European Review for Medical and Pharmacological Sciences 2021; 25: 2361-2366 Prevention of neonatal ventilator-associated pneumonia through oral care with the combined use of colostrum and sodium bicarbonate D.-F. LI, C.-X. SHI, L. ZHAO, F.-Z. SHI, M.-L. JIANG, W.-Q. KANG Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China Abstract. – OBJECTIVE: This study aims to Introduction investigate the effect of oral care via the com- bined use of colostrum and sodium bicarbonate With the popularization of ventilators in the on the prevention of neonatal ventilator-associ- neonatal intensive care unit (NICU), the success ated pneumonia (VAP). rate of neonatal rescue is evidently elevated. How- PATIENTS AND METHODS: In accordance with the inclusion and exclusion criteria, 120 in- ever, ventilator-associated pneumonia (VAP) has fant patients who were hospitalized in the neo- become a major acquired infection in hospitals natal intensive care unit (NICU) from January and the main complication of invasive mechan- to October of 2019 were selected and random- ical ventilation1. VAP lengthens the mechanical ly divided into three groups (40 cases in each ventilation time and the length of stay (LOS) of group), namely, colostrum combined with sodi- infant patients and increases the incidence rate of um bicarbonate nursing (experimental group), their complications, hospitalization expense, and colostrum (control group I), and sodium bi- mortality risk2,3, thereby seriously affecting neo- carbonate (control group II) groups. The pri- mary outcomes measured included incidence natal short- and long-term prognoses. According 4,5 rates of VAP and oral infection, positive rate of to previous studies , the domestic (China) and pathogenic bacteria after sputum culture, me- foreign VAP incidence rates are 30.0%-60.0% chanical ventilation time, and length of stay and 3.0%-28.3%, respectively. Thus, preventing (LOS). neonatal VAP demands a prompt solution. RESULTS: The incidence rates of VAP and The oral cavity is the main path for pathogenic oral infection and the positive rate of pathogen- microorganisms to invade the human body. A ic bacteria after sputum culture of the experi- mental group, which were 6.67%, 10.00%, and large quantity of pathogenic and nonpathogenic 10.00%, respectively, were significantly differ- bacteria is present in the oral cavity of a healthy ent from those of control groups I and II (p < person, but saliva has an autopurification effect 0.05). The mechanical ventilation time of the ex- with strong local mucosal resistance. Bacteria perimental group was 156.07 ± 26.67 h, which can be cleared by eating and gargling. Thus, the was shortened by 9.79% and 9.43% compared flora in the oral cavity can be kept at a relative with those of control groups I and II, respective- equilibrium. Neonates have thin and tender oral ly. The LOS of the experimental group was 17.6 mucosa with abundant blood vessels, have under- ± 1.96 days, which was shortened by 17.74% and 17.50% compared with those of control groups I developed salivary glands, and produce little se- and II, respectively. The differences were statis- cretion, and their oral mucosa is dry and can easi- tically significant (p< 0.05). ly undergo injury and local infection6. Under oro- CONCLUSIONS: Oral care through the com- tracheal intubation, the oral cavity is in an open bined use of colostrum and sodium bicarbonate state with a weakened autopurification effect and can lower the VAP incidence rate of infant pa- local mucosal resistance. Thus, a large quantity tients and shorten their mechanical ventilation of bacteria can be easily reproduced in the oral time and LOS. cavity7, increasing the opportunity for oral infec- tion. El-Solh et al8 pointed out in their study that Key Words: the respiratory pathogenic bacteria of patients Colostrum, Sodium bicarbonate, Oral care, Neona- with hospital-acquired pneumonia are fairly com- tal ventilator-associated pneumonia. parable with those in their oral cavity. Zheng9 Corresponding Author: Wenqing Kang, MD; e-mail: [email protected] 2361 D.-F. Li, C.-X. Shi, L. Zhao, F.-Z. Shi, M.-L. Jiang, W.