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Feeding Problems and Long-Term Outcomes in Preterm Infants-A Systematic Approach to Evaluation and Management

Kamity, Ranjith; Kapavarapu, Prasanna K; Chandel, Amit
Preterm infants are known to have long-term healthcare needs. With advances in neonatal medical care, younger and more preterm infants are surviving, placing a subset of the general population at risk of long-term healthcare needs. Oral feeding problems in this population often play a substantial yet under-appreciated role. Oral feeding competency in preterm infants is deemed an essential requirement for hospital discharge. Despite achieving discharge readiness, feeding problems persist into childhood and can have a residual impact into adulthood. The early diagnosis and management of feeding problems are essential requisites to mitigate any potential long-term challenges in preterm-born adults. This review provides an overview of the physiology of swallowing and oral feeding skills, disruptions to oral feeding in preterm infants, the outcomes of preterm infants with feeding problems, and an algorithmic approach to the evaluation and management of neonatal feeding problems.
PMID: 34943354
ISSN: 2227-9067
CID: 5109082

A quality improvement initiative to reduce hypothermia in a Baby-Friendly nursery - our story of algorithms, K-cards, and Key cards

Joseph, Noel; Dror, Tal; Takhalova, Eva; Kamity, Ranjith; Kothari, Ulka; Connelly, Alena; Hanna, Nazeeh; Nayak, Amrita
BACKGROUND:Baby-Friendly hospitals encourage rooming-in newborns with mothers. In our institution, we noticed increased incidence of hypothermia following Baby-Friendly designation. We aimed to reduce the incidence of hypothermia in the mother-baby-unit to <15% and to decrease the rate of isolated hypothermia admissions to the neonatal intensive care unit (NICU) by 20% over two years. METHODS:After a retrospective review of newborns ≥35 weeks gestation in the mother-baby-unit with hypothermia, we implemented multiple interventions such as nursing education, hypothermia algorithm, Kamishibai cards, and Key cards. RESULTS:Hypothermia incidence in the mother-baby-unit decreased from 20.9 to 14.5% (p < 0.001) and infants requiring NICU admission decreased by 71% (p < 0.001) following all interventions. Apart from nursing education, all interventions led to significant reductions in both outcomes from baseline. CONCLUSION/CONCLUSIONS:Instituting a hypothermia algorithm and utilizing K-cards and Key cards reduces the incidence of hypothermia in the mother-baby-unit and NICU admissions for isolated hypothermia.
PMID: 33986475
ISSN: 1476-5543
CID: 4867772

From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

Kamity, Ranjith; Grella, Melissa; Kim, Maureen L; Akerman, Meredith; Quintos-Alagheband, Maria Lyn
BACKGROUND:Central line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains elusive. We identified frontline and family engagement as key drivers for this initiative. The baseline CLABSI rate for all our paediatric inpatient units (January 2016-January 2017) was 1.71/1000 central line days with maintenance bundle compliance at 87.9% (monthly range 44%-100%). OBJECTIVE:To reduce CLABSI by increasing central line maintenance bundle compliance to greater than 90% using kamishibai card (K-card) audits and family 'key card' education. METHODS:We transitioned our central line maintenance bundle audits from checklists to directly observed K-card audits. K-cards list the central line maintenance bundle elements to be reviewed with frontline staff. Key cards are cue cards developed using a plain-language summary of CLABSI K-cards and used by frontline staff to educate families. Key cards were distributed to families of children with central lines to simultaneously engage patients, families and frontline staff after a successful implementation of the K-card audit process. A survey was used to obtain feedback from families. RESULTS:In the postintervention period (February 2017-December 2019), our CLABSI rate was 0.63/1000 central line days, and maintenance bundle compliance improved to 97.1% (monthly range 86%-100%, p<0.001). Of the 45 family surveys distributed, 20 (44%) were returned. Nineteen respondents (95%) reported being extremely satisfied with the key card programme and provided positive comments. CONCLUSION/CONCLUSIONS:Combining the key card programme with K-card audits was associated with improved maintenance bundle compliance and a reduction in CLABSI. This programme has the potential for use in multiple healthcare improvement initiatives.
PMID: 32636211
ISSN: 2044-5423
CID: 4517962

Pneumothorax in Neonates Born to COVID-19-Positive Mothers: Fact or Fortuity? [Case Report]

