Cost Comparison of a Traditional Didactic versus National Flipped Classroom Curriculum.

OBJECTIVE: We compared the cost of faculty time preparing educational materials for traditional didactic (TD) education provided at local institutions with that of faculty time preparing National Neonatology Curriculum (NNC) flipped classroom (FC) educational materials shared among institutions for fellow education across the United States. STUDY DESIGN: Using survey data and the national average for faculty educators' salaries, we calculated the cost of developing TD versus FC materials. Wilcoxon rank-sum test and comparison of two Poisson rates were utilized to evaluate the time to create versus update TD materials and the cost to create new TD versus FC materials, respectively. RESULTS: FC materials required more time to develop than TD materials (FC, median 17 h, interquartile range [IQR]: 17; TD, median, 5 h, IQR: 5; p < 0.001). However, when the size of individual fellowship programs was factored into the cost analysis, FC materials shared nationally among programs resulted in a 19- to 72-fold cost savings when compared to the creation of new locally used TD materials (FC, $2.49 per fellow; TD $32.05-576.90 per fellow at very large-to-small fellowship programs; p < 0.001). CONCLUSION: Educational materials developed and disseminated to fellowship programs across the country confer significant savings in faculty educator time and cost per learner. Standardized programs such as the NNC may serve as a model to develop shared peer-reviewed educational resources for other specialties. KEY POINTS: · Educational materials developed for national use confer time and cost savings.. · Small fellowships benefit greatly from having access to shared resources.. · Shared, peer-reviewed resources promote equity in education.. · Shared resources can free faculty time to focus on other academic interests..

Best Practices and Educator Strategies for Facilitating a Flipped Classroom in Graduate Medical Education.

OBJECTIVE: Effective flipped classroom (FC) education fosters learner engagement, promoting higher-level cognitive skills. FC learning in graduate medical education (GME) has increased, but few educators have significant experience with FC facilitation. There are no evidence-based practices to support professional development of FC facilitation skills in GME. The objective of this study is to identify best practices for effective FC facilitation in GME. STUDY DESIGN: We conducted a mixed-methods, cross-sectional study of faculty educators who participated in a randomized controlled trial (RCT) using FC for physiology education in neonatal-perinatal medicine. Educators completed a 25-question survey about effective strategies for FC facilitation. A subset of educators participated in interviews to share their FC facilitation experiences and strategies to maximize learner engagement. Quantitative survey data were analyzed with descriptive statistics. Qualitative survey and interview data were coded and analyzed inductively to identify themes. RESULTS: Seventy-five educators completed the survey (75/136, 55% response rate), and 11 participated in semistructured interviews. While educators facilitated a median of two FC sessions (interquartile range: 1, 5) during the RCT, 43 (57%) had not received prior training in FC facilitation. Qualitative data analyses generated five themes that aligned with quantitative survey results: (1) educator preferences, (2) unique FC facilitation skills, (3) learning environment optimization, (4) subject matter expertise, and (5) learner behavior management. Sixty-two educators (83%) felt they were well prepared to lead FC sessions. Thirty-six educators (48%) reported that unprepared learners disrupt the learning environment, and the provision of clear expectations and adequate time to prepare for FCs improves learner preparation. Strategies to facilitate effective FC sessions included creating a safe learning environment and engaging learners in critical thinking. CONCLUSION: Educators highlighted faculty development needs, strategies, and actions to promote effective FC facilitation. Further exploration through learner interviews will provide additional evidence for the development of best practices and resources for FC facilitation. KEY POINTS: · Educators prefer the FC educational modality over traditional didactic lectures.. · Prior experiences in simulation debriefing provide foundational skills for new FC facilitators.. · Setting learner expectations and ensuring safe space in the classroom encourage learner engagement.. · Educator and learner preparation for FC is essential to optimize the learning experience.. · Unique approaches in facilitation are required to support all types of learners..

The Changing Landscape in Pediatric Hospitals: A Multicenter Study of How Pediatric Chronic Critical Illness Impacts NICU Throughput.

