Social Determinants of Health and Redirection of Care for Infants Born Extremely Preterm.

Importance: Redirection of care refers to withdrawal, withholding, or limiting escalation of treatment. Whether maternal social determinants of health are associated with redirection of care discussions merits understanding. Objective: To examine associations between maternal social determinants of health and redirection of care discussions for infants born extremely preterm. Design, Setting, and Participants: This is a retrospective analysis of a prospective cohort of infants born at less than 29 weeks' gestation between April 2011 and December 2020 at 19 National Institute of Child Health and Human Development Neonatal Research Network centers in the US. Follow-up occurred between January 2013 and October 2023. Included infants received active treatment at birth and had mothers who identified as Black or White. Race was limited to Black and White based on service disparities between these groups and limited sample size for other races. Maternal social determinant of health exposures were education level (high school nongraduate or graduate), insurance type (public/none or private), race (Black or White), and ethnicity (Hispanic or non-Hispanic). Main Outcomes and Measures: The primary outcome was documented discussion about redirection of infant care. Secondary outcomes included subsequent redirection of care occurrence and, for those born at less than 27 weeks' gestation, death and neurodevelopmental impairment at 22 to 26 months' corrected age. Results: Of the 15 629 infants (mean [SD] gestational age, 26 [2] weeks; 7961 [51%] male) from 13 643 mothers, 2324 (15%) had documented redirection of care discussions. In unadjusted comparisons, there was no significant difference in the percentage of infants with redirection of care discussions by race (Black, 1004/6793 [15%]; White, 1320/8836 [15%]) or ethnicity (Hispanic, 291/2105 [14%]; non-Hispanic, 2020/13 408 [15%]). However, after controlling for maternal and neonatal factors, infants whose mothers identified as Black or as Hispanic were less likely to have documented redirection of care discussions than infants whose mothers identified as White (Black vs White adjusted odds ratio [aOR], 0.84; 95% CI, 0.75-0.96) or as non-Hispanic (Hispanic vs non-Hispanic aOR, 0.72; 95% CI, 0.60-0.87). Redirection of care discussion occurrence did not differ by maternal education level or insurance type. Conclusions and Relevance: For infants born extremely preterm, redirection of care discussions occurred less often for Black and Hispanic infants than for White and non-Hispanic infants. It is important to explore the possible reasons underlying these differences.

Early-Life Outcomes in Relation to Social Determinants of Health for Children Born Extremely Preterm.

OBJECTIVE: To characterize the relationships between social determinants of health (SDOH) and outcomes for children born extremely preterm. STUDY DESIGN: This is a cohort study of infants born at 22-26 weeks of gestation in National Institute of Child Health and Human Development Neonatal Research Network centers (2006-2017) who survived to discharge. Infants were classified by 3 maternal SDOH: education, insurance, and race. Outcomes included postmenstrual age (PMA) at discharge, readmission, neurodevelopmental impairment (NDI), and death postdischarge. Regression analyses adjusted for center, perinatal characteristics, neonatal morbidity, ethnicity, and 2 SDOH (eg, group comparisons by education adjusted for insurance and race). RESULTS: Of 7438 children, 5442 (73%) had at least 1 risk-associated SDOH. PMA at discharge was older (adjusted mean difference 0.37 weeks, 95% CL 0.06, 0.68) and readmission more likely (aOR 1.27, 95% CL 1.12, 1.43) for infants whose mothers had public/no insurance vs private. Neither PMA at discharge nor readmission varied by education or race. NDI was twice as likely (aOR 2.36, 95% CL 1.86, 3.00) and death 5 times as likely (aOR 5.22, 95% CL 2.54, 10.73) for infants with 3 risk-associated SDOH compared with those with none. CONCLUSIONS: Children born to mothers with public/no insurance were older at discharge and more likely to be readmitted than those born to privately insured mothers. NDI and death postdischarge were more common among children exposed to multiple risk-associated SDOH at birth compared with those not exposed. Addressing disparities due to maternal education, insurance coverage, and systemic racism are potential intervention targets to improve outcomes for children born preterm.

Outcomes of Preterm Infants: Shifting Focus, Extending the View.

