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Katsivalis KV, Jacobson JL, Bowker R, Berenz A, Hovey S, Click KW. Enteral Feedings Do Not Increase the Risk of NEC in ELBW Infants Undergoing Treatment of Patent Ductus Arteriosus With Acetaminophen. J Pediatr Pharmacol Ther 2024; 29:278-285. [PMID: 38863856 PMCID: PMC11163909 DOI: 10.5863/1551-6776-29.3.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/03/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVE Acetaminophen (APAP) is an alternative to indomethacin and ibuprofen for treatment of patent ductus arteriosus (PDA). The side effect profile of non-steroidal anti-inflammatory drugs (NSAIDs) presents enteral feeding safety concerns; however, the safety of enteral feeding on APAP is largely unknown. Optimal feeding strategies during pharmacological PDA treatment are unknown, leading to practice variation. This study aims to assess the incidence of adverse gastrointestinal (GI) outcomes in neonates treated with APAP for PDA closure while receiving enteral feedings. METHODS Single-center retrospective cohort study of 59 extremely low birth weight (ELBW), premature neonates who received APAP for PDA treatment divided into Low Volume (LV; ≤ 20 mL/kg/day) and High Volume (HV; > 20 mL/kg/day) enteral feeding groups. The primary outcome was the incidence of any suspected or confirmed necrotizing enterocolitis (NEC). Timing of nutrition milestones, parenteral nutrition (PN) days, and adverse outcomes (feeding intolerance, liver dysfunction, death prior to discharge) were evaluated. RESULTS The incidence of suspected or confirmed NEC was 19.5% in the LV group and 13.3% in the HV group (p = 0.593). The HV group reached full feeds 6 days sooner (18 vs 24 days, p = 0.024) and had fewer PN days (17 vs 23.5 days, p = 0.044) with no difference in adverse outcomes. CONCLUSIONS Provision of > 20 mL/kg/day of enteral feeds during APAP treatment of PDA decreased time to full feeds and PN days compared to trophic feedings (≤ 20 mL/kg/day) with no difference in adverse GI outcomes. Continuing enteral feeding during APAP PDA treatment appears safe while improving achievement of nutritional milestones.
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Affiliation(s)
| | - Jessica L. Jacobson
- Department of Pharmacy (KVK, JLJ, SH, KMW), Rush University Medical Center, Chicago, IL
| | - Rakhee Bowker
- Department of Pediatrics (RB, AB), Rush University Medical Center, Chicago, IL
| | - Andrew Berenz
- Department of Pediatrics (RB, AB), Rush University Medical Center, Chicago, IL
| | - Sara Hovey
- Department of Pharmacy (KVK, JLJ, SH, KMW), Rush University Medical Center, Chicago, IL
| | - Kristen W. Click
- Department of Pharmacy (KVK, JLJ, SH, KMW), Rush University Medical Center, Chicago, IL
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2
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Porta R, Verd S, Ginovart G. How many times must a man look up before he can see the sky? Pediatr Res 2024; 95:1164-1165. [PMID: 38332137 DOI: 10.1038/s41390-023-02965-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 02/10/2024]
Affiliation(s)
- Roser Porta
- Neonatal Unit, Department of Pediatrics, Germans Trias i Pujol University Hospital, Canyet road, 08916, Badalona, Spain
| | - Sergio Verd
- Pediatric Unit, La Vileta surgery, Department of Primary Care, Matamusinos street, 07013, Palma de Mallorca, Spain.
- Balearic Islands Health Research Institute (IdISBa), 79 Valldemossa road, 07120, Palma de Mallorca, Spain.
| | - Gemma Ginovart
- Neonatal Unit, Department of Pediatrics, Germans Trias i Pujol University Hospital, Canyet road, 08916, Badalona, Spain
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3
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Lapillonne A, Lembo C, Iacobelli S. Breast milk feeding in premature infants with persistent ductus arteriosus. Pediatr Res 2024:10.1038/s41390-024-03048-z. [PMID: 38278848 DOI: 10.1038/s41390-024-03048-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 12/29/2023] [Indexed: 01/28/2024]
Affiliation(s)
- Alexandre Lapillonne
- Department of Neonatology, APHP, Necker-Enfants Malades Hospital, Paris, France.
- EHU 7328 PACT, Paris Cite University, Paris, France.
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA.
| | - Chiara Lembo
- Department of Neonatology, APHP, Necker-Enfants Malades Hospital, Paris, France
| | - Silvia Iacobelli
- Réanimation Néonatale et Pédiatrique, CHU La Réunion, Saint-Pierre, France
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4
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Yusuf K, Francescato G. Nutrition with a patent ductus arteriosus: feast, feed, or famine? Pediatr Res 2023:10.1038/s41390-023-02861-2. [PMID: 37857849 DOI: 10.1038/s41390-023-02861-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Kamran Yusuf
- Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, Univeristy of Calgary, Rm 273, Heritage Medical Research Building, Calgary, AB, T2N 4N1, Canada.
| | - Gaia Francescato
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
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Salas AA, Travers CP. The Practice of Enteral Nutrition: Clinical Evidence for Feeding Protocols. Clin Perinatol 2023; 50:607-623. [PMID: 37536767 PMCID: PMC10599301 DOI: 10.1016/j.clp.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Establishing full enteral nutrition in critically ill preterm infants with immature gastrointestinal function is challenging. In this article, we will summarize emerging clinical evidence from randomized clinical trials suggesting the feasibility and efficacy of feeding interventions targeting the early establishment of full enteral nutrition. We will also examine trial outcomes of higher volume feedings after the establishment of full enteral nutrition. Only data from randomized clinical trials will be discussed extensively. Future opportunities for clinical research will also be presented.
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Affiliation(s)
- Ariel A Salas
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA.
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA
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Lembo C, El-Khuffash A, Fusch C, Iacobelli S, Lapillonne A. Nutrition of the preterm infant with persistent ductus arteriosus: existing evidence and practical implications. Pediatr Res 2023:10.1038/s41390-023-02754-4. [PMID: 37563451 DOI: 10.1038/s41390-023-02754-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/01/2023] [Accepted: 07/09/2023] [Indexed: 08/12/2023]
Abstract
The persistence of a patent ductus arteriosus (PDA) is a common condition in preterm infants with a prevalence inversely proportional to gestational age. PDA is associated with mild-to-severe gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which represent a major challenge for the nutritional management in preterm infants. In this context, the Section on Nutrition, Gastroenterology and Metabolism and the Circulation Section of the European Society for Pediatric Research have joined forces to review the current knowledge on nutritional issues related to PDA in preterm infants. The aim of the narrative review is to discuss the clinical implications for nutritional practice. Because there is little literature on postnatal nutrition and PDA in preterm infants, further research with well-designed studies on this topic is urgently needed. Guidelines should also be developed to clearly define the implementation and course of enteral nutrition and the target nutritional intake before, during, and after pharmacologic or surgical treatment of PDA, when indicated. IMPACT: Persistent ductus arteriosus (PDA) is associated with gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which pose a major challenge to the nutritional management of preterm infants. In PDA infants, fluid restriction may lead to inadequate nutrient intake, which may negatively affect postnatal growth and long-term health. The presence of PDA does not appear to significantly affect mesenteric blood flow and splanchnic oxygenation after enteral feedings. Initiation or maintenance of enteral nutrition can be recommended in infants with PDA.
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Affiliation(s)
- Chiara Lembo
- Department of Neonatology, APHP, Necker-Enfants Malades Hospital, Paris, France
| | - Afif El-Khuffash
- Department of Pediatrics (School of Medicine), Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christoph Fusch
- Neonatology, Department of Pediatrics, General Hospital, Paracelsus Medical School, Nuernberg, Germany
- McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Silvia Iacobelli
- Réanimation Néonatale et Pédiatrique, CHU La Réunion, Saint-Pierre, France
| | - Alexandre Lapillonne
- Department of Neonatology, APHP, Necker-Enfants Malades Hospital, Paris, France.
- EHU 7328 PACT, Paris Cite University, Paris, France.
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The dilemma of feeding during the treatment of patent ductus arteriosus with oral ibuprofen in preterm infants ≤30 weeks of gestation-a randomized controlled trial. J Perinatol 2023; 43:203-208. [PMID: 36604581 DOI: 10.1038/s41372-022-01597-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To evaluate the effect of minimal enteral feeding (MEN) versus withholding feeding on time to reach full feeds during treatment of hs-PDA with oral ibuprofen in infants ≤30 weeks. STUDY DESIGN We performed a single-center, randomized control trial of 126 premature infants born ≤30 weeks gestation, <7 days of age with hs-PDA comparing continuation of MEN (n = 64) vs no feeding (n = 62) during treatment. The primary outcome was time to reach a feed volume of 150 ml/kg/day. Secondary outcomes included were episodes of feed intolerance, GI bleed, NEC and other comorbidities. RESULTS There was no difference in the time to reach full feeds - median age of 16 days in both groups (p = 0.573). Incidence of feed intolerance, NEC and other secondary outcomes were also similar in both groups. CONCLUSIONS Continuing MEN during treatment of hs-PDA with oral ibuprofen does not decrease time to reach full enteral feeds in very preterm infants.