OBJECTIVE: Pediatric inpatient bed availability is increasingly constrained by the prolonged hospitalizations of children with medical complexity. The sickest of these patients are chronic critically ill and often have protracted intensive care unit (ICU) stays. Numbers and characteristics of infants with chronic critical illness are unclear, which undermines resource planning in ICU's and general pediatric wards. The goal of this study was to describe infants with chronic critical illness at six academic institutions in the United States. STUDY DESIGN: Infants admitted to six academic medical centers were screened for chronic, critical illness based on a combination of prolonged and repeated hospitalizations, use of medical technology, and chronic multiorgan involvement. Data regarding patient and hospitalization characteristics were collected. RESULTS: Just over one-third (34.8%) of pediatric inpatients across the six centers who met eligibility criteria for chronic critical illness were <12 months of age. Almost all these infants received medical technology (97.8%) and had multiorgan involvement (94.8%). Eighty-six percent (115/134) had spent time in an ICU during the current hospitalization; 31% were currently in a neonatal ICU, 34% in a pediatric ICU, and 17% in a cardiac ICU. Among infants who had been previously discharged home (n = 55), most had been discharged with medical technology (78.2%) and nearly all were still using that technology during the current readmission. Additional technologies were commonly added during the current hospitalization. CONCLUSION: Advanced strategies are needed to plan for hospital resource allocation for infants with chronic critical illness. These infants' prolonged hospitalizations begin in the neonatal ICU but often transition to other ICUs and general inpatient wards. They are commonly discharged with medical technology which is rarely weaned but often escalated during subsequent hospitalizations. Identification and tracking of these infants, beginning in the neonatal ICU, will help hospitals anticipate and strategize for inpatient bed management. KEY POINTS: · 35% of inpatients with chronic critical illness are infants.. · Nearly 90% of these infants spend some time in an intensive care unit.. · 78% are discharged with medical technology..

Flipping the Teachers: Impact of a Standardized Physiology Curriculum on Neonatology Medical Educators.

OBJECTIVE: Academic physicians must teach elements in an Accreditation Council for Graduate Medical Education (ACGME)-mandated curriculum while balancing career development and clinical workload. Exploring educator perceptions on the learning environment and comparing two instructional methods (traditional didactics [TD] vs. flipped classroom [FC]) in one pediatric subspecialty may elucidate current challenges, barriers, and strategies to optimize learning and educator satisfaction. STUDY DESIGN: A randomized trial comparing effectiveness and learner preference for FC versus TD physiology teaching was conducted in ACGME-accredited neonatal-perinatal medicine (NPM) fellowship programs in 2018 to 2019. Educator preferences were elicited through online surveys pre- and postintervention. Free-text comments were provided for questions exploring strengths, challenges, and opportunities in fellowship education. Statistical analysis included comparisons of demographics and pre-post-intervention educator responses between groups. Thematic analysis of text responses was conducted to identify common subthemes. RESULTS: From 61 participating programs, 114 FC educators and 130 TD educators completed surveys. At baseline, all educators experienced professional satisfaction from teaching fellows, but noted challenges with time available to create and/or deliver educational content, limited content expertise amongst faculty, colleagues' limited enthusiasm toward educating fellows, and lack of perceived value of education by institutions given limited protected time or credit toward promotion. Postintervention, educators in both groups noted a preference to teach physiology using FC due to interactivity, learner enthusiasm, and learner-centeredness. FC educators had a 17% increase in preference to teach using FC (p = 0.001). Challenges with FC included ensuring adequate trainee preparation, protecting educational time, and providing educators with opportunities to develop facilitation skills. CONCLUSION: Overall, NPM educators in a trial evaluating a standardized, peer-reviewed curriculum report professional satisfaction from teaching, but described logistical challenges with developing/delivering content. Educators preferred instruction using FC, but identified challenges with learner preparedness and ensuring adequate educator time and skill. Future efforts should be dedicated to addressing these barriers. KEY POINTS: · Many challenges exist for educators teaching neonatal-perinatal medicine fellows, including time, support, and recognition.. · Many educators preferred using flipped classroom methodology with a standardized curriculum due to interactivity and learner-centeredness.. · Benefits of a standardized, peer-reviewed curriculum include reduced preparation time, adaptability of content, and learning environment enhancement..

Value, Strengths, and Challenges of e-Learning Modules Paired with the Flipped Classroom for Graduate Medical Education: A Survey from the National Neonatology Curriculum.