Kamity, Ranjith; Nayak, Amrita; Dumpa, Vikramaditya
Neonates born to mothers with coronavirus disease 2019 (COVID-19) have been largely asymptomatic based on initial reports. All neonates born to mothers with COVID-19 have tested negative for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in our institution (published data as of April 12, 2020). As novel presentations of COVID-19, such as multisystem inflammatory syndrome in children are being increasingly reported, we raise the possibility of increased incidence of pneumothorax in neonates born to SARS-CoV-2-positive mothers. Two recently described neonates with COVID-19 infection were noted to have pneumothoraces. We describe two SARS-CoV-2-negative neonates born to COVID-19-positive mothers at 38 and 33 weeks, respectively, admitted to our neonatal intensive care unit for respiratory distress and subsequently developed pneumothoraces. As diverse clinical presentations in various age groups are being described, it becomes difficult to differentiate the increased incidence of complications related to an underlying illness, from COVID-19-related illness. It remains to be seen if neonates with in utero exposure to SARS-CoV-2 have an elevated inflammatory response with pneumonitis and exaggerated lung disease, similar to adult COVID-19 patients, due to in utero exposure.
PMID: 33767908
ISSN: 2157-6998
CID: 4822962

The effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants

Dumpa, Vikramaditya; Kamity, Ranjith; Ferrara, Louisa; Akerman, Meredith; Hanna, Nazeeh
OBJECTIVE:To determine whether delaying oral feeding until coming off NCPAP will alter feeding and respiratory-related morbidities in preterm infants. DESIGN/METHODS:In this retrospective pre-post analysis, outcomes were compared in two preterm infant groups (≤32 weeks gestation). Infants in Group 1 were orally fed while on NCPAP, while infants in Group 2 were only allowed oral feedings after ceasing NCPAP. RESULTS:Although infants in Group 2 started feeds at a later postmenstrual age (PMA), they reached full oral feeding at a similar PMA compared with Group 1. Interestingly, there was a positive correlation between the duration of oral feeding while on NCPAP and the time spent on respiratory support in Group 1. CONCLUSIONS:Delayed oral feeding until ceasing NCPAP did not contribute to feeding-related morbidities. We recommend caution when initiating oral feedings in preterm infants on NCPAP without evaluating the safety of the infants and their readiness for oral feedings.
PMID: 32086439
ISSN: 1476-5543
CID: 4322902

Neonatal Coronavirus 2019 (COVID-19) Infection: A Case Report and Review of Literature [Case Report]

Dumpa, Vikramaditya; Kamity, Ranjith; Vinci, Alexandra N; Noyola, Estela; Noor, Asif
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a global pandemic affecting 213 countries as of April 26, 2020. Although this disease is affecting all age groups, infants and children seem to be at a lower risk of severe infection, for reasons unknown at this time. We report a case of neonatal infection in New York, United States, and provide a review of the published cases. A 22-day-old, previously healthy, full-term neonate was hospitalized after presenting with a one-day history of fever and poor feeding. Routine neonatal sepsis evaluation was negative. SARS-CoV-2 polymerase chain reaction (PCR) testing was obtained, given rampant community transmission, which returned positive. There were no other laboratory or radiographic abnormalities. The infant recovered completely and was discharged home in two days once his feeding improved. The family was advised to self-quarantine to prevent the transmission of COVID-19. We believe that the mode of transmission was horizontal spread from his caregivers. This case highlights the milder presentation of COVID-19 in otherwise healthy, full-term neonates. COVID-19 must be considered in the evaluation of a febrile infant. Infants and children may play an important role in the transmission of COVID-19 in the community. Hence, with an understanding of the transmission patterns, parents and caregivers would be better equipped to limit the spread of the virus and protect the more vulnerable population.
PMID: 32432015
ISSN: 2168-8184
CID: 4444292

First Case of Ewingella americana Meningitis in a Term Newborn: A Rare but Real Pathogen [Case Report]

