A comparison of the direct cost of care in an open-bay and single-family room NICU.

OBJECTIVE: This research examined the proposition that the direct costs of care were no different in an open-bay (OPBY) as compared with a single-family room (SFR) neonatal intensive care (NICU) environment. STUDY DESIGN: This was a sequential cohort study. RESULT: General linear models were implemented using clinical and cost data for all neonates admitted to the two cohorts studied. Costs were adjusted to year 2007 U.S. dollars. Models were constructed for the unadjusted regression and subsequently by adding demographic variables, treatment variables, length of respiratory support and length of stay. With the exception of the last, none were found to achieve significance. The full model had R(2)=0.799 with P=0.0095 and predicted direct costs of care less in the SFR NICU. CONCLUSION: For the time, location and administrative practices in place, this study demonstrates that care can be provided in the SFR NICU at no additional cost as compared with OPBY NICU.

Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design.

OBJECTIVE: To compare perceived workplace quality in an open-bay neonatal intensive care unit (NICU) and a single-family room (SFR) NICU. STUDY DESIGN: Prospective non-randomized, non-controlled cohort study. RESULT: Staff workplace quality perceptions assessed included the following: the quality of being a Sanford Health System employee (NS-not significant), the quality of the NICU physical work environment, the quality of NICU patient care, the job quality in the NICU, the quality of health and safety in the NICU (NS), the quality of safety and security in the NICU, the quality of interaction with other members of the NICU health-care team (NS; in subanalysis nurse scores significantly declined), the quality of interaction with NICU technology and the off-job quality of life (NS). Scores for each category and the total scores were statistically greater in the SFR, except as noted (NS). CONCLUSION: Staff perceptions of workplace quality were significantly greater in the SFR than the open-bay NICU.

The impact of architectural design upon the environmental sound and light exposure of neonates who require intensive care: an evaluation of the Boekelheide Neonatal Intensive Care Nursery.

OBJECTIVES: To evaluate the differences in environmental sound, illumination and physiological parameters in the Boekelheide Neonatal Intensive Care Unit (BNICU), which was designed to comply with current recommendations and standards, as compared with a conventional neonatal intensive care unit (CNICU). STUDY DESIGN: Prospectively designed observational study. RESULT: Median sound levels in the unoccupied BNICU (37.6 dBA) were lower than the CNICU (42.1 dBA, P<0.001). Median levels of minimum (6.4 vs 48.4 lux, P<0.05) and maximum illumination (357 vs 402 lux, P<0.05) were lower in the BNICU. A group of six neonates delivered at 32 weeks gestation showed significantly less periodic breathing (14 vs 21%) and awake time (17.6 vs 29.3%) in the BNICU as compared to the CNICU. CONCLUSION: Light and sound were both significantly reduced in the BNICU. Care in the BNICU was associated with improved physiological parameters.

Sn-Mesoporphyrin interdiction of severe hyperbilirubinemia in Jehovah's Witness newborns as an alternative to exchange transfusion.

