Sustainability of a Clinical Examination-Based Approach for Ascertainment of Early-Onset Sepsis in Late Preterm and Term Neonates.

We demonstrated the sustained impact over a 5-year period of a clinical examination-based approach to identification of early-onset sepsis in late preterm and term neonates at our hospital. To date, more than 20 000 neonates have been safely managed using this approach, resulting in a 63% reduction in antibiotic use.

Fewer glucose checks and decreased supplementation using dextrose gel for asymptomatic neonatal hypoglycemia.

OBJECTIVE: Evaluate the impact of a neonatal hypoglycemia (NH) clinical pathway implementing buccal dextrose gel in late preterm and term infants. STUDY DESIGN: Quality improvement study at a children's hospital associated birth center. Number of blood glucose checks, use of supplemental milk, and need for IV glucose were followed for 26-months after implementation of dextrose gel and compared to previous 16-month period. RESULTS: After QI implementation, 2703 infants were screened for hypoglycemia. Of these, 874 (32%) received at least one dose of dextrose gel. Special cause shifts with reductions in mean number of blood glucose checks per infant (pre 6.6 vs. post 5.6), use of supplemental milk (pre 42% vs. post 30%), and need for IV glucose (pre 4.8% vs. post 3.5%) were found. CONCLUSION: Incorporating dextrose gel into a clinical pathway for NH was associated with a sustained reduction in number of interventions, use of supplemental milk and need for IV glucose.

Effect of added calcium, phosphorus, and infant formula on calcium and phosphorus dialyzability in preterm donor human milk.

OBJECTIVES: We studied the effect of preparing donor human milk (DHM) with commonly used nutritional additives on the dialyzability of calcium and phosphate. We hypothesized that the additives to DHM would decrease the dialyzability of calcium and phosphate when prepared according to hospital protocols. METHODS: An in vitro system simulating premature infant digestion was developed to measure dialyzability of calcium and phosphate in DHM. Dialyzable calcium and phosphate were measured after in vitro digestion in DHM before and after preparation of DHM with the following additives according to hospital protocols: calcium glubionate, sodium potassium phosphate, calcium glubionate and sodium potassium phosphate added together, Similac human milk fortifier, Similac NeoSure, or Enfamil Enfacare. RESULTS: The percentage of dialyzable calcium in DHM with added calcium and calcium and phosphate together was greater than the percentage of dialyzable calcium in DHM with added powdered infant formulas (P<0.0001). Dialyzable calcium was greater in DHM with added calcium and with added calcium and phosphate than in all other treatment groups (P<0.0001). Dialyzable calcium in DHM without additives was not different from dialyzable calcium in DHM with added phosphate or with added powdered infant formulas. Dialyzable phosphate did not differ between the treatment groups. CONCLUSIONS: The addition of calcium alone or calcium and phosphate together increased calcium dialyzability in DHM significantly, whereas the addition of powdered human milk fortifier or formulas did not. The addition of calcium or calcium with phosphate together to DHM may provide the most dialyzable calcium.

Extensive subcutaneous fat necrosis of the newborn associated with therapeutic hypothermia.

Subcutaneous fat necrosis of the newborn is a form of panniculitis that most often occurs in full-term infants with predisposing risk factors. Three neonates with hypoxic ischemic encephalopathy were treated with therapeutic hypothermia and developed extensive subcutaneous fat necrosis. All three infants developed extensive subcutaneous fat necrosis, involving the back, scalp, and arms. Mild, asymptomatic hypercalcemia was noted in one infant in the weeks following the subcutaneous fat necrosis. Hypothermia as a risk factor for subcutaneous fat necrosis is reviewed. Clinicians should be aware of subcutaneous fat necrosis as a possible risk factor and complication associated with asphyxiated newborns who may undergo therapeutic hypothermia. Future studies for therapeutic hypothermia should evaluate neonates for the development of subcutaneous fat necrosis.

Ventricular access devices are safe and effective in the treatment of posthemorrhagic ventricular dilatation prior to shunt placement.

