A high proportion of neonates receive unwarranted antibiotics
Up to 89% of neonates were given antibiotics in NICUs; most of them without infections and clear diagnoses.
Current literature does not elaborate the impact of high consumption of antibiotics in Indian neonatal intensive care units (NICUs). In the context of India's varied economic and geographic constraints and challenges, the impact of antibiotics has remained under-studied. Consequently, antibiotic abuse has given rise to compromised healthcare. One of the primary reasons could be the lack of patient's and prescriber's knowledge and awareness, and the absence of local prescribing guidelines.
This study conducted a comparative analysis of antibiotic prescribing practices in the NICUs of two, tertiary-level hospitals in India.
This was a cross-sectional study spanning three years. It was conducted from 2008-2011 in the NICUs of a teaching and non-teaching hospital in the Ujjain district of Madhya Pradesh. The researchers followed the methods recommended by the WHO to analyse the data.
89% (1,399/1,572) of the 1,789 inpatients in the non-teaching hospital and 71% (154/217) in the teaching hospital were prescribed antibiotics. 123 patients in total died. All the antibiotics were prescribed on a consistent basis, with cephalosporins and aminoglycosides being the most commonly prescribed sub-classes. Fixed dose combinations of cephalosporins were commonly prescribed in the non-teaching hospital. 30% of the patients were diagnosed with neonatal sepsis of which93% were prescribed antibiotics. Additionally, 40% of neonates in the non-teaching hospital were admitted for observation and were frequently prescribed antibiotics.
To conclude, the study observed that these two Indian NICUs prescribed antibiotics for non-infectious or uncertain diagnoses along with prescribing combinations of broad-spectrum antibiotics. If such practices prevail, the global risk of treatment failure, neonatal mortality rates, and antibiotic resistance may increase substantially.
References
Hauge C, Lundborg CS, Mandaliya J, et al. Up to 89% of neonates received antibiotics in cross-sectional Indian study including those with no infections and unclear diagnoses. Acta Paediatr. 2017 May 26. doi: 10.1111/apa.13935.
Prolonged infusion of meropenem in neonates with LOS is more effective
Background: Gram-negative bacteria are associated with significant morbidity and mortality in preterm and term newborns. Meropenem has widespread efficacy and often allows for monotherapy in this group. Prolonged infusion instead of infusion over 30 minutes has been suggested to result in higher microbiologic efficacy.
Objective: To compare the clinical and microbiologic efficacy and safety of prolonged infusions versus conventional dosing of meropenem in neonates with Gram negative late onset sepsis (GN-LOS).
Methods: A prospective, randomized, clinical trial was conducted in neonates with GN-LOS admitted to NICU, Mansoura University Children's Hospital between August 2013 to June 2015. Patients were randomly assigned to receive either intravenous infusion of merpenem over 4 hours (Infusion group) vs 30 minutes (Conventional group) at a dosing regimen of 20 mg/kg/dose every 8 hours and 40 mg/kg/dose every 8 hours in meningitis and Pseudomonas infection.
Primary outcomes: Clinical and microbiologic success in eradication of infection.
Secondary outcomes: Neonatal mortality, meropenem related (MR)-duration of mechanical ventilation, MR-length of NICU stay, total length of NICU stay, duration of respiratory support (RS), duration of mechanical ventilation (MV), MR- duration of inotropes, and adverse effects.
Results: A total of 102 infants (51 in each group) were recruited. The infusion group demonstrated a significantly higher rate of clinical improvement and microbiological eradication at 7 days after starting meropenem therapy compared to the conventional group. Mortality and duration of RS were significantly less in the infusion group compared with conventional group. Acute kidney injury (AKI) after meropenem treatment was significantly less in the infusion group compared with the conventional group.
Conclusions: Prolonged infusion of meropenem in neonates with gram-negative (GN)-LOS is associated with higher clinical improvement, microbiologic eradication, less neonatal mortality, shorter duration RS and less AKI compared with the conventional strategy.
(Shabaan AE, et al. Pediatr Infect Dis J. 2017 Apr;36(4):358-363).
Cooling Treatment Reduces Epilepsy in Children
Cooling babies deprived of oxygen at birth can reduce the number of children who develop epilepsy later in childhood, according to a study published in the journal Epilepsia.
It is known that newborn babies who suffer perinatal asphyxia may develop permanent brain injury resulting in cerebral palsy or other conditions, like epilepsy. Until recently, 20% to 30% of these patients would develop epilepsy and many need regular antiepileptic treatment.
Marianne Thoresen, Bristol Medical School, Bristol, United Kingdom, and colleagues followed 165 infants who received therapeutic hypothermia due to lack of oxygen during birth. Children were followed for up to 8 years. The researchers examined how many babies were diagnosed with epilepsy and how many are on regular antiepileptic drug treatment at age 2 years and years 4 to 8.
