Association of Antenatal Corticosteroid Exposure and Infant Survival at 22 and 23 Weeks.

OBJECTIVE: In 2014, the leading obstetric societies published an executive summary of a joint workshop to establish obstetric interventions to be considered for periviable births. Antenatal corticosteroid administration between 220/7 and 226/7 weeks was not recommended given existing evidence. We sought to evaluate whether antenatal steroid exposure was associated with improved survival among resuscitated newborns delivered between 22 and 23 weeks of gestation. STUDY DESIGN: We conducted a population-based cohort study of all resuscitated livebirths delivered between 220/7 and 236/7 weeks of gestation in the United States during 2009 to 2014 utilizing National Center for Health Statistics data. The primary outcome was rate of survival to 1 year of life (YOL) between infant cohorts based on antenatal steroid exposure. Multivariable logistic regression estimated the association of antenatal steroid exposure on survival outcomes. RESULTS: In the United States between 2009 and 2014, there were 2,635 and 7,992 infants who received postnatal resuscitation after delivery between 220/7 to 226/7 and 230/7 to 236/7 weeks of gestation, respectively. Few infants born at 22 (15.9%) and 23 (26.0%) weeks of gestation received antenatal corticosteroids (ANCS). Among resuscitated neonates, survival to 1 YOL was 45.2 versus 27.8% (adjusted relative risk [aRR]: 1.6, 95% confidence interval [CI]: 1.2-2.1) and 57.9 versus 47.7% (aRR: 1.3, 95% CI: 1.1-1.5) for infants exposed to ANCS compared with those not exposed at 22 and 23 weeks of gestation, respectively. When stratified by 100 g birth weight category, ANCS were associated with survival among neonates weighing 500 to 599 g (aRR: 1.9, 95% CI: 1.3-2.9) and 600 to 699 g (aRR: 1.7, 95% CI: 1.1-2.6) at 22 weeks. CONCLUSION: Exposure to ANCS was associated with higher survival rates to 1 YOL among resuscitated infants born at 22 and 23 weeks. National guidelines recommending against ANCS utilization at 22 weeks should be re-evaluated given emerging evidence of benefit. KEY POINTS: · Exposure to antenatal steroids was associated with higher survival rates at 22 and 23 weeks of gestation.. · Women exposed to antenatal steroids were more likely to have an adverse outcome.. · The association between steroids and survival was observed among infants with birth weights > 500 g..

Factors Associated with Occurrence of Stillbirth before 32 Weeks of Gestation in a Contemporary Cohort.

OBJECTIVE: We sought to quantify the distribution of stillbirths by gestational age (GA) in a contemporary cohort and to determine identifiable risk factors associated with stillbirth prior to 32 weeks of gestation. STUDY DESIGN: Population-based case-control study of all stillbirths in the United States during the year 2014, utilizing vital statistics data, obtained from the National Center for Health Statistics. Distribution of stillbirths were stratified by 20 to 44 weeks of GA, in women diagnosed with stillbirth in the antepartum period. Pregnancy characteristics were compared between those diagnosed with stillbirth <32 versus ≥32 weeks of gestation. Multivariate logistic regression estimated the relative influence of various factors on the outcome of stillbirth prior to 32 weeks of gestation. RESULTS: There were 15,998 nonlaboring women diagnosed with stillbirth during 2014 in the United States between 20 and 44 weeks. Of them, 60.1% (n = 9,618) occurred before antenatal fetal surveillance (ANFS) is typically initiated (<32 weeks) and 39.9% (n = 6,380) were diagnosed at ≥32 weeks. Women with stillbirth prior to 32 weeks were more likely to be of non-Hispanic Black race (29.0 vs. 23.9%, p < 0.001), nulliparous (53.8 vs. 50.6%, p = 0.001), have chronic hypertension (CHTN; 6.0 vs. 4.3%, p < 0.001), and fetal growth restriction as evidenced by small for GA (SGA < 10th%) birth weight (44.8 vs. 42.1%, p < 0.001) as opposed to women with stillbirth after 32 weeks. After adjustment, SGA birth weight (adjusted odds ratio [aOR] = 1.2, 95% confidence interval [CI]: 1.1-1.3), Black race (aOR = 1.2, 95% CI: 1.1-1.3), and CHTN (aOR = 1.3, 95% CI: 1.1-1.5) were associated with stillbirth prior to 32 weeks of gestation as opposed to stillbirth after 32 weeks. CONCLUSION: More than 6 out of 10 stillbirths in this study occurred <32 weeks of gestation, before ANFS is typically initiated under American College of Obstetricians and Gynecologists recommendations. Among identifiable risk factors, CHTN, Black race, and fetal growth restriction were associated with higher risk of stillbirth before 32 weeks of gestation. Earlier ANFS may be warranted at in certain "at risk" women. KEY POINTS: · Six out of 10 stillbirths occur before 32 weeks of gestation.. · We evaluated factors associated with stillbirth <32 weeks.. · Hypertension and fetal growth restriction were associated with early stillbirth..

