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Ending the Culture of Culture-Negative Sepsis in the Neonatal ICU


DOI: 10.1542/peds.2017-0044
Sepsis is a major cause of morbidity and mortality among infants in the NICU. Because septic infants present with nonspecific clinical findings, providers are justifiably concerned about missing sepsis. Blood cultures are the gold standard for diagnosis of sepsis, and when adequate volumes are obtained, cultures have excellent sensitivity even when the infant has very low levels of bacteremia.1 However, many providers view sterile culture results with skepticism, especially when the infant appears ill or received antibiotics before cultures were obtained. Therefore, we have developed a culture (no pun intended) of acceptance in treating “culture-negative” sepsis. Recent reports suggest that up to 10 times as much antibiotic is used for culture-negative sepsis as for culture-proven sepsis.2,3 This practice must stop. The evidence for unintended harm caused by prolonged or unnecessary antibiotic exposure continues to mount and includes increased risk for obesity, atopy, and, for preterm infants, necrotizing enterocolitis, sepsis, bronchopulmonary dysplasia, and death.4 Why then do providers view sterile cultures with such skepticism?
The first reason is that providers have all-too-frequent experiences with cultures that are obtained incorrectly. Blood cultures collected inappropriately cannot be trusted, but such cultures, unfortunately, are a common problem. The recommendation is that a minimum of 1 mL of blood, either in 1 culture or divided into 2 0.5 mL cultures, be obtained from infants …


Monitoring the Postnatal Growth of Preterm Infants: A Paradigm Change


DOI: 10.1542/peds.2017-2467
There is no consensus regarding how the growth of preterm infants should be monitored or what constitutes their ideal pattern of growth, especially after term-corrected age. The concept that the growth of preterm infants should match that of healthy fetuses is not substantiated by data and, in practice, is seldom attained, particularly for very preterm infants. Hence, by hospital discharge, many preterm infants are classified as postnatal growth–restricted. In a recent systematic review, 61 longitudinal reference charts were identified, most with considerable limitations in the quality of gestational age estimation, anthropometric measures, feeding regimens, and how morbidities were described. We suggest that the correct comparator for assessing the growth of preterm infants, especially those who are moderately or late preterm, is a cohort of preterm newborns (not fetuses or term infants) with an uncomplicated intrauterine life and low neonatal and infant morbidity. Such growth monitoring should be comprehensive, as recommended for term infants, and should include assessments of postnatal length, head circumference, weight/length ratio, and, if possible, fat and fat-free mass. Preterm postnatal growth standards meeting these criteria are now available and may be used to assess preterm infants until 64 weeks’ postmenstrual age (6 months’ corrected age), the time at which they overlap, without the need for any adjustment, with the World Health Organization Child Growth Standards for term newborns. Despite remaining nutritional gaps, 90% of preterm newborns (ie, moderate to late preterm infants) can be monitored by using the International Fetal and Newborn Growth Consortium for the 21st Century Preterm Postnatal Growth Standards from birth until life at home.