NICU Graduate Reunion: "A Celebration of Life".

BACKGROUND: Few understand the experience of having an infant in the neonatal intensive care unit (NICU). This article provides a discussion about the importance of an annual reunion for former NICU infants, their families, and neonatal staff. PURPOSE: The purpose of this article is to explain the impact of the NICU reunion on families and neonatal healthcare providers and describe the experience of organizing this reunion over the past 20 years. METHODS: This is a description of how a NICU reunion was organized at a regional neonatal center. Graphic-designed invitations were e-mailed to NICU graduates, who previously agreed to being contacted, 2 months prior to the reunion date. Social media were utilized to publicize the event on the hospital's Web site. RESULTS: At the reunion, parents and families introduced their NICU graduate to the neonatal staff who cared for them while hospitalized. Sometimes staff found it difficult to recognize the NICU graduates, who were toddlers or older. Parents were relaxed, expressing their appreciation for care received. IMPLICATIONS FOR PRACTICE: The impact of seeing an infant, born at 24 weeks, now walking, talking, and running cultivates pride in the NICU healthcare team. The reunion adds a positive dimension to the work of NICU caregivers. Parents look forward to attending the reunion to reconnect with NICU staff and other NICU parents. IMPLICATIONS FOR RESEARCH: Directions for future study include a comparison of staff and families who attend the NICU reunion and those who do not, by using a survey or online evaluation tool, to improve future reunions.

Babies born with gastroschisis and followed up to the age of six years faced long-term morbidity and impairments.

AIM: The aims of this Argentinian study were to describe and analyse the outcomes of a continuous interdisciplinary follow-up programme of patients with gastroschisis. METHODS: This was a prospective, longitudinal study of babies with gastroschisis admitted from 1 November 2003 to 31 October 2014, and this paper presents results at one, three and six years of age. Matched-pairs analyses were carried out when they were one and six. RESULTS: We enrolled 62 babies and assessed 52 at one year of age, 34 at three years and 17 at six years. This showed that 63% had mental health problems and 5% had recurrent wheezing. Normal outcomes at one, three and six years were growth (80%, 85% and 80%), neurology-psychomotor development index (64%, 50% and 82%), audiology (100%, 76% and 76%), vision (98%, 94% and 89%) and language (55%, 62% and 65%). The rehospitalisation rates were 30%, 0.3% and zero, and the surgical re-intervention rates were 9%, 0.3% and 12%. Matched-pairs analysis showed no significant differences between outcomes at the ages of one and six. CONCLUSION: Babies born with gastroschisis were at risk for long-term morbidity and impairments, according to follow-up assessments at the ages of one, three and six years.

Using a novel laminar flow unit provided effective total body hypothermia for neonatal hypoxic encephalopathy.

AIM: This was a clinical observational trial on a laminar flow device that provides total body hypothermia for infants with hypoxic ischaemic encephalopathy (HIE). METHODS: We enrolled infants born at up to 35 weeks of gestation, who presented with HIE within six hours of birth. Total body cooling was achieved using the neonatal laminar flow unit for 72 hours, with continuous rectal temperature servo control, isolation and humidification. Outcome measures were cerebral palsy, a Bayley II Mental Development Index score <70, hearing loss or blindness. We compared findings with previously published studies. RESULTS: We included 26 newborn infants (69% male) with a birthweight of 3.341 ± 1658 g and gestational age of 38.2 ± 3.2 weeks. The majority (62.6%) had a Sarnat HIE score of three and 38.4% had a score of two. Total body cooling (33-34°C) was achieved in 70 minutes and maintained with servo control, showing very little variability until rewarming. At 18-24 months of age, two of the 18 survivors were diagnosed with cerebral palsy and one was diagnosed with impaired hearing. CONCLUSION: The laminar flow unit proved effective in maintaining moderate total body hypothermia under well-controlled conditions, and our results were very similar to other studies.