Enrollment and outcomes of home visiting for mothers with and without a history of out-of-home care.

Women previously in out-of-home care (i.e., foster care) experience poorer health and psychosocial outcomes compared to peers, including higher pregnancy rates and child protective services involvement. Home visiting programs could mitigate risks. Studies examining home visiting enrollment for women with a history of out-of-home care are needed. Women previously in out-of-home care based on child welfare administrative data between 2012 and 2017 (n = 1375) were compared to a demographically matched sample (n = 1375) never in out-of-home care. Vital records data identified live births in the two groups. For those who had given live birth (n = 372), linked administrative data were used to determine and compare rates of referral and enrollment into home visiting, and two indicators of engagement: number of days enrolled, and number of visits received. Women previously in out-of-home care were referred for home visiting more often than their peers. There were no differences in rates of enrollment. Women previously in out-of-home care remained enrolled for shorter durations and completed fewer home visits than peers. Findings suggest barriers to home visiting enrollment and retention in home visiting programs for women previously in out-of-home care. Studies with larger samples and more complete assessments of outcomes are warranted.

Introducción: Las mujeres que previamente han estado bajo cuidado fuera de cada (v.g. hogares de cuidado adoptivo temporal) experimentan una más débil salud y resultados sicosociales en comparación con las compañeras, incluyendo tasas más altas de embarazos y participación en servicios de protección a la niñez. Los programas de visitas a casa pudieran mitigar los riesgos. Se necesitan estudios que examinen la entrada en programas de visitas a casa de mujeres con un historial de cuidado fuera de casa. Métodos: Se comparó la información administrativa entre 2012 y 2017 de mujeres (n = 1375) que previamente estuvieron en cuidados fuera de casa basados en la beneficencia infantil con un grupo muestra demográficamente emparejado (n = 1375) que nunca habían estado bajo cuidado fuera de casa. Los datos vitales registrados identificaron nacimientos vivos en los dos grupos. Para quienes habían tenido un parto y nacimiento vivo (n = 372), se usó la información administrativa conectada para determinar y comparar las tasas de referencia y entrada en programas de visitas a casa, y dos indicadores de participación: el número de días en que estuvieron matriculadas y el número de visitas recibidas. Resultados: A las mujeres previamente bajo cuidado fuera de casa se les refirió a los programas de visita a casa más a menudo que a sus compañeras. No se dieron diferencias en las tasas de matrícula. Las mujeres previamente bajo cuidado fuera de casa permanecieron matriculadas por duraciones más cortas y completaron menos visitas a casa que sus compañeras. Conclusiones: Los resultados identifican barreras a la matrícula y retención en programas de visitas a casa para mujeres previamente bajo cuidado fuera de casa. Se justifican los estudios con grupos muestras más grandes y evaluaciones más completas de los resultados.

Les femmes ayant été placées en famille ou foyer d'accueil font l'expérience d'une plus mauvaise santé et de résultats psychologiques moins bons que les autres femmes, y compris des taux de grossesse plus élevés et l'intervention de services de protection de l'enfance. Les programmes de visite à domicile peuvent mitiger les risques. Les études examinant l'inscription aux visites à domicile pour les femmes ayant un passé de placement en famille ou en foyer sont nécessaires. Méthodes: des femmes ayant vécu un placement en famille ou en foyer selon les données administratives de la protection de l'enfance entre 2012 et 2017 (n = 1375) ont été comparées à un échantillon assorti démographiquement (n = 1375) de femmes n'ayant jamais été placées en famille ou foyer d'accueil. Nous avons identifié des naissances vivantes chez les deux groupes. Pour celles ayant donné naissance (naissance vivante) (n = 372) les données administratives liées ont été utilisées afin de déterminer et de comparer les taux d'orientation et d'inscription aux visites à domicile, et deux indicateurs d'engagement: le nombre de jours inscrites et le nombre de visites reçues. Résultats: les femmes ayant été placées dans des familles ou des foyers d'accueil étaient dirigées vers les visites à domicile plus souvent que leurs pairs. Il n'y avait aucune différence dans les taux d'inscription. Les femmes ayant été en familles ou foyers d'accueil sont restées inscrites pendant des durées plus courtes et ont eu moins de visites à domiciles que leurs pairs. Conclusions: les résultats suggèrent qu'il existe des barrières à l'inscription aux visites à domicile et à la rétention dans les programmes de visites à domicile pour les femmes ayant été placées en famille ou en foyer. Des études avec des échantillons plus grands et des évaluations plus compètes sont justifiées.

