Increased Intestinal Blood Flow with Bolus Feedings in Very Low Birth Weight Infants
From Journal of Pediatrics: V Bozzetti et al. DOI: http://dx.doi.org/10.1016/j.jpeds.2016.05.031
Objective
To detect changes in splanchnic perfusion and oxygenation induced by 2 different feeding regimens in infants with intrauterine growth restriction (IUGR) and those without IUGR.
Study design
This was a randomized trial in 40 very low birth weight infants. When an enteral intake of 100 mL/kg/day was achieved, patients with IUGR and those without IUGR were randomized into 2 groups. Group A (n = 20) received a feed by bolus (in 10 minutes), then, after at least 3 hours, received the same amount of formula by continuous nutrition over 3 hours. Group B (n = 20) received a feed administered continuously over 3 hours, followed by a bolus administration (in 10 minutes) of the same amount of formula after at least 3 hours. On the day of randomization, intestinal and cerebral regional oximetry was measured via near-infrared spectroscopy and Doppler ultrasound (US) of the superior mesenteric artery was performed. Examinations were performed before the feed and at 30 minutes after the feed by bolus and before the feed, at 30 minutes after the start of the feed, and at 30 minutes after the end of the feed for the 3-hour continuous feed.
Results
Superior mesenteric artery Doppler US showed significantly higher perfusion values after the bolus feeds than after the continuous feeds. Near-infrared spectroscopy values remained stable before and after feeds. Infants with IUGR and those without IUGR showed the same perfusion and oxygenation patterns.
Conclusion
According to our Doppler US results, bolus feeding is more effective than continuous feeding in increasing splanchnic perfusion.
Related blog posts:
- Which is Safer –Drip Feeds or Bolus Feeds in Healthy … – gutsandgrowth
- Continuous versus Bolus Feeds GutsandGrowth
Iceberg Lake, Glacier Natl Park
FDA Gives Ustekinumab (Stelara) Approval for Crohn’s
Here’s a link summarizing FDA approval: Medscape: FDA Clears Ustekinumab (Stelara) for Crohn’s Disease
An excerpt:
The US Food and Drug Administration (FDA) has approved ustekinumab (Stelara, Janssen Biotech, Inc) for the treatment of moderately to severely active Crohn’s disease in patients aged 18 years or older.
Specifically, the interleukin-12/23 inhibitor is indicated for Crohn’s patients who have failed or were intolerant to immunomodulator or corticosteroid therapy but who never failed treatment with a tumor necrosis factor (TNF) blocker or who failed or were intolerant to treatment with one or more TNF blockers, according to a company news release.
Ustekinumab is already approved in the United States for treatment of patients with plaque psoriasis and psoriatic arthritis…The clinical development program for ustekinumab for Crohn’s disease included more than 1300 patients across three pivotal phase 3 studies, which served as the primary basis for FDA approval.
In clinical studies of patients who were either new to, experienced with, or failed anti-TNF therapy, between 34% and 56% of patients experienced symptom relief in the 6 weeks after receiving a one-time intravenous induction dose of ustekinumab. “Noticeable improvement was observed as early as 3 weeks,” the company said.
Most patients who responded to induction dosing and who continued ustekinumab treatment with subcutaneous maintenance doses every 8 weeks were in remission at the end of 44 weeks (52 weeks from initiation of the induction dose), the company said.
Full prescribing information and a medication guide are available online.
The Indispensable Physician
A recent pair of commentaries (RM Wachter, L Goldman. NEJM 2016; 375: 1009-1011, R Gunderman. NEJM 2016; 375; 1011-13) provides some insight into what has been gained and what has been lost with the proliferation of hospitalist care in the past 20 years.
The growth of hospitalist care has developed due to numerous factors:
- evidence of cost savings/better outcomes
- need for rapid evaluation of acutely ill patients/repeated evaluations which would be disruptive to efficient outpatient physician practices
Decline of comprehensive care:
- at times of extreme vulnerability when admitted to the hospital, patients have a physician assigned to them who they have probably never met. This has led to a diminishment of the patient-physician relationship.
- increasing number of physicians creates opportunities for miscommunication, particularly on admission and discharge, but also at every step of hospital care during “handoffs”
The second commentary, in particular, challenges the way medicine is evolving. This article stresses the central role of the physician as opposed to the hospital filling that role.
“The reality is that medicine can be practiced without hospitals, but hospitals cannot function without physicians.”
The goal of developing personal relationships with our patients is often at odds with work-life balance. Thus, having hospitalists and other ways of having cross-coverage, when we are unavailable, often conflict with being able to provide the best care.
