Variability in Practice and Implementation of Oxygen Target Saturation Policies in United States' Neonatal Intensive Care Units.

OBJECTIVE: This study aimed to describe target oxygen saturation (SpO2) ranges used for premature infants in United States' neonatal intensive care units (NICUs) and to describe if these target SpO2 ranges have changed in recent years. STUDY DESIGN: A 29-question survey focused on target SpO2 practices and policies was distributed via the NICU medical directors listservs for the American Academy of Pediatrics Section of Neonatal-Perinatal Medicine and Pediatrix Medical Group between August and October of 2021. Results were collected via Research Electronic Data Capture (REDCap). RESULTS: We received responses representing 170 unique, levels 2, 3, and 4 NICUs from 36 states. Most NICUs (130, 78%) have recently changed their SpO2 targets in response to target SpO2 clinical trials. Over time, the most commonly reported target SpO2 range has shifted from 88-92% to 90-95%. Of NICUs that changed limits, the most common lower SpO2 limits increased from 88 to 90% and the upper SpO2 limits changed from 92 to 95%. The interquartile range for lower SpO2 limit shifted from 85-88% to 88-90% and the IQR for upper SpO2 limit decreased from 92-95% to 94-95%. Most NICUs had designated conditions that would allow for deviations from standard target SpO2 ranges. These most commonly include pulmonary hypertension (152, 95%), severe bronchopulmonary dysplasia (81, 51%), and retinopathy of prematurity (51, 32%). CONCLUSION: Oxygen saturation limits have changed over time with an overall increase in targeted SpO2. However, there remains considerable interunit variation in SpO2 policies. There is a need to achieve consensus to optimize clinical outcomes. KEY POINTS: · What are the SpO2 ranges in United States' NICUs?. · There is a shift in SpO2 ranges for preterm infants in NICUs across United States.. · Variability still persists in SpO2 ranges for preterm infants in United States' NICUs..

Sex Differences in Binge-Like and Aversion-Resistant Alcohol Drinking in C57BL/6J Mice.

BACKGROUND: Alcohol use disorder is characterized by compulsive alcohol intake, or drinking despite negative consequences. Previous studies have shown that female rodents have a heightened vulnerability to drug use across different stages of the addictive cycle, but no previous studies have studied females in a model of aversion-resistant alcohol intake. Here, we investigated sex differences in binge-like and aversion-resistant alcohol drinking in C57BL/6J mice using a modified drinking-in-the-dark (DID) paradigm. METHODS: In Experiment 1, 24-hour aversion to quinine (0, 100, or 250 µM) was assessed. In Experiment 2, male and female adult C57BL/6J mice consumed 15% ethanol (EtOH) or water in a 2-bottle limited-access DID paradigm for 2 h/d for 15 days. The EtOH was next adulterated with quinine (0, 100, or 250 µM) over 3 consecutive drinking sessions to test aversion-resistant intake. In Experiment 3, intake of quinine-adulterated (100 µM) EtOH was assessed across all 15 drinking sessions. RESULTS: Quinine was equally aversive to both sexes in Experiment 1. In Experiment 2, female mice consumed significantly more alcohol than male mice during the final 6 drinking sessions. Levels of aversion-resistant intake did not differ between the sexes. In Experiment 3, quinine suppressed consumption in all mice, though females drank significantly more on the final 2 sessions. CONCLUSIONS: The results of this study demonstrate that while female mice escalate and consume more EtOH than males, both sexes exhibit similar levels of aversion-resistant drinking. These results inform our understanding of how sex interacts with vulnerability for addiction and argue for the inclusion of females in more studies of aversion-resistant alcohol drinking.

Improved Outcomes in Preterm Infants Fed a Nonacidified Liquid Human Milk Fortifier: A Prospective Randomized Clinical Trial.