Meisler, Sarah; Kamity, Ranjith; Noor, Asif; Krilov, Leonard; Tiozzo, Caterina
Ewingella americana is a Gram-negative, catalase positive and anaerobic enterobacterium first described in 1983. Infections caused by this pathogen, such as bacteremia and pneumonia, are extremely rare and primarily occur in patients with underlying pathologies or immunosuppression. There is still a debate as to whether Ewingella americana is a real pathogen or if it can be considered an opportunistic infectious agent. We report the first documented case of Ewingella americana meningitis in literature and the first case of this pathogen causing infection in a newborn. Case presentation: A term newborn male was born via spontaneous vaginal delivery to a Gravida 2 Para 0, 28 year old woman with negative prenatal screening tests with a birth weight of 4.70 kilograms and Apgar scores of 9 and 9 at 1 and 5 minutes respectively. Rupture of membranes was 27 hours prior to delivery. Infant was noted to be febrile to 101°F at birth, so infant was admitted in the neonatal intensive care unit and started empirically on ampicillin and gentamycin. Cerebrospinal fluid (CSF) drawn due to irritability on day of life 1 presented normal cell and protein count but grew Gram negative rods after 2 days, identified subsequently as Ewingella americana; repeat CSF analysis done at 6 days of life showed pleocytosis. Brain MRI performed at 2 weeks of life showed leptomeningitis. The infant was treated with ceftazidime for 21 days from the first negative CSF culture. He has since followed up with the neurologist and infectious disease specialist. He had a normal electroencephalogram (EEG) and is meeting all developmental milestones at the 24 months of age follow up visit. Conclusion: Our case highlights that Ewingella americana can cause serious invasive infections such as meningitis in the neonatal period with minimal symptomatology. Antibiotic treatment in the neonatal period can present challenges due to the Ewingella americana's variable sensitivity. The role of these emerging low virulence organisms in causing infections has to be further elucidated, especially in vulnerable patients such as newborns.
PMID: 32596194
ISSN: 2296-2360
CID: 4503852

First Case ofEwingella americanaMeningitis in a Term Newborn: ARarebutRealPathogen

Meisler, Sarah; Kamity, Ranjith; Noor, Asif; Krilov, Leonard; Tiozzo, Caterina
ISSN: 2296-2360
CID: 4526142

Simultaneous Videofluoroscopy and Endoscopy for Dysphagia Evaluation in Preterm Infants-A Pilot Study

Kamity, Ranjith; Ferrara, Louisa; Dumpa, Vikramaditya; Reynolds, Jenny; Islam, Shahidul; Hanna, Nazeeh
Introduction: The assessment of dysphagia in preterm infants has been limited to clinical bedside evaluation followed by videofluoroscopic swallow study (VFSS) in selected patients. Recently, fiberoptic endoscopic evaluation of swallowing (FEES) is being described more in literature for preterm infants. However, it is unclear if one test has a better diagnostic utility than the other in this population. Furthermore, it is also unclear if performing FEES and VFSS simultaneously will increase the sensitivity and specificity of detecting dysphagia compared to either test performed independently. Objectives: The primary objective of this study is to evaluate the feasibility of performing VFSS and FEES simultaneously in preterm infants. Our secondary objective is to determine whether simultaneously performed VFSS-FEES improves the diagnostic ability in detecting dysphagia in preterm infants compared to either test done separately. Methods: In this pilot study, we describe the process involved in performing simultaneous VFSS-FEES in five preterm infants (postmenstrual age ≥36 weeks) with dysphagia. A total of 26 linked VFSS-FEES swallows were analyzed, where the same bolus during the same swallow was compared using simultaneous fluoroscopy and endoscopy. The sensitivity and specificity of detecting penetration and aspiration were evaluated in simultaneous VFSS-FEES compared with each test done independently. Results: Our results demonstrated that performing simultaneous VFSS-FEES is feasible in preterm infants with dysphagia. All patients tolerated the procedures well without any complications. Our pilot study in these five symptomatic preterm infants demonstrated a low incidence of aspiration but a high incidence of penetration. Simultaneous VFSS-FEES (26 linked swallows) improved the ability to detect penetration compared to each test done separately. Conclusion: To our knowledge, this study is the first to demonstrate the feasibility of performing VFSS and FEES simultaneously in symptomatic preterm infants with dysphagia resulting in potentially higher diagnostic yield than either procedure done separately.
PMID: 33042904
ISSN: 2296-2360
CID: 4632422

Chlorhexidine baths in preterm infants - are we there yet? [Letter]

Kamity, Ranjith; Hanna, Nazeeh
PMID: 30971766
ISSN: 1476-5543
CID: 3854082