Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birth weight infants

An outbreak of necrotizing enterocolitis associated with norovirus genotype GII.3

BACKGROUND

Necrotizing enterocolitis (NEC) is an acute abdominal emergency of unknown etiology predominantly affecting preterm infants. We describe a cluster of NEC in a level III NICU involving 15 infants over a6-month period. Cohorting and stringent infection control measures were associated with termination of the cluster. A case-control study was used to investigate potential risk factors associated with development of NEC.

METHODS

Stool samples were collected from 55 infants (10 of 15 NEC and 45 non-NEC controls). Enteric pathogens were identified by culture and/or molecular diagnostic techniques. For the case-control study, controls were selected from admitted neonates during the same time and in the preceding 6-month period, matched for gestation and birthweight.

RESULTS

Forty percent (4/10) of NEC infants had norovirus RNA detected compared with 9% (4/45) of non-NEC infants (OR: 6.83, 95% CI: 1.3-34.9,P = 0.021). A lower rate of prolonged rupture of membranes and a higher rate of maternal smoking was also observed in NEC infants than in controls. No significant differences in incidences of chorioamnionitis, intrapartum antibiotics,volume of feedings, time of first formula feeding, and rates of patent ductus arteriosus or intrauterine growth retardation were detected.

CONCLUSIONS

Infants who developed NEC had an increased incidence of norovirus detection in their stool following diagnosis. This further strengthens the case for an etiologic role of norovirus in the pathogenesis of NEC.

Trajectory of metabolic derangement in infants with necrotizing enterocolitis should drive timing and technique of surgical intervention

BACKGROUND

Seven clinical metrics of metabolic derangement (MD7) have improved the timing of surgical intervention in infants with necrotizing enterocolitis (NEC). We compared surgical NEC outcomes based on MD7 at our center (unit S) with a similar center (unit B) that based its intervention on abdominal radiograph.

STUDY DESIGN

Premature infants undergoing surgical care for NEC were evaluated. MD7 included positive blood culture, acidosis, bandemia, hyponatremia, thrombocytopenia, hypotension, and neutropenia. Surgical recommendations were stratified as observation or intervention. Good outcomes included full enteric feeding by discharge and poor outcomes were death or dependence on parenteral nutrition. For unit S and unit B, the frequency, median, and mode of MD7 component per case were determined for observation and intervention. Mann-Whitney U test and Wilcoxon matched pairs were used to compare positive MD7 frequency for observation with intervention. Institutional mortality was compared and metabolic severity of unit cohorts was evaluated by incidence of MD7 in each.

RESULTS

From March 2005 to July 2008, forty-one infants at unit S underwent 62 surgical evaluations. Observation was elected in 38 (median 1 MD7 per case, mode 0). Operative intervention occurred in 24 (median 4 MD7 per case, mode 4). Proportional MD7 difference between observation and intervention was significant (p = 0.018, U = 6). From February 2007 to December 2008, sixty-five unit B infants received 81 evaluations, recommending 37 observations (median 2 MD7 per case, mode 2), and 44 interventions (median 3 MD7 per case, mode 3). MD7 proportions between observation and intervention were not significant (p = 0.318, U = 16). Poor outcomes rates for unit S and unit B infants were 24% and 66%, respectively (p = 0.0001). Severity of MD7 did not differ between institutions (p = 0.53, U = 19).

CONCLUSIONS

These data demonstrate variability in surgical approach to NEC. The MD7 panel describes the trajectory of metabolic derangement, defines more timely surgical intervention, and demonstrates that waiting for free air is too late.

The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis

BACKGROUND AND OBJECTIVE

A 2001 study revealed that $3.6 billion could be saved if breastfeeding rates were increased to levels of the Healthy People objectives. It studied 3 diseases and totaled direct and indirect costs and cost of premature death. The 2001 study can be updated by using current breastfeeding rates and adding additional diseases analyzed in the 2007 breastfeeding report from the Agency for Healthcare Research and Quality.

STUDY DESIGN

Using methods similar to those in the 2001 study, we computed current costs and compared them to the projected costs if 80% and 90% of US families could comply with the recommendation to exclusively breastfeed for 6 months. Excluding type 2 diabetes (because of insufficient data), we conducted a cost analysis for all pediatric diseases for which the Agency for Healthcare Research and Quality reported risk ratios that favored breastfeeding: necrotizing enterocolitis, otitis media, gastroenteritis, hospitalization for lower respiratory tract infections, atopic dermatitis, sudden infant death syndrome, childhood asthma, childhood leukemia, type 1 diabetes mellitus, and childhood obesity. We used 2005 Centers for Disease Control and Prevention breastfeeding rates and 2007 dollars.

RESULTS

If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion per year and prevent an excess 911 deaths, nearly all of which would be in infants ($10.5 billion and 741 deaths at 80% compliance).

CONCLUSIONS

Current US breastfeeding rates are suboptimal and result in significant excess costs and preventable infant deaths. Investment in strategies to promote longer breastfeeding duration and exclusivity may be cost-effective.

Updated meta-analysis of probiotics for preventing necrotizing enterocolitis in preterm neonates

OBJECTIVE

Systematic reviews of randomized, controlled trials (RCTs) indicate lower mortality and necrotizing enterocolitis (NEC) and shorter time to full feeds after probiotic supplementation in preterm (<34 weeks' gestation) very low birth weight (VLBW; birth weight <1500 g) neonates. The objective of this study was to update our 2007 systematic review of RCTs of probiotic supplementation for preventing NEC in preterm VLBW neonates.

METHODS

We searched in March 2009 the Cochrane Central register; Medline, Embase, and Cinahl databases; and proceedings of the Pediatric Academic Society meetings and gastroenterology conferences. Cochrane Neonatal Review Group search strategy was followed. Selection criteria were RCTs of any enteral probiotic supplementation that started within first 10 days and continued for > or =7 days in preterm VLBW neonates and reported on stage 2 NEC or higher (Modified Bell Staging).

RESULTS

A total of 11 (N = 2176), including 4 new (n = 783), trials were eligible for inclusion in the meta-analysis by using a fixed-effects model. The risk for NEC and death was significantly lower. Risk for sepsis did not differ significantly. No significant adverse effects were reported. Trial sequential analysis) showed 30% reduction in the incidence of NEC (alpha = .05 and .01; power: 80%).

CONCLUSIONS

The results confirm the significant benefits of probiotic supplements in reducing death and disease in preterm neonates. The dramatic effect sizes, tight confidence intervals, extremely low P values, and overall evidence indicate that additional placebo-controlled trials are unnecessary if a suitable probiotic product is available.

