Guidelines For Infants Research Articles

Review of trace mineral requirements for preterm infants: what are the current recommendations for clinical practice?

Inadequate nutrient stores at birth are an inevitable consequence of being born prematurely. Preterm infants also have high nutrient requirements, which increase with earlier gestational ages. As a result, early nutrition intervention is required to prevent further deficits that, if not corrected, can affect growth and long-term outcomes. Preterm infants often require several weeks of parenteral nutrition (PN) support, which includes trace mineral supplementation. Trace minerals are considered essential nutrients, unable to be synthesized in the human body. Deficiencies of trace minerals have been reported, yet evidence-based guidelines for assessment and supplementation have not been clearly defined. Food and Drug Administration-approved parenteral trace mineral intake guidelines are more than 30 years old. In an effort to more clearly define trace mineral supplementation and monitoring guidelines for preterm infants, a review of literature was performed with the purpose to (1) summarize trace mineral roles in preterm infants, (2) describe clinical signs of deficiency and toxicity, and (3) present intake recommendations and considerations for preterm infants based on current available literature. Review of literature was completed using PubMed and Cochrane databases to find relevant studies specific to trace mineral requirements for preterm infants, trace mineral supplementation of PN, human milk fortifiers, and preterm infant formulas. Review of literature supports that trace mineral depletion can lead to clinical compromise in preterm infants; therefore, suggesting that every effort be made to ensure adequate provision of trace minerals is given to preterm infants. Practical considerations for the clinical nutrition management of preterm infants were also identified in this review.

Evidence-based nurse-driven interventions for the care of newborns with neonatal abstinence syndrome.

Neonatal abstinence syndrome (NAS) is a growing problem in the United States, related to increased maternal substance use and abuse, and a set of drug withdrawal symptoms that can affect the central nervous system and gastrointestinal and respiratory systems in the newborn when separated from the placenta at birth. Infants with NAS often require a significant length of stay in the neonatal intensive care unit (NICU). Pharmacologic treatments and physician-directed interventions are well researched, but nursing-specific interventions and recommendations are lacking. A thorough review and analysis of the literature and interviews with neonatal experts guided the development of a nursing clinical practice guideline for infants with NAS in a level IV NICU. Recommended nursing-specific interventions include methods for maternal drug-use identification, initiation and timing of the Finnegan Scoring System to monitor withdrawal symptoms, and bedside interventions to lessen the drug-withdrawal symptoms in the newborn with NAS.

Emerging issues in pediatric asthma: gaps in EPR-3 guidelines for infants and children.

There are many complexities to the treatment of infants and children with recurrent wheezing and asthma. The National Heart, Lung and Blood Institute's (NHLBI's) Expert Panel Report-3 (EPR-3), published in 2007, provides guidance to clinicians who care for infants and children with asthma. Since that time, many important clinical trials have further informed the evidence base available to clinicians. In this manuscript, new approaches to long-term therapy, intermittent fixed-dose and dynamic dose therapies, and emerging therapies for asthma are reviewed. Further, additional gaps in guideline-based care and areas for future research are discussed.

Variation in the Management of Infants Hospitalized for Bronchiolitis Persists after the 2006 American Academy of Pediatrics Bronchiolitis Guidelines

To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the American Academy of Pediatrics guideline for infants hospitalized with bronchiolitis and to examine the association between resource utilization and disposition outcomes. We conducted a cross-sectional study of infants ≤12 months hospitalized for bronchiolitis from 2007-2012 at 42 hospitals contributing data to the Pediatric Health Information System. Patients with asthma were excluded. The primary outcome was hospital-level variation in utilization of 5 resources not recommended for routine use: albuterol, racemic epinephrine, corticosteroids, chest radiography, and antibiotics. We also examined the association of resource utilization with length of stay (LOS) and readmission. In total, 64,994 hospitalizations were analyzed. After adjustment for patient characteristics, albuterol (median, 52.4%; range, 3.5%-81%), racemic epinephrine (20.1%; 0.6%-78.8%), and chest radiography (54.9%; 24.1%-76.7%) had the greatest variation across hospitals. Utilization of albuterol, racemic epinephrine, and antibiotics did not change significantly over time compared with small decreases in corticosteroid (3.3%) and chest radiography (8.6%) use over the study period. Utilization of each resource was significantly associated with increased LOS without concomitant decreased odds of readmission. Substantial use and variation in 5 resources not recommended for routine use by the American Academy of Pediatrics bronchiolitis guideline persists with increased utilization associated with increased LOS without the benefit of decreased readmission. Future work should focus on developing processes that can be widely disseminated and easily implemented to minimize unwarranted practice variation when evidence and guidelines exist.

