Vitamin D and Insulin-Dependent Diabetes: A Systematic Review of Clinical Trials

(1) Background: Vitamin D supplementation after type 1 diabetes mellitus (T1DM) onset has led to conflicting results on beta-cell preservation. Aim: This paper presents a systematic review to verify whether randomized prospective controlled trials (RCTs) demonstrate that improved vitamin D status confers protection on T1DM. (2) Methods: A systematic review was conducted up until 18 January 2024 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching MEDLINE, MEDLINE In-Process, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, using keywords "vitamin D", "type 1 diabetes", and "children". (3) Results: Following the above-mentioned search process, 408 articles in PubMed and 791 in Embase met inclusion criteria. After removing duplicates, 471 articles remained. After exclusion criteria, 11 RCTs remained. Because of major heterogeneity in design and outcomes, no meta-analyses were conducted, allowing only for qualitative analyses. There was no strong evidence that vitamin D supplementation has lasting effects on beta-cell preservation or glycemic control in new-onset T1DM. (4) Conclusions: More rigorous, larger studies are needed to demonstrate whether vitamin D improves beta-cell preservation or glycemic control in new-onset T1DM. Because T1DM may cause osteopenia, it is advisable that patients with new onset T1DM have adequate vitamin D stores.

A Statistical Approach to the High Mortality Rate of Israeli Citizens Held Hostage in Gaza

BACKGROUND

According to Hamas sources, many Israeli hostages in Gaza were killed by indiscriminate Israeli airstrikes, together with a large number of Palestinian citizens.

OBJECTIVES

To verify whether the estimated death rate of Israeli hostages was similar to the estimated death rate of Gaza citizens from these acts of war.

METHODS

We used two estimates of hostage death rates, one obtained from Israeli intelligence sources, and one published by a Hamas spokesperson. We used the Palestinian casualty rates published by the Palestinian Ministry of Health. We compared death rates using Fisher's exact test.

RESULTS

By 30 December 2023, the rate of Israeli hostage death was 23/238 (9.7%) according to Israeli intelligence sources, and 60/238 (25.2%) according to Hamas. Both figures are strikingly and significantly higher than the death rate among Palestinians, estimated to be 19,667/2.2 million (0.89%) by 19 December 2023 (P < 0.0001).

CONCLUSIONS

Israeli airstrikes as the cause of death of Israeli hostages are implausible unless they were specifically exposed to these strikes more than Palestinian citizens.

Capnography for catheter location confirmation in minimally invasive surfactant administration

OBJECTIVES

Minimally Invasive Surfactant Treatment (MIST) is a common method for administering surfactant as a treatment for respiratory distress syndrome. However, tracheal catheter placement can be difficult to confirm. We assessed the presence of carbon dioxide (CO₂) in tracheal and esophageal gas aspirated using CO₂ detector.

STUDY DESIGN

Retrospective arm: 20 infants, MIST catheter placement was assessed with a CO₂ detector in two techniques and confirmed with clinical response. Prospective arm-10 infants, aimed to check for CO₂ presence in aspirated esophageal gas during routine nasogastric tube insertion.

RESULTS

Retrospective arm: All infants had positive capnography. One infant that had no clinical response to MIST was diagnosed with total anomalous pulmonary venous return. All 10 infants of the prospective arm had a Negative capnography (P < 0.001, Fisher's exact test).

CONCLUSIONS

Readily available CO₂ detectors can distinguish between tracheal and esophageal placement of MIST catheters prior to MIST.

Nucleated Red Blood Cells as Markers of Perinatal Adaptation in Preterm Neonates Receiving Minimally Invasive Surfactant Therapy

OBJECTIVE

The study aimed to assess the association of nucleated red blood cells (NRBC), a surrogate of intrauterine hypoxia, and elevated pulmonic vascular resistance (E-PVR) and oxygen requirement after minimally invasive surfactant therapy (MIST).

STUDY DESIGN

Retrospective study of a cohort of preterm neonates that received MIST in a single unit.

RESULTS

NRBC were measured in 65 of 75 (87%) neonates administered MIST during the period. In total, 22 of 65 (34%) infants had pre-MIST echocardiography (ECHO).Neonates with elevated NRBC (predefined as >5 × 10⁹/L, n = 16) required higher post-MIST fraction of inspired oxygen (FiO₂) than neonates with normal NRBC (<1 × 10⁹/L, n = 17; FiO₂= 0.31 ± 0.10 and 0.24 ± 0.04, respectively, p = 0.02).NRBC correlated positively with % of time in right to left ductal shunt (r = 0.51, p = 0.052) and inversely with right ventricular stroke volume (r = -0.55, p = 0.031) and time to peak velocity to right ventricular ejection time ratio (r = -0.62, p < 0.001).

CONCLUSION

Elevated NRBC are associated with elevated FiO₂ after MIST and elevated E-PVR. Intrauterine hypoxia may impact postnatal circulatory adaptations and oxygen requirement.

KEY POINTS

· Post-MIST FiO2 requirements are significantly higher in infants with elevated NRBC.. · NRBC correlates positively with elevated PVR in neonates requiring.. · Intrauterine hypoxia may play a role in postnatal circulatory adaptations in neonates with RDS..

Trends in Health Quality-Related Publications Over the Past Three Decades: Systematic Review

Background

Quality assessment in health care is a process of planned activities with the ultimate goal of achieving a continuous improvement of medical care through the evaluation of structure, process, and outcome measures. Physicians and health care specialists involved with quality issues are faced with an enormous and nearly always increasing amount of literature to read and integrate. Nevertheless, the novelty and quality of these articles (in terms of evidence-based medicine) has not been systematically assessed and described.

Objective

The objective of this study was to test the hypothesis that the number of high-evidence journal articles (according to the pyramid of evidence), such as randomized control trials, systematic reviews, and ultimately, practice guidelines, increases over time, relative to lower-evidence journal articles, such as editorials, reviews, and letters to the editors.

Methods

We used PubMed database to retrieve relevant articles published during the 31-year period between January 1, 1989, and December 31, 2021. The search was conducted in April 2022. We used the keywords “quality care,” “quality management,” “quality indicators,” and “quality improvement” and limited the search fields to title and abstract in order to limit our search results to articles nearly exclusively related to health care quality.

Results

During this 31-year evaluation period, there was a significant cubic increase in the total number of publications, reviews, clinical trials (peaking in 2017, with a sharp decline until 2021), controlled trials (peaking in 2016, with a sharp drop until 2021), randomized controlled trials (peaking in 2017, with a sharp drop until 2021), systematic reviews (nearly nonexistent in the 1980s through 1990s to a peak of 222 in 2021), and meta-analyses (from nearly none in the 1980s through 1990s to a peak of approximately 40 per year in 2020). There was a linear increase in practice guidelines from none during 1989-1991 to approximately 25 per year during 2019-2021, including a cubic increase in editorials, peaking in 2021 at 125 per year, and in letters to the editor, peaking at 50-78 per year in the last 4 years (ie, 2018-2021).

Conclusions

Over the past 31 years, the field of quality in health care has seen a significant yearly increase of published original studies with a relative stagnation since 2015. We suggest that contributors to this dynamic field of research should focus on producing more evidence-based publications and guidelines.