The research found reduced epilepsy rates in babies born after 2007 who received the cooling treatment compared with before cooling treatment was introduced. At 2 years, 7% of the children had an epilepsy diagnosis; however, only 2% were on regular antiepileptic drugs.
The study showed that more children had epilepsy when they reached the age of 4 to 8 years, with 7% on regular medication. However, these are very low numbers needing antiepileptic treatment compared with before cooling treatment was introduced as standard of care.
Before therapeutic hypothermia was introduced, poor outcomes -- defined as death or moderate or severe disability -- was around 66% (32% death and 34% surviving with disability).
In this cohort born after 2007, the number of children with poor outcome is lower at 34% (11% death and 23% survived with disability). Also, the severity of cerebral palsy is milder and 7 out of 10 are able to walk. Even if a lesser severity of perinatal asphyxia is accounted for, cooling therapy has increased the number of healthy survivors and there are very few children with epilepsy needing drug treatment.
"Even if we account for a lesser severity of perinatal asphyxia, our research has shown that therapeutic hypothermia reduces the number of children who develop epilepsy later in childhood," said Dr. Thoresen. "Cooling treatment also reduces the number and severity of cerebral palsy and increases the number of patients who survive normally."
(Reference: Liu X, et al. Epilepsia. 2017 Nov;58(11):1902-1911).
Corticosteroid treatment increases survival of preterm infants within hours
A new study by researchers at Korolinska Institutet and EPICE project suggests that survival and health gains for every preterm infants may occur within hours!
'Of the estimated 6.3 million deaths of children under the age of five in 2013, complications from pre-term births accounted for nearly 1.1 million deaths.
The effects of corticosteroid treatments on pregnant women facing preterm delivery to prevent infant death and morbidity have been thought to develop gradually over days. However, a new study by researchers at Karolinska Institutet and colleagues in the European EPICE project - coordinated by Inserm, Paris - suggests that survival and health gains for very preterm infants may occur within hours.
Hundreds of thousands of pregnant women in Europe deliver preterm every year. Even if survival nowadays is the most probable outcome, preterm birth is still one of the major causes of death in children under the age of 5. To prepare the foetus for breathing air and increase chances of survival after birth, corticosteroid treatment is given to pregnant women at risk of preterm delivery. So far, the protective effect of corticosteroids before birth has been thought to develop gradually over days. A large European study - published in JAMA Pediatrics - provides new knowledge, however, indicating an immediate effect.
Our study finds that antenatal (before birth) corticosteroids given to pregnant women only hours before delivery were associated with a survival advantage for their infants", says Mikael Norman, lead author, neonatologist and professor at Karolinska Institutet's Department of Clinical Science, Intervention and Technology in Stockholm, Sweden.
Mikael Norman and colleagues on the EPICE (Effective Perinatal Intensive Care in Europe) research project have studied outcomes in over 4,500 very preterm infants, born at 24 to 31 weeks of gestation (excluding multiple pregnancies and severe congenital malformations) in 11 countries across Europe. In this cohort, 15 per cent of the pregnant women were not exposed to antenatal corticosteroids. 21 per cent of the unexposed infants died after birth.
Infants born already 3 hours after corticosteroid administration to the mother had significantly lower mortality than those not exposed to the treatment, and corticosteroid administration 6 to 12 hours before birth was associated with halved risks of infant death.
Given the current concept of a slow effect, pregnant women at immediate risk of preterm delivery may not receive corticosteroid treatment because it is considered futile", says Dr Norman. "Also our results can provide reassurance for clinicians or parents in situations where it is not possible to wait a day or two to reach the full effect of corticosteroid treatment because of the need for action to reduce or stop ongoing morbidity in the pregnant woman and her foetus", he continues.
In the study, antenatal corticosteroid treatment was also associated with a lower risk of severe neonatal morbidity such as bleedings in the brain. This reduction in the risk was associated with longer administration-to-birth intervals.
Our findings challenge current beliefs that very short exposures to antenatal steroids before delivery have no effect, and suggest that encouraging the administration of antenatal corticosteroids to pregnant women when delivery is very imminent could result in substantial survival and health gains for very preterm infants" says Jennifer Zeitlin, principal investigator of the EPICE study and researcher at Inserm (French National Institute of Health and Medical Research), Paris, France.
The research received funding from the European Union's Seventh Framework Program, the French Institute of Public Health Research/Institute of Public Health and its partners, the National Research Agency through the French Equipex Program of Investments in the Future, the PremUp Foundation in France, the Polish Ministry of Science and Higher Education, regional agreement on medical training and clinical research (ALF) between Stockholm County Council and Karolinska Institutet, and Karolinska University Hospital in Sweden.
Higher Dose of Vitamin D Increases Bone Density in Premature Babies
A study published in in PLoS ONE found that if the standard supplementation of 400 IUs of vitamin D is increased to 800 IUs daily there are reductions in the number of premature and preterm babies with extremely low bone density.
