AimsInfants born extremely prematurely and who develop bronchopulmonary dysplasia (BPD) may require respiratory support for many months, including when they could be able to take oral feeds (usually ...34 weeks postmenstrual age (PMA)). Our aim was to test the hypothesis that full oral feeding in infants with BPD would be achieved earlier in those supported by humidified high flow nasal cannula (HHFNC) rather than nCPAP.MethodsData were compared from infants born prior to 33 weeks of gestational age between 2011 to 2013, who were extubated onto and supported by nCPAP until they required only low flow oxygen (nCPAP group) to those born between 2013 to 2015 who were extubated onto nCPAP and then transferred to HHFNC if they continued to require nCPAP for more than two weeks and had a supplementary oxygen requirement of less than 40% (nCPAP/HHFNC group).ResultsThere were 72 infants in the nCPAP group and 44 infants in the nCPAP/HHFNC group.There were no significant differences with regard to gestational age or birth weight between the two groups. The PMA at trial of first oral feeds was lower (p = 0.015) and the weight at 36 weeks of gestational age (p = 0.001) was higher in the nCPAP/HHFNC group. The length of time spent on CPAP and HHFNC was longer than compared to CPAP alone in the nCPAP group (p = 0.003), but the duration of low flow oxygen was lower in the nCPAP/HHFNC group (p = 0.035). A subgroup analysis was performed of infants requiring non-invasive respiratory support after 34 weeks PMA (27 infants nCPAP group and 33 infants nCPAP/HHFNC group). The PMA at trial of first (p < 0.001) and full oral (p < 0.001) feeds was earlier in the nCPAP/HHFNC group. The duration of low flow supplementary oxygen (p = 0.002) and total length of hospital stay (p = 0.003) were lower in the nCPAP/HHFNC group.ConclusionIn infants with BPD who required respiratory support beyond 34 weeks PMA, use of nCPAP then HHFNC was associated in earlier establishment of full oral feeds and a shorter length of stay.
AimsIn neonates treated for suspected early onset infection, NICE guidance recommends discontinuing antibiotics at 36 h in clinically well patients with negative blood cultures.A local audit ...confirmed that delay in blood culture reporting resulted in 56% of babies needlessly continuing on antibiotics, with negative implications for both the family (mother/infant separation, impact on breast feeding, unnecessary investigations) and the provider (logistical and financial).We aimed to identify the root cause contributing to the delays in blood culture processing and reporting, and introduce key interventions that would facilitate early discharge, thereby enhancing the quality and safety of care provided, and improve family experience.MethodUsing cause and effect analysis, we identified root causes and barriers to blood culture processing and reporting. We then process mapped the journey of a blood culture, from decision to treat to the time the final culture result was available. We then randomly selected patients with suspected early onset neonatal sepsis over a one month period (20 babies), and audited the time taken for each stage of the blood culture journey, to allow interventions to be focused appropriately (Figure 1).Abstract G427(P) Figure 1ResultsThe mean time for blood culture results to be reported was 59 h (range 50–79 h), with the longest delays occurring at laboratory level. This was due to a 10-hour delay in processing of samples taken out of hours. The results demonstrate that 100% of babies audited were unnecessarily continued on intravenous antibiotics, significantly delaying their discharge (Figure 2).Abstract G427(P) Figure 2ConclusionIn collaboration with local microbiology colleagues, several changes were introduced: blood culture reporting protocols have changed from 48 to 36 h, cultures are now processed out of hours and investment in a satellite blood culture analyser on the neonatal unit is being considered. These changes are expected to result in a cost savings of £53,152 per annum based on 0.7 bed days saved/mother-infant pair.