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9
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Yin L, Ma J, Liu H, Gu Q, Huang L, Mu Q, An N, Qian L, Qiao L. Clinical Observation of Extensively Hydrolysis Protein Formula With Feeding Intolerance in Preterm Infants. Front Pediatr 2022; 10:871024. [PMID: 35769218 PMCID: PMC9236285 DOI: 10.3389/fped.2022.871024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To investigate whether feeding extensively hydrolysis protein formula during the NICU hospitalization was more beneficial for preterm infants with a gestational age (GA) ≤34 weeks when breastfeeding was not possible. Methods In total, 587 preterm infants were randomly divided into two groups: observation groups fed with extensively hydrolyzed formula (EHF) milk and control groups fed with standard preterm formula (SPF) milk until discharge from the neonatal intensive care unit (NICU). The incidence of complications during hospitalization was recorded in both groups. Then, two groups were uniformly fed with 0-to-6-month infant formula milk and followed-up for 6 months after discharge. Results The final study included 370 premature infants, including 185 babies in the observation group and 185 in the control group. In contrast to the SPF, feeding EHF among preterm infants of GA <34 weeks during NICU hospitalization significantly reduced the incidence of feeding intolerance (FI) (14.1 vs. 30.3%, p < 0.01). The incidence of necrotizing enterocolitis (NEC) was significantly reduced in the observation group (2.2 vs. 6.5%, p < 0.05), but there was no significant difference in the incidence of other related complications. At discharge, there was no difference in total serum protein (46.6 vs. 46.4 g/L), albumin (33.5 vs. 34.2 g/L), and calcium (2.37 vs. 2.35 mmol/L), but the serum phosphorus concentrations associated with skeletal mineralization (2.10 vs. 2.22 mmol/L, p < 0.05) was significantly reduced and alkaline phosphatase significantly rose (254 vs. 220 IU/L, p < 0.05) in the observation group. No significant difference was found in the growth rates of body weight, head circumference, or body length, either during the NICU hospitalization or during the 6-month follow-up after discharge (p > 0.05). Conclusions Feeding premature infants of GA ≤34 weeks with EHF reduced the incidence of FI, but had no advantage in establishing whole intestinal nutrition, shortening parenteral nutrition (PN) time, or hospitalization time. It had little effect on physical growth or development during NICU hospitalization and within 6 months after discharge. However, it may increase the incidence of metabolic bone disease (MBD).
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Affiliation(s)
- Liping Yin
- Department of Pediatrics, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Jingjing Ma
- Department of Pediatrics, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Heng Liu
- Department of Pediatrics, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Qianying Gu
- Department of Pediatrics, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Li Huang
- Department of Pediatrics, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Qi Mu
- Department of Nuclear Medicine, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Ning An
- College of Pediatrics, Xinjiang Medical University, Ürümqi, China
| | - LiJuan Qian
- Department of Pediatrics, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Lixing Qiao
- Department of Pediatrics, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
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Alsafadi T. Outcome of conservative and pharmacological treatment of hemodynamically significant patent ductus arteriosus in preterm infants less than 34 weeks. J Clin Neonatol 2022. [DOI: 10.4103/jcn.jcn_6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Feeding Strategies in Preterm Very Low Birth-Weight Infants: State-of-the-Science Review. Adv Neonatal Care 2021; 21:493-502. [PMID: 33675303 DOI: 10.1097/anc.0000000000000849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Weeks CL, Marino LV, Johnson MJ. A systematic review of the definitions and prevalence of feeding intolerance in preterm infants. Clin Nutr 2021; 40:5576-5586. [PMID: 34656954 DOI: 10.1016/j.clnu.2021.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Feeding intolerance (FI) is a common phenomenon experienced in preterm infants in neonatal intensive care units, as well as being a focus of many research studies into feeding methods, particularly in relation to comorbidities. There is no widely accepted definition of FI. This systematic review aimed to explore the range of definitions used for FI and provide an estimate of the prevalence amongst preterm infants. METHODS Searches were completed on MEDLINE (includes the Cochrane library), Embase, PsycInfo, CINAHL, NHS Evidence and Web of Science. Inclusion criteria; preterm infants in neonatal units, a clear definition of FI, >10 patients and be available in English language. Case reports were excluded. RESULTS One hundred studies were included. Definitions of FI were inconsistent. Studies were grouped according to definition used into: Group A - measuring gastric residual volume (GRV) only; group B - GRV and abdominal distension (AD); group C - GRV, AD and gastrointestinal symptoms (GI) which included any of vomiting, bilious vomiting and blood in stool; group D- GRV and GI; group E - AD and GI; group F - GI only and group G - any other elements used. Meta-analysis demonstrated that prevalence of FI between groups varied from 15 to 30% with an overall prevalence of 27% (95% confidence interval 23-31%). Group A had the highest prevalence. Review of time to full enteral feed was performed (37 studies) which demonstrated a range of 11.3-18.3 days depending on which FI definition used. DISCUSSION Definitions of FI in research are inconsistent, a similar finding to that seen in studies in both paediatric and adult critical care populations. The difficulty of defining FI in the preterm population is the concern regarding necrotising enterocolitis, with some studies using an overlap in their definitions, despite differing pathophysiology and management. Due to the heterogeneity of data obtained in this review regarding definitions used, further robust research is required in order to conclude which elements which should be used to define FI in this population. PROSPERO NUMBER CRD42019155596. Registered November 2019.
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Affiliation(s)
- Charlotte L Weeks
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK.
| | - Luise V Marino
- Department of Dietetics/SLT, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Mark J Johnson
- NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK; Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
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Thoene M, Anderson-Berry A. Early Enteral Feeding in Preterm Infants: A Narrative Review of the Nutritional, Metabolic, and Developmental Benefits. Nutrients 2021; 13:nu13072289. [PMID: 34371799 PMCID: PMC8308411 DOI: 10.3390/nu13072289] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/25/2021] [Accepted: 06/03/2021] [Indexed: 01/01/2023] Open
Abstract
Enteral feeding is the preferred method of nutrient provision for preterm infants. Though parenteral nutrition remains an alternative to provide critical nutrition after preterm delivery, the literature suggests that enteral feeding still confers significant nutritional and non-nutritional benefits. Therefore, the purpose of this narrative review is to summarize health and clinical benefits of early enteral feeding within the first month of life in preterm infants. Likewise, this review also proposes methods to improve enteral delivery in clinical care, including a proposal for decision-making of initiation and advancement of enteral feeding. An extensive literature review assessed enteral studies in preterm infants with subsequent outcomes. The findings support the early initiation and advancement of enteral feeding impact preterm infant health by enhancing micronutrient delivery, promoting intestinal development and maturation, stimulating microbiome development, reducing inflammation, and enhancing brain growth and neurodevelopment. Clinicians must consider these short- and long-term implications when caring for preterm infants.
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Chen YJ, Chu WY, Yu WH, Chen CJ, Chia ST, Wang JN, Lin YC, Wei YJ. Massive Gastric Hemorrhage after Indomethacin Therapy: A Rare Presentation and Critical Management in an Extremely Preterm Infant. CHILDREN-BASEL 2021; 8:children8070545. [PMID: 34202886 PMCID: PMC8304301 DOI: 10.3390/children8070545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/03/2021] [Accepted: 06/21/2021] [Indexed: 11/16/2022]
Abstract
Indomethacin has been widely used in preterm infants with hemodynamically significant patent ductus arteriosus (PDA). Gastrointestinal complications of indomethacin have been reported in 5% of treated neonates. However, massive gastric mucosa hemorrhage is a rarely reported complication. To the best of our knowledge, the infant in this report is the smallest reported in the literature to have undergone successful surgery for such a complication. A male preterm infant weighing 566 g was born at 252/7 weeks of gestational age without a complicated maternal history. Soon after birth, he received nasal noninvasive respiratory support and minimal feeding. PDA was observed since the first day of life (DOL), treatments were initiated on the second DOL for the hemodynamical significance, and PDA was closed after two courses of indomethacin therapy (0.2 mg/kg). At midnight on the seventh DOL, generalized pallor, bloody gastric drainage, and a distended stomach were observed. Massive gastric bleeding was suspected. He suffered from intermittent hypotension, which was corrected with blood products and fluid resuscitation under monitoring with a radial arterial line. Gastric lavage with cooling saline was performed twice but in vain. Prior to surgical consultation, intravascular volume transfusion was given twice. An exploratory laparotomy was arranged after obtaining the parents' consent. Blood oozing from the gastric mucosa was observed through gastrostomy and was successfully stopped via epinephrine-soaked gauze compression. After the operation, his clinical course remained uneventful, and he was discharged without neurological anomaly at two-year follow-up. Physicians need to be cautious of indomethacin's effect on platelet dysfunction in preterm infants with multiple predisposing factors. The tendency for mucosal bleeding should be continuously monitored after indomethacin therapy.
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Affiliation(s)
- Yen-Ju Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
| | - Wei-Ying Chu
- Department of Pediatrics, Tainan Hospital, Ministry of Health and Welfare, Tainan 700007, Taiwan;
| | - Wen-Hao Yu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
| | - Chau-Jing Chen
- Department of Surgery, Tainan Sinlau Hospital, Tainan 701002, Taiwan;
- Department of Surgery, College of Medicine, National Cheng-Kung University, Tainan 701401, Taiwan;
| | - Shu-Ti Chia
- Department of Surgery, College of Medicine, National Cheng-Kung University, Tainan 701401, Taiwan;
| | - Jieh-Neng Wang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
| | - Yung-Chieh Lin
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
- Correspondence: (Y.-C.L.); (Y.-J.W.); Tel.: +81-052-853-8244 (Y.-C.L.); +886-62-353-535 (ext. 4189) (Y.-J.W.)
| | - Yu-Jen Wei
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan; (Y.-J.C.); (W.-H.Y.); (J.-N.W.)
- Correspondence: (Y.-C.L.); (Y.-J.W.); Tel.: +81-052-853-8244 (Y.-C.L.); +886-62-353-535 (ext. 4189) (Y.-J.W.)
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Parkerson S, Philip R, Talati A, Sathanandam S. Management of Patent Ductus Arteriosus in Premature Infants in 2020. Front Pediatr 2021; 8:590578. [PMID: 33643964 PMCID: PMC7904697 DOI: 10.3389/fped.2020.590578] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/22/2020] [Indexed: 12/14/2022] Open
Abstract
The patent ductus arteriosus (PDA) is the most commonly found cardiac condition in neonates. While there have been several studies and thousands of publications on the topic, the decision to treat the PDA is still strongly debated among cardiologists, surgeons, and neonatologists. This is in part due to the shortage of long-term benefits with the interventions studied. Practice variations still exist within sub-specialties and centers. This article briefly summarizes the history, embryology and histology of the PDA. It also succinctly discusses the hemodynamic significance of a PDA which builds the framework to review all the available literature on PDA closure in premature infants, though not a paradigm shift just yet; it introduces transcatheter PDA closure (TCPC) as a possible armament to the clinician for this age-old problem.