An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products

OBJECTIVE

To evaluate the health benefits of an exclusively human milk-based diet compared with a diet of both human milk and bovine milk-based products in extremely premature infants.

STUDY DESIGN

Infants fed their own mothers' milk were randomized to 1 of 3 study groups. Groups HM100 and HM40 received pasteurized donor human milk-based human milk fortifier when the enteral intake was 100 and 40 mL/kg/d, respectively, and both groups received pasteurized donor human milk if no mother's milk was available. Group BOV received bovine milk-based human milk fortifier when the enteral intake was 100 mL/kg/d and preterm formula if no mother's milk was available. Outcomes included duration of parenteral nutrition, morbidity, and growth.

RESULTS

The 3 groups (total n = 207 infants) had similar baseline demographic variables, duration of parenteral nutrition, rates of late-onset sepsis, and growth. The groups receiving an exclusively human milk diet had significantly lower rates of necrotizing enterocolitis (NEC; P = .02) and NEC requiring surgical intervention (P = .007).

CONCLUSIONS

For extremely premature infants, an exclusively human milk-based diet is associated with significantly lower rates of NEC and surgical NEC when compared with a mother's milk-based diet that also includes bovine milk-based products.

Improving the use of human milk during and after the NICU stay

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.

Breastfeeding promotion for infants in neonatal units: a systematic review

BACKGROUND

Breastfeeding/breastmilk feeding of infants in neonatal units is vital to the preservation of short- and long-term health, but rates are very low in many neonatal units internationally. The aim of this review was to evaluate the effectiveness of clinical, public health and health promotion interventions that may promote or inhibit breastfeeding/breastmilk feeding for infants admitted to neonatal units.

METHODS

Systematic review with narrative synthesis. Studies were identified from structured searches of 19 electronic databases from inception to February 2008; hand searching of bibliographies; Advisory Group members helped identify additional sources.

INCLUSION CRITERIA

controlled studies of interventions intended to increase breastfeeding/feeding with breastmilk that reported breastmilk feeding outcomes and included infants admitted to neonatal units, their mothers, families and caregivers. Data were extracted and appraised for quality using standard processes. Study selection, data extraction and quality assessment were independently checked. Study heterogeneity prevented meta-analysis.

RESULTS

Forty-eight studies were identified, mainly measuring short-term outcomes of single interventions in stable infants. We report here a sub-set of 21 studies addressing interventions tested in at least one good-quality or more than one moderate-quality study. Effective interventions identified included kangaroo skin-to-skin contact, simultaneous milk expression, peer support in hospital and community, multidisciplinary staff training, and Unicef Baby Friendly accreditation of the associated maternity hospital.

CONCLUSIONS

Breastfeeding/breastmilk feeding is promoted by close, continuing skin-to-skin contact between mother and infant, effective breastmilk expression, peer support in hospital and community, and staff training. Evidence gaps include health outcomes and costs of intervening with less clinically stable infants, and maternal health and well-being. Effects of public health and policy interventions and the organization of neonatal services remain unclear. Infant feeding in neonatal units should be included in public health surveillance and policy development; relevant definitions are proposed.

Necrotizing enterocolitis in 20,822 infants: analysis of medical and surgical treatments

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency of the neonate. Previous information about this disease has largely been gathered from limited series. We analyzed 13 years of the National Inpatient Sample (NIS) and 3 years of the Kids' Inpatient Database (KID; 1997, 2000, 2003) to generate the most comprehensive profile of outcomes to date of medically versus surgically treated NEC. We identified 20 822 infants with NEC, of whom 15,419 (74.1%) and 5403 (25.9%) were undergoing medical and surgical management, respectively. Overall, surgical patients had greater length of stay, total hospital charges, and mortality. Among infants dying during admission, there was no significant difference in length of stay or charges between the medical and surgical groups. These findings highlight the need for developing a clinically relevant risk stratification tool to identify NEC patients at high risk for death.

Timing of surgical intervention in necrotizing enterocolitis can be determined by trajectory of metabolic derangement

PURPOSE

Seven metrics of metabolic derangement were evaluated as contributors to clinical decision support for operative intervention in infants with suspected necrotizing enterocolitis (NEC).

METHODS

Records of infants with suspected NEC without radiologic evidence of free air were queried for presence of 7 components of metabolic derangement (CMD), consisting of positive blood culture, acidosis, bandemia, thrombocytopenia, hyponatremia, hypotension, or neutropenia. Cases were stratified by clinical decision after each surgical evaluation as observation (OBS) or intervention (INT). Good outcome was defined as full enteric feeding by discharge and bad outcome as death or ongoing parenteral alimentation. Eleven infants undergoing operative intervention after an initial decision to observe were evaluated as matched pairs. Components of metabolic derangement/case and frequency of each CMD were determined for OBS and INT. Mann-Whitney U test was used to compare proportions of CMD in each group. Outcome was compared using chi(2). Observation was then stratified by outcome to determine whether 3 or more metabolic derangements warranting operative intervention would have changed initial clinical decision. The 11 matched cases were similarly analyzed using Wilcoxon-matched pairs.

RESULTS

Between March 2005 and July 2008, 35 infants with NEC received 53 surgical evaluations. A median of 1 CMD/case was defined in 32 instances of OBS. Surgical intervention was carried out in 19 infants with a median of 3 CMD/case. Mann-Whitney U test indicated significant difference in the frequencies of each CMD component in OBS vs INT (P = .04). Good outcome was achieved in 75% of OBS and 63% of INT (non-significant, NS). Analysis of OBS by outcome demonstrated a median 1 CMD/case of 25 with good outcome and 3 CMD/case in infants with bad outcome. Frequency of CMD was significantly higher in infants with bad outcome (P = .02). Wilcoxon-matched pair analysis of the 11 infants with paired evaluations demonstrated a similar distribution and frequency of CMD.

CONCLUSION

Progressive metabolic derangement of infants with NEC can be clinically tracked. The appearance of any 3 of these 7 metrics indicates timely operative intervention. Application of CMD trajectory to timing of surgical intervention may improve outcome and define the relationship between specific CMD and operative risk.

Can we cut the incidence of necrotizing enterocolitis in half--today?