Intraventricular hemorrhage of prematurity (IVH) is a diagnosis that has become more frequent in recent years. Advances in medical care have led to survival of increasingly premature infants, as well as infants with more complex medical conditions. Treatment with a ventricular access device (VAD) was reported almost 3 decades ago; however, it is unclear how effective this treatment is in the current population of premature infants. At our institution (from 2004 to present), we treat posthemorrhagic hydrocephalus (PHH) with a VAD. In order to look at safety and efficacy, we retrospectively combed the medical records of premature children, admitted to Lucile Packard Children's Hospital from January 2005 to December 2009, and identified 310 premature children with IVH. Of these, 28 children required treatment for PHH with a VAD. There were no infections associated with placement of these devices and a very low rate of other complications, such as need for repositioning (7.41%) or replacement (3.75%). Our data show that treatment with a VAD is very safe, with few complications and can be used to treat PHH in this very complex infant population.

Universal Level Designations for Hospitalized Pediatric Patients in Evacuation.

Children comprise approximately 22% of the population in the United States.1 In a widespread disaster such as a hurricane, pandemic, wildfire or major earthquake, children are at least proportionately affected to their share of the population, if not more so. They also have unique vulnerabilities including physical, mental, and developmental differences from adults, which make them more prone to adverse health effects of disasters.2-4 There are about 5000 pediatric critical care beds and 23 000 neonatal intensive care beds out of 900 000 total hospital beds in the United States.5 While no mechanism exists to consistently track pediatric acute care beds nationally (especially in real time), a previous study6 showed a 7% decline in pediatric medical-surgical beds between 2002 and 2011. This study also estimated there are about 30 000 acute care pediatric beds nationally. Finding appropriate hospital resources for the provision of care for pediatric disaster victims is an important concern for those charged with triaging patients in a major event.

Perioperative management of low birth weight infants for open-heart surgery.

Infants of birth weight ≤2500 g are termed low birth weight (LBW). These children often have considerable morbidity from prematurity and intra-uterine growth restriction. Additionally, LBW infants have increased risk for cardiac and noncardiac congenital anomalies and may require surgery. Primary rather than palliative surgical repair of cardiac lesions has been preferred in recent years. However, LBW remains a risk factor for increased mortality and morbidity after open-heart surgery (OHS). There is a paucity of information about the anesthetic challenges presented by LBW infants undergoing OHS. This review summarizes the perioperative issues of relevance to anesthesiologists who manage these high-risk patients. Emphasis is placed on management concerns that are unique to LBW infants. Retrospective data from the authors' institution are provided for those aspects of anesthetic care that lack published studies. Successful outcome often requires substantial hospital resources and collaborative multi-disciplinary effort.

Learning from Wildfire Disaster Experience in California NICUs.

Wildfires have been affecting California greatly, and vulnerable patients in neonatal intensive care units (NICUs) are not exempt. Our aim was to learn how personnel working in NICUs of California hospitals handled issues of neonatal transfer during wildfire disasters in recent years, with an ultimate goal to share lessons learned with healthcare teams on disaster preparedness. We identified California fires through newspaper articles and the CalFire.gov list. We determined which hospitals were affected and contacted members of the healthcare team through connections via the California Perinatal Quality Care Collaborative (CPQCC) database. We audio recorded interviews over phone or remote conferencing software or by written survey. We coded and analyzed transcripts and survey responses. While describing disaster preparedness, equipment (such as bassinets and backpacks), ambulance access/transport and documentation/charting were noted as important and essential. Teamwork, willingness to do other tasks that are not part of typical job descriptions, and unconventional strategies contribute to the success of keeping NICU babies safe when California wildfire strikes. Healthcare teams developed ingenious and surprising ways to evacuate NICU babies.

California NICU disaster preparedness.