Nutrition patterns in children attending nursery school in Sanok vs. nutritional guidelines

Introduction: Nutrition is a particularly important environmental factor determining health. Research showed that the type of diet affects systemic changes and its influence is stronger at younger age. Breastfeeding is the optimum nutrition method for infants. This type of natural nutrition provides all dietary elements necessary for normal somatic growth and psychomotor development of a child and, at the same time, it comprises an important element of disease prevention. Parents’ knowledge about current nutrition guidelines for infants as well as adjustment of this knowledge to individual needs of a particular child determine whether these recommendations are applied and measurable health outcomes are observed. The purpose of this study was to evaluate nutritional patterns, also introducing complementary foods like gluten and fish, during infancy vs. current infant nutrition guidelines. Material and methods: The study group included 92 healthy infants and children between 10 and 55 months old attending two nursery schools in Sanok. Parents of these children were asked to fill a questionnaire form developed by the author. As a result information about breastfeeding and time of introducing gluten and fish to infant’s diet was obtained. These results were compared with nutrition guidelines introduced in 2007. This type of comparison allowed the author to assess whether parents followed current nutrition guidelines for infants. Results and conclusions: This study showed that introducing supplementary foods to infants’ diet did not match current nutrition recommendations, both quantitatively and qualitatively. Therefore, it may be concluded that parents need to be educated in the field of nutrition adequate for children in order to ensure normal development of their children

Do aggressive feeding guidelines eliminate first week nutrition deficits in very low birth weight infants fed exclusively mother’s own milk? (247.2)

Background: Hospitalized VLBW infants fed human milk are reported to have lower growth rates compared to those fed nutrient‐enriched formulas. Aggressive parenteral nutrition guidelines for VLBW infants have been adopted in many neonatal intensive care units (NICUs) in response to data confirming short‐term safety of this approach and potential long‐term neurocognitive benefits. However, actual intakes during the first week of life have not been extensively evaluated since adoption of these guidelines.Objective: To describe the parenteral and enteral energy and macronutrient intakes in human milk‐fed VLBW infants from NICUs with aggressive nutrition guidelines.Design: Daily parenteral and enteral intakes were prospectively collected for 96 VLBW infants fed only MOM enterally during the first week. Feeding goals included provision of protein (>2.0) and lipids (1.0 g/kg/day) on the day of birth, advancing to 3.5 (protein) and 3.0 (lipid) g/kg/day within the first few days.Results: We found that 34% and 70% of infants did not meet protein and energy goals (of 3.5 g/kg/day and 90‐100 kcal/kg/day), respectively, at the end of the first week.Conclusions: Despite the adoption of more aggressive nutrition guidelines, most MOM‐fed VLBW infants remain undernourished at the end of the first week of life. Strategies to address these deficits may significantly impact the health outcomes of this vulnerable population.Grant Funding Source: Supported by CIHR (MOP#210093).

(369) Systematic review of acute procedural pain guidelines for infants and children

Over the past decade, extensive research has been conducted on the management of acute procedural pain in infants and children, resulting in the development of multiple pediatric pain practice guidelines. The objective is to review the methodological quality of clinical practice guidelines for acute procedural pain in infants and children and provide recommendations for use. A comprehensive search was conducted on MEDLINE, Embase, CINAHL, PsycINFO, and Scopus from 2000 to July 2013. A grey literature search was also conducted through the Translating Research into Practice database, Guidelines International Network database, and National Guideline Clearinghouse.

Thermal Stability of the Premature Infant in Neonatal Intensive Care

Hypothermia continues to be a problem for premature infants being cared for in neonatal intensive care because care and procedures expose infants to cold environmental temperatures and infants have immature thermoregulation. Researchers continue to study this problem in order to optimize care with evidence based thermal practices. This paper reviews current research and recommendations to give nurses evidence to formulate thermal stability guidelines for premature infants as well as areas where more research is needed.

