Quality Indices and Outcomes of a Neonatology Telerounding Program in a Level II Neonatal Intensive Care Unit: Single-Center Experience during the COVID-19 Pandemic.

OBJECTIVE: The objective of this program evaluation was to describe the outcomes of daily neonatologist telerounding with the onsite advanced practice provider (APP) in a Level II neonatal intensive care unit (NICU), before and during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Bedside telerounding occurred with an onsite APP using a telehealth cart and paired Bluetooth stethoscope. Data collected by longitudinal and cross-sectional surveys and chart review before (May 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic were analyzed using descriptive statistics and thematic analysis. RESULTS: A total of 258 patients were admitted to the Level II NICU before (May 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic. Demographic characteristics and outcomes, including breastfeeding at discharge and length of stay were similar pre- and postonset of the COVID-19 pandemic. Postrounding surveys by 10 (response rate 83%) neonatologists indicated parents were present in 80 (77%) of rounds and video was at least somewhat helpful in 94% of cases. Cross-sectional survey responses of 23 neonatologists and APPs (response rate 62%) indicated satisfaction with the program. Common themes on qualitative analysis of open-ended survey responses were "need for goodness of fit" and "another set of eyes" and "opportunities for use." CONCLUSION: Daily telerounding with neonatologists and APPs in a Level II NICU supported neonatal care. Quality metrics and clinical outcomes are described with no differences seen before and during the COVID-19 pandemic. KEY POINTS: · Little is known about Level II NICU quality metrics and outcomes.. · Daily bedside telerounding with neonatologists and APPs is described.. · Telerounding supported neonatal care before and during the COVID-19 pandemic.. · Neonatologists found visual exam helpful in the majority of cases.. · No differences in NICU clinical outcomes were seen during the COVID-19 pandemic..

Characterization of Neutropenia in Preterm Neonates Following Administration of Darbepoetin Alfa.

OBJECTIVE: This study is to evaluate the effects of darbepoetin alfa (darbe) on neutrophil count in preterm neonates treated for anemia of prematurity. METHODS: This was a retrospective chart review comparing the absolute neutrophil counts (ANCs) of neonates administered 2 doses of subcutaneous darbe 10 mcg/kg to that of a randomly selected comparator group of neonates not administered the drug. Neonates <34 weeks gestational age, gestational age between 23w1d and 33w4d, born between July 2016 and June 2019, were included in the study. RESULTS: The ANCs of 45 darbe-treated neonates compared with those of 45 randomly selected comparator control neonates revealed no difference in the rate of occurrence of neutropenia (ANC ≤1000/µL) between the darbe-treated neonates (26.7%) and comparator neonates (24.4%) (p > 0.99). There was also no difference in the rate of occurrence of severe neutropenia (ANC ≤500/µL) between the darbe-treated neonates (11.1%) and comparator neonates (6.7%) (p = 0.70). Darbepoetin alfa did not lead to differences in rates of resolution of neutropenia or severe neutropenia. CONCLUSIONS: Short-term administration of darbe did not affect the ANCs of preterm neonates treated for anemia of prematurity. There was no difference in the rates of occurrence of neutropenia, severe neutropenia, or resolution of either between the darbe-treated neonates and comparator neonates.

From A to AB: A Caucasian Mother with High Anti-B Titer Causing Hemolytic Disease of the Newborn.

We report on a term infant with clinically significant hemolysis and hyperbilirubinemia. Testing revealed ABO incompatibility between maternal type A and infant type AB. The maternal alloantibody screen was negative. The infant's direct antiglobulin test was positive, and anti-B IgG was eluted off the infant's red blood cells (RBCs). Testing of the mother's plasma revealed a high anti-B titer. The infant was successfully treated with phototherapy and intravenous immunoglobulin. The bilirubin and hematocrit stabilized, and the infant was discharged home. This case was unusual because of its severity and unusual ABO constellation. Furthermore, this report is an exemplary educational case study on how effective collaboration between the clinical team and the blood bank laboratory is critical in reaching the correct diagnosis. In summary, the differential diagnosis of more unusual and atypical ABO-incompatible constellations must be considered when an infant presents with unexplained hemolysis.