OBJECTIVE: NICU patients are disproportionately affected by any disaster due to their vulnerability and highly specialized care needs that require a multitude of resources. Research in disaster preparedness and its effect on NICU patients is limited. STUDY DESIGN: From March to May 2018, NICUs across California participated in a survey designed to assess their preparedness for a disaster. RESULTS: Of the 84 responding units, 99% were urban, 73% were nonprofit, and 65% were community NICUs. As for NICU participation in hospital training exercises for disaster preparedness, 10% did not participate in annual drills, 44% did once a year, 36% did twice a year, and 10% did more than two times per year. CONCLUSION: We showed that many NICUs had redundant systems in place and plans for various disasters; however, there is not consistent participation by NICUs in hospital training exercises for disaster preparedness.

Increased Carbon Monoxide Washout Rates in Newborn Infants.

BACKGROUND: Endogenous carbon monoxide (CO) production is primarily due to heme degradation, which also results in the equimolar production of bilirubin. Thus, estimates of total body CO production can serve as indices of total body bilirubin formation. The elimination rate of CO from a person's body (CO washout rate) after exposure to an elevated ambient CO concentration is determined by a variety of factors, and is very different between babies and adults. OBJECTIVE: We determined CO washout rates for babies using a simplified technique to measure total body CO excretion rates (VeCO). METHODS: Using a simplified technique, we measured the times to reach an approximate steady state after a change in ambient CO concentration (decay time constant) and CO washout rates in normal newborn infants using non-linear least squares curve fitting. RESULTS: We found a mean CO washout time of 18.7 ± 4.2 min and a CO equilibration (decay time) constant of 0.12 ± 0.04/min (0.08-0.21) for newborn infants. CONCLUSIONS: We confirm that CO washout rates for babies are much faster than those for adults. Therefore, measurements of carboxyhemoglobin (COHb) or end-tidal CO (ETCO), corrected for ambient CO, (COHbc and ETCOc, respectively) can be used as surrogates for VeCO and can provide accurate estimates of endogenous CO (VCO) and bilirubin production rates under normal environmental conditions. Such measurements can be used to identify infants with severe hyperbilirubinemia due to hemolysis and thus at high risk for bilirubin neurotoxicity.

Fentanyl transdermal analgesia during pregnancy and lactation.

This report describes an infant who was born to a mother with chronic pain treated with fentanyl 100 microg/h transdermal patch throughout her pregnancy and during lactation. On day of life 27, when the baby was feeding and gaining weight on maternal milk, samples of the baby's blood and maternal milk were sent for analysis. The mother's milk fentanyl level was 6.4 ng/ mL. The infant's blood fentanyl level was undetectable. This preliminary report suggests that fentanyl transdermal patch treatment might be a viable option for managing chronic pain during lactation.

Management of Chorioamnionitis-Exposed Infants in the Newborn Nursery Using a Clinical Examination-Based Approach.

BACKGROUND: Antibiotic use in well-appearing late preterm and term chorioamnionitis-exposed (CE) infants was reduced by 88% after the adoption of a care approach that was focused on clinical monitoring in the intensive care nursery to determine the need for antibiotics. However, this approach continued to separate mothers and infants. We aimed to reduce maternal-infant separation while continuing to use a clinical examination-based approach to identify early-onset sepsis (EOS) in CE infants. METHODS: Within a quality improvement framework, well-appearing CE infants ≥35 weeks' gestation were monitored clinically while in couplet care in the postpartum unit without laboratory testing or empirical antibiotics. Clinical monitoring included physician examination at birth and nurse examinations every 30 minutes for 2 hours and then every 4 hours until 24 hours of life. Infants who developed clinical signs of illness were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, and clinical outcomes were collected. RESULTS: Among 319 initially well-appearing CE infants, 15 (4.7%) received antibiotics, 23 (7.2%) underwent laboratory testing, and 295 (92.5%) remained with their mothers in couplet care throughout the birth hospitalization. One infant had group B Streptococcus EOS identified and treated at 24 hours of age based on new-onset tachypnea and had an uncomplicated course. CONCLUSIONS: Management of well-appearing CE infants by using a clinical examination-based approach during couplet care in the postpartum unit maintained low rates of laboratory testing and antibiotic use and markedly reduced mother-infant separation without adverse events. A framework for repeated clinical assessments is an essential component of identifying infants with EOS.