My take (from 2nd commentary): “The true core of good medicine is not an institution but a relationship — a relationship between two human beings.”
Related blog posts:
- “Weekend Effect” –From the Other Side of the Bed | gutsandgrowth Are hospitals really Focused on patients or their physicians/employees?
- “I’ve Got the Best Doctor” | gutsandgrowth
- Better Discharge Planning Needed | gutsandgrowth
- Increasing Rates of Professional Burnout | gutsandgrowth
- “It is never boring to be a physician” | gutsandgrowth
Glacier Nat’l Park
Newborn Bilirubin Measurements To Identify Biliary Atresia
It is remarkable how tricky making a diagnosis of biliary atresia can be, even when one has seen the presentation many times. For parents and many providers, one of the pitfalls includes the inability of recognizing acholic stools. To identify biliary atresia, promotion of stool color cards, over the last two decades, has not been very effective. To address this problem, a recent study (S Harpavat et al. JPGN 2016; 62: 799-803) describes the use of direct or conjugated bilirubin measurements in the newborn period. This study was conducted between 2009-2011.
As with previous studies, 35 infants with biliary atresia all had elevated direct bilirubin. In the non-biliary atresia group, 8936 of 9102 infants had direct bilirubin measurements within the laboratory’s reference range. Thus, this study suggests that newborn direct bilirubin has a sensitivity 100% and specificity of 98.2%.
In a related publication, the same group published a letter to the editor (NEJM 2016; 2016; 375: 605-6) that describes a prospective two-stage screening of newborns for biliary atresia. Of 11,636 infants included over a 15-month period, 121 were identified who had direct-bilirubin >95% reference interval in their laboratory. At a median of 14 days, 11 remained abnormal: 2 had biliary atresia. Overall, they state the net sensitivity was 100%, then net specificity of 99.9%, and the positive predictive value was 18.2%.
Related blog posts:
- Diagnosing biliary atresia earlier | gutsandgrowth
- Helpful Review on Biliary Atresia | gutsandgrowth
- Biliary Atresia More Common in Preterm Infants | gutsandgrowth
- NASPGHAN Awards 2014 | gutsandgrowth
- NASPGHAN Postgraduate Course 2014 -Liver Module | gutsandgrowth
Sullivan’s Island, SC
NEJM: Generic Drug Price Increases
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Biotin Supplementation and Thyroid Laboratory Results
Biotin, which is a water-soluble vitamin, is given in several genetic conditions and often used as a supportive treatment in mitochondrial disorders. A recent report (S Kummer et al. 2016; 375: 704-6 Letter to Editor) noted six children ages 1 mo-9 yrs with markedly abnormal thyroid studies who were receiving biotin. The results mimicked Graves’ disease with high free thyroxine levels, low thyrotropin levels, and elevated anti-thyrotropin receptor antibodies.
After stopping biotin, these biochemical abnormalities resolved in 48 hrs for free T4/TSH and 7 days for anti-thyrotropin receptor antibodies.
My take: High-dose biotin can create concerning laboratory profile of Graves’ disease. Awareness of this phenomenon is important for endocrinologists and pediatric gastroenterologists as well.
Glacier Nat’l Park
Image Only: Suicide Rates by Age Groups
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Image Only: Gastric Ascaris
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Small Pediatric IBD Studies …Briefly Noted
G Wahbeh et al. JPGN 2016; 63: 348-51. This retrospective case series with 4 children (aged 12-17 years) indicated that 2 had a ‘clinical response’ to ustekinumab therapy, though one of these had ongoing elevation of CRP. The dosing may have been too low: 90 mg at week 0 and 4, then every 8 weeks. My take: This study shows that ustekinumab’s use in pediatric IBD seems to be a ‘shot in the dark’ given the lack of coherent data.
Related posts:
- More on Ustekinumab, plus Allopurinol Study | gutsandgrowth
- Using Ustekinumab for Crohn’s Disease | gutsandgrowth
L Zimmerman et al. JPGN 2016; 63: 352-56. Among a cohort of 123 children who had underwent a bowel resection, from 1977-2011, the overall postoperative complication rate was 13%. This included 3 of 24 who had prior infliximab and 9 of 99 who had not received infliximab. It is noteworthy that the infliximab group had more corticosteroid exposure. The authors concluded that preoperative infliximab was not associated with increased complications but noted that their sample size was small. My take: Studies of adults with Crohn’s disease have yielded conflicting results on whether preoperative infliximab increases the risk of complications. This study shows that children likely have a lower rate of postsurgical complications and more pediatric specific data are needed.
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