Implicit Bias and Health Disparities Education in the Neonatal Intensive Care Unit.

OBJECTIVE: This study aimed to characterize implicit bias (IB) and health disparities (HD) education in neonatal-perinatal medicine (NPM), including current educational opportunities, resources, and barriers. STUDY DESIGN: A national web-based survey was sent to NPM fellows, neonatologists, and frontline providers after iterative review by education experts from the National Neonatology Curriculum Committee. Quantitative data were analyzed with chi-square and Fisher's exact tests. Qualitative data were evaluated using thematic analysis. RESULTS: Of the 452 NPM survey respondents, most desired additional IB (76%) and HD (83%) education. A greater proportion of neonatologists than fellows received IB (83 vs. 57%) and HD (87 vs. 74%) education. Only 41% of neonatologists reported that their institution requires IB training. A greater proportion of fellows than neonatologists expressed dissatisfaction with the current approaches for IB (51 vs. 25%, p < 0.001) and HD (43 vs. 25%, p = 0.015) education. The leading drivers of dissatisfaction included insufficient time spent on the topics, lack of specificity to NPM, inadequate curricular scope or depth, and lack of local educator expertise. A minority of faculty who were tasked to educate others have received specific educator training on IB (21%) and HD (16%). Thematic analysis of survey free-text responses identified three main themes on the facilitators and barriers to successful IB and HD education: individual, environmental, and curricular design variables. CONCLUSION: NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education. Identified barriers are important to address in developing an effective IB/HD curriculum for the NPM community. KEY POINTS: · There is a gap between the current delivery of IB/HD education and the needs of the NPM community.. · NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education.. · A successful curriculum should be widely accessible, NPM-specific, and include facilitator training..

Evaluation of the Diversity, Equity, and Inclusion Curriculum of a Pediatrics Residency Program.

OBJECTIVES: Diversity, equity, and inclusion (DEI) training is essential to graduate medical education, but it lacks standardization. Although the impact of providers' biases and cultural competency on patient outcomes is well documented, the value of and satisfaction with DEI curricula in Pediatrics residency training programs is not well studied. This study aimed to complete a cross-sectional evaluation of the current DEI curriculum at a large Pediatrics-focused academic institution and identify areas of perceived deficiency among Pediatrics trainees. METHODS: Residents and residency program directors completed surveys in 2020. Respondents evaluated the DEI curriculum of the program and the competency of residents to complete patient care related to specific DEI-oriented actions. Our analysis used descriptive statistics. RESULTS: In total, 48 of 137 resident trainees (35%) and 7 of 9 program leaders (78%) completed the survey. Respondents were most dissatisfied with current education related to implicit bias, refugee/immigrant health, and lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other health topics. Respondents reported low resident competency in DEI-focused patient care tasks and did not view residents as competent to address the healthcare needs of patients and families experiencing racism. CONCLUSIONS: Pediatrics residents and program directors consider DEI topics important and express a need for more robust DEI curricula.

Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn.

Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..

Use of a Quality Scorecard to Enhance Quality and Safety in Community Hospital Newborn Nurseries.

OBJECTIVE: To implement a quality improvement (QI) scorecard as a tool for enhancing quality and safety efforts in level 1 and 2 community hospital nurseries affiliated with Nationwide Children's Hospital. STUDY DESIGN: A QI scorecard was developed for data collection, analytics, and reporting of neonatal quality metrics and cross-sector collaboration. Newborn characteristics were included for risk stratification, as were clinical and process measures associated with neonatal morbidity and mortality. Quality and safety activities took place in community hospital newborn nurseries in Ohio, and education was provided in both online and in-person collaborations, followed by local team sessions at partner institutions. Baseline (first 12 months) and postbaseline comparisons of clinical and process measures were analyzed by logistic regression, adjusting for potential confounders. RESULTS: In logistic regression models, at least 1 center documented improvements in each of the 4 process measures, and 3 of the 4 centers documented improvements in compliance with glucose checks obtained within 90 minutes of birth among at-risk infants. CONCLUSION: Collaborative QI projects led to improvements in perinatal metrics associated with important outcomes. Formation of a center-driven QI scorecard is feasible and provides community hospitals with a framework for collecting, analyzing, and reporting neonatal QI metrics.

Value, Strengths, and Challenges of e-Learning Modules Paired with the Flipped Classroom for Graduate Medical Education: A Survey from the National Neonatology Curriculum.