OBJECTIVE: To compare growth, feeding tolerance, and clinical and biochemical evaluations in human milk-fed preterm infants randomized to receive either an acidified or a nonacidified liquid human milk fortifier. STUDY DESIGN: This prospective, controlled, parallel, multicenter growth and tolerance study included 164 preterm infants (≤32 weeks of gestation, birth weight 700-1500 g) who were randomized to acidified or nonacidified liquid human milk fortifier from study day 1, the first day of fortification, through study day 29 or until hospital discharge. RESULTS: There was no difference in the primary outcome of weight gain from study days 1 to 29 (acidified liquid human milk fortifier, 16.4 ± 0.4 g/kg/day; nonacidified liquid human milk fortifier, 16.9 ± 0.4 g/kg/day). However, in both the intention-to-treat and the protocol evaluable analyses, infants fed nonacidified liquid human milk fortifier had significantly greater weight gain from study days 1 to 15 (17.9 g/kg/day vs 15.2 g/kg/day; P = .001). Infants fed with acidified liquid human milk fortifier received more protein (4.26 vs g/kg/day 4.11 g/kg/day, P = .0099) yet had lower blood urea nitrogen values (P = .010). The group fed acidified liquid human milk fortifier had more vomiting (10.3% vs 2.4%; P = .018), gastric residuals (12.8% vs 3.7%; P = .022), and metabolic acidosis (27% vs 5%; P < .001) in the intention-to-treat analysis and more abdominal distension (14.0% vs 1.7%; P = .015) in the protocol evaluable analysis. CONCLUSIONS: Infants fed an acidified liquid human milk fortifier had higher rates of metabolic acidosis and poor feeding tolerance compared with infants fed a nonacidified liquid human milk fortifier. Initial weight gain was poorer with the acidified liquid human milk fortifier. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02307760.

Effect of fluconazole prophylaxis on candidiasis and mortality in premature infants: a randomized clinical trial.

IMPORTANCE: Invasive candidiasis in premature infants causes death and neurodevelopmental impairment. Fluconazole prophylaxis reduces candidiasis, but its effect on mortality and the safety of fluconazole are unknown. OBJECTIVE: To evaluate the efficacy and safety of fluconazole in preventing death or invasive candidiasis in extremely low-birth-weight infants. DESIGN, SETTING, AND PATIENTS: This study was a randomized, blinded, placebo-controlled trial of fluconazole in premature infants. Infants weighing less than 750 g at birth (N = 361) from 32 neonatal intensive care units (NICUs) in the United States were randomly assigned to receive either fluconazole or placebo twice weekly for 42 days. Surviving infants were evaluated at 18 to 22 months corrected age for neurodevelopmental outcomes. The study was conducted between November 2008 and February 2013. INTERVENTIONS: Fluconazole (6 mg/kg of body weight) or placebo. MAIN OUTCOMES AND MEASURES: The primary end point was a composite of death or definite or probable invasive candidiasis prior to study day 49 (1 week after completion of study drug). Secondary and safety outcomes included invasive candidiasis, liver function, bacterial infection, length of stay, intracranial hemorrhage, periventricular leukomalacia, chronic lung disease, patent ductus arteriosus requiring surgery, retinopathy of prematurity requiring surgery, necrotizing enterocolitis, spontaneous intestinal perforation, and neurodevelopmental outcomes-defined as a Bayley-III cognition composite score of less than 70, blindness, deafness, or cerebral palsy at 18 to 22 months corrected age. RESULTS: Among infants receiving fluconazole, the composite primary end point of death or invasive candidiasis was 16% (95% CI, 11%-22%) vs 21% in the placebo group (95% CI, 15%-28%; odds ratio, 0.73 [95% CI, 0.43-1.23]; P = .24; treatment difference, -5% [95% CI, -13% to 3%]). Invasive candidiasis occurred less frequently in the fluconazole group (3% [95% CI, 1%-6%]) vs the placebo group (9% [95% CI, 5%-14%]; P = .02; treatment difference, -6% [95% CI, -11% to -1%]). The cumulative incidences of other secondary outcomes were not statistically different between groups. Neurodevelopmental impairment did not differ between the groups (fluconazole, 31% [95% CI, 21%-41%] vs placebo, 27% [95% CI, 18%-37%]; P = .60; treatment difference, 4% [95% CI, -10% to 17%]). CONCLUSIONS AND RELEVANCE: Among infants with a birth weight of less than 750 g, 42 days of fluconazole prophylaxis compared with placebo did not result in a lower incidence of the composite of death or invasive candidiasis. These findings do not support the universal use of prophylactic fluconazole in extremely low-birth-weight infants. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00734539.

Couplet Care-The Next Frontier of Care in the Newborn Intensive Care Unit.