Nipple/Areola Dimensions in Early Breastfeeding

Background: Nipple dimensions may be an important factor in breastfeeding (BF) initiation success. Objective: To establish standards of nipple/areola dimensions in early BF and to determine whether maternal age, gestational age (GA), parity, cup size, previous BF experience, and early (<2 hours) BF affect nipple dimensions (assessed on the second day of BF). Design/Methods: A total of 205 consecutive BF women were enrolled. They were all Caucasians, and had uncomplicated pregnancies, labors, and vertex vaginal deliveries. Measurements (immediately before and after BF) of nipple length and diameter and of prefeeding areolas were by sliding calipers. Results: In average, there were no significant differences between right (R) and left (L) side dimensions, except for post-BF nipple length, and post-BF horizontal nipple diameter (significantly higher on the L side). Both R and L nipple length correlated positively with maternal age, gravidity, parity, number of previously breastfed infants, and cumulative number of BF months. Early (<2 hours) first BF did not correlate with increased nipple length. Pre-BF nipple length correlated significantly with post-BF nipple length on both sides. There were significant differences between pre- and post- BF values in terms of nipple length (longer length post-BF), but not in terms of nipple diameter. In stepwise regression analysis, where pre-BF nipple length was the dependent variable, and parity (or maternal age, or previous BF), early first BF, and GA were independent variables, parity, maternal age, gravidity, or previous BF experience were positively and significantly associated with nipple length (p < 0.001). The correlation maternal age-nipple length remained significant in primigravida mothers. Conclusions: This study provided a set of standards for nipple and areola dimensions on day 2 of BF in Caucasian women. The only areola/nipple dimension significantly affected by BF is the nipple length. Increasing parity, maternal age, or previous BF experience is significantly associated with increased nipple length.

The need for cardiac surgery differential tariffs in Israel at the era of aging population and emerging technology: Importance of procedure type and patient complexity as assessed by EuroSCORE

Background

Reimbursement for cardiac surgical procedures in Israel is uniform and does not account for diversity in costs of various procedures or for diversity in patient mix. In an era of new and costly technology coupled with higher risk patients needing more complex surgery, these tariffs may not adequately reflect the true financial burden on the caregivers. In the present study we attempt to determine whether case mix and complexity of procedures significantly affect cost to justify differential tariffs.

Methods

We included all patients undergoing cardiac surgery at Shaare Zedek Medical Center between the years 1993–2016. Patients were stratified according to (1) type of surgery and (2) clinical profile as reflected by the predicted operative risk according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Approximate cost of each group of patients was estimated by the average number of days in the Intensive Care Unit and days in the postoperative ward multiplied by the respective daily costs as determined by the Ministry of Health. We then added the fixed cost of the components used in the operating room (manpower and disposables). The final estimated cost (the outcome variable) was then evaluated as it relates to type of surgery and clinical profile. ANOVA was used to analyze cost variability between groups, and backward regression analysis to determine the respective effect of the abovementioned variables on cost. Because of non-normal distribution, both costs and lengths of stay were Log-transformed.

Results

Altogether there were 5496 patients: 3863, 836, 685 and 112 in the isolated CABG, CABG + valve, 1 valve and 2 valves replacement groups. By ANOVA, the costs in all EuroSCORE subgroups were significantly different from each other, increasing with increased EuroSCORE subgroup. Cost was also significantly different among procedure groups, increasing from simple CABG to single valve surgery to CABG + valve surgery to 2-valve surgery. In backward stepwise multiple regression analysis, both type of procedure and EuroSCORE group significantly impacted cost. ICU stay and Ward stay were significantly but weakly related while EuroSCORE subgroup was highly predictive of both ICU stay and ward stay.

Conclusions

The cost of performing heart surgery today is directly influenced by both patient profile as well as type of surgery, both of which can be quantified. Modern day technology is costly yet has become mandatory. Thus reimbursement for heart surgery should be based on differential criteria, namely clinical risk profile as well as type of surgery. Our results suggest an urgent need for design and implementation of a differential tariff model in the Israeli reimbursement system. We suggest that a model using a fixed, average price according to the type of procedure costs, in addition to a variable hospitalization cost (ICU + ward) determined by the patient EuroSCORE or EuroSCORE subgroup should enable an equitable reimbursement to hospitals, based on their case mix.

Early breast expression for very low birth infants admitted to neonatal intensive care unit: the challenges of cesarean deliveries

AIM OF THE STUDY

In preterm infants, the use of human milk is associated with unique benefits. However, successful breast feeding rates and prolonged breastfeeding duration is often reduced in preterm infants. Nevertheless, early initiation of breast expression after birth is believed to be one of the major variables that should improve the odds of successful breastfeeding. Hence, we aimed to assess correlation between timing of milk expression initiation and volume produced in regards to mode-of-delivery.

MATERIALS AND METHODS

Prospective, observational study. Mothers delivering infants weighing < 1500 g measured 24-h milk volumes on days 1-7, 14, and 21.

RESULTS

Mothers delivering vaginally (N = 11) expressed milk sooner (3.82 ± 5.03 h) than mothers in the cesarean group (N = 42; 11.5 ± 9.1 h). There were no significant differences in daily number of expressions (i.e. day 1 3.6 ± 1.6 versus 2.5 ± 2.1, p = .125) or daily volume (i.e. day 1 - 7.5 ± 6.1 ml versus 11.6 ± 22.9 ml, p = .563), until day 6 from which, both were lower in the cesarean group (i.e. day 21 - number - 6.0 ± 1.3 versus 4.6 ± 1.7, p = .029; volume - 796 ± 465ml versus 435 ± 368ml, p = .018). Expressed volume initially did not correlate with earlier expression, however, latter expressed volume inversely correlated with earlier expression. In multivariate-analysis, mode of delivery, gestational age, and daily number of expressions were correlated with volumes on day 21 (p = .001).

CONCLUSIONS

Earlier human-milk expression is related to volumes on the second and the third week of lactation. This is overwhelmed by delivery mode, and by frequent milk expression from day 2. When early milk expression is not possible, more frequent milk expression might help increasing volumes.

Neonatal Polycythemia and Hypoglycemia in Newborns: Are They Related?

OBJECTIVE

This study aimed to test whether neonatal hypoglycemia (NH) is more common in infants with neonatal polycythemia (NP).

STUDY DESIGN

This is a retrospective study based on universal screening of NH and targeted screening for NP. Polycythemia was defined as venous hematocrit ≥ 65%. NH was defined as whole blood glucose (BG) concentration < 48 mg/dL (measured using a "point-of-care" analyzer [Accu-Chek]).

RESULTS

The study population consisted of 119 consecutive term polycythemic infants and 117 controls. There were no significant differences between the two groups in perinatal characteristics, minimal BG concentration, and rate of hypoglycemia. In a stepwise backward multiple regression where NH was the dependent variable, only maternal gestational diabetes mellitus (p = 0.032) and toxemia (p = 0.001) remained significant, whereas NP was insignificant.

CONCLUSION

NH is not more common in NP infants than in non-NP infants. We suggest that the occurrence of NH in infants with NP might be related to the common risk factors of the two morbidities.

