UNSHIELDED PARENTERAL NUTRITION AND MORTALITY
The fact that when exposed to light, parenteral nutrition preparations generate oxidants that are deleterious for cell survival is well known. However, the biologic effects of these oxidants in premature infants, even with their immature antioxidant defenses, are unknown. The practice of shielding parenteral nutrition solutions from light during administration to premature infants has therefore been inconsistent, and the benefits of such practices have been questioned.
A new meta-analysis suggests that complete shielding of parenteral nutrition solutions from light should be undertaken.1 The analysis included 4 randomized clinical trials with a total of 800 premature infants that compared light-exposed with light-protected parenteral nutrition administration and determined the effect of shielding on mortality. Mortality in the light-protected group was half of that in the light-exposed group (95% confidence interval, 0.32-0.87) and twice as high in boys compared with girls (P = .01). From this analysis, the investigators concluded that shielding parenteral nutrition from light has vital repercussions that call for action to provide photoprotected delivery systems and infusion sets for use in premature infants. Neonatal intensive care units should review and update their policies to ensure that current practice completely and consistently protects parenteral nutrition from light during transport, storage, and administration.
1. Chessex P, Laborie S, Nasef N, Masse B, Lavoie JC. Shielding parenteral nutrition from light improves survival rate in premature infants: a meta-analysis [published online ahead of print September 16, 2015]. JPEN J Parenter Enteral Nutr. doi:10.1177/0148607115606407. [Context Link]
CONGENITAL HYPERINSULINISM AND NEONATAL HYPOGLYCEMIA
Congenital hyperinsulinism, caused by inactivating mutations of the [beta]-cell ATP-sensitive potassium channel, is the leading cause of persistent hypoglycemia in infants and children.1 The 2 distinct forms of congenital hyperinsulinism are diffuse disease, in which cells throughout the pancreas are hyperactive, and focal disease, which features a discrete lesion of islet cell hyperplasia or adenomatosis.1 Both forms often require surgery. Near-total pancreatectomy is palliative in diffuse disease and the lesions of focal disease can be resected, potentially curing the disease.
Children with congenital hyperinsulinism who require surgery have, in past research, been found to be at risk for the development of diabetes and permanent neurologic injury. However, it was unknown whether recent advances in molecular diagnosis, imaging, and management had improved either or both of these outcomes for the population of children with congenital hyperinsulinism. A team of investigators at Children's Hospital of Philadelphia undertook a cross-sectional study of 121 children (median age = 8.9 years) who received care at their institution from 1960 to 2008 to determine the prevalence of diabetes and neurobehavioral deficits in individuals with surgically treated hyperinsulinism.1 They found that 36% of the children developed diabetes and 48% developed neurobehavioral abnormalities. The high rate of neurologic injury is believed to be the result of recurrent, persistent hypoglycemia in the neonatal period. These findings have implications for those who care for newborn infants. Distinguishing between transitional neonatal glucose regulation in normal newborns and hypoglycemia that persists or occurs for the first time beyond the first 3 days of life is important for prompt diagnosis and effective treatment to avoid serious consequences, including seizures and permanent brain injury.2 Neonates at risk (very large for gestational age, a high glucose requirement to maintain normoglycemia) must be identified and supported with feedings and intravenous dextrose during the first 48 hours of life. After 48 hours, infants with persistent hypoglycemia must be carefully evaluated to determine the underlying cause of the hypoglycemia and treat it appropriately.