Couplet care of mother and newborn intensive care unit (NICU) baby in the same room is a new, rapidly evolving option for the care of NICU babies. This change has structural and operational challenges that require careful planning but its successful implementation is likely to drive enhanced family participation in the care of their baby throughout the NICU stay as well as improve collaboration between obstetric and neonatal providers.

Acoustic Doppler velocity measurement system using capacitive micromachined ultrasound transducer array technology.

This paper describes the design, fabrication, modeling, and characterization of a small (1 cm(2) transducer chip) acoustic Doppler velocity measurement system using microelectromechanical systems capacitive micromachined ultrasound transducer (cMUT) array technology. The cMUT sensor has a 185 kHz resonant frequency to achieve a 13° beam width for a 1 cm aperture. A model for the cMUT and the acoustic system which includes electrical, mechanical, and acoustic components is provided. Furthermore, this paper shows characterization of the cMUT sensor with a variety of testing procedures including Laser Doppler Vibrometry (LDV), beampattern measurement, reflection testing, and velocity testing. LDV measurements demonstrate that the membrane displacement at the center point is 0.4 nm/V(2) at 185 kHz. The maximum range of the sensor is 60 cm (30 cm out and 30 cm back). A velocity sled was constructed and used to demonstrate measureable Doppler shifts at velocities from 0.2 to 1.0 m/s. The Doppler shifts agree well with the expected frequency shifts over this range.

A pivotal moment in the evolution of neonatal care.

While extraordinary advances have been made in the medical care of critically ill newborns, understanding the need of even the smallest of these infants for early, extensive, intimate human contact and facilitating the family's role in the care of their baby has been much slower and inconsistent. There is abundant evidence for the essential role of nurturing parent-infant connections (bonding/attachment) for development of optimal physical, cognitive, and emotional health of all babies. It is time to leave behind the tradition of sensory deprivation and social isolation common in the care of high-risk infants. A paradigm shift is needed in neonatal care to acknowledge the critical importance of infant and family-centered developmental care and to remove any remaining constraints on a family's ability to become full partners in the nurture of their NICU newborn.

Reimagining the NICU: a human-centered design approach to healthcare innovation.

Design charettes have been utilized in architectural and design practice to generate innovative ideas. The Reimagining Workshop is a version that combines practical and blue-sky thinking to improve healthcare facility design. The workshop engages diverse stakeholders who follow a human-centered design framework. The Reimagining the Neonatal Intensive Care Unit workshop sought to generate ideas for the future, optimal NICU without specific site or client constraints. Key themes include family-centered care, technology-enabled care, neighborhood and village design and investing in the care team. Recommendations include a supportive physical environment, celebrating milestones, complementary and alternative medicine, enhancing the transition of care, aiding the transition period, and leveraging technology. The workshop showcased the potential for transformative change in NICU design and provided a roadmap for future advancements. These findings can inform regulatory standards for NICU design and drive improvements in family-centered care, patient experiences, and outcomes within the NICU environment.

Single-Family Room Design in the Neonatal Intensive Care Unit-Challenges and Opportunities.

The trend toward single-family room (SFR) design in the neonatal intensive care unit (NICU) has been driven by a growing understanding of the developmental needs of preterm infants, a desire to provide environments that support and encourage family participation, and infection control considerations. SFR design offers many potential benefits, but also requires substantial change in the NICU culture, as well as additional space and technology when compared to an open ward. The advantages and drawbacks of the SFR design are reviewed, and strategies are offered to assist those who are considering construction or renovation of an NICU.

Recommended standards for newborn ICU design, 9th edition.

The environment of care has a lasting impact on the patients, families, and caregivers who experience it. A newborn intensive care unit (NICU) is typically in use for 10-30 years, over which time decisions made during its design will have human and financial impacts far beyond the initial cost. Good planning is crucial, yet most participants in the planning process have little experience designing a NICU and may be driven as much by what they do not like in their existing NICU as by the evidence and experience reported by others. Standards generated by a group of experts in multiple disciplines can inform these planners, as well as the agencies developing building codes for NICUs. Now in its ninth iteration, these Recommended Standards continue to be refined as new evidence and experience accumulates, along with new guidance for couplet care in the NICU and for detection of latent safety risks prior to occupancy.

Impact of restrictions on parental presence in neonatal intensive care units related to coronavirus disease 2019.