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Affiliation(s)
- Sarah Parkerson
- Department of Pediatrics, University of Tennessee, Memphis, TN, United States
| | - Ranjit Philip
- Division of Pediatric Cardiology, University of Tennessee, Memphis, TN, United States
| | - Ajay Talati
- Division of Neonatology, University of Tennessee, Memphis, TN, United States
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, University of Tennessee, Memphis, TN, United States
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de Waal K, Phad N, Stubbs M, Chen Y, Kluckow M. A Randomized Placebo-Controlled Pilot Trial of Early Targeted Nonsteroidal Anti-Inflammatory Drugs in Preterm Infants with a Patent Ductus Arteriosus. J Pediatr 2021; 228:82-86.e2. [PMID: 32858033 DOI: 10.1016/j.jpeds.2020.08.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/28/2020] [Accepted: 08/21/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To establish the feasibility of a future large randomized trial to compare early treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) while awaiting spontaneous patent ductus arteriosus (PDA) closure. STUDY DESIGN Preterm infants at <29 weeks of gestation with a PDA diameter >1.5 mm and <72 hours after birth were randomized to NSAIDs vs placebo. No open-label NSAID treatment was allowed in either arm, but all infants with PDA volume load received supportive management, including optimization of airway pressure, careful fluid management, and diuretics as needed. The pilot outcomes were recruitment rate and incidence of open-label treatment. Secondary clinical outcomes included chronic lung disease or death, the planned primary outcome for a future large trial. RESULTS Overall, 54% of the approached parents consented to participate in the study. The median recruitment rate was 3 infants per month, and a total of 72 infants were randomized. One patient in each arm received open-label treatment. PDA closure rates were 74% for the NSAIDs arm vs 30% for the placebo arm, but this was not associated with significant changes in clinical outcomes. CONCLUSIONS This pilot trial showed that recruitment of more than one-half of eligible infants with a low incidence of open-label treatment is feasible. PDA closure rates and clinical outcomes were similar to those reported in previous PDA trials.
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Affiliation(s)
- Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia.
| | - Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Michelle Stubbs
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Yan Chen
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
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17
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Keusters L, Purna J, Deshpande P, Mertens L, Shah P, McNamara PJ, Weisz DE, Jain A. Clinical validity of systemic arterial steal among extremely preterm infants with persistent patent ductus arteriosus. J Perinatol 2021; 41:84-92. [PMID: 32393829 DOI: 10.1038/s41372-020-0663-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/06/2020] [Accepted: 03/11/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Investigate relevance of diastolic flow abnormalities in celiac trunk (aCT) and middle cerebral artery (aMCA) among preterms with persistent hemodynamically significant patent ductus arteriosus (phsPDA, diameter ≥ 1.5 mm, and age ≥ 7 days). STUDY DESIGN Five hundred fifteen echocardiograms from 156 neonates born <28 weeks gestation age (GA) were analyzed retrospectively. Infants with aCT or aMCA at any time were compared with the rest. Separate comparisons were performed for aCT and aMCA. Primary outcome was composite of death, chronic lung disease (CLD), or necrotizing enterocolitis ≥ stage 2. Logistic regression was used to adjust for confounders. RESULT Mean (SD) weight and GA were 820(214) g and 25.2(1.3) weeks. aMCA, but not aCT, was associated with primary outcome [adjusted odds ratio 2.17, 95% CI: 1.01-4.67] and CLD [2.20 (0.99-4.87)]. CONCLUSION aMCA may be a valid marker for defining the clinical significance of phsPDA in preterm neonates. aCeT may be of limited value in selecting patients for treatment.
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Affiliation(s)
- Lieke Keusters
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Jyotsna Purna
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Poorva Deshpande
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Luc Mertens
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Prakeshkumar Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Patrick J McNamara
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Dany E Weisz
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada. .,Department of Paediatrics, University of Toronto, Toronto, ON, Canada. .,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada. .,Department of Physiology, University of Toronto, Toronto, ON, Canada.
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18
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Hamrick SEG, Sallmon H, Rose AT, Porras D, Shelton EL, Reese J, Hansmann G. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 2020; 146:e20201209. [PMID: 33093140 PMCID: PMC7605084 DOI: 10.1542/peds.2020-1209] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/07/2023] Open
Abstract
Postnatal ductal closure is stimulated by rising oxygen tension and withdrawal of vasodilatory mediators (prostaglandins, nitric oxide, adenosine) and by vasoconstrictors (endothelin-1, catecholamines, contractile prostanoids), ion channels, calcium flux, platelets, morphologic maturity, and a favorable genetic predisposition. A persistently patent ductus arteriosus (PDA) in preterm infants can have clinical consequences. Decreasing pulmonary vascular resistance, especially in extremely low gestational age newborns, increases left-to-right shunting through the ductus and increases pulmonary blood flow further, leading to interstitial pulmonary edema and volume load to the left heart. Potential consequences of left-to-right shunting via a hemodynamically significant patent ductus arteriosus (hsPDA) include increased risk for prolonged ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis or focal intestinal perforation, intraventricular hemorrhage, and death. In the last decade, there has been a trend toward less aggressive treatment of PDA in preterm infants. However, there is a subgroup of infants who will likely benefit from intervention, be it pharmacologic, interventional, or surgical: (1) prophylactic intravenous indomethacin in highly selected extremely low gestational age newborns with PDA (<26 + 0/7 weeks' gestation, <750 g birth weight), (2) early targeted therapy of PDA in selected preterm infants at particular high risk for PDA-associated complications, and (3) PDA ligation, catheter intervention, or oral paracetamol may be considered as rescue options for hsPDA closure. The impact of catheter-based closure of hsPDA on clinical outcomes should be determined in future prospective studies. Finally, we provide a novel treatment algorithm for PDA in preterm infants that integrates the several treatment modalities in a staged approach.
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Affiliation(s)
- Shannon E G Hamrick
- Divisions of Neonatology and
- Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elaine L Shelton
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeff Reese
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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19
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Perioperative nutrition in extremely preterm infants undergoing surgery for patent ductus arteriosus. CLINICAL NUTRITION EXPERIMENTAL 2020. [DOI: 10.1016/j.yclnex.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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Abstract
Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.
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21
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Su BH, Lin HY, Chiu HY, Tsai ML, Chen YT, Lu IC. Therapeutic strategy of patent ductus arteriosus in extremely preterm infants. Pediatr Neonatol 2020; 61:133-141. [PMID: 31740267 DOI: 10.1016/j.pedneo.2019.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/15/2019] [Accepted: 10/21/2019] [Indexed: 01/29/2023] Open
Abstract
The ductus arteriosus is likely to close without treatment in most infants born at gestational age (GA) > 28 weeks (73%), and those with birth weight > 1000 g (94%). However, the rates of spontaneous ductal closure among less mature or smaller infants with respiratory distress syndrome are not known. Extremely preterm infants born at GA < 28 weeks are associated with a high risk of severe intraventricular hemorrhage (IVH) or pulmonary hemorrhage, which usually occur within 72 h after birth and affect mortality and long-term neurological development. These serious hemorrhagic complications may be closely related to hemodynamic changes caused by a hemodynamically significant patent ductus arteriosus (hs-PDA). While prophylactic indomethacin has been shown to reduce the rates of PDA, PDA ligation, severe IVH and early pulmonary hemorrhage, the available evidence does not support its prophylactic use in preterm infants. Symptomatic or late treatment is associated with lower success rate, and increased complications of a hs-PDA. The issue of "to treat or not to treat a PDA" is controversial. Considering the relationship between the effectiveness and timing of pharmacological treatment, early targeted treatment may be an alternative approach for the early identification of a hs-PDA in specific high-risk patient population, especially infants <26 weeks GA who are at the highest risk of severe IVH or pulmonary hemorrhage. Serial echocardiographic studies can be used to select patients who are candidates for early targeted medical treatment of hs-PDA. Surgical ligation of PDA, and transcatheter closure if proven to be safe, can be used as back-up therapy for patients who fail medical treatment and continue to have cardiopulmonary compromise.
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Affiliation(s)
- Bai-Horng Su
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan.
| | - Hsiang-Yu Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiao-Yu Chiu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Ming-Luen Tsai
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Yin-Ting Chen
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - I-Chun Lu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
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22
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Martini S, Aceti A, Galletti S, Beghetti I, Faldella G, Corvaglia L. To Feed or Not to Feed: A Critical Overview of Enteral Feeding Management and Gastrointestinal Complications in Preterm Neonates with a Patent Ductus Arteriosus. Nutrients 2019; 12:nu12010083. [PMID: 31892190 PMCID: PMC7019993 DOI: 10.3390/nu12010083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/19/2019] [Accepted: 12/24/2019] [Indexed: 12/20/2022] Open
Abstract
The management of enteral feeds in preterm infants with a hemodynamically significant patent ductus arteriosus (hs-PDA) is a major challenge for neonatologists due to the fear of gastrointestinal (GI) complications. This review aims to analyze the available evidence on the complex relation between the presence and management of PDA, enteral feeding practices, and GI outcomes in the preterm population. There is limited evidence, based on small and heterogeneous trials, that hs-PDA may affect the splanchnic hemodynamic response to enteral feeds. While the presence of PDA seems a risk factor for adverse GI outcomes, the benefits of feeding withholding during pharmacological PDA treatment are controversial. The lack of robust evidence in support of or against a timely feeding introduction or feeding withholding during pharmacological PDA closure in preterm neonates does not allow to draw any related recommendation. While waiting for further data, the feeding management of this population should be carefully evaluated and possibly individualized on the basis of the infants’ hemodynamic and clinical characteristics. Large, multicentric trials would help to better clarify the physiological mechanisms underlying the development of gut hypoperfusion, and to evaluate the impact of enteral feeds on splanchnic hemodynamics in relation to PDA features and treatment.