Vitamin D requirements in infancy: an updated systematic review

PURPOSE OF REVIEW

Systematic review looking for new evidence for recommendations for vitamin D supplementation in healthy infants based upon the most recent (4 years) available literature.

RECENT FINDINGS

Randomized controlled trials published since 1 January 2017 that related to vitamin D doses in infancy were reviewed. They do not provide any additional evidence that larger, more generous amounts of daily vitamin D beyond the customary recommended 400 international units (IU) daily dose, affect any significant outcome. Larger amounts may lead to serum 25-hydroxyvitamin D [25(OH)D] concentrations that have been reported to be potentially associated with adverse effects, and a daily dose of 1200 IU may even harm in terms of increasing the risks of allergic sensitization.

SUMMARY

There are still many unanswered questions left, in particular, whether or not more 'generous' amounts of vitamin D in infancy may improve long-term health outcomes such as prevention of adult osteoporosis, allergies, or cancer.

Changes in macronutrients of human milk after bolus feeding: a simulation study

BACKGROUND

Enteral nutrition supply to preterm infants requires feeding through a feeding tube. The aim of this study was to evaluate changes in macronutrient composition of human milk (HM) while passing through a gastric feeding tube.

METHODS

Simulated real-life practice tube feeding was performed by using an infusion pump connected to a feeding tube. A human milk analyzer was used to compare the pre infusion and post infusion macronutrient contents of HM.

RESULT

There was a significant decrease in fat (from 4.06 ± 0.6 g/100 ml to 3.95 ± 0.6 g/100 ml), carbohydrates (from 7.51 ± 0.4 g/100 ml to 7.33 ± 0.5 g/100 ml), and energy content (from 70.77 ± 5.4 kcal/100 ml to 69.72 ± 0.5 kcal/100 ml) after passing through the feeding tube (P < 0.001).

CONCLUSION

A simulated real-life bolus tube feeding model demonstrated small but significant decreases in fat, carbohydrate, and energy content. The biological significance of our results to the very low birth weight infants should be further studied.

The Saga of Pulse Oximetry Screening for Critical Congenital Heart Disease in Israel: A Historical Perspective

BACKGROUND

Many countries have adopted a mandatory routine pulse oximetry screening of newborn infants to identify babies with otherwise asymptomatic critical congenital heart disease (CCHD).

OBJECTIVES

To describe the current status of pulse oximetry CCHD screening in Israel, with a special emphasis on the experience of the Shaare Zedek Medical Center.

METHODS

We review the difficulties of the Israeli Medical system with adopting the SaO2 screening, and the preliminary results of the screening at the Shaare Zedek Medical Center, both in terms of protocol compliance and CCHD detection.

RESULTS

Large scale protocol cannot be implemented in one day, and regular quality assessment programs must take place in order to improve protocol compliance and identify the reasons for protocol failures.

CONCLUSIONS

Quality control reviews should be conducted soon after implementation of the screening to allow for prompt diagnosis and quick resolution.

Infant delivery and maternal stress during the COVID-19 pandemic: a comparison of the well-baby versus neonatal intensive care environments

OBJECTIVE

To describe impact of COVID-19 pandemic on stress and mood of new mothers, in particular in neonatal intensive care unit (NICU); a secondary objective was to assess whether customary social gender distancing practiced by ultra-religious Jews and Muslims offers built-in anti-stress protection.

METHODS

Cross-sectional, observational survey of mothers of 52 normal newborn nursery (NNB) and 52 NICU infants. In all, 86 filled all the 6 questionnaires (Demographics, COVID-19 virus experience, Mental Health Inventory, Neonatal Satisfaction Survey, Parental Stressor Scale, and Questionnaire of Coping Strategies).

RESULTS

Most mothers stated that COVID-19 pandemic had hurt social and family relationships, maternal role, and expressed stress and loneliness. Mothers of NICU infants had higher degree of helplessness. Religious social distancing was not protective. Background tendency to coping poorly with stress and depression most highly predicted stress.

CONCLUSION

COVID-19 pandemic harms psychosocial well-being of most mothers. Detection of high-risk individuals is necessary to provide appropriate support.

Significant Loss of Macronutrients During Passage Through Feeding Tube: An Observational Study

Feeding infants born before week 34 of gestation is based mainly on providing nutrition directly to the gastrointestinal tract through a nasogastric tube. Little is known about the impact of formulas passage through nasogastric tube on their macronutrient content. The aim of our study was to evaluate changes in macronutrient content of various formulas after transfer through a feeding tube.

Methods

Eleven frequently used formulas were chosen. Ten consecutive measurements were performed for each formula. Simulated real-life practice tube feeding was performed by using an infusion pump connected to a feeding tube. A Human Milk Analyzer, using an infrared spectroscopy method, was used to compare the preinfusion and postinfusion macronutrient contents of the different formulas.

Results

A total of 220 measurements were performed. Variations in at least one macronutrient were observed in 5 out of 10 formulas. Fat and energy content were modified in 1 preterm formula.

Conclusions

Changes in the macronutrient content after tube feeding transfer were observed for some infant formulas, including those designed for very low birth weight infants. These alterations might relate to specific formulation of each formula. The biological significance of our results to the very low birth weight infants should be studied further.

The goniomaxillar length/goniomandibular length ratio in normal newborn infants: A clinical tool for defining chin position abnormalities

Retrognathia (recessed chin) and prognathism (prominent chin) often present as signs of an underlying condition. Accurate clinical definitions are important. Yet their definitions were according to "clinical impression", or to seldom used X-ray criteria. We propose a statistical and anthropometric definition of retrognathia and prognathism based upon the ratio between the goniomaxillar length (distance between the gonion at the mandible angle and the subnasale and the goniomandibular length (distance between the mandible angle and the most anterior point of the bony chin). We assumed that an increase in the ratio indicates retrognathia and a decrease reflects prognathism. We conducted a prospective, observational, anthropometric study in 204 consecutive healthy term infants. Measurements took place on the second day of life, using sliding calipers. Mean ± SD of goniomandibular length (5.1 ± 0.3 cm), goniomaxillar length (5.4 ± 0.3 cm), were calculated. All measurements correlated significantly with gestational age, and with infant birthweight. The mean ± SD goniomaxillar length/goniomandibular length ratio was 1.06 ± 0.05. We defined a normal ratio as being within 2 SD of the mean, that is, between 0.96 and and 1.16. This ratio correlated with neither gestational age nor with birthweight. We conclude that the goniomaxillar length/goniomandibular length ratio can be calculated whenever retro - or prognathism is suspected. A ratio outside of the 95% confidence interval should help in making this diagnosis. An increase in this ratio beyond 2 SD above the mean (1.16) could be interpreted as retrognathia and a decrease beyond 2 SD below the mean (0.96) as prognathism.

Head Circumference Growth Is Enhanced by SMOFlipid in Preterm Neonates

BACKGROUND

Suboptimal fat intake during the early postnatal weeks significantly affects brain growth and maturation. Studies to date have focused on the quantity rather than the quality of fat intake.

