High Beta-palmitate formula and bone strength in term infants: a randomized, double-blind, controlled trial.

We aimed to compare the effect of 12-week feeding of commercially available infant formulas with different percentages of palmitic acid at sn-2 (beta-palmitate) on anthropometric measures and bone strength of term infants. It was hypothesized that feeding infants with high beta-palmitate (HBP) formula will enhance their bone speed of sound (SOS). Eighty-three infants appropriate for gestational age participated in the study; of these, 58 were formula-fed and 25 breast-fed infants, serving as a reference group. The formula-fed infants were randomly assigned to receive HBP formula (43 % of the palmitic acid is esterified to the middle position of the glycerol backbone, study group; n = 30) or regular formula with low-beta palmitate (LBP, 14 % of the palmitic acid is esterified to the middle position of the glycerol backbone, n = 28). Sixty-six infants completed the 12-week study. Anthropometric and quantitative ultrasound measurements of bone SOS for assessment of bone strength were performed at randomization and at 6 and 12 weeks postnatal age. At randomization, gestational age, birth weight, and bone SOS were comparable between the three groups. At 12 weeks postnatal age, the mean bone SOS of the HBP group was significantly higher than that of the LBP group (2,896 ± 133 vs. 2,825 ± 79 m/s respectively, P = 0.049) and comparable with that of the breast-fed group (2,875 ± 85 m/s). We concluded that infants consuming HBP formula had changes in bone SOS that were comparable to those of infants consuming breast milk and favorable compared to infants consuming LBP formula.

Combining kangaroo care and live harp music therapy in the neonatal intensive care unit setting.

BACKGROUND: Music therapy has been recommended as an adjuvant therapy for both preterm infants and mothers during their stay in the neonatal intensive care unit (NICU), and has been shown to have beneficial effects. OBJECTIVES: To study the usefulness of combining live harp music therapy and kangaroo care (KC) on short-term physiological and behavioral parameters of preterm infants and their mothers in the NICU setting. METHODS: Included in this study were stable infants born between 32 and 37 weeks of gestation, with normal hearing. Mother-infant dyads were randomly assigned to KC and live harp music therapy or to KC alone. Using repeated measures, neonatal and maternal heart rate, oxygen saturation and respiratory rate were recorded along with neonatal behavioral state and maternal anxiety state. Maternal age, ethnicity, education, and love of music were documented. RESULTS: Fifty-two mother-infant dyads were tested. Compared with KC alone, KC and live harp music therapy had a significantly beneficial effect on maternal anxiety score (46.8 +/- 10 vs. 27.7 +/- 7.1, respectively, P < 0.01). Infants' physiological responses and behavior did not differ significantly. No correlation was found between mothers' age, ethnicity, years of education and affinity for music, and anxiety scores (P = 0.2 to 0.5 for all four variables). CONCLUSIONS: KC combined with live harp music therapy is more beneficial in reducing maternal anxiety than KC alone. This combined therapy had no apparent effect on the tested infants' physiological responses or behavioral state.

Vitamin E levels during early iron supplementation in preterm infants.

On the basis of preliminary data, this larger bi-institutional continuation trial evaluating the efficacy and safety of early iron supplementation in preterm infants calls attention to the levels of vitamin E, a marker of antioxidant activity, during iron treatment. A total of 116 preterm infants were randomly assigned to receive at 2 or 4 weeks of age ( N = 62, N = 54, respectively) 5 mg/kg/d of nonionic iron polymaltose complex concomitantly with a daily dose of 25 IU vitamin E (as dl-alpha-tocopherol acetate) from 2 weeks of age. Vitamin E (alpha-tocopherol) levels, iron, ferritin, hemoglobin concentration, and reticulocyte count were recorded from 2 to 8 weeks of age. The morbidities of prematurity associated with free radicals formation were also documented. A gradual increase of alpha-tocopherol levels within physiological range (0.8 to 3.5 mg/dL) was found in the 2-week and 4-week groups during the study period with no difference among the groups ( P > 0.05 for all comparisons). At 8 weeks of age, iron and ferritin levels, hemoglobin concentration, and reticulocyte count were higher in the 2-week group. No correlation was observed between timing of both iron and vitamin E supplement and hemolysis or morbidities associated with prematurity. Thus, treatment of iron with vitamin E supplement at 2 weeks of age is, in our experience, an efficacious and safe treatment for improving anemia in preterm infants.