OBJECTIVES: To determine the relationship between the emergence of COVID-19 and neonatal intensive care unit (NICU) family presence as well as how NICU design affects these changes. STUDY DESIGN: A cross-sectional survey from April 21 to 30, 2020. We queried sites regarding NICU demographics, NICU restrictions on parental presence, and changes in ancillary staff availability. RESULTS: Globally, 277 facilities responded to the survey. NICU policies preserving 24/7 parental presence decreased (83-53%, p < 0.001) and of preserving full parental participation in rounds fell (71-32%, p < 0.001). Single-family room design NICUs best preserved 24/7 parental presence after the emergence of COVID-19 (single-family room 65%, hybrid-design 57%, open bay design 45%, p = 0.018). In all, 120 (43%) NICUs reported reductions in therapy services, lactation medicine, and/or social work support. CONCLUSIONS: Hospital restrictions have significantly limited parental presence for NICU admitted infants, although single-family room design may attenuate this effect.

Orthotropic material properties of the gerbil basilar membrane.

In this paper, two sets of experimental results to extract the two effective elastic moduli, the effective shear modulus, and the effective Poisson's ratio for the gerbil cochlear partition are analyzed. In order to accomplish this, a geometrically nonlinear composite orthotropic plate model is employed. The model is used to predict both out-of-plane and in-plane motion of the partition under a static finite area distributed load. This loading condition models the small, but finite size, probe tips used in experiments. Both in-plane and out-of-plane motion are needed for comparison with recent experimental results. It is shown that the spatial decay rate (the space constant) for the in-plane deflection is different than for the out-of-plane deflection, which has a significant effect on the derived partition properties. The size of the probe tip is shown to have little influence on the results. Results are presented for two types of boundary conditions. Orthotropy ratios determined from the experimental data are found to vary with longitudinal position and choice of boundary conditions. Orthotropy ratios (the ratio of the two elastic moduli) are in the range of 65 close to the base to 10 in the upper middle turn of the cochlea.

Three Dimensional Viscous Finite Element Formulation For Acoustic Fluid Structure Interaction.

A three dimensional viscous finite element model is presented in this paper for the analysis of the acoustic fluid structure interaction systems including, but not limited to, the cochlear-based transducers. The model consists of a three dimensional viscous acoustic fluid medium interacting with a two dimensional flat structure domain. The fluid field is governed by the linearized Navier-Stokes equation with the fluid displacements and the pressure chosen as independent variables. The mixed displacement/pressure based formulation is used in the fluid field in order to alleviate the locking in the nearly incompressible fluid. The structure is modeled as a Mindlin plate with or without residual stress. The Hinton-Huang's 9-noded Lagrangian plate element is chosen in order to be compatible with 27/4 u/p fluid elements. The results from the full 3d FEM model are in good agreement with experimental results and other FEM results including Beltman's thin film viscoacoustic element [2] and two and half dimensional inviscid elements [21]. Although it is computationally expensive, it provides a benchmark solution for other numerical models or approximations to compare to besides experiments and it is capable of modeling any irregular geometries and material properties while other numerical models may not be applicable.

The impact of altitude on screening for critical congenital heart disease.

OBJECTIVES: The objectives were to determine the frequency with which pulse oximetry identifies critical congenital heart defects in asymptomatic full-term and late preterm newborns using the AAP expert panel algorithm in a variety of different hospital settings and to evaluate the impact of altitude on the rate of positive screens. METHODS: We conducted a prospective clinical study of implementation of a newborn pulse oximetry screening for congenital heart disease in 34 independent hospitals. Infants were eligible for enrollment if their gestational age was 35-44 weeks. RESULTS: Of the 34 sites which enrolled infants into our study, 24 were located at or below 2000 feet; 5 were located between 4700 and 6000 feet and 5 were located above 6000 feet in altitude. We screened 6109 infants; 65 (1.1%) had a positive screen. There were no differences in median gestational age, birth weight, mode of delivery or race/ethnicity for infants with a positive screen compared to infants with a negative screen. Infants with positive screens were more often male and more often born at sites located at high altitudes. The frequency of a positive screen increased from 0.2% for infants born at sites at or less than 2000 feet to 6% for sites located above 6000 feet. We stopped enrollment at the site located at 8163 feet after enrolling 65 infants because 23 (35%) were positive. CONCLUSIONS: Screening infants for critical cardiac defects at altitude is complicated by the increased false positive screens.