Cost comparison of mechanically ventilated patients across the age span.

OBJECTIVE: To compare the use of mechanical ventilation and hospital costs across ventilated patients of all ages, preterm through adults, in a nationally representative sample. STUDY DESIGN: Secondary analysis of the 2009 Agency for Healthcare Research and Quality National Inpatient Sample. RESULTS: A total of 1 107 563 (2.8%) patients received mechanical ventilation. For surviving ventilated patients, median costs for infants ⩽32 weeks' gestation were $51000 to $209 000, whereas median costs for older patients were lower from $17 000 to $25 000. For non-surviving ventilated patients, median costs were $27 000 to $39 000 except at the extremes of age; the median cost was $10 000 for <24 week newborns and $14 000 for 91+ year adults. Newborns of all gestational ages had a disproportionate share of hospital costs relative to their total volume. CONCLUSION: Most intensive care unit resources at the extremes of age are not directed toward non-surviving patients. From a perinatal perspective, attention should be directed toward improving outcomes and reducing costs for all infants, not just at the earliest gestational ages.

Survey of neonatologists' attitudes toward limiting life-sustaining treatments in the neonatal intensive care unit.

OBJECTIVE: To understand neonatologists' attitudes toward end-of-life (EOL) management in clinical scenarios, EOL ethical concepts and resource utilization. STUDY DESIGN: American Academy of Pediatrics (AAP) Perinatal section members completed an anonymous online survey. Respondents indicated preferences in limiting life-sustaining treatments in four clinical scenarios, ranked agreement with EOL-care ethics statements, indicated outside resources previously used and provided demographic information. RESULT: In all, 451 surveys were analyzed. Across clinical scenarios and as general ethical concepts, withdrawal of mechanical ventilation in severely affected patients was most accepted by respondents; withdrawal of artificial nutrition and hydration was least accepted. One-third of neonatologists did not agree that non-initiation of treatment is ethically equivalent to withdrawal. Around 20% of neonatologists would not defer care if uncomfortable with a parent's request. Respondents' resources included ethics committees, AAP guidelines and legal counsel/courts. CONCLUSION: Challenges to providing just, unified EOL care strategies are discussed, including deferring care, limiting artificial nutrition/hydration and conditions surrounding ventilator withdrawal.

Impact of prematurity and co-morbidities on feeding milestones in neonates: a retrospective study.

OBJECTIVE: Feeding problems are an important area of neonatal morbidity that requires attention. We defined the feeding milestones related to transition to per oral feeding among premature infants based on gestational (GA) and postmenstrual ages (PMA), and elucidated the co-morbidity variables affecting with these skills. STUDY DESIGN: Feeding progress was tracked during the first hospitalization in a retrospective study involving 186 infants. We measured the age at acquisition of first feedings, maximum gavage feedings and maximum oral feedings. Resource usage measures included the total length of hospital stay (LOS), duration of gavage tube and duration of respiratory support. Effects of perinatal and co-morbidity factors on the acquisition of feeding milestones were evaluated. ANOVA, t-test, Wilcoxon rank sum test, chi(2) test, univariate and multivariate analysis, stepwise linear regression analysis and logistic regression analysis were applied as appropriate. Data were presented as mean+/-s.d., or as stated. P<0.05 was considered significant. RESULT: We stratified the data into three groups based on GA at birth: <28.0 weeks (group-1), 28.0 to 32.0 weeks (group-2) and 32.0 to 35.0 weeks (group-3). Compared with group-3, group-1 needed four-fold more ventilation and five-fold more continuous positive airway pressure (CPAP) duration (all P<0.001); whereas group-2 needed two-fold more CPAP duration. Age at first feed correlated with age at full gavage feedings and age at full oral feedings (r=0.53 and r=0.71, both P<0.0001). Age at full gavage feedings correlated with age at full oral feedings (r=0.81, P<0.0001). Univariate analysis was significant for GA age, hypotension, the effects of gastroesophageal reflux, and duration of ventilation and CPAP on the PMA at maximal oral feedings (all P<0.05); multivariate analysis for these variables was also significant (R (2)=0.58, P<0.0001). The success rate for oral feedings at discharge accelerated with GA maturation and caffeine use; on the other hand, the need for respiratory support and management of positive blood culture were associated with failure rates (P<0.05). CONCLUSION: Infants < 28 weeks GA have significant feeding delays with respect to initiation and progression to maximal gavage and oral feedings, as well as prolonged LOS. Infants >28 weeks GA attained successful feeding milestones by similar PMA. Specific aero-digestive co-morbidities significantly affected maximal oral feeding milestone. Delays in achieving maximum gavage and maximum oral feeding milestones suggest delays with the development of control and regulation of foregut motility.