Continuous lumbar/thoracic epidural analgesia in low-weight paediatric surgical patients: practical aspects and pitfalls.

PURPOSE: Continuous epidural anaesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of the study was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anaesthesia for major surgery. METHODS: Data were collected prospectively from 44 epidural anaesthetics in 40 infants (18 premature or former premature) weighing 1,400-4,300 g who underwent major abdominal surgery (33 cases), thoracic surgery (5), or both (1), or ano-rectal surgery (5) at our centre. RESULTS: Epidural placement was achieved easily in all cases, with high quality analgesia for 24-96 h. Tracheal extubation was delayed after 4 anaesthetics due to muscle relaxant overdose (n = 1), surgeon's request (n = 2), and systemic opioid administration before epidural anaesthesia was considered (n = 1). Intraoperative complications included haemodynamic instability (n = 1) and vascular catheter placement (n = 5). Postoperative complications included meningitis (n = 1), insertion site erythema (n = 7), apnoea (n = 6; 4 premature and 2 full-term infants) and tracheal re-intubation (n = 6). CONCLUSIONS: Continuous epidural analgesia is effective in low-weight infants undergoing major surgery. The trachea may be extubated immediately after surgery. Attention should be paid to the unique anatomical, physiological, and pharmacological aspects. The patients should be monitored carefully for pain, respiratory failure, and meningitis (an extremely rare complication).

Increased sodium concentrations in drinking water increase blood pressure in neonates.

BACKGROUND: In a previous study, we found that increased sodium concentrations in the drinking water led to an increase in mean arterial pressure (MAP) and systolic blood pressure (SBP) in fourth- and fifth-grade school children. Milk powder formulae have a low content of sodium, almost identical to that of breast milk. However, the final sodium concentration in the milk formula depends upon the concentration of sodium in the diluting water, which varies remarkably. OBJECTIVE: To evaluate changes in blood pressure during the first 2 months of life in neonates receiving low-sodium mineral water (LSMW), high-sodium tap water (HSTW), or breast milk. DESIGN: A randomized, prospective study in a teaching hospital. METHODS: Fifty-eight Jewish term infants maintained on milk formula were randomly assigned to two groups. Group 1 consisted of 25 infants whose formula was diluted with LSMW (Eden Spring Mineral Water) having a sodium concentration of 32 mg/l (1.4 mmol/l). Group 2 contained 33 infants whose formula was diluted with HSTW having a sodium concentration of 196 mg/l (8.5 mmol/l). Fifteen breastfed babies served as the control group (group 3). Weekly weight, height, head circumference, heart rate, and systolic (SBP), diastolic (DBP) and mean (MAP) blood pressures were recorded for each infant for 8 consecutive weeks after birth. After 8 weeks, group 1 reverted to a diet similar to that of group 2. At 6 months of age (week 24), a follow-up blood pressure measurement was performed in 11, 20 and seven infants in groups 1, 2 and 3, respectively. Blood pressure was measured during sleep. Urinary sodium : creatinine ratio was determined monthly during the initial 2 months. RESULTS: Increases in weight and height were equal in all groups. Heart rate did not differ between groups during the entire study period. From the age of 6 weeks until week 8, MAP, SBP and DBP were found to be significantly greater in the group 2 (HSTW). In parallel, the urinary sodium : creatinine ratio was significantly greater in this group. At week 24, blood pressure values in group 1 increased towards those of group 2. CONCLUSIONS: Diluting milk formula with tap water containing a high concentration of sodium will result in the infant being fed a high-salt diet. To equilibrate with breast milk, formula should be diluted with low-salt water. Blood pressure in the neonate is increased by a high sodium intake via drinking water.

Wiedemann-Beckwith syndrome: further prenatal characterization of the condition.