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23
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Xu JH, Coo H, Fucile S, Ng E, Ting JY, Shah PS, Dow K. A national survey of the enteral feeding practices in Canadian neonatal intensive care units. Paediatr Child Health 2019; 25:529-533. [PMID: 33354263 DOI: 10.1093/pch/pxz112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/28/2019] [Indexed: 11/14/2022] Open
Abstract
Aim Nutrition affects the growth and neurodevelopmental outcomes of preterm infants, yet controversies exist about the optimal enteral feeding regime. The objective of this study was to compare enteral feeding guidelines in Canadian neonatal intensive care units (NICUs). Method The research team identified key enteral feeding practices of interest. Canadian Neonatal Network site investigators at 30 Level 3 NICUs were contacted to obtain a copy of their 2016 to 2017 feeding guidelines for infants who weighed less than 1,500 g at birth. Each guideline was reviewed to compare recommendations around the selected feeding practices. Results Five of the 30 NICUs did not have a feeding guideline. The other 25 NICUs used 22 different enteral feeding guidelines. The guidelines in 40% of those NICUs recommend commencing minimal enteral nutrition (MEN) within 24 hours of birth and maintaining that same feeding volume for 24 to 96 hours. In 40% of NICUs, the guideline recommended that MEN be initiated at a volume of 5 to 10 mL/kg/day for infants born at <1,000 g. Guidelines in all 25 NICUs recommend the use of bovine-based human milk fortifier (HMF), and in 56% of NICUs, it is recommended that HMF be initiated at a total fluid intake of 100 mL/kg/day. Guidelines in only 16% of NICUs recommended routine gastric residual checks. Donor milk and probiotics are used in 76% and 72% of the 25 NICUs, respectively. Conclusion This study revealed substantial variability in recommended feeding practices for very low birth weight infants, underscoring the need to establish a national feeding guideline for this vulnerable group.
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Affiliation(s)
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario
| | - Sandra Fucile
- Department of Pediatrics, Queen's University, Kingston, Ontario
| | - Eugene Ng
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Joseph Y Ting
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Prakesh S Shah
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario.,Department of Pediatrics, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario
| | - Kimberly Dow
- Department of Pediatrics, Queen's University, Kingston, Ontario
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24
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Rooney SR, Shelton EL, Aka I, Shaffer CM, Clyman RI, Dagle JM, Ryckman K, Lewis TR, Reese J, Van Driest SL, Kannankeril PJ. CYP2C9*2 is associated with indomethacin treatment failure for patent ductus arteriosus. Pharmacogenomics 2019; 20:939-946. [PMID: 31486736 PMCID: PMC6817966 DOI: 10.2217/pgs-2019-0079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/15/2019] [Indexed: 12/12/2022] Open
Abstract
Aims: To identify clinical andgenetic factors associated with indomethacin treatment failure in preterm neonates with patent ductus arteriosus (PDA). Patients & Methods: This is a multicenter cohort study of 144 preterm infants (22-32 weeks gestational age) at three centers who received at least one treatment course of indomethacin for PDA. Indomethacin failure was defined as requiring subsequent surgical intervention. Results: In multivariate analysis, gestational age (AOR 0.76, 95% CI 0.60-0.96), surfactant use (AOR 9.77, 95% CI 1.15-83.26), and CYP2C9*2 (AOR 3.74; 95% CI 1.34-10.44) were each associated with indomethacin failure. Conclusion: Age, surfactant use, and CYP2C9*2 influence indomethacin treatment outcome in preterm infants with PDA. This combination of clinical and genetic factors may facilitate targeted indomethacin use for PDA.
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Affiliation(s)
- Sydney R Rooney
- Vanderbilt University School of Medicine, UCSF, Nashville, TN 37232, USA
| | - Elaine L Shelton
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Christian M Shaffer
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ronald I Clyman
- Department of Pediatrics & Cardiovascular Research Center, University of California San Francisco, San Francisco, CA 94143, USA
| | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Kelli Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Tamorah R Lewis
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO 64110, USA
| | - Jeff Reese
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
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25
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Understanding the Pathophysiology, Implications, and Treatment Options of Patent Ductus Arteriosus in the Neonatal Population. Adv Neonatal Care 2019; 19:179-187. [PMID: 30720481 DOI: 10.1097/anc.0000000000000590] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is the persistence of a fetal shunt between the pulmonary artery and the aorta. This structure normally closes in the first 3 days after birth; however, closure is delayed in up to 80% of infants born at 25 to 28 weeks of gestation. Persistent PDA results in pulmonary overcirculation and systemic hypoperfusion. PURPOSE The purpose of this article is to review pathophysiology and treatment options for PDA. METHODS A literature review was conducted using PubMed, CINAHL, and Google Scholar (2013-2018). Search terms included neonate, PDA, pathophysiology, pharmacotherapy, nursing, ligation, indomethacin, ibuprofen, and acetaminophen (paracetamol). RESULTS Optimal treatment remains contentious. Options include conservative/medical, pharmacologic, and surgical management. Conservative/medical management includes mild fluid restriction, increased airway pressures, and supportive care. Pharmacologic treatment is accomplished using indomethacin, ibuprofen, or acetaminophen. Surgical intervention is by direct closure or by percutaneous ligation. Treatment may be prophylactic, presymptomatic, or symptomatic. Long-term morbidities associated with PDA include chronic lung disease, retinopathy of prematurity, and neurodevelopmental delay. IMPLICATIONS FOR RESEARCH Absence of a universal scoring system for severity of PDA limits accuracy of comparisons among research studies. Lack of a consistent definition also makes it difficult to aggregate data for meta-analyses. Adoption of a consistent scoring system for hemodynamic significance would facilitate comparisons of outcomes among research studies. IMPLICATIONS FOR PRACTICE Clinicians should be aware of treatment options for PDA and their implications on neonatal outcomes. For nurses, anticipation of possible side effects is important for performance of focused assessments.
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26
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Clyman RI, Liebowitz M, Kaempf J, Erdeve O, Bulbul A, Håkansson S, Lindqvist J, Farooqi A, Katheria A, Sauberan J, Singh J, Nelson K, Wickremasinghe A, Dong L, Hassinger DC, Aucott SW, Hayashi M, Heuchan AM, Carey WA, Derrick M, Fernandez E, Sankar M, Leone T, Perez J, Serize A. PDA-TOLERATE Trial: An Exploratory Randomized Controlled Trial of Treatment of Moderate-to-Large Patent Ductus Arteriosus at 1 Week of Age. J Pediatr 2019; 205:41-48.e6. [PMID: 30340932 PMCID: PMC6502709 DOI: 10.1016/j.jpeds.2018.09.012] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 08/11/2018] [Accepted: 09/06/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare early routine pharmacologic treatment of moderate-to-large patent ductus arteriosus (PDA) at the end of week 1 with a conservative approach that requires prespecified respiratory and hemodynamic criteria before treatment can be given. STUDY DESIGN A total of 202 neonates of <28 weeks of gestation age (mean, 25.8 ± 1.1 weeks) with moderate-to-large PDA shunts were enrolled between age 6 and 14 days (mean, 8.1 ± 2.2 days) into an exploratory randomized controlled trial. RESULTS At enrollment, 49% of the patients were intubated and 48% required nasal ventilation or continuous positive airway pressure. There were no differences between the groups in either our primary outcome of ligation or presence of a PDA at discharge (early routine treatment [ERT], 32%; conservative treatment [CT], 39%) or any of our prespecified secondary outcomes of necrotizing enterocolitis (ERT, 16%; CT, 19%), bronchopulmonary dysplasia (BPD) (ERT, 49%; CT, 53%), BPD/death (ERT, 58%; CT, 57%), death (ERT,19%; CT, 10%), and weekly need for respiratory support. Fewer infants in the ERT group met the rescue criteria (ERT, 31%; CT, 62%). In secondary exploratory analyses, infants receiving ERT had significantly less need for inotropic support (ERT, 13%; CT, 25%). However, among infants who were ≥26 weeks gestational age, those receiving ERT took significantly longer to achieve enteral feeding of 120 mL/kg/day (median: ERT, 14 days [range, 4.5-19 days]; CT, 6 days [range, 3-14 days]), and had significantly higher incidences of late-onset non-coagulase-negative Staphylococcus bacteremia (ERT, 24%; CT,6%) and death (ERT, 16%; CT, 2%). CONCLUSIONS In preterm infants age <28 weeks with moderate-to-large PDAs who were receiving respiratory support after the first week, ERT did not reduce PDA ligations or the presence of a PDA at discharge and did not improve any of the prespecified secondary outcomes, but delayed full feeding and was associated with higher rates of late-onset sepsis and death in infants born at ≥26 weeks of gestation. TRIAL REGISTRATION ClinicalTrials.gov: NCT01958320.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA,Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Melissa Liebowitz
- Department of Pediatrics, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Joseph Kaempf
- Department of Pediatrics, Providence St. Vincent Medical Center, Portland, OR
| | - Omer Erdeve
- Department of Pediatrics, Ankara University School of Medicine Children’s Hospital, Ankara
| | - Ali Bulbul
- Department of Pediatrics, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | | | | | - Aijaz Farooqi
- Department of Pediatrics, Umea University Hospital, Umea, Sweden
| | - Anup Katheria
- Department of Pediatrics, Sharp Mary Birch Hospital, San Diego, CA
| | - Jason Sauberan
- Department of Pediatrics, Sharp Mary Birch Hospital, San Diego, CA
| | - Jaideep Singh
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Kelly Nelson
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Lawrence Dong
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | - Susan W. Aucott
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Madoka Hayashi
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Anne Marie Heuchan
- Department of Pediatrics, University of Glasgow, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
| | | | - Matthew Derrick
- Department of Pediatrics, Northshore University Health System, Evanston, IL
| | - Erika Fernandez
- Department of Pediatrics, University of California San Diego and Rady Children’s Hospital, San Diego
| | - Meera Sankar
- Department of Pediatrics, Good Samaritan Hospital, San Jose, CA
| | - Tina Leone
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Jorge Perez
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
| | - Arturo Serize
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
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27
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Incidence, Risk Factors, and Comorbidities of Vocal Cord Paralysis After Surgical Closure of a Patent Ductus Arteriosus: A Meta-analysis. Pediatr Cardiol 2019; 40:116-125. [PMID: 30167748 PMCID: PMC6348263 DOI: 10.1007/s00246-018-1967-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Abstract
Surgical closure of a patent ductus arteriosus (PDA) is considered standard treatment for symptomatic neonates refractory to medical therapy. Sometimes, iatrogenic injury to the left recurrent laryngeal nerve during the procedure can result in vocal cord paralysis (VCP). This study aimed to estimate the incidence of VCP in patients after surgical PDA closure and to identify any associated risk factors and morbidities associated with VCP in the preterm infant population. A thorough search of the major electronic databases was conducted to identify studies eligible for inclusion into this meta-analysis. Studies reporting data on the incidence of VCP (primary outcomes) or risk factors and morbidities associated with VCP in premature infant population (secondary outcomes) were included. A total of 33 studies (n = 4887 patients) were included into the analysis. Overall pooled incidence estimate of VCP was 7.9% (95%CI 5.3-10.9). The incidence of VCP after PDA closure was significantly much higher in premature infants (11.2% [95%CI 7.0-16.3]) than in non-premature patients (3.0% [95%CI 1.5-4.9]). The data showed that VCP was most common after surgical ligation and in studies conducting universal laryngoscopy scoping. The risk factors for postoperative VCP in preterm infants included birth weight and gestational age. In addition, VCP was significantly associated with the occurrence of bronchopulmonary dysplasia, gastrostomy tube insertion, and increased duration of mechanical ventilation. Vocal cord paralysis remains a frequent complication of surgical closure of a PDA, especially in premature neonates, and is associated with significant post-procedural complications.
