Risk of death at home or on hospital readmission after discharge with pediatric tracheostomy.

OBJECTIVE: To evaluate outcomes of patients discharged home following tracheostomy, including the timing and place of death for non-survivors. STUDY DESIGN: We retrospectively reviewed medical records of infants undergoing tracheostomy between 2006 and 2017, within the first year of life for congenital or acquired neonatal conditions. RESULTS: Of the 224 patients discharged after tracheostomy, 127 (57%) required home mechanical ventilation (MV). Overall, 40 (18%) patients died (65% were on MV); 38% of the deaths occurred at home and 63% at a subsequent hospitalization. Having tube feeding was identified as significantly associated with increased mortality on multivariate analysis. Having a tracheostomy for upper airway obstruction was the only variable significantly associated with increased risk of death at home on multivariate analysis. CONCLUSIONS: Having tube feeding was associated with increased risk of death overall and having the tracheostomy for obstructive airway conditions was associated with death occurring at home.

Back Transfer of Infants with Tracheostomies: A Regional Center Experience.

We describe our center's experience with the back transfer of infants following tracheostomies. We conducted a retrospective cohort study of infants transferred to pediatric critical care units of our regional center with conditions originating in the neonatal period who underwent tracheostomy during the hospitalization within their first year of life between 2006 and 2017. Recovering patients are discharged home or transferred back to the referring hospitals. We evaluated patient characteristics, destination of discharge and type of pulmonary support at discharge, and mechanical ventilation (MV) or tracheotomy masks (TM). Of the 139 included patients, 72% were transferred to the neonatal intensive care unit, 21% to the pediatric cardiothoracic unit, and 7% to the pediatric intensive care unit. Their median gestational age was 35 weeks. They were admitted at a median 22 days of life and lived at a median distance of 56 miles from our center. Furthermore, 34 infants (24%) were back transferred closer to their homes (23 with MV and 11 with TM), and 84 (60%) were discharged home (53 on MV and 31 on TM). Twenty-one patients (15%) died in the hospital (before discharge or transfer). Back transferred patients on MV had a significantly shorter duration between tracheostomy and transfer compared with those discharged home from our center: MV (median = 22 vs. 103 days, p < 0.0001) and TM (median = 13 vs. 35 days, p < 0.0001). Back transfer of infants with tracheostomies closer to their homes was associated with a significantly shorter hospitalization and more efficient use of the subspecialized resources at the RC.

Pulmonary Support of Infants with Tracheotomies in a Regional Neonatal Intensive Care Unit.

OBJECTIVE: We evaluate patient characteristics, hospital course, and outcome by type discharge pulmonary support; mechanical ventilation (MV) or with tracheotomy masks (TM). STUDY DESIGN: We reviewed records of infants admitted to the neonatal intensive care unit (NICU) that underwent tracheotomy within their first year of life between 2006 and 2017. We evaluated patient characteristics, referral pattern, destination of discharge, and outcome by type of pulmonary support at discharge (MV vs. TM). RESULTS: Of the 168 patients, 63 (38%) were inborn, 91 (54%) transferred to our NICU, and 5 (3%) were readmitted after being home. Median gestational age at birth was 34 weeks. Twenty-three (14%) infants were transferred to hospitals closer to their homes (13 with MV and 10 with TM), and 125 (74%) were discharged home (75 on MV and 50 on TM). Twenty patients (12%) died in the regional center (RC). Among those discharged home from our RC, infants on MV were of lower birth weight and younger gestational age, had tracheostomies later in life, had longer duration between tracheostomy to discharge to home, and had longer total duration of hospitalization at the RC. In addition, infants in the MV group were more frequently dependent on MV at time of placement of tracheostomies, less frequently had congenital airway anomalies and more frequently having possibly acquired airway anomalies and more frequently having major congenital anomalies, more frequently treated with diuretics, inhaled medications and medications for pulmonary hypertension, and more frequently had gastrostomies for feeding compared with the TM group. CONCLUSION: Patients with tracheostomies in the NICU and discharged from RC on MV or TM vary by patient characteristic, timing of tracheostomy placement, timing of discharge from RC, type of upper airway anomalies, duration of stay in the hospital, and complexity of medical condition at discharge. KEY POINTS: · Infants on home mechanical ventilation have long hospital stay and complex conditions at discharge.. · We describe factors associated with the type of pulmonary support for infants with tracheostomies.. · Treatment strategy may influence type of discharge pulmonary support in infants with tracheostomies..

