Amplification of Heart Sounds Using Digital Stethoscope in Simulation-Based Neonatal Resuscitation.

OBJECTIVE: The accuracy, timeliness, and reliability of the current methods of heart rate (HR) determination in neonatal resuscitation are debatable, each having its own limitations. We aim to compare three methods of HR assessment: (1) traditional stethoscope, (2) electrocardiogram and traditional stethoscope, and (3) digital stethoscope with loudspeaker amplification of heart sounds. STUDY DESIGN: This was a simulated crossover experiment using a high-fidelity manikin. Each team with a physician, a nurse, and a respiratory therapist performed the resuscitations using the three methods (three different scenarios) in different order. The person controlling the HR via manikin controller was blinded, but the single recorder and the providers were not. RESULTS: Eighteen resuscitations were completed (six teams of three methods each). The time to first HR recording (p < 0.001), total number of HR recorded (p < 0.001), and time to recognize dips in HR was significantly improved in the digital stethoscope group (p = 0.009). CONCLUSION: Use of digital stethoscope with amplification improved documentation of HR and earlier recognition of HR changes. KEY POINTS: · Amplified heartbeats during neonatal resuscitation improved documentation.. · Amplified infant heartbeats resulted in earlier recognition of HR changes (increase or decrease).. · Providers using this method had greater satisfaction..

The U.S. National Trend for Retinopathy of Prematurity.

OBJECTIVE: The use of supplemental oxygen in premature infants is essential for survival. However, its use has been associated with unintended complications. The restricted use of oxygen is associated with increased mortality and necrotizing enterocolitis (NEC), whereas its liberal use is associated with increased risk for retinopathy of prematurity (ROP). Although there is no clear consensus on the acceptable oxygen saturation range, clinicians have recently become more liberal with the use of oxygen. We aim to assess (1) the national trends for ROP in very low birth weight preterm infants, and (2) the associated trends in mortality, NEC, intraventricular hemorrhage (IVH), and length of hospital stay (LOS). STUDY DESIGN: We analyzed deidentified patient data from the National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) from 2002 to 2017. All infants with gestational age ≤32 weeks and birth weight <1,500 g were included. Trends in ROP, severe ROP, mortality, NEC, IVH, severe IVH, and LOS were analyzed using Jonckheere-Terpstra test. RESULTS: A total of 818,945 neonates were included in the study. The overall mortality was 16.2% and the prevalence of ROP was 17.5%. There was a significant trend for increased ROP over the years (p < 0.001). Severe ROP was also significantly increased (p < 0.001). This was associated with a significant trend for increased median LOS in survived infants (p < 0.001). Mortality was significantly decreased (p < 0.001), whereas NEC and severe NEC did not change over time (p = 0.222 and p = 0.412, respectively). CONCLUSION: There is a national trend for increased ROP and severe ROP over the 16 years of the study period. This trend was associated with a significant increase in the LOS in survived infants without change in NEC. KEY POINTS: · Prevalence of ROP and severe ROP has increased in VLBW infants over the 16-year study period.. · The prevalence of NEC did not change over the same time period.. · Increased ROP and severe ROP were consistent in all three GA and BW subgroups..

Clinical Indicators of Late-Onset Sepsis Workup in Very Low-Birth-Weight Infants in the Neonatal Intensive Care Unit.

Background Late-onset sepsis (LOS) in very low-birth-weight (VLBW) infants is associated with significant morbidity and mortality. Objectives To determine the incidence of LOS workup, association, and predictive value of clinical indicators leading to culture-positive versus culture-negative sepsis workup. Methods All sepsis workups performed after 7 days of life, in neonates with birth weight of < 1,500 g were included. Each case (culture-positive workup) was matched with a control (culture-negative workup) for gestational age (GA), birth weight, corrected gestational age, and chronological age, at the time of workup. The clinical indicators leading to the performance of sepsis workup were compared between cases and controls. Results The incidence of culture-positive workup was 87/345 (25.2%) and that of LOS was 84/279 (30.1%). Among various clinical indicators, hypothermia and apnea were significantly associated with culture-positive sepsis workup (p = 0.015 and 0.004, respectively), with a positive predictive value of 81.2 and 71.4%, respectively. Conclusion In VLBW infants, one-fourth of sepsis workups resulted in a positive culture. Apnea and hypothermia were the most significant predictors of culture-positive workup after matching for GA, birth weight, chronological age, and corrected GA at the time of the workup.