OBJECTIVE: The religious convictions of parents who are Jehovah's Witness adherents lead them to reject the use of exchange transfusions as therapy for severe hyperbilirubinemia in newborns in whom intensive phototherapy has failed to control this problem. Consequently, physicians caring for such infants may be obliged to initiate legal action to compel use of the procedure when severe hyperbilirubinemia not sufficiently responsive to phototherapy warrants an exchange transfusion. Our goal was to determine if we could use the potent inhibitor of bilirubin production, Sn-Mesoporphyrin (SnMP), to resolve the troubling medical-legal issues in such situations in 2 infants with hemolytic disease of the newborn who required exchange transfusions for severe hyperbilirubinemia but whose Jehovah's Witness parents rejected the procedure. SnMP was administered in a single dose, as in previous studies, at the time when exchange transfusion would have been initiated and plasma bilirubin levels were monitored at close intervals thereafter. METHODS: SnMP is a potent inhibitor of heme oxygenase, the rate-limiting enzyme in catabolism of heme to bilirubin. We found in earlier studies that in single doses of 6 micromol/kg birth weight, SnMP is extremely effective in moderating the course of hyperbilirubinemia and in eliminating the need for supplemental phototherapy in jaundiced newborns. In the 2 cases described, a single dose of SnMP (6 micromol/kg birth weight) was administered intramuscularly to severely jaundiced infants with immune hemolysis at a time when clinical circumstances dictated the need for exchange transfusion. CASE 1: This patient was a preterm male infant (gestational age: 35 5/7 weeks; birth weight: 2790 g) whose plasma bilirubin concentration (PBC) at 1 hour after birth was 5.0 mg/dL. Despite intensive phototherapy with 3 banks of lights and 1 biliblanket, the PBC increased steadily with no diminution in the rate of increase for 75 hours. In view of the problems of immune hemolysis, and prematurity, and the inability of phototherapy to stop progression of hyperbilirubinemia, a decision to carry out an exchange transfusion was made; the decision was, however, rejected by the Jehovah's Witness parents. Pending legal action to compel use of the procedure, a request to this (Rockefeller) laboratory for SnMP was made; its use was approved by the Food and Drug Administration; and the inhibitor was delivered to the physician-in-charge (D.P.M.) in Sioux Falls, South Dakota. The single dose of SnMP was administered to the infant at 75 hours after birth; the course of hyperbilirubinemia before and after the use of the inhibitor is shown in Fig 1. [figure: see text]. CASE 2: This female term infant (gestational age: 38-39 weeks; birth weight: 4140 g) with immune hemolysis was delivered by cesarean section and because of problems related to meconium aspiration required helicopter transfer to the Special Care Nursery in Abilene, Texas, where 10 hours after birth the first PBC was determined to be 18.0 mg/dL. Double-bank phototherapy plus a biliblanket was initiated; a third bank of lights was later ordered. The PBC fluctuated in the ensuing 2 days between 13.8 to 25.8 mg/dL during which suggestive clinical signs of possible bilirubin encephalopathy became manifest. In view of the clinical circumstances and the continued severe hyperbilirubinemia, permission for a double-exchange transfusion was requested. The parents, who were Jehovah's Witness adherents, refused the procedure. While preparing legal action to compel use of the exchange, a request was made to this (Rockefeller) laboratory for use of SnMP to attempt control of hyperbilirubinemia. With FDA approval, the SnMP was delivered to the attending neonatologist (J. R. M.) in Abilene and administered in a single dose (6 micromol/kg birth weight) at 56 hours after birth when the PBC was 19.5 mg/dL. The course of bilirubinemia before and after SnMP use is shown in Fig 2. [figure: see text]. RESULTS AND CONCLUSIONS: The use of SnMP to moderate or prevent the development of severe hyperbilirubinemia in newborns (preterm, near-term, term with high PBCs [15-18 mg/dL], ABO-incompatibility; glucose-6-phosphate dehydrogenase deficiency) has been extensively studied in carefully conducted clinical trials the results of which have been reported earlier. This inhibitor of bilirubin production has demonstrated marked efficacy in moderating the course of hyperbilirubinemia in all diagnostic groups of unconjugated neonatal jaundice. The 2 cases described in this report confirmed the efficacy of SnMP in terminating progression of hyperbilirubinemia in infants in whom phototherapy had failed to sufficiently control the problem and whose parents, for religious reasons, would not permit exchange transfusions. Interdiction of severe hyperbilirubinemia by inhibiting the production of bilirubin with SnMP can be an effective alternative to the use of exchange transfusion in the management of severe newborn jaundice that has not responded sufficiently to light treatment to ease concern about the development of bilirubin encephalopathy.

Bilateral fetal chylothorax: results of unilateral in utero therapy.

