Guidelines for feeding very low birth weight infants.

Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.

Respiratory syncytial virus prophylaxis in children with cardiac disease: a retrospective single-centre study.

OBJECTIVES: To examine the characteristics of congenital heart disease patients hospitalised with respiratory syncytial virus infection after prophylaxis and determine the associated comorbidities and the incidence of breakthrough respiratory syncytial virus infections. STUDY DESIGN: This is a retrospective, single-centre study that was conducted over a period of 7 years. Respiratory syncytial virus infection was identified by classification codes and confirmed by virological tests. Data on baseline demographics, cardiac anomalies, other underlying disease, criteria for hospitalisation, type of respiratory illness and management, complications, and palivizumab prophylaxis were analysed by standard descriptive methods and comparative statistics. RESULTS: A total of 30 patients were enrolled. The majority were ≤ 2 years (n = 24). The mean admission age was 15.1 months (standard deviation = 18.3). In all, 90% were acyanotic, 40% had haemodynamically significant disease, and 60% had ≥ 1 underlying medical illness. Patients were admitted with: respiratory distress (86.7%), hypoxaemia (66.7%), fever (60%), inability to maintain oral intake (36.7%), and apnoea (16.7%). More than 50% required mechanical ventilation and intensive care with a median stay of 11 days (range: 1-43); the length of hospital stay for all children was 10 days (range: 1-65). Complications included: concurrent bacterial sepsis (20%), electrolyte abnormalities (16.7%), and worsening pulmonary hypertension (13.3%). Of 10 infants ≤ 2 years with haemodynamically significant heart disease, four had received prophylaxis. There was one death, which was attributed to respiratory syncytial virus infection. CONCLUSIONS: Overall, 185 infants ≤ 2 years with haemodynamically significant cardiac disease received prophylaxis. In all, six qualifying infants missed immunisation and were hospitalised. Breakthrough respiratory syncytial virus infections occurred in 2.2%, demonstrating good efficacy of palivizumab in this population compared with the original, multi-centre, randomised trial.

The impact of prophylaxis on paediatric intensive care unit admissions for RSV infection: a retrospective, single-centre study.

Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections and hospitalizations in children aged < 2 years. The aim of this retrospective, single-centre study was to examine the characteristics of patients admitted to a paediatric intensive care unit (PICU) with RSV infection following the implementation of a RSV prophylaxis programme. Electronic hospital medical records of all PICU admissions for RSV infection were searched from 2003 to 2009. Data on baseline demographics, underlying disease, criteria for hospitalization, respiratory diagnosis and management, complications and palivizumab prophylaxis were collected. A total of 181 patients were admitted with RSV infection, accounting for 5.7% of all admissions. Eighty-four percent were ≤ 2 years of age. Majority (70.2%) had no underlying medical illness, and 79.6% received antibiotics as part of their medical treatment. Comparison of children aged ≤ 2 years and those >2 years revealed that fewer of the younger cohort (20.4% versus 79.3%; p < 0.001) had an underlying medical condition. RSV infection occurred in 3.3% (n = 6) children who had received palivizumab prophylaxis, and there were two deaths. The results indicate that > 88% of all PICU admissions would not qualify for RSV prophylaxis under our established guidelines and 66% of the children aged ≤ 2 years were > 36 weeks gestation and are not currently targeted for prophylaxis. The number of high-risk infants admitted to PICU with RSV infection has likely plateaued, and further reductions in admission rates may only be realised with the use of universal, vaccine immunization programmes.

Outcomes of late-preterm infants: a retrospective, single-center, Canadian study.

OBJECTIVE: To study the prevalence of major morbidities and mortality of inborn, late-preterm infants. Methods. A retrospective review was conducted from 2004 to 2008. Descriptive outcomes were compared with predefined aggregate outcomes of term infants during the same period. RESULTS: Data on 1193 late-preterm and 8666 term infants were compared. Majority of late-preterm infants were 36 weeks (43.6%), followed by 35 weeks (29.2%) and 34 weeks (27.2%), respectively. The prevalence of intensive care admission, respiratory support, pneumothorax, and mortality in late preterm infants was significantly higher compared with term infants. Mechanical ventilation and continuous positive airway pressure rates substantially decreased with increased gestational age. Although only 1.0% had positive cultures, 28.5% received parenteral antibiotics. The late-preterm group had a 12-fold higher risk of death with an overall mortality rate of 0.8%. CONCLUSION: This study confirmed the high-risk status of late-preterm infants with worse mortality and morbidities compared with term infants.

