Introduction: There is a need for clear guidelines to support adequate nutrition and growth for premature neonates. Unfortunately, we do not have a consensus on the ideal parameters and timing for assessment of growth in these infants. Even though optimal postnatal growth should ideally replicate intrauterine rates, after the initial physiological normal drop, many premature infants follow gains below intrauterine rates. This extrauterine growth restriction (EUGR) can be quantified as lower weight Z-score medians at discharge than those at birth, indicated by a negative difference between birth and discharge (Δ Z-score) below 1 SD. We hypothesized that improved nutrition could reduce the incidence of EUGR in convalescing premature infants. Materials and methods: We reviewed the clinical information from all EpicLatino units in the past 8 years (2015–2022); all infants who were born at ≤32 weeks’ gestational age (GA) and discharged home at ≥34 weeks’ corrected age were included. Statistical comparisons were performed to analyze growth parameters and potential causes of poor nutrition. The weight Δ Z-score from birth to discharge was used as a surrogate for adequacy of nutrition. Birth weight medians and interquartile ranges were correlated with weight Δ Z-score, GA, and head circumference (HC) at discharge. Results: We reviewed 480 cases that met the established criteria. Gestational age at birth, necrotizing enterocolitis, unit of origin, rupture of membranes >24 hours, temperature at admission, and intraventricular hemorrhage were significantly different. There was a negative correlation between the Δ Z-score and corrected GA at discharge. Head circumference at discharge also correlated with weight Δ Z-score. Conclusion: The frequency of EUGR varied between units. There were some clinical associations, but our sample size was not large enough to establish causality. The risk of EUGR may increase with severity of illness or could be higher in some specific populations. Quality improvement programs to optimize nutrition policies and practices may help.

Background: Bacterial infections are a leading cause of morbidity and mortality in premature and critically ill neonates. In this quality-improvement (QI) study, we sought to characterize the bacterial infections in our neonatal intensive care unit (NICU). Aim: Our aim was to determine whether the spectrum of bacteria causing neonatal sepsis and their antibiotic susceptibility was changing over time. This information is essential for optimizing the empirical antibiotic treatment protocols needed for treating suspected sepsis prior to identification of the bacterial isolates. Materials and methods: We retrospectively reviewed the medical records of all infants treated for culture-positive sepsis in our NICU over the last 10 years. Results: We identified 151 culture-positive bacterial sepsis events in 125 infants. The organisms isolated each year largely remained similar throughout the study. Early-onset sepsis (EOS) was caused most frequently by Escherichia coli (E. coli) and group B Streptococcus, whereas the leading causes of late-onset sepsis (LOS) were coagulase-negative Staphylococcus (CoNS) and methicillin-sensitive Staphylococcus aureus. We are also seeing a trend for increasing Klebsiella isolates since 2015. Conclusion: There was no significant shift in organisms causing neonatal infections during the last 10-years. We need to carefully follow the number of Klebsiella spp. isolates and also record the antibiotic sensitivity profiles of E. coli over time. Clinical significance: In our NICU, the bacterial isolates and antibiotic susceptibility patterns have not shown major changes in recent years. Hence, the empirical antibiotic protocols for suspected sepsis do not need to be revised right now. We do need to monitor the number and antibiotic sensitivity of certain Gram-negative bacterial isolates. Our antibiotic protocols will need fine adjustment to cover the most frequently isolated bacteria for good outcomes, but also to avoid overuse and secondary resistance.

Background: Premature infants fed pasteurized mature donor human milk (DHM) from milk banks have been documented to be at higher risk of developing hyponatremia. Premature infants with a history of hyponatremia have been noted as at a higher risk of suboptimal growth and neurodevelopmental outcomes. In this study, we compared infants with documented hyponatremia vs matched controls to identify the clinical risk factors of low serum sodium (Na) levels and discharge growth parameters. Materials and methods: In this retrospective study, preterm infants with hyponatremia (plasma Na < 135 mEq/L) were compared with a control group of matched gestational age. Demographics, details of the clinical course during their hospital stay, and growth parameters (weight, head circumference, and length) at discharge were recorded. Results: Sixty infants with hyponatremia, including 32 who received supplemental Na and 28 who did not, were compared with 29 controls with normal Na levels. Hyponatremic infants were more often male (70 vs 44.8%), Caucasian (81.4 vs 62.1%), received assisted ventilation (21.7% vs none), received more mother's own milk (49.2 vs 17.9%), had a later Na nadir (14 vs 5 days), and had a longer length of hospital stay (56 vs 43 days). After controlling for length of stay, infants who received supplemental Na did not differ from matched controls in Z-scores for weight, length, or head circumference. Conclusion: Contrary to our assumptions, most infants with hyponatremia had received more MOM, not DHM. Na chloride supplementation did not improve the growth parameters at discharge. Clinical significance: Human milk feedings may not always provide recommended Na intake in preterm infants even after fortification. In our small cohort, NaCl supplementation did not always correct serum Na levels or correct the growth parameters. Current protocols for the addition of NaCl to human milk do not consistently enhance serum Na levels and growth; further studies are needed.