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Kültürsay N, Bilgen H, Türkyılmaz C. Turkish Neonatal Society guideline on enteral feeding of the preterm infant. TURK PEDIATRI ARSIVI 2018; 53:S109-S118. [PMID: 31236024 PMCID: PMC6568297 DOI: 10.5152/turkpediatriars.2018.01811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Early initiation of enteral feeding with the own mother's milk and prevention of postnatal growth failure is the target of nutrition in preterm infants. Together with total parenteral nutrition, mouth care and minimal enteral nutrition is started with colostrum in the very early hours of life in small preterm infants. Expressed mother's milk is given via a gastric tube and gradually increased in accordance with the gestational age/birth weight and the risk factors. For infants born heavier than 1 000 grams, the aim is to reach total enteral feeding at the end of first week, and at the end of the second week for infants weighing less than 1000 grams. Supporting mothers in milk expression and kangaroo mother care, promoting non-nutritive feeding, appropriate fortification of mother' milk, and initiating and advancing breastfeeding as soon as the infant is ready are all crucial. Donor mother milk, and as a second choice, preterm formula is advised if the mother's milk is not available. Individualized post-discharge nutrition decisions can be taken in accordance with the actual growth at the time of discharge. The goal is optimal neurodevelopmental achievement together with the prevention of long-term metabolic problems. Late preterm infants, which constitute the majority of preterm infants, also need close nutritional attention and follow-up.
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Affiliation(s)
- Nilgün Kültürsay
- Division of Neonatology, Department of Pediatrics, Ege University, Faculty of Medicine, İzmir, Turkey
| | - Hülya Bilgen
- Division of Neonatology, Department of Pediatrics, Marmara University, Faculty of Medicine, Pendik Research and Training Hospital, İstanbul, Turkey
| | - Canan Türkyılmaz
- Division of Neonatology, Department of Pediatrics, Gazi University, Faculty of Medicine, Ankara, Turkey
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Köksal N, Aygün C, Uras N. Turkish Neonatal Society guideline on the management of patent ductus arteriosus in preterm infants. Turk Arch Pediatr 2018; 53:S76-S87. [PMID: 31236021 PMCID: PMC6568296 DOI: 10.5152/turkpediatriars.2018.01808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ductus arteriosus is a physiologic phenomenon in utero and it closes spontaneously in term babies. The closure is problematic in preterm infants due to the intrinsic properties of the preterm ductus arteriosus tissue. Although patent ductus arteriosus has been reported to be associated with many adverse outcomes in this population, treatment has not led to a decrease in outcomes such as bronchopulmonary dysplasia. Treatment modalities also have their own risks and restrictions. The aim of the "Turkish Neonatal Society guidelines for the management of patent ductus arteriosus in preterm babies" is to standardize the diagnosis and treatment of patent ductus arteriosus in preterm infants by combining the current scientific data and the resources of our country.
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Affiliation(s)
- Nilgün Köksal
- Division of Neonatology, Department of Pediatrics, Uludağ University, Faculty of Medicine, Bursa, Turkey
| | - Canan Aygün
- Division of Neonatology, Department of Pediatrics, Ondokuz Mayıs University, Faculty of Medicine, Samsun, Turkey
| | - Nurdan Uras
- Zekai Tahir Burak Womens' Health Training and Research Hospital, Ankara, Turkey
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Management strategies for the preemie ductus. Curr Opin Cardiol 2018; 34:41-45. [PMID: 30394907 DOI: 10.1097/hco.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patent ductus arteriosus (PDA) remains the most common cardiovascular condition afflicting neonates. Despite 5 decades of scientific inquiry pediatric cardiologists and neonatologists still cannot answer the simple question of which PDAs should be treated. RECENT FINDINGS Although the volume of the shunt is difficult to calculate, echocardiography, biochemical markers, and clinical exam can provide clues to the magnitude and physiologic consequences of the shunt. Epidemiologic data exists showing a positive relationship between a PDA and numerous morbidities. As a result, for most of the 20th and early 21st century, nearly all PDAs where indiscriminately considered to be hemodynamically significant and attempts to close it where initiated shortly after birth. However, no randomized trials of PDA closure have been able to show significant differences between affected and unaffected groups. In fact, surgical ligation has repeatedly been associated with increased morbidities and worse long-term neurodevelopmental outcomes. As a result, most clinicians favor a strategy of watchful waiting. SUMMARY In this review, we aim to summarize the scientific literature, along with some of the contemporary biases, that exist with regards to the pathophysiology, genetics, and treatment strategies for the neonatal PDA.
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Wang Y, Li X, Guo C. The Association of Nil Per Os (NPO) Days with Necrotizing Enterocolitis. Gastroenterol Res Pract 2018; 2018:2795468. [PMID: 30510571 PMCID: PMC6232799 DOI: 10.1155/2018/2795468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/25/2018] [Accepted: 08/29/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Enteral feeds are an essential part of care for infants and may be a potential risk factor in NEC development. The present study objective was to evaluate the relationship between nil per os (NPO) and clinical outcomes in infants with NEC. METHODS This was a retrospective review of 196 premature, low-birth-weight infants with NEC from January 1, 2011, to October 31, 2016, at four academic tertiary care hospitals. The patients were evaluated based on the median nil per os (NPO) days (5.6 days) in longer NPO (6.3 ± 1.1 days) versus shorter NPO groups (4.2 ± 0.9 days). RESULTS Patients who experienced longer than 5.6 NPO days were more likely associated with perforated NEC (odds ratio (OR), 2.01; 95% confidence interval (CI), 1.07-3.76; p = 0.021), stage III NEC (OR, 1.81; 95% CI, 0.97-3.38; p = 0.042), and longer duration of mechanical ventilation (OR, 0.17; 95% CI, 0.08-0.98; p = 0.005) than the shorter duration group of 5.6 NPO days. For the secondary outcomes, there was a trend towards earlier birth (p = 0.083), longer NICU length of stay (p = 0.093), and higher mortality (p = 0.10) in the longer NPO cohort (p = 0.057). The incidence of bacterial sepsis and short bowel syndrome also increased as the length of NPO increased. There was no statistically significant difference in nutritional variables between the two groups within the in-hospital period. CONCLUSION Longer NPO time was associated with the severity of NEC and more injurious clinical outcomes, as demonstrated by rates of surgical intervention and duration of mechanical ventilation.
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Affiliation(s)
- Yongming Wang
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, China
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Xiaoyu Li
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, China
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Chunbao Guo
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, China
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, China
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Costa S, Maggio L, Alighieri G, Barone G, Cota F, Vento G. Tolerance of preterm formula versus pasteurized donor human milk in very preterm infants: a randomized non-inferiority trial. Ital J Pediatr 2018; 44:96. [PMID: 30115086 PMCID: PMC6097280 DOI: 10.1186/s13052-018-0532-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/06/2018] [Indexed: 12/22/2022] Open
Abstract
Background Human milk (HM) is the best feeding for premature infants. When own mother’s milk (OMM) is insufficient or unavailable, pasteurized donor human milk (PDHM) and preterm formula (PF) are the alternative nutritional sources, but the benefits of donor milk over formula are not defined. This study aimed to assess whether, in the absence of OMM, the PF could guarantee a feeding tolerance not inferior to that seen with the use of PDHM during the first two weeks of life of very preterm infants. Methods Infants with gestational age (GA) of ≤32 weeks who started enteral feeding within the first 7 days of life were randomized to receive PDHM or PF as a supplement to the OMM insufficient or unavailable. The primary outcome was the day of life when full enteral feeding (FEF) of 150 mL/Kg/d was achieved. Results Seventy infants were randomized, 35 in the PF group (GA 30.2 ± 1.7 weeks; BW 1342 ± 275 g), 35 in the PDHM group (GA 30 ± 1.9 weeks; BW 1365 ± 332 g). The time to achieve FEF was the same for infants fed with PF and for infants fed with PDHM (12.3 ± 7.0 days vs 12.8 ± 6.5). Conclusions This trial shows that PF could be a valid alternative for the early feeding of very preterm infants when OMM is insufficient or unavailable. Trial registration UMIN000013922. Date of formal registration: December 31, 2014.