OBJECTIVE

We hypothesized that early nutrition of premature neonates should also include optimization of the type of fat intake, and thus those receiving SMOFlipid, a balanced multicomponent lipid emulsion, would have improved head growth as measured by head circumference (HC) at discharge.

STUDY DESIGN

We retrospectively reviewed HC in infants weighing <1,500 g who were hospitalized for two or more weeks during a 20-month period, in which all preterm infants received fat as Lipofundin, and the following 20-month period, in which all such infants received SMOFlipid.Lipids were dosed up to 3 g/kg/day and reduced as enteral nutrition progressed. Parenteral fish oil (Omegaven) was permitted as rescue therapy during both periods.

RESULTS

Period 2 infants had better head growth (0.79 [0.69,0.90] vs. 0.75 [0.64,0.86] cm/week; p = 0.0158). More infants reached discharge with an HC of ≥50 percentile (51 vs. 31%; p = 0.0007), and fewer infants had an HC of ≤3 percentile (11 vs. 14%; p = 0.023). Median length of stay was reduced by more than 1 week.A multivariable regression was performed using the weekly increase in HC as the dependent variable, and the time epoch, birth weight, gestational age, hospitalization days, and gender as independent variables. Only the time epoch and days of hospitalization were significant (both p < 0.0001).

CONCLUSION

Our data offer preliminary evidence of improved brain growth in those receiving a balanced lipid emulsion as compared with a soybean oil emulsion.

Effect of Freezing and Thawing on Human Milk Macronutrients and Energy Composition: A Systematic Review and Meta-Analysis

Objective: To conduct a systematic review of the effect of freezing and thawing on the macronutrients and energy composition of human milk (HM). Design: Systematic review conducted in May 2019, including all studies reporting macronutrients and energy composition of HM, according to a search of MEDLINE, EMBASE, and Google Scholar using the keywords: HM, breast milk, macronutrients, fat, lipid, protein, carbohydrates, energy, calories, freezing, thawing, and of the references in studies identified as potentially relevant. Meta-analyses were conducted in all the studies that reported one or more of the following: total energy, true protein, fat, and carbohydrates. They were reported according to following groups of freezing duration: 1-7 days, 8-30 days, 31 days-3 months, and >3 months. They were calculated and expressed as weighted averages with pooled standard deviations. Results: Eight studies remained in the final analysis. Regression analyses did not find any significant increase or decrease over time of protein content, lactose content, fat content, or energy content of milk. Conclusions: No dramatic changes in macronutrients and energy contents of milk are expected to occur within the first few months of freezing.

SMOFlipid Protects Preterm Neonates against Perinatal Nutrition-Associated Cholestasis

OBJECTIVE

Intravenous lipid infusions improve both short- and long-term outcomes of premature neonates. However, prolonged infusion of lipids has been implicated in the development of parenteral nutrition-associated cholestasis (PNAC). We speculated that the multicomponent SMOFlipid would be hepatoprotective against PNAC.

STUDY DESIGN

This is a retrospective review comparing the incidence and severity of direct hyperbilirubinemia in preterm infants <1,500 g who were hospitalized for a minimum of 2 weeks during a 20-month period in which all preterm infants on total parenteral nutrition (TPN) received fat as Lipofundin with the following 20-month period in which all preterm infants on TPN received SMOFlipid.

RESULTS

Infants in the SMOFlipid period had a lower incidence of PNAC (6 vs. 13%; p = 0.022), lower peak direct bilirubin levels (3.2 vs. 7.1 mg/dL; p = 0.018), and a shorter length of stay (51 vs. 60 days; p = 0.019). The relative risk of developing direct hyperbilirubinemia during the Lipofundin period was 2.22 (1.1-4.3) as compared with period 1; p = 0.018; NNT-14.

CONCLUSION

SMOFlipid was hepatoprotective in our population of preterm neonates <1,500 g receiving long-term TPN as compared with those receiving Lipofundin, despite similar levels of exposure to both intravenous lipid load and duration in the two groups.

Research productivity across different ophthalmic subspecialties in the United States

Background

The purpose of this study was to compare the h-index, and subsequently the research productivity, among different ophthalmic subspecialties in the United States.

Methods

A cohort of over 15,000 academic ophthalmologists residing in the United States (US) was identified out of the physician list of the American Academy of Ophthalmology. Of them, 1000 ophthalmologists with at least one publication were randomly retrieved, 100 in each of the following 10 subspecialties: cataract, cornea/external disease, glaucoma, medical retina, neuro-ophthalmology, pediatric ophthalmology, plastic/reconstructive ophthalmology, refractive surgery, retina/vitreous surgery and uveitis. Data collected included: number of published papers, h-index score, annual increase in h-index and the mean number of authors on each paper.

Results

The mean h-index amongst all subspecialties was 9.87 ± 13.90, and the mean average annual increase in h-index was 0.22 ± 0.21. The mean number of papers published was 37.20 ± 80.08 and the mean number of authors on each paper was 3.39 ± 0.84. Uveitis was the most prolific subspecialty in mean number of papers (74.78 ± 131.37), in mean h-index (16.69 ± 20.00) and in mean annual increase in h-index (0.35 ± 0.28). The least fertile subspecialty with regards to research was cataract with 11.06 ± 27.65 mean number of papers, a mean h-index of 3.89 ± 5.84, and a mean annual increase in h-index of 0.11 ± 0.11.

Conclusions

This study describes the research productivity in each ophthalmic subspecialty in the US, thus providing information on the research performance of each field and on the expected academic accomplishments within it.

Elevated Nucleated Red Blood Cells in Neonates with Down Syndrome and Pulmonary Hypertension

We report an association between higher absolute nucleated red blood cells and mean corpuscular volume and idiopathic persistent pulmonary hypertension of the newborn in neonates with Down syndrome. Elevation of these blood indicies should prompt echocardiographic studies to monitor pulmonary arterial pressures.

The effect of gestational diabetes mellitus on human milk macronutrients content

OBJECTIVE

To test the null hypothesis that human milk (HM) macronutrients (fat, lactose, protein) and caloric content in women with gestational diabetes mellitus (GDM) is similar to that of women without GDM.

STUDY DESIGN

Sixty-two lactating mothers (31 GDM, 31 no-GDM) were studied after confirmation by 100-g oral glucose tolerance test. Each mother contributed three manually expressed HM samples (within 72 h after labor (colostrum), after 7 days (transitional) and at 14 days (mature)). Analysis was done by infrared transmission spectroscopy.

RESULTS

Non-GDM and GDM groups did not differ by maternal age, pre-pregnancy weight, height, diet, pregnancy weight gain, gestational age, and infant birth weight. Macronutrients content in colostrum and transitional milk did not differ between groups. Fat and energy contents in mature HM were higher in non-GDM samples than in GDM samples (p = 0.07 and p < 0.02, respectively).

CONCLUSION

Fat and energy content of mature HM obtained from mothers with GDM is lower compared to that of mature HM from mothers without GDM.

Breastfeeding Difficulties, Breastfeeding Duration, Maternal Body Mass Index, and Breast Anatomy: Are They Related?