Psychological distress in parents of children with severe congenital heart disease: the impact of prenatal versus postnatal diagnosis.

OBJECTIVE: The purpose of the study was to evaluate coping and psychological functioning of parents of children prenatally or postnatally diagnosed with congenital heart disease. STUDY DESIGN: Parents of 10 infants prenatally diagnosed by fetal echocardiogram and 7 infants postnatally diagnosed with severe congenital heart disease completed the Brief Symptom Inventory (BSI) at the time of diagnosis, at the time of birth and 6 months after birth. Prenatal and postnatal groups were compared to each other and to BSI norms. RESULT: Although both groups scored higher than test norms at the time of diagnosis, they did not differ significantly from each other. Six months after birth, the postnatal group scores did not differ from test norms, but the prenatal group scores were still significantly higher than test norms. The severity of the child's heart lesion at diagnosis was related to parental distress levels; parents with children with more severe lesions had higher BSI scores. CONCLUSION: Results suggest the need to provide parents with psychological support, regardless of the timing of diagnosis. Parents of children with more severe lesions may be at risk for higher levels of psychological distress, particularly over time.

Infant end-of-life care: the parents' perspective.

OBJECTIVE: The purpose of this study was to identify factors important to parents in their infant's end-of-life care. STUDY DESIGN: Participants were parents (n=19 families) whose infant (less than 1 year old) had died. Parents completed the Revised Grief Experience Inventory (RGEI) and a semi-structured interview regarding their infant's end-of-life care. Interviews were rated using the Post-Death Adaptation Scale (PDAS). RESULTS: Parents scored significantly lower than the normative sample on the RGEI, and PDAS scores suggested that these parents were adapting positively. Parent interviews identified the aspects of care that were important to parents: honesty, empowered decision-making, parental care, environment, faith/trust in nursing care, physicians bearing witness and support from other hospital care providers. CONCLUSIONS: Results of this study suggest that parents can effectively cope following the death of an infant and the medical staff can do much to improve the end-of-life care for infants and their families.

The impact of abnormal fetal echocardiography on expectant parents' experience of pregnancy: a pilot study.

To examine the impact of an abnormal fetal echocardiogram (echo) on parental attitudes, emotions and coping strategies. Group interviews were performed for women and their male partners who had a fetal echo and were found to have a fetal congenital heart defect. The women and men were separated into four different focus groups. The interviews were tape recorded, transcribed and analyzed. The women expressed strong emotions of guilt, fear and sadness or hopelessness. They coped by attaching and bonding to the fetus, and were realistic about the future. The women began grieving at the time of the fetal echo. The men experienced emotions of anger and anxiety. They coped by remaining optimistic, and focused on supporting their wives. Men grieved after the birth of the baby. The fetal echo was felt to be beneficial and not harmful by the parents. The fetal echo led to significant changes in the couples' perceptions of themselves and their relationships. Clinicians performing fetal imaging must be aware of parental affective responses and coping mechanisms in order to provide the required psychological support.

End-of-life care for neonates and infants: the experience and effects of a palliative care consultation service.

