Gradual rapid advancement of enteral feeding in preterm infants: results of a multicenter prospective randomized study
Administration of enteral feeding is crucial for the prevention of necrotizing enterocolitis (NEC), optimal growth and neuropsychic development of very preterm infants.
Objective. To assess safety and effectiveness of gradual advancement of enteral feeding 30 ml/kg/day in preterm newborns with a gestational age (GA) of ≤32 weeks and compare it with conventional feeding strategy.
Material and methods. Multicenter prospective randomized study was conducted in National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of Ministry of Health of Russian Federation and Moscow Regional Perinatal Center between June 2020 and December 2021. This study included 287 patients with a GA of 24/3–32/0 weeks and birth weight 475 to 2285 g. Newborns with GA 28/0–32/0 were divided into two groups: gradual advancement (n=119) and a standard advancement (n=119) twice a day. The daily rate of enteral feeding advancement was 30 ml/kg/day. Infants with GA less than 28 weeks were divided into 3 groups: the 1st group (n=15) – with gradual advancement with a daily increase 30 ml/kg, the 2nd (n=16) – with a gradual advancement with daily increase 20 ml/kg, the 3rd (n=18) – by traditional advancement 20 ml/kg/day – twice by 10 ml/kg. Gradual advancement is a technique for increasing the volume of enteral nutrition in each feeding by an equal amount during the day.
Results. Gradual advancement of enteral feeding promotes faster achievement of the targeted daily volumes of 100 and 160 ml/kg, reduces the need for peripherally inserted central catheter by 20% in very low birth weight infants without any increase in the incidence of NEC.
A daily increase in the volume of enteral nutrition of 30 ml/kg/day in newborns with GA less than 28 weeks is safe and leads to a faster achievement of the full volume of enteral feeding without an increase in the incidence of NEC, but does not affect the duration of the functioning of the central and peripheral venous catheters, the length of stay in the hospital and growth.
Conclusion. According to results of our study, gradual advancement of enteral feeding by 30 ml/kg/day in newborns can be recommended for very preterm infants as a safe and effective technique that allows reducing the time to achieve complete enteral nutrition without increasing the risk of developing feeding intolerance and NEC.
Oral stimulation as a part of developmental care in the practice of a neonatologist
Objective: to test and improve the oral stimulation technique for developing sucking function during the transition from tube feeding to bottle feeding/breastfeeding in preterm infants of gestational age of 32 weeks or fewer.
Material and methods. The sucking function was assessed in 68 premature newborns born at 26–32 weeks of gestation. In the main group, the sucking reflex was stimulated by the program “The Premature Infant Oral Motor Intervention” (PIOMI), in the control group, newborns were observed under natural conditions of physiological nursing without the use of special techniques.
Results. The age of the first trial bottle feedings and the age of completion of the transition from tube to oral feeding were significantly less in the intervention group (22 vs 32 days and 30 vs 42 days, р<0.001). The shorter period of transition from tube feeding made it possible to start breastfeeding earlier, either. Because of this, 85.3% of children of in the intervention group received native mother’s milk at discharge, compared with 58.8% of the control group.
Conclusion. The use of an oral stimulation method in preterm infants up to 32 weeks of gestation significantly reduces the number of hospitalization days of the children, staff, and funding consuming and improves the organization of medical care in neonatology departments.
Structural features of extremely and very preterm newborns’ brains according to cranial ultrasound
The brain of a preterm infant is structurally and functionally different from the brain of full-term babies. Knowledge about these structural features of the brain of very preterm infants is important for a specialist in ultrasound diagnostics and a neonatologist. It is significant to have the right evaluation of ultrasound results because according to full-term infants, criteria can lead to the wrong conclusions.
The purpose of the study: analysis of anatomical and ultrasound features of the brain of extremely premature infants based on their observations and the data from the literature. The observations were analyzed for the retrospective analysis of brain ultrasound of 223 premature infants.