OBJECTIVE: This study aimed to determine the value, strengths, and challenges of implementing an e-learning based flipped classroom (FC) educational modality as part of the standardized physiology National Neonatology Curriculum (NNC), created for neonatal-perinatal medicine (NPM) fellow learners and faculty educators. STUDY DESIGN: This is a cross-sectional study of NPM fellows and faculty educators who utilized at least one of the e-learning based NNC FC respiratory physiology programs between May and September 2018. Participants were surveyed anonymously regarding their experiences participating in the NNC, including measures of preparation time. A combination of descriptive statistics and proportion comparisons were used for data analysis. RESULTS: Among 172 respondents, the majority of fellow and faculty respondents reported positive attitudes toward the educational content and case discussions, and the majority supported national standardization of NPM physiology education (92%). Fellows reported greater preclass preparation for their FC compared with previous didactic lectures (30-60 vs. 0-15 minutes, p < 0.01). Faculty facilitators reported less preparation time before facilitating a FC compared with the time required for creating a new didactic lecture (median: 60 vs. 240 minutes, p < 0.01). Both fellows and faculty respondents preferred the FC approach to traditional didactics, with fellows showing a greater degree of preference than faculty (68 vs. 52%, respectively, p = 0.04). CONCLUSION: Fellows and faculty educators supported the FC learning, reporting peer-to-peer learning, and the establishment of a learning community which promotes adult learning and critical thinking skills. A national physiology curriculum creates equitable and engaging educational experiences for all NPM fellows while reducing individual program burden of content creation. Our findings further supported the development of an NNC using a flipped classroom modality.

Mercury, lead, and cadmium exposure via red blood cell transfusions in preterm infants.

BACKGROUND: Mercury, lead, and cadmium are developmental neurotoxicants. We predict that preterm newborns requiring packed red blood cell (PRBC) transfusions may be exposed to neurotoxic doses. We explored the relationship between donor concentration, number of donors, number of transfusions and mercury, lead and cadmium exposure. METHODS: Single-donor PRBCs were analyzed for mercury, lead and cadmium concentration. Dose per transfusion was calculated and compared to intravenous reference doses (IVRfDs). Linear regression analyses were performed to correlate donor and infant exposure. RESULTS: Thirty-six infants received 268 transfusions from 94 donors. Number of donors and transfusions were significantly correlated with birthweight and gestational age. All three metals were detected in ≥95% of donor PRBCs. Number of donors was significantly associated with cumulative dose, and there was a significant correlation between mercury and lead doses/transfusion. IVRfDs were exceeded for mercury and lead in 8.6% and 38% of transfusions, respectively. None exceeded the IVRfD for cadmium. For lead, infants exposed to three donors had more transfusions exceeding IVRfD than those exposed to 1-2 donors. CONCLUSIONS: Preterm infants are exposed to heavy metals via transfusions. Doses exceeded the IVRfDs for mercury and lead. Cadmium did not pose a risk. Prescreening donor blood could reduce exposure risk.

Patient and provider factors impacting referral for neonatal organ donation.

BACKGROUND: As determination of brain death is infrequent in neonates, the AAP endorses donation after circulatory determination of death as an acceptable alternative. Despite this recommendation, neonatal organ donation is infrequent. Timely referral to OPOs is a vital first step in the organ donation process. The aim of this study was to identify patient and provider factors impacting timely referral for neonatal organ donation. METHODS: Medical records were reviewed for deaths occurring in a Level IV NICU from 2007 to 2017. Clinical and demographic factors, provider type, timing of OPO referral (before or after death), and outcome were assessed. Bivariate and multivariable logistic regression models were utilized to identify predictors of OPO referral characteristics. RESULTS: Between 2007 and 2017, 329 deaths occurred in the NICU or delivery room. Of the 265 infants meeting inclusion criteria, 96% had late referrals (after death) and were declined for organ donation. Frequency of timely referrals (before death) improved when OPO contact was by an attending neonatologist, when withdrawal of life support was planned, and with increasing birthweight, gestational age, and PMA. Factors associated with decreased OPO referral included male sex, lower weight at death, earlier PMA, and deaths occurring while receiving maximal intensive care support. No organs or tissues were donated. CONCLUSIONS: This study is the first to report NICU referral patterns for organ donation. We found that timely provider referral of neonates to the OPO was rare. Exploration of provider knowledge will guide future educational interventions aimed to improve the referral process.