Necrotizing enterocolitis (NEC) is a common gastrointestinal emergency of neonates. Population studies estimate the incidence of NEC at between 0.3 and 2.4 per 1000 live births in the United States, with a predominance of cases among preterm neonates born at the earliest gestational ages. The disease burden of NEC includes an overall disease-specific mortality rate of 15-20%, with yet higher rates in those of earliest gestations. The NEC burden also includes an increase in hospital costs approximating $100,000/case, as well as severe late sequellae including parenteral nutrition-associated liver disease and short bowel syndrome. Differentiating NEC from other forms of acquired neonatal intestinal disease is critical to assessing the success of NEC prevention strategies. Promising new prevention strategies are now being tested; one such is prophylactic heparin-binding epidermal growth factor-like growth factor (HB-EGF) administration. However, two prevention strategies have already been shown in meta-analyses to reduce the incidence of NEC, but we speculate that these are not being fully utilized. They are; 1) implementing a written set of feeding guidelines (also called standardized feeding regimens) for newborn intensive care unit (NICU) patients, and 2) implementing programs to increase the availability of human milk for patients at risk of developing NEC.

Probiotic and prebiotic supplementation for the prevention of neonatal necrotizing enterocolitis

The pathophysiology of necrotizing enterocolitis (NEC) has not been clearly elucidated, but recent studies support the role of unbalanced pro-inflammatory signaling, leading to intestinal necrosis in premature infants. Although breast milk feeding is thought to reduce the risk of this condition, there are no preventive or therapeutic approaches that have consistently shown to be effective for this common and devastating disease. Recent studies show that probiotic colonization is abnormal in preterm neonates, and enteral supplementation with a variety of probiotic organisms can reduce the risk of disease. This chapter summarizes the current state-of-the-art regarding probiotics and NEC, but suggests caution until appropriately regulated products are available for use in this high-risk population.

U.S. health policy and access to banked donor human milk

Abstract Barriers to the use of banked donor milk are numerous, and many patients are denied access to it because of lack of policy explicitly addressing its use. This examination of U.S. health policies, both governmental and professional, addressing child health and breastfeeding suggests where donor milk banking services should be included to fulfill the ethical principles of justice (fair access) and autonomy. The need for research to support future policy development is also highlighted.

Very low birth weight preterm infants with surgical short bowel syndrome: incidence, morbidity and mortality, and growth outcomes at 18 to 22 months

OBJECTIVES

The objective of this study was to determine the (1) incidence of short bowel syndrome in very low birth weight (<1500 g) infants, (2) associated morbidity and mortality during initial hospitalization, and (3) impact on short-term growth and nutrition in extremely low birth weight (<1000 g) infants.

METHODS

Infants who were born from January 1, 2002, through June 30, 2005, and enrolled in the National Institute of Child Health and Human Development Neonatal Research Network were studied. Risk factors for developing short bowel syndrome as a result of partial bowel resection (surgical short bowel syndrome) and outcomes were evaluated for all neonates until hospital discharge, death, or 120 days. Extremely low birth weight survivors were further evaluated at 18 to 22 months' corrected age for feeding methods and growth.

RESULTS

The incidence of surgical short bowel syndrome in this cohort of 12316 very low birth weight infants was 0.7%. Necrotizing enterocolitis was the most common diagnosis associated with surgical short bowel syndrome. More very low birth weight infants with short bowel syndrome (20%) died during initial hospitalization than those without necrotizing enterocolitis or short bowel syndrome (12%) but fewer than the infants with surgical necrotizing enterocolitis without short bowel syndrome (53%). Among 5657 extremely low birth weight infants, the incidence of surgical short bowel syndrome was 1.1%. At 18 to 22 months, extremely low birth weight infants with short bowel syndrome were more likely to still require tube feeding (33%) and to have been rehospitalized (79%). Moreover, these infants had growth delay with shorter lengths and smaller head circumferences than infants without necrotizing enterocolitis or short bowel syndrome.

CONCLUSIONS

Short bowel syndrome is rare in neonates but has a high mortality rate. At 18 to 22 months' corrected age, extremely low birth weight infants with short bowel syndrome were more likely to have growth failure than infants without short bowel syndrome.

Clinical predictors of necrotizing enterocolitis in premature infants

BACKGROUND

Necrotizing enterocolitis (NEC) has emerged as the most common neonatal gastrointestinal emergency, is the most common cause of death in neonates undergoing surgery, and accounts for yearly additional hospital charges in excess of $6.5 million. Prematurity is the only common variable identified in case-controlled studies exploring this disease.

OBJECTIVES

To improve the understanding of the relationship between factors related to intestinal inflammation and ischemia and the enteral feeding regimen in the context of the premature gut, thereby identifying antecedents of NEC.

METHODS

Data were collected from the medical records of 247 premature infants for this retrospective case-controlled study. Diagnosis of NEC, as defined by Bell Stages IIA-IIIB, was required for study group assignment (n = 84). Multivariate analysis techniques were used to predict the relationships between selected variables on the outcome of NEC.

RESULTS

Premature infants were 13 times more likely to develop NEC if the infant required increased respiratory support to maintain oxygenation during the early neonatal period and 6.4 times more likely to develop NEC if the infant did not receive nutritionally fortified enteral feedings of breast milk. When both factors were present, the odds of NEC increased 28.6 times when compared with infants without these factors.

DISCUSSION

The study findings extend knowledge of antecedents to NEC beyond prematurity, highlighting the role that respiratory support and nutritional fortification of enteral feedings play in the pathogenesis of this disease. Early identification of antecedents to NEC will improve critical care management of the neonate and, in turn, decrease the incidence of this devastating gastrointestinal disease. The study findings will guide further inquiry in neonatal nutrition, physiologic and metabolic functioning, and acute clinical management of the neonate.

Probiotics for the prevention of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) remains a significant cause of morbidity and mortality for low birth weight premature infants. Prematurity, ischemia, formula feeding, and bacterial colonization are risk factors for the self-perpetuating cycle of damaged intestinal epithelia, inflammation, bacterial entry, sepsis, and shock that characterizes NEC. Probiotics are food supplements containing live bacteria that benefit the recipient by improving the microflora balance within the intestine. Several studies suggest that the administration of probiotics may have a prophylactic effect for NEC and may reduce morbidity and mortality rates for low birth weight infants.

Resuscitation of preterm neonates by using room air or 100% oxygen

OBJECTIVE

In this study of preterm neonates of <32 weeks, we prospectively compared the use of room air versus 100% oxygen as the initial resuscitation gas.

METHODS

A 2-center, prospective, randomized, controlled trial of neonates with gestational ages of 23 to 32 weeks who required resuscitation was performed. The oxygen group was initially resuscitated with 100% oxygen, with decreases in the fraction of inspired oxygen after 5 minutes of life if pulse oxygen saturation was >95%. The room air group was initially resuscitated with 21% oxygen, which was increased to 100% oxygen if compressions were performed or if the heart rate was <100 beats per minute at 2 minutes of life. Oxygen was increased in 25% increments if pulse oxygen saturation was <70% at 3 minutes of life or <80% at 5 minutes of life.