Advances in perinatal care have led to remarkable long-term survival for infants who are born preterm. This article reviews the broader context of follow-up care, highlighting the need to reenvision some areas, such as improving parental support by embedding parental involvement in the neonatal intensive care unit, incorporating parental perspectives about outcomes into follow-up care models and research, supporting their mental health, addressing social determinants of health and disparities, and advocating for change. Multicenter quality improvement networks allow identification and implementation of best practices for follow-up care.

Provision of mother's own milk for preterm infants during the COVID-19 pandemic: Differential effect of insurance.

Mother-infant dyads faced many challenges during the COVID-19 pandemic; however, the impact was different depending on socio-economic determinants. This study aims to investigate the impact of the COVID-19 pandemic on maternal provision of mother's own milk (MOM) at neonatal intensive care unit (NICU) discharge among preterm infants. We hypothesized that fewer infants would be discharged home on any MOM during the pandemic period compared to a pre-pandemic period. This is a retrospective analysis of infants born <34 weeks' gestation admitted to the Women and Infant's Hospital NICU. Infants born pre-pandemic (1/1/2019 to 2/29/2020) were compared to infants born during the pandemic (3/1/2020 to 4/30/2021). Maternal and neonatal variables were analyzed by group. The primary outcome was provision of MOM (defined as feeding exclusively MOM, or a combination of MOM and formula) at NICU discharge. Analyses were performed for time periods, and multivariable regression analyses were run for the total cohort and by insurance type. Analysis included 268 infants born pre-pandemic and 262 infants born during the pandemic. Pandemic group mothers vs. pre-pandemic were less likely to be single (27%, 63/233 vs. 38%, 93/243; p = 0.01) and more likely to have a diagnosis of chorioamnionitis (16%, 38/236 vs. 7%, 17/243; p = 0.002). Rates of public insurance were similar (55% pre-pandemic and 50% pandemic). There was no significant change in provision of MOM between time periods. In multivariable analysis, public insurance decreased the odds of MOM at discharge for the entire study period (aOR 0.31, 95% CI: 0.19-0.50; p = 0.0001). On analysis by insurance type, rates of MOM increased from 77% pre-pandemic to 88% during the pandemic (p = 0.03) for mothers with private insurance and remained unchanged for mothers with public insurance (52% pre-pandemic and 53% pandemic; p = 0.86). Mothers with private insurance had twice the odds (aOR 2.02, 95% CI: 1.02-3.97; p = 0.04) of providing MOM during the pandemic vs. pre-pandemic. For those with public insurance, the odds for any MOM provision during the pandemic were unchanged (aOR 0.95, 95% CI: 0.5-1.7; p = 0.86). These differences may be related to health care disparities requiring additional exploration of risk factors and the need for equitable opportunities for all mother-infant dyads.

Association of High Screen-Time Use With School-age Cognitive, Executive Function, and Behavior Outcomes in Extremely Preterm Children.

Importance: Both preterm birth and increased screen time are known to be associated with an increase in risk of developmental and behavioral sequelae. The association between high screen time or a television or computer in the bedroom in early school age and adverse cognitive, executive function, language, and behavior outcomes of extremely preterm children (EPT) is not well understood. Objective: To assess the association of high screen time with cognition, language, executive function, and behavior of EPT children aged 6 to 7 years; a second objective was to examine the association between high screen time and rates of structured physical activity and weight. Design, Setting, and Participants: This cohort study was a secondary analysis from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial Neuroimaging and Neurodevelopmental Outcomes school-aged cohort and includes 414 EPT children born between February 1, 2005, and February 28, 2009, and evaluated in between 2012 and 2016 at ages 6 years 4 months to 7 years 2 months. The study was conducted from July 7, 2012, and August 15, 2016, and data were analyzed between December 10, 2018, and April 1, 2021. Exposures: Cohorts included children exposed to low (≤2 hours per day) vs high (>2 hours per day) amounts of screen time and by the presence (no vs yes) of a television/computer in the bedroom. Main Outcomes and Measures: In addition to growth parameters, assessments included the Wechsler Intelligence Scale for Children-IV, the Behavior Rating Inventory of Executive Function, the Developmental Neuropsychological Assessment, the Conners 3rd Edition-Parent Short-Form, and the Social Communication Questionnaire. Results: Of the 414 children included in the analysis, 227 (55%) were boys; mean (SD) birth weight was 870.6 (191) g. A total of 238 children (57%) had high screen time and 266 (64%) had a television/computer in their bedroom. In multivariable linear regressions adjusted for center, male sex, gestational age, and social determinants of health, high screen time was independently associated with the following mean (SE) test score changes: lower full-scale IQ (-3.92 [1.64]; P = .02); an increase in association with deficits in executive functions, including metacognition (8.18 [3.01]; P = .007), global executive function (7.49 [2.99]; P = .01), inhibition (-0.79 [0.38]; P = .03), and Conners 3rd Edition-Parent Short-Form inattention (3.32 [1.67]; P = .047). A television/computer in the bedroom was associated with an increase in inhibition (-0.80 [0.39]; P = .04) and hyperactivity/impulsivity (3.50 [1.75]; P = .046) problems. Conclusions and Relevance: The findings of this study suggest that high screen time contributes to adverse cognitive, executive function, and behavior outcomes at ages 6 to 7 years in children born at less than 28 weeks. These findings support the need for clinicians to have heightened awareness of the risks for EPT children and discuss both the benefits and risks of screen time with families.