Milestone Level Changes From Residency to Fellowship: A Multicenter Cohort Study.

BACKGROUND: A vital element of the Next Accreditation System is measuring and reporting educational Milestones. Little is known about changes in Milestones levels during the transition from residency to fellowship training. OBJECTIVE: Evaluate the Accreditation Council for Graduate Medical Education (ACGME) Milestones' ability to provide a linear trajectory of professional development from general pediatrics residency to neonatal-perinatal medicine (NPM) fellowship training. METHODS: We identified 11 subcompetencies that were the same for general pediatrics residency and NPM fellowship. We then extracted the last residency Milestone level and the first fellowship Milestone level for each subcompetency from the ACGME's Accreditation Data System on 89 subjects who started fellowship training between 2014 and 2018 at 6 NPM fellowship programs. Mixed-effects models were used to examine the intra-individual changes in Milestone scores between residency and fellowship after adjusting for the effects of the individual programs. RESULTS: A total of 1905 subcompetency Milestone levels were analyzed. The average first fellowship Milestone levels were significantly lower than the last residency Milestone levels (residency, mean 3.99 [SD = 0.48] vs fellowship 2.51 [SD = 0.56]; P < .001). Milestone levels decreased by an average of -1.49 (SD = 0.65) from the last residency to the first fellowship evaluation. Significant differences in Milestone levels were seen in both context-dependent subcompetencies (patient care and medical knowledge) and context-independent subcompetencies (professionalism). CONCLUSIONS: Contrary to providing a linear trajectory of professional development, we found that Milestone levels were reset when trainees transitioned from general pediatrics residency to NPM fellowship.

Development of a prenatal clinical care pathway for uncomplicated gastroschisis and literature review.

BACKGROUND: Gastroschisis is an abdominal wall defect wherein the bowel is herniated into the amniotic fluid. Controversy exists regarding optimal prenatal surveillance strategies that predict fetal well-being and help guide timing of delivery. Our objective was to develop a clinical care pathway for prenatal management of uncomplicated gastroschisis at our institution. METHODS: We performed a review of literature from January 1996 to May 2017 to evaluate prenatal ultrasound (US) markers and surveillance strategies that help determine timing of delivery and optimize outcomes in fetal gastroschisis. RESULTS: A total 63 relevant articles were identified. We found that among the US markers, intraabdominal bowel dilatation, polyhydramnios, and gastric dilatation are potentially associated with postnatal complications. Prenatal surveillance strategy with monthly US starting at 28weeks of gestational age (wGA) and twice weekly non-stress testing beginning at 32wGA is recommended to optimize fetal wellbeing. Timing of delivery should be based on obstetric indications and elective preterm delivery prior to 37wGA is not indicated. CONCLUSIONS: Close prenatal surveillance of fetal gastroschisis is necessary due to the high risk for adverse outcomes including intrauterine fetal demise in the third trimester. Decisions regarding the timing of delivery should take into consideration the additional prematurity-associated morbidity.

CHRNB1-associated congenital myasthenia syndrome: Expanding the clinical spectrum.

CHRNB1 encodes the ß subunit of the acetylcholine receptor (AChR) at the neuromuscular junction. Inherited defects in the neuromuscular junction can lead to congenital myasthenia syndrome (CMS), a clinically and genetically heterogeneous group of disorders which includes fetal akinesia deformation sequence (FADS) on the severe end of the spectrum. Here, we report two unrelated families with biallelic CHRNB1 variants, and in each family, one child presented with lethal FADS. We contrast the diagnostic odysseys in the two families, one of which lasted 16 years while the other, utilizing rapid exome sequencing, led to specific treatment in the first 2 weeks of life. Furthermore, we note that CHRNB1 variants may be under-recognized because in both families, one of the variants is a single exon deletion that has been previously described but may not easily be detected in clinically available genetic testing.

The impact of increased awareness of acute kidney injury in the Neonatal Intensive Care Unit on acute kidney injury incidence and reporting: results of a retrospective cohort study.