RESULTS

Twenty-three infants in the oxygen group (mean gestational age: 27.6 weeks; range: 24-31 weeks; mean birth weight: 1013 g; range: 495-2309 g) and 18 in the room air group (mean gestational age: 28 weeks; range: 25-31 weeks; mean birth weight: 1091 g; range: 555-1840 g) were evaluated. Every resuscitated patient in the room air group met rescue criteria and received an increase in the fraction of inspired oxygen by 3 minutes of life, 6 patients directly to 100% and 12 with incremental increases. Pulse oxygen saturation was significantly lower in the room air group from 2 to 10 minutes (pulse oxygen saturation at 3 minutes: 55% in the room air group vs 87% in the oxygen group). Heart rates did not differ between groups in the first 10 minutes of life, and there were no differences in secondary outcomes.

CONCLUSIONS

Resuscitation with room air failed to achieve our target oxygen saturation by 3 minutes of life, and we recommend that it not be used for preterm neonates.

Human milk consumption and full enteral feeding among infants who weigh </= 1250 grams

OBJECTIVE

Establishing enteral feeding is an important goal in the care of very low birth weight infants. In such infants, receipt of >/=50 mL/kg per day human milk during hospitalization has been associated with shorter time to full enteral feeding. The objective of this study was to determine whether high proportions (>/=50%) of human milk during feeding advancement are associated with shorter time to full enteral feeding and improved feeding tolerance.

METHODS

This was a prospective cohort study of very low birth weight infants (n = 127) who were grouped into low (<50%; n = 34) and high (>/=50%; n = 93) human milk consumption groups according to their human milk proportion of enteral feeding during the time of feeding advancement. The primary outcomes of interest were ages at which 100 and 150 mL/kg per day enteral feedings were achieved.

RESULTS

The high human milk group reached 100 mL/kg per day enteral feeding 4.5 days faster than the low human milk group. The high human milk group reached 150 mL/kg per day enteral feeding 5 days faster than the low human milk group. After adjustment for gestational age, gender, and respiratory distress syndrome, times to reach 100 and 150 mL/kg per day were significantly shorter for those in the high human milk group. Infants in the high human milk group had a greater number of stools per day; other indicators of feeding tolerance were not statistically different.

CONCLUSION

In infants who weighed </=1250 g, enteral feeding that contained at least 50% maternal human milk was associated with fewer days to full enteral feedings.

Increased mortality and altered immunity in neonatal sepsis produced by generalized peritonitis

Neonates have a higher prevalence of bacterial sepsis and have greater morbidity and mortality from sepsis than other infants and children. Our understanding of the inflammatory and immunological responses to sepsis is hampered by the lack of appropriate neonatal murine models. In the present report, we have developed a cecal slurry model of generalized peritonitis in neonatal mice (age range, 5-7 days) and compared the outcome and the innate and adaptive cellular responses of these animals with those of the young adult animals (age range, 7-10 weeks) with sepsis induced either by cecal slurry administration or by cecal ligation and puncture. Neonatal mice were more susceptible to sepsis and mounted a markedly attenuated systemic inflammatory response compared with young adult animals (specifically, decreased plasma interferon gamma; interleukins 1alpha and 1beta; regulated on activation, normal T expressed and secreted (RANTES); and tumor necrosis factor alpha concentrations). Compared with young adult animals, septic neonatal mice did not lose significant percentage or absolute number of splenic CD4+ T cells. These findings suggest that the cecal slurry model of generalized peritonitis can produce sepsis in neonatal mice with dose-dependent lethality. Inherent differences in the host response to polymicrobial sepsis between neonatal and young adult animals may explain the increased sensitivity of the neonatal mouse to generalized peritonitis.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

The introduction of progressive enteral feeds for very low birth weight infants is often delayed for several days or longer after birth due to concern that earlier introduction may not be tolerated and may increase the risk of necrotising enterocolitis. However, delaying enteral feeding could diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.

OBJECTIVES

To determine the effect of delayed introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very low birth weight infants.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Group was used. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2007), MEDLINE (1966 - December 2007), EMBASE (1980 - December 2007), CINAHL (1982- December 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of delayed (after 96 hours' postnatal age) versus earlier introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very low birth weight infants.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Group were used, with separate evaluation of trial quality and data extraction by two authors. Data were synthesised using a fixed effects model and reported using typical relative risk, typical risk difference and weighted mean difference.

MAIN RESULTS

Two small trials in which a total of 74 infants participated were eligible for inclusion. Only a minority of participants were of extremely low birth weight or extreme preterm gestation. These trials provided no evidence that delayed introduction of progressive enteral feeds affected the incidence of necrotising enterocolitis, mortality or other neonatal morbidities. However, in view of the small number of participants, important beneficial or harmful effects cannot be excluded.

AUTHORS' CONCLUSIONS

The available data are insufficient to inform clinical practice. Further large pragmatic randomised controlled trials are needed to determine how the timing of the introduction of progressive enteral feeds affects important clinical outcomes in very low birth weight infants, and particularly in extremely low birth weight or growth restricted infants.

Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

The major modifiable risk factors for necrotising enterocolitis in very low birth weight infants relate to enteral feeding regimens. Observational studies suggest that conservative feeding regimens such as delaying the introduction of enteral feeds or slowly advancing feed volumes reduce the risk of necrotising enterocolitis

OBJECTIVES

To determine the effect of slow rates of enteral feed advancement on the incidence of necrotising enterocolitis, mortality and other morbidities in very low birth weight infants.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Group was used. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2007), MEDLINE (1966 - December 2007), EMBASE (1980 - December 2007), CINAHL (1982- December 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of slow (up to 24 ml/kg/day) versus faster rates of advancement of enteral feed volumes upon the incidence of necrotising enterocolitis in very low birth weight infants.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Group were used, with separate evaluation of trial quality and data extraction by two authors. Data were synthesised using a fixed effects model and reported using typical relative risk, typical risk difference and weighted mean difference.

MAIN RESULTS

Three randomised controlled trials in which a total of 396 infants participated were identified. Few participants were extremely low birth weight or growth restricted. The trials were generally of good methodological quality but caregivers and investigators were aware of the allocated interventions. Meta-analyses did not detect statistically significant effects on the risk of necrotising enterocolitis [typical relative risk 0.96 (95% confidence interval 0.48 to 1.92); typical risk difference 0.00 (95% confidence interval -0.05 to 0.05)] or all cause mortality [typical relative risk 1.40 (95% confidence interval 0.71 to 2.80); typical risk difference 0.03 (95% confidence interval -0.03 to 0.10)]. Infants who had slow rates of feed volume advancement took longer to regain birth weight [reported median difference between two and five days] and to establish full enteral feeding [reported median difference between three and five days]. No statistically significant effect on the total duration of hospital stay was detected.

