Handoff Tool Improves Transitions from the Operating Room to the Neonatal Intensive Care Unit.

Introduction: Standardized handoffs reduce medical errors and prevent adverse events or near misses. This article describes a quality improvement initiative implementing a unique standardized handoff tool and process to transition from the operating room to the neonatal intensive care unit (NICU) at a level-four regional center with many inpatients requiring surgical intervention. Before this project, there was no standardized handoff tool or process for postsurgical transitions. The primary aim was to achieve 80% compliance with completing a structured postoperative OR to NICU handoff tool within 12 months of implementation. Methods: An interdisciplinary team developed and implemented a standardized NICU postoperative handoff tool and process that requires face-to-face communication, defines team members who should be present, and highlights communication with the family. In addition, the handoff tool compliance and process measures were monitored, evaluated, and audited. Results: Although not consistent, we achieved eighty percent compliance with the outcome measures using the handoff tool. We did not sustain 80% of appropriate providers present at handoff. In addition, insufficient data assess overall parental satisfaction with the surgical experience. Although improved, the process measure of immediate postoperative family updates did not reach the targeted goal. However, the balancing measure of staff experience and satisfaction did improve. Conclusion: Implementing a standardized handoff tool and process with an interdisciplinary and interdepartmental collaboration improves critical patient transitions from the operating room to the NICU.

Maternal Hypertension and Early-Onset Neonatal Neutropenia.

Objective: Maternal hypertension is considered a risk factor for early neonatal neutropenia. We sought to explore this relationship. Study Design: This retrospective cohort study compared initial neutrophil counts in infants born to mothers with preeclampsia with severe features (PSF) and infants born to normotensive mothers using Negative Binomial Regression (NBR) and logistic regression models. Results: Maternal hypertension negatively affected the early neonatal neutrophil count (adjusted NRB coefficient 0.4 [0.2, 0.6], p < 0.0001) but did not increase the risk of neutropenia (OR 2.07 [0.97, 4.41], p = 0.06). The initial neutrophil count and neutropenia risk were not different between PSF subgroups. Gestational age had the greatest impact on neutropenia risk (OR 0.72 [0.64, 0.81], p < 0.0001). Almost all neutropenia resolved within 48 h. Conclusion: Maternal hypertension negatively affects the early neonatal neutrophil count while not increasing the risk of neonatal neutropenia.

Extracorporeal membrane oxygenation in the care of a preterm infant with COVID-19 infection: Case report.

Coronavirus disease 2019 (COVID-19) was first reported to the World Health Organization (WHO) in December 2019 and has since unleashed a global pandemic, with over 518 million cases as of May 10, 2022. Neonates represent a very small proportion of those patients. Among reported cases of neonates with symptomatic COVID-19 infection, the rates of hospitalization remain low. Most reported cases in infants and neonates are community acquired with mild symptoms, most commonly fever, rhinorrhea and cough. Very few require intensive care or invasive support for acute infection. We present a case of a 2-month-old former 26-week gestation infant with a birthweight of 915 grams and diagnoses of mild bronchopulmonary dysplasia and a small ventricular septal defect who developed acute respiratory decompensation due to COVID-19 infection. He required veno-arterial extracorporeal membrane oxygenation support for 23 days. Complications included liver and renal dysfunction and a head ultrasound notable for lentriculostriate vasculopathy, extra-axial space enlargement and patchy periventricular echogenicity. The patient was successfully decannulated to conventional mechanical ventilation with subsequent extubation to non-invasive respiratory support. He was discharged home at 6 months of age with supplemental oxygen via nasal cannula and gastrostomy tube feedings. He continues to receive outpatient developmental follow-up. To our knowledge, this is the first case report of a preterm infant during their initial hospitalization to survive ECMO for COVID-19.

The effects of maternal hypertension on the early neonatal platelet count.