OBJECTIVE: This study aimed to determine the value, strengths, and challenges of implementing an e-learning based flipped classroom (FC) educational modality as part of the standardized physiology National Neonatology Curriculum (NNC), created for neonatal-perinatal medicine (NPM) fellow learners and faculty educators. STUDY DESIGN: This is a cross-sectional study of NPM fellows and faculty educators who utilized at least one of the e-learning based NNC FC respiratory physiology programs between May and September 2018. Participants were surveyed anonymously regarding their experiences participating in the NNC, including measures of preparation time. A combination of descriptive statistics and proportion comparisons were used for data analysis. RESULTS: Among 172 respondents, the majority of fellow and faculty respondents reported positive attitudes toward the educational content and case discussions, and the majority supported national standardization of NPM physiology education (92%). Fellows reported greater preclass preparation for their FC compared with previous didactic lectures (30-60 vs. 0-15 minutes, p < 0.01). Faculty facilitators reported less preparation time before facilitating a FC compared with the time required for creating a new didactic lecture (median: 60 vs. 240 minutes, p < 0.01). Both fellows and faculty respondents preferred the FC approach to traditional didactics, with fellows showing a greater degree of preference than faculty (68 vs. 52%, respectively, p = 0.04). CONCLUSION: Fellows and faculty educators supported the FC learning, reporting peer-to-peer learning, and the establishment of a learning community which promotes adult learning and critical thinking skills. A national physiology curriculum creates equitable and engaging educational experiences for all NPM fellows while reducing individual program burden of content creation. Our findings further supported the development of an NNC using a flipped classroom modality.

The impact of fluid balance on outcomes in premature neonates: a report from the AWAKEN study group.

BACKGROUND: We evaluated the epidemiology of fluid balance (FB) over the first postnatal week and its impact on outcomes in a multi-center cohort of premature neonates from the AWAKEN study. METHODS: Retrospective analysis of infants <36 weeks' gestational age from the AWAKEN study (N = 1007). FB was defined by percentage of change from birth weight. OUTCOME: Mechanical ventilation (MV) at postnatal day 7. RESULTS: One hundred and forty-nine (14.8%) were on MV at postnatal day 7. The median peak FB was 0% (IQR: -2.9, 2) and occurred on postnatal day 2 (IQR: 1,5). Multivariable models showed that the peak FB (aOR 1.14, 95% CI 1.10-1.19), lowest FB in first postnatal week (aOR 1.12, 95% CI 1.07-1.16), and FB on postnatal day 7 (aOR 1.10, 95% CI 1.06-1.13) were independently associated with MV on postnatal day 7. In a similar analysis, a negative FB at postnatal day 7 protected against the need for MV at postnatal day 7 (aOR 0.21, 95% CI 0.12-0.35). CONCLUSIONS: Positive peak FB during the first postnatal week and more positive FB on postnatal day 7 were independently associated with MV at postnatal day 7. Those with a negative FB at postnatal day 7 were less likely to require MV.

Pediatric Residency Graduates Preparedness for Neonatal-Perinatal Medicine Fellowship: The Perspective of First-Year Fellows.

OBJECTIVE: This study aimed to report on Neonatal-Perinatal Medicine (NPM) fellows' views of self-preparedness upon starting postresidency training. STUDY DESIGN: We conducted a national survey of first-year NPM fellows in the United States. The validated survey had five major areas: professionalism, psychomotor ability, independence/graduated responsibility, clinical evaluation, and academia. Survey responses were analyzed using descriptive statistics, and the free-text answers were categorized. RESULTS: Of 228 potential first-year NPM fellows, 140 (61%) initially responded to the survey. Overall, the fellows perceived themselves positively in professionalism and independence/graduated responsibility domains. Marked variability was observed in perceived preparedness in psychomotor ability, with confidence in neonatal intubation and arterial line placement of 86 and 49%, respectively. Lack of confidence in performing neonatal intubation procedures correlates with lack of attempts. The majority (75%) of fellows reported being interested in academia, but less than half felt capable of writing an article. CONCLUSION: First-year NPM fellows identified deficiencies in the domains of psychomotor ability and academia. Residency and fellowship programs should partner to address these deficiencies.

The impact of fluid balance on outcomes in critically ill near-term/term neonates: a report from the AWAKEN study group.