Results. It was found that neurosonography in extremely premature infants often reveals median subcallous cavities, enlarged cerebrospinal spaces, weak development of furrows and convolutions, and structural features of the white and gray matter of the hemispheres. The peculiarities of the ultrasound picture of the brain of premature infants, relying on immaturity, were abundantly expressed in the group of the lower gestational age.
The usage of the international growth standards to assess the physical development of newborn and premature children
The article substantiates the need to use in clinical practice international standards for weight, body length, and head circumference, which take into account not only the sex of the child but also his gestational age (24–42 weeks). An assessment of the physical parameters of the newborn is necessary for judging the general condition of the child and to correspond to the gestational age. The International Standards for Physical Development reflect the growth patterns of children who were predominantly breastfed for at least 4 months and received breast milk after complementary foods were introduced for up to 12 months. The International Newborn Growth Standards provide a more objective and accurate description of a child’s physical growth.
The value of non-nutritive sucking in the development of enteral feeding of a premature baby
For premature babies, the establishment of effective enteral feeding, the assessment of the newborn’s readiness for nutritional sucking, and the tactics of transition from tube feeding to breastfeeding remain serious problems. Currently, there are a limited number of methods to improve the oral-motor skills of infants. One of the main methods is the non-nutritive sucking of a pacifier or breast. Numerous studies indicate that non-nutritive sucking improves the oral-motor skills of a premature baby, but in practical healthcare, there is no single method for using this tool.
Postnatal cytomegalovirus infection in preterm infants
Postnatal cytomegalovirus infection (CMVI) in premature infants can occur due to the transmission of cytomegalovirus (CMV) through breast milk, donor blood products, or as a result of contact with infected biological fluids. Premature babies with a gestational age of less than 32 weeks and a body weight of less than 1500 g are at the highest risk of developing symptomatic postnatal CMVI. This risk increases with decreasing gestational age and birth weight. In 70–100% of CMV-seropositive women, CMV activation occurs in the milk ducts after delivery, causing the risk of CMV transmission with native breast milk. Postnatal CMVI manifests after 3 weeks of life, and in premature babies, clinical manifestations vary in severity – from asymptomatic to severe with a fatal outcome. Randomized trials have not evaluated the efficacy and safety of the therapy for infants with postnatal CMVI. In modern publications, the main approach to treatment is associated with the use of anticytomegalovirus drugs (ganciclovir/valganciclovir), and in some cases it is possible to prescribe anticytomegalovirus immunoglobulin, in case of its severe course. There are no uniform recommendations regarding preventive measures. There is no widespread mandatory use of blood products from CMV-seronegative donors in very preterm infants, and there are no unified approaches to breast milk feeding. Feeding practices for very preterm infants differ significantly, representing the use of native or pasteurized, or frozen breast milk. A promising method is the short-term pasteurization of mother’s milk, in which CMV will inactivate, and most of the nutritional, bioactive, and immunological components of milk are preserved. Considering the accumulation of data on the short-term effects of postnatal CMVI and the possible long-term health risks for children with extreme and very low birth weight, efforts to develop a treatment and prevention of this disease are justified.
Birth trauma in newborns
Birth trauma is damage to the fetus (soft tissues, bone, musculoskeletal system, internal organs, central and peripheral nervous system) by the action of adverse factors during childbirth. In some cases, birth trauma can be formed antenatally.
Birth injuries of newborns during vaginal delivery occur in 3.6% of cases and during cesarean section – 1.2%. Recently, there has been an increase in the prevalence of birth injuries due to damage to the scalp of newborns, while there has been a decrease in severe injuries leading to significant long-term consequences, disability, and death.
Birth trauma most often occurs with complicated delivery and operative delivery. However, in some cases, birth trauma is a consequence of natural forces acting during the birth act. In this regard, it is impossible to exclude birth trauma in newborns even with an uncomplicated course of pregnancy, the absence of external influences on the fetus, and instrumental delivery.
Neuroprotective therapy for newborns with hypoxic-ischemic encephalopathy: a scoping review
Hypoxic-ischemic encephalopathy (HIE) is a significant cause of neonatal mortality and morbidity. The most studied method for the treatment of HIE is therapeutic hypothermia. However, the efficacy of hypothermia varies in different regions and clinical settings. It became clear, especially after publishing the results of the HELIX trial. Therefore, there is a need to identify known clinical options and new therapies for HIE.