Fetal exposure to mercury and lead from intrauterine blood transfusions.

BACKGROUND: Mercury (Hg) and lead (Pb) exposure during childhood is associated with irreversible neurodevelopmental effects. Fetal exposure to Hg and Pb from intrauterine blood transfusion (IUBT) has not been reported. METHODS: Fetal exposure was estimated based on transfusion volume and metal concentration in donor packed red blood cell (PRBCs). As biomarkers to quantify prenatal exposure are unknown, Hg and Pb in donor PRBCs were compared to estimated intravenous (IV) RfDs based on gastrointestinal absorption. RESULTS: Three pregnant women received 8 single-donor IUBTs with volumes ranging from 19 to 120 mL/kg. Hg and Pb were present in all donor PRBC units. In all, 1/8 IUBT resulted in Hg dose five times higher than the estimated IV RfD. Median Pb dose in one fetus who received 5 single-donor IUBTs between 20-32 weeks gestation was 3.4 µg/kg (range 0.5-7.9 µg/kg). One donor unit contained 12.9 µg/dL of Pb, resulting in a fetal dose of 7.9 µg/kg, 40 times higher than the estimated IV RfD at 20 weeks gestation. CONCLUSION: This is the first study documenting inadvertent exposure to Hg and Pb from IUBT and quantifying the magnitude of exposure. Screening of donor blood is warranted to prevent toxic effects from Hg and Pb to the developing fetus.

Supports and Barriers to the Provision of Human Milk by Mothers of African American Preterm Infants.

BACKGROUND: Mother's own milk (MOM) provides significant health benefits to very low birth-weight infants (VLBW, ≤1500 g). However, 60% of African American (AA) women initiate lactation, and less than 35% provide MOM 6 months following the birth of their infant. Previous research focuses on term infants and is not specific to AA mothers of VLBW infants. PURPOSE: To qualitatively describe supports and barriers experienced by AA mothers while providing MOM for their VLBW infants. METHODS: In this qualitative, descriptive study, we conducted semistructured interviews with AA mothers who provided MOM for their VLBW infant. Interviews were transcribed and manually coded concurrently with enrollment until theoretical saturation was achieved. Infant charts were reviewed for demographics, and triangulation with notes from the medical record by bedside nurse lactation consultants and other providers was performed to increase validity. Member checks were completed to ensure true meaning of responses. RESULTS: Theoretical saturation was achieved after 9 interviews. Themes perceived to support provision of MOM included (1) Being a Mother; (2) Neonatal intensive care unit environment; (3) Community support; and (4) Useful resources. Themes that emerged as barriers to the provision of MOM were: (1) Maternal illness; (2) Milk expression; (3) Challenging home environment; and (4) Emotional distress. IMPLICATIONS FOR PRACTICE: African American mothers report supports similar to published data but faced challenges not previously reported. These factors warrant attention by professionals who support lactation in this population. IMPLICATIONS FOR RESEARCH: Future research will address perceived barriers to improve provision of MOM and the quality of the lactation journey of AA mothers of preterm infants.

Perceptions of Palliative Care in the NICU.

BACKGROUND AND PURPOSE: The American Academy of Pediatrics supports palliative care (PC) for all children with life-threatening illnesses. Thus, many neonatal intensive care unit (NICU) patients and their families could benefit from PC. Our study objective was to examine provision of PC as experienced by mothers and healthcare providers (HCPs) of NICU patients with life-threatening illnesses. Palliative care components explored included communication, choices, comfort, psychosocial and spiritual needs, and coordination of care. METHODS: In this qualitative, descriptive study, we conducted semistructured interviews with mothers of infants with life-threatening illnesses and NICU HCPs who cared for these infants. Mothers selected HCPs who were key figures during their infant's NICU stay to participate. Interviews were transcribed and manually coded until themes emerged and theoretical saturation was achieved. Researchers reviewed charts for demographics and notes pertaining to PC. Triangulation of maternal interviews, HCP interviews, and chart notes was performed. RESULTS: Theoretical saturation was achieved after 12 interviews. Mothers identified 5 nurses and 1 physician to be interviewed. Five themes were identified following data analysis and triangulation: (1) communication, (2) privacy, (3) continuity of care and relationship building, (4) maternal knowledge seeking, and (5) emotional turmoil. IMPLICATIONS FOR PRACTICE AND RESEARCH: Of domains of pediatric PC explored, participants emphasized transparent communication, family meetings as a venue for collaboration and shared decision making, the significance of psychosocial support for maternal emotional distress, and the importance of continuity of care across an often long and stressful hospitalization. Although mothers desired privacy, participants valued the security of the open-room NICU design. Future research should address components of PC that predominate in this specialized population.

