Division of Newborn Medicine Alumni Information

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Summer Students present at the Annual Pediatric Academic Societies' Meeting in Boston in May 2012

Stooling Kinetics Associated with Low Gestational Age and Necrotizing Enterocolitis
Katherine E. Gregory, Abigail B. Winston, Amen Ismail, Stephanie Meller, Linda J. Van Marter. Brigham and Women's Hospital, Boston, MA; Children's Hospital, Boston, MA; University of Arkansas Medical School, Little Rock, AR; Yale School of Medicine, New Haven, CT.
BACKGROUND: Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency affecting premature infants. Because the onset of NEC is often sudden and its progression rapid, improved clinical predictors of NEC are needed to anticipate the disease and more effectively intervene. The stooling kinetics associated with low gestational age and NEC may be an important early indicator of disease.

OBJECTIVE: To investigate the relationship between premature infant stooling and NEC.

DESIGN/METHODS: Case-control study of 162 infants born prior to 29 weeks gestation: 81 infants with NEC and gestational age matched controls. The diagnosis of NEC, as defined by Bell Stages I-IIIB, was required for assignment to the case group. Analyses excluded data after disease onset. Five controls were lost to death prior to 28 days. The relationship between infant stooling prior to NEC was assessed via non-parametric methods using SAS, where cases were excluded after onset of disease.

RESULTS: On average, infants who developed NEC stooled more frequently during the first week (p=.051). The case group did not differ significantly on the first day stool was passed, the duration of meconium, or the presence of heme positive stools.

Stooling pattern during the first 28 days

Mean Stool

Controls Median [IQR]

NEC Cases Median [IQR]

p-value

Week1

0.57 [0.28-1.00]N=81

0.86 [0.33-1.57]N=81

0.051

Week2

2.00 [1.00-3.00]N=79

1.80 [1.00-3.00]N=64

0.756

Week3

2.29 [1.43-3.43]N=77

2.61 [1.42-3.29]N=38

0.859

Week4

2.57 [2.07-3.43]N=76

2.42 [2.16-3.33]N=23

0.71

When the case group was stratified by NEC Bell Stage, the same trends were observed, with NEC cases stooling more frequently during the first week.

Stooling pattern by NEC Bell Stage

Mean Stool

Controls Median [IQR]

Bell Stage I Median [IQR]

Bell Stage II Median [IQR]

Bell Stage III Median [IQR]

p-value

Week1

0.57 [0.28-1.00]N=81

1.00 [0.57-1.43]N=31

1.28 [0.28-1.71]N=19

0.60 [0.14-1.57]N=31

0.0408

Week2

2.00 [1.00-3.00]N=79

1.64 [1.00-2.57]N=26

2.36 [1.57-3.14]N=18

1.54 [0.43-3.62]N=20

0.6132

Week3

2.28 [1.43-3.43]N=77

2.57 [1.43-3.00]N=13

2.86 [2.33-3.14]N=13

2.44 [0.93-3.52]N=12

0.9264

Week4

2.57 [2.07-3.43]N=76

2.75 [2.43-3.43]N=9

2.43 [1.28-2.86]N=7

2.43 [1.57-3.33]N=7

0.602

CONCLUSIONS: This analysis suggests that stooling kinetics over the first 28 postnatal days may differentiate premature infants who develop NEC from controls. The finding indicate that stooling kinetics during the first week could be predictive of disease.

Nutritional Practice Changes and Growth in the Newborn Intensive Care Unit, 2002-2010

Vincent C. Smith, Wen-Yang Mao, Naysa Sierra. Neonatology, BIDMC, Boston, MA; Biology, Claremont McKenna College, Claremont, CA.
BACKGROUND: Nutrition is vital to growth of infants in the Newborn Intensive Care Unit (NICU). Changes are made to nutritional practices in the NICU presumably to improve infant growth.

OBJECTIVE: The aim of this study is to explore the temporal association between several nutritional practice changes in the NICU and the growth of populations of infants before and after each change.

DESIGN/METHODS: We analyzed data for all infants in the NICU from 2002-10. There were five nutritional practice changes: advancing the protein content of the parental nutrition (PN); initiation of starter PN on the day of birth; decreasing modular use (e.g. extra calories from fat/carbohydrate); adding extra protein into enteral feeds; and alternating commercially available formulas. The outcomes were the mean infant discharge weight, length, head circumference, body mass index (BMI), and overall NICU weight growth velocity (WGV). Multivariate linear regression analyses controlled for infant gender, method of delivery, exposure to breast, singleton vs. multiple status, gestational age at birth, birth weight, 1 and 5 minute Apgar scores, NICU length of stay, and maternal age and race.

RESULTS: The entire cohort (n= 11,684) had a mean birth weight and gestational age of 2462 grams and 36 weeks. In bivariate analyses, advancing the protein content of the parental nutrition (PN) was significantly associated (p<0.0001) with heavier discharge weight (2711 vs. 2633g), longer discharge length (46 vs. 44 cm), and larger discharge head circumference (32 vs. 31cm). Similar discharge weight, length, and head circumference bivariate results were noted with all the other nutritional changes except alternating commercially available formulas. BMI was significantly associated with both decreasing modular use and adding extra protein into enteral feeds (13 vs. 12 for both analyses p=0.0008 and 0.0002 respectively); and the overall WGV was significantly faster with one commercially available formula (-2.57 vs. -4.17 g/kg/day, p=0.43). The multivariate results were the same as the bivariate results except association between commercial formula and WGV was no longer significant.

CONCLUSIONS: Nutritional practice changes over the years seem to have had an impact on growth attainment of the infants. Discharge weight, length, and head circumference have all increased while BMI has decreased. This implies that infants are showing the “desired” type of growth and not just gaining fat.

Graduation

The Experience -- Student feedback from the 2007 and 2008 Programs

  • "The Program did a good job introducing us to the full spectrum of newborn medicine by showing us what occurs in normal delivery and care, as well as special circumstances in the NICU and Infant Follow-Up."
  • "I really enjoyed that both research and clinical work were the focus of this Program. I now have a better understanding of the clinical practice of neonatology and the direction in which neonate research is going."
  • "The Program is a fantastic mix of clinical experience and research experience."
  • "Most of my peers in other programs were solely exposed to either research or clinics. That was what I thought was so great about this Program. The research was intense; however, I also got clinical exposure in a field of medicine that most medical students don’t see until residency. The clinical exposure added an extra dimension to an already abstract experience, allowing us to see why the research we were taking part in was so important."
  • "The research was intense, and I was able to complete a project which is something I have never done before."
  • "I loved the case presentations every Wednesday, the shadowing opportunities, the binder chock-full of information…everything! It was all so well organized and put together, and I learned so much!"
  • "Loved the clinical aspect of the Program! I really enjoyed the weekly conferences and all the learning that took place."
  • "I always had an interest in pediatrics, but I had never been exposed to neonatology. This Program has helped me learn more about neonatology and I now consider it a field to pursue in the future."
  • "The Program has exposed me to other areas of pediatrics, such as developmental pediatrics, that I would like to pursue. Also, it has sold me on Boston as a place to train."
  • "Before this Program I was still deciding if I should apply for an M.D. or Ph.D. However, after this Program, I realized how much more I enjoy the clinical setting and how the M.D. path is definitely one that I should pursue."
  • "This Program has given me tremendous exposure to the field of neonatology. With that exposure and first hand experience, I will be more able to make an informed career decision when the time comes."
  • "This Program solidified my interest in pursuing a career in pediatrics and especially in engaging in clinical research."

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