Triage by Resource Allocation for INpatients: A Novel Disaster Triage Tool for Hospitalized Pediatric Patients.

OBJECTIVE: To develop a disaster triage tool for the evacuation of hospitalized neonatal and pediatric populations. METHODS: We expanded an existing neonatal disaster triage tool for the evacuation of a children's hospital. We assessed inpatients using bedside visual assessments and chart review to categorize patients transport level based on local emergency medical services protocols and expert opinion. The tool was refined by using multiple Plan Do Study Act cycles. Primary outcome was the number of each level of transport required for hospital evacuation. Secondary outcome was improved efficiency of obtaining information about specific transport needs for evacuation. RESULTS: We evaluated 1382 patients both visually and through electronic chart review over 10 random days. Accordance between visual assessment and electronic chart review reached 96.3%. During a 2 hour statewide disaster drill, no hospital units completed self-assessed transport needs for their patients; a single nurse used Triage by Resource Allocation in INpatients to determine transportation needs in less than 1 hour. (Disaster Med Public Health Preparedness. 2018;12:692-696).

Chemical Contaminants in Raw and Pasteurized Human Milk.

BACKGROUND: Environmental contaminants ranging from legacy chemicals like p,p'-dichlorodiphenyltrichloroethane (DDT) to emerging chemicals like phthalates are ubiquitous. Research aims/questions: This research aims to examine the presence and co-occurrence of contaminants in human milk and effects of pasteurization on human milk chemical contaminants. METHODS: We analyzed human milk donated by 21 women to a milk bank for 23 chemicals, including the persistent organic pollutants (POPs) polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), dichlorodiphenyltrichloroethane (DDT), and dichlorodiphenyldichloroethylene (DDE) isomers that are known to sequester in adipose tissue, along with the current-use and nonpersistent pesticides chlorpyrifos and permethrin, phthalates, and bisphenol A (BPA). Human milk was analyzed raw and pasteurized for these chemicals using gas chromatography-tandem mass spectrometry for the POPs and high-performance liquid chromatography-tandem mass spectrometry for non-POPs. RESULTS: Within the different chemical classes, PBDE47, PCB153, ppDDE, and MEHHP (phthalate metabolite) had the highest median concentrations and were observed in all samples. We also observed chlorpyrifos and BPA in all samples and permethrin in 90% of the samples tested. Only two chemicals, chlorpyrifos and permethrin, were susceptible to substantial degradation from pasteurization, a standard method for processing donated human milk. CONCLUSION: We detected 19 of 23 chemicals in all of our prepasteurized milk and 18 of 23 chemicals in all of our pasteurized milk. Pasteurization did not affect the presence of most of the chemicals. Future research should continue to explore human milk for potential chemical contamination and as a means to surveil exposures among women and children.

Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis.

BACKGROUND: The risk of early-onset sepsis is low in well-appearing late-preterm and term infants even in the setting of chorioamnionitis. The empirical antibiotic strategies for chorioamnionitis-exposed infants that are recommended by national guidelines result in antibiotic exposure for numerous well-appearing, uninfected infants. We aimed to reduce unnecessary antibiotic use in chorioamnionitis-exposed infants through the implementation of a treatment approach that focused on clinical presentation to determine the need for antibiotics. METHODS: Within a quality-improvement framework, a new treatment approach was implemented in March 2015. Well-appearing late-preterm and term infants who were exposed to chorioamnionitis were clinically monitored for at least 24 hours in a level II nursery; those who remained well appearing received no laboratory testing or antibiotics and were transferred to the level I nursery or discharged from the hospital. Newborns who became symptomatic were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, culture results, and clinical outcomes were collected. RESULTS: Among 277 well-appearing, chorioamnionitis-exposed infants, 32 (11.6%) received antibiotics during the first 15 months of the quality-improvement initiative. No cases of culture result-positive early-onset sepsis occurred. No infant required intubation or inotropic support. Only 48 of 277 (17%) patients had sepsis laboratory testing. The implementation of the new approach was associated with a 55% reduction (95% confidence interval 40%-65%) in antibiotic exposure across all infants ≥34 weeks' gestation born at our hospital. CONCLUSIONS: A management approach using clinical presentation to determine the need for antibiotics in chorioamnionitis-exposed infants was successful in reducing antibiotic exposure and was not associated with any clinically relevant delays in care or adverse outcomes.