Essentials of Neonatal-Perinatal Medicine fellowship: part 2 - clinical education and experience.

This is the second article in a seven-part series in the Journal of Perinatology that aims to critically examine the current state of Neonatal-Perinatal Medicine (NPM) fellowship training from the structure and administration of a program, to the clinical and scholarly requirements, and finally to the innovations and future careers awaiting successful graduates. This article focuses on the current clinical requirements; recent changes to the clinical environment and their effect on learning; and additional challenges and opportunities in clinical education.

Comparison of knowledge acquisition and retention following traditional didactic vs. flipped classroom education utilizing a standardized national curriculum: a randomized controlled trial.

OBJECTIVE: Measure the effectiveness of and preference for a standardized, national curriculum utilizing flipped classrooms (FC) in neonatal-perinatal medicine (NPM) fellowships. STUDY DESIGN: Multicentered equivalence, cluster randomized controlled trial of NPM fellowship programs randomized to receive standardized physiology education as in-class lectures (traditional didactic, TD arm) or as pre-class online videos followed by in-class discussions (FC arm). Four multiple-choice question quizzes and three surveys were administered to measure knowledge acquisition, retention, and educational preferences. RESULTS: 530 fellows from 61 NPM fellowships participated. Quiz performance was comparable between groups at all time points (p = NS, TD vs FC at 4 time points). Post intervention, more fellows in both groups preferred group discussions (pre/post FC 42% vs. 58%, P = 0.002; pre/post TD 43% vs. 60%, P = < 0.001). FC fellows were more likely to rate classroom effectiveness positively (FC/TD, 70% vs. 36%, P < 0.001). CONCLUSIONS: FCs promote knowledge acquisition and retention equivalent to TD and FC modalities are preferred by fellows.

Early changes in plasma amino acid concentrations during aggressive nutritional therapy in extremely low birth weight infants.

OBJECTIVE: To examine the changes in plasma amino acid (AA) concentrations over time when extremely low birth weight infants are provided either a standard intravenous AA supplementation (standard AA) or an early and high supplementation regimen (early and high AA). STUDY DESIGN: Sixty-two infants were enrolled at birth in a randomized, double-masked, prospective fashion and treated for 7 days. The infants with standard AA concentrations received intravenous AA starting at 0.5 g/kg/d and increased by 0.5 g/kg every day to a maximum of 3 g/kg/d. Infants in the early and high AA group received 2 g/kg/d of intravenous AA soon after birth and advanced by 1 g/kg every day to 4 g/kg/d. Plasma AA concentrations were determined by high-pressure liquid chromatography on days 1, 3, and 7. RESULTS: Total AA concentrations, total essential AA concentrations, and total nonessential AA concentrations were significantly higher in the infants in the early and high AA group; essential AA concentrations and total AA concentrations were higher at 1 and 3 days, and nonessential AA concentrations were different only on day 3. There were significant differences between standard AA and early and high AA groups for all AA concentrations except the nonessential AAs Glu, Asn, Gly, Gln, Ala, and Tyr and the conditionally essential AA Cys. CONCLUSION: Infants who received early and higher parenteral AA had higher plasma AA concentrations.

Disagreement About Surgical Intervention in Trisomy 18.

In this case, we explore physician conflict with performing surgery (tracheostomy) for long-term ventilation in a term infant with trisomy 18 and respiratory failure. Experts in neonatal-perinatal medicine, pediatric bioethics, and pediatric palliative care have provided comments on this case. An additional commentary was written by the parent of another infant with trisomy 18, who is also a medical provider (physical therapist).

Protein kinase A and mitogen-activated protein kinase pathways mediate cAMP induction of alpha-epithelial Na+ channels (alpha-ENaC).

