Partnering for the future clinic: A multidisciplinary perinatal substance use program.

OBJECTIVE: The current model of obstetric care does not integrate multiple subspecialty services for high-risk pregnancies with substance use disorder (SUD), resulting in fragmented care. We describe the framework of our multidisciplinary and integrated perinatal substance use clinic and provide recent clinical outcomes. METHODS: We detail the Partnering for the Future (PFF) clinic, which integrates numerous subspecialty and support services for patients with SUDs and complex mental health needs. Additionally, a retrospective chart review of patients receiving care in the PFF clinic from 2017 to 2021 was completed. RESULTS: Seven integrated services are detailed with a focus on reducing stigma, providing trauma-informed care and mitigating harm. During the study period, 182 patients received care in PFF clinic, with opioid use disorder the most common indication for care. Co-occurring mental illness was common (81%). NICU admissions and severe NOWS diagnosis declined after the implementation of Eat-Sleep-Console. Social services identified care coordination, transportation assistance and adjustment counseling as the most common needs. A novel virtual behavioral health consultation service was successfully launched. CONCLUSIONS: Our integrated care model supports the holistic care of pregnant people with SUD and mental health disease. Patient-centered care and co-located services have improved perinatal outcomes, particularly for opioid-exposed pregnancies.

Management Practices for Standard-Risk and High-Risk Patients With Bronchiolitis.

OBJECTIVE: Management guidelines for bronchiolitis advocate for supportive care and exclude those with high-risk conditions. We aim to describe and compare the management of standard-risk and high-risk patients with bronchiolitis. METHODS: This retrospective study examined patients <2 years of age admitted to the general pediatric ward with an International Classification of Diseases, 10th Revision discharge diagnosis code of bronchiolitis or viral syndrome with evidence of lower respiratory tract involvement. Patients were defined as either standard- or high-risk on the basis of previously published criteria. The frequencies of diagnostic and therapeutic interventions were compared. RESULTS: We included 265 patients in this study (122 standard-risk [46.0%], 143 high-risk [54.0%]). Increased bronchodilator use was observed in the standard-risk group (any albuterol dosing, standard-risk 65.6%, high-risk 44.1%, P = .003). Increased steroid use was observed in the standard-risk group (any steroid dosing, standard-risk 19.7%, high-risk 14.7%, P = .018). Multiple logistic regression revealed >3 doses of albuterol, hypertonic saline, and chest physiotherapy use to be associated with rapid response team activation (odds ratio [OR] >3 doses albuterol: 8.36 [95% confidence interval (CI): 1.99-35.10], P = .048; OR >3 doses hypertonic saline: 13.94 [95% CI: 4.32-44.92], P = .001); OR percussion and postural drainage: 5.06 [95% CI: 1.88-13.63], P = .017). CONCLUSIONS: A varied approach to the management of bronchiolitis in both standard-risk and high-risk children occurred institutionally. Bronchodilators and steroids continue to be used frequently despite practice recommendations and regardless of risk status. More research is needed on management strategies in patients at high-risk for severe disease.

Biliblanket Utilization for Outpatient Treatment of Newborn Jaundice.

Hyperbilirubinemia is a common neonatal diagnosis. Biliblankets have the potential to reduce readmission for hyperbilirubinemia. The study purpose was to characterize home biliblanket treatment for hyperbilirubinemia using retrospective medical record review of newborns with total serum bilirubin of 0.1 to 3 mg/dL below inpatient threshold seen at 9 pediatric clinics (N = 359). The main outcomes were whether a biliblanket was used and whether the usage impacted readmissions. Home biliblankets were used for 44% of newborns. Nine percent of newborns were readmitted for hyperbilirubinemia. Four percent of newborns treated with a biliblanket were readmitted compared with 13% of those not treated with a biliblanket (P = .002). Newborns treated with a biliblanket (odds ratio [OR] = 0.16; 95% confidence interval [CI] = 0.06-0.44) and newborns 3 days or older (OR = 0.16; 95% CI = 0.06-0.43) were less likely to be readmitted than newborns not treated with a biliblanket and 2-day-old newborns. We found that home biliblanket use was associated with lower odds of hospital readmission for newborn jaundice.

The Length of Gomco Clamp Timing and Its Effect on Bleeding.

BACKGROUND: Bleeding is the most common complication of circumcisions in newborns. Gomco clamps are used to perform neonatal circumcisions. Although a clamp time of 5 minutes is recommended, there is no evidence to support this recommendation. METHODS: Circumcisions performed by attending physicians from the Division of Pediatric Hospital Medicine at an academic children's hospital were split into 2 groups. Group 1 had a clamp time of 5 minutes. Group 2 did not have a clamp time minimum. Nursing staff examined for bleeding at intervals of 15- and 30-minutes' postprocedure. Bleeding was determined to be significant if pressure and/or a microfibrillar collagen hemostat agent was applied. RESULTS: The study sample contained 23 physicians who saw a total of 1252 patients: 13 physicians (647 patients) in group 1 and 10 physicians (605 patients) in group 2. The average clamp time in group 2 was 2 minutes, 5 seconds. The estimated percentage of circumcisions that required microfibrillar collagen hemostat application was 5.1% (95% confidence interval [CI], 3.1-8.1) for group 1 and 5.6% (95% CI: 3.5-8.8]) for group 2. Circumcisions that had pressure applied were estimated to be 0.6% (95% CI: 0.2-1.7) for group 1 and 1.3% (95% CI: 0.5-3.1) for group 2. The difference between groups, in both categories, was not statistically significant. CONCLUSIONS: In this prospective study we evaluated clamp time duration and bleeding outcomes for neonatal circumcision. Clamp time does not appear to have an association with bleeding risk. Providers need not maintain a 5-minute clamp time to decrease postprocedural bleeding.

Cutting Ties With an Old Friend: Omphalitis and Bacteremia With Umbilical Cord Nonseverance.

Umbilical cord nonseverance (UCNS) is the practice of leaving the umbilical cord attached to the placenta after delivery. Limited case reports exist revealing adverse outcomes of UCNS. We report a case of neonatal omphalitis associated with Escherichia coli bacteremia and urinary tract infection after UCNS.

Parental Refusal of Standard-of-Care Prophylactic Newborn Practices: In One Center's Experience, Many Refuse One but Few Refuse All.

OBJECTIVES: Several interventions to reduce neonatal morbidity and mortality are universally recommended: intramuscular (IM) vitamin K (VK), erythromycin ophthalmic prophylaxis, and hepatitis B vaccine for newborns, and maternal pertussis vaccine. Despite robust efficacy and safety evidence, parental refusal of these practices is increasing. We sought to define the current declination rate and characterize the association between declination of 1 intervention and declination of the others. METHODS: A retrospective cohort study was performed of all inborn singletons admitted to the well newborn nursery over a 12-month period (November 15, 2015 through November 15, 2016) at a large quaternary center. RESULTS: In total, 3758 infants met inclusion criteria. 25% (n = 921) did not receive at least 1 of the 4 interventions. 13.6% (n = 511) did not receive the hepatitis B vaccine, 2.3% (n = 85) did not receive IM VK, 5.9% (n = 223) did not receive erythromycin, and 7.2% (n = 271) of mothers did not receive the prenatal tetanus, diphtheria, pertussis vaccine. Odds of refusal of IM VK were 6.2 times greater for infants delivered by a certified nurse midwife versus physician (95% confidence interval 3.3-11.6). Pattern of declination was variable; of 921 mother-infant dyads who did not receive at least 1 intervention, only 2 dyads received none of the interventions. CONCLUSIONS: Our study is one of the first in which patterns of refusal of standard-of-care perinatal practices are characterized. Alarmingly, one-fourth of our cohort did not receive at least 1 core infant health intervention. Our finding of only modest overlap in declination of each intervention carries implications for the development of targeted interventions.

Lotus Birth: A Case Series Report on Umbilical Nonseverance.

Lotus birth is the practice of leaving the umbilical cord uncut until separation occurs naturally. Our case series report describes delivery characteristics, neonatal clinical course, cord and placenta management, maternal reasons for a lotus birth, and desire for future lotus births. Between April 2014 and January 2017, six lotus births occurred. Mothers (four of the six) were contacted by phone after giving birth. A chart review was completed on each patient to evaluate if erythromycin ointment, hepatitis B vaccine, and vitamin K (intramuscular or oral) were administered, treatment of the placenta, maternal group B streptococcus status, postnatal infant fevers, infant hemoglobin or hematocrit levels, jaundice requiring phototherapy, and infant readmissions. Three of the six families decided to cut the cord before hospital discharge. No infections were noted. All contacted mothers would elect for a lotus birth again (4/6). One hepatitis B vaccine was given; all others declined perinatal immunization.

Adherence to AAP Healthy Newborn Discharge Criteria in a Tertiary Care Children's Hospital.

OBJECTIVES: In 2015, the American Academy of Pediatrics (AAP) published an updated consensus statement containing 17 discharge recommendations for healthy term newborn infants. In this study, we identify whether the AAP criteria were met before discharge at a tertiary care academic children's hospital. METHODS: A stratified random sample of charts from newborns who were discharged between June 1, 2015, and May 31, 2016, was reviewed. Of the 531 charts reviewed, 433 were included in the study. A review of each chart was performed, and data were collected. RESULTS: Descriptive statistics for our study population (N = 433) revealed that all 17 criteria were followed <5% of the time. The following criteria were met 100% of the time: clinical course and physical examination, postcircumcision bleeding, availability of family members or health care providers to address follow-up concerns, anticipatory guidance, first appointment with the physician scheduled or parents knowing how to do so, pulse oximetry screening, and hearing screening. These criteria were met at least 95% to 99% of the time: appropriate vital signs, regular void and stool frequency, appropriate jaundice and sepsis management, and metabolic screening. The following criteria were met 50% to 95% of the time: maternal serologies, hepatitis B vaccination, and social risk factor assessment. Four of the criteria were met <50% of the time: feeding assessment, maternal vaccination, follow-up timing for newborns discharged at <48 hours of life, and car safety-seat assessment. CONCLUSIONS: Our data reveal that the AAP healthy term newborn discharge recommendations are not consistently followed in our institution.

Quality of consumer-targeted internet guidance on home firearm and ammunition storage.

BACKGROUND AND OBJECTIVES: Four storage practices protect against unintentional and/or self-inflicted firearm injury among children and adolescents: keeping guns locked (1) and unloaded (2) and keeping ammunition locked up (3) and in a separate location from the guns (4). Our aim was to mimic common Google search strategies on firearm/ammunition storage and assess whether the resulting web pages provided recommendations consistent with those supported by the literature. METHODS: We identified 87 web pages by Google search of the 10 most commonly used search terms in the USA related to firearm/ammunition storage. Two non-blinded independent reviewers analysed web page technical quality according to a 17-item checklist derived from previous studies. A single reviewer analysed readability by US grade level assigned by Flesch-Kincaid Grade Level Index. Two separate, blinded, independent reviewers analysed deidentified web page content for accuracy and completeness describing the four accepted storage practices. Reviewers resolved disagreements by consensus. RESULTS: The web pages described, on average, less than one of four accepted storage practices (mean 0.2 (95% CL 0.1 to 0.4)). Only two web pages (2%) identified all four practices. Two web pages (2%) made assertions inconsistent with recommendations; both implied that loaded firearms could be stored safely. Flesch-Kincaid Grade Level Index averaged 8.0 (95% CL 7.3 to 8.7). The average technical quality score was 7.1 (95% CL 6.8 to 7.4) out of an available score of 17. There was a high degree of agreement between reviewers regarding completeness (weighted κ 0.78 (95% CL 0.61 to 0.97)). CONCLUSIONS: The internet currently provides incomplete information about safe firearm storage. Understanding existing deficiencies may inform future strategies for improvement.