Hospital Readmissions Among Infants With Neonatal Opioid Withdrawal Syndrome.

Importance: Although cases of neonatal opioid withdrawal syndrome (NOWS) increased 5-fold in recent years, no study has examined national hospital readmission rates for these infants. Objective: To examine hospital readmissions for infants with and without NOWS. Design, Setting, and Participants: This retrospective cohort study analyzed serial cross-sectional samples of US hospital discharge records from the Nationwide Readmissions Database for calendar years 2016 to 2020. Infants with NOWS were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The data analysis was performed between January 5, 2023, and May 6, 2024. Exposure: Neonatal opioid withdrawal syndrome. Main Outcome and Measures: Survey-weighted logistic regression was used to examine 90-day all-cause and cause-specific hospital readmissions. Multivariable models adjusted for sex, low birth weight, gestational age, multiple gestation, type of insurance, and year of birth. Results: Of the 13 855 246 newborns identified in this weighted analysis, 89 018 (0.6%) were diagnosed with NOWS, of whom 53.8% were male and 81.1% born full-term (>36 weeks gestation). The 90-day all-cause readmission rate was 4.2% for infants with NOWS compared with 3.0% for those without NOWS (P < .001). After risk adjustment, the odds of all-cause readmission were higher among infants with NOWS (adjusted odds ratio [AOR], 1.18; 95% CI, 1.08-1.29). Infants with NOWS had significantly higher odds of readmissions for seizures (AOR, 1.58; 95% CI, 1.01-2.46), failure to thrive (AOR, 1.99; 95% CI, 1.36-2.93), traumatic brain injury (AOR, 2.95; 95% CI, 1.76-4.93), and skull fractures (AOR 3.72; 95% CI, 2.33-5.93). Infants with NOWS had higher odds of receiving a diagnosis of confirmed maltreatment (AOR, 4.26; 95% CI, 2.19-8.27), including for neglect (AOR, 14.18; 95% CI, 5.55-36.22) and physical abuse (AOR, 2.42; 95% CI, 0.93-6.29); however, the latter finding was not statistically significant. Conclusions and Relevance: In this nationally representative cohort study, infants with NOWS were at increased risk of readmission for any cause as well as for trauma and confirmed maltreatment. These findings may in part reflect the dual stressors that mothers with opioid use disorder face in caring for a newborn with NOWS in the context of a substance use disorder and underscore the need for family-based, in-home services that focus concurrently on substance use treatment and parenting support.

Professional Guidelines for the Care of Extremely Premature Neonates: Clinical Reasoning versus Ethical Theory.

AbstractProfessional statements guide neonatal resuscitation thresholds at the border of viability. A 2015 systematic review of international guidelines by Guillen et al. found considerable variability between statements' clinical recommendations for infants at 23-24 weeks gestational age (GA). The authors concluded that differences in the type of data included were one potential source for differing resuscitation thresholds within this "ethical gray zone." How statements present ethical considerations that support their recommendations, and how this may account for variability, has not been as rigorously explored. We performed a mixed-methods exploratory analysis of 25 current international guidelines for neonatal resuscitation at 22+0-25+0 weeks GA. Qualitative analysis using a modified grounded theory yielded 34 distinct codes, eight categories, and four overarching themes. Three themes, consequentialism, principlism, and rights-based, consisted of concepts central to these ethical frameworks. The fourth theme, clinical reasoning, described counseling practices, medical management, outcomes data, and prognostic uncertainty, without any ethical context. The theme of clinical reasoning appeared in 22 of 25 guidelines. Ten guidelines lacked any ethical theme. Guidelines with an identified ethical theme were more likely to recommend comfort care than guidelines without an identified ethical theme, and recommended it at a higher average GA (22.7 weeks vs. 22.0 weeks, p = 0.03). Thus, how ethical concepts are incorporated into guidelines potentially impacts resuscitation thresholds. We argue that inclusion of explicit discussion of ethical considerations surrounding resuscitation in the "gray zone" would clarify values that inform recommendations and facilitate discussions about how neonatology ought to approach periviability as outcomes continue to evolve.

Does Maternal Incarceration Impact Infants with Neonatal Abstinence Syndrome?

OBJECTIVES: Opioid exposed infants born to incarcerated women represent a vulnerable and understudied subset of infants with neonatal abstinence syndrome (NAS). The impact of maternal incarceration on length of stay (LOS) for infants with NAS is unknown. We hypothesized that infants with NAS born to incarcerated women have longer hospitalizations compared to infants with NAS born to non-incarcerated women. METHODS: This is a retrospective cohort study of infants with NAS born between 2011 and 2018 at the primary delivery site for Connecticut's only women's prison. Opioid exposed infants were assessed by Finnegan Scores for withdrawal and received morphine as a first line agent and phenobarbital as a second line agent. LOS was compared using Poisson regression. RESULTS: Of 206 infants identified, 166 were included in the analysis, with 28 born to incarcerated women and 138 to non-incarcerated women. Incarcerated women were more likely to report prenatal alcohol use, 14.3% vs 2.2% p = 0.016 and benzodiazepine use 21.4% vs 7.3% p = 0.032. Infants of incarcerated women were less likely to be fed breast milk at discharge, 3.6% vs 37% p < 0.001. Adjusted mean LOS was longer among infants born to incarcerated women, 18.5 vs 16.6 days (p = 0.009). CONCLUSIONS FOR PRACTICE: Infants with NAS born to incarcerated women in Connecticut had longer LOS, lower rates of being fed breast milk, and different prenatal substance exposures than infants with NAS born to non-incarcerated women. Supporting the maternal-infant dyad until infant discharge may mitigate the potential negative impact of maternal incarceration on the care of infants with NAS.