OASIS +: leveraging machine learning to improve the prognostic accuracy of OASIS severity score for predicting in-hospital mortality.

BACKGROUND: Severity scores assess the acuity of critical illness by penalizing for the deviation of physiologic measurements from normal and aggregating these penalties (also called "weights" or "subscores") into a final score (or probability) for quantifying the severity of critical illness (or the likelihood of in-hospital mortality). Although these simple additive models are human readable and interpretable, their predictive performance needs to be further improved. METHODS: We present OASIS +, a variant of the Oxford Acute Severity of Illness Score (OASIS) in which an ensemble of 200 decision trees is used to predict in-hospital mortality based on the 10 same clinical variables in OASIS. RESULTS: Using a test set of 9566 admissions extracted from the MIMIC-III database, we show that OASIS + outperforms nine previously developed severity scoring methods (including OASIS) in predicting in-hospital mortality. Furthermore, our results show that the supervised learning algorithms considered in our experiments demonstrated higher predictive performance when trained using the observed clinical variables as opposed to OASIS subscores. CONCLUSIONS: Our results suggest that there is room for improving the prognostic accuracy of the OASIS severity scores by replacing the simple linear additive scoring function with more sophisticated non-linear machine learning models such as RF and XGB.

Regional Contribution of Previable Infant Deaths to Infant Mortality Rates in the United States.

OBJECTIVE: Lack of standardization of infant mortality rate (IMR) calculation between regions in the United States makes comparisons potentially biased. This study aimed to quantify differences in the contribution of early previable live births (<20 weeks) to U.S. regional IMR. STUDY DESIGN: Population-based cohort study of all U.S. live births and infant deaths recorded between 2007 and 2014 using Centers for Disease Control and Prevention's (CDC's) WONDER database linked birth/infant death records (births from 17-47 weeks). Proportion of infant deaths attributable to births <20 vs. 20 to 47 weeks, and difference (ΔIMR) between reported and modified (births ≥20 weeks) IMRs were compared across four U.S. census regions (North, South, Midwest, and West). RESULTS: Percentages of infant deaths attributable to birth <20 weeks were 6.3, 6.3, 5.3, and 4.1% of total deaths for Northeast, Midwest, South, and West, respectively, p < 0.001. Contribution of < 20-week deaths to each region's IMR was 0.34, 0.42, 0.37, and 0.2 per 1,000 live births. Modified IMR yielded less regional variation with IMRs of 5.1, 6.2, 6.6, and 4.9 per 1,000 live births. CONCLUSION: Live births at <20 weeks contribute significantly to IMR as all result in infant death. Standardization of gestational age cut-off results in more consistent IMRs among U.S. regions and would result in U.S. IMR rates exceeding the healthy people 2020 goal of 6.0 per 1,000 live births.

Subclinical and Overt Newborn Opioid Exposure: Prevalence and First-Year Healthcare Utilization.

OBJECTIVES: To categorize newborn infants in Hamilton County, Ohio by late pregnancy fetal opioid exposure status and to assess their first-year healthcare utilization. STUDY DESIGN: We used a population-based cohort of 41 136 live births from 2014-2017 and analyzed healthcare encounters in the first year of life from electronic health records. We prospectively assessed for the presence of opioids in maternal urine collected at delivery and for a diagnosis of newborn neonatal abstinence syndrome (NAS). At birth, infants were classified as unexposed to opioids, exposed to opioids and diagnosed with NAS, or subclinically exposed to opioids (exposure that did not result in NAS). RESULTS: The prevalence of newborn opioid exposure was 37 per 1000 births. The duration of the hospital birth encounter was significantly longer for infants with subclinical exposure compared with unexposed infants (10% increase; 95% CI, 7%-13%). However, duration for infants with subclinical exposure was shorter compared to those with NAS. Neither subclinical exposure nor NAS was associated with total emergency department visits. Subclinical exposure was associated with increased odds of having at least 1 hospitalization in the first year. However, the total length of stay for hospitalizations was 82% that of the unexposed group (95% CI, 75%-89%). Infants with NAS had a 213% longer total length of stay compared with the unexposed group (95% CI, 191%-237%). CONCLUSIONS: Subclinical and overt opioid exposure among newborn infants was associated with increased first-year healthcare utilization. From 2014 to 2017, this cost the Hamilton County healthcare system an estimated $1 109 452 for longer birth encounters alone.

