Perspectives from military neonatal transport: past, present, and future.

This article traces the historical development of neonatal transport, from ancient Greek mythology to the modern era, with a particular focus on the contributions of U.S. military aviation. The narrative begins with early efforts in thermoregulation through stationary incubators and progresses to the pivotal role of aerial hospitals during World War II. Post-WWII, the establishment of neonatal transport services in New York and advancements in incubator technology set the stage for further innovation. The U.S. military's involvement in neonatal transport, initiated in the 1970s, witnessed significant milestones, including the adaptation of ECMO technology for air transport. The narrative unfolds through the lens of U.S. military neonatology in the Western Pacific, particularly at Clark Air Base. The article concludes with insights into the U.S. Indo-Pacific Command's neonatal transport mission, highlighting challenges faced during the SARS-CoV-2/COVID-19 pandemic and the development of specialized infection containment transport systems.

Qualitative Analysis of the Lived Experience of Reproductive and Pediatric Health Care in the Military Health Care System.

INTRODUCTION: Persistent inequities exist in obstetric and neonatal outcomes in military families despite universal health care coverage. Though the exact underlying cause has not been identified, social determinants of health may uniquely impact military families. The purpose of this study was to qualitatively investigate the potential impact of social determinants of health and the lived experiences of military individuals seeking maternity care in the Military Health System. MATERIALS AND METHODS: This was an Institutional Review Board-approved protocol. Nine providers conducted 31 semi-structured interviews with individuals who delivered within the last 5 years in the direct or purchased care market. Participants were recruited through social media blasts and clinic flyers with both maximum variation and homogenous sampling to ensure participation of diverse individuals. Data were coded and themes were identified using inductive qualitative research methods. RESULTS: Three main themes were identified: Requirements of Military Life (with subthemes of pregnancy notification and privacy during care, role of pregnancy instructions and policies, and role of command support), Sociocultural Aspects of the Military Experience (with subthemes of pregnancy as a burden on colleagues and a career detractor, postpartum adjustment, balancing personal and professional requirements, pregnancy timing and parenting challenges, and importance of friendship and camaraderie in pregnancy), and Navigating the Healthcare Experience (including subthemes of transfer between military and civilian care and TRICARE challenges, perception of military care as inferior to civilian, and remote duty stations and international care). CONCLUSIONS: The unique stressors of military life act synergistically with the existing health care challenges, presenting opportunities for improvements in care. Such opportunities may include increased consistency of policies across services and commands. Increased access to group prenatal care and support groups, and increased assistance with navigating the health care system to improve care transitions were frequently requested changes by participants.

Utility of the Neonatal Early-Onset Sepsis Calculator in a Low-Risk Population.

OBJECTIVE: To compare early-onset sepsis (EOS) risk estimation and recommendations for infectious evaluation and/or empiric antibiotics using a categorical risk assessment versus the Neonatal Early-Onset Sepsis Calculator in a low-risk population. STUDY DESIGN: Retrospective chart review of late preterm (≥350/7-366/7 weeks' gestational age) and term infants born at the Brooke Army Medical Center between January 1, 2012 and August 29, 2019. We evaluated those born via cesarean section with rupture of membranes (ROM) < 10 minutes. Statistical analysis was performed to compare recommendations from a categorical risk assessment versus the calculator. RESULTS: We identified 1,187 infants who met inclusion criteria. A blood culture was obtained within 72 hours after birth from 234 (19.7%) infants and 170 (14.3%) received antibiotics per routine clinical practice, using categorical risk assessment. Respiratory distress was the most common indication for evaluation, occurring in 173 (14.6%) of patients. After applying the Neonatal Early-Onset Sepsis Calculator to this population, the recommendation was to obtain a blood culture on 166 (14%), to start or strongly consider starting empiric antibiotics on 164 (13.8%), and no culture or antibiotics on 1,021 (86%). Utilizing calculator recommendations would have led to a reduction in frequency of blood culture (19.7 vs. 14%, p < 0.0001) but no reduction in empiric antibiotics (14.3 vs. 13.8%, p = 0.53). There were no cases of culture-proven EOS. CONCLUSION: This population is low risk for development of EOS; however, 19.7% received an evaluation for infection and 14.3% received antibiotics. Utilization of the Neonatal Early-Onset Sepsis Risk Calculator would have led to a significant reduction in the evaluation for EOS but no reduction in antibiotic exposure. Consideration of delivery mode and indication for delivery may be beneficial to include in risk assessments for EOS. KEY POINTS: · Cesarean section with rupture of membranes at delivery confers low risk for EOS.. · Respiratory distress often triggers an EOS evaluation.. · Delivery mode should be considered in EOS risk..