BACKGROUND: In sick neonates admitted to the NICU, improper fluid balance can lead to fluid overload. We report the impact of fluid balance in the first postnatal week on outcomes in critically ill near-term/term neonates. METHODS: This analysis includes infants ≥36 weeks gestational age from the Assessment of Worldwide Acute Kidney injury Epidemiology in Neonates (AWAKEN) study (N = 645). Fluid balance: percent weight change from birthweight. PRIMARY OUTCOME: mechanical ventilation (MV) on postnatal day 7. RESULTS: The median peak fluid balance was 1.0% (IQR: -0.5, 4.6) and occurred on postnatal day 3 (IQR: 1, 5). Nine percent required MV at postnatal day 7. Multivariable models showed the peak fluid balance (aOR 1.12, 95%CI 1.08-1.17), lowest fluid balance in 1st postnatal week (aOR 1.14, 95%CI 1.07-1.22), fluid balance on postnatal day 7 (aOR 1.12, 95%CI 1.07-1.17), and negative fluid balance at postnatal day 7 (aOR 0.3, 95%CI 0.16-0.67) were independently associated with MV on postnatal day 7. CONCLUSIONS: We describe the impact of fluid balance in critically ill near-term/term neonates over the first postnatal week. Higher peak fluid balance during the first postnatal week and higher fluid balance on postnatal day 7 were independently associated with MV at postnatal day 7.

Rare GATA5 sequence variants identified in individuals with bicuspid aortic valve.

BACKGROUND: Bicuspid aortic valve (BAV) is the most common type of congenital heart disease (CHD) and has a proposed genetic etiology. BAV is categorized by cusp fusion, with right-left (R-L) cusp fusion being associated with additional CHD, and right-noncoronary cusp (R-NC) fusion being associated with aortic valve dysfunction. Loss of murine Gata5, which encodes a cardiac transcription factor, results in a partially penetrant R-NC BAV, and we hypothesize that mutations in GATA5 are associated with R-NC BAV in humans. METHODS: A cohort of 78 BAV patients (50 with isolated BAV and 28 with associated aortic coarctation) was analyzed using Sanger sequencing to identify GATA5 sequence variants. Biochemical assays were performed to identify functional deficits of identified sequence variants. RESULTS: We identified two rare heterozygous nonsynonymous variants, p.Gln3Arg and p.Leu233Pro, for a frequency of 2.6% (2/78). Both individuals with nonsynonymous variants had BAV and aortic coarctation, one R-L and one R-NC subtype. Of the nonsynonymous variants, only p.Gln3Arg demonstrated decreased transcriptional activity in vitro. CONCLUSION: Rare sequence variants in GATA5 are associated with human BAV. Our findings suggest a genotype-phenotype correlation in regards to associated CHD but not cusp fusion.

Describing patterns in serum creatinine in infants with and without necrotizing enterocolitis.

OBJECTIVE: To evaluate serum creatinine (SCr) patterns and the development of acute kidney injury (AKI), as potential biomarkers of necrotizing enterocolitis (NEC). STUDY DESIGN: Retrospective chart review of preterm infants with and without NEC born 23-32 weeks gestation admitted to Nationwide Children's Hospital NICU. Medical versus surgical NEC was determined by radiographic and clinical findings. Available inpatient SCr levels obtained on days 8 through 365 were included. RESULT: In this cohort, 77 NEC and a randomly selected group of 82 non-NEC infants met inclusion criteria. Fifteen of the 70 (21.4%) with NEC met criteria for AKI versus 0 of 43 (0.0%) without NEC. One of the 13 with AKI had AKI within 7 days prior to NEC diagnosis (7.7%). CONCLUSION: AKI is more prevalent in infants with NEC. The temporal association between AKI and NEC could not be evaluated due to inconsistent SCr surveillance and should be evaluated in future studies.

Part 6: Essentials of Neonatal-Perinatal Medicine fellowship: program administration.

A successful Neonatal-Perinatal Medicine fellowship (NPM-F) program requires presence and insight of national and institutional supervisory organizations as well as effective program-specific leaders: program director (PD), associate program director (APD), program coordinator (PC), and core faculty. It is becoming more common for PDs and APDs to have advanced training in medical education and conduct medical education research. While NPM-F program leaders benefit from a strong national NPM educator community, they face challenges of increased regulatory burden and unclear national guidelines with variable local interpretation for protected time. National and local organizations can support program leaders and promote their academic success while reducing burnout and turnover by providing leadership training, academic mentoring, and adequate protected time for research and program-specific tasks.

Addressing bias and knowledge gaps regarding race and ethnicity in neonatology manuscript review.

A recent shift in public attention to racism, racial disparities, and health equity have resulted in an abundance of calls for relevant papers and publications in academic journals. Peer-review for such articles may be susceptible to bias, as subject matter expertise in the evaluation of social constructs, like race, is variable. From the perspective of researchers focused on neonatal health equity, we share our positive and negative experiences in peer-review, provide relevant publicly available data regarding addressing bias in peer-review from 12 neonatology-focused journals, and give recommendations to address bias and knowledge gaps in the peer review process of health equity research.