Adherence to Well-Child Care and Home Visiting Enrollment Associated with Increased Emergency Department Utilization.

INTRODUCTION: Pediatric primary care and home visiting programs seek to reduce health disparities and promote coordinated health care use. It is unclear whether these services impact high-cost, emergency department (ED) utilization. We evaluated the association of well-child care (WCC) and home visiting with ED visit frequency for children < 1 year with an established medical home. METHODS: Retrospective cohort study using linked administrative data for infants ≥ 34 weeks' gestation from 2010 to 2014, within a multisite, academic primary care system. Latent class analysis characterized longitudinal patterns of WCC. Multivariable negative binomial regression models tested the independent association between WCC patterns and home visiting enrollment with ED visits. RESULTS: Among 10,363 infants, three WCC latent classes were identified: "Adherent" (83.4% of the cohort), "Intermediate" (9.7%), and "Decreasing adherence" (7.0%). Sixty-one percent of the sample had ≥ 1 ED visit in the first 12 months of life, and 73% of all ED visits were triaged as non-urgent. There was a significant interaction effect between WCC pattern and insurance status. Among Medicaid-insured infants, "Intermediate" and "Decreasing adherence" WCC patterns were associated with a lower incident rate of ED visits compared with the "Adherent" pattern (incident rate ratios (IRR) 0.88, p = 0.03 and 0.79, p < 0.001 respectively); this effect was not observed among privately-insured infants. Home visiting enrollment was independently associated with a higher rate of ED visits (IRR 1.24, p < 0.001). DISCUSSION: Among infants with an established medical home, adherence to recommended WCC and home visiting enrollment was associated with greater ED use for non-urgent conditions.

Effect of Needle Exchange Program on Maternal Hepatitis C Virus Prevalence.

OBJECTIVE: This study aimed to quantify the prevalence of maternal hepatitis C virus (HCV) before and after implementation of the needle exchange program (NEP) in Scioto County, Ohio. STUDY DESIGN: We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of maternal HCV was compared before (2006-2011) and after (2012-2015) the implementation of an NEP (2011) in Portsmouth, Ohio (Scioto County). Trends in maternal HCV prevalence in neighboring counties both physically adjacent and regional to Scioto County were also evaluated before and after NEP implementation. RESULTS: During the study period, there were 7,069 reported cases of maternal HCV infection at the time of delivery among 1,463,506 (0.5%) live births in Ohio. The rate of maternal HCV infection increased 137% in Scioto County between 2006 and 2011. After initiation of the NEP in Portsmouth, Ohio, in 2011, the rate of increase in the following 4 years (2012-2015) was 12%. The rate of increase in maternal HCV declined precipitously in counties physically adjacent to Scioto County, whereas regional counties continued to have substantial increases in maternal HCV. CONCLUSION: Rate of maternal HCV infection increased 137% versus 12% (rate difference: 125%) between pre- and post-NEP implementation time periods in Scioto County.

Trimester specific PM2.5 exposure and fetal growth in Ohio, 2007-2010.