Safe oxygen saturation targeting and monitoring in preterm infants: can we avoid hypoxia and hyperoxia?

UNLABELLED: Oxygen is a neonatal health hazard that should be avoided in clinical practice. In this review, an international team of neonatologists and nurses assessed oxygen saturation (SpO2 ) targeting in preterm infants and evaluated the potential weaknesses of randomised clinical trials. CONCLUSION: SpO2 of 85-89% can increase mortality and 91-95% can cause hyperoxia and ill effects. Neither of these ranges can be recommended, and wider intermediate targets, such as 87-94% or 88-94%, may be safer.

Evolution of Preterm Infant Nutrition from Breastfeeding to an Exclusive Human Milk Diet: A Review.

The benefits of feeding human milk to human infants are well-established. Preterm infants, particularly those born with very low birthweight (VLBW; <1,500 g), are a uniquely vulnerable population at risk for serious, life-threatening complications as well as disruptions in normal growth and development that can affect their lives into adulthood. Feeding VLBW preterm infants an exclusive human milk diet (EHMD) from birth that consists of the mother's own milk or donor human milk plus a nutritional fortifier made exclusively from human milk has been associated with a reduction in morbidity and mortality and improved early growth and developmental metrics. Preliminary evidence suggests that the health benefits of adopting an EHMD (or avoiding cow milk products) early in life may last into adulthood. This review briefly summarizes the history of breastfeeding and describes the available evidence on the benefits of an EHMD among VLBW preterm infants as well as the importance of high-quality manufacturing standards for producing safe and effective human milk-based products.

Stability of thyroid hormones during continuous infusion.

We investigated the stability of thyroid hormones during a mode of continuous drug infusion via polypropylene tubing using the same conditions that would be applied to treating patients in a hospital setting. The diluted thyroid hormones were prepared using aseptic technique, stored at 2-8°C (36-46°F) and tested within 24 h of preparation for stability and percent recovery from within plastic tubing. Experiments were done in duplicate with triplicate sets of readings for each assay point. Only T(4) prepared with 5% dextrose water (D5W) containing 1 mg/mL albumin remained constant, stable, predictable and accurate over time under various conditions. Other methods of preparation lost drug by adhering to the plastic containers and tubing by as much as 40% of starting concentration. T(3) recovery in the presence of 1 mg/mL of albumin was 107±2% (mean±standard error of the mean) of anticipated drug concentrations. We conclude from this series of experiments that to maintain an accurate and stable dosing of patients receiving intravenous thyroid hormones, 1 mg/mL of albumin must be added to the infusate to prevent lost on the plastic intravenous tubing.

Evaluation and clinical application of changes in thyroid hormone and TSH levels in critically ill full-term newborns.

INTRODUCTION: The term "euthyroid sick syndrome" (ESS) has been used to describe a pattern of thyroid hormone changes during the course of critical illness in adult patients without thyroid disease, often associated with reduced thyroid hormone secretion. OBJECTIVE: To describe the thyroid hormone profile in full-term newborns critically ill compared with thyroid hormone profile of healthy infants, and determine if alterations could be related to the severity of the disease and outcome. METHODS: A cross-sectional, observational, and prospective study of full-term infants admitted to the neonatal intensive care unit (NICU) of the Hospital de Pediatría J.P. Garrahan between July 2007 and April 2008. Serum T3, T4, and thyroid stimulating hormone (TSH) levels were measured at admission and severity of the disease was evaluated through SNAP, lactic acid, respiratory assistance and number of organs affected. RESULTS: Sick newborns showed significantly lower T3 and T4 levels compared with healthy infants [T3: -0.97 µg/dL (95% CI -0.89, -1.13) and T4: -4.37 µg/dL (95% CI -2.95, -5.78)]. Only 29 out of 94 (31%) infants presented a normal profile; 37 (39%) infants showed isolated low T3 levels, 20 (21%) infants had low T3 and T4 levels and eight (9%) infants had low TSH, T3, and T4. Of this latter group, five of eight (62%) children died suggesting a significantly higher risk of death for patients with low T3 associated with low T4 and TSH [Risk ratio (RR) 10.75 95% CI 3.93, 29]. CONCLUSIONS: Full-term sick newborns frequently have lower thyroid hormone levels than healthy ones. These observed thyroid hormones changes might be related to the underlying disease and could be used as a prognostic marker of the severity and fatal outcome of the patient.

