Variation in NICU utilization: a narrative review and path forward.

Utilization of the Neonatal Intensive Care Unit (NICU) varies widely in the United States. Over recent decades, there has been a growth in NICUs, that varies by region, and has not been correlated to changes in demand or illness severity. Unnecessary NICU admissions are costly, stressful to families, may increase the risk of hospital acquired morbidities, and decrease breast feeding. Most of the variation in NICU utilization is based on the care of late preterm, early term, and term babies and is related to hospital level factors, including financial incentives, driving utilization. Improvement strategies to reduce variation include regionalization of care, certificate of need legislation, improving discharge processes, and caring for babies with some conditions such as Neonatal Opioid Withdrawal Syndrome or those with risk factors for sepsis outside of the NICU.

Infant Feeding and Weight Trajectories in the Eat, Sleep, Console Trial: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Infants with neonatal opioid withdrawal syndrome (NOWS) cared for with the Eat, Sleep, Console (ESC) care approach receive less pharmacologic treatment and have shorter hospital stays compared to usual care with the Finnegan Neonatal Abstinence Scoring Tool, but the effects of these approaches on feeding and weight are unknown. Objective: To evaluate feeding practices and weight trajectories in infants cared for with ESC vs usual care. Design, Setting, and Participants: ESC-NOW is a cluster randomized trial of infants with NOWS born at 36 weeks' gestation or later at 26 US hospitals from September 2020 to March 2022. Each site transitioned from usual care to ESC (the study intervention) at a randomized time. Feeding was per site practice and not specified by the intervention. Feeding and weight outcomes were assessed at hospital discharge. Intervention: ESC vs usual care. Main Outcomes and Measures: Outcomes include prospectively identified secondary end points related to feeding and weight. z Scores were used for growth to account for corrected gestational age at the time of measurement. All analyses were intention to treat and adjusted for study design. Maternal/infant characteristics were included in adjusted models. Results: The analyses included 1305 infants (702 in usual care and 603 in ESC; mean [SD] gestational age, 38.6 [1.3] weeks; 655 [50.2%] male and 650 [49.8%] female). Baseline demographic characteristics were similar between groups. The proportion of breastfed infants was higher in the ESC group (52.7% vs 41.7%; absolute difference, 11%; 95% CI, 1.0-20.9). A higher proportion of infants cared for with ESC received exclusive breast milk (15.1% vs 6.7%; absolute difference, 8.4%; 95% CI, 0.9-5.8) or any breast milk (38.8% vs 27.4%; absolute difference, 11.4%; 95% CI, 0.2-23.1) and were directly breastfeeding at discharge (35.2% vs 19.5%; absolute difference, 15.7%; 95% CI, 4.1-27.3). There was no difference in proportion of infants with weight loss greater than 10% or maximum percentage weight loss, although infants cared for with ESC had a lower weight z score on day of life 3 (-1.08 vs -1.01; absolute difference, 0.07; 95% CI, 0.02-0.12). When pharmacologic treatment was added into the model, no breastfeeding outcomes were statistically significant. Conclusions and Relevance: In this study, infants cared for with ESC were more likely to initiate and continue breastfeeding and had no difference in percentage weight loss. The improvement in breastfeeding with ESC may be driven by reduction in pharmacologic treatment and provision of effective nonpharmacologic care. Trial Registration: ClinicalTrials.gov Identifier: NCT04057820.

Endoscopic endonasal approach for resection of odontoid process, decompression of the cervicomedullary junction spinal cord, and resection of pannus.

Odontoid pannus is an abnormal collection of degenerative or inflammatory tissue on the C1-dens joint that can result in severe spinal cord compression myelopathy. Treatment options vary depending on severity and etiology. In cases of severe cord compression, surgical management could be either through a purely posterior approach or in combination with an anterior decompression via endoscopic endonasal approach (EEA). This case presents a 77-year-old female who underwent posterior cervical fixation for odontoid pannus causing dramatic cervical myelopathy who failed to improve over a 6-month period and required anterior transodontoid pannus resection and decompression via EEA. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23176.

Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal: A Post Hoc Subgroup Analysis of the ESC-NOW Randomized Clinical Trial.

Importance: The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown. Objective: To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool. Design, Setting, and Participants: This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks' gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024. Exposure: Opioid treatment for NOWS and the ESC care approach. Main Outcomes and Measures: For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics. Results: In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001). Conclusion and Relevance: When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later. Trial Registration: ClinicalTrials.gov Identifier: NCT04057820.

Racial Disparities Among Predicted Bronchopulmonary Dysplasia Risk Outcomes in Premature Infants Born <30 Weeks Gestation.

Background and Objective: There is extensive literature to support eliminating race-based risk stratification. The National Institute of Child Health and Human Development (NICHD) calculator, used to predict risk of bronchopulmonary dysplasia (BPD), includes race as a variable. We sought to investigate how utilizing race in determination of risk for BPD may lead to inequitable care. Methods: The study included a retrospective cohort of infants born <30 weeks gestation between January 2016 and February 2022. The primary outcome was the difference in predictive risk of BPD for non-Hispanic Black compared to non-Hispanic White infants. The secondary outcome was the disparity in theoretical administration of post-natal corticosteroids when the calculator was applied to the cohort. Analysis included paired T-tests and Chi-Square. Results: Of the 273 infants studied, 154 were non-Hispanic Black (56%). There was no difference between the groups in gestation or respiratory support on day of life (DOL) 14 or 28. The predicted risk of moderate or severe BPD in non-Hispanic White babies was greater than non-Hispanic Black babies on both DOL 14 and 28 (p<0.01). When applied retrospectively to the cohort, the calculator resulted in differences in corticosteroid administration (risk >40%-non-Hispanic White 51.3% vs. non-Hispanic Black 35.7%, p=0.010; risk >50%-non-Hispanic White 42.9% vs. non-Hispanic Black 29.9%, p=0.026). Conclusion: When applied to our study cohort, the calculator resulted in a reduction in the predicted risk of BPD in non-Hispanic Black infants. If utilized to guide treatment, the calculator can potentially lead to disparities in care for non-Hispanic Black infants.

The impact of the baby friendly hospital initiative on healthcare utilization among newborns insured by Medicaid in Delaware.

BACKGROUND: The Baby Friendly Hospital Initiative was created to enhance breastfeeding, although its impact on infant healthcare utilization is unclear. Breast feeding infants are vulnerable to readmission soon after birth secondary to dehydration and hyperbilirubinemia. Breastfeeding can also protect infants from unnecessary health care utilization later in life by preventing infection. The objective of this study was to examine the impact of the Baby Friendly Hospital Initiative on readmissions and emergency department utilization among Medicaid births in Delaware. METHODS: The study was a quasi-experimental design. Medicaid claims files were used to study births at five hospitals in Delaware born between January 1, 2014, and December 31, 2018, and covered under Medicaid at time of birth. Three hospitals were designated Baby Friendly, two were not and served as controls. Outcomes included Emergency Department (ED) utilization and readmissions within 30 days and one-year of birth hospitalization. Exposure to the Baby Friendly Hospital Initiative was determined by year and hospital of birth. Logistic regression and interrupted time series segmented regression analysis with controls were used to assess the effect of Baby Friendly Hospital Initiative on healthcare utilization. RESULTS: In total, 19,695 infants were born at five hospitals with 80% (15,939) born at hospitals that were designated Baby Friendly. ED utilization and readmissions over the 1st year of life for breastfeeding related diagnosis at the Baby Friendly hospitals occurred in 240 (1.5%) and 226 (1.4%) of infants, respectively. Exposure to the Baby Friendly Hospital Initiative was associated with increased odds of all cause 30-day readmission (AOR: 1.15; 95% CI: 1.03-1.28) but not readmissions over the 1st year of life. While 30-day ED visits did not change after BFHI, one-year ED visits were reduced (0.91, 95% CI 0.86-0.97). A significant negative trend was seen over time for ED utilization post BFHI compared to controls (B: -5.90, p < 0.01). CONCLUSION: There was a small observed increase in the odds of all cause 30-day readmissions with no change in one-year readmissions after BFHI in Delaware. Although there were no observed changes in 30-day ED utilization, there was a reduction in one-year ED utilization following the implementation of the Baby Friendly Hospital Initiative in Delaware birth hospitals. Our data help to inform policy and decision making for statewide systems of care that may be used to support breast feeding.