Readmission Reduction for Hyperbilirubinemia in Infants ≥ 35 Weeks Estimated Gestational Age Using a Standardized Protocol.

BACKGROUND: Most newborns experience hyperbilirubinemia. Monitoring and treatment must be balanced with the risk of unintended harm, including readmission to the birth hospital. From January 2019 to April 2021, the average rate of inborn readmission for all causes was 2.09% at the study hospital; hyperbilirubinemia accounted for 91% of these readmissions. The aim of this project was to decrease readmission rate for hyperbilirubinemia by 60% within eight months of protocol implementation. METHODS: The Lean system of quality improvement was used to assess root causes and implement countermeasures. A hyperbilirubinemia protocol was developed, and phototherapy equipment was upgraded. Monthly readmission rates were the main outcome measure. Process measures included hour of life for initial transcutaneous bilirubin measurement. Balance measures included number of serum bilirubin labs obtained per 100 infants, percentage treated with phototherapy, mean length of phototherapy treatment, and length of hospital stay. Statistical process control charts were used to measure changes in quality over time. RESULTS: Baseline data showed a monthly readmission rate for hyperbilirubinemia of 1.9%. Following countermeasure implementation, there was a clinically significant downward shift in the monthly readmission rate to 0.64%, representing a 66% decrease from baseline. CONCLUSION: Implementation of the project protocol was associated with a clinically significant decrease in readmissions for hyperbilirubinemia with no concurrent clinically significant changes in the number of labs drawn, number of infants started on phototherapy, or average length of hospital stay. For military treatment facilities or institutions with similar staffing models, this protocol may offer a model for improvement.

A Multimodal, Resident-led Newborn Emergencies Night Curriculum.

INTRODUCTION: Following graduate medical education duty hour reform, many programs have migrated to a night float model to achieve duty hour compliance. This has led to increased focus on optimizing nighttime education. A 2018 internal program evaluation of the newborn night rotation revealed that most pediatric residents received no feedback and perceived little didactic education during their four-week, night float rotation. One hundred percent of resident respondents were interested in increased feedback, didactics, and procedural opportunities. Our objective was to develop a newborn night curriculum to ensure timely formative feedback, enhance trainee didactic experience, and guide formal education. MATERIALS AND METHODS: A multimodal curriculum was designed to include senior resident-led, case-based scenarios, a pre- and post-test, a pre- and post-confidence assessment, a focused procedure "passport," weekly feedback sessions, and simulation cases. The San Antonio Uniformed Services Health Education Consortium implemented the curriculum starting from July 2019. RESULTS: Thirty-one trainees completed the curriculum in over 15 months. There was a 100% pre- and post-test completion rate. Test scores rose from an average of 69% to 94% (25% increase, P < .0001) for interns and an average of 84% to 97% (13% increase, P < .0001) for third-year residents (PGY-3s). When averaged across domains assessed, intern confidence rose by 1.2 points and PGY-3 confidence rose by 0.7 points on a 5-point Likert scale. One hundred percent of trainees utilized the on-the-spot feedback form to initiate at least one in-person feedback session. CONCLUSIONS: As resident schedules evolve, there is an increased need for focused didactics during the night shift. The results and feedback from this resident-led and multimodal curriculum suggest that it is a valuable tool to improve knowledge and confidence for future pediatricians.

Newborn medication adherence and childhood under-immunization in military beneficiaries.

BACKGROUND: The American Academy of Pediatrics recommends birth doses of vitamin K, erythromycin ointment, and the hepatitis B vaccine, but the relationship between birth medication administration and childhood immunization compliance is understudied. The objective of this study is to evaluate rates of newborn medication administration, and risk factors for refusal in military beneficiaries and determine the relationship between medication refusal and under-immunization at 15 months. METHODS: A retrospective chart review was completed for all term and late preterm infants born at Brooke Army Medical Center, San Antonio, TX, from January 1, 2016, to December 31, 2019. The electronic medical record was queried for birth medication administration, maternal age, active-duty status, rank, and birth order. Childhood immunization records were extracted for all patients who continued care at our facility. A patient was considered completely immunized if they had received at least 22 vaccines by 15 months: three doses of the hepatitis B vaccine [PediarixTM], two doses of the rotavirus vaccine [RotarixTM], four doses of the DTAP vaccine [PediarixTM and Acel-ImmuneTM], three doses of Haemophilus influenza B vaccine [PedvaxhibTM], four doses of pneumococcal [Prevnar 13TM], three doses of IPV [PediarixTM], one dose of measles, mumps, and rubella [MMRTM], one dose of varicella [VarivaxTM] and one dose of hepatitis A vaccine [HarvixTM]. RESULTS: Seven thousand one hundred and forty infants were included; 99.3% received vitamin K, 98.8% received erythromycin ointment, and 93.8% received the hepatitis B vaccine. Refusal of the erythromycin ointment and hepatitis B vaccine was associated with older maternal age and higher birth order. Childhood immunization records were available for 607 infants; 7.2% (n = 44) were under-immunized by 15 months, with no infants being non-immunized. Refusal of the hepatitis B vaccine (RR: 2.9 (CI 1.16-7.31)) only at birth was associated with a higher risk of being under-immunized. CONCLUSIONS: Refusal of the hepatitis B vaccine in the nursery is associated with a risk of being under-immunized in childhood. Obstetric and pediatric providers should be aware of this association for appropriate family counseling.