AUTHORS' CONCLUSIONS

The currently available data do not provide evidence that slow advancement of enteral feed volumes reduces the risk of necrotising enterocolitis in very low birth weight infants. Increasing the volume of enteral feeds at slow rather than faster rates results in several days delay in regaining birth weight and establishing full enteral feeds but the long-term clinical importance of these effects is unclear. Further randomised controlled trials are needed to determine how the rate of daily increment in enteral feed volumes affects important clinical outcomes in very low birth weight infants, and particularly in extremely low birth weight or growth restricted infants.

Extremely long hospitalizations of newborns in the United States: data, descriptions, dilemmas

PROBLEM

Neonatal and pediatric nurses and physicians care for newborn children who have been saved by technological support but who then spend extremely long periods of time in the hospital, perhaps never being able to be discharged to home. There has been little research identifying newborns who are too sick to be discharged from the health care setting and rare reports of staff or parental response to these long-term hospitalizations.

PURPOSE

This study provides both the numerical data and description of acutely, chronically ill newborn children whose illnesses caused hospitalizations for greater than 6-months (179 days) in the US.

METHODOLOGY

Method triangulation using a national data set (HCUPKID 2003), a researcher created LONGTERM survey, and a qualitative question was used to identify pathologies associated with newborn length of stays greater than 6 months. Neonatal nurses and physicians provided descriptions of children spending at least 6 months in the hospital, including anecdotal reports of caring for those children.

RESULTS

The national H-CUP data set identified 680 infants staying 6 months or longer in the hospital during 2003. Four hundred and twenty-two providers submitted LONGTERM surveys describing these infants, with 228 first hand reports on how it felt to care for children with hospital stays between 6 months and 6 years. Extreme prematurity, respiratory distress and necrotizing enterocolitis contributed to the extremely long hospital stays. Nurse and physician participants felt that extremely long hospital stays were often due to situations in which parents or colleagues were insisting upon continued futile treatment.

A case of necrotizing enterocolitis associated with adenovirus infection in a term infant with 22q11 deletion syndrome

Infections with adenoviruses are a common problem in the pediatric population. Normally asymptomatic to mild, those infections tend to take a more severe course in immunocompromised patients. 22q11 deletion syndrome (22q11DS) represents a common genetic disorder causing immunodeficiency from thymic hypoplasia or aplasia, heart defects, a characteristic facial appearance, and velopharyngeal dysfunction. Necrotizing enterocolitis (NEC) is a frequent gastrointestinal emergency observed in neonatal intensive care units. The occurrence of NEC is more prevalent in preterm infants. However, there are cases in term infants, but usually, they are associated with predisposing disorders. In this case report, a child is presented with 22q11DS that postnatally developed NEC associated with an adenoviral infection. Although other viruses such as toroviruses or cytomegaloviruses have been implicated in the pathogenesis of NEC in preterm infants, we could not find any report in the recent medical literature describing an association between adenoviral infections, NEC, and 22q11DS in a term infant.

Probiotics for prevention of necrotizing enterocolitis in preterm infants

BACKGROUND

Necrotizing enterocolitis (NEC) and nosocomial sepsis are associated with increased morbidity and mortality in preterm infants. Through prevention of bacterial migration across the mucosa, competitive exclusion of pathogenic bacteria, and enhancing the immune responses of the host, prophylactic enteral probiotics (live microbial supplements) may play a role in reducing NEC and associated morbidity.

OBJECTIVES

To compare the efficacy and safety of prophylactic enteral probiotics administration versus placebo or no treatment in the prevention of severe NEC and/or sepsis in preterm infants.

SEARCH STRATEGY

The standard search strategy for the Cochrane Neonatal Review Group was performed by two review authors. Searches were made of MEDLINE (1966 to December 2006), EMBASE (1980 to December 2006), Cochrane Library Controlled Trials Register (CENTRAL, The Cochrane Library Issue 3, 2006), and abstracts of annual meetings of the Society for Pediatric Research (1995 - 2006). The authors of published articles were contacted.

SELECTION CRITERIA

Only randomized or quasi-randomized controlled trials that enrolled preterm infants < 37 weeks gestational age and/or < 2500 g birth weight were considered. Trials were included if they involved enteral administration of any live microbial supplement (probiotics) and measured at least one prespecified clinical outcome.

DATA COLLECTION AND ANALYSIS

Standard methods of the Cochrane Collaboration and its Neonatal Group were used to assess the methodologic quality of the trials. Retrieved articles were assessed for eligibility and data abstracted independently by two review authors. Where data were incomplete, the primary investigator were contacted for further information and clarification. Where appropriate, data of individual trials were combined using meta-analytic techniques to provide a pooled estimate of effect assuming a fixed effect model.

MAIN RESULTS

Nine eligible trials randomizing 1425 infants were included. Included trials were highly variable with regard to enrollment criteria (i.e. birth weight and gestational age), baseline risk of NEC in the control groups, timing, dose, formulation of the probiotics, and feeding regimens. Data regarding extremely low birth weight infants (ELBW) could not be extrapolated. In a meta-analysis of trial data, enteral probiotics supplementation significantly reduced the incidence of severe NEC (stage II or more) [typical RR 0.32 (95% CI 0.17, 0.60)] and mortality [typical RR 0.43 (95% CI 0.25, 0.75]. There was no evidence of significant reduction of nosocomial sepsis [typical RR 0.93 (95% CI 0.73, 1.19)] or days on total parenteral nutrition (TPN) [WMD -1.9 (95% CI -4.6, 0.77)]. The included trials reported no systemic infection with the probiotics supplemental organism. The statistical test of heterogeneity for NEC, mortality and sepsis was insignificant.

AUTHORS' CONCLUSIONS

Enteral supplementation of probiotics reduced the risk of severe NEC and mortality in preterm infants. This analysis supports a change in practice in premature infants > 1000 g at birth. Data regarding outcome of ELBW infants could not be extracted from the available studies; therefore, a reliable estimate of the safety and efficacy of administration of probiotic supplements cannot be made in this high risk group. A large randomized controlled trial is required to investigate the potential benefits and safety profile of probiotics supplementation in ELBW infants.