Delayed myelopathy after remote C1-2 sublaminar wire fixation: illustrative case.

BACKGROUND: Atlantoaxial sublaminar wiring complications, both early and delayed, have been documented. However, delayed neurological compromise 27 years after successful fusion is a rare but possible occurrence. OBSERVATIONS: A 76-year-old male, who had undergone C1-2 sublaminar wire fusion for atlantoaxial instability in 1995, presented with symptoms of progressive right arm weakness, falls, and incontinence of bowel and bladder over a 1-week period. Initial imaging workup revealed bowing of the C1-2 sublaminar wires resulting in cervical spinal cord compression and T2-weighted signal changes. A C1-2 laminectomy was performed to remove the wires and decompress the spinal cord with improvement in the patient's neurological status. LESSONS: This rare case highlights the potential for delayed cervical myelopathy and cord compression from sublaminar wires, even after a successful fusion. In patients with a history of sublaminar wiring who experience new neurological deficits, it is essential to evaluate the hardware for migration.

Usability and acceptability testing of a Plan of Safe Care in a mobile health platform.

Purpose: Women who are pregnant or parenting while recovering from substance use disorder (SUD) are at risk for insufficient recovery support. With the federal mandate, implementation has been left to each state for the Plan of Safe Care (POSC), leading to challenges in providing comprehensive care coordination and meeting federal reporting requirements. Methods: This research tests the usability and acceptability of a POSC platform, called SAFE4BOTH, which combines a mobile health (mHealth) app for use by mothers with substance use disorder (MSUD) with a web-based case management system for use by stakeholders to reduce the issue of fragmented postnatal maternal and infant care. The platform was designed to enable access to services, improve reporting task workflow, and assist in improving interactions between mothers and service providers.After applying a user-centered design approach, the usability and acceptability of the SAFE4BOTH platform were evaluated using focus groups, interviews, and a System Usability Scale (SUS). The evaluation involved four staff members from a Medication for Addiction Treatment clinic (comprising of three case management workers and one peer counselor), four state employees of the Delaware Division of Family Services, and 20 mothers with MSUD who had delivered infants in need of a POSC.Features tested in the SAFE4BOTH platform included a secure, web-based POSC, a contingency management-based reward system, a micro-learning library, a resources locator, a chat messaging and videoconferencing system, a directory for contact management, a QR code reader, use of an appointment compliance system engaging geofencing, and an enhanced calendar. Family services and treatment center staff accessed SAFE4BOTH from their laptops or tablets, and MSUD accessed SAFE4BOTH from their phones. Results: Family services staff, treatment center staff, and MSUD participants rated SAFE4BOTH as usable and acceptable with average System Usability Scale scores of 68.1 (SD 8.5), 92.5 (SD 11.73), and 78.4 (SD 12.5) (respectively). Conclusion: The platform was judged both usable and acceptable by all three target populations (family services staff, treatment center staff, and MSUD). Further studies are planned to explore the efficacy of longitudinally supporting the mother's recovery and the infant's healthy development.

Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal.