We describe three unrelated cases of Wiedemann-Beckwith syndrome (WBS). Two of them were diagnosed postnatally while the third was detected during pregnancy that resulted in elective termination. Amniotic karyotypes were normal in all. PCR amplification of polymorphic loci mapping to 11p15.5 region documented partial trisomy of 11p15.5 due to paternal translocation in one, and segmental and mosaic segmental unipaternal disomy (UPD) in the second and third cases, respectively. Based on findings documented in these cases and the literature, we tabulated the anomalies that might be detected prenatally by ultrasound and that may suggest the syndrome. Constant findings included fetal overgrowth, polyhydramios, enlarged placenta, and specifically a distended abdomen. As most described signs developed after 22 weeks of gestation, a careful follow-up should be carried on until late stages of pregnancy. An amniotic karyotype might not detect subtle chromosomal rearrangements. We therefore recommend utilizing PCR of polymorphic loci on 11p15.5, in addition to conventional cytogenetic analysis of the fetus and both parents to detect possible maternal deletions or inversions, paternal duplications, and UPD that may account for the largest subset of sporadic WBS reaching 25% of cases. An early diagnosis of WBS is important for counseling the parents concerning potential risk for developing embryonic tumors, selection of the mode of delivery due to potential adrenal cysts that might bleed during labor, and prevention of neonatal hypoglycemia.

Urinary tract infection in very low birth weight preterm infants.

BACKGROUND: The prevalence of urinary tract infection (UTI) in preterm neonates ranges between 4 and 25%. The need for a radiologic investigation has not yet been established in very low birth weight premature newborns (<1500 g birth weight). PATIENTS AND METHODS: For an 11-year period (1990 to 2001), medical records of 62 very low birth weight premature infants admitted to a Level III neonatal intensive care unit and who developed UTI were reviewed retrospectively. Results of renal ultrasound and voiding cystourethrograms were compared between extremely low birth weight infants (birth weight, <1000 g) (Group A, Patient 34) and premature infants with birth weight between 1001 and 1500 g (Group B, Patient 28). RESULTS: UTI was more common in Group A (12.2%) than in Group B (5.7%) infants. Renal ultrasound detected mild renal pelvic dilatation (unilateral or bilateral) in 9 infants in Group A (26%) and in 1 infant in Group B (3.5%). Voiding cystourethrograms were performed in 26 of 34 (76%) infants in Group A and in 17 of the 28 (61%) premature infants in Group B. Vesicourethral reflux (VUR) was observed in 6 infants, 2 in group A (7.7%) and 4 in Group B (23%). CONCLUSIONS: We found that the rate of VUR was lower in very low birth weight premature newborns than that reported in the medical literature among term newborns who developed UTI. VUR was less frequent in extremely low birth weight infants who developed UTI than in infants weighing 1001 to 1500 g.

Spontaneous activity in premature infants affects bone strength.

OBJECTIVE: Determination of bone strength of lower extremities in very low birth weight (VLBW) premature infants with central nervous system pathology resulting in reduced unilateral spontaneous leg movements. STUDY DESIGN: Quantitative ultrasound (QUS) measurements of speed of sound (SOS) of the tibiae of both legs in three VLBW premature infants with brain insult and unilateral reduced spontaneous activity. Results were compared to QUS measurements of both legs in healthy premature infants. Measurements were performed by the same investigator who was blinded to the clinical course of the participants. RESULTS: Reduced spontaneous activity of one leg due to brain pathology resulted in decreased tibial SOS in the affected side. There was no difference in bone SOS between the legs of the healthy controls. CONCLUSION: Spontaneous movements (mainly antigravity flexion and extension) are important for bone structure and mineralization in VLBW premature infants. QUS may become an important diagnostic modality for the evaluation, treatment, and follow-up of bone strength and osteopenia in this unique population.

The effects of exercise on body weight and circulating leptin in premature infants.