Neighborhood Inequality and Emergency Department Use in Neonatal Intensive Care Unit Graduates.

Neonatal intensive care unit graduates residing in high-risk neighborhoods were at increased risk of emergency department use and had higher rates of social/environmental risk factors. Distances to primary care provider and emergency department did not contribute to emergency department use. Knowledge of neighborhood risk is important for preventative service reform.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status.

OBJECTIVE: To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge. STUDY DESIGN: This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37 weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5 days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors. RESULTS: Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5 years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits. CONCLUSIONS: Among immigrant mothers, non-English primary language, >5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Neurodevelopment: The Impact of Nutrition and Inflammation During Preconception and Pregnancy in Low-Resource Settings.

The rapid pace of fetal development by far exceeds any other stage of the life span, and thus, environmental influences can profoundly alter the developmental course. Stress during the prenatal period, including malnutrition and inflammation, impact maternal and fetal neurodevelopment with long-term consequences for physical and mental health of both the mother and her child. One primary consequence of maternal malnutrition, inflammation, and other sources of prenatal stress is a poor birth outcome, such as prematurity or growth restriction. These phenotypes are often used as indications of prenatal adversity. In fact, the original evidence supporting the fetal programming hypothesis came from studies documenting an association between birth phenotype and the development of subsequent physical and mental health problems. Fetal growth restriction in both term and preterm infants is associated with neonatal morbidities and a wide variety of behavioral and psychological diagnoses in childhood and adolescence, including attention-deficit/hyperactivity disorder, anxiety, depression, internalizing and thought problems, poor social skills, and autism spectrum disorder. Improving maternal-child health requires interventions that begin before pregnancy and continue throughout gestation and into the postpartum period. Such interventions might include supporting pregnancy intention, maternal nutrition, health/medical care, mental health, and providing social support. This article discusses the impact of maternal nutrition and inflammation during preconception and pregnancy among women living in low-resource settings, with an emphasis on key knowledge gaps that need to be addressed to guide program and policy decisions at local, regional and global levels.

Are outcomes of extremely preterm infants improving? Impact of Bayley assessment on outcomes.

OBJECTIVES: To compare 18- to 22-month cognitive scores and neurodevelopmental impairment (NDI) in 2 time periods using the National Institute of Child Health and Human Development's Neonatal Research Network assessment of extremely low birth weight infants with the Bayley Scales of Infant Development, Second Edition (Bayley II) in 2006-2007 (period 1) and using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley III), with separate cognitive and language scores, in 2008-2011 (period 2). STUDY DESIGN: Scores were compared with bivariate analysis, and regression analyses were run to identify differences in NDI rates. RESULTS: Mean Bayley III cognitive scores were 11 points higher than mean Bayley II cognitive scores. The NDI rate was reduced by 70% (from 43% in period 1 to 13% in period 2; P < .0001). Multivariate analyses revealed that Bayley III contributed to a decreased risk of NDI by 5 definitions: cognitive score <70 and <85, cognitive or language score <70; cognitive or motor score <70, and cognitive, language, or motor score <70 (P < .001). CONCLUSION: Whether the Bayley III is overestimating cognitive performance or whether it is a more valid assessment of emerging cognitive skills than the Bayley II is uncertain. Because the Bayley III identifies significantly fewer children with disability, it is recommended that all extremely low birth weight infants be offered early intervention services at the time of discharge from the neonatal intensive care unit, and that Bayley scores be interpreted with caution.

Special health care needs of infants born at the limits of viability.

OBJECTIVE: The objective of this study was to compare rates of survival and special health care needs (SHCN) from discharge to 18 months' corrected age between infants who were born between 22 and 24 weeks and 25 and 27 weeks and to determine predictors and persistence of SHCN. METHODS: Data were collected on 508 infants who were born between 22 and 27 weeks from January 1, 1998, to December 31, 2002 at Women and Infants Hospital. SHCN was defined as need for home oxygen, medication, monitor, gastrostomy tube, or ventriculoperitoneal shunt. chi(2) was used to compare rates of survival and SHCN between groups. Regression analyses explored predictors of SHCN and their persistence. RESULTS: Survival at 22 to 24 weeks was 53% vs 90% at 25 to 27 weeks. There were no 22-week survivors. Survivors at 23 to 24 weeks were more likely to be discharged on oxygen, a monitor, or medications; remain on oxygen or a monitor or require tube feeds at 18 months; and have a SHCN at any time than survivors who were born at 25 to 27 weeks. The strongest predictor of SHCN at discharge was chronic lung disease and at 18 months was public health insurance. CONCLUSIONS: Rates of SHCN were high for infants who were born at the limits of viability. Although rates decreased with increasing age, 40% had persistent SCHN at 18 months. The association of public health insurance with persistent SHCN indicates a need for comprehensive health care and support services for infants with combined biological and environmental risks.

Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age.

OBJECTIVE: Beneficial effects of breast milk on cognitive skills and behavior ratings have been demonstrated previously in term and very low birth weight infants. Extremely low birth weight infants are known to be at increased risk for developmental and behavior morbidities. The benefits of breast milk that is ingested in the NICU by extremely low birth weight infants on development and behavior have not been evaluated previously. METHODS: Nutrition data including enteral and parenteral feeds were collected prospectively, and follow-up assessments of 1035 extremely low birth weight infants at 18 months' corrected age were completed at 15 sites that were participants in the National Institute of Child Health and Human Development Neonatal Research Network Glutamine Trial between October 14, 1999, and June 25, 2001. Total volume of breast milk feeds (mL/kg per day) during hospitalization was calculated. Neonatal characteristics and morbidities, interim history, and neurodevelopmental and growth outcomes at 18 to 22 months' corrected age were assessed. RESULTS: There were 775 (74.9%) infants in the breast milk and 260 (25.1%) infants in the no breast milk group. Infants in the breast milk group were similar to those in the no breast milk group in every neonatal characteristic and morbidity, including number of days of hospitalization. Mean age of first day of breast milk for the breast milk infants was 9.3 +/- 9 days. Infants in the breast milk group began to ingest non-breast milk formula later (22.8 vs 7.3 days) compared with the non-breast milk group. Age at achieving full enteral feeds was similar between the breast milk and non-breast milk groups (29.0 +/- 18 vs 27.4 +/- 15). Energy intakes of 107.5 kg/day and 105.9 kg/day during the hospitalization did not differ between the breast milk and non-breast milk groups, respectively. At discharge, 30.6% of infants in the breast milk group still were receiving breast milk. Mothers in the breast milk group were significantly more likely to be white (42% vs 27%), be married (50% vs 30%), have a college degree (22% vs 6%), and have private health insurance (34% vs 18%) compared with the no breast milk group. Mothers who were black, had a low household income (< or = dollar 20000), or had higher parity were less likely to provide breast milk feeds. The analysis of outcomes between the any human milk and no human milk groups were adjusted for maternal age, maternal education, marital status, race/ethnicity, and the other standard covariates. Children in the breast milk group were more likely to have a Bayley Mental Development Index > or = 85, higher mean Bayley Psychomotor Development Index, and higher Bayley Behavior Rating Scale percentile scores for orientation/engagement, motor regulation, and total score. There were no differences in the rates of moderate to severe cerebral palsy or blindness or hearing impairment between the 2 study groups. There were no differences in the mean weight (10.4 kg vs 10.4 kg), length (80.5 cm vs 80.5 cm), or head circumference (46.8 cm vs 46.6 cm) for the breast milk and no breast milk groups, respectively, at 18 months. Multivariate analyses, adjusting for confounders, confirmed a significant independent association of breast milk on all 4 primary outcomes: the mean Bayley (Mental Development Index, Psychomotor Development Index, Behavior Rating Scale, and incidence of rehospitalization). For every 10-mL/kg per day increase in breast milk ingestion, the Mental Development Index increased by 0.53 points, the Psychomotor Development Index increased by 0.63 points, the Behavior Rating Scale percentile score increased by 0.82 points, and the likelihood of rehospitalization decreased by 6%. In an effort to identify a threshold effect of breast milk on Bayley Mental Development Index and Psychomotor Development Index scores and Behavior Rating Scale percentile scores, the mean volume of breast milk per kilogram per day during the hospitalization was calculated, and infants in the breast milk group were divided into quintiles of breast milk ingestion adjusted for confounders. Overall, the differences across the feeding quintiles of Mental Development Index and Psychomotor Development Index were significant. There was a 14.0% difference in Behavior Rating Scale scores between the lowest and highest quintiles. For the outcomes (Mental Development Index, Psychomotor Development Index, Behavior Rating Scale, and Rehospitalization <1 year), only the values for the >80th percentile quintile of breast milk feeding were significantly different from the no breast milk values. In our adjusted regression analyses, every 10 mL/kg per day breast milk contributed 0.53 points to the Bayley Mental Development Index; therefore, the impact of breast milk ingestion during the hospitalization for infants in the highest quintile (110 mL/kg per day) on the Bayley Mental Development Index would be 10 x 0.53, or 5.3 points. CONCLUSIONS: An increase of 5 points potentially would optimize outcomes and decrease costs by decreasing the number of very low birth weight children who require special education services. The societal implications of a 5-point potential difference (one third of an SD) in IQ are substantial. The potential long-term benefit of receiving breast milk in the NICU for extremely low birth weight infants may be to optimize cognitive potential and reduce the need for early intervention and special education services.

A multisite study to examine the efficacy of the otoacoustic emission/automated auditory brainstem response newborn hearing screening protocol: recommendations for policy, practice, and research.

PURPOSE: This article examines whether changes in hearing screening practices are warranted based on the results of the recent series of studies by J. L. Johnson, K. R. White, J. E. Widen, J. S. Gravel, B. R. Vohr, M. James, T. Kennalley, A. B. Maxon, L. Spivak, M. Sullivan-Mahoney, Y. Weirather, and S. Meyer (Johnson, White, Widen, Gravel, James, et al., 2005; Johnson, White, Widen, Gravel, Vohr, et al., 2005; White et al., 2005; Widen et al., 2005) that found a significant number of infants who passed an automated auditory brainstem response (A-ABR) screening after failing an initial otoacoustic emission (OAE) screening later were found to have permanent hearing loss in one or both ears. METHOD: Similar to the approach used by F. H. Bess and J. Paradise (1994), this article addresses the public health tenets that need to be in place before screening programs, or in this case, a change in screening practice (use of a 2-step screening protocol) can be justified. RESULTS: There are no data to suggest that a 2-step OAE/A-ABR screening protocol should be avoided. CONCLUSION: Research is needed before any change in public policy and practice surrounding current early hearing detection and intervention programs could be supported.

Impact of family health insurance and other environmental factors on universal hearing screen program effectiveness.

OBJECTIVE: The study objective was to evaluate the relationship among health insurance type, other demographic factors, and newborn hearing screen compliance and outcomes. STUDY DESIGN: The cohort consisted of 39,153 infants screened in Rhode Island between July 1, 1995 and June 30, 1998. Multivariate analyses were completed to evaluate relationships between health insurance type and completion of the in-hospital hearing screen and the rescreen, if indicated. RESULTS: Successful newborn screen rates ranged from 98.1% to 99.8%. Infants with traditional Medicaid insurance were more likely to not be screened (p<0.0001) and to not return for a rescreen (p<0.0001). Infants in families with managed care Medicaid had screen compliance similar to infants with commercial health insurance. Multivariate analyses revealed that Medicaid insurance, no insurance, neonatal intensive care unit status, and out-of-state address predicted no initial screen (p<0.001) and no rescreen (p<0.0001). CONCLUSION: In population-based health services, it is important that the effects of socioeconomic and demographic variables on outcomes be evaluated.