BACKGROUND: Although clinicians have traditionally used the Finnegan Neonatal Abstinence Scoring Tool to assess the severity of neonatal opioid withdrawal, a newer function-based approach - the Eat, Sleep, Console care approach - is increasing in use. Whether the new approach can safely reduce the time until infants are medically ready for discharge when it is applied broadly across diverse sites is unknown. METHODS: In this cluster-randomized, controlled trial at 26 U.S. hospitals, we enrolled infants with neonatal opioid withdrawal syndrome who had been born at 36 weeks' gestation or more. At a randomly assigned time, hospitals transitioned from usual care that used the Finnegan tool to the Eat, Sleep, Console approach. During a 3-month transition period, staff members at each hospital were trained to use the new approach. The primary outcome was the time from birth until medical readiness for discharge as defined by the trial. Composite safety outcomes that were assessed during the first 3 months of postnatal age included in-hospital safety, unscheduled health care visits, and nonaccidental trauma or death. RESULTS: A total of 1305 infants were enrolled. In an intention-to-treat analysis that included 837 infants who met the trial definition for medical readiness for discharge, the number of days from birth until readiness for hospital discharge was 8.2 in the Eat, Sleep, Console group and 14.9 in the usual-care group (adjusted mean difference, 6.7 days; 95% confidence interval [CI], 4.7 to 8.8), for a rate ratio of 0.55 (95% CI, 0.46 to 0.65; P<0.001). The incidence of adverse outcomes was similar in the two groups. CONCLUSIONS: As compared with usual care, use of the Eat, Sleep, Console care approach significantly decreased the number of days until infants with neonatal opioid withdrawal syndrome were medically ready for discharge, without increasing specified adverse outcomes. (Funded by the Helping End Addiction Long-term (HEAL) Initiative of the National Institutes of Health; ESC-NOW ClinicalTrials.gov number, NCT04057820.).

The Influence of Mediators on the Relationship Between Antenatal Opioid Agonist Exposure and the Severity of Neonatal Opioid Withdrawal Syndrome.

OBJECTIVES: (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. METHODS: This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. RESULTS: A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. CONCLUSIONS FOR PRACTICE: MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy.

Prolactin at moderately increased levels confers a neuroprotective effect in non-secreting pituitary macroadenomas.

CONTEXT: Prolactin, a hormone synthesized by the anterior pituitary gland demonstrates promise as a neuroprotective agent, however, its role in humans and in vivo during injury is not fully understood. OBJECTIVE: To investigate whether elevated levels of prolactin attenuate injury to the retinal nerve fiber layer (RNFL) following compression of the optic chiasm in patients with a prolactin secreting pituitary macroadenoma (i.e., prolactinoma). DESIGN SETTING AND PARTICIPANTS: A retrospective cross-sectional study of all pituitary macroadenoma patients treated at a single institution between 2009 and 2019. MAIN OUTCOME MEASURE(S): Primary outcome measures included RNFL thickness, mean deviation, and prolactin levels for both prolactin-secreting and non-secreting pituitary macroadenoma patients. RESULTS: Sixty-six patients met inclusion criteria for this study (14 prolactin-secreting and 52 non-secreting macroadenoma patients). Of 52 non-secreting macroadenoma patients, 12 had moderate elevation of prolactin secondary to stalk effect. Patients with moderate elevation in prolactin demonstrated increased RNFL thickness compared to patients with normal prolactin levels (p < 0.01). Additionally, a significant positive relation between increasing levels of prolactin and RNFL thickness was identified in patients with moderate prolactin elevation (R = 0.51, p-value = 0.035). No significant difference was identified between prolactinoma patients and those with normal prolactin levels. CONCLUSIONS: Moderately increased serum prolactin is associated with increased RNFL thickness when compared to controls. These associations are lost when serum prolactin is < 30 ng/ml or elevated in prolactinomas. This suggests a neuroprotective effect of prolactin at moderately increased levels in preserving retinal function during optic chiasm compression.

Empty Sella Syndrome as a Window Into the Neuroprotective Effects of Prolactin.