OBJECTIVE: To assess the effect of daily movements on weight gain, serum leptin, and insulin-like growth factor I (IGF-I) in premature infants. STUDY DESIGN: Twenty very-low-birth-weight premature infants were matched and randomized to a daily movement (n = 10) and control groups (n = 10). Daily movement consisted of passive range of motion with gentle compression of both the upper and lower extremities 5 days per week for 4 weeks. RESULTS: Daily movements led to a significant increase in weight gain (784 +/- 51 vs 608 +/- 26 g in movements and controls, respectively, p < 0.02), and to a significant increase in leptin (0.60 +/- 0.19 vs 0.13 +/- 0.06 ng/ml in movements and controls, respectively 18.8 +/- 4.1 vs 9.2 +/- 4.1 ng/ml in movements and controls, respectively); however, this increase was not statistically significant. CONCLUSION: A relatively brief range of motion daily movement intervention was associated with greater weight gain and increased leptin levels in very-low-birth-weight premature infants. This may suggest that at least part of the daily movements associated with increase in body weight resulted from an increase in adipose tissue.

The effect of neonatal sepsis on bone turnover in very-low birth weight premature infants.

Neonatal sepsis is very common in preterm infants, and severe morbidity during the neonatal period is a major cause of osteopenia of prematurity. We examined the effect of neonatal sepsis on bone turnover markers in premature infants. Twenty-four premature infants participated in the study. Ten of the premature infants developed sepsis during their hospitalization in the neonatal intensive care unit (mean gestational age [GA] 27.3 +/- 0.4 weeks; mean birth weight [BW] 898 +/- 82 g). Fourteen infants who did not develop sepsis served as controls (GA: 26.8 +/- 0.8 weeks, BW: 892 +/- 66 g). Blood samples for bone turnover markers were collected during the initial sepsis workup, and at the end of the first week of treatment, and were compared to the corresponding weekly changes in bone markers in the controls. In addition, samples were collected at the end of the 10th week of life to determine long-term effects of sepsis on bone turnover. Bone osteoblastic activity was assessed by measurements of circulating osteocalcin, bone-specific alkaline phosphatase (BSAP) and the C-terminal procollagen peptide (PICP) levels. Bone resorption was assessed by measurements of circulating carboxy terminal cross-links telopeptide of type I collagen (ICTP). There were no significant differences in the weekly changes of all bone turnover markers in premature infants who developed or did not develop sepsis. No significant differences were found in bone turnover markers at the age of 10 weeks between the groups. Neonatal sepsis in premature infants was not associated with biochemical evidence of reduced bone turnover.

Bone speed of sound in infants of mothers with gestational diabetes mellitus.

OBJECTIVE: Bone strength in infants of mothers with gestational diabetes mellitus (IGDM) was reported to be either decreased or unaltered. However, no report using quantitative ultrasound measurement of speed of sound (QUS-SOS) for bone strength assessment has been published. The aim of the present study was to assess bone strength by QUS-SOS measurements in IGDM in comparison to healthy matched full-term infants. DESIGN: Nineteen IGDM and 18 healthy controls participated in the study. Postnatal tibial bone SOS was measured by Sunlight Omnisense. RESULTS: Mean birth weight (BW) of IGDM (3,587.6+/-148.6 g) was higher compared to the control infants (3,311.1+/-74.5 g), but this difference was not statistically significant. Mean bone SOS was significantly lower in IGDM (2,976.7+/-27.2 m/sec) compared to the control infants (3,093.3+/-23.6 m/sec; p <0.003). There was a significant negative correlation between bone SOS and BW in all the study participants (r = -0.32, p <0.025). No significant difference in BW and bone SOS was noted between infants with postnatal hypoglycemia and normoglycemia. There was no correlation between maternal HbA1c during pregnancy and neonatal bone SOS. CONCLUSIONS: Bone strength was significantly decreased in IGDM compared to healthy controls. Neonates with higher BW had lower bone SOS. Since mechanical strain is a potent stimulation for bone formation and strength, it is suggested that the reduced bone strength in IGDM may also be the result of reduced intrauterine fetal mobility due to maternal gestational diabetes mellitus.

Enriched post-discharge formula versus term formula for bone strength in very low birth weight infants: a longitudinal pilot study.