Impact of Donor Milk Availability on Breast Milk Use and Necrotizing Enterocolitis Rates.

OBJECTIVES: To examine the availability of donor human milk (DHM) in a population-based cohort and assess whether the availability of DHM was associated with rates of breast milk feeding at NICU discharge and rates of necrotizing enterocolitis (NEC). METHODS: Individual patient clinical data for very low birth weight infants from the California Perinatal Quality Care Collaborative were linked to hospital-level data on DHM availability from the Mothers' Milk Bank of San José for 2007 to 2013. Trends of DHM availability were examined by level of NICU care. Hospitals that transitioned from not having DHM to having DHM availability during the study period were examined to assess changes in rates of breast milk feeding at NICU discharge and NEC. RESULTS: The availability of DHM increased from 27 to 55 hospitals during the study period. The availability increased for all levels of care including regional, community, and intermediate NICUs, with the highest increase occurring in regional NICUs. By 2013, 81.3% of premature infants cared for in regional NICUs had access to DHM. Of the 22 hospitals that had a clear transition to having availability of DHM, there was a 10% increase in breast milk feeding at NICU discharge and a concomitant 2.6% decrease in NEC rates. CONCLUSIONS: The availability of DHM has increased over time and has been associated with positive changes including increased breast milk feeding at NICU discharge and decrease in NEC rates.

Cultures of Holder-pasteurized donor human milk after use in a neonatal intensive care unit.

OBJECTIVE: Current guidelines state that human milk, once thawed, should be kept in a refrigerator for only 24 hours. We cultured Holder-pasteurized donor human milk (DHM) after thawing and refrigeration under clinical conditions. STUDY DESIGN: Bottles of pasteurized DHM were thawed and used in a regional level 3 neonatal intensive care unit (NICU) in standard clinical fashion and kept refrigerated when not in use. Once no longer needed clinically, aliquots were cultured for bacteria. RESULTS: In total, 30 bottles were returned for culture; six were excluded from analysis because human milk fortifier had been added, and two had been left out of the refrigerator. The remaining 22 bottles were culture-negative after having been thawed for 7-122 hours. CONCLUSIONS: DHM without additives was culture-negative for 24 hours or longer after thawing and routine NICU handling. These data indicate that unfortified Holder-pasteurized DHM handled appropriately and refrigerated remains sterile for 24 hours after thawing and perhaps longer. Further study is needed to confirm this.

Impact of an EMR-Based Daily Patient Update Letter on Communication and Parent Engagement in a Neonatal Intensive Care Unit.

OBJECTIVE: To evaluate the impact of using electronic medical record (EMR) data in the form of a daily patient update letter on communication and parent engagement in a level II neonatal intensive care unit (NICU). STUDY DESIGN: Parents of babies in a level II NICU were surveyed before and after the introduction of an EMR-generated daily patient update letter, Your Baby's Daily Update (YBDU). RESULTS: Following the introduction of the EMR-generated daily patient update letter, 89% of families reported using YBDU as an information source; 83% of these families found it "very useful", and 96% of them responded that they "always" liked receiving it. Rates of receiving information from the attending physician were not statistically significantly different pre- and post-implementation, 81% and 78%, respectively (p = 1). Though there was no statistically significant improvement in parents' knowledge of individual items regarding the care of their babies, a trend towards statistical significance existed for several items (p <.1), and parents reported feeling more competent to manage information related to the health status of their babies (p =.039). CONCLUSION: Implementation of an EMR-generated daily patient update letter is feasible, resulted in a trend towards improved communication, and improved at least one aspect of parent engagement-perceived competence to manage information in the NICU.