BACKGROUND: Exposure to particulate matter, particularly with aerodynamic diameter < 2.5 µm (PM2.5), may increase inflammation and oxidative stress in pregnant women and affect fetal growth. We examined trimester specific PM2.5 exposure levels and small for gestational age (SGA) using the statewide birth registry of Ohio from 2007 to 2010. METHODS: Exposure to PM2.5 in each trimester and for each gestational week was determined using data from 57 Environmental Protection Agency network monitoring stations across the state of Ohio. We restricted the data to 224,921 singleton live births, with a gestational age of 20-42 weeks, no genetic disorders or congenital abnormalities, and who had home addresses within a 10 km radius of any PM2.5 monitoring station. We estimated odds ratios of SGA using Generalized Linear Models (GLMs) and Distributed Lag Models (DLMs), and adjustment for maternal age, race, education, parity, body mass index, insurance type, tobacco use, prenatal care initiation, birth year, season of birth, and sex of the baby. RESULTS: Mean PM2.5 levels during the entire pregnancy were 13.03 µg/m3 with a standard deviation of 1.57 µg/m3. Covariates adjusted odds ratios and 95% confidence intervals of a 10 µg/m3 increase in PM2.5 levels with a 10 km buffer radius for SGA and trimesters modeled separately were 0.94 (0.88, 1.00) for the first trimester, 0.93 (0.86, 1.00) for the second trimester, 1.07 (1.00, 1.15) for the third trimester, and 0.92 (0.81, 1.06) for the entire pregnancy. When a 5 km buffer radius was used, adjusted odds ratios and 95% confidence intervals for SGA were 0.97 (0.89, 1.05) for the first trimester, 0.96 (0.88, 1.05) for the second trimester, 1.09 (1.02, 1.17) for the third trimester, and 0.99 (0.85, 1.14) for the overall pregnancy, indicating sensitivity to buffer choice. DLMs showed gestational weeks 30-35 to be a particular window of vulnerability. CONCLUSION: Increasing exposure to PM2.5 during the third trimester of pregnancy was associated with a small increase in risk of SGA in this population-based study. Selection of a buffer radius significantly impacted our results in the first trimester, but not in the third trimester.

Data Challenges With Real-Time Safety Event Detection And Clinical Decision Support.

BACKGROUND: The continued digitization and maturation of health care information technology has made access to real-time data easier and feasible for more health care organizations. With this increased availability, the promise of using data to algorithmically detect health care-related events in real-time has become more of a reality. However, as more researchers and clinicians utilize real-time data delivery capabilities, it has become apparent that simply gaining access to the data is not a panacea, and some unique data challenges have emerged to the forefront in the process. OBJECTIVE: The aim of this viewpoint was to highlight some of the challenges that are germane to real-time processing of health care system-generated data and the accurate interpretation of the results. METHODS: Distinct challenges related to the use and processing of real-time data for safety event detection were compiled and reported by several informatics and clinical experts at a quaternary pediatric academic institution. The challenges were collated from the experiences of the researchers implementing real-time event detection on more than half a dozen distinct projects. The challenges have been presented in a challenge category-specific challenge-example format. RESULTS: In total, 8 major types of challenge categories were reported, with 13 specific challenges and 9 specific examples detailed to provide a context for the challenges. The examples reported are anchored to a specific project using medication order, medication administration record, and smart infusion pump data to detect discrepancies and errors between the 3 datasets. CONCLUSIONS: The use of real-time data to drive safety event detection and clinical decision support is extremely powerful, but it presents its own set of challenges that include data quality and technical complexity. These challenges must be recognized and accommodated for if the full promise of accurate, real-time safety event clinical decision support is to be realized.

Torticollis in Infants with a History of Neonatal Abstinence Syndrome.

In this retrospective cohort study, we assessed the incidence of torticollis in infants with a history of neonatal abstinence syndrome. Understanding the elevated risk of torticollis in this population is important for early identification and treatment.

Primary Care and Home Visiting Utilization Patterns among At-Risk Infants.

OBJECTIVE: To describe well child care (WCC) utilization in the first year of life among at-risk infants, and the relationship to home visiting enrollment. STUDY DESIGN: Retrospective cohort study using linked administrative data for infants ≥34 weeks' gestation from 2010 to 2014, within a regional, academic primary care system. Association between WCC visits and home visiting enrollment was evaluated using bivariate comparisons and multivariable Poisson regression. Latent class analysis further characterized longitudinal patterns of WCC attendance. Multivariable logistic regression tested the association between home visiting and pattern of timeliest adherence to recommended WCC. RESULTS: Of 11 936 infants, mean number of WCC visits was 4.1 in the first 12 months of life. Of 3910 infants eligible for home visiting, 28.5% were enrolled. Among enrolled infants, mean WCC visits was 4.7 vs 4.4 among eligible, nonenrolled infants, P value < .001. After multivariable adjustment, there was no significant association between enrollment and WCC visit count (adjusted incident rate ratio 1.03, 95% CI 0.99, 1.07). Using latent class analysis, 3 WCC classes were identified: infants in class 1 (77.7%) were most adherent to recommended WCC, class 2 (12.5% of cohort) had progressively declining WCC attendance over the first year of life, and class 3 (9.8%) maintained moderate attendance. In multivariable regression, home visiting was associated with class 1 membership, aOR 1.27, 95% CI 1.04, 1.57. CONCLUSIONS: A pattern of timely WCC attendance was more likely among infants in home visiting; however, most infants eligible for home visiting were not enrolled.

