Abstracts "Pediatrics"

Mayo 2007

 

Abstract 1 of 9

 

Randomized Clinical Trial of Prevention of Hydrocephalus After Intraventricular Hemorrhage in Preterm Infants: Brain-Washing Versus Tapping Fluid.

 

Andrew Whitelaw, MD et als;  Department of Clinical Science at North Bristol , Bristol, United Kingdom

 

OBJECTIVE. Hydrocephalus is a serious complication of intraventricular hemorrhage in preterm infants, with adverse consequences from permanent ventriculoperitoneal shunt dependence. The development of hydrocephalus takes several weeks, but no clinical intervention has been shown to reduce shunt surgery in such infants. The aim of this study was to test a new treatment intended to prevent hydrocephalus and shunt dependence after intraventricular hemorrhage.

METHODS. We randomly assigned 70 preterm infants who had gestational ages of 24 to 34 weeks and were progressively enlarging their cerebral ventricles after intraventricular hemorrhage to either (1) drainage, irrigation, and fibrinolytic therapy to wash out blood and cytokines or (2) tapping of cerebrospinal fluid by reservoir as required to control excessive expansion and signs of pressure (standard treatment). We evaluated outcomes at 6 months of age or hospital discharge (if later).

RESULTS. Of 34 infants who were assigned to drainage, irrigation, and fibrinolytic therapy, 2 died and 13 underwent shunt surgery (dead or shunt: 44%). Of 36 infants who were assigned to standard therapy, 5 died and 14 underwent shunt surgery (dead or shunt: 50%). This difference was not significant. Twelve (35%) of 34 infants who received drainage, irrigation, and fibrinolytic therapy had secondary intraventricular hemorrhage compared with 3 (8%) of 36 in the standard group. Secondary intraventricular hemorrhage was associated with an increased risk for subsequent shunt surgery and more blood transfusions.

CONCLUSIONS. Despite its logical basis and encouraging pilot data, drainage, irrigation, and fibrinolytic therapy did not reduce shunt surgery or death when tested in a multicenter, randomized trial. Secondary intraventricular hemorrhage is a major factor that counteracts any possible therapeutic effect from washing out old blood.

 

 

Abstract 2 of 9 

 

Neurodevelopmental and Growth Outcomes of Extremely Low Birth Weight Infants Who Are Transferred From Neonatal Intensive Care Units to Level I or II Nurseries

 

Shabnam Lainwala, PhD, et als; for the National Institute of Child Health and Human Development Neonatal Research Network

Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island
 

OBJECTIVE. Transfer of clinically stable infants to level I and II nurseries alleviates demands on NICUs and allows better use of beds and resources. This study compared growth, neurodevelopmental impairments, postdischarge rehospitalization and deaths, and compliance for follow-up assessment at 18 to 22 months' corrected age of extremely low birth weight infants who transferred to level I and II nurseries with those who continued to receive care to discharge in a NICU.

METHODS. A retrospective analysis of prospectively collected data from the National Institute of Child Health and Human Development Neonatal Research Network was performed. Between January 1998 and June 2002, 4896 infants born with birth weights of 401 to 1000 g and cared for in 19 National Institute of Child Health and Human Development Neonatal Research Network centers were included. The sample consisted of 4392 survivors who received continuing care in the NICU to discharge home and 504 infants who were transferred to level I and II nurseries before discharge home. Demographics, perinatal characteristics, growth, and neurodevelopmental impairments were compared. Bivariate and logistic regression analyses were performed.

RESULTS. Transfer of infants to level I and II nurseries was associated significantly with white race, private insurance, outborn status, and lower neonatal morbidities and compliance for follow-up compared with the NICU group. After adjusting for known covariates, transfer to level I and II nurseries was not associated with neurodevelopmental impairments or death; however, it was associated with increased postdischarge rehospitalization.