Direct breastfeeding frequency of late preterm and term infants in the neonatal intensive care unit and availability of mother's own milk at six months of age. a retrospective cohort study.

BACKGROUND: Mother's Own Milk (MOM) reduces the risk of complications in premature infants. Breastfeeding rates for late preterm and term infants in the neonatal intensive care unit (NICU) are significantly lower than that of breastfed healthy term newborns at 6 months of age. DESIGN: This was a retrospective cohort study of neonates born at 34 weeks 0 days or later. Infants who were directly breastfed in the NICU and were discharged on breast milk were included. Logistic regression modeling was used to determine the significance of association. RESULTS: 171 mother-infant dyads were included. After adjusting for confounders, the number of breastfeeding attempts during the NICU stay was significantly associated with the availability of MOM at six months of age (p = 0.003, 95% CI 1.02 to 1.14). CONCLUSION: This study is the first to show an association between the number of direct breastfeeding attempts in the NICU and availability of MOM at six months of age.

Comparison of Parental In-Person Visitation and Webcam Usage Patterns at a Single-Center Neonatal Intensive Care Unit.

Purpose: Barriers to parents visiting the neonatal intensive care unit (NICU) in person for infant bonding include socioeconomic status, distance from NICU, and having children at home. Use of NICU bedside webcam can increase access to parent-infant interaction. This study aimed to describe the pattern of webcam logins by parents, relationship of logins to in-person visitation, and maternal factors affecting usage. Methods: In this retrospective cohort study, data pertaining to parental webcam logins and in-person visitation, maternal screening for depression, anxiety, and stress, and family sociodemographics were collected from medical records. Relationships between chart variables and webcam or in-person visitation were measured using Pearson's correlation coefficient and Mann-Whitney U test, as applicable. Login data were obtained from weeks 2 through 5 of NICU stay of the infant, while depression, anxiety, and stress scores were obtained in the second week as standard procedure by a dedicated NICU social worker. Results: A total of 59 mother-baby dyads were included. Percentage of days visited and webcam logins decreased from week 2 to week 5. A higher rate of webcam login was documented for all parents on days they did not visit in person. Parents who lived ≥15 miles away (P=0.004) and those with government insurance (P=0.01) visited in person significantly less, although webcam logins showed no difference between groups. One negative correlation was found between percentage of in-person visits and DASS-21 depression score (P=0.03), but no such correlation was seen with webcam logins. Conclusions: Parents utilized NICU webcams to connect with their infants when unable to be at the bedside. Webcam use reduced visitation disparities known to be exacerbated by insurance status, home-to-hospital distance, and psychological distress.

Predicting outcomes of mechanically ventilated premature infants using respiratory severity score.

