This perspective work by academic neonatal providers is written specifically for the audience of newborn care providers and neonatologists involved in neonatal hypoglycemia screening. Herein, we propose adding a screen for congenital hyperinsulinism (CHI) by measuring glucose and ketone (i.e., β-hydroxybutyrate (BOHB)) concentrations just prior to newborn hospital discharge and as close to 48 h after birth as possible, at the same time that the mandated state Newborn Dried Blood Spot Screen is obtained. In the proposed protocol, we do not recommend specific metabolite cutoffs, as our primary objective is to simply highlight the concept of screening for CHI in newborns to newborn caregivers. The premise for our proposed screen is based on the known effect of hyperinsulinism in suppressing ketogenesis, thereby limiting ketone production. We will briefly discuss genetic CHI, other forms of neonatal hypoglycemia, and their shared mechanisms; the mechanism of insulin regulation by functional pancreatic islet cell membrane K_ATP channels; adverse neurodevelopmental sequelae and brain injury due to missing or delaying the CHI diagnosis; the principles of a good screening test; how current neonatal hypoglycemia screening programs do not fulfill the criteria for being effective screening tests; and our proposed algorithm for screening for CHI in newborns.

Background: Avoidance of early formula feeding (EFF) and advancement of mother's own milk (MOM) in very low birth weight (VLBW) infants are important health influencers to decrease serious morbidities. Objective: To present the challenges and feeding strategy successes implemented to counteract a decline in MOM at discharge after initiation of donor milk (DM) to avoid EFF in racially and ethnically diverse VLBW infants. Patients and Methods: Retrospective review of prospectively tracked inborn surviving VLBW infants and their mothers admitted to neonatal intensive care unit from 2010 to 2020 during three feeding strategy implementations baby friendly (BF), DM program, and MOM bundle. Analysis included type of feeding (MOM, DM, or formula) and maternal with descriptive and comparative statistical analysis as indicated. Results: Analysis included 616 VLBW infants. Initiation of BF program resulted in 58.5% of infants discharged on MOM with 41.5% exposed to EFF. Initiation of the DM program resulted in a decline in EFF to 5% and decline in MOM at discharge to 26%. MOM bundle strategy resulted in an increase in MOM at discharge to 41% with sustained EFF exposure 0%. MOM at discharge varied among maternal racial and ethnic backgrounds in all epochs. Early DM use was not different among mothers by race or ethnicity with DM by African American (AA) mothers 89% > White mothers 83% > Other/Hispanic mothers 75%. MOM at discharge was lowest for AA mothers 33% < Hispanic mothers 40% < White mothers 55% < Asian/Other mothers at 60%. Conclusion: Changes in VLBW feeding strategies to avoid EFF utilizing DM can be successful among diverse maternal racial and ethnic populations. Nursing and maternal education coupled with early lactation support and attention to maternal individual long-term feeding plans were critical to improve MOM at discharge among mothers of all racial—ethnic backgrounds for successful attainment of MOM utilization in term corrected VLBW infants at discharge.

To determine the effect of supine vs prone body position on oxygenation, ventilation, and diaphragmatic workload in infants born ≤32 weeks of gestation on noninvasive neurally adjusted ventilatory assist (NAVA). This study was conducted in 2 level III-IV neonatal intensive care units. Infants were randomly assigned into 1 of 2 starting positions: supine or prone. Infants alternated between supine and prone positioning every 3 hours, for a total of 12 hours. Nursing care and feeding were done every 3 hours with position changes. Infants were allowed a period of 1 hour after nursing care before data collection resumed. Thirty subjects (22-32 weeks of gestation at birth) were included in the study. Edi peaks were lower in prone positioning; 8.61 ± 5.57 vs 9.79 ± 6.14 μV (P = .02). Edi minutes were similarly lower in the prone position; 2.76 vs 3.05 μV (P = .04). Peak airway pressure, heart rate, respiratory rate, oxygen saturation, transcutaneous carbon dioxide level, and oxygen requirements were not affected by position. When stratified by gestational age, Edi peaks remained lower in prone vs supine positioning; 8.60 ± 5.14 vs 10.14 ± 5.54 μV (P = .009). The number of clinically significant events were similar between both groups. Prone positioning is associated with lower diaphragmatic workload in infants born premature on noninvasive NAVA. Despite this, infants had comparable clinical parameters in both prone and supine positions, suggesting that nivNAVA is able to eliminate differences related to body position to provide consistent proportional and synchronized respiratory support.

Objective: Establish the feasibility of optimizing PEEP (PEEP _OPT ) using ventilator software in infants receiving prolonged invasive mechanical ventilation. Methods: A retrospective review of infants who underwent PEEP _OPT studies. Paired-t test was used to compare dynamic lung compliance (Cdyn), tidal volume (VT), and oxygen saturation (SpO ₂ ) before and after PEEP _OPT studies. Results: Fifteen infants with bronchopulmonary dysplasia and/or receiving prolonged invasive mechanical ventilation were included with a median gestational age of 24 4/7 weeks and postmenstrual age of 40 1/7 weeks at the time of the PEEP _OPT study. PEEP _OPT was different from clinically set PEEP (PEEP _SET ) in 14/15 infants; PEEP _OPT was higher in 27% and lower in 67% of infants (–2 to +5cmH ₂ O). Cdyn improved for most infants by 0.23 (0.01–0.60) mL/H ₂ O ( p < 0.001). VT increased for most infants by 1.5 (–0.5 to 3.4) mL/kg ( p < 0.001), and SpO ₂ increased by 2% (–1 to 12%). Conclusion: Assessment of PEEP _OPT using our standardized protocol is feasible, non-invasive, and provides a low-cost bedside tool. PEEP _OPT differed from PEEP _SET in most subjects, highlighting the importance of evaluating PEEP _OPT .