CONCLUSIONS. Extremely low birth weight infants who are transferred to level I and II nurseries have similar growth and neurodevelopmental outcomes to infants who are discharged from a NICU. They are, however, more likely to be readmitted to the hospital and are less compliant for follow-up. Establishment of consistent guidelines for comprehensive discharge planning for level I and II nurseries may improve follow-up compliance and reduce rehospitalization rates among these infants who are transferred.

 

 

Abstract 3 of 9 

 

The Effect of Breastfeeding on Cardiorespiratory Risk Factors in Adult Life

 

Alicja R. Rudnicka, PhD, et als;  Division of Community Health Sciences, St George's, University of London, London, United Kingdom

 

OBJECTIVE. Nutrition in the first weeks of life may program disease risk in adulthood. We examined the influence of initial infant feeding on cardiorespiratory risk factors in adulthood.

PATIENTS AND METHODS. A total of 9377 persons born during 1 week in 1958 in England, Scotland, and Wales were followed-up periodically from birth into adulthood. Infant feeding was recorded from a parental questionnaire at 7 years old as never breastfed, breastfed partially or wholly for <1 month, or breastfed for >1 month. Height; waist circumference; hip circumference; waist/hip ratio; body mass index; blood pressure; forced expiratory volume; total, high-density, and low-density lipoprotein cholesterol; triglycerides; hemoglobin A1c; fibrinogen; fibrin D-dimer; C-reactive protein; von Willebrand factor; and tissue plasminogen activator antigen were measured at 44 to 45 years of age.

RESULTS. Breastfeeding for >1 month was associated with reduced waist circumference, waist/hip ratio, von Willebrand factor, and lower odds of obesity compared with formula feeding after adjustment for birth weight, prepregnancy maternal weight, maternal smoking during pregnancy, socioeconomic position in childhood and adulthood, region of birth, gender, and current smoking status. Infant feeding status was not associated with other cardiorespiratory risk factors after adjustment, except for lower fibrinogen and C-reactive protein levels in women.

CONCLUSIONS. The inverse associations of breastfeeding for >1 month with measures of central obesity and inflammatory markers in the current study are small and of little public health importance. Although there was no substantial long-term protective effect of breastfeeding for >1 month on other cardiorespiratory risk factors in adult life, further studies with contemporaneous data on exclusive breastfeeding are needed to confirm these findings.

 

 

Abstract 4 of 9 

 

A Cluster-Randomized Trial of Benchmarking and Multimodal Quality Improvement to Improve Rates of Survival Free of Bronchopulmonary Dysplasia for Infants With Birth Weights of Less Than 1250 Grams

 

Michele Walsh, MD, et als; for the National Institute of Child Health and Human Development Neonatal Research Network

Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio

 

OBJECTIVE. We tested whether NICU teams trained in benchmarking and quality improvement would change practices and improve rates of survival without bronchopulmonary dysplasia in inborn neonates with birth weights of <1250 g.

METHODS. A cluster-randomized trial enrolled 4093 inborn neonates with birth weights of <1250 g at 17 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Three centers were selected as best performers, and the remaining 14 centers were randomized to intervention or control. Changes in rates of survival free of bronchopulmonary dysplasia were compared between study year 1 and year 3.

RESULTS. Intervention centers implemented potentially better practices successfully; changes included reduced oxygen saturation targets and reduced exposure to mechanical ventilation. Five of 7 intervention centers and 2 of 7 control centers implemented use of high-saturation alarms to reduce oxygen exposure. Lower oxygen saturation targets reduced oxygen levels in the first week of life. Despite these changes, rates of survival free of bronchopulmonary dysplasia were all similar between intervention and control groups and remained significantly less than the rate achieved in the best-performing centers (73.3%).

CONCLUSIONS. In this cluster-randomized trial, benchmarking and multimodal quality improvement changed practices but did not reduce bronchopulmonary dysplasia rates.

