Sociodemographic Factors and Intestinal Microbiome Development in Preterm, Very Low Birth Weight Infants.

OBJECTIVE: Preterm very low birth weight (VLBW) infants are at risk for intestinal morbidities and dysbiotic development of the intestinal microbiome. Despite the influence of sociodemographic factors on premature infant health outcomes, whether they shape the intestinal microbiome early in life is not clear. The objective was to explore the associations between race, sex, and socioeconomic status and the intestinal microbiome of VLBW infants during the first 4 weeks of life. STUDY DESIGN: This was a secondary analysis of data from an ongoing randomized trial of 79 infants ≤30 weeks' gestation and ≤1,500 g. Stool samples were collected at week 1 through week 4, frozen to -80°C and analyzed by 16S rRNA sequencing of the V4 region using Illumina MiSeq. Reads were analyzed to measure α and ß diversity as well as relative abundance of bacteria in the intestinal microbiome. RESULTS: Of the 79 infants, 63 had at least one sample available. Twenty-three (37%) of infants were African American, 30 (48%) were male, and 44 (71%) had Medicaid insurance. There were no statistically significant (<0.05) differences in α diversity or ß diversity, and the differential abundance analysis suggests limited patterns of distinction in the intestinal microbiome between non-African American and African American infants, male and female infants, and infants with maternal private or Medicaid insurance. CONCLUSION: Our results suggest race, sex, and socioeconomic status shape colonization of specific microorganisms to a limited extent. Future studies should confirm these findings and determine clinical relevance through further study of differentially abundant microorganisms and additional factors contributing to colonization patterns. KEY POINTS: · Diversity of the gut microbiome was similar between infants of varying race, sex, and socioeconomic status.. · We observed sociodemographic-linked differences in colonization of individual taxa.. · Further study is required to confirm these results and the clinical relevance of these findings..

A Scoping Review of the Oral Microbiome in Preterm Infants.

The purpose of this scoping review was to examine the oral microbiome composition in preterm infants, sampling and collection methods, as well as exposures associated with oral microbiome composition and health implications. We conducted a scoping review of the literature using the Arskey and O'Malley framework. We identified a total of 13 articles which met our inclusion criteria and purpose of this scoping review. Articles included in this review compared the oral microbiome in preterm infants to term infants, examined alterations to the oral microbiome over time, compared the oral microbiome to different body site microbiomes, and explored associations with clinically relevant covariates and outcomes. Exposures associated with the diversity and composition of the oral microbiome in preterm infants included delivery mode, oral feeding, oropharyngeal care, skin-to-skin care, and antibiotics. Day of life and birth weight were also associated with oral microbiome composition. The oral microbiome may be associated with the composition of the tracheal and gut microbiomes, likely due to their proximity. Alpha and beta diversity findings varied across studies as well as the relative abundance of taxa. This is likely due to the different sampling techniques and timing of collection, as well as the wide range of infant clinical characteristics. Multiple factors may influence the composition of the oral microbiome in preterm infants. However, given the heterogeneity of sampling techniques and results within this review, the evidence is not conclusive on the development as well as short- and long-term implications of the oral microbiome in preterm infants and needs to be explored in future research studies. KEY POINTS: · Day of life is a critical factor in oral microbiome development in preterm infants.. · The oral microbiome may be associated with tracheal and gut microbiome colonization.. · Future research should examine sampling methodology for examining the oral microbiome.. · Future research should explore associations with the oral microbiome and adverse health outcomes..

Nonpharmacologic Factors Affecting Milk Production in Pump-Dependent Mothers of Critically Ill Infants: State of the Science.