BACKGROUND: Extremely low birth weight (ELBW) infants have significant morbidities and higher mortality. The major morbidities are bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP). Release of proinflammatory cytokines has been implicated in the development of systemic inflammation that contributes to BPD aND ROP. Also, cumulative oxygen exposure in the first 3 days of life and use of mechanical ventilation was associated with 3-fold increase in severe IVH. Therefore, early ventilation and oxygenation may contribute significantly to morbidities in ELBW infants. Respiratory severity score (RSS), a product of Mean airway pressure (MAP) and FiO2, is a steady-state noninvasive assessment tool useful in infants to monitor the severity of respiratory failure. We used RSS, in the first 3 days of life of ELBW infants, to predict neonatal morbidities and mortality. STUDY DESIGN: In a single-center retrospective cohort study in an urban setting, convenience sampling of ELBW infants meeting the study criteria who were mechanically ventilated at birth for the first 3 days of life were included. Time-weighted average RSS was plotted on receiver-operating characteristic (ROC) curve in the first 3 days of life to predict outcomes. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated. RESULTS: A total of 69 infants qualified for the study. RSS in the first 3 days significantly predicted the composite outcome of death, ROP, IVH or BPD with an area under the curve (AUC) of 0.82 (p < 0.001). Individually, RSS predicted death, severe ROP and IVH with an AUC of 0.86, 0.77 and 0.71 respectively; but did not predict severe BPD (AUC 0.61). RSS was more sensitive and specific than each of its component; FiO2 and MAP. Weighted RSS in the first 3 days had high-negative predictive value of 98.1% for death between 7 days and 36 weeks, 94.6% for ROP and 91.7% for IVH. CONCLUSIONS: This study is the first to show that RSS in the first 3 days of life is a good predictor of composite neonatal outcomes: severe IVH, BPD, ROP, or mortality. Early RSS had a high positive predictive value for the composite outcome of morbidities/mortality and a high specificity for mortality, ROP, and IVH individually.

COVID-19 Pandemic Response and Adaptations by International Community Access to Child Health (ICATCH) Projects in Low- and Middle-Income Countries.

Background. The health personnel in low/low and middle-income countries have faced significant challenges during the COVID-19 pandemic. The International Community Access to Child Health (ICATCH) grants support locally initiated projects in those countries. The aim of this study was to highlight how the challenges countered by grant project teams continuing their projects and demonstrating their skills to adapt to an increasingly difficult environment. Methods. This was a mixed methodology study for which data were obtained from the evaluation of annual reports submitted by the projects. The annual reports review comprised of answers to questions on whether project objectives were met, problems or barriers encountered, and reviewer feedback in the form of specific concerns or recommendations. The reports were analyzed both quantitatively and qualitatively. Results. A total of 34 (92%) of annual reports were included with 17 (94%) received in 2020 and 17 (89%) in 2021. Compared to 2020, in 2021 the projects that indicated meeting objectives increased by more than half from 29% to 58%. Over one third of the projects encountered barriers in both years. The percentage of projects with major concerns decreased by almost 2/3 in 2021 while unexpected expenses decreased by 1/3. Four themes emerged from the qualitative analysis: Concerns over COVID-19, Barriers to accomplishing project goals, Positivity around adaptations, and Despair over lack of ability to overcome challenges. Conclusions. ICATCH funded projects demonstrated resiliency and adaptations to meet program objectives despite the challenges posed by the COVID-19 pandemic demonstrating greater success in 2021.

Did the Timing of State Mandated Lockdown Affect the Spread of COVID-19 Infection? A County-level Ecological Study in the United States.

OBJECTIVES: Previous pandemics have demonstrated that several demographic, geographic, and socioeconomic factors may play a role in increased infection risk. During this current coronavirus disease 2019 (COVID-19) pandemic, our aim was to examine the association of timing of lockdown at the county level and aforementioned risk factors with daily case rate (DCR) in the United States. METHODS: A cross-sectional study using publicly available data was performed including Americans with COVID-19 infection as of May 24, 2020. The United States counties with >100 000 population and >50 cases per 100 000 people were included. The independent variable was the days required from the declaration of lockdown to reach the target case rate (50/100 000 cases) while the dependent (outcome) variable was the DCR per 100 000 on the day of statistical calculation (May 24, 2020) after adjusting for multiple confounding socio-demographic, geographic, and health-related factors. Each independent factor was correlated with outcome variables and assessed for collinearity with each other. Subsequently, all factors with significant association to the outcome variable were included in multiple linear regression models using stepwise method. Models with best R2 value from the multiple regression were chosen. RESULTS: The timing of mandated lockdown order had the most significant association on the DCR per 100 000 after adjusting for multiple socio-demographic, geographic and health-related factors. Additional factors with significant association with increased DCR include rate of uninsured and unemployment. CONCLUSIONS: The timing of lockdown order was significantly associated with the spread of COVID-19 at the county level in the United States.

Application of Kaiser Sepsis Calculator in culture-positive infants with early onset sepsis.

BACKGROUND: Kaiser Sepsis Calculator (KSC) reduces antibiotic use, testing and intravenous infiltrates but there are concerns about the missed early onset sepsis (EOS) cases. We sought to apply the KSC score for culture-positive infants retrospectively in infants born in the last 10 years in our hospital. METHODS: In a retrospective cohort study, the comparison groups were divided into Group A (no antibiotics recommended by KSC) and Group B (antibiotics recommended). RESULTS: Overall, 17/24 (71%) infants would have been started on antibiotics per KSC but 7/24 (29%) would not. The initial EOS risk was not significantly different between the groups (Group A vs. Group B: 0.44 vs. 0.76, P = 0.41), but the final risk score was (0.33 vs. 9.41, P < 0.001). In Group A (no antibiotics), 3/7 infants became symptomatic between 9 and 42 hours. CONCLUSION: There may be a potential delay in starting antibiotics in infants that are asymptomatic at birth while using KSC.

Association of the previous history of maternal depression with post-partum depression, anxiety, and stress in the neonatal intensive care unit.

BACKGROUND: A history of depression in post-partum women who have infants admitted to the neonatal intensive care unit (NICU), is associated with higher risk for anxiety and stress. These conditions, which can be harmful to neonates, may be missed if maternal mental health screening is confined to depression. OBJECTIVE: To determine if the history of a previously diagnosed depression would be associated with an increased risk of both postpartum depression and other stress-related disorders (i.e. anxiety and stress) among mothers with infants in the NICU. DESIGN: Prospective survey questionnaire-based study conducted over a period of 9 months. SETTING: Urban inpatient hospital-based setting, serving mainly low-income population. PARTICIPANTS: A total of 118 mothers of newborns who had been in the NICU for 7-29 days were approached for enrollment. Out of 118, 96 mothers consented to be screened and were asked to fill out the 21-item Depression Anxiety and Stress Scale-21 (DASS-21) questionnaire. OUTCOME: Primary outcome was to determine whether the history of a previously diagnosed depression is associated with an increased risk of both postpartum depression and other stress-related disorders (i.e. anxiety and stress). RESULTS: Out of the 96 subjects, 36 (37.5%) had a previous history of depression before delivery (Group A) while 60/96 (62.5%) did not (Group B) and 46/96 (48%) of the mothers were positive for either depression, anxiety, or stress. This included 22/96 (22.9%) mothers who screened positive for depression; 37/96 (38.5%) who screened positive for anxiety; and 32/96 (33.3%) who screened positive for stress. After adjusting for maternal drug abuse, birth weight and maternal gravidity, the association between a previous history of depression and current depression scores were statistically significant (p = .04), as were the associations between previous depression and current anxiety and stress scores (p = .02 and p = .003, respectively). CONCLUSIONS AND RELEVANCE: A history of depression, documented in the antepartum medical record, identifies post-partum women who are at higher risk for anxiety and stress. Screening for depression alone may lead to missing these mental health issues.

Telemedicine, a tool for follow-up of infants discharged from the NICU? Experience from a pilot project.

OBJECTIVE: Follow-up of infants from the NICU by neonatologist is limited to premature and complicated infants although parents of infants with advanced gestation may have concerns as well. We compared parental questions of infants < 35 weeks gestation (group A), during virtual telemedicine visits, to ≥35 week infants (group B). STUDY DESIGN: In a retrospective cohort study, questions asked by parents were extracted from the electronic medical record of all infants post discharge from the NICU, after their pediatrician visit. RESULTS: Gestation and birth weight of infants in group A were significantly lower than group B but their stay was longer. There were no significant differences in the number of parents who had questions, between the groups (A 68.1% vs B 67.3%, p = 0.91, 95% CI 0.46-1.99, OR = 0.96). CONCLUSIONS: Telemedicine is a feasible tool for follow-up of NICU infants post discharge. Parents of infants with advanced gestation and weight may benefit from NICU follow-up.