Physicians have been prescribing vitamin D in premature and preterm infants in neonatal intensive care units (NICU) to prevent rickets. In spite of this, a sizeable number of infants still develop rickets, said Ann Anderson Berry, MD, University of Nebraska Medical Center, Omaha, Nebraska.
She said current recommendations of vitamin D supplementation for preterm infants span a wide range of doses, even among major medical groups such as the American Academy of Pediatrics, the Institute of Medicine, and the Endocrine Society. And response to vitamin D supplementation and impact on outcomes in preterm infants is not well understood, she said.
The study provided more evidence in regards to bone health and ideal supplementation. The objective was to evaluate changes in vitamin D in the blood over 4 weeks in 2 groups of premature infants born between 24 to 32 weeks gestation. The researchers studied 32 infants receiving 400 or 800 IU/day of vitamin D.
The researchers saw an improvement in bone density and vitamin D levels in the blood at 4 weeks. They also saw improvement in growth that significantly decreased the risk of infants having very low bone density.
"We are hopeful that neonatologists will consider giving preterm infants 800 IUs," said Anderson Berry, MD, University of Nebraska Medical Center. "We know that even with standard vitamin D dosing, we were still seeing a fair number of preterm infants who suffered from impaired bone health. This is another form of NICU therapy that can help decrease that risk."
The study is one of the first to look at higher dosing of vitamin D in premature infants. Information will be incorporated as a recommended practice for health professionals.
(Reference: https://doi.org/10.1371/journal.pone.0185950)
Newborns Often Take Weeks to Return to Birth Weight
Even though doctors often tell parents that newborns will regain weight lost after birth within a week or two, many infants take much longer to achieve this milestone, a U.S. study suggests.
Nearly all newborns lose weight during the first days after birth, regardless of whether they are breastfed or formula fed. Many doctors expect babies to regain those lost ounces and surpass their birth weight within 10 to 14 days.
But by 14 days, 14 percent of babies born vaginally and 24 percent of infants delivered via cesarean section surgeries didn't return to their birth weight, the study of almost 144,000 newborns found.
"It is normal for newborns to lose a significant amount of weight in the first 1 to 3 days after delivery due to both urinating excess fluid and limited intake," said lead study author Dr. Ian Paul, a researcher at Penn State College of Medicine in Hershey, Pennsylvania.
C-section babies may lose more weight after birth because they come into the world more hydrated than other infants due to intravenous fluids given to women prior to and during the surgery, Paul added by email.
"Upon birth, the newborn weighs relatively more after a C-section and has therefore more fluid to urinate out resulting in greater relative weight loss," Paul said.
The American Academy of Pediatrics suggests that most newborns should surpass their birth weight by the time they are 7 to 10 days old, with weekly gains of 4 to 7 ounces for the first several months of life.
For the current study, researchers examined data on babies delivered at Kaiser Permanente Northern California Medical Centers between 2009 and 2013. All of the babies were born at or near full term and had a healthy weight at birth.
Half of the newborns were at or above their birth weight at 9 and 10 days after vaginal and cesarean deliveries, respectively, researchers report in Pediatrics, online November 9th.
After 21 days, however, 5 percent of babies with vaginal births and 8 percent of infants with cesarean deliveries still weren't back to their birth weights, the study also found.
One limitation of the study is that researchers lacked data on how infants were fed once they went home from the hospital, which can influence the amount of weight they gain, the authors note.
Even so, the findings should be reassuring to parents of babies that don't return to their birth weight within 7 to 10 days, said Tessa Crume, a researcher at the Colorado School of Public Health in Aurora who wasn't involved in the study.
In particular, women who breastfeed should take these results as a reason not to panic, Crume added by email.
"For families who want to breastfeed, this is important reassurance that slower regain of infant birth weight does not signal inadequate maternal breast milk supply, but rather a normal newborn growth pattern," Crume said.
To increase the odds that breastfed babies will gain enough weight, though, women should focus on eating a healthy diet high in fruits, vegetables and healthy fats while they are pregnant and breastfeeding, Crume added by email.
Women can also increase their milk production by starting to breastfeed as soon as possible after delivery or by pumping breast milk, said Dr. Sarbattama Sen, a researcher at Harvard University and Brigham and Women's Hospital in Boston.
While parents shouldn't necessarily worry when babies don't regain their birth weight quickly, they should still watch for potential signs of trouble such as dehydration, inactivity, low urine or stool output and jaundice, Sen, who wasn't involved in the study, added by email.
"Parents whose infants have not regained birth weight by 7-10 days should continue to be closely monitored by healthcare providers," Sen said.
As long as babies get these checkups, slow and steady weight gain - even if it's slower than current guidelines suggest - may be just fine, said Dr. Charles Wood of the University of North Carolina at Chapel Hill.
"This study will help clinicians and parents reframe expectations around adequate weight gain in early life," Wood, who wasn't involved in the study, said by email.
(SOURCE: http://bit.ly/2gfG4FZ)