The optimal method for antenatal treatment of pleural effusions from congenital chylothorax unknown. A fetus with bilateral congenital chylothorax and hydrops had a pleural catheter placed in utero on only one side of the fetal chest for 14 days prior to delivery. The fetal hydrops partially resolved. After birth there was significantly less drainage from the pleural space that had been antenatally drained. This case demonstrates potential neonatal advantages of pleuro-amniotic shunt placement.

Polyhydramnios-oligohydramnios in a twin pregnancy complicated by fetal glomerulocystic kidney disease.

Polyhydramnios and oligohydramnios in twin gestation is most often caused by twin-twin transfusion syndrome. Presented is a monozygotic twin pair with polyhydramnios and oligohydramnios, in which both twins had glomerulocystic kidney disease of differing severity. The more severely affected donor twin died of renal failure in the neonatal period. The surviving twin is well following unilateral nephrectomy. This case illustrates the varied spectrum of pathology in glomerulocystic kidney disease.

Amniotic fluid analysis in a fetus with laryngeal atresia.

Complete laryngeal atresia is a rare congenital malformation that is known to cause hypertrophy of the fetal lung in utero. A fetus with laryngeal atresia was found to have markedly immature amniotic fluid lung maturity studies at term. Inappropriately low amniotic fluid lung maturity studies may be an important clue to the diagnosis of this condition.

Survival of the tiny neonate: USD School of Medicine/Sioux Valley Hospital experience, 1981-1992.

The survival of very low birth weight newborn infants of < or = 1000 gms cared for in the University of South Dakota School of Medicine/Sioux Valley Hospital Neonatal Intensive Care Unit was analyzed for the 12 year period of 1981-1992. Survival has increased from 45% in 1981-1983 to 65% in 1990-1992. The most recent figures for 1990-1992 indicate 54% survival in neonates of < or = 600 gms, 73% in those of 601-700 gms, 56% in those of 701-800 gms, 60% in those of 801-900 gms and 81% in those of 901-1000 gms. Survival rates by birth weight and gestational age are comparable to nationally published statistics. The potential for normal long term outcome, including physical growth and intellectual development, appears to be very good, with 74% of long term survivors having no evidence of severe physical or neurologic impairment at the time of discharge from the hospital.

Does prenatal care decrease the incidence and cost of neonatal intensive care admissions?

This study was conducted to examine the potential effects of expanded Medicaid coverage for low income women. Statewide birth data for 1983 to 1985 were examined to determine the relationship between prenatal care and admissions to neonatal intensive care units (NICUs) and the costs of this care. An NICU sample was constituted from infants who were discharged live following more than 7 NICU days, were referred to an out of state tertiary center, or died following NICU admission. Inadequate care (no prenatal care, only last trimester care, or less than five visits) was received by 11% of the total birth cohort and by 18% of the infants in the NICU sample (p less than 0.001). Infants with inadequate care had a NICU admission rate of 5.10% versus 2.86% for those with adequate prenatal care (p less than 0.001). The hospital billings for infants in the NICU sample with inadequate care were significantly higher than were those for infants with adequate care (p less than 0.05). Assuming that economic resources limit access to prenatal care, the projection can be made that had all women with inadequate prenatal care received Medicaid-covered adequate prenatal care, expenditure for this care would yield more than a two to one return in savings in NICU costs.

A new syndrome of aphalangy, hemivertebrae, and urogenital-intestinal dysgenesis.

Two cases of aphalangy, hemivertebrae, and urogenital-intestinal dysgenesis in a sibship are described. This constellation of malformations may represent a previously undescribed autosomal recessive trait.

Mothers and their children look at baby pictures: the NICU experience in retrospect.

