REEMERGENCE OF VITAMIN K DEFICIENCY BLEEDING
Late last year, the Centers for Disease Control and Prevention reported a cluster of cases of late-onset vitamin K–deficiency bleeding (VKDB) that occurred in 4 infants born in Nashville, Tennessee, whose parents had declined routine vitamin K prophylaxis in the newborn period.
Late-onset VKDB is a coagulopathy that can occur in exclusively breastfed infants between the ages of 2 and 24 weeks, resulting in potentially life-threatening hemorrhage. The clinical presentation is severe, with intracranial hemorrhaging in 50%, and persistent neurological damage is common in survivors. Mortality rate is reported to be 20%. Like classic VKDB, late-onset VKDB is preventable with the administration of a single dose of parenteral (but not oral) vitamin K after birth.
In the Tennessee cluster, the infants all had been developing normally until they exhibited sudden symptomatic bleeding at the age of 6 to 15 weeks. One of the 4 infants suffered a gastrointestinal hemorrhage, and the other 3 infants were diagnosed with diffuse intracranial hemorrhages. One of these infants is already showing signs of a gross motor deficit.
The parents of the 4 infants with late-onset VKDB were asked why they declined vitamin K prophylaxis for their babies. Their reasons included concern about an increased risk for leukemia when vitamin K is administered, an impression that the injection was unnecessary, and a desire to minimize their newborn's exposure to “toxins.” Most claimed to be unaware of the delayed risk for bleeding.
Vitamin K administration has been a routine practice in newborn care since 1961. A records review conducted in 2013 showed that 3.4% of neonates were discharged from a Tennessee hospital and 28% from a Tennessee birth center without receiving vitamin K. It is tempting to speculate that parental refusal of vitamin K administration was responsible for these omissions; however, nationwide shortages of phytonadione were ongoing in 2013. Still, research suggests that even well-educated parents need balanced information about the reasons that newborns need vitamin K, and the risks to infants who do not receive it, particularly in a breastfeeding population.
1. Centers for Disease Control and Prevention. Notes from the field: late vitamin K deficiency bleeding in infants whose parents declined vitamin K prophylaxis—Tennessee, 2013. MMWR Morb Mortal Wkly Rep. 2013;62:901–902.
2. Lippi G, Franchini M. Vitamin K in neonates: facts and myths. Blood Transfus. 2011;9:4–9.
3. Eventov-Friedman S, Vinograd O, Ben-Haim M, Penso S, Bar-Oz B, Zisk-Rony RY. Parents' knowledge and perceptions regarding vitamin K prophylaxis in newborns. J Pediatr Hematol Oncol. 2013;35:409–413.
SURFACTANT: A CLINICAL REPORT
Surfactant was the first drug developed solely for the treatment of neonates, and a major breakthrough in the care of preterm infants with respiratory distress syndrome (RDS). Surfactant replacement, given as prophylaxis or rescue treatment, reduces the incidence of RDS and air leaks and lowers mortality rate in preterm infants with RDS but it has not been shown to affect the incidence of neurologic, developmental, behavioral, medical, or educational outcomes in preterm infants.
In a clinical report, the American Academy of Pediatrics reaffirms the important role that surfactant plays in the management of respiratory failure in the neonate. The statement summarizes the evidence concerning the indications, administration, formulations, and outcomes for surfactant-replacement therapy in neonates, and the clinical strategy of intubation, surfactant administration, and extubation to continuous positive airway pressure (CPAP).
Four clinical recommendations are offered as a result of a comprehensive review of the current state of the science on surfactant:
- Preterm infants born at less than 30 weeks' gestation who need mechanical ventilation because of severe RDS should be given surfactant after initial stabilization.
- Using CPAP immediately after birth with subsequent selective surfactant administration should be considered as an alternative to routine intubation with prophylactic or early surfactant administration in preterm infants.
- Rescue surfactant may be considered for infants with hypoxic respiratory failure attributable to secondary surfactant deficiency (eg, pulmonary hemorrhage, meconium aspiration syndrome, or sepsis/pneumonia).
- Preterm and term neonates who are receiving surfactant should be managed by nursery and transport personnel with the technical and clinical expertise to administer surfactant safely and deal with multisystem illness. Providers who are inexperienced with surfactant administration or managing an infant who has received surfactant should wait for the transport team to arrive.
1. Speer CP, Sweet DG, Halliday HL. Surfactant therapy: past, present and future. Early Hum Dev. 2013;89(suppl 1):S22–S24.
2. Carlo WA, Polin RA, and Committee on Fetus and Newborn. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics. 2014;133:156–163.
RESPIRATORY SUPPORT FOR PRETERM INFANTS: A POLICY STATEMENT
For many infants, CPAP is as good as or better than prophylactic surfactant or intubating the infant just for the purpose of providing surfactant. That is one of the conclusions of a literature review about respiratory support for preterm infants published by the American Academy of Pediatrics.