OBJECTIVE: To evaluate the impact of nephrology integration in the NICU on acute kidney injury (AKI) incidence, provider reporting, and nephrology referral. STUDY DESIGN: Cohort study in a single-center NICU from January 2012 to December 2017 (n = 1464). We assessed the impact of clinical practice changes including neonatal-nephrology rounds on the incidence of AKI. RESULTS: AKI occurred in 318 neonates (22%). AKI occurred less frequently in those admitted after clinical practice changes (P < 0.001). After multivariable adjustment, clinical practice changes were associated with reduced odds of AKI (adjusted odds ratio, 0.31; 95% CI 0.22-0.44, P < 0.001). Provider reporting of AKI improved (P < 0.001) and more neonates were referred for nephrology follow-up (P < 0.001). CONCLUSIONS: Increased nephrology integration in the NICU was associated with decreased AKI incidence. While recognition of AKI improved, AKI remained poorly reported and nephrology AKI follow-up did not routinely occur. This study supports the importance of increased nephrology involvement in the NICU.

Utility of Formulas Using Fetal Thigh Soft Tissue Thickness in Estimating Weight in Gastroschisis.

OBJECTIVES: To evaluate the utility of the fetal thigh soft tissue thickness (STT) in calculating the estimated fetal weight (EFW) in fetuses with gastroschisis versus the standard formula of Hadlock et al (Am J Obstet Gynecol 1985; 151:333-337) compared to the actual birth weight (ABW). METHODS: A retrospective study of neonates born with gastroschisis delivered at our institution was performed. Two reviewers measured the fetal thigh STT on saved images. The estimated gestational age, fetal biometric measurements, and ABW were abstracted. In addition to the Hadlock formula, 3 STT-based formulas reported by Scioscia et al (Ultrasound Obstet Gynecol 2008; 31:314-320) and Kalantari et al (Iran J Reprod Med 2013; 11:933-938) were used to calculate the EFW. RESULTS: Eighty-two patients with gastroschisis qualified for inclusion in our study. The mean STTs ± SD as measured by readers 1 and 2 were 10.9 ± 2.7 and 10.6 ± 2.7 mm, respectively. Seventeen (21%) fetuses were small for gestational age at birth. The Hadlock formula underestimated the EFW relative to the ABW, with an average difference of -97 g (-3.9%) and - 5.1% in terms of growth percentiles. All of the STT-based EFW formulas overestimated the EFW on average by 327 to 701 g (13%-24%) in terms of weight and 26% to 52% in terms of growth percentiles. The Hadlock formula classified 22 as having intrauterine growth restriction (sensitivity, 65%; specificity, 83%, based on the ABW). None of the STT-based formulas classified any fetuses as intrauterine growth restricted. CONCLUSIONS: In a group of patients with gastroschisis, we found that the EFW by the fetal thigh STT calculation overestimated the average fetal weight in all of our cases.

Assessment and Management of Gastroesophageal Reflux in The Newborn.

Gastroesophageal reflux is the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation and is considered a normal physiologic process, occurring daily in greater than one-third of all infants. Gastroesophageal reflux disease (GERD) is pathologic reflux associated with poor weight gain, irritability, dysphagia and often requires evaluation and treatment. No gold-standard testing for GERD exists. Measurements made by pH probe or multichannel intraesophageal impedance may provide insight into the quantity and character of reflux. Those events do not correlate well with clinical symptoms. Most cases of GERD can be treated conservatively with alterations in the infant's environment and/or feeding pattern. Proton pump inhibitors remain the mainstay for pharmacotherapy of GERD, although these have been associated with increased rates of infection, especially in the preterm population. Neonatal GERD remains a difficult entity to define and manage, and additional studies to aid in the clinical diagnosis and management are needed. [Pediatr Ann. 2020;49(2):e77-e81.].

Point-of-care ultrasound for peripherally inserted central catheter monitoring: a pilot study.