Objective: We examined the influence of maternal body mass index (BMI), and of breast and nipple anatomic variations, on breastfeeding difficulties and duration. Methods: In this prospective observational study, we collected demographic and anthropometric data from 109 mothers of full-term newborns. Women were classified as underweight, normal weight, overweight, and obese using the World Health Organization definitions and were otherwise healthy. Breast anthropometrics assessments were recorded after delivery and during hospitalization. Latching difficulties were collected as reported by the mothers. Breastfeeding duration was assessed by phone interview at 3, 6, 1 year, or more postdelivery. Results: The four prepregnancy BMI groups included 12 underweight, 59 normal weight, 20 overweight, and 18 obese women. The higher the BMI group, the larger the breast was (p = 0.005). In univariate regression, nipple diameter, nipple length, and areola diameter correlated significantly with breast size. The overall rate of latching difficulties was 15.5%, without significant differences among all four BMI groups. In multivariate analysis, the higher the BMI group the lower was the likelihood of breastfeeding at 6 months of age (odds ratio [OR] = 0.88, 95% confidence interval [CI]: 0.79-0.99), and the higher the birth order the higher was the likelihood of breastfeeding at 6 months of age (OR = 3.36, 95% CI: 1.44-7.83). Early latching difficulties predicted shorter breastfeeding duration. Conclusion: We conclude that high prepregnancy BMI has a negative impact on breastfeeding initiation and duration.

Ethical Dilemmas in Neonatology - Four Theoretical Cases and Three Monotheistic Approaches: A Pilot Study

BACKGROUND

Israel's population is diverse, with people of different religions, many of whom seek spiritual guidance during ethical dilemmas. It is paramount for healthcare providers to be familiar with different religious approaches.

OBJECTIVES

To describe the attitudes of the three major monotheistic religions when encountering four complex neonatal situations.

METHODS

A questionnaire related to four simulated cases was presented to each participant: a non-viable extremely premature infant (case 1), a severely asphyxiated term infant with extensive brain damage (case 2), a small preterm infant with severe brain hemorrhage and likely extensive brain damage (case 3), and a term infant with trisomy 21 syndrome and a severe cardiac malformation (case 4).

RESULTS

Major differences among the three religious opinions were found in the definition of viability and in the approach towards quality of life.

CONCLUSIONS

Neonatologists must be sensitive to culture and religion when dealing with major ethical issues in the neonatal intensive care unit.

Upper Lip Tie and Breastfeeding: A Systematic Review

BACKGROUND

Upper lip tie (ULT) articles have been recorded in Medline since 1998, while "labial frenum" articles have been recorded since 1946.

OBJECTIVE

to study the existing medical literature on ULT (or labial frenum or fraenum) as they relate to breastfeeding.

MATERIALS AND METHODS

Medline search engine was used to determine and subsequently retrieve all articles published on ULT from 1946 to 2018. Key-words of upper lip tie OR labial frenum were used for the search. We also used Google Scholar and Embase to widen our search, and used the PRISMA criteria for systematic reviews (SRs). Articles were classified as case reports (or series), reviews, editorials (or opinions), cohort studies, clinical trials (nonrandomized), randomized controlled trials (RCT), and SRs according to Medline's own classification. We systematically summarized all articles published to date.

RESULTS AND CONCLUSION

No RCT were found, and the evidence for routine ULT release in infants with breastfeeding difficulties is poor. The classification system proposed by Kotlow has not been found reliable both in terms of inter and intraobserver agreement and in terms of predicting the severity of the breastfeeding difficulties.

Might Bilirubin Serve as a Natural Antioxidant in Response to Neonatal Encephalopathy?

BACKGROUND

Neonatal asphyxia is often associated with hepatic injury. We hypothesized that this might lead to increased bilirubin concentrations.

STUDY DESIGN

Term neonates admitted between January 2015 and April 2017 who remained hospitalized for ≥ 4 days and who had serial serum bilirubin concentrations recorded were divided into those with neonatal encephalopathy (NE) and controls. Serial serum bilirubin concentrations during the first days of life were compared between groups.

RESULTS

Twenty-nine neonates with NE and 84 age-matched controls were identified. Mean total serum bilirubin concentrations of NE babies were significantly lower than those controls throughout the first days of life. At 96 hours of age, NE serum bilirubin concentrations were 4.5 (3.2, 5.8) versus controls of 10.5 (9.4, 11.5) mg/dL (p < 0.0001). The mean area under the curve (AUC) for the NE group was 268 (215, 321) versus 663 (608, 718), p < 0.0001, for the control group. All of the NE babies remained below the 40th percentile of the Bhutani curve and none required phototherapy.

CONCLUSION

Contrary to our hypothesis, bilirubin concentrations in NE infants are significantly lower than expected during the first 4 days postnatally. We speculate that, under conditions of severe oxidative stress, bilirubin is consumed as an antioxidant.

Opinions of Israeli neonatologists about life and death decisions in neonates

BACKGROUND

In 2005, the Israeli parliament passed the "law of dying patients" legalizing life and death decisions (do not resuscitate) in patients with life expectancy less than 6 months.

OBJECTIVE

To determine whether ethnic and religious backgrounds (both religion and religiosity) influence neonatologists' attitudes in simulated clinical situations and opinions about the new law.

DESIGN/METHODS

Prospective design, using standard questionnaire sent to all 155 board-certified practising Israeli Neonatologists. The questionnaire sought demographic and descriptive data, personal opinions regarding four simulated cases, and opinions about five statements regarding variables that may influence decision-making. Statistical analyses were by stepwise backward regression analysis, linear regression, and Kruskal-Wallis tests, wherever indicated.

RESULTS

Sixty-nine percent of the neonatologists replied, representing 27 NICUs out of the 29 NICUs in Israel. Most neonatologists would respect the wish of the family as long as it would be within the limits of the law or their personal beliefs. In stepwise regression analysis, religion, religiosity, age, gender, experience, or country of training did not influence significantly the neonatologists' opinions or their decisions in simulated practice. Most neonatologists felt that Ethical Committees had no role in NICUs and were seldom consulted. Most felt that likelihood of severe handicap was critical in decision-making. Issues related to treatment cost of a handicapped or dying infant, as well as impact of a handicapped infant on family's well-being, were not deemed critical.

CONCLUSION

Israeli neonatologists appear to be a relatively homogeneous group in end-of-life decisions, regardless of their ethnic, religious, or religiosity background.

Packed red blood cells transfusion in neonates: effect on FiO2 and PaO2/SaO2 ratio, and implications for neonatal saturation targeting

OBJECTIVE

To assess the effect of blood transfusions in neonates on partial pressure of oxygen in arterial blood (PaO2), arterial hemoglobin oxygen saturation (SaO2) and arterial hemoglobin oxygen saturation as measured by pulse oximetry (SpO2).

STUDY DESIGN

Retrospective study of neonates that received a first blood transfusion while having an indwelling arterial line. We compared PaO2, SaO2, SpO2, SaO2/PaO2 ratio and fraction of inspired oxygen (FiO2) 12 h before and after blood transfusion.

RESULTS

Post-transfusion neonates had higher PaO2 and SaO2, had lower SaO2/PaO2 ratio, and received higher FiO2 with no change in SpO2.