IntroductionProton pump inhibitors are being used excessively for treatment of neonates with gastroesophageal reflux disease, however, whether or not these infants do benefit from this treatment is ...still questionable.The aim of the study: is to evaluate the effect of 0.7mg/kg/day of intravenous omeprazole on neonatal GERD by using multichannel oesophageal impedance and PH monitoring before and after treatment with PPI.MethodsA randomised cross over study was performed on 20 neonates (31–37 weeks’ gestational age) with symptoms and signs of GERD.Infants had multichannel oesophageal impedance and PH monitoring done before and after omeprazole therapy (on day 0 and day 7 post treatment).ResultsOmeprazole significantly reduced the lowest PH recorded in lower oesophagus (pre treatment 0.85 vs post 2.4, p < 0.001) and significantly reduced mean acid clearance time (%) (pre 15.1% vs post 2.1%,p < 0.001) however, the total number of impedance lowering events wasn’t affected (pre 35 vs post 32, p = 0.154).Abstract G401(P) Figure 1Regarding the symptom sensitivity index pre and post treatment with PPI*The number of Acidic reflux episodes decreased significantly (pre 9 vs post 0,p < 0.001), whereas total number of weakly acidic episodes median was 25 before PPI therapy with IQR(16–28), and after therapy was 30 with IQR(21–34).Regarding the symptomatology of gastroesophageal reflux disease in the studied neonates, all 20 neonates had poor weight gain, recurrent aspiration and anaemia while 11 neonate (55% of total patients) had sandifer’s syndrome,15(75%) experienced spells and the frequency of spell per patient was on average (1–3 episode/day), 18 neoante (90%)had irritability, and all did suffer from regurgitation and the average frequency of regurgitation per day was from 5–8 episodes per neonate.ConclusionsPPI therapy does not affect the symptoms, signs or number of weakly acidic or alkaline reflux episodes which represent the commonest type of neonatal GERD. However, it affects only the acid clearance time and the number of acidic reflux episodes. These findings may indicate the over-use of PPI and the need to change the prescription pattern for neonatal GERD.
IntroductionHuman rhinoviruses (RV) are one of the main aetiological agents responsible for respiratory tract infections. RVs are divided into three species termed Rhinovirus A, B and C with over 150 ...types identified within these species. There has been growing evidence of RV infections causing severe respiratory illness in vulnerable populations such as infants with underlying respiratory or immunocompromised conditions.Aims and objectives We aimed to evaluate molecular epidemiology and associated clinical severity of Rhino virus infections retrospectively in hospitalised children aged < than 2 years.Materials and methodsNasopharyngeal and respiratory secretions from hospitalised children who tested positive for Rhino virus were included. The only exclusion factor was children with cystic fibrosis. We analysed rhino virus subtypes and its clinical association on samples obtained during the study period from January 2014 until August 2014. In total 100 clinical samples met the criteria which was then subtyped. Viral subtyping was performed by nucleic acid extraction, amplification and sequencing of the 5’ non-coding region (NCR) of the viral genome. Information on demographics, antecedent respiratory conditions and risk factors (immune suppression), clinical presentation and progress (oxygen and ventilation requirements) were collected. Additional data collected includes presence or absence of viral respiratory co infections, bacterial infections and antibiotic treatment.ResultsThe distribution of RV species, subtyped by sequencing regions of the 5’NCR observed in this study were; 57 RV-A, two RV-B and 29 RV-C. The data generated in this study provided some suggestive evidence of RV-C infection being associated with more severe acute respiratory symptoms and that RV-A infection although more prevalent commonly results in fever and is associated with extended patient length of stay in hospital. The 5’NCR sequencing assay utilised in this study was able to subtype 91% of clinical samples within a diagnostic laboratory setting using only clinical sample nucleic acid extracts.ConclusionThe knowledge of sub type in infants and young children would be quite useful to predict the disease severity and clinical course especially in vulnerable population. Also it does illustrate the importance of prevention of nosocomial Rhinovirus infections in the interest of avoiding excessive bed-days.
IntroductionPulse oximetry is an easily available, non- invasive continuous method for assessment and management of oxygenation. However, previous studies have reported discrepancies between pulse ...(SpO2) and arterial hemoximetry saturations (SaO2) with SpO2 overestimating SaO2 especially at low saturations. Whether new generation SpO2 monitors are less prone to such discrepancies is not known.AimTo prospectively assess correlation between SpO2 and SaO2 in term and preterm infants.MethodsInfants admitted to NICU over a period of 11 months, with an arterial line and SpO2 monitoring were eligible for this study. Infants on iNO were excluded. During routine arterial blood gas analysis, measured SaO2 was compared with stable SpO2 value just prior to initiating blood gas draw. Data was analysed using Bland-Altman method to assess measurement agreement.Results221 paired measurements were obtained from 36 neonates. 77.8% were fit for analysis. Of these, 6.4% SpO2 values were between 85–89%, 42.4% between 90–95%, 47.6% between 96–100% and the rest 3.6% were <85%. On an average, SaO2 was lower than SpO2 with a mean difference of -1.056. The 95% limits of agreement were –7.216 to 5.014 (SD =3.08). For the SpO2 categories between 85–89%, 90–95%, 96–100%; 73%, 53% and 73% respectively correlated with the SaO2 measurements. However, SaO2 was lower than SpO2 in 18%, 21% and 27% respectively.ConclusionThough the study showed that SpO2 and SaO2 measurements did not correlate completely, the observed difference was not clinically significant. This could be because of small sample size or due to improved SpO2 technology.