Prevention and treatment of necrotising enterocolitis in preterm neonates

Prevention and treatment of NEC has become an area of priority for research due to the increasing number of preterm survivors at risk, and the significant mortality and morbidity related to the illness. Probiotic supplementation appears to be a promising option for primary prevention of NEC but further large trials are necessary for documenting their safety in terms of sepsis as well as long-term neurodevelopmental outcomes and immune function. As new frontiers including immunomodulating agents like pentoxifylline continue to be explored, the impact of well-established simple strategies like antenatal glucocorticoid therapy, and early and preferential use of breast milk must not be forgotten. Clinical research on manifestations of ileus of prematurity, and feeding in the presence of common risk factors such as IUGR is needed. Safety of minimal enteral feeds in terms of NEC and benefits of standardised feeding regimens need to be confirmed. Association of common clinical practices such as red cell transfusions, H2 receptor blockade, and thickening of feeds with NEC warrants attention. An approach utilising a package of potentially better practices seems to be the most appropriate strategy for the prevention and treatment of NEC.

Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants

BACKGROUND

Necrotizing enterocolitis (NEC) is a frequent cause of mortality and morbidity in very low birth weight (VLBW) infants. Human milk (HM) feeding has been associated with lower risk of NEC. However, mothers of VLBW infants often experience insufficient milk production, resulting in mixed feedings of HM and formula. Moreover, medical complications often limit the volume of feeding they can be given.

OBJECTIVE

To determine if high proportions of (50% or greater) HM enteral feeding within the first 14 days of life are protective against NEC.

METHOD

This was a prospective cohort study of VLBW infants who were grouped according to the HM proportion of enteral feeding in the first 14 days: <50% (low human milk, LHM, n=46) and > or =50% (high human milk, HHM, n=156). The outcome of interest was development of NEC (Bell stage 2 or 3). Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) and to assess potential confounding due to perinatal risk factors.

RESULT

Two hundred and two infants were studied. Confirmed NEC occurred in 5/46 (10.6%) of the LHM group, as compared with 5/156 (3.2%) of the HHM. Gestational age was the only perinatal factor associated with risk of NEC. After adjustment for gestational age, HHM was associated with a lower risk of NEC ((OR=0.17, 95% CI: 0.04 to 0.68), P=0.01).

CONCLUSION

Enteral feeding containing at least 50% HM in the first 14 days of life was associated with a sixfold decrease in the odds of NEC.

Banking for the future: investing in human milk

Perspective on the paper by Boyd et al (see page F169 )

Exploratory laparotomy or peritoneal drain? Management of bowel perforation in the neonatal intensive care unit

Premature infants in the neonatal intensive care unit are at risk for necrotizing enterocolitis (NEC) and bowel perforation. Unfortunately the mortality and morbidity for intestinal perforation in neonates, especially extremely low-birth-weight infants (VLBW), is high. The criterion standard traditional management for bowel perforation has been exploratory laparotomy (LAP). Another less invasive alternative treatment modality for selected intestinal perforation is primary peritoneal drainage (PPD). The role and efficacy of PPD as a definitive treatment instead of laparotomy remains to be determined. To better appreciate the emergence and evolving role of PPD in the management of intestinal perforation in NEC or isolated intestinal perforation, 8 selected research articles will be reviewed. Findings from these studies will be summarized to address the original purpose of PPD as a rescue and stabilizing measure for VLBW infants with complicated NEC, the expanded and superior role of PPD when it is used for VLBW infants with isolated ileal perforation, and PPD not as a sole surgical management but as an adjunct therapy to LAP in perforated NEC for the VLBW infants.

Global health policies that support the use of banked donor human milk: a human rights issue

This review examines the role of donor human milk banking in international human rights documents and global health policies. For countries looking to improve child health, promotion, protection and support of donor human milk banks has an important role to play for the most vulnerable of infants and children. This review is based on qualitative triangulation research conducted for a doctoral dissertation. The three methods used in triangulation were 1) writing as a method of inquiry, 2) an integrative research review, and 3) personal experience and knowledge of the topic. Discussion of the international human rights documents and global health policies shows that there is a wealth of documentation to support promotion, protection and support of donor milk banking as an integral part of child health and survival. By utilizing these policy documents, health ministries, professional associations, and donor milk banking associations can find rationales for establishing, increasing or continuing to provide milk banking services in any country, and thereby improve the health of children and future generations of adults.

Extremely long hospitalizations of newborns in the United States: data, descriptions, dilemmas

PROBLEM

Neonatal and pediatric nurses and physicians care for newborn children who have been saved by technological support but who then spend extremely long periods of time in the hospital, perhaps never being able to be discharged to home. There has been little research identifying newborns who are too sick to be discharged from the health care setting and rare reports of staff or parental response to these long-term hospitalizations.

PURPOSE

This study provides both the numerical data and description of acutely, chronically ill newborn children whose illnesses caused hospitalizations for greater than 6-months (179 days) in the US.

METHODOLOGY

Method triangulation using a national data set (HCUP-KID 2003), a researcher created LONGTERM survey, and a qualitative question was used to identify pathologies associated with newborn length of stays greater than 6 months. Neonatal nurses and physicians provided descriptions of children spending at least 6 months in the hospital, including anecdotal reports of caring for those children.

RESULTS

The national H-CUP data set identified 680 infants staying 6 months or longer in the hospital during 2003. Four hundred and twenty-two providers submitted LONGTERM surveys describing these infants, with 228 first hand reports on how it felt to care for children with hospital stays between 6 months and 6 years. Extreme prematurity, respiratory distress and necrotizing enterocolitis contributed to the extremely long hospital stays. Nurse and physician participants felt that extremely long hospital stays were often due to situations in which parents or colleagues were insisting upon continued futile treatment.

Necrotising enterocolitis hospitalisations among neonates in the United States

The objective of this study was to estimate the rate and describe the epidemiology of necrotising enterocolitis (NEC) among neonates (infants <1 month of age) hospitalised in the United States. Hospital discharge records for neonates with an NEC diagnosis and an in-hospital death or routine discharge were selected for analysis from the 2000 Kids' Inpatient Database. An estimated 4463 (SE = 219) hospitalisations associated with NEC occurred among neonates in the United States during the year 2000, resulting in a hospitalisation rate of 109.9 [95% CI 97.2, 122.6] per 100 000 livebirths. The rate of NEC hospitalisations was highest among non-Hispanic Black neonates. The median hospital length of stay was 49 days. The in-hospital fatality rate was 15.2% (SE = 1.0%). Neonates who underwent a surgical procedure during hospitalisation were more likely to have a longer length of stay and to die than were those who did not have surgical intervention. Low-birthweight (LBW) neonates with NEC were more likely than LBW neonates hospitalised with other diagnoses to be very LBW (VLBW), non-Hispanic Black and male. In addition, compared with LBW neonates hospitalised with other diagnoses, LBW neonates with NEC had higher hospital charges and longer lengths of stay, and were more likely to die during hospitalisation. This study provides the first national estimate of the rate of hospitalisation for NEC among neonates in the United States. During 2000, there was one NEC hospitalisation per 1000 livebirths, with approximately 1 in 7 NEC hospitalisations ending in death. NEC accounts for substantial morbidity; thus, the development of prevention strategies and effective therapies continues to be an important issue.