CONCLUSIONS

Post-transfusion, neonates had lower hemoglobin oxygen affinity. They received higher FiO2 and had higher PaO2 at the same SpO2. We speculate that FiO2 was increased in order to maintain SpO2. Larger prospective trials are needed to confirm our findings.

Publication outcome of abstracts submitted to the American Academy of Ophthalmology meeting

Objective

Abstracts submitted to meetings are subject to less rigorous peer review than full-text manuscripts. This study aimed to explore the publication outcome of abstracts presented at the American Academy of Ophthalmology (AAO) annual meeting.

Methods

Abstracts presented at the 2008 AAO meeting were analyzed. Each presented abstract was sought via PubMed to identify if it had been published as a full-text manuscript. The publication outcome, journal impact factor (IF), and time to publication were recorded.

Results

A total of 690 abstracts were reviewed, of which 39.1% were subsequently published. They were published in journals with a median IF of 2.9 (range 0–7.2) and a median publication time of 426 days (range 0–2,133 days). A quarter were published in the journal Ophthalmology, with a shorter time to publication (median 282 vs. 534 days, p=0.003). Oral presentations were more likely to be published than poster presentations (57.8% vs. 35.9%, p<0.001) and in journals with higher IFs (3.2 vs. 2.8, p=0.02). Abstracts describing rare diseases had higher publication rates (49.4% vs. 38.0%, p=0.04) and were published in higher IF journals (3.7 vs. 2.9, p=0.03), within a shorter period of time (358 vs. 428 days, p=0.03). In multivariate analysis, affiliation with an institute located in the United States (p=0.002), abstracts describing rare diseases (p=0.03), and funded studies (p=0.03) were associated with publication in higher IF journals.

Conclusions

Almost 40% of abstracts were published. Factors that correlated with publication in journals with higher IF were a focus on rare diseases, affiliation with a US institute, and funding.

A Dramatic Increase in Tongue Tie-Related Articles: A 67 Years Systematic Review

BACKGROUND

Tongue tie or ankyloglossia articles are recorded in the Medline since 1949.

OBJECTIVE

To study trends in yearly number of tongue tie or ankyloglossia publications.

METHODS

Medline search engine was used to determine the yearly number of published consensus statements from 1949 to 2016. Keywords of tongue tie OR ankyloglossia OR frenotomy OR frenulotomy were used for the search. Articles were classified as case reports (or series), reviews, editorials (or opinions), cohort studies, clinical trials (nonrandomized), randomized controlled trials (RCT), and systematic reviews (SR). Linear or polynomial regression was used to determine trends. We also systematically summarized all RCTs published to date.

RESULTS

The total number of yearly published articles increased in a cubic fashion (r² = 82.6%, p < 0.0001) over time (0-7 per year from 1949 to 1989, and up to 27-44 in the last 5 years). In terms of strength of evidence hierarchy, most articles belonged to low hierarchy categories (case reports 37.9%, reviews 15.4%, and editorials/opinions 13.4%), with only 8 RCTs and 10 SRs (all of them published during the last 10 years of the study period).

CONCLUSION

The yearly number of tongue tie or ankyloglossia-related articles has increased dramatically in past few years. Most articles bring little evidence, but the past few years have witnessed publication of few RCTs and SRs. If this trend continues, much more solid evidence should accumulate about diagnosis and management of tongue tie, as it relates to breastfeeding and other outcomes.

The effect of maternal habitus on macronutrient content of human milk colostrum

OBJECTIVE

There is a paucity of studies on the impact of maternal body mass index (BMI) on macronutrient content of human milk colostrum (HMC). The objective of this study was to compare macronutrient content of HMC in healthy women of term infants in relation to their BMI. We hypothesized that mother habitus influences human milk colostrum content.

METHOD

Colostrum was collected from 109 healthy mothers of hospitalized healthy term infants divided into four prepregnancy BMI groups: 12 underweight, 59 normal weight, 20 overweight, and 18 obese women between 24 and 72 h after birth. Macronutrient content was measured using mid-infrared spectroscopy.

RESULTS

There were no significant differences in macronutrients between the BMI groups. We performed four separate stepwise backward multiple regression analyses taking into account fat, carbohydrate, protein or energy content as dependent variables and maternal BMI, parity, gestational age, infant gender, maternal age, maternal education, mode of delivery and time postdelivery. In these analyses, fat, carbohydrate and energy content were not related to maternal BMI, while protein content was significantly and positively correlated with BMI (P=0.008) and negatively correlated with gestational age (P=0.004) and time postdelivery (P<0.001). Colostrum carbohydrate content was positively correlated with parity. Colostrum fat and energy content were negatively correlated with maternal age and positively correlated with parity.

CONCLUSION

Most macronutrient and energy content of colostrum are unaffected by prepregnancy maternal BMI, with the exception of protein content that is positively related to maternal BMI.

Vitamin D requirements in infancy: a systematic review

PURPOSE OF REVIEW

New evidence for recommendations for vitamin D supplementation in healthy infants based upon recent literature.

RECENT FINDINGS

Randomized controlled trials published since 2009 that related to vitamin D doses in infancy were reviewed. They do not provide any additional evidence that larger, more generous amounts of daily vitamin D beyond the customary recommended 400 IU daily dose, affect any significant outcome. Larger amounts may lead to serum 25 hydroxy vitamin D concentrations that have been reported to be potentially associated with adverse effects.

SUMMARY

There are still many unanswered questions left, in particular whether or not more 'generous' amounts of vitamin D in infancy may improve long-term health outcomes such as prevention of osteoporosis, allergies, or cancer.

Publication outcomes of neonatology abstracts presented at the Pediatric Academic Societies meeting

OBJECTIVE

To examine publication outcomes of neonatology abstracts presented at Pediatric Academic Society (PAS) meeting, and to analyze variables affecting publication.

STUDY DESIGN

All neonatology studies accepted for presentation (oral or poster) at 2008 PAS meeting were identified. A biphasic manual PubMed search of published articles was performed using a pre-designed algorithm.

RESULTS

A total of 1078 neonatology abstracts were presented at the meeting, among them 481 (44.62%) published by 2016. Abstracts presented orally versus posters (56.11 versus 42.32%; P<0.001) and basic science versus clinical abstracts (53.08 versus 40.2%; P<0.001) were more likely to be published. Positive or negative results of a study or its sample size did not predict rates of publication.

CONCLUSIONS

Less than half of the abstracts presented at the PAS meeting were published within 8 years. Oral presentations were more likely to be published than posters.Journal of Perinatology advance online publication, 6 April 2017; doi:10.1038/jp.2017.46.

Preterm Human Milk Macronutrient and Energy Composition: A Systematic Review and Meta-Analysis

This study is a systematic review of the macronutrient and energy composition of preterm human milk to enable the practicing neonatologist to make informed nutritional decisions in preterm infants. Meta-analyses were conducted in all the studies that reported total energy, true protein, fat, and lactose. Protein content decreased massively (by one-half) and significantly from day 1 to 3 at week 10 to 12. There was a significant linear increase in fat, lactose, and energy content during the same timeframe. Theoretic calculations on energy and macronutrient intake of preterm infants must be made according to a lactation time-specific manner.