Aim: This study evaluates the technical feasibility of Infafeed, a novel noninvasive prototype for measuring ingested milk volumes in neonates, offering an objective assessment to support breastfeeding. Materials and methods: A single-center pilot study was conducted. Twenty-four newborn infants (mean gestational age: 37 ± 1 weeks, birth weight: 2.88 ± 0.63 kg) receiving bottle or syringe feeds were recruited. Two cases were excluded due to data-saving errors, and two more were removed due to excessive noise. The Infafeed monitor recorded feeding sounds via a microphone placed on the infant's neck, while a secondary microphone captured background noise for cancellation. Power spectral density analysis was performed to differentiate swallow and nonswallow events, and a linear regression model was used to estimate feed volumes based on 20 recordings. Results: Spectral analysis revealed a significant difference in swallow vs nonswallow spectral power in bottle-fed infants. Total power in the 400−600 Hz frequency band showed the strongest correlation with milk volume per swallow (r = 0.94). The linear regression model achieved a mean absolute error of 6.44 mL for estimated feed volumes. Conclusion: The Infafeed monitor demonstrated feasibility for neonatal feeding assessment. The observed acoustic differences between swallow and nonswallow periods provide a foundation for automated swallow detection, which can enhance milk volume estimation. Further studies with a larger cohort are required to improve accuracy and evaluate the technical and clinical applicability. Clinical significance: Maternal concern about insufficient milk supply is a leading cause of premature cessation of exclusive breastfeeding. The Infafeed monitor has the potential to provide a noninvasive, objective tool for assessing neonatal milk intake, reducing unnecessary supplementation, enabling early identification of feeding problems, and supporting breastfeeding continuation. If validated in larger studies, this device could enhance breastfeeding support strategies in both clinical and home settings.

The outcomes of premature infants with congenital heart defects following surgical correction can be improved with carefully planned and evidence-based management during the postoperative period. Many pathophysiological changes related to surgery-related tissue disruption and cardiopulmonary bypass include sodium (Na)/water overload, systemic inflammatory response syndrome (SIRS), and ischemia/reperfusion in the heart and other major organs are seen during this period. Focused intensive care is needed with close monitoring of cardiac function, tissue oxygenation, hemostasis, pain control, and sedation. There are also some center-specific needs; all care-providers need to reach a consensus on evidence-based protocols for initiation, maintenance, and weaning from assisted ventilation, which can facilitate earlier extubation and prevent ventilation-related complications. Close monitoring of the cardiac rhythm/function and the hemodynamic status can reduce critical organ dysfunction and SIRS. Measurement of specified laboratory parameters, and imaging such as chest radiography, echocardiography, and structural/functional assessment of other critical organs can help in monitoring these patients for signs of recovery. Monitoring of the sleep−wakefulness cycle, ambient noise and light control, glycemic control, monitoring of electrolytes and other metabolic parameters, feedings, nutrition, and mobilization can promote the quality of recovery. Individualized antibiotic prophylaxis may be needed based on specific defects, type of surgery, severity of illness, prior data, bacterial flora in the center, and assessments by other specialists. Finally, a checklist with clearlydefined management steps for possible needs prior to and after discharge can promote patient safety.