Diagnosis of Neonatal Herpes Simplex Infection from the Placenta.

Due to a high rate of fetal demise and premature birth in intrauterine HSV infection, the outcome in neonates is usually adverse. A female preterm infant with a gestational age of 25 1/7 weeks with expected early clinical course tested positive for neonatal herpes simplex virus (HSV) 2 after the neonatologist was informed of positive immunohistochemistry for the virus on the fifth day of life by the pathologist. Pathological examination of the placenta had revealed subacute necrotizing inflammation with stromal cell necrosis suggestive of intrauterine infection, possibly ascending due to prolonged rupture of membranes. To the best of our knowledge, this is the first case wherein placental pathology indicated exposure to HSV in utero before the infant presented with signs or symptoms of neonatal HSV resulting in a favorable outcome for the infant. Due to the variability of presentation of intrauterine HSV infection, pathological examination of the placenta in the first 2-5 days of life in premature infants can provide clues to the diagnosis of neonatal HSV which may significantly impact the outcome.

Comparison of keyboard colonization before and after use in an inpatient setting and the effect of keyboard covers.

Computer keyboards may contribute to patient infections. We cultured new keyboards, with/without keyboard covers, before placing them in adult inpatient rooms and recultured after 6 months. Nonpathogenic bacteria were present initially but potentially pathogenic bacteria were cultured only after use. Coagulase negative Staphylococcus colonization increased after use (P < .001). Keyboards with a cover had more potentially pathogenic bacteria (22% vs 16%), which although not significant statistically (P = .72), likely due to sample size, trended against covers offering protection.

Partial Obstruction of the Endotracheal Tube by the Plastic Coating Sheared from a Stylet.

A preterm with gestational age of 24 weeks was intubated at day of life 16. The intubation was done in a routine manner with the use of a stylet. It took a significant effort from the clinician to pull the stylet out after intubation. After intubation the respiratory status of the neonate deteriorated requiring significantly greater support. When ventilating and oxygenating the infant was getting progressively difficult, the decision was made to change the endotracheal tube (ETT). The cause for deterioration of respiratory status was then determined to be a sheared piece of plastic from the sheath of the stylet which was lodged in the lumen of the ETT. After removal of the plastic particle, the condition of the infant improved significantly.

A comparison of manual versus automated saturation of peripheral oxygenation in the neonatal intensive care unit.

BACKGROUND: It is vital to maintain the saturation of peripheral oxygenation (SpO2) in a targeted range in extremely premature infants to improve survival without significant morbidities. OBJECTIVES: To compare manual versus automated monitor documentations of daily upper and lower values of SpO2 in premature infants. METHODS: In a prospective observational study, the highest and lowest daily SpO2 manually recorded values from electronic medical records were compared with automatically recorded values from bedside cardiorespiratory monitors. RESULTS: Eighteen infants were monitored for 605 patient days, with a mean birth weight of 859 ± 183 g, and gestational age of 26.0 ± 1.3 wks. Within the lowest SpO2 values, manually recorded values were consistently higher than the simultaneous automatically recorded monitor values. The highest SpO2 point differences in documentation was seen in patients with SpO2 range ≤ 70% (16 ± 13 points), followed by 71-80% (10 ± 7 points) and 81-90% (7 ± 4 points); p < 0.01. CONCLUSIONS: The difference between manually and automatically recorded SpO2 is large in lower SpO2 ranges and small in higher SpO2 ranges. Automated oxygen administering systems should be considered to reduce potential errors.