Trends in Neonatal Extracorporeal Membrane Oxygenation During a Venovenous Cannula Shortage.

OBJECTIVES: To report temporal trends in venovenous extracorporeal membrane oxygenation (ECMO) use for neonatal respiratory failure in U.S. centers before and after functional venovenous cannula shortage due to withdrawal of one dual lumen venovenous cannula from the market in 2018. DESIGN: Retrospective cohort study. SETTING: ECMO registry of the Extracorporeal Life Support Organization. PATIENTS: Infants who received neonatal (cannulated prior to 29 d of age) respiratory ECMO at a U.S. center and had a record available in the ECMO registry from January 1, 2010 to July 20, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was receipt of venovenous ECMO (vs venoarterial or other), and secondary outcomes were survival to hospital discharge and adverse neurologic outcomes. Using an interrupted time series design, we fit multivariable mixed effects logistic regression models with receipt of venovenous ECMO as the dependent variable, treatment year modeled as a piecewise linear variable using three linear splines (pre shortage: 2010-2014, 2014-2018; shortage: 2018-2021), and adjusted for center clustering and multiple covariates. We evaluated trends in venovenous ECMO use by primary diagnosis including congenital diaphragmatic hernia, meconium aspiration, pulmonary hypertension, and other. Annual neonatal venovenous ECMO rates decreased after 2018: from 2010 to 2014, adjusted odds ratio (aOR) for yearly trend 0.98 (95% CI 0.92-1.04), from 2014 to 2018, aOR for yearly trend 0.90 (95% CI 0.80-1.01), and after 2018, aOR for yearly trend 0.46 (95% CI 0.37-0.57). We identified decreased venovenous ECMO use after 2018 in all diagnoses evaluated, and we failed to identify differences in temporal trends between diagnoses. Survival and adverse neurologic outcomes were unchanged across the study periods. CONCLUSIONS: Venovenous ECMO for neonatal respiratory failure in U.S. centers decreased after 2018 even after accounting for temporal trends, coincident with withdrawal of one of two venovenous cannulas from the market.

The effect of ibuprofen and caffeine prophylaxis on retinopathy of prematurity.

PURPOSE: To determine whether prophylactic caffeine and ibuprofen, which have been shown to have vascular endothelial growth factor-modulating properties in other contexts, have a detectable effect on the incidence of severe retinopathy of prematurity (ROP) when administered in extremely low birth weight infants during the first 48 hours of life. METHODS: In this retrospective cohort study, the incidence and severity of ROP with respect to total exposure to caffeine and ibuprofen were assessed. The effect of oxygen exposure at 28 days' postnatal age (PNA) and 36 weeks' corrected gestational age (GA) was also studied. RESULTS: A total of 109 infants were included; of these, complete data were available for 93 infants (87%), of whom 18 (19%) had severe ROP (ETROP type 1, or stage 3), and 75 (81%) had mild-to-moderate ROP at final diagnosis. Infants with severe ROP had lower GA (P = 0.0006). Total caffeine and ibuprofen exposure did not vary with severity of ROP (P = 0.86 caffeine; P = 0.57 ibuprofen). Presence of oxygen at 28 days' PNA (P = 0.01) or 36 weeks' corrected GA varied significantly with ROP severity (P = 0.0005). CONCLUSIONS: A relationship between prophylactic caffeine and ibuprofen exposure and severity of ROP could not be detected in our study cohort. Presence of oxygen at 28 days' PNA or 36 weeks' corrected GA was associated with ROP severity.

Transient neonatal myasthenia gravis: refining risk estimate for infants born to women with myasthenia gravis.

