Hemodynamic assessment by neonatologist using echocardiography: Primary provider versus consultation model.

Hemodynamic instability is very common in sick neonates and the currently used traditional hemodynamic monitoring tools lack sensitivity and specificity. Hemodynamic evaluation on echocardiography can provide direct information regarding the pathophysiology causing the hemodynamic instability and help the bedside clinician in making a personalized treatment approach based upon the deranged pathophysiology. Assessment of cardiac function and hemodynamics is essential in the management of neonates with cardiorespiratory failure, and hence neonatologist-performed echocardiography is becoming an essential tool in modern neonatal care. Depending on the level and size of the NICU, there is a daily need for echocardiography, and for a subset of sick infants, serial echocardiographic assessments are warranted. Comprehensive guidelines for neonatologists performing echocardiography and targeted neonatal echocardiography have been published providing a framework for training and quality assurance. There has been a significant interest among the providers to learn echocardiography skills. This manuscript explores the various needs of neonatal care providers around echocardiography, the current challenges neonatologists face in learning echocardiography, and how they, especially neonatal fellows, can learn these important skills during their training.

Economic and Clinical Impact of Using Human Milk-Derived Fortifier in Very Low Birth Weight Infants.

Background: Implementation of exclusive human milk (EHM) feeding defined as mother's own milk or donor human milk fortified with human milk-derived fortifiers can place an economic burden on institutions. Methods: Retrospective study of very low birth weight (VLBW) infants before and after the implementation of EHM feedings. Neonatal demographics and clinical outcomes including necrotizing enterocolitis, severe retinopathy of prematurity, bronchopulmonary dysplasia, late-onset sepsis, days on parenteral nutrition (PN), and length-of-stay were collected. The net cost to the institution was estimated using published data. Results: Sixty-four infants in the pre-EHM period and 57 infants in the post-EHM period were enrolled. Net product acquisition cost in 2020 and 2021 was $884,823. The EHM feeding guideline led to a reduction in the mean length of stay and mean days of PN use by 6.3 and 6.8 days per infant, respectively. This led to a cost saving of $1,813,444 ($31,815 per infant). No significant difference in incidence of short-term morbidities was observed. Combining the cost avoidance from clinical outcomes, the estimated financial impact over 2 years excluding insurance reimbursement was an estimated $ 913,840 ($16,032 per infant). Conclusion: Implementation of EHM-based feeding in VLBW infants is a cost-effective option for neonatal intensive care units that can result in reduced length of stay and days on PN without adversely impacting short-term morbidities.

Resource utilization patterns using non-invasive ventilation in neonates with respiratory distress syndrome.

OBJECTIVES: To describe the frequency of non-invasive ventilation (NIV) and endotracheal intubation use in neonates diagnosed with respiratory distress syndrome (RDS); to describe resources utilization (length of stay (LOS), charges, costs) among NIV and intubated RDS groups. STUDY DESIGN: Retrospective study from the national Kid's Inpatient Database of the Healthcare Cost and Utilization Project, for the years 1997-2012. Propensity scoring and multivariate regression analysis used to describe differences. RESULTS: A total of 595,254 out of 42,912,090 cases were identified with RDS. There was an increase in NIV use from 6% in 1997 to 17% in 2012. After matching, patients receiving NIV only were associated with shorter LOS: (95%CI) 25 (25.3,25.7) vs. 35 (34.2,34.9) days, decreased costs: ($/1k) 46.1 (45.5,46.8) vs. 65.0 (64.1,66.0), decreased charges: 130.3 (128.6,132.1) vs. 192.1 (189.5,194.6) compared to intubated neonates. CONCLUSION: There was a three-fold increase in NIV use within the 15-year study period. NIV use was associated with decreased LOS, charges and costs compared to intubated patients.

Longitudinal assessment of hemoglobin oxygen saturation in preterm and term infants in the first six months of life.

OBJECTIVE: To report longitudinal home recordings of hemoglobin O(2) saturation by pulse oximetry (Spo(2)) during unperturbed sleep in preterm and term infants. STUDY DESIGN: We recorded continuous pulse oximetry during the first 3 minutes of each hour of monitor use (nonevent epochs) for 103 preterm infants born at <1750 g and ≤ 34 weeks postmenstrual age (PMA), and 99 healthy term infants. RESULTS: Median baseline Spo(2) was approximately 98% for both the preterm and term groups. Episodes of intermittent hypoxemia occurred in 74% of preterm and 62% of term infants. Among infants with intermittent hypoxemia, the number of seconds/hour of monitoring <90% Spo(2) was initially significantly greater in the preterm than the term group and declined with age at a similar rate in both groups. The 75(th) to 95(th) percentiles for seconds/hour of Spo(2) <90% in preterm infants were highest at 36 weeks PMA and progressively decreased until 44 weeks PMA, after which time they did not differ from term infants. CONCLUSIONS: Clinically inapparent intermittent hypoxemia occurs in epochs unperturbed by and temporally unrelated to apnea or bradycardia events, especially in preterm infants at 36 to 44 weeks PMA.

A Cost Minimization Comparison of Two Surfactants-Beractant and Poractant alfa-Based Upon Prospectively Designed, Comparative Clinical Trial Data.

OBJECTIVES: To compare the pharmacoeconomic profiles of beractant (Survanta(®), Ross Laboratories, Columbus, Ohio) and poractant alfa (Curosurf(®), DEY LP, Napa, CA) via a cost-minimization analysis. METHODS: This analysis was based upon clinical data from two previously published studies (Speer C, et al. Arch Dis Child 1995;72: F8-13; and Ramanathan R, et al. Am J Perinatol 2004; 21:109-19) where investigators found significant differences in the number of doses required to achieve a similar clinical response. Our analyses employed several models based upon single-use or multiple-use of single-use vial scenarios, average wholesale pricing, and costs computed on a per-patient basis. Model 1 involved single-dose vials and mean weight of the infants (both trials). Models 2 and 3, based on individual patient weights, assessed single-dose and multiple-use of single-dose vials cost scenarios, respectively. Individual patient weights allowed for statistical evaluation in Models 2 and 3. RESULTS: Model 1 savings with poractant alfa treatment was $949.67 (53%) based upon Speer and $617.90 (46%) based upon Ramanathan. Models 2 and 3 reported savings for poractant alfa of $220.50 (20%) (P = 0.11) and $180 (20%) (P = 0.018), respectively over beractant. CONCLUSIONS: These analyses would suggest poractant alfa may offer a less costly, clinically-equivalent option. Savings may vary with vial usage and mix, patient weight distribution, and how surfactants are used in practice. Institutions utilizing surfactants may wish to examine usage patterns, dosing protocols, and patient mix to determine what potential savings may exist.