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Optimal management of patent ductus arteriosus (PDA) is unclear. One treatment, surgical ligation, is associated with adverse outcomes. We reviewed data from the Kids' Inpatient Database (2000-2012) to determine if PDA ligation rates: (1) changed over time, (2) varied geographically, or (3) influenced surgical complication rates. In 2012, 47,900 infants <1500g birth weight were born in the United States, including 2,800 undergoing PDA ligation (5.9%). Ligation was more likely in infants <1000g (85.9% vs. 46.2%), and associated with necrotizing enterocolitis (59.2% vs. 37.5%), BPD (54.6% vs. 15.2%), severe intraventricular hemorrhage (16.4% vs. 5.3%), and hospital transfer (37.6% vs. 16.4%). Ligation rates peaked in 2006 at 87.4 per 1000 hospital births, dropping to 58.8 in 2012, and were consistently higher in Western states. Infants undergoing ligation were more likely to experience comorbidities. Rates of ligation-associated vocal cord paralysis increased over time (1.2-3.9%); however, mortality decreased (12.4-6.5%). Thus, PDA ligation has become less frequent, although infants being ligated are smaller and more medically complex. Despite increase in some complications, mortality rates improved perhaps reflecting advances in care.
Copyright © 2018 Elsevier Inc. All rights reserved.
Although currently available data are variable, it appears that the incidence of surgical necrotizing enterocolitis (NEC) has not decreased significantly over the past decade. Pneumoperitoneum and clinical deterioration despite maximal medical therapy remain the most common indications for operative treatment. Robust studies linking outcomes with specific indications for operation are lacking. Promising biomarkers for severe NEC include fecal calprotectin and S100A12; serum fatty acid-binding protein; and urine biomarkers. Recent advances in ultrasonography make this imaging modality more useful in identifying surgical NEC and near-infrared spectroscopy (NIRS) is being actively studied. Another fairly recent finding is that regionalization of care for infants with NEC likely improves outcomes. The neurodevelopmental outcomes after surgical treatment are known to be poor. A randomized trial near completion will provide robust data regarding neurodevelopmental outcomes after laparotomy versus drainage as the initial operative treatment for severe NEC.
Copyright © 2016 Elsevier Inc. All rights reserved.
PURPOSE OF REVIEW - This review is written from the perspective of the pediatric clinician involved in the care of premature infants at risk for pulmonary hypertension. The main objective is to better inform the clinician in the diagnosis and treatment of pulmonary hypertension in premature infants by reviewing the available relevant literature and focusing on the areas for which there is the greatest need for continued research.
RECENT FINDINGS - Continued knowledge regarding the epidemiology of pulmonary hypertension in the premature infant population has aided better diagnostic screening algorithms. Included in this knowledge, is the association of pulmonary hypertension in infants with bronchopulmonary dysplasia (BPD). However, it is also known that beyond BPD, low birth weight and other conditions that result in increased systemic inflammation are associated with pulmonary hypertension. This information has led to the recent recommendation that all infants with BPD should have an echocardiogram to evaluate for evidence of pulmonary hypertension prior to discharge from the neonatal ICU.
SUMMARY - Pulmonary hypertension can be a significant comorbidity for premature infants. This review aims to focus the clinician on the available literature to improve recognition of the condition to allow for more timely interventions.
We examined superior mesenteric artery blood flow velocity in response to feeding in infants randomized to trophic feeds (n = 16) or nil per os (n = 18) during previous treatment for patent ductus arteriosus. Blood flow velocity increased earlier in the fed infants, but was similar in the 2 groups at 30 minutes after feeding.
Copyright © 2014 Mosby, Inc. All rights reserved.
BACKGROUND - Serial C-reactive protein (CRP) values may be useful for decision-making regarding duration of antibiotics in neonates. However, established standard of practice for its use in preterm very low birth weight (<1500 g, VLBW) infants are lacking.
OBJECTIVE - Evaluate compliance with a CRP-guided computerized decision support (CDS) algorithm and compare characteristics and outcomes of compliant versus non-compliant cases. Measure correlation between CRPs and white blood count (WBC) indices.
METHODS - We examined 3 populations: 1) all preterm VLBW infants born at Vanderbilt 2006-2011 - we assessed provider compliance with CDS algorithm and measured relevant outcomes; 2) all patients with positive blood culture results admitted to the Vanderbilt NICU 2006-2012 - we tested the correlation between CRP and WBC results within 7 days of blood culture phlebotomy; 3) 1,000 randomly selected patients out of the 7,062 patients admitted to the NICU 2006-2012 - we correlated time-associated CRP values and absolute neutrophil counts.
RESULTS - Of 636 VLBW infants in cohort 1), 569 (89%) received empiric antibiotics for suspected early-onset sepsis. In 409 infants (72%) the CDS algorithm was followed; antibiotics were discontinued ≤48 hours in 311 (55%) with normal serial CRPs and continued in 98 (17%) with positive CRPs, resulting in significant reduction in antibiotic exposure (p<0.001) without increase in complications or subsequent infections. One hundred sixty (28%) were considered non-compliant because antibiotics were continued beyond 48 hours despite negative serial CRPs and blood cultures. Serial CRPs remained negative in 38 (12%) of 308 blood culture-positive infants from cohort 2, but only 4 patients had clinically probable sepsis with single organisms and no immunodeficiency besides extreme prematurity. Leukopenia of any cell type was not linked with CRPs in cohorts 2 and 3.