OBJECTIVE: Transient neonatal myasthenia gravis (TNMG) can render a neonate vulnerable to catastrophic respiratory depression. Our aim was to describe the clinical manifestations of TNMG, and to determine when the myasthenic signs become apparent in TNMG. METHODS: We reviewed our own experience of infants who underwent routine inpatient monitoring for TNMG and combined our local data with observations from previous studies. RESULTS: Only three case series (n = 110) reported both the type and timing of onset of myasthenic signs. Adding local data (n = 37) yielded 147 infants born to women with MG. Fifteen infants (10%) developed signs of TNMG with onset being 1.5 ± 2.6 days (mean ± 3SD) after birth. Feeding difficulties and low tone were the commonest presenting signs, and only 1 of the 147 infants needed intubation for hypoventilation. CONCLUSIONS: TNMG signs were mostly not life-threatening. We suggest only 4 days of routine postnatal observation for infants born to women with MG.

Impact of In-utero Exposure to Selective Serotonin Reuptake Inhibitors and Opioids on Neonatal Opioid Withdrawal Syndrome.

OBJECTIVE: The objective of this study was to compare short-term outcomes of neonatal opioid withdrawal syndrome (NOWS) treatment in infants exposed in-utero to opioids and selective serotonin reuptake inhibitors (SSRIs) or opioids alone. METHODS: This was a retrospective cohort study of mother-infant dyads, 34 weeks or greater gestation, receiving opioids and/or SSRIs during pregnancy. Intravenous or oral methadone was administered according to a pre-existing protocol for NOWS treatment guided by withdrawal scores. Primary outcome was length of treatment (LOT). Secondary outcomes included length of stay (LOS), total methadone exposure, time to symptom control, need for a second agent, and NOWS medications at discharge. RESULTS: Fifty-five mother-infant dyads were included in the study. LOT was longer in the infants in the SSRI plus opioid group but not significantly different [24 ±â€Š23 days (SSRI plus opioid) vs 20 ±â€Š14 days (opioid alone); P = 0.78]. There was a trend towards shorter LOS (30 ±â€Š22 day vs 27 ±â€Š15 days; P = 0.86), lower total methadone exposure (3.2 ±â€Š4.3 mg/kg vs 2.7 ±â€Š5.1 mg/kg; P = 0.66), less time to control symptoms (1 ±â€Š1.7 days vs 0.5 ±â€Š0.36 days; P = 0.31) and less need for a second agent (OR 2.65, 95% CI 0.69-10.5) in the opioid only group, although these observations also did not reach statistical significance. CONCLUSIONS: This study could not demonstrate a statistically significant difference in short-term NOWS outcome of LOT between the 2 groups. However, there was a trend towards longer LOT and LOS in the SSRI plus opioid group which could be clinically significant. A larger cohort may detect a true significant difference in these short-term outcomes.

The opioid epidemic and neonatal abstinence syndrome in the USA: a review of the continuum of care.

As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and their infants. This review summarises how increasing rates of neonatal abstinence syndrome resulted in a need to improve care to pregnant women and opioid-exposed infants. We discuss the variations in care delivery with particular emphasis on screening at-risk mothers, scoring systems for neonatal drug withdrawal, type and duration of pharmacotherapy, and discharge safety.

Improving Care for Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVE: Care for neonatal abstinence syndrome (NAS), a postnatal drug withdrawal syndrome, remains variable. We designed and implemented a multicenter quality improvement collaborative for infants with NAS. Our objective was to determine if the collaborative was effective in standardizing hospital policies and improving patient outcomes. METHODS: From 2012 to 2014, data were collected through serial cross-sectional audits of participating centers. Hospitals assessed institutional policies and patient-level data for infants with NAS requiring pharmacotherapy, including length of pharmacologic treatment and length of hospital stay (LOS). Models were fit, clustered according to hospital, to evaluate changes in patient outcomes over time. RESULTS: Among 199 participating centers, the mean number of NAS-focused guidelines increased from 3.7 to 5.1 of a possible 6 (P < .001), with improvements noted in all measured domains. Among infants cared for at participating centers, decreases occurred in median (interquartile range) length of pharmacologic treatment, from 16 days (10 to 27 days) to 15 days (10 to 24 days; P = .02), and LOS from 21 days (14 to 33 days) to 19 days (15 to 28 days; P = .002). In addition, there was a statistically significant decrease in the proportion of infants discharged on medication for NAS, from 39.7% to 26.5% (P = .02). After adjusting for potential confounders, standardized NAS scoring process was associated with shorter LOS (-3.3 days,95% confidence interval, -4.9 to -1.4). CONCLUSIONS: Involvement in a multicenter, multistate quality improvement collaborative focused on infants requiring pharmacologic treatment for NAS was associated with increases in standardizing hospital patient care policies and decreases in health care utilization.