BACKGROUND: Improved health outcomes for critically ill infants including neurodevelopmental, immunological, and cost benefits are dependent upon the dose and duration of mother's own milk feedings. However, mothers of infants admitted to the neonatal intensive care unit (NICU) must express their milk (pump-dependent) and often struggle with milk production. PURPOSE: To examine the state of the science on nonpharmacologic modifiable expression factors that may influence milk production in pump-dependent mothers of critically ill infants admitted to the NICU. DATA SOURCES: PubMed, Embase, and CINAHL databases from 2005 to 2020. SEARCH STRATEGY: Guided by the lactation conceptual model, the authors searched for peer-reviewed studies with terms related to milk volume, pump dependency, critically ill infants, and modifiable factors, which may influence milk volume and assessed 46 eligible studies. DATA EXTRACTION: Data were extracted by 3 reviewers with a systematic staged review approach. RESULTS: Evidence from 26 articles found expressed milk volume may be influenced by multiple potentially modifiable factors. Simultaneous expression with a hospital-grade electric pump at least 5 times per day beginning 3 to 6 hours after delivery, and adding complementary techniques including hand expression, hands-on-pumping, music, breast massage, warm compresses, skin-to-skin care, and the mother expressing near her infant may promote increased milk volume. IMPLICATIONS FOR PRACTICE AND RESEARCH: Healthcare providers should assist pump-dependent mothers with early initiation and frequent milk removal with a hospital-grade breast pump. Further research is needed to explore optimal frequency of expressions, dose and timing of skin-to-skin care, and other targeted strategies to improve expressed milk volume.

Comparison of 3 Methods for Measuring Gastric Tube Length in Newborns: A Randomized Clinical Trial.

BACKGROUND: Incorrectly positioned gastric tubes occur in approximately 60% of infants hospitalized in the neonatal intensive care unit (NICU), increasing the risk of potentially serious complications. PURPOSE: To compare 3 methods of determining gastric tube insertion length in infants in the NICU. METHODS: In this randomized triple-blind clinical trial, 179 infants admitted to the NICU were randomized to have their gastric tube insertion length determined by 1 of 3 methods: (1) the nose, earlobe, mid-umbilicus (NEMU) method, (2) a weight-based method, or (3) an age-related height-based (ARHB) method. Positioning of the gastric tube was verified by radiograph. R software was used for analyses. To compare categorical variables, Fisher's exact test, χ 2 tests, and simulated χ 2 tests were used. RESULTS: Overall, infants had a mean gestational age of 35 weeks, 115 (58.8%) were male, and the mean birth weight was 2481.5 g. Upon radiological assessment, 145 gastric tubes (81.3%) were correctly positioned in the gastric body or greater curvature of the stomach with the weight-based method having the highest percentage of correctly positioned gastric tubes (n = 53; 36.6%), followed by the ARHB method (n = 47; 32.4%) and the NEMU method (n = 45; 31.0%). No significant differences were identified between groups ( P = .128). IMPLICATION FOR PRACTICE AND RESEARCH: Despite the NEMU method being the most commonly used method in clinical practice, the weight-based and ARHB methods to determine gastric tube insertion length may be more accurate.

Influence of Sociodemographic and Occupational Factors on Safety Culture in Neonatal Intensive Care in Brazil.

BACKGROUND: Patient safety culture is influenced by factors such as professional category, experience, and age. Understanding these factors can inform initiatives to improve safety. PURPOSE: To evaluate the relationship between sociodemographic and occupational characteristics on health professionals' perception of patient safety culture. METHODS: A cross-sectional study involving 514 health care professionals from Brazilian neonatal intensive care units was conducted using the Hospital Survey on Patient Safety Culture. RESULTS: Several sociodemographic and occupational characteristics were associated with higher perceptions of safety culture, including older age and having a higher level of education. CONCLUSION: Sociodemographic and occupational factors may influence the safety culture in neonatal intensive care units and should be considered when developing and implementing strategies to improve safety.

Content validity of a Safe Nursing Care Checklist for a neonatal unit.

