Faculty Bibliography

Objective To determine cerebral regional tissue oxygen saturation (CrSO2), renal regional tissue oxygen saturation (RrSO2), and splanchnic regional tissue oxygen saturation (SrSO2) values in healthy term infants.Study Design Near-infrared spectroscopy was used to simultaneously measure CrSO2, RrSO2, and SrSO2 continuously for a 1-hour period on the first and second days of life.Results A total of 41 subjects were monitored out of which complete data were available for 38 subjects. Mean CrSO2 was 78.2 +/- 7.9% on first day; 78.3 +/- 6.1% on second day (p = 0.95). Mean RrSO2 was 92.1 +/- 5.3% on first day; 88.9 +/- 5.9% on second day (p < 0.01). Mean SrSO2 was 69.9 +/- 12.1% on first day and 75.3 +/- 12.4% on second day (p = 0.02).Conclusion There appears to be consistency in rSO2 values in healthy newborns. CrSO2 was similar on both days. Differences observed in RrSO2 and SrSO2 between days may represent a shift in somatic blood flow distribution taking place during the first day of life.

Abstract Objective: Family-centered care (FCC), which includes involving parents in conversations about medical management, is increasingly employed in the neonatal intensive care unit (NICU). Our aim was to determine which care decisions are discussed by neonatologists with families most frequently and the percentage of clinicians influenced by such conversations. Methods: Anonymous web-based survey provided to 2137 neonatologists assessing information sharing and parental involvement. Results: Thousand and two neonatologists responded in which 893 fully completed the surveys. 88% practice FCC. Topics most frequently discussed with parents were blood transfusion, steroids for lung disease and patent ductus arteriosus (PDA) surgery, each being reported and discussed by more than 90% of respondents. Many therapies, including aminoglycoisdes, total parenteral nutrition, and phototherapy, were discussed with parents by far fewer clinicians. Additionally, parents had most influence on clinicians in two categories, blood transfusion and steroids, with more than 70% reporting that their practice was influenced by parental opinion if communicated. For some topics, such as PDA surgery and central line placement, conversations impacted few clinicians. Conclusions: FCC appears to have an impact on NICU clinical decision-making processes, some more than others. Further investigation in this area may provide information on how to best communicate with families and run effective, efficient FCC rounds.

PURPOSE: The splanchnic-cerebral oxygenation ratio (SCOR) is a measurement comparing regional tissue oxygen saturation of splanchnic organs and brain tissue. SCOR has been previously proposed as a marker of clinical conditions associated with gut ischemia. Our goal was to determine SCOR values in healthy neonates in their first and second days of life. METHODS: Prospective observational study measuring SCOR in term neonates in the nursery using near-infrared spectroscopy (NIRS). RESULTS: Forty-five subjects with a mean gestational age of 39.4 +/- 1.3 weeks were included. Mean SCOR on the first day was 0.90 +/- 0.16 and 0.97 +/- 0.16 on the second day, p = 0.02 (n = 45). No correlation was found between SCOR and gestational age; however, we did find a positive correlation between hour of life and SCOR values (r = 0.28, r (2) = 0.08, p < 0.01, two tails); SCOR appears to stabilize by 36 h. CONCLUSIONS: Our findings demonstrate SCOR values in healthy neonates consistent with those previously theorized and help to validate it as a diagnostic measure. In addition, we have demonstrated that SCOR values may normally be lower in infants during their first days of life, and this information may be helpful to clinicians using NIRS as a diagnostic tool.

Objective To determine etiology of neonatal intensive care unit (NICU) admission and acute morbidities in late preterm (LPT) neonates.Methods Neonates admitted at New York University Langone Medical Center's NICU were grouped as follows: period 1: all LPT neonates with gestational age between 340/7 and 366/7 weeks and born between January 2006 and June 2007; period 2: all term neonates born between January 2007 and June 2008. Neonatal and maternal data were collected from both the groups and compared.Results Thirty-three percent of LPT births were admitted to the NICU, compared with 7% of term births (p < 0.05). LPT neonates had an increased incidence of low birth weight, hypoglycemia, hypothermia, and hyperbilirubinemia as an admission diagnosis (p < 0.001). The overall incidence of respiratory distress syndrome (RDS) was 9%, 4%, 3%, 0.7%, 0.2% and 0% in 34-week, 35-week, 36-week, 37-week, 38- to 39-week, and 40-week gestational age neonates (p < 0. 001).There was an increased incidence of RDS and persistent pulmonary hypertension, along with an increased need for surfactant replacement therapy, continuous positive airway pressure, and ventilator support in the LPT group when compared with the term neonates (p < 0.001).Conclusions LPT neonates are at increased risk for hypothermia, hypoglycemia, hyperbilirubinemia, and respiratory morbidity requiring increased respiratory support when compared with term neonates.