Improving the identification of acute kidney injury in the neonatal ICU: three centers' experiences.

OBJECTIVE: To describe three different standardized approaches to improving neonatal acute kidney injury (AKI) identification and the impact on AKI identification, incidence, and nephrology consultation and referral. STUDY DESIGN: A retrospective cohort study in three academic NICUs. We compared AKI identification, AKI incidence, nephrology consultation, and nephrology follow-up before and after implantation of local protocols to standardize neonatal AKI identification. RESULT: Neonatal AKI identification improved in all three NICUs following protocol implementation (26-85%, P < 0.0001). Each center also saw increases in nephrology consultation (15-83%, P < 0.0001) and nephrology follow-up (7-73%, P < 0.0001). AKI incidence decreased significantly (21-12%, P < 0.0001). CONCLUSION: Multiple strategies can be successfully operationalized to improve neonatal AKI identification. While different in approach, each strategy resulted in increased AKI identification and nephrology involvement. This study emphasizes the importance of local standardized approaches to AKI to improve AKI identification and nephrology involvement in the NICU.

Plugging the Leaky Pipeline: The Role of Peer Mentorship for Increasing Diversity.

I arrived to my shift early, nervous about caring for critically ill patients as a first-year fellow. I sat in the workroom alone, paralyzed, not sure how to preround despite being months into fellowship. The senior fellow appeared minutes before sign-out; fresh, knowledgeable, and calm, despite her busy night and lack of sleep. She asked me how I was doing. With tears in my eyes, my emotions poured out. I explained that I felt lost, unsure of myself, my place, and my knowledge. For the first time, I confessed out loud, "I don't think I'm supposed to be here. I have no idea what I'm doing." I could trust her in a way I couldn't trust others. She was like me: othered by her identity, minoritized by society. Though different from my own, her identity allowed her to understand my own experiences. We were different from one another and we were also the same. Unlike the senior faculty, it was safe to talk to her. And, unlike my other cofellows, there was a kinship between us in our otherness. She looked at me, closed the door, and shared words of strength that I needed to hear. I belonged. I was more than enough. She shared that the pressure I was experiencing was common among systematically minoritized individuals; she too had felt it before. Sitting with her, I was finally seen, supported, and comforted. As a peer mentor from a minoritized background, she provided a sense of security and belonging that had not been provided in my training and was distinct from the support of senior faculty.

Comparison of knowledge acquisition and retention following traditional didactic vs. flipped classroom education utilizing a standardized national curriculum: a randomized controlled trial.

OBJECTIVE: Measure the effectiveness of and preference for a standardized, national curriculum utilizing flipped classrooms (FC) in neonatal-perinatal medicine (NPM) fellowships. STUDY DESIGN: Multicentered equivalence, cluster randomized controlled trial of NPM fellowship programs randomized to receive standardized physiology education as in-class lectures (traditional didactic, TD arm) or as pre-class online videos followed by in-class discussions (FC arm). Four multiple-choice question quizzes and three surveys were administered to measure knowledge acquisition, retention, and educational preferences. RESULTS: 530 fellows from 61 NPM fellowships participated. Quiz performance was comparable between groups at all time points (p = NS, TD vs FC at 4 time points). Post intervention, more fellows in both groups preferred group discussions (pre/post FC 42% vs. 58%, P = 0.002; pre/post TD 43% vs. 60%, P = < 0.001). FC fellows were more likely to rate classroom effectiveness positively (FC/TD, 70% vs. 36%, P < 0.001). CONCLUSIONS: FCs promote knowledge acquisition and retention equivalent to TD and FC modalities are preferred by fellows.

An Initiative to Increase Residency Program Diversity.

A physician workforce that reflects the patient population is associated with improved patient outcomes and promotes health equity. Notwithstanding, racial and ethnic disparities persist within US medical schools, making some individuals underrepresented in medicine (URM). We sought to increase the percentage of URM residents who matched into our pediatric residency programs from a baseline of 5% to 35% to achieve demographic parity with our patients. We developed a multifaceted approach using multiple iterative tests of change, with the primary strategy being increased visibility of URM trainees and faculty to residency applicants. Strategies included applicant interviews with URM faculty, interview dinners with URM residents, visibility at academic conferences for URM trainees, development of targeted marketing materials, and a visiting student program supported by networking with URM residents. The primary outcome measure was the percentage of matched residents in the categorical pediatrics, child neurology, and medical genetics training programs who identified as URM. The percentage of URM residents increased to 16% (6 of 37) in 2018, 26% (11 of 43) in 2019, 19% (8 of 43) in 2020, and 21% (9 of 43) in 2021 (a four-year average of 22% URM residents; P = .0002). This progress toward a more representative residency program was met by challenges, such as pipeline concerns, the minority tax, and recruitment during a pandemic. We were able to implement small, low-resource strategies that had a large cumulative impact and could be implemented in other residency programs. Specific tactics and challenges encountered are discussed in this special article.