Bronchopulmonary dysplasia in very low birth weight infants is associated with prolonged hospital stay

BACKGROUND

Bronchopulmonary dysplasia (BPD) is associated with prolonged hospital length of stay (LOS) and delayed discharge home.

OBJECTIVES

To evaluate the association between BPD and LOS and to assess the contribution of concomitant major morbidities on LOS among infants with BPD.

STUDY DESIGN

A population-based observational study of very low birth weight (VLBW) infants born from 1995 through 2003. Multivariate analyses, adjusted for perinatal variables, assessed the association between BPD and concomitant morbidities on LOS.

RESULTS

Of 10 134 survivors, 1926 (19.0%) had BPD. The adjusted LOS for infants with and without BPD was 84.1 days (95% CI, 82.8, 85.6) and 58.1 days (95% CI, 57.2, 59.0), respectively. Addition of a single concomitant morbidity increased mean LOS by 4 to 13 days.

CONCLUSIONS

BPD is a major cause of increased length of hospitalization among VLBW infants. Preventive or therapeutic modalities are required to reduce the significant burden of this condition.

Neonatal gut injury and infection rate: impact of surgical debridement on outcome

Infectious burden of gut injury (G-INJ) associated with necrotizing enterocolitis (NEC) or with spontaneous intestinal perforation (SIP) in neonates has not been ascertained. We sought to test the hypotheses that: (1) infants with G-INJ develop higher number of infections including non-concurrent infections than infants without G-INJ in a neonatal intensive care unit (NICU); (2) surgical debridement (DEB) of infants with severe G-INJ is associated with lower infectious morbidity and mortality. All infants admitted to the regional NICU from October 1991 to February 2003 were included in this prospective prevalence investigation of G-INJ and infections. Non-viable (<23 week gestational age) infants, infants with congenital anomalies, and those who developed NEC after SIP were excluded. Standard definitions of National Centers for Disease Control and Prevention were used for different categories of infections. Episodes of infections were classified as concurrent or non-concurrent (post G-INJ) based upon their timing in association with G-INJ. Infants with G-INJ associated with Bell stage II or higher NEC or with SIP were further stratified by DEB into two subgroups. A previously described 7-point clinical score was used to divide G-INJ into mild (0-2), moderate (3-5), and severe (6-7) categories. Surgical outcomes were determined by using chi(2) and logistic regression analyses. Data are expressed as mean +/- SD or as odds ratio (OR) with 95% confidence intervals (CI); P < 0.05 was considered significant. Of all 5,481 infants, 954 (17.4%) developed 1,734 episodes of infections. Prevalence of G-INJ was 4% (n = 222); of these, 33% (n = 73) underwent DEB. Infants with G-INJ had lower mean birth weight (1,414+/-766 vs. 2,153+/-104 g; P < 0.0001) and lower mean gestational age (29.6+/-4.2 vs. 32.9+/-4.8 weeks; P < 0.0001) than their peers (n = 5,259). Controlling for birth weight and gestational age, odds for non-concurrent blood stream infections (BSIs) in G-INJ infants were higher (OR 13.98, CI 10.289-19.01, P < 0.0001) than the remaining population without G-INJ. Forty-four percent of all episodes of fungemia, 32% of all episodes of BSIs occurred in G-INJ infants (P < 0.0001). Within the G-INJ group, there were no demographic differences between the DEB and non-DEB infants. Controlling for severity of G-INJ, odds for non-concurrent BSIs (OR 3.45, CI 1.04-11.36, P < 0.05) and for mortality (OR 3.35, CI 1-10, P < 0.05) among non-DEB infants were higher than in DEB infants. Infants with G-INJ suffered from a disproportionate number of all blood-stream infections in our intensive care nursery. Infants with severe G-INJ whose management includes DEB are more likely to survive and to incur less infectious morbidity.

Lactoferrin-enhanced anoikis: a defense against neonatal necrotizing enterocolitis

Enteral nutrition with human milk lowers the incidence of necrotizing enterocolitis in preterm human infants. Lactoferrin, the major whey protein in human milk, has many functions related to host defense against bacterial infection. Here, we hypothesize that lactoferrin also helps terminate bacterial invasion of enterocytes via a detachment-induced apoptosis called anoikis. Death of infected epithelia by anoikis prevents local spread of bacterial pathogens because the bacteria are trapped within the cell. Such infected, apoptotic and sloughed epithelia also cannot infect the lower gastrointestinal tract, and the epithelia exit the body in the stool. Currently, anoikis is a phenomenon related to the renewal of enterocytes, and it is not recognized as an anti-bacterial host defense. We suggest that anoikis of infected enterocytes is a process in which lactoferrin plays an important role. In a pilot study in which neonatal rats were pre-treated with intra-gastric recombinant human lactoferrin, we found evidence of epithelia with anoikis in ileal fluid after enteric infection. This finding was rarely seen in infected neonatal rats without pre-treatment with lactoferrin. Quantitative analysis of intestinal lavage specimens and quantitative stereology of apoptotic epithelia in this model will be required to verify the theory. We propose that oral use of recombinant human lactoferrin might have these hypothesized and other anti-bacterial effects in preterm infants, and hence, this protein might prevent necrotizing enterocolitis in preterm infants who cannot take human milk.

Neonatal necrotizing enterocolitis: an update

Necrotizing enterocolitis (NEC) is a leading cause of mortality and morbidity in neonatal intensive care units. Here we review selected manifestations of NEC, risk factors involved in its pathophysiology as well as putative mechanisms associated with how an immature gut might be more susceptible to NEC. Treatment and potential preventive strategies are discussed.