1. Lord K, Radcliffe J, Gallagher PR, Adzick NS, Stanley CA, De Leon DD. High risk of diabetes and neurobehavioral deficits in individuals with surgically treated hyperinsulinism [published online ahead of print September 1, 2015]. J Clin Endocrinol Metab. doi:http://dx.doi.org/10.1210/jc.2015-2539. [Context Link]
2. Thornton PS, Stanley CA, De Leon DD, et al. Recommendations from the Pediatric Endocrine Society for evaluation and management of persistent hypoglycemia in neonates, infants, and children. J Pediatr. 2015;167:238-245. [Context Link]
EFFECT OF RUDENESS ON TEAMWORK
Intimidation, one type of workplace incivility, is believed to be a stumbling block to patient safety because it hampers effective communication.1 Like intimidation, rudeness can influence interactions among team members. In healthcare settings, rudeness can come from peers, supervisors, or even patients and families. Rude behavior may escalate during times of stress, when events are not unfolding the way one would prefer. But do these behaviors improve a stressful situation? Little is known about the effects of such behaviors as rudeness and incivility on team performance. Could rude behavior negatively affect performance, and therefore outcomes, by preventing team members from being helpful and cooperative during situations in which the contributions of each member are critical?
An interesting study2 tested the impact of rudeness on the performance of teams of neonatal intensive care unit caregivers (nurses and physicians) at 4 Israeli hospitals. Caregivers were placed in 24 teams comprising 1 physician and 2 nurses. Each team participated in a simulation exercise involving a preterm neonate whose condition acutely deteriorated owing to necrotizing enterocolitis. The teams were told that a foreign expert would be observing them and then they were randomly assigned either to a control situation or an exposure group. In the exposure group, the foreign expert made mildly rude comments during the exercise, although not related to the team's performance. The videotaped simulation sessions were evaluated by 3 independent judges (blinded to team exposure), who assessed team performance, information sharing, and help seeking.
The teams exposed to rudeness had lower mean diagnostic scores and procedural performance scores than control teams, indicating that rude behavior has adverse consequences on the performance of teams in a critical, potentially stressful situation. Information sharing and help-seeking behaviors mediated the effects of rudeness on team performance. Although this study did not assess the effects of peer-to-peer rudeness on team performance, it suggests that interpersonal interactions during a stressful situation can affect outcomes.
1. Lamontagne C. Intimidation: a concept analysis. Nurs Forum. 2010;45:54-65. [Context Link]
2. Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015;136:487-495 [Context Link]
TWENTY YEARS OF NEONATAL OUTCOME IMPROVEMENT
A major National Institutes of Health study reveals that extremely preterm infants born at US academic centers during the last 20 years are surviving in greater numbers with fewer complications.1 Survival increased most markedly for infants born at 23 to 24 weeks' gestation. Of those born at 24 weeks, for example, only 52% survived in 1993 whereas 65% survived in 2012. Survival without major morbidity increased for infants born at 25 to 28 weeks' gestation. For infants born at 27 weeks, for example, survival without major morbidity increased from 29% in 1993 to 47% in 2012. No change was seen for infants born at 22 to 24 weeks' gestation.
To document these improvements, the authors reviewed 20-year trends in maternal/neonatal care, complications, and deaths among extremely preterm infants born at 26 Neonatal Research Network Centers between 1993 and 2012. They analyzed data from a prospective registry of 34,636 infants born at 22 to 28 weeks' gestation, weighing 401 to 1500 g at birth.
Some interesting trends in prenatal and neonatal care were found. Use of antenatal corticosteroids increased from 24% in 1993 to 87% in 2012. Delivery room intubation decreased from 80% in 1993 to 65% in 2012. After increasing in the 1990s, postnatal steroid use declined to 8% in 2004, with no significant change thereafter. Although most infants were ventilated, the use of continuous positive airway pressure without ventilation increased from 7% in 2002 to 11% in 2012.
Trends in rates of morbidities varied. Despite no improvement from 1993 to 2004, rates of late-onset sepsis declined between 2005 and 2012 for infants of each gestational age. Rates of other morbidities also declined, but bronchopulmonary dysplasia increased between 2009 and 2012 for infants born at 26 to 27 weeks' gestation.
The investigators concluded that among extremely preterm infants born at US academic centers over the last 20 years, changes in maternal and infant care practices have led to improved survival and modest reductions in several morbidities. These findings may be valuable in counseling families and developing novel interventions.
1. Stoll BJ, Hansen NI, Bell EF, et al. Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993-2012. JAMA. 2015;314:1039-1051. [Context Link]