BACKGROUND: Nursing checklists have been shown to improve communication, reduce the occurrence of adverse events, and promote safe, quality care in different care settings. However, to date, there is no validated patient care safety checklist for nurses caring for infants in Neonatal Intensive Care Units (NICU). AIM: To describe development and content validation of the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit". STUDY DESIGN: Online Survey. METHODS: Based upon an integrative literature review, we developed a checklist focused on safe nursing care for infants in the NICU. Nursing experts participated in three rounds of a content validation process where they rated the items online. An agreement level ≥0.90 was required for inclusion in the checklist. Forty- three expert nurses with experience working in the NICU and who were certified in neonatal nursing or had a master's or doctoratal degree in child health provided content validation of the patient care checklist. RESULTS: The final checklist contained 45 items with content validation index scores greater than 90%. The instrument was structured into six dimensions including patient identification, effective communication, medication safety, infection prevention, fall prevention, and pressure injuries/skin injuries prevention. CONCLUSION: Content validity was established for the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit" which can identify strengths and weaknesses in safe nursing care for infants in the NICU as well as direct educational interventions to promote nursing care based on scientific evidence. RELEVANCE TO CLINICAL PRACTICE: This checklist can potentially be used by bedside nurses to promote provision of safe care to infants in the NICU and to guide corrective strategies and encourage evidence-based decision-making. Validation in the clinical setting is needed.

Integrating longitudinal clinical and microbiome data to predict growth faltering in preterm infants.

Preterm birth affects more than 10% of all births worldwide. Such infants are much more prone to Growth Faltering (GF), an issue that has been unsolved despite the implementation of numerous interventions aimed at optimizing preterm infant nutrition. To improve the ability for early prediction of GF risk for preterm infants we collected a comprehensive, large, and unique clinical and microbiome dataset from 3 different sites in the US and the UK. We use and extend machine learning methods for GF prediction from clinical data. We next extend graphical models to integrate time series clinical and microbiome data. A model that integrates clinical and microbiome data improves on the ability to predict GF when compared to models using clinical data only. Information on a small subset of the taxa is enough to help improve model accuracy and to predict interventions that can improve outcome. We show that a hierarchical classifier that only uses a subset of the taxa for a subset of the infants is both the most accurate and cost-effective method for GF prediction. Further analysis of the best classifiers enables the prediction of interventions that can improve outcome.

Effect of Routine Gastric Residual Aspiration on the Preterm Infant Fecal Microbiome.

OBJECTIVE: Enteral feeding tubes are used in neonatal intensive care units (NICUs) to assess feeding tolerance by utilizing preprandial gastric residual aspiration. This study evaluates the effect of gastric residual aspiration on the preterm infant fecal microbiome and gastrointestinal inflammation. STUDY DESIGN: Fifty-one very low birth weight (VLBW) infants (≤32 weeks' gestational age and ≤1,250 g) enrolled in a larger single-center randomized controlled trial evaluating the effects of routine and nonroutine gastric residual aspiration were selected for further analysis. Of those infants, 30 had microbiome analysis performed on stools collected at 6 weeks by sequencing the bacterial V1 to V3 variable regions of the genes encoding for 16S rRNA. In an additional 21 infants, stool samples collected at 3 and 6 weeks were analyzed for intestinal inflammation using a cytokine multiplex panel. RESULTS: Microbial communities between groups were not distinct from each other and there was no difference in intestinal inflammation between groups. Analyses using gene expression packages DESeq2 and edgeR produced statistically significant differences in several taxa, possibly indicating a more commensal intestinal microbiome in infants not undergoing gastric residual aspiration. CONCLUSION: Omission of routine gastric residual aspiration was not associated with intestinal dysbiosis or inflammation, providing additional evidence that monitors preprandial gastric residuals is unnecessary. KEY POINTS: · Omission of routine gastric residual aspiration was not associated with intestinal dysbiosis or inflammation.. · Existing literature indicates preprandial gastric aspiration does not reliably correlate with development of necrotizing enterocolitis but does correlate with delayed enteral nutrition.. · Further study is required but this data that suggest monitoring preprandial gastric residuals are unnecessary..