A major mechanism for Na+ transport across epithelia occurs through epithelial Na+ channels (ENaC). ENaC is a multimeric channel consisting of three subunits (alpha, beta, and gamma). The alpha-subunit is critical for ENaC function. In specific culture conditions, the rat submandibular gland epithelial cell line (SMG-C6) demonstrates minimal Na+ transport properties and exposure to dibutyryl cAMP (DbcAMP) for up to 48 h caused an elevation of alpha-ENaC mRNA and protein expression and amiloride-sensitive short-circuit current (I(SC)). Here we examined the early signaling pathways evoked by DbcAMP which contribute to the eventual increase in Na+ transport is present. Treatment with either of the protein kinase A (PKA) inhibitors KT5720 or H-89 followed by exposure to 1 mM DbcAMP for 24 h markedly attenuated DbcAMP-induced alpha-ENaC protein formation and I(SC). Exposure of SMG-C6 cells to 1 mM DbcAMP induced a rapid, transient phosphorylation of the cAMP response element binding protein (CREB). This response was attenuated in the presence of either KT5720 or H-89. Dominant-negative CREB decreased DbcAMP-induced alpha-ENaC expression. Suppression of the extracellular signal-regulated protein kinase (ERK 1,2) with PD98059 or the p38 mitogen-activated protein kinase (MAPK) pathway with SB203580 reduced DbcAMP-induced alpha-ENaC protein levels in SMG-C6 cells. DbcAMP-induced phosphorylation of CREB was markedly attenuated by PD98059 or SB203580. DbcAMP-induced activation of the either the p38 or the ERK 1,2 MAPK pathways was abolished by either of the PKA inhibitors, H-89 or KT5720. Cross talk between these signaling pathways induced by DbcAMP via the activation of CREB appears to contribute to increased levels of alpha-ENaC observed after 24 h of treatment in SMG-C6 epithelial cells.

Metabolic responses to early and high protein supplementation in a randomized trial evaluating the prevention of hyperkalemia in extremely low birth weight infants.

OBJECTIVE: To determine whether early and higher intravenous amino acid (EHAA) supplementation decreases hyperkalemia in extremely low birth weight (ELBW) infants (<1000 g). STUDY DESIGN: Infants were enrolled at birth in a randomized, double-masked, prospective fashion and treated for 7 days. The standard group (SAA) infants received intravenous amino acid (AA) starting at 0.5 g x kg(-1) x d(-1) and increased by 0.5 g x kg(-1) every day to a maximum of 3 g x kg(-1) x d(-1). EHAA group infants received 2 g x kg(-1) x d(-1) of AA soon after birth and advanced by 1 g x kg(-1) every day to 4 g x kg(-1) x d(-1). Data analysis was by SPSS 11.5, with statistical significance at alpha = 0.05 and 90% power to determine a difference in mean K(+) level of 2. RESULTS: Sixty-two patients, mean gestational age of 26.0 +/- 2.0 weeks and birth weight of 775 +/- 136 g, were enrolled. Hyperkalemia (K(+) > or =6.5 mEq/L) occurred in 13% of the studied population; no difference in incidence of hyperkalemia was found between the SAA and EHAA groups (16% vs 10%, respectively, P = .70). Serum blood urea nitrogen was higher in the EHAA group. AA infusion was stopped early in 6 patients for high blood urea nitrogen or elevated ammonia level. CONCLUSIONS: During the study period, hyperkalemia decreased significantly and was not affected by EHAA supplementation in the first week of life.

Flipping the classroom: a national pilot curriculum for physiology in neonatal-perinatal medicine.

OBJECTIVE: To explore interest, feasibility, perceived effectiveness, and acceptability of a standardized, national physiology curriculum for neonatal-perinatal medicine (NPM) fellows using online videos for knowledge acquisition paired with flipped classrooms (FCs) for knowledge application. STUDY DESIGN: Two educational programs pairing online videos with FCs were developed and peer-reviewed. These programs were piloted at five institutions. Fellows completed surveys, and fellows and educators participated in focus groups after their FC experiences. RESULTS: Thirty-five fellows responded to the survey. Forty-one fellows and six educators participated in focus groups. Fellows and educators preferred online videos paired with FCs over didactic teaching and perceived them to be effective for knowledge acquisition and application. CONCLUSION: Fellows and educators preferred FC learning over traditional didactics and reported that FCs facilitated creation of a learning community, fostering active learning. The favorable response toward this pilot project and the feasibility of its use supports further development of a standardized NPM physiology curriculum for fellowship training.