Photographs of Neonatal Intensive Care Unit (NICU) patients are frequently given to parents to promote bonding, but little attention has been paid to how families respond years later to viewing these special baby pictures. This study examines how 71 mothers of 3 to 7-year-old developmentally normal (DQ greater than or equal to 80) children who weighed less than 1,500 g at birth describe this experience. Compared to a group of mothers whose children were full term at birth, the NICU mothers described personally feeling and perceiving their children as more fearful (p less than .05), inquisitive (p less than .0001), worried (p less than .01), thoughtful (p less than .0001), and tearful (p less than .05). The responses of NICU mothers were significantly more highly correlated with their perceptions of their children's responses than were the mother-child correlations observed in a comparison group. The NICU children were reported by their mothers to ask about the NICU equipment, pain, being alone, their physical scars, and if their being "bad" caused their need for intensive neonatal care. Recommendations are provided on how pediatric care providers can assist NICU parents anticipate questions and respond to their children's concerns as they view these potentially distressing photographs.

State reporting of live births of newborns weighing less than 500 grams: impact on neonatal mortality rates.

The National Center for Health Statistics reports that in 1983 65% of all infant deaths in the United States occurred in the neonatal period. Of these reported neonatal deaths, 17% were of infants weighing less than 500 g at birth. There was, however, variation in state-reported incidence of live births of newborns in this weight cohort (0.2 to 2.2 per 1,000 live births). The states with the lowest neonatal mortality rate have the lowest incidence of birth weights less than 500 g (rho = .77). If it is assumed that mortality for this weight category is nearly 100%, there is marked variation (5% to 32%) in the contribution of this weight cohort to a state's total neonatal mortality rate. Contributing to this variation may be definitions of live birth used by states. The World Health Organization defines a live birth as the product of conception showing signs of life "irrespective of the duration of pregnancy" and this definition is used by 33 states. Only one state (Ohio) includes the gestational criteria of "at least 20 weeks" in its definition of live birth. There is evidence to suggest that definitions are not uniformly used within individual states. For example, in 1983, 20 states did not report any live births with weights less than 500 g among their "other" populations of nonwhite, nonblack residents. Half of these states, however, use the World Health Organization definition of live birth. Despite the exclusionary wording in Ohio's definition of liver birth, 16% of newborns who died in that state had birth weights less than 500 g.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of esophageal and pharyngeal perforation in the newborn infant.

Perforation of the esophagus or pharynx may occur during placement of endotracheal or nasogastric tubes in the newborn infant. Controversy exists, however, whether medical or surgical therapy is better in the management of these perforations. Nine patients who had esophageal or pharyngeal perforation in the neonatal period and were treated medically with antibiotics, nutritional support, and closed chest-tube drainage of pneumothoraces are described. All perforations healed without surgical repair. No mortality or morbidity occurred secondary to these perforations. This study, together with a review of the 73 patients described in the literature, indicate that perforations of the pharynx and esophagus can be satisfactorily managed medically. There is no apparent advantage to routine early surgical exploration. Only complications such as mediastinitis and mediastinal mass formation seem to require surgical treatment. Medical therapy with close observation for signs of sepsis and/or mediastinal changes will enable most newborn infants to avoid an operation and will identify those infants for whom surgery is definitely indicated.

Effect of antenatal administration of Betamethasone on hospital costs and survival of premature infants.

Prenatal administration of glucocorticoids has been shown to decrease in incidence and severity of respiratory distress syndrome in premature infants, but little is known regarding the immediate economic impact of this reduction in respiratory morbidity. This study retrospectively examined 342 infants born during 1978 and 1979 and hospitalized in the University of Minnesota Hospitals. Comparison of survival and the hospital charges for infants whose mothers had not received prenatal glucocorticoid therapy showed that administration of glucocorticoids has a significant effect in lowering mortality in infants with birth weights between 750 and 1,249 gm (27 to 29 weeks' gestation). Glucocorticoid therapy was also effective in decreasing morbidity as reflected by hospital charges of surviving infants with birth weights between 1,250 and 1,749 gm (30 to 32 weeks' gestation). In both steroid-treated and nontreated mothers, prolongation of gestation decreases hospital charges in a linear fashion. The noted decrease in hospital costs should not justify prenatal glucocorticoid administration but should stimulate examination of long-term effects of the drug on surviving infants.