 

 

Abstract 5 of 9 

 

How Reliable Is a Negative Blood Culture Result? Volume of Blood Submitted for Culture in Routine Practice in a Children's Hospital

 

Thomas G. Connell, MRCPI et als: Infectious Diseases Unit, Department of General Medicine, Department of Paediatrics, University of Melbourne, Parkville, Australia

 

OBJECTIVES. The primary aims of this study were to determine the volume of blood submitted for culture in routine clinical practice and to establish the proportion of blood cultures with a blood volume inadequate for reliable detection of bacteremia.

METHODS. The volumes of blood samples submitted for culture from infants and children up to 18 years of age were measured over a 6-month period. Blood cultures were deemed adequate submissions if they contained an appropriate (age-related) volume of blood and were submitted in the correct blood culture bottle type. During the study, an educational intervention designed to increase the proportion of adequate blood culture submissions was undertaken.

RESULTS. The volume of blood submitted in 1358 blood culture bottles from 783 patients was analyzed. Of the 1067 preintervention blood cultures, 491 (46.0%) contained an adequate blood volume and only 378 (35.4%) were adequate submissions on the basis of collection into the correct blood culture bottle type. After the intervention, there were significant increases in both the proportion of blood cultures containing an adequate blood volume (186 [63.9%] of 291 cultures) and the proportion of adequate submissions (149 [51.2%] of 291 cultures). Overall, blood cultures with an adequate blood volume were more likely than those with an inadequate blood volume to yield positive blood culture results (34 [5.2%] of 655 cultures vs 14 [2.1%] of 648 cultures). Similarly, adequate blood culture submissions were more likely than inadequate submissions to yield positive blood culture results (26 [5.1%] of 506 cultures vs 22 [2.8%] of 797 cultures).

CONCLUSIONS. In routine clinical practice, a negative blood culture result is almost inevitable for a large proportion of blood cultures because of the submission of an inadequate volume of blood. Even after an educational intervention, nearly one half of blood cultures were inadequate submissions.

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    Abstract 6 of 9

     

    Determinants of Outcomes After Head Cooling for Neonatal Encephalopathy

     

    John S. Wyatt, MBBS et als;  for the CoolCap Study Group ; Department of Paediatrics and Child Health, University College London, London, United Kingdom

     

    OBJECTIVE. The goal of this study was to evaluate the role of factors that may determine the efficacy of treatment with delayed head cooling and mild systemic hypothermia for neonatal encephalopathy.

    METHODS. A total of 218 term infants with moderate to severe neonatal encephalopathy plus abnormal amplitude-integrated electroencephalographic recordings, assigned randomly to head cooling for 72 hours, starting within 6 hours after birth (with the rectal temperature maintained at 34.5 ± 0.5°C), or conventional care, were studied. Death or severe disability at 18 months of age was assessed in a multicenter, randomized, controlled study (the CoolCap trial).

    RESULTS. Treatment, lower encephalopathy grade, lower birth weight, greater amplitude-integrated electroencephalographic amplitude, absence of seizures, and higher Apgar score, but not gender or gestational age, were associated significantly with better outcomes. In a multivariate analysis, each of the individually predictive factors except for Apgar score remained predictive. There was a significant interaction between treatment and birth weight, categorized as ≥25th or <25th percentile for term, such that larger infants showed a lower frequency of favorable outcomes in the control group but greater improvement with cooling. For larger infants, the number needed to treat was 3.8. Pyrexia (≥38°C) in control infants was associated with adverse outcomes. Although there was a small correlation with birth weight, the adverse effect of greater birth weight in control infants remained significant after adjustment for pyrexia and severity of encephalopathy.

    CONCLUSIONS. Outcomes after hypothermic treatment were strongly influenced by the severity of neonatal encephalopathy. The protective effect of hypothermia was greater in larger infants.

     

     

    Abstract 7 of 9

     

    Therapeutic Drug Monitoring for Caffeine in Preterm Neonates: An Unnecessary Exercise?

