Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal disease which mostly occurs in very low birth weight (VLBW) infants. In addition to decreasing gestational age (GA) or birth weight (BW), artificial formula, delayed initiation or rapidly advanced feeding, severe anemia and systemic infections were associated with NEC. Several studies demonstrated that breast milk, standardized feeding advancement regimens and treatment of anemia are associated with less incidence of NEC. It is not known if including all these interventions in one multifaceted program will lead to significant reduction in NEC. The NICU team at The George Washington University Hospital created a multifaceted interdisciplinary quality improvement project to tackle several aspects of NEC prevention that addressed researched risk factors for NEC. The program was made of four quality improvement protocols: 1) Standardized Structured Feeding Program, 2) Feeding Intolerance Management Algorithm, 3) Enteral Osmolality Control Tool, and 4) Packed Red Blood Cell (RBC) Standardized Transfusion Protocol. This time-series, quasi experimental study design examined the differences in the incidence of NEC between infants with BW < 1500 g who were admitted to the GW Hospital NICU before and after the program implementation. Data from 408 VLBW infants were included in the study. Although not statistically significant, there was a decreasing trend of NEC incidence in the post-implementation group (n = 199) compared to the pre-implementation group (n = 209), (3.5% vs. 5.3%, p = 0.88). The trend in the incidence of NEC declined further after the introduction of RBC transfusion protocol which was introduced ten month after starting the other elements of the program. Integration of the multifaceted quality improvement program may be associated with a decline in the occurrence of NEC. Further analysis with a larger sample size is required to determine if the changes seen are statistically significant.

Objective Cue-based feeding aims at matching introduction of per oral (PO) feeding with physiological readiness of preterm infants to facilitate PO intake and avoid oral aversion. It was claimed that cue-based feeding may lead to delay in the initiation or achieving full PO feeding in clinical setting primarily using bubble nasal continuous positive airway pressure (CPAP). The study aimed to examine the association of cue-based feeding with time of introduction and completing oral feeding in infants primarily managed with bubble CPAP. Study Design A retrospective analysis where outcomes of preterm infants ≤32 weeks' gestational age (GA) and ≤2,000 g birth weight (BW) were compared after a practice change from volume-based feeding advancement to cue-based feeding. Continuous variables were compared by using t-test and multilinear regression analysis to control for confounding variables. Results Of the 311 preterm infants who met inclusion and exclusion criteria, 194 were in the cue-based feeding group and 117 were in the volume-based advancement historical comparison group. There were no differences between groups regarding demographic or clinical variables. Postmenstrual age (PMA) of initial feeding assessment was less in the cue-based feeding group. Age of first PO feeding and when some PO was achieved every feed was mildly delayed in the cue-based feeding compared with comparison group, 34 (±1.3) versus 33.7 (±1.2) weeks, and 36.2 (±2.3) versus 36.0 (±2.4) weeks, (p < 0.01) respectively. However, the age of achieving full PO did not differ between groups, 36.8 (±2.2) versus 36.4 (±2.4) weeks (p = 0.13). There was no difference between groups regarding growth parameters at 36 weeks' PMA or at discharge. Similar results were obtained when examining subcategories of infants ≤1,000 g and 1,001 to 2,000 g. Conclusion Cue-based feeding may not be associated with a delay in achieving full oral feeding or prolongation of the length of stay in preterm infants managed with CPAP. Key Points

Objectives Our objective was to investigate the prevalence of small intestinal atresia and Hirschsprung's disease (HD) in infants with Down syndrome (DS) and its impact on outcomes. Study Design We analyzed the National Inpatient Sample dataset. We included infants with DS, small intestinal atresia, HD, and the concomitant occurrence of both conditions. Regression analysis was used to control clinical and demographic variables. Results A total of 66,213,034 infants were included, of whom, 99,861 (0.15%) had DS. The concomitant occurrence of small intestinal atresia and HD was more frequent in infants with DS compared with the general population, adjusted odds ratio (aOR): 122, 95% confidence interval (CI): 96–154, (p < 0.001). Infants with DS and concomitant small intestinal atresia and HD had higher mortality compared with those without these conditions, aOR: 8.59, 95% CI: 1.95–37.8. Conclusion Infants with DS are at increased risk of concomitant small intestinal atresia and HD, and this condition is associated with increased mortality. Key Points

Objective: To examine the changes over recent years in neonatal survival to discharge, prevalence of adverse events, surgical procedures, tracheostomy and/or gastrostomy tube (G-tube) placement, and length of stay (LOS) in infants with Trisomy 13. Methods: We identified newborn infants with Trisomy 13 in the National Inpatient Sample in the years 2003–2018. We calculated prevalence of associated conditions. We examined procedures done, and common adverse events associated with each condition, survival rates, and LOS. We also calculated changes in trends over the years. Results: The study identified 5792 newborn infants with Trisomy 13. Mortality during neonatal period was 58%. There was no significant change in mortality trends over the years, (p < 0.001). Average LOS was 10 (+ 34) days which had significantly increased over recent years (p < 0.001) and it was highest in conditions of NEC followed by gastrointestinal anomalies and sepsis. Among survivors, 2% were discharged with tracheostomy and 9% with G-tubes. LOS was significantly increased in association with these procedures. Conclusion: There was a slight decrease in infants admitted to neonatal intensive care units with Trisomy 13 over recent years. In-hospital neonatal mortality was unchanged. However, there was a significant increase in LOS, which was increased with procedures such as tracheostomy and G-tube placement, which may reflect a trend toward increasing interventions without a corresponding improvement in mortality.