Objective To assess the feasibility and accuracy of point-of-care ultrasound (POCUS) in monitoring peripherally inserted central catheter (PICC) location in neonates by non-radiologist physicians. Methods A prospective cohort study compared PICC localization by ultrasound in neonates with a recent radiograph. The ultrasound exam was performed using a standardized protocol with 13-6 MHz linear and 8-4 MHz phased array transducers by a neonatal-perinatal fellow who was blinded to PICC location on the radiograph. Results Of the 30 neonates included, 96.6% (n = 29) were preterm, with 63.3% (n = 19) weighing <1500 g. Nighty-four percent (n = 94) of ultrasound scans matched the radiograph report. The protocol had a sensitivity of 0.97, specificity of 0.66 and positive predictive value of 0.98. Conclusion Limited ultrasound exams to monitor PICC position in neonates using a standardized protocol by non-radiologist physicians are feasible and accurate in a single ultrasound user. Further study in multiple providers is needed before widespread use.

Apgar score of 0 at 10 min and survival to 1 year of age: a retrospective cohort study in Washington state.

OBJECTIVE: To determine 1-year survival in a cohort of newborns with an Apgar score of 0 at 5 and 10 min of age. STUDY DESIGN: A retrospective cohort study of the Washington State Comprehensive Hospital Abstract Reporting System from 2005 to 2014. RESULTS: Of 879,340 births, 199 (0.02%) had an Apgar score of 0 at 5 min, and 109 (0.01%) also had a score of 0 at 10 min. One-year survival was 46% for newborns with Apgar score of 0 at 5 and 10 min. One-year survival by gestational age was 4% for newborns <30 weeks, 38% for 30-35 weeks, and 67% for ≥36 weeks. CONCLUSION: Survival at 1 year of age for newborns with an Apgar score of 0 at 5 and 10 min has improved, as compared with historic cohorts. Cautious optimism is warranted since morbidity-free survival could not be assessed.

Acute Funisitis Correlates With the Risk of Early-Onset Sepsis in Term Newborns Assessed Using the Kaiser Sepsis Calculator.

BACKGROUND: The risk of neonatal early-onset sepsis (EOS) is traditionally assessed on maternal signs of clinical chorioamnionitis. Recently, an online EOS risk calculator was developed by Kaiser Permanente using maternal and neonatal clinical parameters. We were interested in whether an increased Kaiser sepsis risk score correlates with histologic acute chorioamnionitis or acute funisitis. DESIGN: Included in this retrospective review are 119 chorioamnionitis-exposed term neonates from January 1, 2015 and December 31, 2016. Clinical charts from mother-baby pairs were reviewed. An EOS risk score was obtained using the online Kaiser Sepsis Calculator. The presence and severity of acute chorioamnionitis and acute funisitis were recorded. A SPSS software was used for statistical analysis (IBM, New Jersey, USA). RESULTS: The Kaiser Sepsis Calculator could identify 97 of 119 (81.5%) neonates without increased risk for sepsis. Histologic acute chorioamnionitis was present in 100 of 119 cases (84%), in which 44 cases (44%) show severe acute chorioamnionitis. Acute funisitis was recognized in 87 of 119 (73.1%) cases, all of which had concurrent acute chorioamnionitis. Severe funisitis was seen in 38 of the 87 cases (43.7%). The Kaiser Sepsis risk score correlates with the presence and severity of acute funisitis (P = .037 and P = .044, respectively) but not with the presence or the severity of acute chorioamnionitis (P = .105 and P = .672, respectively). CONCLUSION: Our study provides histological evidence to support that the Kaiser Sepsis Calculator may help to effectively reduce unwarranted blood culture, antibiotics exposure, and neonatal intensive care unit admission in term neonates.

Use of an Early Onset-Sepsis Calculator to Decrease Unnecessary NICU Admissions and Increase Exclusive Breastfeeding.