Effectiveness of a clinical pathway with methadone treatment protocol for treatment of neonatal abstinence syndrome following in utero drug exposure to substances of abuse*.

OBJECTIVE: To evaluate the effectiveness of methadone for the treatment of neonatal abstinence syndrome when used according to a preexisting clinical pathway. DESIGN: This is a 3-year retrospective study conducted at a single institution. In this study, neonates who received methadone for the treatment of neonatal abstinence syndrome according to a predefined clinical treatment pathway were evaluated for treatment success: defined as adherence to the methadone regimen with no residual signs of withdrawal. Data were collected for methadone dosages, Lipsitz scores, length of methadone treatment, total length of hospital stay, and relevant clinical data. SETTING: Level III neonatal ICU. PATIENTS: Newborn infants with in utero exposure to substances of abuse. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty patients were included. The mean gestational age and birth weight were 37.07 ± 3.05 weeks and 2.77 ± 0.6 kg. All 60 patients exhibited neonatal abstinence syndrome within first 72 hours of life. Fifty-seven of 60 patients (95%) initiated methadone treatment according to protocol. There was deviation from the protocol at 48 and 72 hours of treatment with approximately 59% and 13% of the patients still on methadone at more than the prescribed amount to control neonatal abstinence syndrome. The mean ± SD total methadone exposure was 1.99 ± 1.63 mg/kg, length of treatment 11.66 ± 9.02 days, and total hospital length of stay 22.43 ± 29.3 days, suggesting significant variability in response. No significant correlation was found between birth weight or gestational age and length of treatment. CONCLUSION: Clinical pathway for treating neonatal abstinence syndrome was closely followed at the initial diagnosis. The doses of methadone used in the first 24-48 hours of this study were insufficient for adequate symptom control. Despite a formal treatment protocol, there was substantial variability in total methadone exposure, length of treatment, and length of stay, suggesting other contributory factors for the observed variability.

Methods of mortality risk adjustment in the NICU: a 20-year review.

BACKGROUND AND OBJECTIVES: Improving the quality of care delivered in NICUs relies on the ability to partition variation associated with patient characteristics from those attributed to processes of care delivery through risk adjustment. Multiple methods of mortality risk adjustment have been proposed for NICU populations. We review existing literature pertaining to mortality risk adjustment in the NICU. METHODS: PubMed and Scopus were searched to identify unique methods of mortality risk adjustment in the NICU and their trends in citation since original publication. Additional online searches were performed to identify organizational and government agency means of mortality risk adjustment for patients in the NICU. RESULTS: Among 10 unique neonatal mortality risk adjustment scores identified by this review, there are >3 dozen different measurement components. No score includes >28 components; no score contains <6. Scores differ substantively in their intended purposes, component parameters and intensity of data collection. The Clinical Risk Index for Babies (CRIB) has been referenced most frequently in other research articles (447 citations), while the National Institutes of Child Health and Human Development "calculator" has the greatest rate of citations per year since initial publication (37). The scores are notably inconsistent in their approaches to timing of data collection and inclusion of comorbidity indicators. CONCLUSIONS: Rigorous means of risk adjustment in the NICU are essential to enhancing the quality of care delivered to neonates, by facilitating more meaningful comparisons in quality improvement. Building on the first 20 years of neonatal mortality risk adjustment will ultimately allow researchers and quality improvement teams to apply measures that facilitate cross-institutional comparisons thoroughly and fairly.