Risk-Scoring Tool for respiratory syncytial virus prophylaxis in premature infants born at 33-35 completed weeks' gestational age in Canada.

OBJECTIVE: To study the impact of the Risk-Scoring Tool (RST) as a strategy for targeting prophylaxis effectively in 33-35-week gestational age (GA) Canadian infants who range from low to high risk by evaluating the subsequent incidence of respiratory syncytial virus (RSV) infections resulting in emergency room (ER) visits and hospitalization. DESIGN: Prospective, descriptive study. SETTING: McMaster Children's Hospital and St Joseph's Healthcare in Hamilton, Ontario. PARTICIPANTS: Premature infants between 33 and 35 weeks' completed gestation who were less than 6 months' chronological age at the start of, or during, the local 2005-2008 RSV winter seasons. METHODS: A validated, Canadian RST was used to calculate a total risk score based on seven risk factors. Only infants at moderate (RST score 49-64) and high risk (RST score 65-100) received palivizumab at monthly intervals from November to April and were followed during the respective RSV seasons. All parents received information on RSV prevention at hospital discharge. Parents of all recruited infants were contacted by telephone in May at the end of each season, and medical records were checked to determine ER visits for RSV-related respiratory tract infections and RSV hospitalization. Means, standard deviations, ranges, and percents were used to describe the variables for patients enrolled in the study. RESULTS: Over 3 years, 430 infants were recruited. Of these, 346 (81%), 57 (13%), and 27 (6%) were in the low-, moderate- and high-risk categories, respectively, based on their risk scores. A total of 78 (18.1%) infants received full courses of palivizumab. Six out of 57 (10.5%) infants in the moderate-risk group did not receive prophylaxis, while all 27 high-risk group infants received palivizumab. Seven (1.6%) infants were RSV-positive and five (low-risk) infants were hospitalized. One high-risk, RSV-positive infant, was seen in the ER, and discharged home. There were no statistical differences in the number of infants with RSV-related ER visits and hospitalizations within the risk category groups (p = 0.43). The limitations of this study include the observational design and the relatively small sample size. CONCLUSIONS: The RST is a practical, easy-to-use instrument to guide judicious RSV prophylaxis for moderate-high-risk, 33-35-week GA infants. It is cost-effective, reducing hospitalization in infants who are most 'at-risk', while avoiding prophylaxis in a large segment (81.9%) of this GA cohort who are considered low risk for RSV infection.

Heat Loss Prevention (HeLP) in the delivery room: A randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants.

OBJECTIVES: To determine if polyethylene occlusive skin wrapping of very preterm infants prevents heat loss after delivery better than conventional drying and to evaluate if any benefit is sustained after wrap removal. STUDY DESIGN: This was a randomized controlled trial of infants <28 weeks' gestation. The experimental group was wrapped from the neck down. Only the head was dried. Control infants were dried completely. Rectal temperatures were compared on admission to the neonatal intensive care unit immediately after wrap removal and 1 hour later. RESULTS: Of 55 infants randomly assigned (28 wrap, 27 control), 2 died in the delivery room and 53 completed the study. Wrapped infants had a higher mean rectal admission temperature, 36.5 degrees C (SD, 0.8 degrees C), compared with 35.6 degrees C (SD, 1.3 degrees C) in control infants ( P = .002). One hour later, mean rectal temperatures were similar in both groups (36.6 degrees C, SD, 0.7 degrees C vs 36.4 degrees C, SD, 0.9 degrees C, P = .4). Size at birth was an important determinant of heat loss: Mean rectal admission temperature increased by 0.21 degrees C (95% CI, 0.04 to 0.4) with each 100-g increase in birth weight. CONCLUSIONS: Polyethylene occlusive skin wrapping prevents rather than delays heat loss at delivery in very preterm infants.

Comparison of capillary blood sampling using an automated incision device with and without warming the heel.

OBJECTIVE: To determine if heel warming prior to heelstick increases the volume of blood collected compared to no warming. STUDY DESIGN: Randomized controlled trial involving 100 preterm and term infants requiring capillary blood sampling (CBS), randomized to receive warming (Control) (n=50) or nonwarming (Experimental) (n=50). RESULTS: This sample of infants showed no benefit of warming the heel prior to CBS. Volume of blood, collection time, crying time, and repeat procedures were not different between groups. More infants in the Control group received squeezing during the procedure compared to the Experimental group. CONCLUSION: Heel warming prior to CBS may be an unnecessary technique in preterm and term infants that expends nursing time and hospital financial cost.