OBJECTIVE: Neonates and infants have the highest death rate in the pediatric population, yet there is a paucity of data about their end-of-life care and whether a palliative care service can have an impact on that care. The objective of this study was to describe end-of-life care for infants, including analysis of palliative care consultations conducted in this population. We hypothesized that the palliative care consultations performed had an impact on the infants' end-of-life care. DESIGN: A retrospective chart review using the "End of Life Chart Review" from the Center to Improve Care for the Dying was conducted. The participants were the patients at Children's Hospital of Wisconsin who died at <1 year of age during the 4-year period between January 1, 1994, and December 31, 1997. The patients' place of death, medical interventions performed, and emotionally supportive services provided to families were analyzed. RESULTS: Among the 196 deaths during the study period, 25 (13%) of these infants and families had palliative care consultations. The rate of consultations increased from 5% of the infant deaths in 1994 to 38% of the infant deaths in 1997. Infants of families that received consultations had fewer days in intensive care units, blood draws, central lines, feeding tubes, vasopressor and paralytic drug use, mechanical ventilation, cardiopulmonary resuscitation, and x-rays, and the families had more frequent referrals for chaplains and social services than families that did not have palliative care consultations. CONCLUSIONS: This study describes the end-of-life care that infants and their families received. Fewer medical procedures were performed, and more supportive services were provided to infants and families that had a palliative care consultation. This suggests that palliative care consultation may enhance end-of-life care for newborns.

Decisions regarding resuscitation of the extremely premature infant and models of best interest.

Differences concerning the care of an extremely premature infant may stem from alternative points of view on how to determine the infant's best interest. These alternatives are illustrated by differences between recently published statements by the American Academy of Pediatrics (AAP) Committee on Fetus and Newborn (COFN) and the Committee on Bioethics (COB). The statements agree that a goal of neonatal medicine is to minimize both under- and overtreatment of the extremely premature infant, and advocate that the decision-making process ought to be based on the concept of the premature infant's best interest. However, the two AAP Committees appear to diverge in how they operationalize the concept of an infant's best interest. The COFN adopts a process consistent with an "expertise" model of best interest, while the COB process is consistent with a "negotiated" model. In the "expertise" model, medical re-evaluation of the infant's status, the best outcome data available, and the treating physician's best medical judgment determine best interest. This model limits parental and societal input, and can lead a physician to act paternalistically. In the "negotiated" model, best interest is determined by outcome data and physician assessment, as well as the moral value of an outcome. This model maximizes parental input, accepts physicians as moral agents, and respects social influence in a decision. It is important to clarify one's model of best interest to help understand the differences of opinion regarding decisions based on best interest. The negotiated model of best interest is a more ethically appropriate model to approach decision making.

Experience with neonatal palliative care consultation at the Medical College of Wisconsin-Children's Hospital of Wisconsin.

At Children's Hospital of Wisconsin there is a pediatric palliative care consultation service that serves a diverse patient population, including infants. However, the value of a palliative care consultation for infants has not been well evaluated. We performed a retrospective, case series, descriptive chart review of infants in our neonatal intensive care unit (NICU) who received palliative care consults between January 1996 and June 1998. We specifically looked at their diagnoses, the timing of consults, reasons that consultations were ordered, what recommendations were made, and the subsequent outcomes. During the series period there were 898 admissions to the NICU, 51 neonatal deaths, and 12 neonatal palliative care consultations. The diagnostic categories for those with a palliative care referral included prematurity, lethal anomalies, and catastrophic or overwhelming illness. Reasons for the consultations were organization of home hospice, facilitation of medical options, such as do-not-resuscitate (DNR) orders and treatment withdrawal, facilitation of comfort measures, and grief/loss issues. Recommendations that the palliative care staff made fell into four categories: advance directive planning, the optimal environment for supporting neonatal death, comfort and medical care, and psychosocial support. This series is a description of what a palliative care service can offer for terminally ill infants in an NICU. We speculate that such consults can more consistently and comprehensively provide appropriate end-of-life care for these patients and their families.

Cardiopulmonary resuscitation of the newborn. An update.

The abrupt transition from intrauterine to extrauterine life represents a series of profound physiologic changes. This process puts the baby at risk for asphyxia. At birth, the newborn is, therefore, more frequently in need of resuscitation than at any other age. This article reviews the rationale for the sequence and process of neonatal resuscitation, emphasizing recent changes in recommendations.