Strategies to Improve Mother's Own Milk Expression in Black and Hispanic Mothers of Premature Infants.

BACKGROUND: Mother's own milk (MOM) is the gold standard of nutrition for premature infants. Yet, Hispanic and Black preterm infants are less likely than their White counterparts to receive MOM feedings. Evidence is lacking concerning potential modifiable factors and evidence-based strategies that predict provision of MOM among minority mothers of premature infants. PURPOSE: A review of the literature was conducted to answer the clinical question: "What evidence-based strategies encourage and improve mother's own milk expression in Black and Hispanic mothers of premature infants?" METHODS/SEARCH STRATEGY: Multiple databases including PubMed, Cochrane, and CINAHL were searched for articles published in the past 10 years (2010 through May 2020), reporting original research and available in English. Initial search yielded zero articles specifically addressing the impact of lactation interventions on MOM provision in minority mothers. Additional studies were included and reviewed if addressed breastfeeding facilitators and barriers (n = 3) and neonatal intensive care unit breastfeeding support practices (n = 7). FINDINGS/RESULTS: Current strategies used to encourage and improve MOM expression in minority mothers are based on or extrapolated from successful strategies developed and tested in predominantly White mothers. However, limited evidence suggests that variation in neonatal intensive care unit breastfeeding support practices may explain (in part) variation in disparities and supports further research in this area. IMPLICATIONS FOR PRACTICE: Neonatal intensive care unit staff should consider implementing scaled up or bundled strategies showing promise in improving MOM milk expression among minorities while taking into consideration the cultural and racial norms influencing breastfeeding decisions and practice. IMPLICATIONS FOR RESEARCH: Experimental studies are needed to evaluate the effectiveness of targeted and culturally sensitive lactation support interventions in Hispanic and Black mothers.

Milk Volume Outcomes in Pump-Dependent Mothers of Critically Ill Infants.

INTRODUCTION: Mother's own milk improves health outcomes in infants of all gestational ages. Although pump-dependent mothers of extremely premature infants are at risk of insufficient milk production, whether mother's milk production is impacted by gestational age and pump dependency in mothers of more mature critically ill infants is unknown. PURPOSE: To determine whether there is a relationship between gestational age, milk production, and time to secretory activation in mothers delivering a critically ill infant. METHODS: A convenience sample of 136 pump-dependent mothers whose infants were admitted to the neonatal intensive care unit was enrolled between 2013 and 2016 as part of a quality improvement project. Group 1 (early preterm) delivered infants at 30 to 33 weeks of gestation (n = 41), group 2 (late preterm) 34 to 36 weeks (n = 48), and group 3 (term) 37 weeks and more (n = 47). Milk volume on days 1 to 7 was measured by weighing each vial of expressed milk and compared using general linear mixed-model analysis. Time to the onset of secretory activation was compared using censored regression analysis. RESULTS: Main effect for gestational age controlling for day was statistically significant (P = .0234). The early preterm group produced more milk over the 7-day study than the term (P = .01) and late preterm (P = .02) groups. The early preterm group achieved secretory activation earlier than the late preterm group (adjusted P = .039). IMPLICATIONS FOR PRACTICE: Pump-dependent mothers of all infants admitted to the neonatal intensive care unit may be at risk of inadequate milk production and delayed secretory activation and may therefore benefit from early milk production monitoring and lactation support. IMPLICATIONS FOR RESEARCH: Further studies should examine targeted interventions to increase milk production in pump-dependent mothers.

Differences in Neonatal Outcomes Among Premature Infants Exposed to Mother's Own Milk Versus Donor Human Milk.