CONCLUSIONS - CDS/CRP-guided antibiotic use is safe and effective in culture-negative VLBW infants. CRP results are not affected by low WBC indices.
OBJECTIVES - Catheter-associated bloodstream infections are a significant source of morbidity and healthcare cost in the neonatal ICU. Previous studies examining the prevalence of bloodstream infections after removal of peripherally inserted central venous catheters in neonates are equivocal.
DESIGN - A retrospective cohort study.
PATIENTS - All infants with peripherally inserted central venous catheters treated at the Vanderbilt neonatal ICU between 2007 and 2009.
MEASUREMENTS AND MAIN RESULTS - We evaluated the following outcomes: 1) bloodstream infections, 2) culture-negative sepsis, 3) number of sepsis evaluations, and 4) number of significant apnea/bradycardia events comparing odds ratios between 72 hours before and 72 hours after peripherally inserted central venous catheter removal. We analyzed a total of 1,002 peripherally inserted central venous catheters in 856 individual infants with a median (interquartile range) gestational age of 31 weeks (28-37 wk) and a median birth weight of 1,469 g (960-2,690 g). Comparing 72 hours before with 72 hours after peripherally inserted central venous catheter removal did not show a difference in the prevalence of bloodstream infections (9 vs 3, p = 0.08), prevalence of culture-negative sepsis (37 vs 40, p = 0.73), number of sepsis evaluations (p = 0.42), or number of apnea/bradycardia events (p = 0.32). However, in peripherally inserted central venous catheter not used for delivery of antibiotics, there was a 3.83-fold increase in odds for culture-negative sepsis following peripherally inserted central venous catheter removal (95% confidence interval, 1.48-10.5; p = 0.001). For infants less than 1,500 g birth weight (very low birth weight), odds for culture-negative sepsis increased to 6.3-fold following removal of peripherally inserted central venous catheters not used for antibiotic delivery (95% confidence interval, 1.78-26.86; p < 0.01).
CONCLUSIONS - Although these data do not support the routine use of antibiotics for sepsis prophylaxis prior to peripherally inserted central venous catheter removal, they suggests that very low birth weight infants not recently exposed to antibiotics are at increased odds for associated adverse events following discontinuation of their peripherally inserted central venous catheter.
BACKGROUND - Respiratory syncytial virus (RSV) infection is a leading cause of hospitalization among infants. However, estimates of the RSV hospitalization burden have varied, and precision has been limited by the use of age strata grouped in blocks of 6 to ≥ 12 months.
METHODS - We analyzed data from a 5-year, prospective, population-based surveillance for young children who were hospitalized with laboratory-confirmed (reverse-transcriptase polymerase chain reaction) RSV acute respiratory illness (ARI) during October through March 2000-2005. The total population at risk was stratified by month of age by birth certificate information to yield hospitalization rates.
RESULTS - There were 559 (26%) RSV-infected children among the 2149 enrolled children hospitalized with ARI (85% of all eligible children with ARI). The average RSV hospitalization rate was 5.2 per 1000 children <24 months old. The highest age-specific rate was in infants 1 month old (25.9 per 1000 children). Infants ≤ 2 months of age, who comprised 44% of RSV-hospitalized children, had a hospitalization rate of 17.9 per 1000 children. Most children (79%) were previously healthy. Very preterm infants (<30 weeks' gestation) accounted for only 3% of RSV cases but had RSV hospitalization rates 3 times that of term infants.
CONCLUSIONS - Young infants, especially those who were 1 month old, were at greatest risk of RSV hospitalization. Four-fifths of RSV-hospitalized infants were previously healthy. To substantially reduce the burden of RSV hospitalizations, effective general preventive strategies will be required for all young infants, not just those with risk factors.
Morbidity in the premature (PT) infant may reflect difficult adaptation to oxygen. We hypothesized that feeding including formula feeding (F) and feeding mother's milk (HM) with added fortifier would affect redox status. Therefore, 65 PT infants (birth weight: 1146 ± 261 g; GA: 29 ± 2.5 wk; mean ± SD) were followed biweekly, once oral feeds were introduced. Feeding groups: F (>75% total feeds) and HM (>75% total feeds) were further subdivided according to human milk fortifier (HMF) content of 0-19, 20-49, and ≥ 50%. Oxidative stress was quantified by F2-isoprostanes (F2-IsoPs) in urine, protein carbonyls, and oxygen radical absorbance capacity (ORAC) in plasma. F2-IsoPs (ng/mg creatinine): 0-2 wk, 125 ± 63; 3-4 wk, 191 ± 171; 5-6 wk, 172 ± 83; 7-8 wk, 211 ± 149; 9-10 wk, 222 ± 121; and >10 wk, 183 ± 67. Protein carbonyls from highest [2.41 ± 0.75 (n = 9)] and lowest [2.25 ± 0.89 (n = 12) pmol/μg protein] isoprostane groups did not differ. ORAC: baseline, 6778 ± 1093; discharge, 6639 ± 735 [full term 4 and 12 M, 9010 ± 600 mg (n = 12) TE]. Highest isoprostane values occurred in infants with >50% of their mother's milk fortified. Further research on HMF is warranted.