AimsApproximately 1 in 3000 live births have a congenital diaphragmatic hernia (CDH). Affected infants have a high mortality and morbidity. The aim of this study was to determine whether the response ...to resuscitation differed between CDH infants who did and did not survive.MethodsInfants born at 34 weeks of gestation or greater and diagnosed antenatally with a CDH were eligible for entry into this study. All underwent our standard resuscitation protocol for CDH infants. None of the infants were subjected to face mask resuscitation. The infants were intubated as soon as possible after birth.. A neuromuscular blocking agent was given as soon as access was established and as soon as possible after intubation. The response to resuscitation was recorded using a respiratory function monitor which began as soon as the infants were intubated. Flow, airway pressure, tidal volume (VTe), compliance and end tidal carbon dioxide (ETCO2) were simultaneously recorded using the respiratory monitor. Oxygen saturation was also continuously recorded.ResultsThirty seven CDH infants were included in the study. Eleven infants died, their median gestational age and birthweight did not significantly differ from those who survived. During the first minute of recorded resuscitation, the peak inflation pressure (PIP) did not differ significantly between non survivors and survivors, but the VTe (median 1.89 vs. 2.81 ml/kg) (p = 0.010), the ETCO2 (median 11.7 vs. 42.2 mm Hg) (p = 0.025) and the compliance (0.06 vs. 0.09 ml/cmH2O/kg) (p = 0.02) were significantly lower in the non survivors. In the last minute of resuscitation, the PIP was higher (32.5 vs. 30.3 cm H2O) (p = 0.03), the VTe (3.23 vs. 4.66 ml/kg) (p = 0.004) and the compliance (0.10 vs. 0.16 ml/cmH2O/kg) (p = 0.004) were lower in the non survivors. The maximum oxygen saturation (93 vs. 100%) achieved in the labour suite was lower in the non survivors (p = 0.044).ConclusionInfants with CDH who did not survive responded less well even to initial resuscitation, as indicated by lower tidal volumes and ETCO2 levels despite similar inflation pressures.
AimsIn September 2014 a new neonatal speciality doctor role was created in a busy central London teaching hospital. The remit was to enhance patient and parent experience on post natal ward. Timely ...and expert senior review of infants with any extra care needs were prioritised. It was anticipated that this might result in earlier intervention where needed and facilitate earlier discharge in well infants. Post natal reviews were previously managed by junior peadiatric trainee doctors. Babies who are screened and treated in view of a risk for sepsis and are on IV antibiotics form the majority of the cohort who were deemed to require early review. We aimed to demonstrate that this post would improve family centred care with a reduced length of hospital stay resulting in cost saving for the trust.MethodsA database was created with contemporaneous recording of septic screens, number of antibiotic doses, length of stay and sepsis related readmissions. Two years of activity were recorded, one pre and one post the specialty doctor appointment.ResultsDuring the 2 year study period, of 10,768 live born infants, 1,425 babies were screened and treated for risks for sepsis and received IV antibiotics in the postnatal ward. Each day of a postnatal ward stay without consumables costs £365.31. Results are shown in the table below:Abstract G193(P) Table 1Results of activity pre and post the specialty doctor appointmentYear 1Year 2Number of babies731694No of antibiotic doses49043430Length of stay (days)26301870Reduction of doses1474Reduction of antibiotic days760 daysSaving£277635.6There were no sepsis related readmissions.ConclusionA significant reduction in antibiotic doses and IV antibiotic related length of stay was observed with an estimated cost saving of £270,000 pa. The presence of an experienced clinician on postnatal ward appears cost effective and beneficial for the patient experience.
