. Twelve of twenty-one newborns who received nitric oxide demonstrated significant improvement in oxygenation index (a 10% decrease from prior value). Overall survival was 70.8%, however non-transfer or inadequate respiratory treatment may have exacerbated mortality.

Extrauterine Growth Restriction: Need for an Accurate Definition.

Neonates show considerable variation in growth that can be recognized through serial measurements of basic variables such as weight, length, and head circumference. If possible, measurement of subcutaneous and total body fat mass can also be useful. These biometric measurements at birth may be influenced by demographics, maternal and paternal anthropometrics, maternal metabolism, preconceptional nutritional status, and placental health. Subsequent growth may depend on optimal feeding, total caloric intake, total metabolic activity, genetic makeup, postnatal morbidities, medications, and environmental conditions. For premature infants, these factors become even more important; poor in utero growth can be an important reason for spontaneous or induced preterm delivery. Later, many infants who have had intrauterine growth restriction (IUGR) and are born small for gestational age (SGA) continue to show suboptimal growth below the 10th percentile, a condition that has been defined as extrauterine growth restriction (EUGR) or postnatal growth restriction (PNGR). More importantly, a subset of these growth-restricted infants may also be at high risk of abnormal neurodevelopmental outcomes. There is a need for well-defined criteria to recognize EUGR/PNGR, so that correctional steps can be instituted in a timely fashion.

Human Milk-Derived Fortifier as Rescue Therapy in Very Preterm Infants Intolerant to Cow's Milk-Derived Fortifier.

This was a retrospective, descriptive study where human milk-derived fortifier (HMDF) was used to rescue infants intolerant to cow's milk-derived fortifier (CMDF). Rescue therapy was used for newborns with feed intolerance, systemic symptoms, or thrombocytosis. In a total of 412 very preterm infants (gestational age ≤ 32 wk) admitted to NICU during the study period, 14 infants met the rescue protocol inclusion criteria. The mean gestational age of these 14 infants was 29.2 ± 1.2 wk and birth weight was 1161 ± 201 g. All the infants who received rescue protocol by changing over to HMDF tolerated feeds well and showed a positive growth trend. Four infants had thrombocytosis, out of which 2 infants had elevated platelet count even with HMDF. Premature infants with intolerance to CMDF were effectively managed using HMDF as a rescue protocol. Infants tolerated HMDF well and showed positive growth trends till the discharge.

Nutritional Management of Short Bowel Syndrome.

Short bowel syndrome (SBS) of infancy is a cause of prolonged morbidity with intolerance to enteral feeding, specialized nutritional needs, and partial/total dependence on parenteral nutrition. These infants can benefit from individualized nutritional strategies to support and enhance the process of intestinal adaptation. Early introduction of enteral feeds during the period of intestinal adaptation is crucial, even though the enteral feedings may need to be supplemented with an effective, safe, and nutritionally adequate parenteral nutritional regimen. Newer generation intravenous lipid emulsions can be effective in preventing and treating intestinal failure-associated liver disease. Prevention of infection(s), pharmaceutical interventions to enhance bowel motility and prevent/mitigate bacteria overgrowth, and specialized multidisciplinary care to minimize the injury to other organs such as the liver, kidneys, and the brain can assist in nutritional rehabilitation and lower the morbidity in SBS.

Sirolimus in infants with congenital hyperinsulinism (CHI) - a single-centre experience.

Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycaemia in neonates and infants. Medical treatment includes the use of high concentrations of glucose and combinations of diazoxide, octreotide and glucagon. We report our experience of using sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, in the treatment of CHI in seven newborns who are poorly responding to standard medical therapy. Majority (87%) of infants achieved euglycaemia using a combination of oral feeding and the addition of sirolimus to standard medical treatment. One infant who failed to achieve euglycaemia even after surgery managed successfully with sirolimus. Diagnosis was confirmed by genetics evaluation; in three infants, novel mutations were detected. Outcome and long-term follow-up of all cases are described.Conclusion: Sirolimus can be considered in treatment of CHI refractory to standard medical treatment or in cases unresponsive to surgical treatment. What is Known: • Congenital hyperinsulinism (CHI) or persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI) associated with mutations such as the ABBC8 or KCNJ gene known to cause hypoglycaemia refractory to standard medical treatment such as diazoxide and octreotide and may need subtotal pancreatectomy (STP). • Sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, was recently reported to be useful for refractory CHI cases with variable efficacy. What is New: • Our case series describes efficacy and safety of sirolimus in seven genetically proven refractory CHI cases with mainly neonatal presentation. All patients' follow-ups are described. • Out of seven infants, six infants responded well to sirolimus, and among these one infant who failed to respond to surgery (STP) also successfully managed with sirolimus. • It highlights the right patient selection and right dose to successfully manage these cases without much adverse effects.

Pasteurized Donor Human Milk Should Not Replace Mother's Own Milk in Preterm Neonates: A Quality Initiative Toward Decreasing the "PDHM Dependency".

Aim: Mother's own milk (MOM) is the preferred source of neonatal nutrition. Due to various challenges, mothers are often unable to provide exclusive MOM to neonates admitted in neonatal intensive care units (NICUs) and depend on pasteurized donor human milk (PDHM). The aim of this quality improvement (QI) initiative was to enable mothers to provide MOM and consequently decrease the "PDHM dependency." Methods: Neonates <32 weeks of gestation (n = 120) were included. A multidisciplinary team was formed, and a detailed root cause analysis was done to understand the cause of PDHM dependency during the observation phase (November 1 to December 15, 2019). Various evidence-based practices were planned, tested, and implemented through Plan-Do-Study-Act cycles during the intervention phase (December 16, 2019 to January 31, 2020). These were further strengthened and adopted as a unit culture during the maintenance phase (February 1 to July 31, 2020). Results from the observation and intervention phases were compared. Results: Within 6 weeks of QI interventions, the average proportion of MOM significantly increased from 74.4% to 93.5% (p = 0.0003), and the proportion of PDHM significantly decreased from 20.5% to 4.6% (p = 0.005). The proportion of MOM remained at 82.5% during the maintenance phase. There was a significant decrease in the number of days to reach full feeds and regain birth weight. Conclusions: Provision of PDHM from our newly functional milk bank led to a reduced drive to express MOM in mothers of NICU babies. Our QI project focused on various strategies to improve MOM feeding and reduce PDHM dependence.

Quality improvement initiative to decrease extrauterine growth restriction in preterm neonates.

BACKGROUND: Prevention of extrauterine growth restriction (EUGR) in preterm neonates is one of the biggest challenges to neonatologists. Lack of uniformity and inconsistency in nutrition practices are the most common causes. We started a quality improvement (QI) initiative with an intention to decrease the proportion of EUGR. METHODS: We performed prospective nonrandomized QI from May 2018 to July 2019. Ninety-six neonates (born at <32 weeks and/or <1.2 kg) were compared with 111 historical controls. A continuous feedback loop was maintained, and changes were analyzed as plan-do-study-actcycle. RESULTS: Although EUGR was lower after the intervention (93.7% vs 87.5%), this change was not statistically significant. However, other measures of in-hospital neonatal growth showed improvement, including median discharge weight percentile from 1% to 3% (P = .003). Median difference in the z-score for weight from birth to discharge also improved significantly from -1.84 to -1.65 (P = .04). Babies in the intervention group regained birth weight earlier (P = .005) and had better growth velocity (P = .0005). The feeding was started early (P < .0001), and these babies reached full feeds (P < .0001) earlier than the control cohort. CONCLUSION: Although our QI initiative failed to achieve a significant reduction in EUGR, it did achieve a significant improvement in discharge weight percentile and difference in the z-score for weight at birth and during discharge from hospital. There was a significant improvement in growth velocity and an early regaining of birth weight. The implementation of written nutrition practice guidelines facilitated improved outcomes.