[Second Clinical Consensus of the Ibero-American Society of Neonatology: hemodynamic management of newborns]. / Segundo Consenso Clínico de la Sociedad Iberoamericana de Neonatología: manejo hemodinámico del recién nacido.

This study reports on the process and results of the Second Clinical Consensus of the Ibero-American Society of Neonatology. Eighty neonatologists from 23 countries were invited to collaborate and participate in the event. Several questions of clinical-physiological importance in the hemodynamic management of newborns were addressed. Participants were divided into groups to facilitate interaction and teamwork, with instructions to respond to three to five questions by analyzing the literature and local factors. Meeting in Mar del Plata, Argentina, the Consensus Group served as a form for various presentations and discussions. In all, 54 neonatologists from 21 countries attended, with the objective of reaching a consensus on such matters as concepts and definitions of hemodynamic instability, the physiopathology of hemodynamic compromise, recommended therapy strategies, and hemodynamic monitoring. It is hoped that this international experience will serve as a useful initiative for future consensus building and reduction of the existing disparities among the countries of the Region in terms of treatment and outcomes.

What happens to 35 week infants that receive delivery room continuous positive airway pressure?

OBJECTIVE: Delivery room (DR) continuous positive airway pressure (CPAP) is increasing. Our study examined the risk for neonatal morbidities after DR CPAP in 35 week neonates. STUDY DESIGN: A retrospective study of 259 infants born at 35 weeks gestational age between January 1, 2017-December 31, 2018 at a single center. RESULTS: DR resuscitation was administered in 30.5%, with 19.7% receiving CPAP alone. Eighty percent who received DR CPAP were admitted to the NICU. DR CPAP was associated with the highest NICU admission risk, 9.3 times the risk of those without DR positive pressure, and with respiratory conditions (RDS: OR 4.22 {CI 1.46-11.51}, TTN: OR 3.30 {CI 1.36-7.64}). For the DR CPAP group, non-invasive positive pressure was administered post resuscitation in 90%. CONCLUSIONS: In our institution, 35 week infants frequently received DR CPAP. Of these infants, a majority were admitted to the NICU for respiratory disorders.

Inhaled nitric oxide in preterm infants undergoing mechanical ventilation.

BACKGROUND: Bronchopulmonary dysplasia in premature infants is associated with prolonged hospitalization, as well as abnormal pulmonary and neurodevelopmental outcome. In animal models, inhaled nitric oxide improves both gas exchange and lung structural development, but the use of this therapy in infants at risk for bronchopulmonary dysplasia is controversial. METHODS: We conducted a randomized, stratified, double-blind, placebo-controlled trial of inhaled nitric oxide at 21 centers involving infants with a birth weight of 1250 g or less who required ventilatory support between 7 and 21 days of age. Treated infants received decreasing concentrations of nitric oxide, beginning at 20 ppm, for a minimum of 24 days. The primary outcome was survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age. RESULTS: Among 294 infants receiving nitric oxide and 288 receiving placebo birth weight (766 g and 759 g, respectively), gestational age (26 weeks in both groups), and other characteristics were similar. The rate of survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age was 43.9 percent in the group receiving nitric oxide and 36.8 percent in the placebo group (P=0.042). The infants who received inhaled nitric oxide were discharged sooner (P=0.04) and received supplemental oxygen therapy for a shorter time (P=0.006). There were no short-term safety concerns. CONCLUSIONS: Inhaled nitric oxide therapy improves the pulmonary outcome for premature infants who are at risk for bronchopulmonary dysplasia when it is started between 7 and 21 days of age and has no apparent short-term adverse effects. (ClinicalTrials.gov number, NCT00000548 [ClinicalTrials.gov] .).