Objective. To explore the diversity of available neuroprotective interventions tested in clinical trials and examine emerging evidence.
Material and methods. A scoping review was undertaken using JBI guidance and reported following the PRISMA extension for Scoping Reviews (PRISMA-ScR). The search was performed in the MEDLINE, CENTRAL, CDSR, Epistemonikos, Google Scholar, and nine trial registries. Additionally, the references of all the included sources were checked. Randomized and quasi-randomized studies, registered trial protocols, systematic reviews, and registered systematic review protocols were included. The following data were extracted: the design of studies, participant characteristics, treatment methods, and primary outcomes. Data synthesis is presented as a narrative summary, together with tables and infographics.
Results. In this scoping review were included 156 sources. There were described 16 neuroprotective interventions in published studies, 19 interventions in unpublished studies, 17 interventions in published systematic reviews, and 7 interventions in the protocols of planning systematic reviews. In summary, there was a description of 24 unique neuroprotective interventions in published literature and 31 unique neuroprotective interventions in published and unpublished literature altogether.
Conclusions. There is a wide diversity of neuroprotective treatment options for HIE and methodological approaches to conducting studies all over the world.
Liver abscess in a newborn child with malformation and necrotizing enterocolitis (clinical case)
Abscess of the liver is a rare pathology of the liver in newborns. It is most common among premature babies with infectious diseases or with surgical pathology of the abdominal organs. Diagnosis can be difficult due to the lack of specific clinical and laboratory signs at this age. The main diagnostic methods are ultrasound, MRI, and CT. Performing a puncture and drainage of a liver abscess to diagnose the bacterium and treat it is not always possible in neonatal surgery. Empiric antibiotic therapy with broad-spectrum drugs is the main treatment for liver abscess in newborns but is often associated with the development of drug resistance and requires escalation of antibiotic therapy. In the above clinical observation, a liver abscess developed in the postoperative period in a newborn with bladder exstrophy and necrotizing enterocolitis. Early diagnosis of the disease based on ultrasound data and timely escalation of antibiotic therapy according to the results of microbiological studies made it possible to achieve regression of the disease without surgical intervention.
Interaction of medical personnel with legal representatives of patients: complexities of legal relations. Part 2
The article is devoted to the difficulties of establishing contact with minor patients who have a separate set of rights in the field of public health protection, as well as the specifics of providing information about the health status of minor patients.
Palliative status in paediatrics. Ways of communication with depressed parents
This article describe communication features with depressed parents of a child with palliative status.
Neurally adjusted ventilatory assist in infants: A review article
Neurally adjusted ventilatory assist (NAVA) and non-invasive (NIV)-NAVA are innovative modes of synchronized and proportional respiratory support. They can synchronize with the patients’ breathing and promote patient comfort. Both techniques are increasingly being used these years, however experience with their use in newborns and premature infants in Taiwan is relatively few. Because increasing evidence supports the use of NAVA and NIV-NAVA in newborns and premature infants requiring respiratory assist to achieve better synchrony, the aim of this article is to discuss whether NAVA can provide better synchronization and comfort for ventilated newborns and premature babies. In a review of recent literature, we found that NAVA and NIV-NAVA appear to be superior to conventional invasive and non-invasive ventilation. Nevertheless, some of the benefits are controversial. For example, treatment failure in premature infants is common due to insufficient triggering of electrical activity of the diaphragm (EAdi) and frequent apnea, highlighting the differences between premature infants and adults in settings and titration. Further, we suggest how to adjust the settings of NAVA and NIV-NAVA in premature infants to reduce clinical adverse events and extubation failure. In addition to assist in the use of NAVA, EAdi can also serve as a continuous and real-time monitor of vital signs, assisting physicians in the administration of sedatives, evaluation of successful extubation, and as a reference for the patient’s respiratory condition during special procedures.