The Use of Multinutrient Human Milk Fortifiers in Preterm Infants: A Systematic Review of Unanswered Questions

There is evidence that multinutrient fortification of human milk increases in-hospital growth of preterm infants, but fortification has not been shown to improve long-term growth and neurodevelopmental outcome. We aimed to ascertain whether randomized controlled trials have determined the effect of early versus late introduction of fortifiers on growth and/or other outcomes, and have compared the efficacy/adverse effects of human milk-based versus cow milk-based fortifiers. We conclude that there is little evidence that early introduction of human milk fortification affects important outcomes, and limited evidence that a bovine fortifier places the infant at a higher risk of NEC.

Thyroxine-Based Screening for Congenital Hypothyroidism in Neonates with Down Syndrome

OBJECTIVE

To ascertain whether thyroxine (T4)-based screening programs for congenital hypothyroidism (initial measurement of total T4 [tT4] followed by thyroid stimulating hormone [TSH] measurement in patients with tT4 <10th percentile) identifies congenital hypothyroidism in all neonates with Down syndrome.

STUDY DESIGN

Retrospective cohort study of 159 neonates with Down syndrome, born during the period 1998-2007 were included. Screening test results were compared with those of the general population. All primary care physicians of these infants were contacted and infants' thyroid status verified.

RESULTS

tT4 concentrations in children with Down syndrome were significantly lower, and TSH higher than those in the general population; tT4 concentrations did not correlate with screening TSH concentrations. Twenty children with Down syndrome were treated with L-thyroxin within the first month of life although only 10 babies had been identified by the routine screening test.

CONCLUSIONS

T4-based screening does not identify many cases of congenital hypothyroidism in neonates with Down syndrome. We recommend that neonates with Down syndrome be screened by simultaneous measurements of both tT4 and TSH.

Is obstructive sleep apnea syndrome in children season dependent?

INTRODUCTION

The most common cause of obstructive sleep apnea (OSA) in children is an enlargement of tonsils and/or adenoids. Previous studies have shown that the size of adenoids and tonsils is influenced by upper respiratory tract infections and exposure to allergens. The rate of exposure to bacteria, viruses, and allergens fluctuates from season to season. Therefore, we hypothesized that the rate of polysomnograms positive for OSA may vary according to season.

OBJECTIVE

The objective of this study is to determine whether the prevalence of OSA in children, as determined by polysomnography, is affected by the season during which the study was performed.

METHODS

We retrospectively reviewed polysomnography tests of 296 children, ages 0-12 years, referred for suspected OSA. We compared the Obstructive Apnea Hypopnea Index (OAHI) between the seasons and the rates of abnormal tests in each season according to the degree of severity.

RESULTS

The mean OAHI did not significantly differ among the seasons (winter, 3.0 ± 5.0; spring, 3.0 ± 4.9; summer, 4.0 ± 6.3; fall, 3.4 ± 5.7, p = 0.183). When dividing the OAHI by levels of severity, no seasonality was found in moderate (winter, 13.8 %; spring, 6.7 %; summer, 11.7 %; fall, 14.1 %, p = NS) and severe OSA (winter, 8.8 %; spring, 11.2 %; summer, 10 %; fall, 7.8 %, p = NS). There was a small increase in the frequency of mild OSA diagnoses in the summer compared to the other seasons.

CONCLUSION

In this study, season does not appear to affect the rate of diagnosis of significant OSA in children. Re-evaluation during a different season is unlikely to provide different results and may postpone surgery unnecessarily.

Eradication of Cytomegalovirus from Human Milk by Microwave Irradiation: A Pilot Study

BACKGROUND

Cytomegalovirus (CMV)-infected human milk (HM) can lead to significant CMV morbidity and mortality in preterm very-low-birth weight infants. The eradication of CMV in HM while preserving its properties poses a major clinical challenge.

OBJECTIVE

We aimed to compare two methods used to neutralize the virus in HM, one recognized as partially effective (freezing) and another not tested to date (microwave exposure).

MATERIALS AND METHODS

We sampled HM from 31 CMV-seropositive mothers whose infants were hospitalized at the Lis Maternity Hospital. Fifteen samples that were positive for CMV antigen were divided into five 5 mL aliquots: the first a control, the second was frozen at -20°C for 1 day, the third was frozen at -200°C for 3 days, and the fourth and fifth aliquots were exposed for 30 seconds to microwave radiation at a low-power setting (500 W) and high-power setting (750 W), respectively.

RESULTS

Only microwave radiation at a high-power setting led to complete neutralization of CMV in all samples. Low-power microwave irradiation had a 13% failure rate while 3-day freezing and 1-day freezing had failure rates of 7% and 20%, respectively.

CONCLUSION

It is possible to eradicate CMV successfully in HM by using microwave radiation at a high-power setting. Further studies are needed to evaluate the effect of microwave heating on breast milk properties.

Fatty acids composition of human milk fed to small for gestational age infants

OBJECTIVES

To test the null hypothesis that mothers of asymmetric small for gestational age (SGA) infants produce milk with fatty acids composition similar to that of lactating mothers of appropriate-for-gestational-age (AGA) infants.

METHODS

We obtained human milk (HM) from 2 groups of lactating volunteers that gave birth to asymmetric SGA (study group) or AGA infants (control group). Each mother was asked to contribute by manual expression at least one of 3 samples: first 72 hours after labor (colostrum), day 2-7 postpartum (transitional milk) and 14 days post partum (mature milk). After lipid extraction using Folch's cold-extraction procedure fatty acids were analyzed using gas chromatography.

RESULTS

A total of 108 samples were obtained in 60 women. In univariate analysis, there were no significant differences in any of the fatty acids concentrations examined between groups. This remained true when timing of the sample (colostrum, transitional or mature milk) or gestational age were introduced as confounders in analysis of variance (general linear model).

CONCLUSION

Fatty acid composition of human milk is not affected by whether or not the infant was fetal growth restricted. We suggest that mothers of SGA infants may be reassured about the fat quality of their milk.

Human Milk Macronutrients Content: Effect of Advanced Maternal Age

BACKGROUND

Little is known about the effect of advanced maternal age upon macronutrients of human milk. This study was designed to study contents of macronutrients (fat, lactose, and protein) in human milk collected in the first 2 weeks of life in older (≥35 years) compared with younger (<35 years) mothers.

SUBJECTS AND METHODS

Seventy-two lactating mothers (38 older, 34 younger) of newborns were recruited within the first 3 days of delivery. Macronutrient contents were measured at 72 hours, 7 days, and 14 days after delivery using infrared transmission spectroscopy.

RESULTS

The groups did not differ in terms of maternal prepregnancy weight, height, and diet or infant birth weight or gestational age. They differed significantly in terms of maternal age and maternal weight after pregnancy. Fat content in colostrum and carbohydrate content in mature milk were significantly higher in the older mothers group. Moreover, carbohydrates in mature milk correlated positively with maternal age. Fat content at an infant age of 7 days and 2 weeks was not affected by maternal age. There was no significant relationship between maternal body weight for height (or body mass index) and energy, protein, fat or lactose content at any stage.