Implementation of a Regional Perinatal Data Repository from Clinical and Billing Records.

Objectives To describe the implementation of the first phase of a regional perinatal data repository and to provide a roadmap for others to navigate technical, privacy, and data governance concerns in implementing similar resources. Methods Our implementation integrated regional physician billing records with maternal and infant electronic health records from an academic delivery hospital. These records, representing births during 2013-2015, constituted a data core supporting linkage to additional ancillary data sets. Measures obtained from pediatric follow-up, urgent care, emergency, and inpatient encounters were linked at the individual level as were measures obtained by home visitors during pre- and postnatal encounters. Residential addresses were geocoded supporting linkage to area-level measures. Results Integrated data contained regional billing records for 69,290 newborns representing approximately 81% of all regional live births and nearly 95% of live births in the region's most populous county. Billing records linked to 7293 infant delivery hospital records and 7107 corresponding maternal hospital records. Manual review demonstrated 100% validity of matches among audited records. Additionally, 2430 home visiting records were linked to the data core as were pediatric primary care, urgent care, emergency department, and inpatient visits representing 42,541 children. More than 99% of the newborn billing records were geocoded and assigned a census tract identifier. Conclusions for Practice Our approach to methodological and regulatory challenges affords opportunities for expansion of systems to integrate electronic health records originating from additional medical centers as well as individual- and area-level linkage to additional data sets relevant to perinatal health.

Comparison of Neonatal Abstinence Syndrome Treatment with Sublingual Buprenorphine versus Conventional Opioids.

OBJECTIVE: The objective of this study was to compare duration of opioid treatment and length of stay outcomes for neonatal abstinence syndrome (NAS) using sublingual buprenorphine versus traditional weaning with methadone or morphine. STUDY DESIGN: This retrospective cohort analysis evaluated infants treated for NAS at a single community hospital from July 2013 through June 2017. A standardized weaning protocol was introduced in June 2015, allowing for treatment with sublingual buprenorphine regardless of type of intrauterine opioid exposure. General linear models were used to calculate adjusted mean duration of opioid treatment and length of hospitalization with 95% confidence intervals for infants treated with buprenorphine compared with traditional weaning with either methadone or morphine. RESULTS: A total of 360 infants were treated with either buprenorphine (n = 174) or a traditional opioid (n = 186). Infants treated with buprenorphine experienced a 3.0-day reduction in opioid treatment duration of 7.4 (6.3-8.5) versus 10.4 (9.3-11.5) days (p < 0.001) and a 2.8-day reduction in length of stay of 12.4 (11.3-13.6) versus 15.2 (14.1-16.4) days (p < 0.001). CONCLUSION: Our study provides an independent confirmation that among infants experiencing NAS following a wide array of intrauterine opioid exposures, buprenorphine weaning supports a shortened treatment duration compared with conventional weaning agents.

Evaluation of Early Onset Sepsis, Complete Blood Count, and Antibiotic Use in Gastroschisis.

OBJECTIVE: Gastroschisis is a congenital defect in which the abdominal viscera herniate through the abdominal wall. In this population, antibiotics are often initiated immediately following delivery; however, this may be unnecessary as infections typically develop as a consequence of chronic issues in gastroschisis. The objective of this study was to evaluate the incidence of culture positive early onset sepsis, the reliability of the immature to mature neutrophil count (I:T) ratio as an infectious biomarker, and antibiotic use in infants with gastroschisis. STUDY DESIGN: This retrospective chart review analyzed clinical data from 103 infants with gastroschisis and 103 weight-matched controls that were evaluated for early onset infection. RESULTS: Compared with the control group, there was a significantly increased percentage of infants with an I:T ratio > 0.2 in the gastroschisis group (43% vs. 12%, p < 0.001) and an increased percentage of infants exposed to greater than 5 days of antibiotics regardless of their I:T ratio (75% vs. 6%, p < 0.001). There were no episodes of culture positive early onset sepsis in either group. CONCLUSION: Our results indicate that I:T ratio is not a reliable marker of infection in gastroschisis, and suggest that empiric septic evaluation and antibiotic use, immediately following delivery in gastroschisis infants, may be unnecessary.