Necrotizing enterocolitis following the use of intravenous immunoglobulin for haemolytic disease of the newborn.

AIM: To describe a series of patients who received intravenous immunoglobulin (IVIg) for the treatment of neonatal hyperbilirubinaemia and developed necrotizing enterocolitis (NEC) shortly thereafter. POPULATION AND RESULTS: We describe three healthy breastfed newly born infants with isoimmunization-derived hyperbilirubinaemia refractory to phototherapy who were treated with IVIg. Shortly after the perfusion finished they developed clinical and radiological signs compatible with NEC and needed antibiotic therapy, prolonged parenteral nutrition and even surgery in one case. Other conditions such as septicaemia or coagulopathy were ruled out. Microscopic examination of the resected intestine revealed the presence of disseminated thrombi obstructing multiple minor vessels of the mesenteric circulation. CONCLUSION: IVIg in the newborn period should be cautiously employed and always administered under strict medical control.

Early Detection with Pulse Oximetry of Hypoxemic Neonatal Conditions. Development of the IX Clinical Consensus Statement of the Ibero-American Society of Neonatology (SIBEN).

This article reviews the development of the Ninth Clinical Consensus Statement by SIBEN (the Ibero-American of Neonatology) on "Early Detection with Pulse Oximetry (SpO2) of Hypoxemic Neonatal Conditions". It describes the process of the consensus, and the conclusions and recommendations for screening newborns with pulse oximetry.

Clinical hypoxic-ischemic encephalopathy score of the Iberoamerican Society of Neonatology (Siben): A new proposal for diagnosis and management.

Hypoxic ischemic encephalopathy is a major complication of perinatal asphyxia, with high morbidity, mortality and neurologic sequelae as cerebral palsy, mostly in poor or developing countries. The difficulty in the diagnosis and management of newborns in these countries is astonishing, thus resulting in unreliable data on this pathology and bad outcomes regarding mortality and incidence of neurologic sequelae. The objective of this article is to present a new clinical diagnostic score to be started in the delivery room and to guide the therapeutic approach, in order to improve these results.

Neonatal thyroxine supplementation for transient hypothyroxinemia of prematurity : beneficial or detrimental?

Extremely low birth-weight newborns (<1000g) experience low levels of thyroid hormone that vary inversely with the severity of neonatal illness and the extent of developmental immaturity with levels reaching a nadir at approximate, equals7 days after birth; this phenomenon can persist for several weeks. In the absence of transplacental passage, 30-50% of these neonates cannot generate sufficient quantities of thyroid hormone to meet postnatal demands, placing them at an increased risk for developmental delay and cerebral palsy. Population surveys and interventional trials suggest that a therapeutic opening exists during a 'window of opportunity' corresponding to this period of diminished capacity. Variables to consider before intervention focus on the consideration that supplementation of both the substrate thyroxine and the active hormone triiodothyronine may be necessary in quantities that do not suppress thyroid-stimulating hormone release, yet overcome the persistence of increased conversion to 3,3'5'-triodo-L-thyronine, terminal deiodination, and activity of the sulfation inactivation pathways, as well as the diminished capacity of the newborn to accommodate postnatal physiologic changes. Single daily replacement doses may suppress levels of converting enzymes in the brain, suggesting that physiologic 'mimicry' provided by a constant infusion may be the preferred dosing option. Properly powered clinical trials targeting long-term developmental outcomes are needed to discern whether these interventions will do more than simply elevate blood levels of thyroid hormones to the target values of either the fetus or developing neonate. Identifying the appropriate indications for supplementation may alleviate individual pain and distress due to disability for several hundred extremely low birth-weight neonates each year in the US alone, and save society a pro-rated lifetime cost of nearly $US1 million per child.