OBJECTIVE: To evaluate the effects of use of the Kaiser Neonatal Early-Onset Sepsis Calculator (NEOSC) on NICU admissions, laboratory testing, antibiotic exposure, and exclusive breastfeeding (EBF) rates in full-term neonates exposed to chorioamnionitis. DESIGN: Quality improvement project with review of retrospective data. SETTING/LOCAL PROBLEM: In this single-site, community hospital with approximately 4,000 births per year, all neonates exposed to chorioamnionitis required NICU admission, laboratory evaluation, and empiric antibiotics. PARTICIPANTS: Term neonates born to mothers diagnosed with chorioamnionitis identified through the International Classification of Diseases, Tenth Revision codes based on the discharge diagnosis. INTERVENTION/MEASUREMENTS: The baseline retrospective analysis included calculation of sepsis risk with the Kaiser NEOSC through a chart review of neonates exposed to chorioamnionitis from January 1, 2015, to December 31, 2016. We compared the risk for sepsis with actual laboratory testing and antibiotic use and examined EBF before implementation of the use of the NEOSC. Implementation began January 2017; postintervention data were examined at 6 months and 1 year. All cases of neonates exposed to chorioamnionitis after the intervention were reviewed for use of the NEOSC, NICU admission/readmission for sepsis, laboratory testing, use of antibiotics, and EBF. RESULTS: In the 12 months after NEOSC use was implemented, NICU admissions, laboratory testing, and antibiotic use decreased. Among all neonates exposed to chorioamnionitis after implementation (N = 74), 68 (93%) were not admitted to the NICU, and only 8 (11%) required laboratory evaluation. Rates of EBF in neonates exposed to chorioamnionitis increased from less than 10% to greater than 50% after implementation. The length of the NICU stay for neonates exposed to chorioamnionitis decreased from an average of 138 to 12 days with no negative consequences. CONCLUSION: Most neonates exposed to chorioamnionitis appeared well and did not require NICU admission, laboratory testing, or antibiotic therapy. Rates of EBF improved after use of NEOSC was implemented. The practice change helped prevent adverse consequences, such as painful interventions and separation of the mother and neonate. No neonates were readmitted for sepsis.

Identification of a deletion containing TBX4 in a neonate with acinar dysplasia by rapid exome sequencing.

We describe a neonate with severe respiratory failure due to acinar dysplasia found by rapid exome sequencing (rES), to have a deletion containing the TBX4 gene. rES can affect patient management in the intensive care unit and should be considered in concert with lung biopsy in neonates with undifferentiated respiratory failure.

Long-term Risk of Neuropsychiatric Disease After Exposure to Infection In Utero.

Importance: The developmental origins of mental illness are incompletely understood. Although the development of autism and schizophrenia are linked to infections during fetal life, it is unknown whether more common psychiatric conditions such as depression might begin in utero. Objective: To estimate the risk of psychopathologic conditions imparted from fetal exposure to any maternal infection while hospitalized during pregnancy. Design, Setting, and Participants: A total of 1 791 520 Swedish children born between January 1, 1973, and December 31, 2014, were observed for up to 41 years using linked population-based registries. Children were excluded if they were born too late to contribute person-time, died before being at risk for the outcome, or were missing particular model data. Infection and psychiatric diagnoses were derived using codes from hospitalizations. Directed acyclic graphs were developed from a systematic literature review to determine Cox proportional hazards regression models for risk of psychopathologic conditions in the children. Results were evaluated using probabilistic and simple bias analyses. Statistical analysis was conducted from February 10 to October 17, 2018. Exposures: Hospitalization during pregnancy with any maternal infection, severe maternal infection, and urinary tract infection. Main Outcomes and Measures: Inpatient diagnosis of autism, depression, bipolar disorder, or psychosis among offspring. Results: A total of 1 791 520 Swedish-born children (48.6% females and 51.4% males) were observed from birth up to age 41 years, with a total of 32 125 813 person-years. Within the directed acyclic graph framework of assumptions, fetal exposure to any maternal infection increased the risk of an inpatient diagnosis in the child of autism (hazard ratio [HR], 1.79; 95% CI, 1.34-2.40) or depression (HR, 1.24; 95% CI, 1.08-1.42). Effect estimates for autism and depression were similar following a severe maternal infection (autism: HR, 1.81; 95% CI, 1.18-2.78; depression: HR, 1.24; 95% CI, 0.88-1.73) or urinary tract infection (autism: HR, 1.89; 95% CI, 1.23-2.90; depression: HR, 1.30; 95% CI, 1.04-1.61) and were robust to moderate unknown confounding. Within the directed acyclic graph framework of assumptions, the relationship between infection and depression was vulnerable to bias from loss to follow-up, but separate data from the Swedish Death Registry demonstrated increased risk of suicide among individuals exposed to pregnancy infection. No evidence was found for increased risk of bipolar disorder or psychosis among children exposed to infection in utero. Conclusions and Relevance: These findings suggest that fetal exposure to a maternal infection while hospitalized increased the risk for autism and depression, but not bipolar or psychosis, during the child's life. These results emphasize the importance of avoiding infections during pregnancy, which may impart subtle fetal brain injuries contributing to development of autism and depression.