Neonatal mortality and disparities within the military health system.

INTRODUCTION: Racial disparity exists in U.S. neonatal mortality; Black, non-Hispanic neonates are at higher risk of death. We aim to examine overall and race-specific neonatal mortality within the Military Health System (MHS). METHODS: Retrospective cohort study of infants delivered within the MHS between 2013-2015. Variables were extracted from the Military Health System Data Repository. RESULTS: There were 320,283 live births within the MHS from 2013-2015; 588 neonates died, a death rate of 1.84/1000. Cohort neonatal mortality and incidence of preterm delivery (7.2%) were lower than concurrent U.S. STATISTICS: Black, non-Hispanic neonates had a 2-fold increased risk of death (OR: 2.11; 95% CI 1.73-2.56, p < 0.001) over White, non-Hispanic neonates. Officer versus enlisted rank conferred no difference in neonatal mortality (OR: 0.88; 95% CI 0.74-1.03). CONCLUSION: Neonatal mortality within the MHS is lower than in the U.S. Despite universal insurance coverage and access to care, racial disparity persists. Risk of death is not modified by socioeconomic status. These findings highlight the need for critical examination of healthcare equity within neonatal-perinatal medicine.

Early Antibiotic Exposure in Low-Risk Late Preterm and Term Infants.

OBJECTIVE: This study aimed to examine the epidemiology of antibiotic exposure and early onset sepsis (EOS) in late preterm and term infants born via cesarean section with rupture of membranes less than 10 minutes. STUDY DESIGN: Retrospective review of 1,187 late preterm and term infants born at Brooke Army Medical Center between January 1, 2012 and August 29, 2019. Subjects were assessed for factors related to antibiotic treatment. Statistical analysis was performed to compare infants treated with antibiotics versus observation. RESULT: An early blood culture was obtained from 234 (19.7%) infants; 170 (14.3%) were treated with antibiotics. Infants treated with antibiotics were significantly younger (p < 0.0001), smaller (p < 0.0001), more often diagnosed with respiratory distress (p < 0.0001), and were more frequently admitted to the neonatal intensive care unit (p < 0.0001). There were no cases of culture proven EOS. CONCLUSION: Although this population lacks risk factors for the development of EOS, a significant percentage was treated with antibiotics. This population may benefit from future antibiotic stewardship efforts. KEY POINTS: · This population is at risk for respiratory morbidity.. · There were no cases of culture proven early onset sepsis.. · This is a group of interest for antibiotic stewardship..

Urinary tract infection is common in VLBW infants.

OBJECTIVE: Determine the significance of urinary tract infection (UTI) as a cause of late onset sepsis (LOS) in very low birth weight (VLBW) infants in the Neonatal Intensive Care Unit (NICU). STUDY DESIGN: Analysis of blood, cerebrospinal fluid and urine culture results in VLBW infants >72-h old, admitted to the Georgetown University Hospital NICU between 2005 and 2015. RESULT: Of 527 VLBW infants, 297 (56.4%) underwent 911 evaluations for LOS; only one-third included urine cultures. UTI was diagnosed in 8.5% of VLBW infants (range 2-15.9%) and in 13.8% of infants weighing < 1000 g at birth. Gram-negative infections predominated. Concomitant blood cultures were negative in 96% of infants. UTI was more common than bloodstream infection by 2015. CONCLUSION: UTI is a significant cause of infection in VLBW infants. Urine culture should be included in all LOS evaluations in order to facilitate accurate diagnosis and appropriate antibiotic therapy.

Intrauterine Herpes Simplex Virus Infection Presenting as a Zosteriform Eruption in a Newborn.

There is significant morbidity and mortality associated with the transmission of herpes simplex virus (HSV) from pregnant women to their fetus or newborn. Although most commonly transmitted in the peripartum period, in rare cases HSV can lead to intrauterine infection. Cutaneous lesions are the most common manifestation of intrauterine HSV, and have a wide spectrum of presentation. We present a rare case of intrauterine HSV-2 infection presenting with a zosteriform eruption mimicking congenital varicella syndrome in a newborn.