Consensus on an implicit bias and health disparities curriculum in neonatal medicine: a Delphi study.

OBJECTIVE: Despite longstanding and recurrent calls for effective implicit bias (IB) education in health professions education as one mechanism to reduce ongoing racism and health disparities, such curricula for neonatal-perinatal medicine (NPM) are limited. We aim to determine the key curricular elements for educating NPM fellows, advanced practice providers, and attending physicians in the critical topics of IB and health disparities. STUDY DESIGN: A modified Delphi study was performed with content experts in IB and health disparities who had educational relationships to those working and training in the neonatal intensive care unit. RESULT: Three Delphi rounds were conducted from May to November 2021. Experts reached consensus on a variety of items for inclusion in the curriculum, including educational goals, learning objectives, teaching strategies, and educator principles. CONCLUSION: Essential curricular components of an IB and health disparities curriculum for neonatal medicine were defined using rigorous consensus building methodology.

Prenatal Exposures Are Associated With Worse Neurodevelopmental Outcomes in Infants With Neonatal Opioid Withdrawal Syndrome.

Aim: To define a developmental trajectory in infants with neonatal opioid withdrawal syndrome (NOWS) and determine whether the impacted developmental domain varies with the type of antenatal exposure. Methods: We performed a retrospective cohort study of infants treated pharmacologically for NOWS and assessed using a standardized schedule for follow-up visits. We compared outcomes of the study population to published norms using one-sample t-tests. Multivariable models examined associations with exposures in addition to opioids. Results: In our cohort of 285 infants with 9-12-months testing, 164 (55.7%) were seen at 3-4 months, and 125 (44%), at 15-18 months. The majority (58%) had intrauterine drug exposures in addition to opioids. Neurodevelopmental scores of infants with NOWS at 3-4 and 9-12 months were not different from published norms. Cognitive and language scores at 15-18 months were worse than published norms. Male sex, older maternal age, and additional barbiturate or alcohol exposure were associated with worse outcomes. Conclusion: Infants with pharmacologically treated NOWS had development similar to unexposed infants during the 1st year but worse cognitive and language scores during the 2nd year. These data support the need for a prospective follow-up of large cohorts of infants with NOWS, with systematic assessments and an evaluation of contributing factors.

Flipping the classroom: a national pilot curriculum for physiology in neonatal-perinatal medicine.

OBJECTIVE: To explore interest, feasibility, perceived effectiveness, and acceptability of a standardized, national physiology curriculum for neonatal-perinatal medicine (NPM) fellows using online videos for knowledge acquisition paired with flipped classrooms (FCs) for knowledge application. STUDY DESIGN: Two educational programs pairing online videos with FCs were developed and peer-reviewed. These programs were piloted at five institutions. Fellows completed surveys, and fellows and educators participated in focus groups after their FC experiences. RESULTS: Thirty-five fellows responded to the survey. Forty-one fellows and six educators participated in focus groups. Fellows and educators preferred online videos paired with FCs over didactic teaching and perceived them to be effective for knowledge acquisition and application. CONCLUSION: Fellows and educators preferred FC learning over traditional didactics and reported that FCs facilitated creation of a learning community, fostering active learning. The favorable response toward this pilot project and the feasibility of its use supports further development of a standardized NPM physiology curriculum for fellowship training.

Acute kidney injury in the fetus and neonate.

Acute kidney injury (AKI) is an under-recognized morbidity of neonates; the incidence remains unclear due to the absence of a unified definition of AKI in this population and because previous studies have varied greatly in screening for AKI with serum creatinine and urine output assessments. Premature infants may be born with less than half of the nephrons compared with term neonates, predisposing them to chronic kidney disease (CKD) early on in life and as they age. AKI can also lead to CKD, and premature infants with AKI may be at very high risk for long-term kidney problems. AKI in neonates is often multifactorial and may result from prenatal, perinatal, or postnatal insults as well as any combination thereof. This review focuses on the causes of AKI, the importance of early detection, the management of AKI in neonates, and long-term sequela of AKI in neonates.