County-level Variation in Infant Mortality Reporting at Early Previable Gestational Ages.

BACKGROUND: Infant mortality rate (IMR), or number of infant deaths per 1000 livebirths, varies widely across the US While fetal deaths are not included in this measure, reported infant deaths do include those delivered at previable gestations, or ≤20 weeks gestation. Variation in reporting of these events may have a significant impact on IMR estimates. METHODS: This retrospective analysis used US National Center for Health Statistics 2007-2013 data from 2391 US counties. Counties were categorised by US region, demographic characteristics, and state-level fetal death reporting requirements. County percentage of fetal deaths among all 17-20 week fetal and infant deaths was evaluated using multivariable linear regression. County-level characteristics were then included in multivariable linear regression to determine the associated change in county IMR. RESULTS: County percentage of deaths at 17-20 weeks reported as fetal ranged from 0% to 100% (mean 63.7%). Every 1 point increase in this percentage was associated with a 0.02 point decrease in county IMR (95% confidence interval (CI) 0.02, 0.03). When county IMRs were recalculated holding the percentage of fetal vs. infant deaths at 17-20 weeks constant at 63.7%, results suggest that the predicted gap in county IMR between Northeast and Midwest regions would narrow by 0.45 points. CONCLUSIONS: Variable reporting of previable fetal and infant deaths may compromise the validity of county IMR comparisons. Improved consistency and accuracy of fetal and infant death reporting is warranted.

Evaluation of Early Childhood Home Visiting to Prevent Medically Attended Unintentional Injury.

STUDY OBJECTIVE: We evaluated the influence of home visiting on the risk for medically attended unintentional injury during home visiting (0 to 3 years) and subsequent to home visiting (3 to 5 years). METHODS: A retrospective, quasi-experimental study was conducted in a cohort of mother-child pairs in Hamilton County, OH. The birth cohort (2006 to 2012) was linked to administrative home visiting records and data from a population-based injury surveillance system containing records of emergency department (ED) visits and hospitalizations. Cox proportional-hazard regression was used to compare medically attended unintentional injury risk (0 to 2, 0 to 3, and 3 to 5 years) in a home-visited group versus a propensity score-matched comparison group. The study population was composed of 2,729 mother-child pairs who received home visiting and 2,729 matched mother-child pairs in a comparison group. RESULTS: From birth to 2 years, 17.2% of the study population had at least one medically attended unintentional injury. The risk for medically attended unintentional injury from aged 0 to 2 and 0 to 3 years was significantly higher in the home-visited group relative to the comparison group (hazard ratio 1.17, 95% confidence interval 1.01 to 1.35; hazard ratio 1.15, 95% confidence interval 1.00 to 1.31, respectively). Additional injuries in the home-visited group were superficial, and the increased risk for medically attended unintentional injury was observed for ED visits and not hospitalizations. CONCLUSION: Home-visited children were more likely to have a medically attended unintentional injury from birth to aged 3 years. This finding may be partially attributed to home visitor surveillance of injuries or greater health care-seeking behavior. Implications and alternative explanations are discussed.

Infant Mortality, Cause of Death, and Vital Records Reporting in Ohio, United States.

Introduction Infant mortality rate is a sensitive metric for population health and well-being. Challenges in achieving accurate reporting of these data can lead to inaccurate targeting of public health interventions. We analyzed a cohort from a pediatric tertiary care referral medical center to evaluate concordance between autopsy cause of death (COD) and death certificate documentation for infants <1 year of age. We predicted that infant COD as documented through vital records would not correspond to that as determined by autopsy. Methods We conducted a retrospective review comparing causes of infant death reported through Ohio Department of Health documents to those on Cincinnati Children's Hospital Medical Center autopsy reports over an 8-year period from January 1, 2006 through December 31, 2013. Results We analyzed 276 total cases of which 167 (61.5 %) represented infants born preterm. Autopsy reports identified 55 % of cases had a congenital anomaly. Additionally, 34 % of all cases had primary or contributing COD related to infection and 14.5 % of all cases indicated chorioamnionitis. We identified 156 (56.5 %) death certificates discordant with autopsy COD of which 52 (33.3 %) involved infection and 24 (15.4 %) involved congenital anomalies. Discussion There are opportunities to improve COD reporting through training for providers, and improvement of established state certification systems. Future strategies to reduce infant mortality will be better informed through enhancements in vital records COD reporting.