Accuracy of hospital administrative data in reporting central line-associated bloodstream infections in newborns.

OBJECTIVES: Central line-associated bloodstream infections (CLABSIs) are a significant source of morbidity and mortality in the NICU. In 2010, Medicaid was mandated not to pay hospitals for treatment of CLABSI; however, the source of CLABSI data for this policy was not specified. Our objective was to evaluate the accuracy of hospital administrative data compared with CLABSI confirmed by an infection control service. METHODS: We evaluated hospital administrative and infection control data for newborns admitted consecutively from January 1, 2008, to December 31, 2010. Clinical and demographic data were collected through chart review. We compared cases of CLABSI identified by administrative data (International Classification of Diseases, Ninth Revision, Clinical Modification 999.31) with infection control data that use national criteria from the Centers for Disease Control and Prevention as the gold standard. To ascertain the nature possible deficiencies in the administrative data, each patient's medical record was searched to determine if clinical phrases that commonly refer to CLABSI appeared. RESULTS: Of 2920 infants admitted to the NICU during our study period, 52 were identified as having a CLABSI: 42 by infection control data only, 7 through hospital administrative data only, and 3 appearing in both. Against the gold standard, hospital administrative data were 6.7% sensitive and 99.7% specific, with a positive predictive value of 30.0% and a negative predictive value of 98.6%. Only 48% of medical records indicated a CLABSI. CONCLUSIONS: Our findings from a major children's hospital NICU indicate that International Classification of Diseases, Ninth Revision, Clinical Modification code 993.31 is presently not accurate and cannot be used reliably to compare CLABSI rates in NICUs.

Variation in lumbar punctures for early onset neonatal sepsis: a nationally representative serial cross-sectional analysis, 2003-2009.

BACKGROUND: Whether lumbar punctures (LPs) should be performed routinely for term newborns suspected of having early onset neonatal sepsis (EONS) is subject to debate. It is unclear whether variations in performance of LPs for EONS may be associated with patient, hospital, insurance or regional factors. Our objective was to identify characteristics associated with the practice of performing LPs for suspected EONS in a nationally representative sample. METHODS: Utilizing data from the 2003, 2006 and 2009 Kids' Inpatient Database (KID) compiled by the Agency for Healthcare Research and Quality, we examined the frequency and characteristics of term, normal-birth weight newborns receiving an LP for EONS. Survey-weighting was applied for national estimates and used in chi squared and multivariable regression analysis. RESULTS: In 2009, there were 13,694 discharges for term newborns that underwent LPs for apparent EONS. Newborns having LPs performed were more likely to be covered by Medicaid vs. private insurance (51.9 vs. 45.1 percent; p < 0.001), be born in urban vs. rural hospitals (94.8 vs. 87.3 percent; p < 0.001), teaching vs. non-teaching (60.8 vs. 43.1 percent; p < 0.001) and children's hospitals vs. non-children's (23.0 vs. 11.2 percent; p < 0.001). Lastly, newborns having LPs performed were disproportionately born in the Northeast census region (p = 0.03). In multi-year adjusted analysis, infants with Medicaid coverage, and those born in urban or teaching hospitals, consistently had higher odds of having an LP performed. CONCLUSIONS: We found pronounced variation in LPs performed for EONS, even when adjusting for clinical conditions that would prompt LPs. These findings indicate practice variations in newborn care that merit further examination and explanation.

Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009.