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Affiliation(s)
- Simonetta Costa
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Luca Maggio
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giovanni Alighieri
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giovanni Barone
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Francesco Cota
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
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Abstract
Preterm infants are at increased risk for patent ductus arteriosus (PDA). Prolonged exposure to PDA may be deleterious and has been associated with neonatal morbidity and mortality. Although the molecular mechanisms underlying regulation of postnatal ductus arteriosus closure are not fully understood, clinical experience and research trials have informed recent changes in PDA management strategies and refocused treatment strategies on smaller subsets of infants who require intervention. This review examines current diagnostic and management approaches to PDA in preterm neonates.
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Affiliation(s)
- Maria Gillam-Krakauer
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
| | - Jeff Reese
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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Dose-response Relationship Between Donor Human Milk, Mother's Own Milk, Preterm Formula, and Neonatal Growth Outcomes. J Pediatr Gastroenterol Nutr 2018; 67:90-96. [PMID: 29543698 DOI: 10.1097/mpg.0000000000001959] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND A dose-response relationship between proportions of donor human milk (DHM) intake and in-neonatal intensive care unit (in-NICU) growth rates, if any, remains poorly defined. Objective was to evaluate interrelationships between percentages of DHM, mother's own milk (MOM), and preterm formula (PF) intake and neonatal growth parameters at 36 weeks postmenstrual age or NICU discharge. METHODS Infants eligible for this single-center retrospective study were inborn at ≤32 weeks gestation or ≤1800 g, stayed in the NICU for ≥7 days, and received enteral nutrition consisting of human milk fortified with Enfamil human milk fortifier acidified liquid. Study exposures were defined as 10% increments in the total volumetric proportions of infant diet provided as MOM, DHM, or PF. Outcomes were growth parameters at 36 weeks postmenstrual age or NICU discharge. Multivariable linear regression modeled the adjusted additive effect of infant diet on individual growth parameters. RESULTS A total of 314 infants records were eligible for analysis. Using MOM as reference, the adjusted mean growth velocity for weight significantly decreased by 0.17 g · kg · day for every 10% increase in DHM intake, but did not vary with PF intake. The adjusted mean change in weight z score significantly decreased with increasing proportion of DHM intake but significantly improved with increasing PF intake. The adjusted mean head circumference velocity was significantly decreased by 0.01 cm/wk for every 10% increase in DHM intake, in reference to MOM, but did not vary with PF intake. Neither proportion of DHM nor PF intake was associated with length velocity. CONCLUSIONS When DHM and MOM are fortified interchangeably, preterm infants receiving incremental amounts of DHM are at increased risk of postnatal growth restriction. The dose-response relationship between DHM, MOM, and PF and long-term growth and neurodevelopmental outcomes warrants further research.
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Luecke CM, Liviskie CJ, Zeller BN, Vesoulis ZA, McPherson C. Acetaminophen for Patent Ductus Arteriosus in Extremely Low-Birth-Weight Neonates. J Pediatr Pharmacol Ther 2018; 22:461-466. [PMID: 29290747 DOI: 10.5863/1551-6776-22.6.461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Although non-steroidal anti-inflammatory drugs (NSAIDs) are the current standard therapy for the treatment of patent ductus arteriosus (PDA), many neonates have contraindications to receiving or may fail NSAID therapy. To avoid surgical ligation, these patients may benefit from an alternative therapy. The objective of this research is to report the efficacy and safety of acetaminophen for the treatment of PDA in a cohort of premature neonates. METHODS Demographics and clinical course were retrospectively evaluated for all neonates admitted during the study period who received acetaminophen for the treatment of PDA. Initial acetaminophen dosing was 15 mg/kg every 6 hours (88% intravenous). Efficacy was analyzed from ductal constriction on echocardiogram as well as need for further PDA treatment. Markers of hepatic and renal function as well as respiratory support and neonatal morbidities were evaluated to describe the safety of acetaminophen. RESULTS Forty-one neonates were identified with a median birth weight of 760 g (IQR 614-948 g) and median gestational age of 25 weeks (IQR 24-27 weeks). Treatment was initiated at a median postnatal age of 15 days (IQR 8-19 days) for a median duration of 7 days (IQR 6-10 days). Twenty-seven neonates (66%) required no further PDA treatment, with echocardiographic PDA closure documented in 10 neonates (24%) and reduced ductal size in 15 neonates (37%). No clinically significant adverse effects attributable to acetaminophen therapy were detected. CONCLUSIONS Most patients in this study responded to acetaminophen treatment for PDA, indicating that this therapy may be an option for extremely low-birth-weight neonates in order to avoid surgical ligation.
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Affiliation(s)
- Caitlyn M Luecke
- Department of Pharmacy (CML, CJL, BNZ, CM), St. Louis Children's Hospital, St Louis, Missouri, Department of Pediatrics (ZAV, CM), Washington University School of Medicine, St Louis, Missouri
| | - Caren J Liviskie
- Department of Pharmacy (CML, CJL, BNZ, CM), St. Louis Children's Hospital, St Louis, Missouri, Department of Pediatrics (ZAV, CM), Washington University School of Medicine, St Louis, Missouri
| | - Brandy N Zeller
- Department of Pharmacy (CML, CJL, BNZ, CM), St. Louis Children's Hospital, St Louis, Missouri, Department of Pediatrics (ZAV, CM), Washington University School of Medicine, St Louis, Missouri
| | - Zachary A Vesoulis
- Department of Pharmacy (CML, CJL, BNZ, CM), St. Louis Children's Hospital, St Louis, Missouri, Department of Pediatrics (ZAV, CM), Washington University School of Medicine, St Louis, Missouri
| | - Christopher McPherson
- Department of Pharmacy (CML, CJL, BNZ, CM), St. Louis Children's Hospital, St Louis, Missouri, Department of Pediatrics (ZAV, CM), Washington University School of Medicine, St Louis, Missouri
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Abstract
Necrotizing enterocolitis (NEC) is a multifactorial disease that occurs when multiple risk factors and/or stressors overlap, leading to profound inflammation and intestinal injury. Due to its multifactorial nature, there has been much uncertainty in identifying clear strategies for prevention of NEC. Despite these obstacles, the incidence of NEC has gradually been decreasing over the past 10 years, in part due to quality improvement (QI) initiatives to prevent NEC. Current QI strategies primarily target the various predisposing conditions. This article reviews the evidence on which QI interventions to prevent NEC have been based and provides examples of successful QI interventions.
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Implementation of Feeding Guidelines Hastens the Time to Initiation of Enteral Feeds and Improves Growth Velocity in Very Low Birth-Weight Infants. Adv Neonatal Care 2017; 17:139-145. [PMID: 27750266 DOI: 10.1097/anc.0000000000000347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Growth and nutrition are critical in neonatal care. Whether feeding guidelines improve growth and nutrition and reduce morbidity is unknown. PURPOSE Feeding guidelines for very low birth-weight (VLBW) infants were implemented in our neonatal intensive care unit (NICU) to start and achieve full enteral feeds sooner, and increase weight gain over the first month. METHODS Feeding guidelines for VLBW infants were implemented in January 2014, stratified by birth weight (<750, 750-1000, and 1000-1500 g). After trophic feedings, enteral feedings were advanced by 20 to 30 mL/kg/d.Data were analyzed for 2 years prior (baseline) and 6 months after (guideline) guidelines were implemented and included days to initiation of enteral feeds, days on total parenteral nutrition (TPN), and weight gain over the first month. Potential concomitant factors that could affect feeding tolerance were examined including indomethacin or dopamine treatment, delivery room cardiopulmonary resuscitation, and growth restriction. RESULTS A total of 95 infants with a birth weight of less than 1500 g were included (59 baseline and 36 guideline). Days to start enteral feeds decreased by 47% (P < .01) and days on TPN decreased by 25% (16 days vs 11 days; P < .01). Weight gain over the first month of life increased by 15% (p < .05). Dopamine and indomethacin use decreased during the study period, and small for gestational age infants were overrepresented in the guideline group. IMPLICATIONS FOR PRACTICE/RESEARCH Establishment of feeding guidelines for VLBW infants in our NICU reduced the days to start feeds and days on TPN while increasing weight gain over the first month. Improving growth and nutrition and reducing need for TPN in this vulnerable population may ultimately prevent infection and improve neurodevelopmental outcomes.
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Effect of prophylactic indomethacin administration and early feeding on spontaneous intestinal perforation in extremely low-birth-weight infants. J Perinatol 2017; 37:188-193. [PMID: 27763630 DOI: 10.1038/jp.2016.196] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/07/2016] [Accepted: 09/19/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the effect of concomitant administration of prophylactic indomethacin and early enteral feeds on the risk of spontaneous intestinal perforation (SIP) in extremely low-birth-weight (ELBW) infants, and to describe the variation in prophylactic indomethacin use in Canada. STUDY DESIGN A retrospective cohort study of 4268 ELBW infants born at <30 weeks' gestation admitted to Canadian neonatal units between 2010 and 2014 was conducted. Prophylactic indomethacin (I+ or I-, administered within 24 h) and early feeding (E+ or E-, initiated in the first 2 days) exposures were studied concurrently and independently. The primary outcomes were SIP and death before discharge. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. RESULTS Compared with the I-/E+ reference group (n=1829), infants in I+/E+ (n=285; aOR 2.92, 95% CI 1.41 to 6.08) and I+/E- (n=213; aOR 2.84, 95% CI 1.35 to 5.98) groups had higher odds of SIP, whereas those in the I-/E- group had similar odds (n=1941; aOR 1.37, 95% CI 0.88 to 2.14). Odds of SIP were higher in the indomethacin exposed group (I+) compared with the unexposed (I-) group when controlled for early feeding (aOR 2.43, 95% CI 1.41 to 4.19), but not in the early feeding group when controlled for indomethacin. The use of prophylactic indomethacin ranged from 0% usage in 13 sites to 78% use in one site. CONCLUSION Prophylactic indomethacin was associated with increased odds of SIP independently from early feeding in this cohort; however, early enteral feeding was not associated with SIP. Marked variation in the use of prophylactic indomethacin was identified.