A Cohort Comparison of Buprenorphine versus Methadone Treatment for Neonatal Abstinence Syndrome.

OBJECTIVES: To compare the duration of opioid treatment and length of stay among infants treated for neonatal abstinence syndrome (NAS) by using a pilot buprenorphine vs conventional methadone treatment protocol. STUDY DESIGN: This retrospective cohort analysis evaluated infants who received pharmacotherapy for NAS at 6 hospitals in Southwest Ohio from January 2012 through August 2014. A single neonatology provider group used a standardized methadone protocol across all 6 hospitals. However, at one of the sites, infants were managed with a buprenorphine protocol unless they had experienced chronic in utero exposure to methadone. Linear mixed models were used to calculate adjusted mean duration of opioid treatment and length of inpatient hospitalization with 95% CIs in infants treated with oral methadone compared with sublingual buprenorphine. The use of adjunct therapy was examined as a secondary outcome. RESULTS: A total of 201 infants with NAS were treated with either buprenorphine (n = 38) or methadone (n = 163) after intrauterine exposure to short-acting opioids or buprenorphine. Buprenorphine therapy was associated with a shorter course of opioid treatment of 9.4 (CI 7.1-11.7) vs 14.0 (12.6-15.4) days (P < .001) and decreased hospital stay of 16.3 (13.7-18.9) vs 20.7 (19.1-22.2) days (P < .001) compared with methadone therapy. No difference was detected in the use of adjunct therapy (23.7% vs 25.8%, P = .79) between treatment groups. CONCLUSION: The choice of pharmacotherapeutic agent is an important determinant of hospital outcomes in infants with NAS. Sublingual buprenorphine may be superior to methadone for management of NAS in infants with select intrauterine opioid exposures.

Racial disparity in previable birth.

BACKGROUND: Extremely preterm birth of a live newborn before the limit of viability is rare but contributes uniformly to the infant mortality rate because essentially all cases result in neonatal death. OBJECTIVE: The objective of the study was to quantify racial differences in previable birth and their contribution to infant mortality and to estimate the relative influence of factors associated with live birth occurring before the threshold of viability. STUDY DESIGN: This was a population-based retrospective cohort of all live births in Ohio over a 7 year period, 2006-2012. Demographic, pregnancy, and delivery characteristics of previable live births at 16 0/7 to 22 6/7 weeks of gestation were compared with a referent group of live births at 37 0/7 to 42 6/7 weeks. Rates of birth at each week of gestation were compared between black and white mothers, and relative risk ratios were calculated. Logistic regression estimated the relative risk of factors associated with previable birth, with adjustment for concomitant risk factors. RESULTS: Of 1,034,552 live births in Ohio during the study period, 2607 (0.25% of all live births) occurred during the previable period of 16-22 weeks. There is a significant racial disparity in the rate and relative risk of previable birth, with a 3- to 6-fold relative risk increase in black mothers at each week of previable gestational age. The incidence of previable birth for white mothers was 1.8 per 1000 and for black mothers, 6.9 per 1000. Factors most strongly associated with previable birth, presented as adjusted relative risk ratio (95% confidence interval [CI]), were maternal characteristics of black race adjusted relative risk 2.9 (95% CI, 2.6-3.2), age ≥ 35 years 1.3 (95% CI, 1.1-1.6), and unmarried 2.1 (95% CI, 1.8-2.3); fetal characteristics including congenital anomaly, 5.4 (95% CI, 3.4-8.1) and genetic disorder, 5.1 (95% CI, 2.5-10.1); and pregnancy characteristics including prior preterm birth 4.4 (95% CI, 3.7-5.2) and multifetal gestation, twin, 16.9 (95% CI, 14.4-19.8) or triplet, 65.4 (95% CI, 32.9-130.2). The majority, 80%, of previable births (16-22 weeks) were spontaneous in nature, compared with 73% in early preterm births (23-33 weeks), 72% in late preterm births (34-36 weeks), and 65% of term births (37-42 weeks) (P < .001). Previable births constituted approximately 28% of total infant mortalities in white newborns and 45% of infant mortalities in black infants in Ohio during the study period. CONCLUSION: There is a significant racial disparity in previable preterm births, with black mothers incurring a 3- to 6-fold increased relative risk compared with white mothers, most of which are spontaneous in nature. This may explain much of the racial disparity in infant mortality because all live-born previable preterm births result in death. Focused efforts on the prevention of spontaneous previable preterm birth may help to reduce the racial disparity in infant mortality.