CONTEXT: Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome primarily caused by maternal opiate use. No national estimates are available for the incidence of maternal opiate use at the time of delivery or NAS. OBJECTIVES: To determine the national incidence of NAS and antepartum maternal opiate use and to characterize trends in national health care expenditures associated with NAS between 2000 and 2009. DESIGN, SETTING, AND PATIENTS: A retrospective, serial, cross-sectional analysis of a nationally representative sample of newborns with NAS. The Kids' Inpatient Database (KID) was used to identify newborns with NAS by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The Nationwide Inpatient Sample (NIS) was used to identify mothers using diagnosis related groups for vaginal and cesarean deliveries. Clinical conditions were identified using ICD-9-CM diagnosis codes. NAS and maternal opiate use were described as an annual frequency per 1000 hospital births. Missing hospital charges (<5% of cases) were estimated using multiple imputation. Trends in health care utilization outcomes over time were evaluated using variance-weighted regression. All hospital charges were adjusted for inflation to 2009 US dollars. MAIN OUTCOME MEASURES: Incidence of NAS and maternal opiate use, and related hospital charges. RESULTS: The separate years (2000, 2003, 2006, and 2009) of national discharge data included 2920 to 9674 unweighted discharges with NAS and 987 to 4563 unweighted discharges for mothers diagnosed with antepartum opiate use, within data sets including 784,191 to 1.1 million discharges for children (KID) and 816,554 to 879,910 discharges for all ages of delivering mothers (NIS). Between 2000 and 2009, the incidence of NAS among newborns increased from 1.20 (95% CI, 1.04-1.37) to 3.39 (95% CI, 3.12-3.67) per 1000 hospital births per year (P for trend < .001). Antepartum maternal opiate use also increased from 1.19 (95% CI, 1.01-1.35) to 5.63 (95% CI, 4.40-6.71) per 1000 hospital births per year (P for trend < .001). In 2009, newborns with NAS were more likely than all other hospital births to have low birthweight (19.1%; SE, 0.5%; vs 7.0%; SE, 0.2%), have respiratory complications (30.9%; SE, 0.7%; vs 8.9%; SE, 0.1%), and be covered by Medicaid (78.1%; SE, 0.8%; vs 45.5%; SE, 0.7%; all P < .001). Mean hospital charges for discharges with NAS increased from $39,400 (95% CI, $33,400-$45,400) in 2000 to $53,400 (95% CI, $49,000-$57,700) in 2009 (P for trend < .001). By 2009, 77.6% of charges for NAS were attributed to state Medicaid programs. CONCLUSION: Between 2000 and 2009, a substantial increase in the incidence of NAS and maternal opiate use in the United States was observed, as well as hospital charges related to NAS.

The effect of late preterm birth on mortality of infants with hypoplastic left heart syndrome.

OBJECTIVES: We evaluated the effect of late preterm (34 to 36 weeks' gestation) delivery on hospital mortality of infants with hypoplastic left heart syndrome (HLHS). STUDY DESIGN: Retrospective review of records of infants born at or after 34 weeks with no other lethal anomalies, cared for in a single tertiary perinatal center between 2002 and 2009. Factors associated with death prior to discharge from the hospital were ascertained using univariate and multivariate analyses. RESULTS: Of the 243 infants with HLHS, 35 were late preterm and 208 were ≥37 weeks (term). Using logistic regression analysis, late preterm delivery (odds ratio [OR] 2.95; 95% confidence interval [CI] 1.35 to 6.45), the presence of other major cardiac defects (OR 3.76; 95% CI 1.31 to 10.81), and the presence of noncardiac congenital anomalies (OR 6.13; 95% CI 1.43 to 26.22) were independently associated with hospital death. CONCLUSION: Late preterm birth of infants with HLHS was independently associated with an increased risk of hospital death compared with those delivered at term.

Myth: neonatology is evidence-based.

The practice of evidence-based medicine involves the judicious use of current best evidence in the care of individual patients. Decisions about diagnosis, prognosis and treating patients require knowledge of the probability and value of outcomes. Decision analysis illustrates how probabilities and values help define one another, and each are important. Whereas initial probability estimates can be obtained by 'searching for the best evidence', values belong to individuals. Obtaining values from patients or parents is sometimes difficult and requires a respectful, thoughtful, systematic approach, but only after doing this is neonatal care evidence-based.

A validated search assessment tool: assessing practice-based learning and improvement in a residency program.