OBJECTIVE: To examine the relationship between maternal hypertension and early neonatal platelet counts. STUDY DESIGN: This single site retrospective cohort study compared initial platelet counts in the first day of life of infants born to mothers with preeclampsia with severe features (PSF) (n = 224) and infants born to normotensive mothers using multivariable logistic and Quasi-Poisson regression models. RESULT: There was no statistical difference in initial platelet counts or likelihood of thrombocytopenia (aOR = 1.19, 95% CI 0.68-2.08) between infants born to mothers with PSF and infants born to normotensive mothers after multivariable adjustment. Initial platelet counts and thrombocytopenia risk were unaffected by the presence of maternal end organ dysfunction. Small for gestational age (SGA) status was the most significant risk factor for the development of thrombocytopenia (aOR = 2.24, 95% CI 1.13-4.30). CONCLUSION: Maternal PSF does not directly affect neonatal initial platelet counts. SGA status confers the greatest risk of early thrombocytopenia.

Cardiac Collapse Secondary to Phenytoin Toxicity in a Neonate Treated with Extracorporeal Membrane Oxygenation Support (ECMO).

INTRODUCTION: Although medication toxicity is uncommon in neonates, there are several medications used in this population that pose a risk. Phenytoin has an increased risk of toxicity given its narrow therapeutic window and variations in drug elimination. CASE REPORT: We describe the case of a 3-day-old male infant who developed cardiovascular collapse secondary to severe phenytoin toxicity (max phenytoin level 86 µg/mL) and was placed on extracorporeal membrane oxygenation support (ECMO). Several ancillary treatments were utilized in an attempt to decrease serum phenytoin concentrations and limit toxicity including albumin boluses, phenobarbital administration, intravenous lipid infusion, and folic acid supplementation. DISCUSSION: Although uncommon, drug toxicity should be considered in patients with acute changes who are exposed to medications with potential toxicity. With elevated levels of phenytoin, the half-life can be prolonged resulting in longer exposure to elevated levels of the drug as seen in our patient. This case report highlights the importance of ECMO utilization for cardiac support in neonates with medication toxicity and other potential ancillary treatments to decrease serum phenytoin concentrations.

Association of Intestinal Alkaline Phosphatase With Necrotizing Enterocolitis Among Premature Infants.