Current practice guidelines recommend the administration of surfactant at or soon after birth in preterm infants with RDS. However, recent multicenter randomized controlled trials indicate that early use of CPAP with subsequent selective surfactant administration in extremely preterm infants results in lower rates of bronchopulmonary dysplasia/death when compared with treatment with prophylactic or early surfactant therapy. Continuous positive airway pressure started at or soon after birth with subsequent selective surfactant administration may be considered as an alternative to routine intubation with prophylactic or early surfactant administration in preterm infants. Preterm infants treated with early CPAP alone are not at increased risk for adverse outcomes if treatment with surfactant is delayed or not given at all. The early initiation of CPAP may lead to a reduction in duration of mechanical ventilation and postnatal corticosteroid therapy. If it is likely that respiratory support with a ventilator will be needed, early administration of surfactant followed by rapid extubation is preferable to prolonged ventilation. Finally, infants with RDS can vary markedly in the severity of the respiratory disease, maturity, and presence of other complications, and thus it is necessary to individualize patient care. Care for these infants is provided in various care settings, and the capabilities of the healthcare team must be considered.
1. American Academy of Pediatrics. Committee on Fetus and Newborn. Respiratory support in preterm infants at birth. Pediatrics. 2014;113:171–174.
AND WHAT ABOUT THOSE OXYGEN SATURATION TARGETS?
We have been going back and forth for years about the optimal oxygen saturation targets for preterm infants, like Goldilocks trying to decide between “too high,” “too low,” and “just right.” The real problem is that infants fluctuate so much that it is extremely difficult to keep their oxygen saturation levels within the desired ranges, whatever those may be. A recent study found that preterm infants' pulse oxygen saturation (Spo2) levels at 2 neonatal intensive care units were within the targeted range of 88% to 92% only 31% of the time, spending 59% of the time in hyperoxia (≥93%) and 9% of the time in hypoxia (≤87%).
The optimal oxygen saturation range for extremely low-birth-weight infants in the postnatal period beyond the delivery room is not known. Aiming too low increases the risk for cellular injury and mortality, and aiming too high raises risks for retinopathy of prematurity and blindness. A recent meta-analysis, called the NEOPROM (Neonatal Oxygenation Prospective Meta-analysis), summarized existing randomized trials examining the effect of low versus high functional oxygen saturation targets in the postnatal period in premature infants with gestational age less than 28 weeks. These trials included the SUPPORT (Surfactant, Positive Pressure and Pulse Oximetry Randomized Trial), the 3 BOOST II (Benefits of Oxygen Saturation Targeting) studies, and the COT (Canadian Oxygen Trial).
Combined, these trials provided data on 4911 infants who were randomized within the first 24 hours after birth to either a low (85%-89%) or high (91%-95%) SpO2 group. Mortality and necrotizing entercolitis were significantly increased, and severe retinopathy of prematurity was significantly reduced in low compared with high oxygen saturation target infants. One extra infant is at risk for death for every 2 cases of severe retinopathy of prematurity prevented. There were no differences in physiologic bronchopulmonary dysplasia, brain injury, or patent ductus arteriosus between the low and high target groups. On the basis of these results, it is suggested that functional SpO2 should be targeted at 90% to 95% in infants with gestational age less than 28 weeks' until 36 weeks' postmenstrual age.
Saugstad and colleagues suggest that the increased mortality rate in the low saturation group might be explained by the higher rate of intermittent hypoxemia events observed in infants with low saturation targets. A higher SpO2 target is also very difficult to maintain without risking a high proportion of time spent in hyperoxia, as shown in the study by Lim and colleagues. It is doubtful that we have reached the end of this story.
Lim K, Wheeler KI, Gale TJ, et al. Oxygen saturation targeting in preterm infants receiving continuous positive airway pressure [published online ahead of print January 13, 2014]. J Pediatr. doi: 10.1016/j.jpeds.2013.11.072
2. Saugstad OD, Aune D. Optimal oxygenation of extremely low birth weight infants: a meta-analysis and systematic review of the oxygen saturation target studies. Neonatology. 2014;105:55–63.
FOCUSING ON FATHERS
Some fathers in the neonatal intensive care unit (NICU) are right there with the mothers, holding, feeding, changing diapers—even doing skin-to-chest hair. Some are rarely seen, if ever, or are present only to read the chart and challenge the nurses. Somewhere in the middle are most fathers, trying to figure out how to be a supportive husband and father during a very difficult and stressful time. No doubt, the role of the father in the NICU can be a puzzling one. Is he just a go-between for the mother and the anxious relatives in the waiting room? Does he matter at all to the new little life in the incubator?
With the premise that fathers do matter, neonatal nurses in Iran used the resources of the HUG (HUG stands for Help–Understanding–Guidance) program, which included an educational DVD, a handout, and one-on-one time with an HUG educator, to increase new fathers' knowledge and confidence levels and promote the parent-child relationship of fathers with their preterm babies in the NICU. Fathers in the intervention group demonstrated higher levels of knowledge about preterm infant behavior, and lower levels of stress, than fathers in the control group.
HUG Your Baby (http://www.hugyourbaby.org) is a Durham, North Carolina–based international program that trains new mothers and fathers in parenting techniques, with resources for both parents and professionals who work with new parents. HUG's leadership includes representatives from the United States, Korea, Japan, and Iran.
1. Kadivar M, Mozafarinia SM. Supporting fathers in a NICU: effects of the HUG Your Baby program on fathers' understanding of preterm infant behavior. J Perinat Educ. 2013;22:113–119. http://www.medscape.com/viewarticle/817606