Mask leak increases and minute ventilation decreases when chest compressions are added to bag ventilation in a neonatal manikin model

To determine changes in respiratory mechanics when chest compressions are added to mask ventilation, as recommended by the International Liaison Committee on Resuscitation (ILCOR) guidelines for newborn infants. Using a Laerdal Advanced Life Support leak-free baby manikin and a 240-mL self-inflating bag, 58 neonatal staff members were randomly paired to provide mask ventilation, followed by mask ventilation with chest compressions with a 1:3 ratio, for two minutes each. A Florian respiratory function monitor was used to measure respiratory mechanics, including mask leak. The addition of chest compressions to mask ventilation led to a significant reduction in inflation rate, from 63.9 to 32.9 breaths per minute (p < 0.0001), mean airway pressure reduced from 7.6 to 4.9 cm H2 O (p < 0.001), minute ventilation reduced from 770 to 451 mL/kg/min (p < 0.0001), and there was a significant increase in paired mask leak of 6.8% (p < 0.0001). Adding chest compressions to mask ventilation, in accordance with the ILCOR guidelines, in a manikin model is associated with a significant reduction in delivered ventilation and increase in mask leak. If similar findings occur in human infants needing an escalation in resuscitation, there is a potential risk of either delay in recovery or inadequate response to resuscitation.

Evaluation of Parenteral Nutrition–Associated Liver Disease in Infants With Necrotizing Enterocolitis Before and After the Implementation of Feeding Guidelines

In 2009, an intestinal rehabilitation team implemented feeding guidelines for infants following gastrointestinal surgery at our institution. The purpose of this study was to determine the effect of enteral feeding guidelines on the incidence of parenteral nutrition (PN)-associated liver disease (PNALD) in infants with surgically managed necrotizing enterocolitis (NEC). This retrospective study included infants treated during 18-month time periods before and after the implementation of feeding guidelines. PNALD diagnosis was based on serum direct bilirubin >2 mg/dL after ≥14 days of PN exposure. Of the 140 infants identified, 64 were surgically managed and included in the analysis. The duration of PN and the time nil per os (NPO) were significantly reduced after guideline implementation from a median of 106 days to 65 days (P = .03) and from 29 days to 16 days (P = .02), respectively. The incidence of PNALD decreased from 73% before guideline implementation to 42% after guideline implementation (P = .01). Implementation of feeding guidelines resulted in decreased time NPO and duration of PN support. Significantly fewer infants developed PNALD after guideline implementation. These data suggest that feeding guidelines may expedite the transition from PN to enteral nutrition and may improve outcomes.

Development of evidence-based clinical practice guidelines for endotracheal suction in premature infants

Endotracheal suctioning (ETS) for mechanically ventilated premature infants is a routine practice in neonatal intensive care. However, ETS is associated with hypoxemia and bradycardia, which may cause brain damage and negatively affect neurodevelopmental outcomes. This study develops a set of evidence-based clinical-practice ETS guidelines for premature infants. A multidisciplinary task group at a medical center in southern Taiwan was established. Team members analyzed current ETS practice guidelines, constructed foreground questions, reviewed each question systemically, drafted a new set of guidelines, established expert consensus, disseminated the developed guidelines within a hospital setting, and evaluated their efficacy in practice. The developed ETS guidelines address 13 issues with 39 recommendations. The Delphi method found that 75% of experts agreed with all of the recommendations. Issues addressed in the ETS included pre-assessment, frequency of suctioning, pre-oxygenation, suction-tube selection, infection control, suction pressure and depth decision making, humidity with normal saline, suction duration and number, containment and comforting, assessment during and after suctioning, recovery time, and documentation. The panel of clinical and methodological experts recommended that ETS be used in practice and nurses in the neonatal intensive care unit evaluated the ETS as applicable and accessible. The cardiorespiratory responses to ETS of 5 premature infants were within normal ranges without episodes of hypoxemia (oxygen saturation < 85%) or bradycardia (heart rate < 100 beat/min). This set of evidence-based ETS guidelines for premature infants integrated recommendations from the best available literature and obtained a high consensus among clinical experts. Thus, these guidelines are recommended for clinical application.

Clinical guidelines for postpartum women and infants in primary care–a systematic review

BackgroundWhile many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care.MethodsPubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument.ResultsSix guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.ConclusionsOnly one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.

Congenital Rickets: Report of Four Cases

Introduction: Vitamin D deficiency and rickets continue to be health problems in developing countries and most of the infants with congenital rickets may present with hypocalcemic seizure. Case Report: In this article, the report on four infants who presented with hypocalcemic seizures but subsequently were found to have congenital rickets is presented. All of them had hypocalcaemia and low level of serum 25- hydroxy vitamin D. Their mothers had not received vitamin D supplementation during pregnancy and so evidence of vitamin D deficiency was presented. Conclusion: Although current vitamin D supplementation guidelines for infants was effective in prevention of rickets in Iranian children, it is necessary to evaluate women before pregnancy to prevent this entity. Also infants without vitamin D supplementation therapy who present with seizures during the first 6 months of age should undergo biochemical and other investigations for rickets.

