Improved Growth and Decreased Morbidity in Preterm Neonates with Early CPAP and Aggressive Nutrition

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Improved Growth and Decreased Morbidity in
Preterm Neonates with Early CPAP and Aggressive
Nutrition

• Melinda Caskey, MDRafael Fonseca, MD
• University of Texas Medical Branch
• Department of Pediatrics
• Faculty Mentor-Cara Geary, MD, PhD

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Abstract

• Objective The objective of this study was to
  compare morbidity outcomes after five clinical
  practice changes were introduced in the Infant
  Special Care Unit (ISCU) at the University of
  Texas Medical Branch.
• Method A retrospective cohort study was done
  comparing appropriate for gestational age ELBW
  neonates from before and after the changes.
• Results Our results showed that infants in the
  group born following initiation of the changes
  had significantly fewer days on mechanical
  ventilation, fewer days on oxygen, fewer were
  discharged home on oxygen, fewer central line
  days, better growth, less BPD, less exposure to
  pressors, steroids, and surfactant, fewer
  inguinal hernia surgeries and a 12-day shorter
  hospitalization. No differences were seen in
  incidences of intraventricular hemorrhage,
  periventricular leukomalacia, pulmonary
  hemorrhage, pneumothorax, spontaneous
  perforations or nectrotizing enterocolitis,
  although the study was not adequately powered to
  test for these morbidities. Combining infants
  from both cohorts demonstrated that of the
  infants that developed BPD, 74 were exposed to
  mechanical ventilation in their first 48 hours of
  life.
• Conclusions Our conclusions are that the
  physiologically appropriate adaptations in the
  nutritional and respiratory management of the
  ELBW neonate have dramatically improved multiple
  morbidity and growth outcomes. Decreased
  exposure to barotrauma, oxygen toxicity and
  inadequate nutrition will translate into improved
  neurodevelopmental outcomes for high-risk
  neonates. Successful management on CPAP for the
  first 48 hours of life is protective against the
  development of BPD.

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Changes in Care of ELBW Neonate at UTMB Neonatal
ICU

• Extubation to CPAP after prophylactic dose of
  surfactant
• Goals for oxygen saturation lowered to 90-95
• Nutritional changes
• Early parenteral nutrition
• Earlier initiation and faster advancement of
  enteral feeds
• Cue-based feeding

Fall 2003 Changes Made
2001 2002 2003
2004 2005

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Methods

• Retrospective Cohort Study
• Group 1 - born January 2001-June 2002
• Group 2 - born July 2004-December 2005
• Inclusion criteria
• Less than 1000 grams (ELBW)
• Offered resuscitation
• AGA
• Inborn
• No congenital malformations

Fall 2003 Changes Made
Group 1
Group 2
2001 2002 2003
2004 2005

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Methods

• Development of database based on established
  databases
• Vermont Oxford and NICHDs Neonatal Research
  Network
• Development of new discharge summary form for
  medical record incorporating all data
• IRB approval obtained
• Training NNPs and team on proper guidelines for
  data entry
• Chart review of 165 ELBW infants
• Data analysis - Chi-square, t-test, and logistic
  regression

Jan 2004 Project Start
Chart reviews
2004
2005
2006
Jan 2005 New Form In use
Database
Data entry/analysis
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Plt0.05
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Bronchopulmonary Dysplasia(Pediatrics 2005 116
1353-1360)

• Definition
• Oxygen Requirement at 28 days or 36 weeks
  gestational age
• National Institute of Child Health and Human
  Development criteria
• Severity scores-none, mild, moderate, and severe
• Incidence
• Varies among institutions
• ELBW infants lt1000 grams - Overall 44
• Pathogenesis
• Mechanical injury
• Oxygen Toxicity
• Inflammation
• Morbidities
• Arrested lung development
• Higher risk of mortality
• Increased risk of respiratory infection
• Abnormal pulmonary function into childhood
• Increase risk for neurodevelopmental sequelae

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Ventilator-induced Lung Injury138 day preterm
lamb (term 150 days)
Unventilated
Ventilated for 24 hr
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Nasal CPAP(Seminars in Neonatology 2002 7
379-389)

• Mimics natural physiology
• Constant distending pressure on developing lungs
• Increased functional residual capacity
• Recruits atelectatic alveoli
• Improved gas exchange
• PaO2 ? and PaCO2 ?
• Less hypoxic vasoconstriction
• Decreased pulmonary vascular resistance
• Increased pulmonary blood flow
• Less shunting

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Dr. Caskeys Hypotheses

• Physiologically appropriate changes in management
  
• Decreased oxygen exposure
• Early CPAP
• Hypotheses
• 25 decrease in the incidence of BPD
• Sample size calculation 70 required in each
  group
• Significant decrease in hypotension requiring
  pressors in first 24 hours

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plt0.00006
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Logistic Regression P0.003 for Group 1 vs.
Group 2
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Plt 0.04 for both comparisons (logistic
regression)
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Other Outcomes
Plt0.01
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Dr. Caskeys Summary

• ELBW infants are being exposed to significantly
  less oxygen and fewer days on the ventilator
• ELBW infants are receiving fewer doses of
  surfactant and postnatal steroids and fewer are
  going home on oxygen
• Decreased incidence of moderate and severe BPD
  and a 15 reduction in BPD by previous criteria
• Decreased hypotension requiring treatment in the
  first 24 hours of life
• Continuous CPAP for the first 24-48 hours is
  protective against the development of BPD

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Growth and Nutrition in ELBW(Semin Neonatol
2001 6365-375 383-391 / Peds 2003
112(3)359-366)

• Sequelae of ELBW (lt1000 gram)
• 10 of ELBW infants are SGA at admission
• 54-70 of ELBW infants are SGA at follow-up
• SGA strongly associated with neurodevelopmental
  delay
• ELBW infants discharged SGA are 5 cm shorter as
  adults
• Barker Hypothesis
• LBW is associated with increased incidence of
  adult
• CVD
• Renal failure
• Diabetes Mellitus

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Dr. Fonsecas Hypotheses

• Physiologically appropriate changes in management
• Early parenteral nutrition
• Earlier initiation and faster advancement of
  enteral feeds
• Cue-based feeding
• Hypotheses
• Significant decrease in hospital length of stay
• Significant decrease in number of ELBW infants
  discharged SGA

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p0.0002
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Other Comparisons
Plt0.05
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Dr. Fonsecas Summary

• ? the percent of BW lost, and the days to regain
  BW
• ? days to achieve full feeds
• ? days on TPN and days with central lines
• ? rate of weight gain
• ? the incidence of ELBW being discharged SGA
• ? length of stay by 10 days (suggestive, p
  value0.057)
• ? the incidence/development of inguinal hernias
• ? the overall incidence of bad outcomes
• death, severe BPD, surgical NEC, grade III/IV
  IVH, PVL, SGA

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Infections and Antibiotic Use
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Total Hospital Costs
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Acknowledgements

• Michael Malloy M.D.
• C. Joan Richardson M.D.
• Felix Morales, MD
• Irene Taylor
• Nurse Practitioners