AIM: To initiate a longitudinal pilot study comparing the effect of nutrient-enriched post-discharge formula (PDF) with standard term formula (TF) on bone strength of very low birth weight (VLBW) infants in the first six months post-term. METHODS: Two matched groups of VLBW infants were randomly assigned to enriched PDF (n=10) or TF (n=10) at corrected age of 40 weeks. Anthropometric measurements of growth and measurements of bone speed of sound (SOS) indicating bone strength and bone turnover markers (bone-specific alkaline phosphatase and cross-linked carboxy terminal telopeptide of type I collagen) were taken at term and at three and six months corrected age. RESULTS: The anthropometric measurements of infants fed PDF and TF were comparable at three and six months corrected age. Bone SOS of the PDF group increased from 2760+/-113 m/s at term to 2877+/-90 m/s and 3032+/-60 m/s at three and six months corrected age, respectively (P<0.001). Likewise, bone SOS of the TF group increased from 2695+/-116 m/s at term to 2846+/-72 and 2978+/-83 m/s at three and six months, respectively (P<0.001). No statistically significant difference was found between the groups in terms of growth and bone SOS measurements. The levels of both bone turnover markers decreased significantly during the study period (P<0.001 for both groups). CONCLUSION: Feeding with PDF after term had no short-term beneficial effect on bone strength and bone turn-over of VLBW infants.

The efficacy and safety of early supplementation of iron polymaltose complex in preterm infants.

The purpose of this study was to examine the efficacy and safety of early nonionic iron supplementation in preterm infants. Infants with gestational age < or = 32 weeks who were fed enriched human milk were assigned concurrently to receive 5 mg/kg/d enteral iron polymaltose complex (IPC) at 2 or 4 weeks of age. The levels of hemoglobin, reticulocytes, serum iron, ferritin, and soluble transferrin receptor were recorded at 2, 4, and 8 weeks of age. The incidence of morbidities associated with prematurity and the need for red blood cell transfusions (RBCTs) were recorded. The 2-week group (n = 32) had a better iron status than the 4-week group (n = 36) at 4 weeks and at 8 weeks of age. The incidence of morbidities associated with prematurity was not different among the groups ( P = 0.26). RBCT was required in one infants of the 2-week group and in 10 infants in the 4-week group ( P = 0.045). The number needed to treat to prevent one RBCT was five. Supplementation of 5 mg/kg/d enteral IPC to preterm infants fed enriched human milk as early as 2 weeks of age was more beneficial to iron status than at 4 weeks of age, and was associated with decreased need for RBCTs and no increase in the incidence of morbidities associated with prematurity.

Live music is beneficial to preterm infants in the neonatal intensive care unit environment.

BACKGROUND: Music stimulation has been shown to provide significant benefits to preterm infants. We hypothesized that live music therapy was more beneficial than recorded music and might improve physiological and behavioral parameters of stable preterm infants in the neonatal intensive care unit. METHODS: Thirty-one stable infants randomly received live music, recorded music, and no music therapy over 3 consecutive days. A control of the environment noise level was imposed. Each therapy was delivered for 30 minutes. Inclusion criteria were postconceptional age > or = 32 weeks, weight > or = 1,500 g, hearing confirmed by distortion product otoacoustic emissions (DPOAEs), and no active illness or documentation of hyperresponsiveness to the music. Heart rate, respiratory rate, oxygen saturation, and a behavioral assessment were recorded, every 5 minutes, before, during, and after therapy, allowing 30 minutes for each interval. The infant's state was given a numerical score as follows: 1, deep sleep; 2, light sleep; 3, drowsy; 4, quiet awake or alert; 5, actively awake and aroused; 6, highly aroused, upset, or crying; and 7, prolonged respiratory pause > 8 seconds. The volume range of both music therapies was from 55 to 70 dB. Parents and medical personnel completed a brief questionnaire indicating the effect of the three therapies. RESULTS: Live music therapy had no significant effect on physiological and behavioral parameters during the 30-minute therapy; however, at the 30-minute interval after the therapy ended, it significantly reduced heart rate (150 +/- 3.3 beats/min before therapy vs 127 +/- 6.5 beats/min after therapy) and improved the behavioral score (3.1 +/- 0.8 before therapy vs 1.3 +/- 0.6 after therapy, p < 0.001). Recorded music and no music therapies had no significant effect on any of the tested parameters during all intervals. Both medical personnel and parents preferred live music therapy to recorded music and no music therapies; however, parents considered live music therapy significantly more effective than the other therapies. CONCLUSIONS: Compared with recorded music or no music therapy, live music therapy is associated with a reduced heart rate and a deeper sleep at 30 minutes after therapy in stable preterm infants. Both recorded and no music therapies had no significant effect on the tested physiological and behavioral parameters.