Background: The goal of this study was to relate diffusion MR measures of white matter integrity of the retinofugal visual pathway with prolactin levels in a patient with downward herniation of the optic chiasm secondary to medical treatment of a prolactinoma. Methods: A 36-year-old woman with a prolactinoma presented with progressive bilateral visual field defects 9 years after initial diagnosis and medical treatment. She was diagnosed with empty-sella syndrome and instructed to stop cabergoline. Hormone testing was conducted in tandem with routine clinical evaluations over 1 year and the patient was followed with diffusion magnetic resonance imaging (dMRI), optical coherence tomography (OCT), and automated perimetry at three time points. Five healthy controls underwent a complementary battery of clinical and neuroimaging tests at a single time point. Results: Shortly after discontinuing cabergoline, diffusion metrics in the optic tracts were within the range of values observed in healthy controls. However, following a brief period where the patient resumed cabergoline (of her own volition), there was a decrease in serum prolactin with a corresponding decrease in visual ability and increase in radial diffusivity (p < 0.001). Those measures again returned to their baseline ranges after discontinuing cabergoline a second time. Conclusions: These results demonstrate the sensitivity of dMRI to detect rapid and functionally significant microstructural changes in white matter tracts secondary to alterations in serum prolactin levels. The inverse relations between prolactin and measures of white matter integrity and visual function are consistent with the hypothesis that prolactin can play a neuroprotective role in the injured nervous system.

Site-Level Variation in the Characteristics and Care of Infants With Neonatal Opioid Withdrawal.

BACKGROUND AND OBJECTIVES: Variation in pediatric medical care is common and contributes to differences in patient outcomes. Site-to-site variation in the characteristics and care of infants with neonatal opioid withdrawal syndrome (NOWS) has yet to be quantified. Our objective was to describe site-to-site variation in maternal-infant characteristics, infant management, and outcomes for infants with NOWS. METHODS: Cross-sectional study of 1377 infants born between July 1, 2016, and June 30, 2017, who were ≥36 weeks' gestation, with NOWS (evidence of opioid exposure and NOWS scoring within the first 120 hours of life) born at or transferred to 1 of 30 participating hospitals nationwide. Site-to-site variation for each parameter within the 3 domains was measured as the range of individual site-level means, medians, or proportions. RESULTS: Sites varied widely in the proportion of infants whose mothers received adequate prenatal care (31.3%-100%), medication-assisted treatment (5.9%-100%), and prenatal counseling (1.9%-75.5%). Sites varied in the proportion of infants with toxicology screening (50%-100%) and proportion of infants receiving pharmacologic therapy (6.7%-100%), secondary medications (1.1%-69.2%), and nonpharmacologic interventions including fortified feeds (2.9%-90%) and maternal breast milk (22.2%-83.3%). The mean length of stay varied across sites (2-28.8 days), as did the proportion of infants discharged with their parents (33.3%-91.1%). CONCLUSIONS: Considerable site-to-site variation exists in all 3 domains. The magnitude of the observed variation makes it unlikely that all infants are receiving efficient and effective care for NOWS. This variation should be considered in future clinical trial development, practice implementation, and policy development.

Do extremely preterm infants need retinopathy of prematurity screening earlier than 31 weeks postmenstrual age?

OBJECTIVE: To evaluate the utility of screening all extremely preterm infants for retinopathy of prematurity (ROP) at 4 weeks chronologic age, which is earlier than recommended by the 2018 AAP guidelines. STUDY DESIGN: Retrospective analysis of infants <27 weeks gestation from two tertiary NICUs between 2006 and 2018 who survived until first eye examination. RESULTS: 550 infants (gestational age 25.1 ± 1.2 weeks and birth weight 758 ± 323 g) had 1310 examinations performed by 32 weeks postmenstrual age (PMA), and 676 (51.6%) of these were prior to 31 weeks PMA. No examinations in infants prior to 31 weeks PMA met the criteria for laser therapy. Of 87/550 infants (15.8%) who required laser therapy, none did so prior to 32 weeks PMA. CONCLUSIONS: No infants born <27 weeks gestation were found to have severe ROP prior to 31 weeks PMA, supporting the most recent AAP recommendation of initiating ROP screening at 31 weeks PMA for extremely preterm infants.