CONCLUSIONS

Fat content of colostrum and carbohydrate content of mature milk obtained from mothers with advanced age are elevated compared with those of younger mothers. Moreover, there is a positive correlation between maternal age and carbohydrate content in mature milk. The biological significance of our findings is yet to be determined.

Circadian Macronutrients Variations over the First 7 Weeks of Human Milk Feeding of Preterm Infants

BACKGROUND

Little is known about circadian variations of macronutrients content of expressed preterm human milk (HM). This study evaluated diurnal variations of macronutrients and energy content of preterm HM over the first 7 weeks of lactation and tested the hypothesis that values obtained during a morning sample are predictive of those obtained from an evening sample.

MATERIALS AND METHODS

Expressed HM was obtained from 32 mothers of preterm infants (26-33 weeks in gestational age), who routinely expressed all their milk every 3 hours from the beginning of the second to the seventh week after delivery. One aliquot was obtained from the first morning expression and the second from the evening expression. Energy and macronutrients contents were measured using an HM analyzer.

RESULTS

Mean fat and energy contents of all samples obtained during the whole period were significantly higher in evening samples (p < 0.0001). There were no significant differences between morning and evening carbohydrates and protein contents. Concentrations of protein, carbohydrates, and fat from morning samples were predictive of evening concentrations to different extents (R(2) = 0.720, R(2) = 0.663, and R(2) = 0.20, respectively; p < 0.02). The predictability of evening values by morning values was not influenced by the week of lactation at sampling or by individual patients. In repeated-measures analysis of variance performed on 11 patients who completed the whole 7-week period, over time, there was a significant decrease in fat, energy, and protein contents, whereas carbohydrates content remained unchanged. Day-night differences remained significant only for fat content.

CONCLUSIONS

Circadian variations in fat and energy concentrations of HM are consistent over the first 7 weeks of lactation. There are no consistent circadian variations in HM protein and carbohydrates. Over a given day, there are little variations in protein and carbohydrates content, but fat concentrations are more variable, and evening values are less well predicted by morning sample analysis than values for protein or carbohydrates.

Absolute nucleated red blood cells counts do not predict the development of bronchopulmonary dysplasia

OBJECTIVE

We tested the hypothesis that infants with bronchopulmonary dysplasia (BPD) have higher absolute nucleated red blood cells (aNRBCs) counts at birth than controls as a proxy measurement of exposure to intrauterine hypoxia.

METHODS

We studied 39 preterm infants with BPD and compared them to 39 pair-matched controls without BPD. Criteria for exclusion in both groups included factors that may influence the aNRBCs at birth.

RESULTS

In logistic regression, when pre-eclampsia, birthweight, gender, antenatal steroid therapy, 1-min Apgar scores, respiratory distress syndrome (RDS) (or surfactant use), intraventricular hemorrhage of grade 3 or more, nosocomial sepsis, patent ductus arteriosus, and aNRBC counts (or lymphocyte counts) were used as independent variables, and BPD as the dependent variable, only RDS (or its proxy measurement of surfactant use) and nosocomial sepsis remained included in the final analysis.

CONCLUSIONS

aNRBC counts and lymphocyte counts do not appear to be elevated in infants that develop BPD, as compared to pair-matched controls without BPD. We speculate that chronic intrauterine hypoxia does not appear to play a major role in the pathogenesis of BPD. In contrast, postnatal events such as RDS and nosocomial sepsis appear to play a determining role in the pathogenesis of BPD.

Trends in Pediatric Versus Adult Ophthalmology Publications Over 15 Years

PURPOSE

To evaluate and compare trends in different categories of pediatric and adult ophthalmology publications.

METHODS

Publications in ophthalmology between January 1, 1998, and December 31, 2012, were retrieved from PubMed. An age filter separated pediatric from adult articles.

RESULTS

There was a significant linear increase in the number of publications in both pediatric and adult publications. There was an increase over time in pediatric and adult clinical trials, letters to the editor, meta-analyses, and systematic reviews. There was a significant increase in adult randomized controlled trials only. No meaningful statistical analyses could be conducted for practice guidelines.

CONCLUSIONS

Pediatric and adult ophthalmology have demonstrated a significant increase in annual published articles. Practicing ophthalmologists have an increasing number of articles to read and might become more and more dependent on search engines and reviews to remain informed, emphasizing the need for official practice guidelines that are, unfortunately, seldom published.

Adverse effects reported in the use of gastroesophageal reflux disease treatments in children: a 10 years literature review

Gastroesophageal reflux (GER) is commonly observed in children, particularly during the first year of life. Pharmacological therapy is mostly reserved for symptomatic infants diagnosed with GER disease (GERD), usually as defined in a recent consensus statement. The purpose of the present article was to review the reported adverse effects of pharmacological agents used in the treatment of paediatric GERD. We conducted this review using the electronic journal database Pubmed and Cochrane database systematic reviews using the latest 10-year period (1 January 2003 to 31 December 2012). Our search strategy included the following keywords: omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole, rantidine, cimetidine, famotidine, nizatidine, domperidone, metoclopramide, betanechol, erythromycin, baclofen, alginate. We used Pubmed's own filter of: 'child: birth-18 years'. All full articles were reviewed and we only included randomized controlled trials retrieved from our search. We addressed a summary of our search on a drug-by-drug basis with regard to its mechanism of action and clinical applications, and reviewed all of the adverse effects reported and the safety profile of each drug. Adverse effects have been reported in at least 23% of patients treated with histamine H2 receptor antagonists (H2 RAs) and 34% of those treated with proton pump inhibitors (PPIs), and mostly include headaches, diarrhoea, nausea (H2 RAs and PPIs) and constipation (PPIs). Acid suppression may place immune-deficient infants and children, or those with indwelling catheters, at risk for the development of lower respiratory tract infections and nosocomial sepsis. Prokinetic agents have many adverse effects, without major benefits to support their routine use.

Human Milk Warming Temperatures Using a Simulation of Currently Available Storage and Warming Methods

Human milk handling guidelines are very demanding, based upon solid scientific evidence that handling methods can make a real difference in infant health and nutrition. Indeed, properly stored milk maintains many of its unique qualities and continues to be the second and third best infant feeding alternatives, much superior to artificial feeding. Container type and shape, mode of steering, amount of air exposure and storage temperature may adversely affect milk stability and composition. Heating above physiological temperatures significantly impacts nutritional and immunological properties of milk. In spite of this knowledge, there are no strict guidelines regarding milk warming. Human milk is often heated in electrical-based bottle warmers that can exceed 80°C, a temperature at which many beneficial human milk properties disappear. High temperatures can also induce fat profile variations as compared with fresh human milk. In this manuscript we estimate the amount of damage due to overheating during warming using a heat flow simulation of a regular water based bottle warmer. To do so, we carried out a series of warming simulations which provided us with dynamic temperature fields within bottled milk. We simulated the use of a hot water-bath at 80°C to heat bottled refrigerated milk (60 ml and 178 ml) to demonstrate that large milk portions are overheated (above 40°C). It seems that the contemporary storage method (upright feeding tool, i.e. bottle) and bottle warming device, are not optimize to preserve the unique properties of human milk. Health workers and parents should be aware of this problem especially when it relates to sick neonates and preemies that cannot be directly fed at the breast.