AimsTo define the burden of group B Streptococcal disease in infants younger than 90 days in 2014–2015; their clinical presentation; the frequency of established risk factors; the mortality and ...short-term complication rates (at hospital discharge); the responsible serotypes and their distribution. In addition, to compare these parameters to those of the previous national surveillance in 2000–2001.MethodsProspective, enhanced, active surveillance was undertaken through the British Paediatric Surveillance Unit (BPSU), microbiology reference laboratories and national public health agencies.Cases were identified by paediatricians and microbiologists. Paediatricians reporting a case were asked to complete a questionnaire. Microbiologists were encouraged to report cases through established routine laboratory reporting systems, and to submit all invasive GBS isolates to the relevant Reference Units. Surveillance was then enhanced by reconciling data from the clinicians and laboratory reports with referred isolates. Referral of isolates was further optimised through direct contact with all microbiology departments.ResultsIn the 13 months from April 2014 817 cases were identified (incidence 0.89/1000 live births, 95% CI; 0.87–0.91). The incidence for early-onset (EO) disease was 0.54/1000 (0.51–0.57), and for late-onset (LO) disease 0.36/1000 (0.33–0.39).Clinical information is currently available for 77% of cases. Serotype information is available for 46% of cases. Of those cases where gestation is available, 21% of EO cases and 40% of LO cases were in infants born prematurely.36% of EO cases where information is available had one or more risk factors present at or before delivery.There were 147 meningitis cases (55 EO, 92 LO).38 infants died (4.7%); 16 were EO cases and 22 were LO.ConclusionSince the national surveillance of 2000–2001 there has been a significant increase in the incidence of invasive GBS disease in all five British Isles countries. There has been a proportionately greater increase in the incidence of LO disease; however the increase was also evident for EO incidence, despite the presence of national prevention guidelines. New strategies for preventing GBS in this age group are urgently required.
AimsGastro-oesophageal reflux (GOR) symptoms in infants are a common. NICE Guidelines published in January 2015, offer guidance on how to differentiate between GOR and gastro-oesophageal reflux ...disease (GORD) and recommendations on management. The existing practice in a large Children’s Accident and Emergency unit was audited against the following recommendations:Weight should be recorded.Feed history should be reviewed.Symptoms and history should be reviewed to differentiate between GOR and GORD.Patients with symptoms of GORD should receive a trial of PPI or H2RA.Bottle fed babies should have feed amounts calculated.Alginate therapy should be offered once measures such as smaller, more frequent feeds and breast feeding assessments have been unsuccessful.Parents should be given advice.MethodNotes reviewed for 100 presentations to the Emergency department for patients:Coded as ‘GOR’ or ‘GORD’ as diagnosis in A&E notesAge < 1 yearRepresentations excludedResultsA&E documentation available for 68 of 100 patients.Number of Patients:Abstract G34 Table 1YesNoPresenting weight documented?5117Weight loss considered?3335Feeding history reviewed?5414Feed amount calculated/overfeeding considered?3632Medications started following presentation?47 (55% gaviscon, 36% ranitidine, 2% omeprazole, 7% carobel)21Indication given for starting medication?068Any documentation of advice given?3533ConclusionThere is a lot of variation in the way reflux is currently investigated and managed in the department. The audit standards as per NICE guidelines are currently not being met. Current weight, faltering growth and feeding amounts are not being routinely reviewed. A large proportion of patients have been started on medication without documented indication. Incorporating these standards into practice may improve diagnosis, symptom control and reduce the need for medications.A pro forma has been developed for patients with suspected reflux. This incorporates the NICE recommendations. As a large proportion of patients had no documented advice, a parent information leaflet has been developed.
ObjectiveTo describe the treatment challenges in the management of an exclusively breastfed infant with new onset type I diabetes.MethodsWe present an exclusively breastfed 5 month old male who ...presented to our emergency department with diabetic ketoacidosis. His mother reports that she found him floppy, pale and unresponsive after a 4 day history of vomiting. He was in severe shock, requiring multiple fluid boluses via the intraosseous route. He was hyperglycaemic with ketosis and severe acidosis (pH 6.871, PCO2 3.19, HCO3 4.4, BE –26.9). In view of fluctuating conscious level he was ventilated and transferred to paediatric intensive care unit. After 3 days, his glucose and ketones normalised and he was extubated.ResultsFour days after initial presentation, he was switched from IV insulin to subcutaneous insulin detemir (1.0u daily) and aspart (0.5u as required), with oral glucose gel for hypoglycaemia (<4 mmol/L). However glucose levels varied between 2.6 mmol/L and 21.5 mmol/L and he was commenced on continuous glucose monitoring (CGM). In view of the impracticality of carbohydrate counting, he was commenced on correction boluses of aspart, for glucose >14 mmol/L. After 8 days he was commenced on an insulin pump (Total basal insulin 0.8 u/day), with periodic correction boluses as required, with a correction target of 7 mmol/L. With the assistance of CGM, we have refined his basal rate, and he is now stable with fewer glycaemic excursions (7 day glucose average 9.8 mmol/L).ConclusionAt 5 months old, this exclusively breastfed baby with type I diabetes presented particular challenges. His blood glucose measurements were extremely variable with particular difficulties faced managing hypoglycaemia. As an exclusively breastfed male, the options include dextrose gel and breastfeeding where possible. We recommend the combination of an insulin pump, coupled with CGM and “rescue” correction boluses as the most practical approach to management.