Scientific Rationale for Study Design of Community-based Simplified Antibiotic Therapy Trials in Newborns and Young Infants With Clinically Diagnosed Severe Infections or Fast Breathing in South Asia and sub-Saharan Africa

Background:Newborns and young infants suffer high rates of infections in South Asia and sub-Saharan Africa. Timely access to appropriate antibiotic therapy is essential for reducing mortality. In an effort to develop community case management guidelines for young infants, 0–59 days old, with clinically diagnosed severe infections, or with fast breathing, 4 trials of simplified antibiotic therapy delivered in primary care clinics (Pakistan, Democratic Republic of Congo, Kenya and Nigeria) or at home (Bangladesh and Nigeria) are being conducted.Methods:This article describes the scientific rationale for these trials, which share major elements of trial design. All the trials are in settings of high neonatal mortality, where hospitalization is not feasible or frequently refused. All use procaine penicillin and gentamicin intramuscular injections for 7 days as reference therapy and compare this to various experimental arms utilizing comparatively simpler combination regimens with fewer injections and oral amoxicillin.Conclusion:The results of these trials will inform World Health Organization policy regarding community case management of young infants with clinical severe infections or with fast breathing.

Adherence to management guidelines for growth faltering and anaemia in remote dwelling Australian Aboriginal infants and barriers to health service delivery.

BackgroundRemote dwelling Aboriginal infants from northern Australia have a high burden of disease and frequently use health services. Little is known about the quality of infant care provided by remote health services. This study describes the adherence to infant guidelines for anaemia and growth faltering by remote health staff and barriers to effective service delivery in remote settings.MethodsA mixed method study drew data from 24 semi-structured interviews with clinicians working in two remote communities in northern Australia and a retrospective cohort study of Aboriginal infants from these communities, born 2004–2006 (n = 398). Medical records from remote health centres were audited. The main outcome measures were the period prevalence of infants with anaemia and growth faltering and management of these conditions according to local guidelines. Qualitative data assessed clinicians’ perspectives on barriers to effective remote health service delivery.ResultsData from 398 health centre records were analysed. Sixty eight percent of infants were anaemic between six and twelve months of age and 42% had documented growth faltering by one year. Analysis of the growth data by the authors however found 86% of infants experienced growth faltering over 12 months. Clinical management and treatment completion was poor for both conditions. High staff turnover, fragmented models of care and staff poorly prepared for their role were barriers perceived by clinicians’ to impact upon the quality of service delivery.ConclusionAmong Aboriginal infants in northern Australia, malnutrition and anaemia are common and occur early. Diagnosis of growth faltering and clinicians’ adherence to management guidelines for both conditions was poor. Antiquated service delivery models, organisation of staff and rapid staff turnover contributed to poor quality of care. Service redesign, education and staff stability must be a priority to redress serious deficits in quality of care provided for these infants.

Symposium Summary: Looking Back and Looking Forward

Current clinical practice is based on the application of the best-available knowledge. Nutritional guidelines for preterm infants were last updated in 2005. This symposium served to establish a global consensus and a firm scientific base for neonatal nutrition practices. We feel confident to present updated recommendations in the Table.

Human Milk and the Nutritional Needs of Preterm Infants

Key principles underpinning feeding guidelines for preterm infants include support for developmental care, breastfeeding, milk expression, and creating feeding plans. Early trophic feeding with colostrum and transitional milk improves immune protection and promotes gut maturation. Studies of preterm infants demonstrate that feeding mother's milk (MM) decreases the incidence of infection and necrotizing enterocolitis and improves neurodevelopmental outcome but may decrease ponderal and linear growth. Standard practice in neonatal units is to promote mother's own milk as the feed of choice for all infants. However, it is not feasible or prudent to do so for all preterm infants. Mothers of preterm infants have lower rates of successful breastfeeding compared with those of term infants. MM can contain harmful bacterial or viral pathogens. Although preterm human milk (HM) contains higher concentrations of protein, sodium, zinc, and calcium than mature HM, it falls short of supplying adequate quantities of nutrients required by preterm infants. Therefore, HM supplemented with nutrients is recommended for all infants born before 32 weeks gestation and for certain infants born at 32-36 weeks of gestation. HM is the preferred feed, but preterm formula is an appropriate option when there is an inadequate supply of MM.