     

    Girija Natarajan, MD et als; Divisions of Neonatology Children's Hospital of Michigan, Detroit, Michigan

     

    OBJECTIVE. Our goal was to determine the value of measuring plasma caffeine levels in preterm neonates treated with caffeine for apnea. We evaluated plasma concentrations of caffeine attained in preterm neonates at standard doses, at varying postconceptual ages, with renal or hepatic dysfunction and when there was clinical lack of efficacy. We hypothesized that measurement of plasma caffeine concentrations during apnea therapy is not clinically helpful.

    PATIENTS/METHODS. An observational study was conducted at Hutzel Women's Hospital between January 2000 and September 2005. Preterm neonates who were being treated with caffeine and who had a plasma caffeine level measured on at least 1 occasion were included.

    RESULTS. A total of 231 caffeine blood levels were obtained from 101 preterm neonates with a median gestation of 28 weeks (range: 23–32 weeks) and birth weight of 1030 g (range: 540–2150 g). The caffeine citrate dose used ranged form 2.5 to 10.9 mg/kg (median: 5 mg/kg), and the levels ranged from 3.0 to 23.8 mg/L. Levels were between 5.1 and 20 mg/L in 94.8%, <5 mg/L in 2.1%, and >20 mg/L in 3.1%. Levels in the 5.1 to 20 mg/L range were attained on 91.3% of occasions when there was concomitant renal dysfunction (n = 23) and in all cases of hepatic dysfunction (n = 13). The median (25th, 75th quartiles) levels drawn for lack of efficacy (14.1 [10.2, 8.3] mg/L; n = 94) were comparable to those obtained for routine monitoring (13.7 [11, 9] mg/L; n = 107).

    CONCLUSIONS. A majority of preterm neonates attain plasma caffeine levels between 5 and 20 mg/L, independent of gestation. This observation held even for the small number of subjects with elevated blood urea nitrogen, serum creatinine, or liver enzyme levels. Therapeutic drug monitoring is not necessary when caffeine is used for the treatment of apnea of prematurity in neonates.

     

    Abstract 8 of 9  

     

    Maternal Antibodies in Breast Milk Protect the Child From Enterovirus Infections

     

    Karita Sadeharju, MD, et als; Department of Virology, University of Tampere and Tampere University Hospital, Tampere, Finland

     

    OBJECTIVE. Enterovirus infections are frequent in infants and may cause severe complications. We set out to assess whether breastfeeding can protect against these infections and whether such an effect is related to maternal antibodies in breast milk or in the peripheral circulation of the infant.

    METHODS. One hundred fifty infants who were prospectively followed up from birth were monitored for enterovirus infections. The duration of breastfeeding was recorded, and maternal breast milk and blood samples were regularly taken at 3-month intervals for the detection of enterovirus antibodies and RNA. Maternal serum was available from early pregnancy, delivery, and 3 months postpartum.

    RESULTS. Enterovirus infections were frequent and were diagnosed in 43% of infants before the age of 1 year and in 15% of the mothers during pregnancy. Infants exclusively breastfed for >2 weeks had fewer enterovirus infections by the age of 1 year compared with those exclusively breastfed for ≤2 weeks (0.38 vs 0.59 infections per child). High maternal antibody levels in serum and in breast milk were associated with a reduced frequency of infections. This effect was seen only in those infants breastfed >2 weeks, indicating that breast milk antibodies mediate this effect. Enterovirus RNA was not found in any of the breast milk samples.

    CONCLUSIONS. These results suggest that breastfeeding has a protective effect against enterovirus infections in infancy. This effect seems to be mediated primarily by maternal antibodies in breast milk.

    • Abstract 9 of 9

     

    Implementing Pay-for-Performance in the Neonatal Intensive Care Unit

     

    Jochen Profit, MD et als;  Section of Neonatology, Texas Children's Hospital

     

    Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-for-performance and the state of quality measurement science, experimentation with pay-for-performance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting.