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1.
J Pediatr ; 253: 165-172.e1, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36181871

RESUMO

OBJECTIVE: The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity. STUDY DESIGN: We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network. RESULTS: Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios. CONCLUSIONS: A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location.


Assuntos
Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Lactente , Recém-Nascido , Humanos , Criança , Idade Gestacional , Cuidados Críticos , Inquéritos e Questionários
2.
Acta Paediatr ; 112(11): 2329-2337, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-37675588

RESUMO

AIM: To assess the inter-rater reliability of modified Downes' scores assigned by physicians and nurses in the Ethiopian Neonatal Network and to calculate the concordance of score-based treatment for preterm infants with respiratory distress. METHODS: We included preterm infants admitted from June 2020 to July 2021 to four tertiary neonatal intensive care units (NICUs) of the Ethiopian Neonatal Network that presented with respiratory distress. We calculated the kappa statistic to determine the nurse and physician correlation for each component of the modified Downes' score and total score on admission and evaluated the concordance of scores above and below the treatment threshold of 4. RESULTS: Of the 1151 eligible infants admitted, 817 infants (71%) had scores reported concurrently and independently by nurse and physician. The kappa statistic for modified Downes' score components ranged from 0.88 to 0.92 and was 0.89 for the total score. There was 98% concordance for score-based treatment. CONCLUSION: Incorporation of the modified Downes' score on admission for preterm infants with respiratory distress was feasible in tertiary NICUs in Ethiopia. The kappa statistics showed near-perfect agreement between nurse and physician assessments, translating to a very high degree of concordance in score-based treatment recommendations. These results highlight an opportunity for task-shifting assessments and empowering nurses.

3.
Am J Perinatol ; 2022 Jun 06.
Artigo em Inglês | MEDLINE | ID: mdl-35381608

RESUMO

OBJECTIVES: A statewide Maryland Perinatal Neonatal Quality Collaborative, facilitated by the Maryland Patient Safety Center (MPSC), identified the three specific, measurable, attainable, relevant, and time-limited (SMART) aims to improve outcomes of neonatal abstinence syndrome (NAS) care as follows: (1) to reduce hospital length of stay (LOS), (2) to reduce interhospital transfers, and (3) to reduce 30-day readmission rates of infants with NAS. STUDY DESIGN: The Maryland collaborative developed a bundle of best practices for care of infants with NAS. MPSC partnered with Vermont Oxford Network (VON) to utilize the VON NAS toolkit and provided its standardized NAS educational curriculum to address the three objectives for participating birthing hospitals. Efforts began in quarter 4 (Q4) of 2016 and continued for 2 years. Thirty-one of Maryland's 32 delivery hospitals (97%) participated in the 2-year collaborative. Additionally, one specialty pediatric hospital with an NAS unit participated in the group learnings. Participating facilities implemented components of the MPSC NAS bundle and provided their staff caring for infants with NAS and their mothers access to the VON standardized educational curriculum. MPSC partnered with VON to conduct two audits of implementation of policies and procedures in Q1 of 2016 and Q3 of 2018. The Maryland Department of Health supplied quarterly aggregate hospital information on LOS, interhospital transfers, and 30-day readmissions of infants with a discharge diagnosis of the International Classification of Disease, 10th Revision (ICD-10), P96.1. RESULTS: Among term infants with NAS with total hospital stay greater than 5 days, we observed a nonsignificant reduction in both mean and median LOS of 1.5 days. In this same group, the rate of interhospital transfers fell significantly from 20.1% in 2016 to 13.8 and 11.0% in 2017 and 2018, respectively. CONCLUSION: The best practice bundle created by the Maryland collaborative was associated with a reduction in the percentage of infants with NAS who required interhospital transfer, thereby reducing family disruption. KEY POINTS: · A state NAS collaborative engaged 97% of delivery hospitals in education and standardization of care.. · The collaborative witnessed a 1.5-day decrease in length of stay, similar to that observed in other state collaboratives.. · The unique outcome of our collaborative was a 50% decrease in the rate of interhospital transfer..

4.
J Pediatr ; 216: 67-72, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31668886

RESUMO

OBJECTIVES: To utilize a large multicenter neonatal cohort to describe survival and clinical outcomes of very low birth weight (VLBW) or preterm infants with ectopia cordis. STUDY DESIGN: Data were prospectively collected on 2 211 262 infants (born 2000-2017) from 845 US centers. Both VLBW (401-1500 g or 22-29 weeks of gestation) and non-VLBW (>1500 g and >29 weeks) infants had diagnoses or anatomic descriptors consistent with ectopia cordis and/or pentalogy of Cantrell. The primary outcome was neonatal survival, defined as hospital discharge or initial length of stay of ≥12 months. RESULTS: In total, 180 infants had ectopia cordis, 135 (76%) with findings of pentalogy of Cantrell. VLBW infants comprised 52% of the population. VLBW mortality was 96% with 79% dying within 12 hours, compared with 59% and 36%, respectively, for non-VLBW. One-third of VLBW infants received life support compared with 65% of non-VLBW. Surgery was reported for 34% of VLBW and 68% of non-VLBW infants. Congenital heart disease was reported in 8% of VLBW and 36% of non-VLBW, with conotruncal abnormalities most common. Survival exceeded 50% for infants >2500 g and >37 weeks of gestation. CONCLUSIONS: Survival of VLBW infants with ectopia cordis was poor and substantially worse compared with non-VLBW, with notable discrepancies in resuscitative efforts and surgical interventions. Although gestational age and weight strongly influence current survival, more detailed information regarding the severity of cardiac and noncardiac abnormalities is required to fully determine prognosis and inform counseling.


Assuntos
Ectopia Cordis/mortalidade , Tempo de Internação/estatística & dados numéricos , Estudos de Casos e Controles , Pré-Escolar , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Recém-Nascido de muito Baixo Peso , Estudos Prospectivos , Estados Unidos/epidemiologia
5.
Pediatr Res ; 87(2): 227-234, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31357209

RESUMO

Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.


Assuntos
Saúde da Família/etnologia , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Criança Pós-Termo/crescimento & desenvolvimento , Nascimento Prematuro/etnologia , Nascimento Prematuro/prevenção & controle , Racismo/etnologia , Determinantes Sociais da Saúde , Segregação Social , Criança , Desenvolvimento Infantil , Pré-Escolar , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Lactente , Recém-Nascido , Gravidez , Fatores Raciais , Medição de Risco , Fatores de Risco , Estados Unidos/epidemiologia
6.
J Pediatr ; 198: 174-180.e13, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29631772

RESUMO

OBJECTIVE: To estimate the risks of mortality and morbidities in large for gestational age (LGA) infants relative to appropriate for gestational age infants born at 22-29 weeks of gestation. STUDY DESIGN: Data on 156 587 infants were collected between 2006 and 2014 in 852 US centers participating in the Vermont Oxford Network. We defined LGA as sex-specific birth weight above the 90th centile for gestational age measured in days. Generalized additive models with smoothing splines on gestational age by LGA status were fitted on mortality and morbidity outcomes to estimate adjusted relative risks and their 95% CIs. RESULTS: Compared with appropriate for gestational age infants, being born LGA was associated with decreased risks of mortality, respiratory distress syndrome, patent ductus arteriosus, necrotizing enterocolitis, late-onset sepsis, severe retinopathy of prematurity, and chronic lung disease. Early onset sepsis and severe intraventricular hemorrhage were increased among LGA infants, but these risks were not homogeneous across the gestational age range. CONCLUSIONS: Being born LGA was associated with lower risks for all the examined outcomes except for early onset sepsis and severe intraventricular hemorrhage.


Assuntos
Peso ao Nascer , Idade Gestacional , Doenças do Prematuro/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Estudos Retrospectivos
7.
Am J Obstet Gynecol ; 219(2): 195.e1-195.e14, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29750954

RESUMO

BACKGROUND: It is unclear whether a neonatal or a fetal growth standard is a better predictor of adverse in-hospital newborn infant outcomes. OBJECTIVE: We aimed to evaluate and compare the power of birthweight for gestational age to predict adverse neonatal outcomes using neonatal and fetal growth charts. Gestational age-specific birthweight was examined either as a percentile score or as a binary indicator for birthweight <10th percentile (small for gestational age) with the use of 3 fetal growth charts (National Institute of Child Health and Human Development, World Health Organization, and Intergrowth-21st) and 1 neonatal sex-specific birthweight chart. STUDY DESIGN: Inborn singleton infants from 2006-2014 with gestational age between 22 and 29 weeks and who were enrolled at 1 of the 852 US centers that were participating in the Vermont Oxford Network were studied. Outcomes included death, necrotizing enterocolitis, severe intraventricular hemorrhage, severe retinopathy of prematurity, and chronic lung disease. Receiver operating characteristic curve analysis was used to assess the predictive power of birthweight for gestational age, either as a score or as a small-for-gestational-age indicator, with the use of the 4 charts. We also examined the relative risks of the outcomes by comparing small-for-gestational-age and non-small-for-gestational-age infants with the use of the 4 charts. RESULTS: The percentage of small-for-gestational-age newborn infants ranged from 25.9-29.7% when with used the fetal growth charts. In contrast, the percentage was 10% when we used the neonatal charts. The areas under the receiver operating characteristic curves were similar across the 4 classification methods and were all <0.60, which suggests a poor predictive power. Small-for-gestational-age status, as classified by the neonatal chart, showed stronger associations with death, necrotizing enterocolitis, severe retinopathy of prematurity, and chronic lung disease, compared with those associations that were based on the other classification methods. CONCLUSION: Neither the neonatal nor the fetal growth charts are predictive of adverse infant in-hospital outcomes. In contrast to fetal charts, the use of the neonatal charts results in stronger associations between small-for-gestational-age and adverse outcomes.


Assuntos
Hemorragia Cerebral Intraventricular/epidemiologia , Enterocolite Necrosante/epidemiologia , Desenvolvimento Fetal , Gráficos de Crescimento , Pneumopatias/epidemiologia , Retinopatia da Prematuridade/epidemiologia , Doença Crônica , Feminino , Idade Gestacional , Humanos , Lactente Extremamente Prematuro , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido Pequeno para a Idade Gestacional , Masculino , Morte Perinatal , Medição de Risco , Índice de Gravidade de Doença
8.
J Pediatr ; 188: 192-197.e6, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28712519

RESUMO

OBJECTIVE: To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis. STUDY DESIGN: Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS). RESULTS: Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome. CONCLUSIONS: Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.


Assuntos
Gastrosquise/epidemiologia , Gastrosquise/cirurgia , Estudos de Coortes , Anormalidades Congênitas/epidemiologia , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Enterocolite Necrosante/epidemiologia , Feminino , Gastrostomia/estatística & dados numéricos , Humanos , Transtornos da Nutrição do Lactente/epidemiologia , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Atresia Intestinal/epidemiologia , Atresia Intestinal/cirurgia , Jejunostomia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , América do Norte/epidemiologia , Fatores de Risco , Sepse/mortalidade
9.
Res Nurs Health ; 38(5): 333-41, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26291315

RESUMO

The neonatal intensive care unit (NICU) is a setting with high nurse-to-patient ratios. Little is known about the factors that determine nurse workload and assignment. The goals of this study were to (1) develop a measure of NICU infant acuity; (2) describe the acuity distribution of NICU infants; (3) describe the nurse/infant ratio at each acuity level, and examine the factors other than acuity, including nurse qualifications and the availability of physicians and other providers, that determined staffing ratios; and (4) explore whether nurse qualifications were related to the acuity of assigned infants. In a two-stage cohort study, data were collected in 104 NICUs in 2008 by nurse survey (6,038 nurses and 15,191 infants assigned to them) and administrators reported on unit-level staffing of non-nurse providers; in a subset of 70 NICUs in 2009-2010, census data were collected on four selected shifts (3,871 nurses and 9,276 infants assigned to them). Most NICU infants (62%) were low-acuity (Levels 1 and 2); 12% of infants were high-acuity (Levels 4 and 5). The nurse-to-infant ratio ranged from 0.33 for the lowest-acuity infants to 0.95 for the highest-acuity infants. The staffing ratio was significantly related to the acuity of assigned infants but not to nurse education, experience, certification, or availability of other providers. There was a significant but small difference in the percentage of high-acuity (Levels 4 and 5) infants assigned to nurses with specialty certification (15% vs. 12% for nurses without certification). These staffing patterns may not optimize patient outcomes in this highly intensive pediatric care setting.


Assuntos
Unidades de Terapia Intensiva Neonatal/organização & administração , Enfermagem Neonatal/organização & administração , Recursos Humanos de Enfermagem Hospitalar/provisão & distribuição , Admissão e Escalonamento de Pessoal/organização & administração , Carga de Trabalho/estatística & dados numéricos , Competência Clínica , Estudos de Coortes , Humanos , Recém-Nascido , Relações Enfermeiro-Paciente , Gravidade do Paciente , Estados Unidos
10.
Pediatrics ; 154(1)2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38872618

RESUMO

OBJECTIVE: To ascertain how NICU teams are undertaking action to follow through, involving teams, families, and communities as partners to address health-related social needs of infants and families. METHODS: Nineteen potentially better practices (PBPs) for follow through first published in 2020 were reported and analyzed as a sum, overall, and by safety-net hospital status, hospital ownership, and NICU type, among US NICUs that finalized Vermont Oxford Network data collection in 2023. RESULTS: One hundred percent of 758 eligible hospitals completed the annual membership survey, of which 57.5% reported screening for social risks. Almost all NICUs offered social work, lactation support, and translation services, but only 16% included a lawyer or paralegal on the team. Overall, 90.2% helped families offset financial costs while their infants were in the hospital, either with direct services or vouchers. At discharge, 94.0% of NICUs connected families with appropriate community organizations and services, 52.9% provided telemedicine after discharge, and 11.7% conducted home visits. The median number of PBPs at each hospital was 10 (25th percentile: 8, 75th percentile: 12). The number of PBPs reported differed by hospital control or ownership and level of NICU care. There were no differences by safety-net hospital status. CONCLUSIONS: Despite concerns about time and resources, a diverse set of US NICUs reported adopting potentially better practices for follow through. However, the marked variation among NICUs and the lower rates at for-profit and lower-level NICUs suggest there is substantial opportunity for improvement.


Assuntos
Unidades de Terapia Intensiva Neonatal , Humanos , Recém-Nascido , Provedores de Redes de Segurança , Estados Unidos , Vermont , Alta do Paciente
11.
J Perinatol ; 44(1): 108-115, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-37735208

RESUMO

OBJECTIVE: To quantify the association between necrotizing enterocolitis (NEC) and neurodevelopmental disability (NDI) in extremely low birth weight (ELBW) infants with intraventricular hemorrhage (IVH). STUDY DESIGN: ELBW survivors born 2011-2017 and evaluated at 16-26 months corrected age in the Vermont Oxford Network (VON) ELBW Follow-Up Project were included. Logistic regression determined the adjusted relative risk (aRR) of severe NDI in medical or surgical NEC compared to no NEC, stratified by severity of IVH. RESULTS: Follow-up evaluation occurred in 5870 ELBW survivors. Compared to no NEC, medical NEC had no impact on NDI, regardless of IVH status. Surgical NEC increased risk of NDI in patients with no IVH (aRR 1.69; 95% CI 1.36-2.09), mild IVH (aRR 1.36;0.97-1.92), and severe IVH (aRR 1.35;1.13-1.60). CONCLUSIONS: ELBW infants with surgical NEC carry increased risk of neurodevelopmental disability within each IVH severity stratum. These data describe the additive insult of surgical NEC and IVH on neurodevelopment, informing prognostic discussions and highlighting the need for preventative interventions.


Assuntos
Enterocolite Necrosante , Doenças do Prematuro , Lactente , Recém-Nascido , Humanos , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Doenças do Prematuro/epidemiologia , Hemorragia Cerebral/complicações , Enterocolite Necrosante/complicações , Enterocolite Necrosante/epidemiologia , Enterocolite Necrosante/cirurgia , Prognóstico , Peso ao Nascer
12.
Pediatrics ; 153(1)2024 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-38053449

RESUMO

BACKGROUND: Mortality and morbidity for very preterm infants in the United States decreased for years. The current study describes recent changes to assess whether the pace of improvement has changed. METHODS: Vermont Oxford Network members contributed data on infants born at 24 to 28 weeks' gestation from 1997 to 2021. We modeled mortality, late-onset sepsis, necrotizing enterocolitis, chronic lung disease, severe intraventricular hemorrhage, severe retinopathy of prematurity, and death or morbidity by year of birth using segmented relative risk regression, reporting risk-adjusted annual percentage changes with 95% confidence intervals overall and by gestational age week. RESULTS: Analyses of data for 447 396 infants at 888 hospitals identified 3 time point segments for mortality, late onset sepsis, chronic lung disease, severe intraventricular hemorrhage, severe retinopathy of prematurity, and death or morbidity, and 4 for necrotizing enterocolitis. Mortality decreased from 2005 to 2021, but more slowly since 2012. Late-onset sepsis decreased from 1997 to 2021, but more slowly since 2012. Severe retinopathy of prematurity decreased from 2002 to 2021, but more slowly since 2011. Necrotizing enterocolitis, severe intraventricular hemorrhage, and death or morbidity were stable since 2015. Chronic lung disease has increased since 2012. Trends by gestational age generally mirror those for the overall cohort. CONCLUSIONS: Improvements in mortality and morbidity have slowed, stalled, or reversed in recent years. We propose a 3-part strategy to regain the pace of improvement: research; quality improvement; and follow through, practicing social as well as technical medicine to improve the health and well-being of infants and families.


Assuntos
Enterocolite Necrosante , Doenças do Prematuro , Pneumopatias , Retinopatia da Prematuridade , Sepse , Lactente , Recém-Nascido , Humanos , Estados Unidos/epidemiologia , Recém-Nascido Prematuro , Retinopatia da Prematuridade/epidemiologia , Idade Gestacional , Mortalidade Infantil , Hemorragia Cerebral , Morbidade
13.
J Pediatr Surg ; 2024 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-38561308

RESUMO

BACKGROUND: Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) affect 6-8% of extremely low birth weight (ELBW) infants. SIP has lower mortality than NEC, but with similar short-term morbidity in length of stay, growth failure, and supplemental oxygen requirements. Comparative long-term neurodevelopmental outcomes have not been clarified. METHODS: Data were prospectively collected from 59 North American neonatal units, regarding ELBW infants (401-1000 g or 22-27 weeks gestational age) born between 2011 and 2018 and evaluated again at 16-26 months corrected age. Outcomes were collected from infants with laparotomy-confirmed NEC, laparotomy-confirmed SIP, and those without NEC or SIP. The primary outcome was severe neurodevelopmental disability. Secondary outcomes were weight <10th percentile, medical readmission, post-discharge surgery and medical support at home. Adjusted risk ratios (ARR) were calculated. RESULTS: Of 13,673 ELBW infants, 6391 (47%) were followed including 93 of 232 (40%) with NEC and 100 of 235 (42%) with SIP. There were no statistically significant differences in adjusted risk of any outcomes when directly comparing NEC to SIP (ARR 2.35; 95% CI 0.89, 6.26). However, infants with NEC had greater risk of severe neurodevelopmental disability (ARR 1.43; 1.09-1.86), rehospitalization (ARR 1.46; 1.17-1.82), and post-discharge surgery (ARR 1.82; 1.48-2.23) compared to infants without NEC or SIP. Infants with SIP only had greater risk of post-discharge surgery (ARR 1.64; 1.34-2.00) compared to infants without NEC or SIP. CONCLUSIONS: ELBW infants with NEC had significantly increased risk of severe neurodevelopmental disability and post-discharge healthcare needs, consistent with prior literature. We now know infants with SIP also have increased healthcare needs. LEVELS OF EVIDENCE: Level II.

14.
J Pediatr Surg ; 59(5): 818-824, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38368194

RESUMO

BACKGROUND: Limited data exists regarding the mortality of very low birth weight (VLBW) neonates with congenital diaphragmatic hernia (CDH). This study aims to quantify and determine predictors of mortality in VLBW neonates with CDH. METHODS: This analysis of 829 U.S. NICUs included VLBW [birth weight ≤1500g] neonates, born 2011-2021 with and without CDH. The primary outcome was in-hospital mortality. A generalized estimating equation regression model determined the adjusted risk ratio (ARR) of mortality. RESULTS: Of 426,140 VLBW neonates, 535 had CDH. In neonates with CDH, 48.4% had an additional congenital anomaly vs 5.5% without. In-hospital mortality for neonates with CDH was 70.4% vs 12.6% without. Of those with CDH, 73.3% died by day of life 3. Of VLBW neonates with CDH, 38% were repaired. A subgroup analysis was performed on 60% of VLBW neonates who underwent delivery room intubation or mechanical ventilation, as an indicator of active treatment. Mortality in this group was 62.7% for neonates with CDH vs 16.4% without. Higher Apgars at 1 min and repair of CDH were associated with lower mortality (ARR 0.91; 95%CI 0.87,0.96 and ARR 0.28; 0.21,0.39). The presence of additional congenital anomalies was associated with higher mortality (ARR 1.14; 1.01,1.30). CONCLUSION: These benchmark data reveal that VLBW neonates with CDH have an extremely high mortality. Almost half of the cohort have an additional congenital anomaly which significantly increases the risk of death. This study may be utilized by providers and families to better understand the guarded prognosis of VLBW neonates with CDH. TYPE OF STUDY: Level II. LEVEL OF EVIDENCE: Level II.


Assuntos
Hérnias Diafragmáticas Congênitas , Recém-Nascido , Humanos , Peso ao Nascer , Recém-Nascido de muito Baixo Peso , Razão de Chances , Mortalidade Hospitalar , Estudos Retrospectivos
15.
JAMA Health Forum ; 4(5): e230960, 2023 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-37171798

RESUMO

Importance: For neonates with very low birth weight (VLBW), randomized clinical trials (RCTs) indicate that probiotic treatment decreases the risk of necrotizing enterocolitis (NEC), with smaller decreases in the risk of sepsis and death. There is little evidence on the rate of probiotic adoption in US neonatal intensive care units (NICUs) and whether the benefits seen in trials have materialized in practice. Objective: To estimate changes in probiotic use among neonates with VLBW and to test whether neonates with VLBW treated at NICUs adopting routine probiotic use experience better outcomes compared with neonates treated at nonadopting NICUs. Design, Setting, and Participants: This cohort study used Vermont Oxford Network data on neonates with VLBW in US NICUs from January 1, 2012, to December 31, 2019. Data were analyzed from January 2022 through February 2023. Exposure: Probiotics adoption vs nonadoption. Adopting NICUs were defined as those that currently or previously treated at least 20% of neonates with VLBW with probiotics. Main Outcomes: The primary outcomes were rates of NEC, in-hospital mortality, and sepsis, defined as bacterial or fungal infection occurring after day 3 from birth. A difference-in-differences analysis compared changes in VLBW infant outcomes between adopting and nonadopting NICUs before and after hospital-level adoption of probiotics. Additional analyses used the proportion of neonates treated with probiotics in each neonate's birth NICU and year. Results: The analysis included 307 905 neonates with VLBW (mean [SD] gestational age, 28.4 [2.9] weeks; 50.0% male) at 807 US hospitals. The rate of probiotic treatment of neonates with VLBW rose from 1572 of 38 296 neonates (4.1%) in 2012 to 4788 of 37 910 (12.6%) in 2019. Only 123 of 745 NICUs (16.5%) adopted probiotics by 2019, with 4591 of 6017 neonates with VLBW (76.3%) receiving probiotics in 2019 at adopting NICUs. Incidence of NEC declined by 18% at adopting NICUs (odds ratio [OR], 0.82; 95% CI, 0.70-0.95; P = .10) compared with nonadopting NICUs. Probiotic adoption was not associated with a significant reduction in sepsis (OR, 1.11; 95% CI, 0.98-1.25; P = .09) or mortality (OR, 0.93; 95% CI, 0.80-1.08; P = .33). Conclusion and Relevance: In this cohort study, adoption of routine use of probiotics increased slowly in US NICUs and was associated with lower NEC risk but not with sepsis or mortality among neonates with VLBW. The findings for probiotic adoption and NEC, sepsis, and mortality were smaller than would have been predicted by the totality of RCT evidence but are consistent with a meta-analysis restricted to studies at low risk of bias.


Assuntos
Enterocolite Necrosante , Probióticos , Sepse , Lactente , Masculino , Recém-Nascido , Humanos , Adulto , Feminino , Recém-Nascido de muito Baixo Peso , Probióticos/uso terapêutico , Enterocolite Necrosante/epidemiologia , Enterocolite Necrosante/prevenção & controle , Idade Gestacional , Sepse/epidemiologia , Sepse/prevenção & controle
16.
Pediatr Infect Dis J ; 42(2): 152-158, 2023 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-36638403

RESUMO

BACKGROUND: Serratia spp. are opportunistic, multidrug resistant, Gram-negative pathogens, previously described among preterm infants in case reports or outbreaks of infection. We describe Serratia late-onset infection (LOI) in very preterm infants in a large, contemporary, nationally representative cohort. METHODS: In this secondary analysis of prospectively collected data of preterm infants born 401-1500 grams and/or 22-29 weeks gestational age from 2018 to 2020 at 774 Vermont Oxford Network members, LOI was defined as culture-confirmed blood and/or cerebrospinal fluid infection > 3 days after birth. The primary outcome was incidence of Serratia LOI. Secondary outcomes compared rates of survival and discharge morbidities between infants with Serratia and non-Serratia LOI. RESULTS: Among 119,565 infants, LOI occurred in 10,687 (8.9%). Serratia was isolated in 279 cases (2.6% of all LOI; 2.3 Serratia infections per 1000 infants). Of 774 hospitals, 161 (21%) reported at least one Serratia LOI; 170 of 271 (63%) cases occurred at hospitals reporting 1 or 2 Serratia infections, and 53 of 271 (20%) occurred at hospitals reporting ≥5 Serratia infections. Serratia LOI was associated with a lower rate of survival to discharge compared with those with non-Serratia LOI (adjusted relative risk 0.88, 95% CI: 0.82-0.95). Among survivors, infants with Serratia LOI had higher rates of tracheostomy, gastrostomy and home oxygen use compared with those with non-Serratia LOI. CONCLUSIONS: The incidence of Serratia LOI was 2.3 infections per 1000 very preterm infants in this cohort. Lower survival and significant morbidity among Serratia LOI survivors highlight the need for recognition and targeted prevention strategies for this opportunistic nosocomial infection.


Assuntos
Doenças do Prematuro , Infecções por Serratia , Lactente , Recém-Nascido , Humanos , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Infecções por Serratia/epidemiologia , Recém-Nascido de muito Baixo Peso , Idade Gestacional , Serratia
17.
Pediatrics ; 151(2)2023 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-36594226

RESUMO

BACKGROUND AND OBJECTIVES: High-risk infant follow-up programs (HRIFs) are a recommended standard of care for all extremely low birth weight (ELBW) infants to help mitigate known risks to long-term health and development. However, participation is variable, with known racial and ethnic inequities, though hospital-level drivers of inequity remain unknown. We conducted a study using a large, multicenter cohort of ELBW infants to explore within- and between-hospital inequities in HRIF participation. METHODS: Vermont Oxford Network collected data on 19 503 ELBW infants born between 2006 and 2017 at 58 US hospitals participating in the ELBW Follow-up Project. Primary outcome was evaluation in HRIF at 18 to 24 months' corrected age. The primary predictor was infant race and ethnicity, defined as maternal race (non-Hispanic white, non-Hispanic Black, Hispanic, Asian American, Native American, other). We used generalized linear mixed models to test within- and between-hospital variation and inequities in HRIF participation. RESULTS: Among the 19 503 infants, 44.7% (interquartile range 31.1-63.3) were seen in HRIF. Twenty six percent of the total variation in HRIF participation rates was due to between-hospital variation. In adjusted models, Black infants had significantly lower odds of HRIF participation compared with white infants (adjusted odds ratio, 0.73; 95% confidence interval, 0.64-0.83). The within-hospital effect of race varied significantly between hospitals. CONCLUSIONS: There are significant racial inequities in HRIF participation, with notable variation within and between hospitals. Further study is needed to identify potential hospital-level targets for interventions to reduce this inequity.


Assuntos
Etnicidade , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Recém-Nascido , Lactente , Humanos , Seguimentos , Hispânico ou Latino , População Negra , Peso ao Nascer
18.
JAMA Netw Open ; 6(5): e2312107, 2023 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-37145593

RESUMO

Importance: In an ideal regionalized system, all infants born very preterm would be delivered at a large tertiary hospital capable of providing all necessary care. Objective: To examine whether the distribution of extremely preterm births changed between 2009 and 2020 based on neonatal intensive care resources at the delivery hospital. Design, Setting, and Participants: This retrospective cohort study was conducted at 822 Vermont Oxford Network (VON) centers in the US between 2009 and 2020. Participants included infants born at 22 to 29 weeks' gestation, delivered at or transferred to centers participating in the VON. Data were analyzed from February to December 2022. Exposures: Hospital of birth at 22 to 29 weeks' gestation. Main Outcomes and Measures: Birthplace neonatal intensive care unit (NICU) level was classified as A, restriction on assisted ventilation or no surgery; B, major surgery; or C, cardiac surgery requiring bypass. Level B centers were further divided into low-volume (<50 inborn infants at 22 to 29 weeks' gestation per year) and high-volume (≥50 inborn infants at 22 to 29 weeks' gestation per year) centers. High-volume level B and level C centers were combined, resulting in 3 distinct NICU categories: level A, low-volume B, and high-volume B and C NICUs. The main outcome was the change in the percentage of births at hospitals with level A, low-volume B, and high-volume B or C NICUs overall and by US Census region. Results: A total of 357 181 infants (mean [SD] gestational age, 26.4 [2.1] weeks; 188 761 [52.9%] male) were included in the analysis. Across regions, the Pacific (20 239 births [38.3%]) had the lowest while the South Atlantic (48 348 births [62.7%]) had the highest percentage of births at a hospital with a high-volume B- or C-level NICU. Births at hospitals with A-level NICUs increased by 5.6% (95% CI, 4.3% to 7.0%), and births at low-volume B-level NICUs increased by 3.6% (95% CI, 2.1% to 5.0%), while births at hospitals with high-volume B- or C-level NICUs decreased by 9.2% (95% CI, -10.3% to -8.1%). By 2020, less than half of the births for infants at 22 to 29 weeks' gestation occurred at hospitals with high-volume B- or C-level NICUs. Most US Census regions followed the nationwide trends; for example, births at hospitals with high-volume B- or C-level NICUs decreased by 10.9% [95% CI, -14.0% to -7.8%) in the East North Central region and by 21.1% (95% CI, -24.0% to -18.2%) in the West South Central region. Conclusions and Relevance: This retrospective cohort study identified concerning deregionalization trends in birthplace hospital level of care for infants born at 22 to 29 weeks' gestation. These findings should serve to encourage policy makers to identify and enforce strategies to ensure that infants at the highest risk of adverse outcomes are born at the hospitals where they have the best chances to attain optimal outcomes.


Assuntos
Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal , Recém-Nascido , Feminino , Lactente , Masculino , Humanos , Adulto , Idade Gestacional , Estudos Retrospectivos , Hospitais
19.
J Perinatol ; 43(1): 91-96, 2023 01.
Artigo em Inglês | MEDLINE | ID: mdl-35715599

RESUMO

OBJECTIVE: To evaluate the impact of necrotizing enterocolitis (NEC) on mortality in very low birth weight (VLBW) infants with intraventricular hemorrhage (IVH). STUDY DESIGN: Data were collected on VLBW infants born 2014-2018 at Vermont Oxford Network (VON) centers. NEC and IVH were categorized by severity. Adjusted risk ratios (ARR) for in-hospital mortality were calculated. RESULTS: This study included 187 187 VLBW infants. Both medical and surgical NEC increased mortality risk compared to those without NEC. Stratification by IVH severity modified this effect (no IVH: ARR 3.04 (95%CI 2.74-3.38) for medical NEC and 4.17 (3.84-4.52) for surgical NEC; mild IVH: ARR 2.14 (1.88-2.44) for medical NEC and 2.49 (2.24-2.78) for surgical NEC; severe IVH: ARR 1.14 (1.03-1.26) for medical NEC and 1.10 (1.02-1.18) for surgical NEC). CONCLUSION: The relative impact of NEC on mortality decreased as IVH severity increased. Given the frequent coexistence of NEC and IVH, these data inform multidisciplinary management of these complex patients.


Assuntos
Hemorragia Cerebral , Enterocolite Necrosante , Doenças do Recém-Nascido , Recém-Nascido de muito Baixo Peso , Feminino , Humanos , Lactente , Recém-Nascido , Peso ao Nascer , Hemorragia Cerebral/complicações , Hemorragia Cerebral/mortalidade , Enterocolite Necrosante/complicações , Enterocolite Necrosante/mortalidade , Doenças do Recém-Nascido/mortalidade , Recém-Nascido Prematuro
20.
Neonatology ; 120(2): 208-216, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36649689

RESUMO

BACKGROUND: Postmenstrual age for surviving infants without congenital anomalies born at 24-29 weeks' gestational age from 2005 to 2018 in the USA increased 8 days, discharge weight increased 316 grams, and median discharge weight z-score increased 0.19 standard units. We asked whether increases were observed in other countries. METHODS: We evaluated postmenstrual age, weight, and weight z-score at discharge of surviving infants without congenital anomalies born at 24-29 weeks' gestational age admitted to Vermont Oxford Network member hospitals in Austria, Ireland, Italy, Switzerland, the UK, and the USA from 2012 to 2020. RESULTS: After adjustment, the median postmenstrual age at discharge increased significantly in Austria (3.6 days, 99% CI [1.0, 6.3]), Italy (4.0 days [2.3, 5.6]), and the USA (5.4 days [5.0, 5.8]). Median discharge weight increased significantly in Austria (181 grams, 99% CI [95, 267]), Ireland (234 [143, 325]), Italy (133 [83, 182]), and the USA (207 [194, 220]). Median discharge weight z-score increased in Ireland (0.24 standard units, 99% CI [0.12, 0.36]) and the USA (0.15 [0.13, 0.16]). Discharge on human milk increased in Italy, Switzerland, and the UK, while going home on cardiorespiratory monitors decreased in Austria, Ireland, and USA and going home on oxygen decreased in Ireland. CONCLUSIONS: In this international cohort of neonatal intensive care units, postmenstrual discharge age and weight increased in some, but not all, countries. Processes of care at discharge did not change in conjunction with age and weight increases.


Assuntos
Doenças do Prematuro , Recém-Nascido Prematuro , Lactente , Humanos , Recém-Nascido , Alta do Paciente , Recém-Nascido de muito Baixo Peso , Idade Gestacional , Unidades de Terapia Intensiva Neonatal
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