OBJECTIVE: The objective of this study was to validate an assessment instrument for MEDLINE search strategies at an academic medical center. METHOD: Two approaches were used to investigate if the search assessment tool could capture performance differences in search strategy construction. First, data from an evaluation of MEDLINE searches from a pediatric resident's longitudinal assessment were investigated. Second, a cross-section of search strategies from residents in one incoming class was compared with strategies of residents graduating a year later. MEDLINE search strategies formulated by faculty who had been identified as having search expertise were used as a gold standard comparison. Participants were presented with a clinical scenario and asked to identify the search question and conduct a MEDLINE search. Two librarians rated the blinded search strategies. RESULTS: Search strategy scores were significantly higher for residents who received training than the comparison group with no training. There was no significant difference in search strategy scores between senior residents who received training and faculty experts. CONCLUSION: The results provide evidence for the validity of the instrument to evaluate MEDLINE search strategies. This assessment tool can measure improvements in information-seeking skills and provide data to fulfill Accreditation Council for Graduate Medical Education competencies.

Clinical course of symptomatic spontaneous pneumothorax in term and late preterm newborns: report from a large cohort.

The purpose of this observational study was to characterize the clinical course of newborn infants with spontaneous pneumothorax and to identify those infants who eventually required further interventions. We performed a retrospective review of newborns with symptomatic spontaneous pneumothorax, born between January 2002 and December 2007. Seventy-six infants ≥36 weeks' gestation were identified with symptomatic spontaneous pneumothorax. Twenty-two (29%) of the 76 infants with spontaneous pneumothorax required either thoracentesis or/and thoracostomy drainage, and 54 (71%) were managed without such intervention. In all, 18 (24%) infants received mechanical ventilation and 12 (16%) infants developed persistent pulmonary hypertension (PPHN) during the course of illness. Ten of the 22 infants requiring thoracentesis and/or thoracostomy for progressively worsening respiratory distress developed PPHN. Seven of these 10 infants with PPHN received inhaled nitric oxide, and four infants subsequently required extracorporeal membrane oxygenation. In contrast, the majority of the infants (50 of 54, 93%) not requiring thoracentesis or/and thoracostomy could be managed simply with supplemental oxygen or close observation. Progressively worsening respiratory distress prompting intervention in infants with spontaneous pneumothorax may indicate presence of PPHN that needs prompt recognition and referral to tertiary-level neonatal units for escalating respiratory support.

Isolation of tracheal aspirate mesenchymal stromal cells predicts bronchopulmonary dysplasia.

BACKGROUND: We have isolated mesenchymal stem cells (MSCs) from tracheal aspirates of premature infants with respiratory distress. Under the influence of transforming growth factor ß, MSCs differentiate into α-smooth-muscle actin-expressing myofibroblasts. Myofibroblasts are increased in the lungs of patients with bronchopulmonary dysplasia (BPD), a chronic lung disease of prematurely born infants. OBJECTIVE: We tested whether isolation of MSCs from tracheal aspirates of premature infants with respiratory distress during the first week of life correlates with BPD. METHODS: Eighty-four infants born at a gestational age of <33 weeks and requiring mechanical ventilation were studied. Aspirates were collected during suctioning and centrifuged. Cell pellets were resuspended in culture medium and plated. Adherent cells were grown to confluence. RESULTS: MSCs were isolated from the tracheal aspirates of 56 infants; 28 aspirate samples showed no MSCs. There was no statistical difference in gestational age or birth weight between the MSC and no-MSC groups. In the MSC group, 12 infants died and 25 developed BPD, as defined by a requirement for supplemental oxygen at 36 weeks' postmenstrual age. In the no-MSC group, 6 infants died and 1 developed BPD. Accounting for potential influences of gender, birth weight, gestational age, number of tracheal aspirate samples taken, and the duration of endotracheal intubation (up to 7 days), isolation of MSCs increased the adjusted odds ratio of BPD more than 21-fold (95% confidence interval: 1.82-265.85). CONCLUSIONS: Isolation of tracheal aspirate MSCs predicts the development of BPD, which suggests that MSCs play an important role in the pathogenesis of this disease.