-Q. Kang compared sputum cultures of the deep trachea Rodriguez et al24 verified the safety of colostrum. and oropharynx and found that VAP pathogenic In 2013, Thibeau and Boudreaux25 reported the bacteria are highly homologous to oropharyngeal effect of oropharyngeal colostrum administra- bacteria in patients. Approximately 30%-70% of tion on neonates with very low birth weight who the tardive VAP (incubation time exceeds five received mechanical ventilation via a ventilator days) is induced by Gram-negative bacilli, most and found that the positive rates of respiratory of which are oropharyngeal bacteria10. There- secretion culture and blood culture in the oro- fore, the oral care of a mechanical ventilation pharyngeal colostrum administration group were patient is important. Huang et al11 and Wang et evidently decreased in comparison with those al12 showed that local application of sanitizer to in the control group. Zhang et al26 revealed that remove oropharyngeal bacteria can effectively breast milk (i.e., colostrum, transitional milk, and prevent VAP or reduce the VAP incidence rate. mature milk) for oral care can effectively prevent The main oral care solutions at present include neonatal VAP and shorten mechanical ventilation normal saline13, chlorhexidine14, electrolyzed ox- and LOS, but many shortcomings remain, such idizing water15, 2.0%-2.5% sodium bicarbonate as insufficient sample sizes and uncertain cura- solution, and breast milk16,17, but these solutions tive effects. According to research suggestions, have disadvantages18,19. Clinically, 2.0%-2.5% so- a set of comprehensive oral hygiene care should dium bicarbonate is most frequently used as a be carried out for patients with high VAP risk27. neonatal oral care solution to prevent VAP and This study aims to discuss the preventive effect of to inhibit fungal reproduction19. Guo et al20 have the combined use of colostrum and 2.5% sodium combined hydrogen peroxide with sodium bicar- bicarbonate for oral care on neonatal VAP. bonate in oral care and found that this treatment can effectively eliminate neonatal oral bacterial colonization and prevent neonatal VAP, thereby Patients and Methods shortening the mechanical ventilation time and the LOS of infant patients. However, hydrogen Study Object peroxide may irritate the oral mucosa even at low According to the inclusion and exclusion cri- concentrations and can lead to adverse reactions, teria (Table I), 120 infant patients who were hos- such as hypertrophy of the lingual papilla, when pitalized in the NICU from January to October used for a long time. of 2019 were selected after obtaining informed Several studies have proven that breast milk consent from their guardians, and the random contains abundant cytokines and immune agents, grouping method was used to divide the patients e.g., IgA, IgM, TGF-β, TNF-α, IL-1, IL-6, and into three groups (40 cases in each group), name- IL-8, which are always under dynamic equilib- ly, colostrum combined with sodium bicarbonate rium in vivo, thereby strengthening the resis- nursing (experimental group), colostrum (control tance of pathogenic microorganisms; exerting a group I) and sodium bicarbonate (control group protective effect on bacteriostasis, sterilization, II) groups. This study was reviewed and ap- antivirus, anti-inflammation, immunoregulation, proved by the Ethics Committee in our hospital. and anti-infection; and playing a significant role in neonatal growth and development21. Colos- Operation Steps trum is early-stage breast milk generated due In order to test the efficacy of combining colos- to tight junctions and the opening of mammary trum and sodium bicarbonate in preventing VAP, epithelial cells, and many early immune factors the experimental group received oral care with can be transferred from the mother’s blood into colostrum and 2.5% sodium. Only colostrum was the colostrum via alternative cellular pathways. applied in control group I, and the control group Therefore, colostrum contains secretory immuno- II was treated with 2.5% sodium bicarbonate globulin A (slgA), anti-inflammatory cytokines, alone. All three treatments were carried out every growth factors, lactoferrin, antioxidants, and oth- 6 h. All staff participating in this project were er protective ingredients at high concentrations22. allowed to perform treatment only after they be- In 2009, Rodriguez et al23 expounded neonatal came qualified after strict and scientific training. oropharyngeal colostrum administration from a Before oral care, oral secretions were cleared by theoretical perspective and pointed out that co- gentle vacuum aspiration. Operators were in- lostrum can provide a wide range of protection structed to (1) wash hands; (2) collect colostrum for neonates with very low birth weight. In 2010, and prepare 2.5% sodium bicarbonate solution 2362 Neonatal VAP through oral care with the use of colostrum and sodium bicarbonate Table I. Inclusion and exclusion criteria of the grouped cases. Inclusion criteria 1. NICU-hospitalized patients (gestational age = 37-42 weeks), 2. Patients needing mechanical ventilation due to diseases, 3. Patients without respiratory infection before orotracheal intubation, 4. Mechanical ventilation time ≥ two days through preliminary evaluation, and 5. Patients neither receiving a large quantity