Importance: Necrotizing enterocolitis (NEC) in preterm infants is an often-fatal gastrointestinal tract emergency. A robust NEC biomarker that is not confounded by sepsis could improve bedside management, lead to lower morbidity and mortality, and permit patient selection in randomized clinical trials of possible therapeutic approaches. Objective: To evaluate whether aberrant intestinal alkaline phosphatase (IAP) biochemistry in infant stool is a molecular biomarker for NEC and not associated with sepsis. Design, Setting, and Participants: This multicenter diagnostic study enrolled 136 premature infants (gestational age, <37 weeks) in 2 hospitals in Louisiana and 1 hospital in Missouri. Data were collected and analyzed from May 2015 to November 2018. Exposures: Infant stool samples were collected between 24 and 40 or more weeks postconceptual age. Enrolled infants underwent abdominal radiography at physician and hospital site discretion. Main Outcomes and Measures: Enzyme activity and relative abundance of IAP were measured using fluorometric detection and immunoassays, respectively. After measurements were performed, biochemical data were evaluated against clinical entries from infants' hospital stay. Results: Of 136 infants, 68 (50.0%) were male infants, median (interquartile range [IQR]) birth weight was 1050 (790-1350) g, and median (IQR) gestational age was 28.4 (26.0-30.9) weeks. A total of 25 infants (18.4%) were diagnosed with severe NEC, 19 (14.0%) were suspected of having NEC, and 92 (66.9%) did not have NEC; 26 patients (19.1%) were diagnosed with late-onset sepsis, and 14 (10.3%) had other non-gastrointestinal tract infections. For severe NEC, suspected NEC, and no NEC samples, median (IQR) fecal IAP content, relative to the amount of IAP in human small intestinal lysate, was 99.0% (51.0%-187.8%) (95% CI, 54.0%-163.0%), 123.0% (31.0%-224.0%) (95% CI, 31.0%-224.0%), and 4.8% (2.4%-9.8%) (95% CI, 3.4%-5.9%), respectively. For severe NEC, suspected NEC, and no NEC samples, median (IQR) enzyme activity was 183 (56-507) µmol/min/g (95% CI, 63-478 µmol/min/g) of stool protein, 355 (172-608) µmol/min/g (95% CI, 172-608 µmol/min/g) of stool protein, and 613 (210-1465) µmol/min/g (95% CI, 386-723 µmol/min/g) of stool protein, respectively. Mean (SE) area under the receiver operating characteristic curve values for IAP content measurements were 0.97 (0.02) (95% CI, 0.93-1.00; P < .001) at time of severe NEC, 0.97 (0.02) (95% CI, 0.93-1.00; P < .001) at time of suspected NEC, 0.52 (0.07) (95% CI, 0.38-0.66; P = .75) at time of sepsis, and 0.58 (0.08) (95% CI, 0.42-0.75; P = .06) at time of other non-gastrointestinal tract infections. Mean (SE) area under the receiver operating characteristic curve values for IAP activity were 0.76 (0.06) (95% CI, 0.64-0.86; P < .001), 0.62 (0.07) (95% CI, 0.48-0.77; P = .13), 0.52 (0.07) (95% CI, 0.39-0.67; P = .68), and 0.57 (0.08) (95% CI, 0.39-0.69; P = .66), respectively. Conclusions and Relevance: In this diagnostic study, high amounts of IAP protein in stool and low IAP enzyme activity were associated with diagnosis of NEC and may serve as useful biomarkers for NEC. Our findings indicated that IAP biochemistry was uniquely able to distinguish NEC from sepsis.

Neonatal Intensive Care Unit Boot Camp: A Preparatory Curriculum for Pediatric Residents.

Introduction: Resident training has changed significantly in recent years, resulting in reduced experiences and practice. Because pediatric residents have fewer required intensive care unit (ICU) rotations, we introduced a neonatal ICU (NICU) boot camp (2014-2015) that continues today to prepare residents immediately prior to beginning an NICU rotation. Methods: The NICU boot camp consists of three 1-hour sessions: two interactive lectures with case-based application and one hands-on, integrative learning using simulation. The sessions are designed to cover basic information to assist in daily rounding and decision making while in the NICU. After their NICU rotation, residents complete a 12-item questionnaire. Program evaluation includes direct observation during sessions, faculty debriefing, and a postprogram resident survey. Results: Fifty-seven residents participated; questionnaire responses were available from 46 (80.70%). Combined percentages of very useful and extremely useful responses for the three sessions were 82.61%, 78.26%, and 82.60%, with 86.95% for the overall program; 80.40% agreed that repeating boot camp prior to each NICU rotation would be useful. Analysis of narrative responses revealed that participation in boot camp enhanced residents' readiness and confidence for patient care in the NICU and as stated for each educational objective. Discussion: Program evaluation results support highly effective and sustainable implementation and achievement of educational objectives. Minor refinements continue for enhancing active learning and content materials and for increasing rigor of program evaluation. Results also suggest that our boot camp may benefit other pediatric programs and serve as a model for use in other resident specialty programs.

Neonatal severe hyperparathyroidism caused by homozygous mutation in CASR: A rare cause of life-threatening hypercalcemia.