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Worthington P, Balint J, Bechtold M, Bingham A, Chan LN, Durfee S, Jevenn AK, Malone A, Mascarenhas M, Robinson DT, Holcombe B. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr 2017; 41:324-377. [PMID: 28333597 DOI: 10.1177/0148607117695251] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.
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Affiliation(s)
| | - Jane Balint
- 2 Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Angela Bingham
- 4 University of the Sciences, Philadelphia, Pennsylvania, USA
| | | | - Sharon Durfee
- 6 Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | | | | | - Maria Mascarenhas
- 9 The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Robinson
- 10 Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Beverly Holcombe
- 11 American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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William W. Optimizing nutrition of the preterm infant. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017. [PMID: 28100316 PMCID: PMC7390124 DOI: 10.7499/j.issn.1008-8830.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
The goal of nutrition of the preterm infant is to meet the growth rate of the healthy fetus of the same gestational age and to produce the same body composition of the healthy fetus in terms of organ growth, tissue components, and cell number and structure. Nutritional quantity and quality are fundamental for normal growth and development of preterm infants, including neurodevelopmental outcomes. Failure to provide the necessary amounts of all of the essential nutrients has produced not only growth failure, but also increased morbidity and less than optimal neurodevelopment. Growth velocities during the NICU hospitalization period for preterm infants exert a significant effect on neurodevelopmental and anthropometric outcomes. Despite the obvious need for optimal nutrition, growth failure is almost universal among preterm infants. There is every reason, therefore, to optimize nutrition of the preterm infant, in terms of total energy and protein, but also in terms of individual components such as amino acids, specific carbohydrates and lipids, and even oxygen. This review presents scientific rationale for nutrient requirements and practical guidelines and approaches to intravenous and enteral feeding for preterm infants. Intravenous feeding, including amino acids, should be started right after birth at rates that are appropriate for the gestational age of the infant. Enteral feeding should be started as soon as possible after birth, using mother's colostrum and milk as first choices. Enteral feeding should begin with trophic amounts and advanced as rapidly as tolerated, decreasing IV nutrition accordingly, while maintaining nutrient intakes at recommended rates. Feeding protocols are valuable for improving nutrition and related outcomes. Further research is needed to determine the optimal nutrition and rate of growth in preterm infants that will achieve optimal neurocognitive benefits while minimizing the longer-term risk of chronic diseases.
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Affiliation(s)
- W.Hay,Jr William
- />Perinatal Research Center, Child Maternal Health Program, Colorado Clinical and Translational Sciences Institute University of Colorado School of Medicine, Aurora, Colorado, USA
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Enteral feeding during indomethacin treatment for patent ductus arteriosus: association with gastrointestinal outcomes. J Perinatol 2016; 36:544-8. [PMID: 26914015 DOI: 10.1038/jp.2016.11] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/03/2016] [Accepted: 01/12/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Enteral feeds are often discontinued or reduced during indomethacin treatment for patent ductus arteriosus (PDA) in preterm neonates, but the clinical impact of this practice is unknown. The objective of this study was to study the associations between enteral feed volume at the time of indomethacin therapy in preterm neonates with PDA and subsequent gastrointestinal outcomes. STUDY DESIGN Retrospective cohort study. Single-center level III Neonatal Intensive Care Unit. RESULTS All consecutive preterm neonates who had received treatment with indomethacin for PDA over a 5-year period were included and categorized based on enteral feed volume exposure during treatment (Group A: nil per oral (NPO, N=229); Group B: ⩽60 ml kg(-1) day(-1) (N=142); Group C:>60 ml kg(-1) day(-1) (N=44)). Baseline characteristics and clinical outcomes were compared between the three groups. The primary outcome was necrotizing enterocolitis (NEC) ⩾stage IIa, while secondary outcomes included other gastrointestinal complications and common prematurity-related morbidities. Group C had a higher gestational age (mean±s.d.; A: 26.3±1.8; B: 26.1±1.8; C: 27.0±2.0 weeks), birth weight (A: 864±239; B: 847±202; C: 932±234 g) and postnatal age at the time of indomethacin treatment (A: 5.3±2.9; B: 7.2±4.9; C: 15.4±6.6 days). All groups had similar rates of the primary outcome NEC (A: 6.1%, B: 7.8% and C: 4.6%, respectively). They also had similar rates of the secondary outcomes with the exception of days to reach enteral feeds of 120 ml kg(-1) day(-1) (A: 22.8±8.5; B: 20.5±8.6; C: 16.8±7.7; P<0.05 for all inter-group comparisons). Secondary analysis including only those neonates who were not already NPO before indomethacin treatment (N=261) and categorized based on preemptive management (made NPO; enteral feed volume reduced; enteral feed volume unchanged/increased) also showed similar results. CONCLUSIONS This large retrospective study did not identify any association between enteral feed volumes during indomethacin treatment or preemptive reduction in enteral feeds and subsequent incidence of adverse gastrointestinal outcomes in preterm neonates. Preemptive reduction in enteral feed volume was associated with longer time to reach full enteral feeds.
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Abstract
Necrotising enterocolitis (NEC) is a serious infection of the bowel that predominantly affects preterm infants and is a leading cause for mortality and morbidity in preterm infants. It involves a spectrum of pathology including widespread inflammation of the intestinal mucosa, invasion of the immature gut by enteric gas forming bacteria, dissection of the gut wall and portal veins by this gas, often culminating in ischemic necrosis of the intestine. This article provides an overview of the incidence, etio-pathological risk factors, preventive strategies and medical management of NEC.
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Mena P, Milad M, Vernal P, Escalante MJ. [Nutrition in the preterm hospitalized newborn. Recommendations of the Chilean Neonatology Branch, Chilean Pediatric Society]. ACTA ACUST UNITED AC 2016; 87:305-21. [PMID: 27156140 DOI: 10.1016/j.rchipe.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/29/2016] [Indexed: 11/27/2022]
Abstract
Recommendations based on current publications are presented for postnatal preterm nutrition, depending on birth weight: less 1000g, between 1000 and 1500g, and above 1500g, as well for the development periods: adaptation, stabilisation, and growth. A review is also presented on the nutritional management of morbidities that affect or may affect nutrition, such as: osteopenia, bronchopulmonary dysplasia, patent ductus arteriosus, red cell transfusion, and short bowel syndrome.
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Affiliation(s)
- Patricia Mena
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile y Servicio de Recién Nacidos Hospital Dr. Sótero del Río, Santiago, Chile.
| | - Marcela Milad
- Servicio de Neonatología, Clínica Santa María, Santiago, Chile
| | - Patricia Vernal
- Servicio de Recién Nacidos, Hospital San José, Santiago, Chile
| | - M José Escalante
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile y Servicio de Recién Nacidos Hospital Dr. Sótero del Río, Santiago, Chile
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Talavera MM, Bixler G, Cozzi C, Dail J, Miller RR, McClead R, Reber K. Quality Improvement Initiative to Reduce the Necrotizing Enterocolitis Rate in Premature Infants. Pediatrics 2016; 137:peds.2015-1119. [PMID: 27244778 DOI: 10.1542/peds.2015-1119] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To reduce the incidence of necrotizing enterocolitis (NEC) among very low birth weight (VLBW) infants admitted to 8 intensive care nurseries from a 2010 baseline of 8.0% to <4.0% by 2012 and sustain for 6 months using quality improvement (QI) methodology. METHODS A multidisciplinary NEC QI team used the Vermont Oxford Network definition of NEC and the Institute for Healthcare Improvement model. The specific aims were evidenced based and included (1) standardized early human milk feedings, (2) conservative feeding guidelines during blood transfusions and indomethacin treatment, and (3) restriction of ranitidine use in VLBW infants. Inclusion criteria included VLBW infants admitted within the study period without NEC. Exclusion criteria included established NEC or spontaneous intestinal perforation unrelated to NEC. The incidence of NEC and NEC-related surgery were tracked using statistical process control methodology. RESULTS The baseline NEC rate in 2010 was 8% (27 NEC cases in 335 VLBW infants). After initiation of early human-milk feeding and conservative feeds during blood transfusions guidelines in November 2011, only 3.1% (19 of 606 VLBW infants) had developed NEC through December 2013 (P = .001). Special cause variation was noted in June 2012 establishing a new centerline at 3.1%. NEC-related mortality decreased from a 2010 baseline mean of 2.7% to a new baseline mean of 0.9% from January 2011 to December 2013. CONCLUSIONS Implementation of QI initiatives decreased the NEC rate from 8.0% to <4.0%. Early human milk feedings and conservative feeding during blood transfusion policies appear to have significant impact on NEC reduction.