Nutritional Needs of the Micropreterm Infant

We have used an expansive definition of a micropreterm infant as <30 weeks' gestation to provide a global perspective to a "high risk" group of preterm infants for which there are little published data to guide nutritional management. Consensus nutritional guidelines for preterm infants have been developed for infants >1000 g birth weight and >28 weeks' gestational age. Micropreterm infants have greater nutritional deficits at birth than more mature preterm infants and accumulate greater postnatal deficits. Nutritional guidelines based on the needs of preterm infants born >28 weeks' gestation are unlikely, on a theoretical basis, to meet nutritional requirements of micropreterm infants. Unfortunately, very few good quality studies have addressed the nutritional requirements of this group specifically; this makes it difficult to formulate solid, evidence-based nutritional recommendations for these neonates. Nutritional management of micropreterm infants is based on recommendations established for preterm infants, which are adjusted after considering an infant's gestational age, birth weight, and clinical status. Minimal enteral feeding should commence on the first or second day of life, with incremental advancement and fortification of human milk when 100 mL/kg is tolerated. Early use of parenteral nutrition is recommended, ideally initiated within the first hours of life and enteral feeds are being established; this will help prevent the accumulation of nutritional deficits and incidence of growth failure. Fortified human milk should be given in order to meet nutritional requirements. When human milk is not available in sufficient quantity, a preterm formula should be given.

Compassionate ethics for clinics

Biomedical ethicists and clinical practitioners both champion the good of the patient, but sometimes their approaches diverge. The harmony of the ideal and the real is our utmost goal, but we often confront situations where theory falls apart in practice. A neonatal study performed by several noted institutions that is being audited by the US Office for Human Research Protections (OHRP) is a case in point. Prematurely born infants have underdeveloped lungs that need an intentional oxygen supply. However, too much oxygen carries other risks. Thus, to determine the optimal oxygen level within the range of levels allowed in the current clinical guidelines, researchers at 23 well-known academic institutions carried out a US government-financed study, the Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial (SUPPORT), from 2004 to 2009. According to their article in the New England Journal of Medicine (2010;362:1959-1969), infants receiving the lower oxygen concentration, which was 85 to 89 percent, showed a higher mortality rate than those in the higher oxygen concentration group, who received 91 to 95 percent. This result fundamentally changed the treatment guidelines for premature infants. The OHRP, however, has noted that the researchers did not properly notify the subjects that their babies could have faced differing risks of either death or developing serious ocular problems according to the treatment protocol randomly assigned to them. While the principle investigator of SUPPORT, Dr. Neil Finer at the University of California at San Diego, has argued that at the time of the study design, there was no basis in the literature for attributing a greater risk of death to the lower oxygen level, the OHRP has identified published research on the greater risk of blindness with the higher oxygen level. The OHRP acknowledges the value of the research objective of the SUPPORT group, but in a March 2013 letter, they suggested that the consent form for SUPPORT was not clearly written, such that the research institutions failed to warn the participants about these risks. Shades of the Tuskegee syphilis experiment in the 1930s come to mind, but the current case is not so cut and dried. Before drawing a hasty conclusion, the experience of Dr. Dan Brock, who is an ethics philosopher at Harvard Medical School, is worth considering. When he got cancer, he was forced to confront the interface between theory and practice. In Malignant: Medical Ethicists Confront Cancer, he described the mental anguish of trying to choose a treatment path alone when his physicians, following best practices, did not push him to pursue one treatment over another because definitive research evidence was lacking. When infants are treated, clinical practitioners usually make careful decisions based on the physical condition of the patients in consultation with their parents. This approach was taken in the SUPPORT study, given that the oxygen levels of all of the participants were within the standard range of the American Academy of Pediatrics' guideline. We await the outcome of the careful deliberations between the SUPPORT group and OHRP. Meanwhile, let our ethical standards be practical and compassionate and our clinical practice be theoretically sound. Both are equally vital in the treatment of our patients.

1312 Stabilising Preterm Infants (< 32 Weeks) in the Delivery Suite: Current Clinical Practice in the UK

BackgroundResuscitation guideline for preterm infants has evolved over the last two decades but this still lacks standardisation and clear recommendations. Clinical practice in stabilising preterm infants in the delivery suite...