BACKGROUND: Growing evidence supports the superior benefits of exposure to mother's own milk (MOM) in reducing prematurity-related comorbidities. Neonatal exposure to donor human Milk (DHM) is a suitable alternative when MOM is insufficient or unavailable. However, the same protective composition and bioactivity in MOM are not present in DHM. Additional evidence is needed to justify and inform evidence-based practices increasing MOM provision while optimizing adequate use of DHM for premature infants. PURPOSE: A systematic review of the literature was conducted to determine differences in neonatal outcomes among premature infants exposed to predominately MOM versus DHM. METHODS/SEARCH STRATEGY: Databases including PubMed, CINAHL and Cochrane were searched (2020-2021) using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines. Evidence was classified using the John Hopkins evidence-based practice levels and quality of evidence. RESULTS: Eleven studies met inclusion criteria. Studied neonatal outcomes included ( a ) growth parameters (n = 8), ( b ) neonatal morbidities (n = 6), and ( c ) gut microbiome (n = 4). Overall, evidence suggests DHM exposure is beneficial but not equivalent to MOM feeding. Compared with DHM, greater doses of MOM are ideal to enhance protection primarily related to infant growth, as well as gut microbiome diversity and richness. IMPLICATIONS FOR PRACTICE: Standardized and evidence-based practices are needed to clearly delineate optimal use of DHM without undermining maternal and neonatal staff efforts to support and promote provision of MOM. IMPLICATIONS FOR RESEARCH: Additional evidence from high-quality studies should further examine differences in neonatal outcomes among infants exposed to predominately MOM or DHM in settings using standardized and evidence-based feeding practices.

Ultrasound to Verify Gastric Tube Position in Infants and Children: A Systematic Review.

BACKGROUND: Placement of gastric tubes is commonly performed in infants and children but malpositioning is common and is associated with significant complications. OBJECTIVE: The aim of this systematic review is to identify the evidence on the use of ultrasound to verify correct gastric tube placement in infants and children and gaps in the research. METHODS: This review was performed using CINAHL, PUBMED, EMBASE and Web of Science databases. Studies were included if they used an empirical study design, were published in English, included infants or children, and evaluated the use of ultrasound to verify correct gastric tube placement compared to radiograph. Sensitivity, specificity, positive and negative predictive values were evaluated. RESULTS: Four articles were included in the review. Sensitivity estimates were 0.88 to 1.00 and a positive predictive value of 0.99 was reported in one study. Specificity was not reported in any of the included studies. Ultrasound may be an important method to correctly identify gastric tube placement in infants and children with less radiation exposure and cost. IMPLICATIONS FOR PRACTICE: Ultrasound could be a used to verify gastric tube positioning in infants and children for both initial placement and continued verification leading to reduced radiation exposure and cost. IMPLICATIONS FOR RESEARCH: Research should focus on evaluating ultrasound specificity and the clinical feasibility of using ultrasound as a standard practice, including cost and time required to complete the exam, as well as the ability of ultrasound to verify gastric tube placement in infants weighing less than 1500 grams.

Knowledge and Practices for Central Line Infection Prevention Among Brazilian Nurses: A Mixed-Methods Study.

BACKGROUND: The risk of central line-associated bloodstream infections (CLABSIs) increases when preventive guidelines are not adhered to. However, studies have generally been quantitative and aimed at determining the effectiveness of CLABSI prevention bundles. Few studies have used a mixed-methods approach to investigate nursing professionals' knowledge and practices regarding CLABSI prevention. PURPOSE: To determine nursing professionals' knowledge and practices regarding CLABSI prevention and identify facilitators and barriers to adherence to CLABSI prevention strategies in a Brazilian neonatal intensive care unit. METHODS: A mixed-methods approach was used. Nursing professionals answered questionnaires regarding knowledge and practices surrounding CLABSI prevention. Semistructured interviews explored barriers nursing professionals face that hinder adherence to CLABSI preventive practices. FINDINGS: Nursing professionals had moderate knowledge regarding CLABSI prevention practices. Daily assessment of the continued need for central venous lines (CVLs), hub disinfection before and after handling, and hand hygiene before handling CVLs were practices less adhered to. Interviews revealed barriers to adherence to preventive practices included lack of adequate equipment, resources for hand hygiene, and inadequate physical structure. Increased education and awareness of safe CVL practices and accountability of the entire healthcare team may improve adherence to CLABSI prevention practices. Results of this study reinforce the importance of considering current nursing practices when developing strategies to increase adherence to CLABSI prevention guidelines. IMPLICATIONS FOR PRACTICE: Providing continuing education may increase adherence to CLABSI prevention strategies. IMPLICATIONS FOR RESEARCH: Research is needed to develop strategies aimed at increasing nursing adherence to CLABSI prevention strategies.

Measures of Lactation Outcomes in Women Delivering Preterm Infants.

BACKGROUND: Mother's own milk (MOM) is well known to decrease prematurity-related morbidities, yet mothers delivering preterm infants often produce insufficient quantities of milk to provide these benefits. Although a critical need exists for research to support lactation success in this vulnerable population, development and investigation of interventions to increase available MOM for infant consumption requires consistent, valid, and reliable measures of lactation outcomes. OBJECTIVES: The aim of this study was to compare and contrast methods of measuring lactation outcomes in mothers of preterm infants and evaluate their advantages and disadvantages. METHODS: Measures of lactation outcomes were reviewed and synthesized. Insights on best practices and future research directions are provided. RESULTS: Volume of MOM produced, lactation duration, and time to onset of secretory activation are important measures of lactation success. The most valid and reliable measure of milk production is likely weighing each vial of expressed milk combined with test weighing when infants breastfeed. Measures of lactation duration should include actual days mothers lactated rather than limiting to infant consumption of MOM as a proxy for duration and include not only whether mothers are lactating at infant discharge but whether they are also lactating at other health-relevant time points during hospitalization. Although time to onset of secretory activation is an important lactation outcome, information regarding valid and reliable indicators of onset in women delivering preterm infants is limited, and investigation of such indicators is a research priority. Variables that may affect lactation outcomes, including time to initiation of expression following delivery, duration of expression sessions, expression method, time spent in skin-to-skin care, maternal demographics and comorbidities, as well as maternal intent to lactate, must be considered when researchers investigate lactation outcomes in mothers of very low birth weight infants. DISCUSSION: Consistent and valid measures of lactation outcomes are required to produce reliable results from which evidence-based practice recommendations can be developed in order to improve lactation success in this vulnerable population.

Exploring Social and Demographic Factors as Determinants of Intestinal Inflammation in Very Low Birth-Weight Infants.

BACKGROUND: Very low birth-weight (VLBW) infants are disproportionately affected by inflammatory morbidities including necrotizing enterocolitis. Despite the influence of social and demographic factors on infant health outcomes, their relationship with intestinal inflammation is unknown. PURPOSE: To explore the influence of maternal race, maternal socioeconomic status, and infant sex on intestinal inflammation in VLBW infants. METHODS: This was a secondary analysis of existing data from a randomized controlled trial of 143 infants 32 weeks' gestation or less and weighing 1250 g or less. In the previous study, fecal calprotectin and S100A12 values were collected at weeks 3 and 6. The infant sample was determined on the basis of the availability of these results, which served as intestinal inflammation biomarkers for the present study. General linear mixed models assessed the relationship between biomarkers and social and demographic factors. Gestational age, antibiotic exposure, mother's own milk feeding, acuity, and week of sample collection were used as control variables. FINDINGS/RESULTS: The sample included 124 infants. Fifty-two infants (42%) were African American, 86 (69%) had Medicaid coverage, and 65 (53%) were male. Fecal calprotectin levels were higher in African American infants (P = .02) and infants with private insurance coverage (P = .009); no difference was found between sexes. There was no association between S100A12 levels and infant sex, maternal race, or socioeconomic status. IMPLICATIONS FOR PRACTICE AND RESEARCH: Consideration of social and demographic factors may be important when caring for VLBW infants. Further exploration of factors contributing to associations between social or demographic factors and intestinal inflammation is needed.

Feeding Strategies in Preterm Very Low Birth-Weight Infants: State-of-the-Science Review.

BACKGROUND: Providing enteral feeds to preterm very low birth-weight (VLBW) infants is critical to optimize nutrition, enhance growth, and reduce complications. Protocols guiding feeding practices can improve outcomes, but significant variation exists between institutions, which may limit their utility. To be most effective, protocols should be based on the best available evidence. PURPOSE: To examine the state of the science on several key components of feeding protocols for VLBW infants. SEARCH STRATEGY: The authors searched PubMed, CINAHL, and EMBASE databases for terms related to feeding VLBW infants less than 32 weeks' gestational age, including initiation of feedings, rate of feeding advancement, timing of human milk (HM) fortification, and feeding during blood transfusions, when diagnosed with a patent ductus arteriosus (PDA) and during medical treatment of PDA closure. RESULTS: Initiation of feeds within the first 3 days of life and advancement by 30 mL/kg/d may decrease time to attain full feeds without increasing complications. Insufficient evidence guides optimal timing of HM fortification, as well as feeding infants undergoing blood transfusions, infants diagnosed with a PDA, and infants receiving medical treatment of PDA closure. IMPLICATIONS FOR PRACTICE: Integration of existing research regarding feeding initiation and advancement into feeding protocols may improve outcomes. Infants at highest risk of feeding-related complications may benefit from a personalized feeding approach. IMPLICATIONS FOR RESEARCH: Additional research is needed to provide evidence concerning the optimal timing of HM fortification and feeding strategies for infants undergoing blood transfusions and those diagnosed with a PDA or receiving medical treatment of PDA closure to incorporate into evidence-based feeding protocols.

Decreasing Admissions to the NICU: An Official Transition Bed for Neonates.

BACKGROUND: Evidence supports the need to decrease healthcare costs. One approach may be minimizing use of low-value care by reducing the number of unnecessary neonatal intensive care unit (NICU) admissions through the use of official neonatal transition beds. PURPOSE: To evaluate whether transition beds decrease unnecessary NICU admissions and estimate the cost savings of this practice change. METHODS: This retrospective chart review examined the records of all neonates of 350/7 weeks' gestational age and greater with birth weights of 2000 g and more admitted to a neonatal transition bed from January 1, 2017, to December 31, 2017. Outcomes evaluated were number of neonates returned to their mothers and an estimate of dollars saved for a 1-year period. RESULTS: A total of 194 neonates were admitted to transition beds, which resulted in 144 NICU admissions averted. Respiratory distress was the most common reason for admission to transition beds. There was a statistically significant difference in length of stay in transition beds between neonates admitted to the NICU and those returned to couplet care after admission to transition beds (135.92 minutes vs 159.27 minutes; P = .047). There was no difference in gestational age based on admission to NICU or returned to couplet care (37.9 weeks vs 38 weeks; P = .772). The estimated cost savings was $3000 per neonate returned to couplet care totaling $432,000 annually. IMPLICATIONS FOR PRACTICE: The use of neonatal transition beds is a potential strategy to decrease unnecessary NICU admissions and reduce low value care. IMPLICATIONS FOR RESEARCH: Research regarding potential benefits of transition beds including the effect on hospital resources and low-value care at other institutions is needed. Additional research regarding potential benefits to the family including parent satisfaction and the effect of transition beds on rates of breastfeeding and skin-to-skin care is important.

Effect of Aspiration and Evaluation of Gastric Residuals on Intestinal Inflammation, Bleeding, and Gastrointestinal Peptide Level.

OBJECTIVE: To determine the effect of gastric residual aspiration and evaluation on preterm very low birth weight infants' gastrointestinal function, intestinal inflammation, and gastrointestinal mucosal bleeding. STUDY DESIGN: This single-center, randomized trial compared omission of gastric residuals vs prefeed gastric residuals in 143 infants ≤32 weeks of gestation with a birthweight of ≤1250 g for 6 weeks after birth. Serum levels of gastrin and motilin were collected between 14 and 21 days of life. Stools were collected at 3 and 6 weeks of age and analyzed for calprotectin and S100A12 levels. All stools were tested for occult blood for 6 weeks. RESULTS: Means for gastrin (P = .999) and motilin (P = .694) were similar between groups and there were no statistically significant differences in adjusted means for transformed calprotectin (P = .580), and S100A12 (P = .212). Both calprotectin (P = .003) and S100A12 (P = .002) increased from week 3 to week 6. The mean percentage of stools positive for occult blood (P = .888) were similar between the groups. CONCLUSIONS: Gastrointestinal function, intestinal inflammation, and gastrointestinal mucosal bleeding were similar whether aspiration and evaluation of gastric residuals were eliminated or not, suggesting routinely evaluating gastric residuals before every feeding may be unnecessary. TRIAL REGISTRATION CLINICALTRIALS.GOV:: NCT01863043.

Determinants of the Very Low-Birth-Weight Infant's Intestinal Microbiome: A Systematic Review.

The intestinal microbiome is the genetic material from microorganisms residing in the intestinal tract. Very low-birth-weight infants (VLBW; birth weight ≤1500 g) are a physiologically compromised population undergoing a unique period of initial intestinal microbiome establishment. Evidence supports a connection between the intestinal microbiome and gastrointestinal illness that disproportionately affects VLBW infants. Necrotizing enterocolitis, an inflammatory and often necrotic condition of the intestine, and late-onset sepsis, a bloodstream infection occurring after 3 days of life, are thought to be associated with delayed or abnormal intestinal microbiome development. Here, we review the determinants, or factors, that influence the VLBW infant's intestinal microbiome and discuss clinical implications. PubMed, Web of Science, EMBASE, and CINAHL were systematically searched for publications addressing factors with the potential to affect the intestinal microbiome of VLBW infants. Results indicate that infant's age and weight, mode of delivery, antibiotic exposure, medication use, feeding regime, environment, and perinatal-/infant-associated factors may be important determinants of the microbiome in this vulnerable population. Clinicians have opportunities to support positive development of the VLBW infant's intestinal microbiome through antibiotic stewardship, support of human milk feeding, and hygienic care practices.

Consumption of Mother's Own Milk by Infants Born Extremely Preterm Following Implementation of a Donor Human Milk Program: A Retrospective Cohort Study.

OBJECTIVE: To compare mothers' own milk (MOM) consumption by infants born extremely preterm before and after implementation of a donor human milk (DHM) program and determine healthcare provider's knowledge and practices regarding DHM. STUDY DESIGN: One hundred fifty-seven infants born at <30 weeks of gestation were enrolled during 3 time-periods. Group 1: before DHM program implementation, Group 2: the year following implementation, and Group 3: the second year after implementation. The proportion of feeds consisting of MOM for 6 weeks following birth was analyzed using a generalized linear mixed model. The study's second phase surveyed healthcare providers regarding knowledge and practices concerning DHM. RESULTS: Group 1 consumed feeds with a greater proportion of MOM than Group 3 during weeks 1 (P < .001) and 3 (P = .007) and more than both Group 2 (P = .033) and 3 (P = .021) in week 4. During the first 14 days, Group 1 consumed feeds with 23.6% more MOM than Group 3 (P = .002) and had a greater odds of consuming feeds with > 90% MOM (P < .001) than Group 3. During days 1-28, Group 1 consumed feeds with 22% more MOM than Group 3 (P = .003) and had greater odds of consuming feeds with >90% MOM than Group 2 (P = .020) and 3 (P = .004). Knowledge regarding DHM was inconsistent among providers and they were unlikely to communicate potential risks and benefits of DHM to mothers. CONCLUSIONS: Following implementation of a DHM program, MOM consumption decreased over 2 years. Strategies focused on lactation success are necessary to increase MOM consumption.