Neonatal severe hyperparathyroidism (NSHPT) is a rare, life-threatening condition that presents with severe hypercalcemia, hyperparathyroidism, and osteopenia in the newborn period. Treatment of NSHPT traditionally includes hydration and bisphosphonates; however newer calcimimetic agents, such as cinacalcet, are now being utilized to prevent or delay parathyroidectomy which is technically difficult in the newborn. Medical treatment success is related to calcium sensing receptor (CaSR) genotype. We report a 4-day-old infant who presented with hyperbilirubinemia, poor feeding, weight loss, severe hypotonia and was ultimately diagnosed with NSHPT. The patient's total serum calcium level of 36.8 mg/dL (reference range: 8.5-10.4 mg/dL) is, to our knowledge, the highest ever documented in this setting. Exome data previously obtained on the infant's parents was re-analyzed demonstrating bi-parental heterozygosity for a mutation of the CASR gene: c.206G > A, and Sanger sequencing data confirmed the patient was a homozygote for the same mutation. Though a patient with the same CaSR gene mutation described here has responded to cinacalcet, our patient did not respond and required parathyroidectomy. Though this case has previously been published as a surgical case report, a full report of the medical management and underlying genetic etiology is warranted; this case underscores the importance of disclosing bi-parental heterozygosity for a gene causing severe neonatal disease particularly when treatment is available and illustrates the need for further in vitro studies of this CaSR mutation.

Discharge planning.

Hospital discharge is a time of transition for infants and families that requires oversight of common postnatal adaptations, screening tests, and establishment of necessary follow-up care. Preterm infants face additional medical problems that vary in complexity by the degree of prematurity. Infants born at lowest gestational ages are at highest risks for complicated neonatal course and adverse long-term outcomes. Successful transition from hospital to home care is essential to improved outcomes for high-risk infants.

Enhancing residents' neonatal resuscitation competency through unannounced simulation-based training.

BACKGROUND: Almost half of pediatric third-year residents surveyed in 2000 had never led a resuscitation event. With increasing restrictions on residency work hours and a decline in patient volume in some hospitals, there is potential for fewer opportunities. PURPOSE: Our primary purpose was to test the hypothesis that an unannounced mock resuscitation in a high-fidelity in-situ simulation training program would improve both residents' self-confidence and observed performance of adopted best practices in neonatal resuscitation. METHODS: Each pediatric and medicine-pediatric resident in one pediatric residency program responded to an unannounced scenario that required resuscitation of the high fidelity infant simulator. Structured debriefing followed in the same setting, and a second cycle of scenario response and debriefing occurred before ending the 1-hour training experience. Measures included pre- and post-program confidence questionnaires and trained observer assessments of live and videotaped performances. RESULTS: Statistically significant pre-post gains for self-confidence were observed for 8 of the 14 NRP critical behaviors (p=0.00-0.03) reflecting knowledge, technical, and non-technical (teamwork) skills. The pre-post gain in overall confidence score was statistically significant (p=0.00). With a maximum possible assessment score of 41, the average pre-post gain was 8.28 and statistically significant (p<0.001). Results of the video-based assessments revealed statistically significant performance gains (p<0.0001). Correlation between live and video-based assessments were strong for pre-post training scenario performances (pre: r=0.64, p<0.0001; post: r=0.75, p<0.0001). CONCLUSIONS: Results revealed high receptivity to in-situ, simulation-based training and significant positive gains in confidence and observed competency-related abilities. Results support the potential for other applications in residency and continuing education.

Child safety seat knowledge among postpartum mothers in an urban setting.

BACKGROUND: To help direct future educational efforts, this study was conducted to assess the knowledge and attitudes relating to child safety seat use in an urban postpartum population. METHODS: An oral survey was administered to postpartum patients at two urban hospitals (one private and one public) to collect demographic information and to assess knowledge of proper use of a child safety seat. RESULTS: Mothers in the private hospital scored higher on knowledge assessment than those in the public hospital. The most important factors relating to knowledge were maternal education and reported previous child safety seat education, while having a previous child had no significant influence. CONCLUSIONS: In this urban setting, educational interventions are most needed in mothers with lower levels of education, and mothers with previous children should be included in such efforts. Additional investigation is needed to enhance infant safety for a large number of mothers who travel by public transportation.