Breakthrough candida Infection in a preterm infant with congenital cutaneous Candida albicans infection.

Amphotericin B is the primary antifungal agent used for candida sepsis in neonates. Breakthrough candidemia was not reported in neonates during either amphotericin B or liposomal amphotericin B (AmBisome) treatment. We describe a case of a premature infant with congenital cutaneous candida infection, who had two episodes of breakthrough infection, from Candida albicans and Candida parapsilosis, while he was treated with amphotericin B and AmBisome, respectively. We discuss the pathogenesis of breakthrough infections, and the relevance of antifungal resistance and sensitivities testing.

High maternal estriol level in pregnancy as a predictor of surgical intervention for undescended testis.

To assess whether elevated levels of estriol (E3) in pregnancy are a factor in the fetal environment associated with undescended testes, we carried out a two-part study: case-control followed by a retrospective cohort study on cryptorchid boys born in the Sapir Medical Center (Kfar Saba, Israel). We found significantly lower pregnancy urinary E3 levels in cryptorchid newborns as compared to controls; however, subgroup comparison yielded significantly higher pregnancy unconjugated E3 levels in the infants who underwent orchiopexy as compared to those who did not.

Serum amyloid A protein is a useful inflammatory marker during late-onset sepsis in preterm infants.

BACKGROUND: Few studies demonstrated that serum amyloid A (SAA), a non-specific acute-phase reactant, could be used as a reliable early marker for the diagnosis of late-onset sepsis (LOS). OBJECTIVES: To evaluate the diagnostic value and the dynamics of SAA levels during the course of LOS and to compare it to those of other inflammatory markers. METHODS: Levels of SAA, C-reactive protein (CRP) and IL-6 together with clinical variables, biochemical parameters and cultures retrieved from all preterm infants suspected of LOS were checked at the first suspicion of sepsis and after 8, 24, 48 and 72 h. Results were compared to healthy, matched infants. RESULTS: One hundred and sixteen infants were included in the study, 38 in the sepsis and 78 in the non-sepsis group. High levels of SAA were observed at sepsis onset, with a gradual decline thereafter, while CRP levels increased only at 24 h after sepsis onset. In the sepsis group, levels of SAA returned faster to baseline than CRP levels. Receiver-operating characteristic analysis values revealed that SAA at 10 mug/ml had the highest sensitivity at 0, 8 and 24 h after sepsis onset (95, 100 and 97%, respectively) and a negative predictive value (97, 100 and 98%, respectively). CONCLUSIONS: SAA is an accurate acute-phase protein during LOS in preterm infants. Quick and reliable SAA kits can make this marker a useful tool in LOS in preterm infants.

Bacillus species sepsis in the neonatal intensive care unit.

OBJECTIVES: In 2002 there was an increase in the incidence of Bacillus species sepsis in our NICU that was almost completely resolved in 2003-2004 after the NICU was relocated. Our aims were to identify the source, the risk factors, and to characterize the clinical features of these infections. METHODS: The epidemiological investigation commenced during the outbreak and thereafter. The patient's data were collected retrospectively and a case control study was used to analyze the risk factors. RESULTS: There were eight cases of Bacillus species sepsis: five during 2002, two in 2003, and one in 2004. All infants recovered and salvaging percutaneous central venous catheter (PCVC) was successful in 4/6 of the cases. A case control study identified necrotizing enterocolitis (NEC) and PCVC as risk factors in univariate analysis but only NEC in multivariate analysis. No focal source of Bacillus bacteria was identified, but a high load of bacteria was found in the NICU's air before it was relocated. CONCLUSION: The risk factors for Bacillus species sepsis in our NICU were NEC and PCVC. The clinical course was milder than previously described, and PCVC was successfully salvaged in most cases. The increase in the incidence could be related to the construction work connected with NICU's relocation.