Search

Premature infants or infants born with complex medical problems are at increased risk of having delayed or dysfunctional oral feeding ability. These patients typically require assisted enteral nutrition in the form of a nasogastric tube (NGT) during their NICU hospitalization. Historically, once these infants overcame their initial reason(s) for admission, they were discharged from the NICU only after achieving full oral feedings or placement of a gastrostomy tube. Recent programs show that these infants can be successfully discharged from the hospital with partial NGT or gastrostomy tube feedings with the assistance of targeted predischarge education and outpatient support. Caregiver opinions have also been reported as satisfactory or higher with this approach. In this review, we discuss the current literature and outcomes in infants who are discharged with an NGT and provide evidence for safe practices, both during the NICU hospitalization, as well as in the outpatient setting.

Background Feeding dysfunction is a common consequence of prematurity and illness in neonates, often requiring supplemental nasogastric (NG) or gastrostomy (GT) feeding tubes. A standardized approach to the discharge of infants receiving home enteral nutrition (HEN) is currently lacking. Methods The Home Enteral Feeding Transitions (HEFT) program was developed to identify patients eligible for HEN and create a standard discharge process. A structured tool helped determine discharge timing and route, and a dedicated outpatient clinic was created for infants discharged on HEN. Demographic, inpatient, and outpatient data were prospectively collected and compared with a historical cohort. Results A total of 232 infants discharged from our neonatal intensive care unit (NICU) over 9 months met inclusion criteria. Ninety-eight (42%) were discharged with HEN, 68 NG and 30 GT, compared with 134 (58%) receiving full oral feeds. This represented a 10% increase in HEN utilization (P = 0.003) compared with our historical control group. Median HEN length of stay was 31.5 days compared with our historical average of 41 days (P = 0.23). Frequency of emergency department visits and admissions because of HEN was unchanged postintervention. Parents were satisfied (8.6/10), and 98% said they would choose HEN again. The median time to NG discontinuation after discharge was 13.5 days, with an estimated cost savings of $2163 per NICU day. Conclusion Our program is the first of which we know to use a standard care-process model to guide the decision-making and utilization of HEN at NICU discharge. HEFT shows that HEN at NICU discharge can be safe and effective, with high parental satisfaction.

BACKGROUND Congenital dyserythropoietic anemia type 1 (CDA1) is an autosomal recessive disorder of ineffective erythropoiesis, resulting in increased iron storage. CDA1 is usually diagnosed in children and adolescents but can rarely present in the neonatal period with severe anemia at birth. There are no prior reports of neonatal liver histologic findings of CDA1. We report a case of CDA1 in a newborn presenting with severe anemia, cholestasis and liver failure, where liver biopsy helped confirm the diagnosis. CASE SUMMARY A term infant, born via emergency Cesarean section, presented with cholestasis, hepatosplenomegaly, multiorgan failure and severe anemia at birth. A prior pregnancy was significant for fetal demise at 35 wk without autopsy or known etiology for the fetal demise. Parents are both healthy and there is no history of consanguinity. On further evaluation, the patient was found to have severe ferritin elevation and pulmonary hypertension. An extensive infectious and metabolic work-up was negative. Salivary gland biopsy was negative for iron deposition. At 2 wk of age, a liver biopsy showed findings consistent with CDA1. A genome rapid sequencing panel revealed novel variants in the CDAN1 gene. The patient’s liver dysfunction, cholestasis and organomegaly resolved, however she remains transfusion-dependent. CONCLUSION We report liver pathology findings of CDA1 with a novel genetic mutation for the first time in a newborn.

W are having trouble with Soviet strategic doctrine. Soviet thinking about strategy and nuclear war differs in sigificant ways from our own. To the extent one should care about this -and that extent is a matter of debate-we do not like the way the Soviets seem to think. Before 1972, appreciation of differences between Soviet and American strategic thinking was limited to a small number of specialists. Those who held it a matter of high concern for policy were fewer still. Since that time, concern about the nature, origins, and consequences of these differences is considerably more widespread, in large measure as a result of worry about the Soviet strategic arms buildup and the continued frustrations 'of achieving a real breakthrough in SALT. Heightened attention to the way the other side thinks about strategic nuclear power is timely and proper. The nature of the Soviet buildup and some of our own previous choices have locked us out of pure "hardware solutions" to our emerging strategic security problems that are independent of the other side's values and perceptions. Whatever one thinks about the wisdom or folly of the manner in which we have pursued SALT so far, it is desirable that management of the U.S.Soviet strategic relationship have a place for an explicit dialogue. That dialogue should include more attention to strategic concepts than we have seen in past SALT negotiations. Moreover, whatever the role of SALT in the future, the existence of "rough parity" or worse almost by definition means that we cannot limit strategic policy to contending merely with the opponent's forces. In the cause of deterrence, crisis management, and, if need be, war, we must thwart his strategy. That requires understanding that opponent better.

BACKGROUND/PURPOSE: Meckel diverticulum (MD) is present in 2% of the population. Many practitioner feel the diagnosis relies upon technetium-99m pertechnetate scintigraphy. When negative, patients undergo additional invasive procedures delaying definitive therapy. This study aims to identify features of bleeding MD and generate a risk score, which could preclude unnecessary testing and facilitate earlier operation. METHODS: All patients

Background Neonates with intestinal failure (IF) have prolonged admissions in the neonatal intensive care unit (NICU) and require lifelong follow-up with gastroenterology (GE) as outpatients. Inpatient management of these patients typically relies on many rotating practitioners and currently discharge criteria do not exist. We sought to create standardized discharge criteria with a continuity care model for neonatal IF patients. Methods Inpatient care was streamlined to two GE physicians with weekly consultations. We implemented standardized discharge goals for both enteral and total parental nutrition (TPN) by: 1) Enteral feedings of at least 5 mL/h were tolerated; 2) Stable central venous access was intact; 3) TPN was cycled to 20 h/day or less; and 4) No other medical issues required NICU admission. Patient records were reviewed after 18 months of implementing standardized discharge criteria and we compared their outcomes to a historical cohort of IF patients. Results Optimal discharge criteria were met in 12 patients and a cohort of 26 historical patients was used for comparison. Patients in optimal versus historical groups had similar baseline characteristics (medians, all P values = non-significant (NS)): gestational age (36 vs. 35 weeks), birth weight (1,990 vs. 2,076 g), birth length (45 vs. 44 cm), and small bowel length after definitive surgery (63 vs. 55 cm). Compared to the historical group, the optimal cohort was discharged earlier (median length of stay 69 vs. 126 days, P < 0.01), with a reduced total stay of 684 NICU days, fewer central line-associated bloodstream infections (CLABSIs) (4 vs. 10 per 1,000 patient days, P = 0.04), and had fewer readmissions (7 vs. 17 per 1,000 patient days, P < 0.01), respectively. Conclusions Concentrating the care of IF patients to a GE team invested in long-term care, while implementing safe discharge criteria, resulted in a dramatic length of stay reduction with fewer CLABSIs and readmissions compared to historical management. At approximately 4,000 dollars per day in NICU hospital charges, this program saved over 2.7 million dollars in care costs while allowing families and their infants more time at home. The safety and applicability of the optimal discharge criteria presented here should be studied further. Similar programs may be effective at other large NICUs.