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Affiliation(s)
- Maria M Talavera
- Division of Neonatology, Department of Pediatrics, The Ohio State University, Columbus, Ohio;
| | - Gary Bixler
- Pediatrix Medical Group of Ohio, Dayton, Ohio
| | - Corin Cozzi
- Pediatrix Medical Group of Ohio, Columbus, Ohio; and
| | - James Dail
- QI Services, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Richard McClead
- Division of Neonatology, Department of Pediatrics, The Ohio State University, Columbus, Ohio; QI Services, Nationwide Children's Hospital, Columbus, Ohio
| | - Kristina Reber
- Division of Neonatology, Department of Pediatrics, The Ohio State University, Columbus, Ohio
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Sivanandan S, Agarwal R. Pharmacological Closure of Patent Ductus Arteriosus: Selecting the Agent and Route of Administration. Paediatr Drugs 2016; 18:123-38. [PMID: 26951240 DOI: 10.1007/s40272-016-0165-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Opinions are divided regarding the management of a persistently patent ductus arteriosus (PDA). Some of the adverse effects associated with a large hemodynamically significant duct, including prolonged ventilation, pulmonary hemorrhage, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), and mortality, indicate that active management of infants with large ductal shunts may sometimes be necessary. Indomethacin and ibuprofen are the two US FDA-approved cyclooxygenase (COX) inhibitors used for the closure of a ductus in preterm babies. Both these drugs are effective in 70-80% of extremely low birthweight infants. Treatment with COX inhibitors may be associated with renal impairment, gastrointestinal hemorrhage, NEC, and spontaneous intestinal perforation when given concurrently with steroids, as well as changes in cerebrovascular auto-regulation. Ibuprofen appears to be a better choice for PDA closure, with a better side effect profile and efficacy that equals that of indomethacin. However, long-term outcome studies of ibuprofen are lacking, and prophylactic ibuprofen is ineffective in decreasing severe IVH. The choice of one drug over the other also depends on local availability of both drugs and the intravenous or enteral preparation. The oral preparation of ibuprofen appears as effective as the intravenous preparation. The use of paracetamol to close a hemodynamically significant PDA has increased in recent years. Paracetamol also decreases prostacyclin synthesis; however, unlike COX inhibitors, it does not have a peripheral vaso-constrictive effect and can be given to infants with contraindications to non-steroidal anti-inflammatory drugs. It appears to have similar efficacy based on limited data available from randomized trials. Until more data are available on efficacy, safety, and long-term outcomes, it cannot be recommended as the first choice.
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Affiliation(s)
- Sindhu Sivanandan
- Division of Neonatology, Department of Pediatrics (Newborn Health Knowledge Center (NHKC), ICMR Center for Advanced Research in Newborn Health and WHO Collaborating Centre for Newborn Training and Research, New Private Ward-1st Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ramesh Agarwal
- Division of Neonatology, Department of Pediatrics (Newborn Health Knowledge Center (NHKC), ICMR Center for Advanced Research in Newborn Health and WHO Collaborating Centre for Newborn Training and Research, New Private Ward-1st Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Raiten DJ, Steiber AL, Carlson SE, Griffin I, Anderson D, Hay WW, Robins S, Neu J, Georgieff MK, Groh-Wargo S, Fenton TR. Working group reports: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr 2016; 103:648S-78S. [PMID: 26791182 PMCID: PMC6459074 DOI: 10.3945/ajcn.115.117309] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The "Evaluation of the Evidence to Support Practice Guidelines for the Nutritional Care of Preterm Infants: The Pre-B Project" is the first phase in a process to present the current state of knowledge and to support the development of evidence-informed guidance for the nutritional care of preterm and high-risk newborn infants. The future systematic reviews that will ultimately provide the underpinning for guideline development will be conducted by the Academy of Nutrition and Dietetics' Evidence Analysis Library (EAL). To accomplish the objectives of this first phase, the Pre-B Project organizers established 4 working groups (WGs) to address the following themes: 1) nutrient specifications for preterm infants, 2) clinical and practical issues in enteral feeding of preterm infants, 3) gastrointestinal and surgical issues, and 4) current standards of infant feeding. Each WG was asked to 1) develop a series of topics relevant to their respective themes, 2) identify questions for which there is sufficient evidence to support a systematic review process conducted by the EAL, and 3) develop a research agenda to address priority gaps in our understanding of the role of nutrition in health and development of preterm/neonatal intensive care unit infants. This article is a summary of the reports from the 4 Pre-B WGs.
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Affiliation(s)
- Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD;
| | | | | | | | | | | | - Sandra Robins
- Fairfax Neonatal Associates at Inova Children's Hospital, Fairfax, VA
| | - Josef Neu
- University of Florida, Gainesville, FL
| | | | - Sharon Groh-Wargo
- Case Western Reserve University-School of Medicine, Cleveland, OH; and
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Abstract
PURPOSE OF REVIEW A patent ductus arteriosus (PDA) in premature infants is common and is associated with a number of adverse outcomes. The purpose of this review is to discuss recent literature in PDA diagnosis and management. RECENT FINDINGS The diagnosis of a 'hemodynamically significant' PDA is challenging and a robust definition is lacking. The risks and benefits of therapies, either medical or surgical, designed to close the PDA, are controversial. Oral acetaminophen has gained increasing attention as an alternative pharmaceutical agent for PDA closure in premature infants, although safety concerns remain. Compared to surgical ligation, transcatheter PDA closure may be associated with less risk and fewer adverse events. Both aggressive and conservative management of PDA has similar clinically important outcomes, although the strength of evidence is derived mostly from cohort studies. SUMMARY Clinicians should weigh the potential adverse effects of pharmaceutical or surgical PDA closure against the likelihood of spontaneous closure. The infant population most likely to benefit from PDA closure remains ill-defined and clinical context is recommended.
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Dutta S, Singh B, Chessell L, Wilson J, Janes M, McDonald K, Shahid S, Gardner VA, Hjartarson A, Purcha M, Watson J, de Boer C, Gaal B, Fusch C. Guidelines for feeding very low birth weight infants. Nutrients 2015; 7:423-42. [PMID: 25580815 PMCID: PMC4303848 DOI: 10.3390/nu7010423] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 12/19/2014] [Indexed: 11/16/2022] Open
Abstract
Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.
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Affiliation(s)
- Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Balpreet Singh
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Lorraine Chessell
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Wilson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Marianne Janes
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Kimberley McDonald
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Shaneela Shahid
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Victoria A Gardner
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Aune Hjartarson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Margaret Purcha
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Watson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Chris de Boer
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Barbara Gaal
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Christoph Fusch
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
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Bhat R, Das UG. Management of patent ductus arteriosus in premature infants. Indian J Pediatr 2015; 82:53-60. [PMID: 25532746 DOI: 10.1007/s12098-014-1646-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 11/28/2014] [Indexed: 11/25/2022]
Abstract
Patency of the ductus arteriosus is required for fetal survival in utero. In infants born prematurely, ductus fails to close and shunt reverses from left to right. Incidence of patent ductus arteriosus (PDA) is inversely proportional to the gestational age. A large PDA (>1.5 mm diameter) with left to right shunt in very low birth weight infants can cause pulmonary edema, congestive heart failure, pulmonary hemorrhage and increase the risk for bronchopulmonary dysplasia. Attempts to prevent or close the duct by pharmacological or surgical methods have not changed the morbidity or the long term outcome. Pharmacological treatment with indomethacin or ibuprofen is successful in 75 to 80 % of infants but its use also exposes these infants to undesirable side effects like gastrointestinal bleeding, perforation and necrotizing enterocolitis. Prophylactic therapy with indomethacin or ibuprofen to prevent PDA has not altered the morbidity or long term outcome. Currently, there is a dilemma as to how to treat, when to treat and whom to treat. Recent literature suggests a trial of conservative management during the first week followed by selective use of anti-inflammatory drugs. Surgical ligation is reserved for infants who fail medical therapy and still remain symptomatic. Spontaneous closure of the PDA has been reported in up to 40-67 % of very low birth weight (VLBW) infants by 7 d. In this review authors discuss these controversies and propose a more rational approach.
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Affiliation(s)
- Rama Bhat
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, 53201, USA,
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50
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Kelleher J, Salas AA, Bhat R, Ambalavanan N, Saha S, Stoll BJ, Bell EF, Walsh MC, Laptook AR, Sánchez PJ, Shankaran S, VanMeurs KP, Hale EC, Newman NS, Ball MB, Das A, Higgins RD, Peralta-Carcelen M, Carlo WA. Prophylactic indomethacin and intestinal perforation in extremely low birth weight infants. Pediatrics 2014; 134:e1369-77. [PMID: 25349317 PMCID: PMC4533280 DOI: 10.1542/peds.2014-0183] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Prophylactic indomethacin reduces severe intraventricular hemorrhage but may increase spontaneous intestinal perforation (SIP) in extremely low birth weight (ELBW) infants. Early feedings improve nutritional outcomes but may increase the risk of SIP. Despite their benefits, use of these therapies varies largely by physician preferences in part because of the concern for SIP. METHODS This was a cohort study of 15,751 ELBW infants in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network from 1999 to 2010 who survived beyond 12 hours after birth. The risk of SIP was compared between groups of infants with and without exposure to prophylactic indomethacin and early feeding in unadjusted analyses and in analyses adjusted for center and for risks of SIP. RESULTS Among infants exposed to prophylactic indomethacin, the risk of SIP did not differ between the indomethacin/early-feeding group compared with the indomethacin/no-early-feeding group (adjusted relative risk [RR] 0.74, 95% confidence interval [CI] 0.49-1.11). The risk of SIP was lower in the indomethacin/early-feeding group compared with the no indomethacin/no-early-feeding group (adjusted RR 0.58, 95% CI 0.37-0.90, P = .0159). Among infants not exposed to indomethacin, early feeding was associated with a lower risk of SIP compared with the no early feeding group (adjusted RR 0.53, 95% CI 0.36-0.777, P = .0011). CONCLUSIONS The combined or individual use of prophylactic indomethacin and early feeding was not associated with an increased risk of SIP in ELBW infants.
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Affiliation(s)
- John Kelleher
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ramachandra Bhat
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Shampa Saha
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Abbot R. Laptook
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Pablo J. Sánchez
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island
| | - Seetha Shankaran
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Ellen C. Hale
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nancy S. Newman
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - M. Bethany Ball
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abhik Das
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California; and
| | - Rosemary D. Higgins
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | | | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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