Increasing data shows that macrophages, the primary immune cells in the growing fetus/neonate, retain an innate immune memory of prior stimuli. This memory is rooted in epigenetic regulation of lineage- and tissue-specific transcription either to enhance the responses or to induce tolerance to repeated exposures to a stimulus. As we understand, epigenetics refers to the study of heritable information transmitted during cell divisions that can alter gene expression via inclusion of chemical tags but no changes in the DNA sequence. We now recognize the lineage-determining transcription factors as important mediators that can make the local chromatin more accessible to other factors; one example is the erythroblast transformation-specific gene PU.1 (purine-rich sequence binding protein 1). The PU.1 can upregulate the basal activation state of many promoters by increasing histone H3 lysine 4 trimethylation (H3K4me3). There are several other newly discovered regulators that perform similar regulatory roles. These mediators enhance macrophage differentiation into several phenotypes essential for host defense or tissue homeostasis in response to environmental stimuli. The two ends of this polarization spectrum include the classically-activated (M1) macrophages induced by interferon-γ and microbial products; and the alternatively-activated (M2) macrophages induced by the T-helper 2 cytokines interleukin (IL)-4 and IL-13. The M1 macrophages participate in host defense and clearing pathogens, whereas all the known subtypes of M2 cells promote resolution of inflammation and tissue repair. Maladaptive changes in macrophages can disrupt the normal sequence of immune/inflammatory responses and predispose to disease states. The review summarizes our current understanding of the involved mechanisms; this information can help understand the immune responses in neonates who are yet to develop mature neutrophil function or adaptive immunity and are largely dependent on mononuclear cells for immune defenses.

Objective: We describe an infant of diabetic mother (IDM) with an unusually severe, extensive, and persistent neonatal small colon syndrome (NSCS). Case presentation: We report a 36-week-gestation female IDM who developed signs of intestinal obstruction at about 6 hours after birth. A contrast enema showed a small-caliber distal small intestine and colon. There was no clinical improvement over next 2 weeks, and so an exploratory laparotomy was performed; the involved bowel contained viscous meconium with pellets. Histopathological examination showed normal bowel histoarchitecture with an appropriate morphology/number of ganglion cells. A double barrel enterostomy was created, and the distal gastrointestinal tract was regularly flushed. She has since shown good improvement and has been discharged on full, exclusive breastfeeds. Laboratory investigations, including blood counts and chemistries, thyroid function, and screening for cystic fibrosis (CF) were reassuring. Our working diagnosis is an unusually severe/extensive NSCS. We have followed this infant for gastrointestinal symptoms now for 3 months since discharge. Conclusion: Neonatal small colon syndrome may not always show prompt, spontaneous resolution. It should be included in the differential diagnosis of a newborn infant with unusually prolonged signs of intestinal obstruction. Some infants may require surgical management with ostomy formation.

Omphalocele is a congenital midline defect into the base of the umbilical cord, which frequently contains herniated abdominal viscera. Giant omphaloceles (GOs) are defined as larger than 5 cm. Management of omphaloceles is usually focused on closing the abdominal wall defect after supportive care to stabilize the patient. Some clinicians prefer a nonoperative “paint and wait” strategy without graft closure; the sac is maintained with topical medications such as silver sulfadiazine or combinations of polyvinylpyrrolidone and iodine (the most frequently used commercial preparation being povidone-iodine®) mixed with topical antibiotic powder sprays. Povidone-iodine can cause thyroid dysfunction, especially in preterm infants. The authors present one such case in the article; the goal is to sensitize the medical care-providers to these adverse effects. A female infant born at 26⁺² weeks’ gestation/birth weight of 830 gm showed a GO with intact membranes. A transparent silicone adhesion wound-contact dressing was used to cover the abdominal herniation, and on the 2nd postnatal day, the surgeon began applying povidone-iodine over the omphalocele followed by nonadherent dressings. Serum thyroid stimulating hormone (TSH), free T4, and iodine levels were followed over time. The iodine levels were monitored but the levels at 35 weeks’ corrected gestational age suddenly rose to 33,917 μg/L (normal 40−100 µg/L). The infant was still receiving daily povidone-iodine dressings at this time. These dressings were stopped immediately, and the serum iodine levels dropped to 97 μg/L in 2 months. The authors seek to remind that infants, especially preterm, who are exposed to repeated topical exposure to iodine-containing antiseptic solutions over a large surface area are at risk of developing transient hypothyroidism. There is a need to remain cognizant of these complications and be aware of the need for close monitoring of thyroid function in high-risk infants.