Breastfeeding and Formula Selection in Neonatal Abstinence Syndrome.

OBJECTIVE: This study aimed to determine if formula selection, low lactose versus standard term formula, has an effect on outcomes with a comparison to breastfed infants. STUDY DESIGN: Retrospective cohort study of neonates ≥35 weeks gestation born with Neonatal Abstinence Syndrome (NAS) was conducted from July 2014 to November 2016. Primary outcomes included length of pharmacologic treatment (LOT), and length of stay (LOS), and weight change per day comparing term standard and low lactose formula majority feeding infants with secondary outcomes comparing breast fed majority feeding infants. RESULTS: After investigating feeding methods for 249 NAS infants, a direct comparison of formula groups showed no differences in LOS (3, 95% confidence interval [CI]: -1.1 to 7 days), LOT (3.9, 95% CI: -0.4 to 8.1 days), or weight change per day (-2.4, 95% CI: -11.7 to 6.9 g/day). Breastfeeding improved LOT by 6.9 (95% CI: 3.4-10.5) and 10.8 days (95% CI: 5.9-15.6) and LOS by 7.4 (95% CI: 4.1-10.7) and 10.3 (95% CI: 5.8-14.9) days all reaching significance, in comparison to term and low lactose formula groups, respectively. Weight change per day was greater in the breast versus formula feeding groups when compared individually. CONCLUSION: We detected no benefit to low lactose formula in NAS infants. Breastfeeding is associated with clinical reduction in LOS and LOT but is associated with increased weight loss. KEY POINTS: · Best formula choice for a neonatal abstinence syndrome (NAS) infant is unknown.. · Many NAS moms cannot breastfeed.. · Low lactose formula has no impact on NAS outcomes..

Mechanical ventilation in aneurysmal subarachnoid hemorrhage: systematic review and recommendations.

OBJECTIVE: Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation. DATA SOURCES: PubMed was queried for publications with the Medical Subject Headings (MeSH) terms "mechanical ventilation" and "aneurysmal subarachnoid hemorrhage" published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest. STUDY SELECTION: Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies. DATA EXTRACTION: Articles were reviewed by one team member, and interpretation was verified by a second team member. DATA SYNTHESIS: Thirty-one articles met the inclusion criteria for this review. CONCLUSIONS: We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.

Evaluating the Health Outcomes of the Healthy Women Healthy Babies Program in Delaware.

OBJECTIVES: The Delaware Healthy Women Healthy Babies Program (HWHB) was developed in response to increasing rates of infant mortality (IMR) and widening racial disparity. The primary aim of this study was to examine birth outcomes of enrolled and non-enrolled black and Hispanic women in the program whose payer was Medicaid. METHODS: We utilized a retrospective cohort of linked birth certificate and HWHB program participant data during 2011-2015. Our primary outcome variables (dependent variables) of interest included cigarette use, low birth weight, preterm birth and neonatal mortality. We utilized inverse probability of treatment weighting (IPTW) and estimated crude odds ratios (COR) and adjusted odds ratio (AOR) with 95% confidence intervals (CI) using IPTW as a weight variable. RESULTS: HWHB enrolled women were 10% less likely to smoke during pregnancy COR 0.89 (95% CI 0.82-0.96); were 9% less likely to deliver a low birth weight infant (AOR 0.91; 95% CI 0.84-0.99; p = 0.023); were 15% less likely to deliver a preterm infant (AOR 0.85; 0.78-0.92; p < .0001) as compared with non-HWHB women. Infants delivered by HWHB enrolled women had 27% less likelihood (AOR 0.73; 95% CI 0.54-0.98; p = 0.035) of experiencing a neonatal death (i.e., < 28 days) as compared with infants of non-enrolled HWHB women. CONCLUSION: The primary goal of this evaluation was to assess the effectiveness of the HWHB program on modifiable risk factors of IMR among HWHB enrolled and non-enrolled women. We found that HWHB program is a promising practice in improving the outcomes of infants born to participating black and Hispanic mothers.