The evolution of neonatology

In 1960, the terms "neonatology" and "neonatologist" were introduced. Thereafter, an increasing number of pediatricians devoted themselves to full-time neonatology. In 1975, the first examination of the Sub-Board of Neonatal-Perinatal Medicine of the American Board of Pediatrics and the first meeting of the Perinatal Section of the American Academy of Pediatrics were held. One of the most important factors that improved the care of the neonate was the miniaturization of blood samples needed to determine blood gases, serum electrolytes, glucose, calcium, bilirubin, and other biochemical measurements. Another factor was the ability to provide nutrition intravenously, and the third was the maintenance of normal body temperature. The management of respiratory distress syndrome improved with i.v. glucose and correction of metabolic acidosis, followed by assisted ventilation, continuous positive airway pressure, antenatal corticosteroid administration, and the introduction of exogenous surfactant. Pharmacologic manipulation of the ductus arteriosus, support of blood pressure, echocardiography, and changes in the management of persistent pulmonary hypertension, including the use of nitric oxide and extracorporeal membrane oxygenation, all have influenced the cardiopulmonary management of the neonate. Regionalization of neonatal care; changes in parent-infant interaction; and technological changes such as phototherapy, oxygen saturation monitors, and brain imaging techniques are among the important advances reviewed in this report. Most remarkable, a 1-kg infant who was born in 1960 had a mortality risk of 95% but had a 95% probability of survival by 2000. However, errors in neonatology are acknowledged, and potential directions for the future are explored.

Prolonged hospital stay for extremely premature infants: risk factors, center differences, and the impact of mortality on selecting a best-performing center

OBJECTIVE

The first objective was to identify factors associated with prolonged hospital stay (PHS: hospitalized >42 weeks postmenstrual age) in extremely premature (EP: born less than or equal to 28 weeks gestation) infants. The second objective was to identify a PHS best-performing benchmark center.

METHODS

This study was a retrospective cohort analysis of infants born < or =28 weeks gestation and admitted to one of 12 tertiary centers between January 1998 and October 2001. Risk-adjusted odds of PHS, defined as hospitalization beyond 42 weeks postmenstrual age, and the competing outcome, mortality, were assessed using logistic regression models.

RESULTS

Among 3892 EP survivors who had complete data for multivariable analysis, 685 (18%) had PHS. Variables contributing to PHS included chronic lung disease (oxygen use at discharge home or 36 week postmenstrual age) (OR 6.75; 95% CI: 5.04 to 9.03), necrotizing enterocolitis requiring surgery (OR 13.83; 95% CI: 8.05 to 23.76), and >two episodes of late-onset sepsis (OR 2.39; 95% CI: 1.66 to 3.44). Centers' risk-adjusted PHS odds differed from the reference center, which had the lowest incidence of PHS and mortality (overall P-value <0.0001). Mortality contributed to PHS, but in an opposite direction compared to other factors. Centers with lowest PHS odds were among those with highest mortality.

CONCLUSIONS

These findings suggest that reduction of CLD, surgical NEC, and late onset sepsis could reduce PHS in EP infants. Risk adjusted odds of PHS and mortality are both crucial for selecting a PHS best-performing center.

The developing intestinal ecosystem: implications for the neonate

Interactions of resident intestinal microbes with the luminal contents and the mucosal surface play important roles in normal intestinal development, nutrition, and innate and adaptive immunity. The neonate, especially the premature, who possesses a highly immunoreactive intestinal submucosa underlying a single layer of epithelial cells that are continuously exposed to the luminal environment, is highly susceptible to perturbations of the luminal environment. Understanding the interactions of the intestinal ecosystem with the host and luminal nutritional environment, especially in regard to human milk and pre- and probiotics, has major implications for the pathogenesis of diseases that affect not only the intestine but distal organs such as the lung and brain.

Human torovirus: a new virus associated with neonatal necrotizing enterocolitis

AIM

Toroviruses have been associated with gastroenteritis in both animals and humans. The aim of this study was to examine the fecal excretion of torovirus in infants with necrotizing enterocolitis (NEC).

METHODS

We reviewed all infants with NEC admitted to our tertiary care NICU over a 5-y period who had stool specimens sent for microbial culture and virology. Infants in the NICU during the same period with diagnoses other than NEC served as controls.

RESULTS

Forty-four infants with NEC stages I-III were identified, and pathogenic organisms were identified in 27 (61%). Toroviruses were identified in stool cultures in 48% of patients with NEC, and 17% of the non-NEC controls (p<0.001). There was no significant difference in illness severity or mortality between the torovirus-positive and -negative infants with NEC.

CONCLUSION

Torovirus should be added to the list of infectious agents associated with NEC in newborn infants. The exact role torovirus plays in the etiology and progression of NEC warrants further investigation.

Sharing the science on human milk feedings with mothers of very-low-birth-weight infants

Mother's milk provides protection from serious and costly morbidity for very-low-birth-weight infants (<1500 g), including enteral feeding intolerance, nosocomial infection, and necrotizing enterocolitis. However, NICU and maternity nurses may be hesitant to encourage mothers to initiate lactation because of a reluctance to make mothers feel guilty or coerced. This article reviews the evidence for the health outcomes of mothers' milk feeding in very-low-birth-weight infants and provides examples of ways to share this science with mothers so that they can make an informed feeding decision.

Epidemiology of necrotizing enterocolitis--Part I: Changing regional trends in extremely preterm infants over 14 years

OBJECTIVES

Advances in perinatal care include exogenous surfactant, unequivocal acceptance of antenatal steroids and in utero and ex utero transfers to tertiary centres. Increased survival of extremely premature infants may change the incidence and outcome of necrotizing enterocolitis (NEC). Our aim was to examine the trends in the incidence of NEC, surgery and mortality in infants of 24-28 weeks gestation in a retrospective regional review of three epochs over a span of 14 years.

METHODS

Radiologically or surgically proven NEC cases were determined from the New South Wales Neonatal Intensive Care Unit Study database. Three epochs were examined. A total of 360 infants were admitted in 1986-87 (Epoch 1), 622 in 1992-93 (Epoch 2) and 673 in 1998-99 (Epoch 3).

RESULTS

There was an increase in neonatal intensive care unit admissions and a decrease in early and overall mortality of these very premature infants across the epochs. None of the early deaths was due to NEC. The incidence of NEC decreased in post day 5 survivors: 33 cases in Epoch 1 (12%), 60 cases in Epoch 2 (12%) and 34 cases in Epoch 3 (6%, P < 0.001). There was no change in surgical intervention (45%, 57% and 41%, respectively) or mortality due to NEC (37%, 27% and 32%). The reduced incidence of NEC was not singularly influenced by antenatal steroids, exogenous surfactant or outborn delivery. In a multivariate analysis, only later epoch of birth was independently associated with reduced NEC risk.

CONCLUSIONS

With improved care and survival of extremely premature infants, the incidence of NEC has decreased, but it remains a disease of high mortality and morbidity.