BACKGROUND: Premature neonates often receive red blood cell (RBC) transfusions to improve tissue perfusion and oxygen delivery. Clinical and laboratory indicators used to guide transfusion therapy are inadequate to determine physiologic need with high predictability and transfusions frequently do not result in clinical improvement. The splanchnic-cerebral oxygenation ratio (SCOR) provides insight into overall tissue oxygen sufficiency and can be determined using near-infrared spectroscopy (NIRS). Our aim was to assess the usefulness of SCOR as a marker for transfusion need in preterm infants. STUDY DESIGN AND METHODS: This study was a prospective observational pilot study utilizing NIRS to analyze the SCOR in symptomatic anemic premature neonates receiving RBC transfusions and nontransfused asymptomatic premature neonates with similarly low hemoglobin (Hb) levels. Subject clinical status was determined based on frequency of apnea, bradycardia, pulse-oximetry desaturation events, heart rate, respiratory support, and feeding tolerance. We then assessed for any difference between baseline (pretransfusion) SCOR of 1) symptomatic subjects who improved after transfusion, 2) symptomatic subjects who did not improve, and 3) asymptomatic subjects. RESULTS: The study included 52 subjects (34 transfused, 18 asymptomatic): mean birth weight was 1164 g, mean gestational age was 28.6 weeks, and mean Hb level was 9.0 g/dL. Of 34 transfused subjects, 19 improved (56%). Mean baseline SCOR values were lower in neonates who improved with transfusion, 0.61 +/- 0.22, when compared to those without improvement, 0.75 +/- 0.17, and asymptomatic neonates, 0.77 +/- 0.16 (p = 0.03). Infants with a low baseline SCOR (</=0.73) were more likely to improve after transfusion (likelihood ratio, 2.8; 95% confidence interval, 1.1-6.7). CONCLUSION: SCOR may help identify premature infants who will benefit from RBC transfusion

Exogenous surfactants commonly used to treat a variety of neonatal respiratory diseases are derived from either bovine or porcine sources. The extent to which parents are aware of this fact is currently unclear, as is the impact that this may have on familial cultural or religious belief systems. Our primary aims were to assess U.S. neonatologists' utilization of bovine and porcine surfactant preparations, their views on parent disclosure pertaining to the particular animal origins of exogenous surfactant therapy, and their willingness to provide alternative surfactant preparations based on parental religious preferences. An anonymous Web-based survey was provided to 2,137 neonatologists. There was a 46.9% response rate. We found that 63.4% of respondents used only bovine-derived surfactants, 14.9% exclusively used porcine-based surfactants, and 21.7% used combinations. While 74.3% of neonatologists discussed surfactant use with parents, only 2.2% always discussed its animal origins. When asked, 47.9% of neonatologists believed parental preference for religious reasons would not impact their surfactant choice, 19.4% reported it would affect their choice, and 32.7% said it maybe would. Access to only one surfactant was a major barrier to communication. Results showed that many neonatologists may be open to being inclusive of parents regarding surfactant therapy. Carrying different surfactant types on hospital pharmacy formularies and encouraging physician–parent communication may achieve a more family-centered approach to neonatal care.

Prematurity is defined as birth before 37 weeks of gestation and is the major determinant of morbidity and mortality in newborns. The gestational ages known as near term or late preterm represent about 75% of preterm births and are the fastest growing subgroups of premature infants. These infants range in gestational age from 34 0/7 to 36 6/7 weeks and are at greater risk of morbidity, such as respiratory complications, temperature instability, hypoglycemia, kernicterus, feeding problems, neonatal intensive care unit admissions, and adverse neurological sequelae when compared with term infants. Long-term neurological and school-age outcomes of late preterm infants are concerns of major public health importance because even a minor increase in the rate of neurological disability and scholastic failure in this group can have a huge impact on the health care and educational systems. There is an urgent need to educate health care providers and parents about the vulnerability of late preterm infants, who are in need of diligent monitoring and care during the initial hospital stay and a comprehensive follow-up plan for post neonatal and long-term evaluations. Clinicians involved in the day-to-day care of late preterm infants, as well as those developing guidelines and recommendations, would benefit from having a clear understanding of the potential differences in risks faced by these infants, compared with their more mature counterparts

Preterm infants often receive multiple packed red blood cell (PRBC) transfusions that are intended to improve tissue oxygen levels. Near-infrared spectroscopy (NIRS) monitors regional cerebral tissue oxygen saturation (CrSO(2)) and splanchnic tissue oxygen saturation (SrSO(2)). Before such technology can be employed in neonatal transfusion management, it must first be established that transfusions result in an increase in tissue oxygen saturation. This prospective, observational study used NIRS to determine if PRBC transfusions increase the CrSO(2) and SrSO(2) of symptomatic anemic premature neonates. CrSO(2) and SrSO(2) values were compared for 20-minute duration immediately before, during, immediately after, and 12 hours after transfusion. As a secondary objective, CrSO(2) and SrSO(2) values were correlated with hemoglobin (Hgb) levels. One-way analysis of variance and Pearson correlation statistical tests were used for analysis. A statistically significant increase in CrSO(2) and SrSO(2) values were observed after transfusion in the 30 subjects included (CrSO(2): 62.8 +/- 1.6, 65.6 +/- 1.7, 68.0 +/- 1.3, 67.6 +/- 1.4, P < 0.001 and SrSO(2): 41.3 +/- 2.2, 46.7 +/- 3.0, 52.1 +/- 2.8, 48.2 +/- 2.5, P < 0.001). No correlation was found between CrSO(2) or SrSO(2) and Hgb values. NIRS identified increases in CrSO(2) and SrSO(2) in preterm neonates after PRBC transfusions and has the potential to become incorporated into neonatal transfusion management paradigms