Limited Ultrasound Protocol for Upper Extremity Peripherally Inserted Central Catheter Monitoring: A Pilot Study in the Neonatal Intensive Care Unit.

OBJECTIVES: To assess whether a limited ultrasound (US) scanning protocol to monitor the upper extremity peripherally inserted central catheter (PICC) location in neonates is feasible for experienced US operators. METHODS: A radiologist, who was blinded to the PICC location on chest radiography, performed 14 US scans on 11 neonates with upper extremity PICCs. A US machine with 13-6-MHz linear and 8-4-MHz phased array transducers was used for the examinations. RESULTS: The study population included 54% (n = 6) preterm infants, with 72% (n = 8) weighing less than 1500 g. The US location of the PICC was the same as the chest radiographic report in all 14 scans. A subclavicular long-axis view of the anterior chest visualized all PICCs in the subclavian or brachiocephalic veins. A parasternal long-axis right ventricular inflow view was able to visualize PICCs in the superior vena cava (SVC), and a subcostal long-axis view evaluated PICCs in the lower SVC and heart. The scanning time was location dependent: less than 5 minutes for PICCs in the brachiocephalic or subclavian vein and 5 to 10 minutes for PICCs in the SVC or heart. There were no desaturations below 90%, increases in the fraction of inspired oxygen need, or hypotension episodes during scanning. CONCLUSIONS: A limited US scanning protocol to determine the upper extremity PICC location is feasible. Our protocol needs to be tested in neonatal providers before further dissemination.

Recurrent bloody stools associated with visceral infantile haemangioma in a preterm twin girl.

A premature twin infant girl was transferred to a level IV neonatal intensive care unit for recurrent bloody stools, anaemia and discomfort with feeds; without radiographic evidence of necrotising enterocolitis. Additional imaging after transfer revealed a large retroperitoneal mass in the region of the pancreas compressing the inferior vena cava and abdominal aorta, raising suspicion for neuroblastoma. Abdominal exploration and biopsy unexpectedly revealed that the lesion was an infantile capillary haemangioma involving the small bowel, omentum, mesentery and pancreas. The infant was subsequently treated with propranolol, with a decrease in the size of the lesion over the first year of her life and a drastic improvement in feeding tolerance. While cutaneous infantile haemangiomas are common, visceral infantile haemangiomas are less so and may present a significant diagnostic challenge for clinicians. This interesting case demonstrates that such lesions should be considered in the differential diagnosis for unexplained gastrointestinal bleeding or abdominal symptoms in newborns.

Implication of antibodies against human leukocyte antigen in simultaneous presentation of fetal and neonatal alloimmune thrombocytopenia and neutropenia.

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) and neonatal alloimmune neutropenia (NAN) are two rare complications of newborns caused by antibodies against paternal inherited antigens. Human platelet (HPA) and neutrophil antigens (HNA) are the common targets. Human leukocyte antigen (HLA) class I proteins are also expressed on platelets and neutrophils and anti-HLA antibodies have occasionally been implicated in these complications. We report a premature twin infant who presented with severe thrombocytopenia and neutropenia clinically compatible with FNAIT and NAN, from a mother with no identifiable HPA or HNA antibodies, but with very high levels of complement-fixing antibodies against paternal inherited HLA. These antibodies were also detected in the infant. HLA antibodies are commonly present in multiparous women who deliver healthy infants. They can, however, be cytotoxic and cause clinical complications after blood products transfusion (TRALI and becoming refractory to platelets transfusion) and after organ transplantation (allogeneic organ rejection).