A Quality Initiative to Improve Mother's Own Milk Feeding in Preterm Neonates.

Background: The rates of "any" human milk use in neonatal intensive care units have improved during the last decade. However, efforts to help mothers in expressing and maintaining mother's own milk (MOM) through discharge remain a concern. This study aims to improve MOM in preterm neonates. Methods: The study was a quality improvement (QI) initiative conducted from May 2018 to April 2019. All preterm neonates <34 weeks were included. In the "initiation phase" (May 2018 to August 2018), a breastfeeding support group was formed and mothers were given structured antenatal and postnatal counseling regarding MOM using videos and leaflets. This improved MOM rates when compared with retrospective controls. In the continuation phase (August-2018 to April-2019), various plan-do-study-act cycles were conducted to test strategies such as frequent telephonic reminders, standardization of Kangaroo mother care, nonnutritive sucking protocols, and involving family members during daily counseling sessions. The initiation and continuation phases were compared with the retrospective baseline data. Results: Of a total of 125 preterm neonates, 27 were excluded for various reasons. Within 3 months of initiating the study, the proportion of neonates who received MOM within first 24 hours improved from 24% in retrospective controls to 82.9% in the initiation phase (p < 0.0001) and remained stable at 90.3% in the continuation phase. The amount of MOM received on day 1 increased significantly (p < 0.0001) from a median of 0 mL to 1 mL in the initiation phase and was maintained at 3 mL in the continuation phase. Amount of MOM increased significantly on day 3 (p = 0.0003) and day 7 (p = 0.03). Babies discharged on MOM also improved significantly (p = 0.005) from 48.3% in the retrospective cohort to 77.4% in the continuation phase. The number of babies receiving total parenteral nutrition decreased significantly (p = 0.02) from 54.6% to 26.7%. Conclusions: QI has shown promising results in improving MOM in preterm neonates.

A quality initiative to improve exclusive breast milk feeding in preterm neonates.

BACKGROUND AND OBJECTIVE: Preterm babies thrive well on exclusive breastfeeding with fewer complications. In a retrospective analysis, challenges were noticed in the form of delayed first milk expression and frequency of expression, which was limited to 2-3 times a day. A quality improvement initiative was designed to increase the exclusive breast milk feeding rates in admitted preterm babies. The purpose of the present study is to evaluate the proportion of preterm neonates receiving mother's own milk by day 7 of life after such an initiative. METHODS: The quality improvement initiative was conducted at a level 3 neonatal intensive care unit from May 10, 2018, to August 10, 2018. Inborn preterm neonates <34 weeks with a minimum hospital stay of 7 days were included. Neonates of critically sick mothers and neonates having major congenital malformations were excluded. Mothers were given structured antenatal counseling regarding expressing breast milk (EBM). Postnatal visits were conducted to provide information through a video and a leaflet and formation of breastfeeding support group. RESULTS: A total of 30 babies were recruited during a period of 3 months and compared to historical controls. The median age of the first EBM improved from 2.5 days to 1.16 days, and the amount of EBM on the first day improved from 0.24 ml to 2.6 ml (p = .002). The proportion of babies receiving EBM on the first day improved from 24% to 80% (p = .0001), and at the end of 7 days, it increased to 73% from 46% (p = .02). The factors time to reach full enteral feeds, time to regain birth weight, rate of necrotizing enterocolitis, rate of sepsis, and proportion of babies on exclusive mother's milk during discharge appear comparable in both the groups. CONCLUSIONS: A simple quality improvement approach through the formation of breastfeeding support group, antenatal counseling, and postnatal support for breast milk expression has made a significant improvement in milk expression from mothers delivered prematurely. It reflects on a team approach using the available resources.