How to hold an effective NICU family meeting: capturing parent perspectives to build a more robust framework.

OBJECTIVE: To record the content and parental perceptions of family meetings in a Neonatal Intensive Care Unit (NICU) to improve existing frameworks for facilitating these meetings. STUDY DESIGN: A prospective, mixed-methods study. NICU family meetings were audio-recorded, transcribed, and analyzed by an iteratively derived coding framework until thematic saturation. We used descriptive statistics of parental post-meeting assessments. RESULTS: Qualitative analysis of 21 meetings identified both Communication Facilitators and Barriers. Facilitators included use of visual-aids and participation of social workers to clarify information for parents. Barriers included staff rarely eliciting parental comprehension (3 meetings) or concerns (5) before providing new information, resulting in 39% of parents reporting they didn't ask questions they wanted to ask. In 33% of meetings an important participant was absent. CONCLUSIONS: This novel qualitative and quantitative dataset of NICU family meetings highlights areas for improving communication. Attention to these components may improve parental perceptions of family meetings.

Constructing a Culturally Informed Spanish Decision-Aid to Counsel Latino Parents Facing Imminent Extreme Premature Delivery.

Objective How Latino parents perceive and understand antenatal counseling for extreme prematurity, < 26 weeks of gestational age (GA), is not clear. We aim to characterize Latino parental perceptions of antenatal counseling in order to construct and validate a Spanish decision-aid (SDA) to improve parental knowledge of prematurity after antenatal consults. Methods This is a three-phased, prospective, multicenter study. First, interviews of 22 Latino parents with a history of birth < 26 weeks GA were conducted. Thematic analysis identified themes valued during antenatal counseling for decisions regarding neonatal resuscitation. Next, we incorporated these themes into the SDA. Finally, improvement in knowledge of prematurity in two Spanish-speaking groups, 'experienced' parents with a history of extremely premature birth and 'naïve' adult Latino volunteers, was measured using a multiple choice test before and after simulated counseling with the SDA. Result Twenty-two interviews generated seven unique themes. An SDA was constructed that preserved six themes paralleled by those found in a previously studied English population, and addressed a novel theme of "intercultural linguistic barriers" unique to our population. Knowledge scores rose in "naive" volunteers, 41 ± 12% to 71 ± 15% (P < 0.001), after simulated counseling with the SDA. 'Experienced' parents had a ceiling effect in knowledge scores, 62 ± 9% to 65 ± 11% (P = 0.22). The SDA was well received by participants. Conclusions for Practice Interviews of Latino parents with a history of premature birth generated similar themes to English-speaking parents, with intercultural linguistic barriers as a novel theme. An SDA for Latino parents facing extremely premature birth may improve comprehension of antenatal counseling.

All-trans-retinoic acid-induced scrotal ulcers in a patient with acute promyelocytic leukemia.

Acute promyelocytic leukemia (APL) accounts for 10% of acute myelocytic leukemias and is characterized by t(15;17) that produces the PML-RARα (promyelocytic leukemia-retinoic acid receptor α) fusion oncoprotein. The discovery and implementation of all-trans-retinoic acid (ATRA) therapy for APL has led to complete remission rates greater than 90% when coupled with chemotherapy. We report a novel case of ATRA-induced scrotal ulcers in a black man with APL. The differential diagnosis of scrotal ulcerations in immunocompromised patients is lengthy, and misdiagnosis can lead to substantial morbidity and mortality. It is important for dermatologists to be aware of this potential complication of ATRA therapy.

Are family characteristics associated with attendance at family centered rounds in the PICU?.

OBJECTIVE: The objective of this study was to identify if family characteristics or opinions affected participation in family centered rounds. DESIGN: Observational study of 431 patient encounters on daily work rounds, followed by 100 questionnaires completed by family members of patients in the unit during observation. SETTING: PICU at a tertiary care, academic, free-standing children's hospital. SUBJECTS: Patients and families admitted to the PICU during the observation period. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The most frequent family members present for rounds were mothers (40%). Race, educational level, age of the family member, age of the child, whether the admission was expected, and whether the family member was a medical professional had no association with whether the family member attended rounds. Both family members who were present and those who were not present felt being at rounds would improve the care of their child (87% vs. 100%, p = 0.57). A family's response that they preferred to attend rounds was the only factor associated with a higher likelihood of attending rounds (odds ratio 3.4, 95% confidence interval 1.1-10.8, p = 0.03). CONCLUSION: Families feel that participating in family centered rounds improves the care of their children. Those that like attending rounds are more likely to participate in family centered rounds, but family demographic characteristics were not associated with rounds attendance. Future studies are needed to identify barriers to family participation in family centered rounds.