Inter-rater reliability of the modified Sarnat examination in preterm infants at 32-36 weeks' gestation.

OBJECTIVE: To test the inter-rater reliability of the modified Sarnat neurologic examination in preterm neonates and to correlate abnormalities with the presence of perinatal acidosis. METHODS: Prospective study of 32-36 weeks' gestational age infants admitted to the neonatal intensive care unit. Each infant had two Sarnat examinations performed at <6 h, one by a gold standard (GS) study investigator, and the second either by (a) another GS examiner or (b) an attending physician (28 examiners), all blinded to clinical variables. Agreement was calculated using kappa (k) statistics. RESULTS: One hundred and two (9, fetal acidosis) infants underwent a modified Sarnat examination. Among GS examiners, agreement was excellent (k > 0.8) except for Moro, while among all examiners agreement was very good (k > 0.7) except for both Moro and tone. Subgroup analysis at 32-34 weeks' showed fair/poor Moro compared to excellent agreement at ≥35 weeks. Increasing abnormalities correlated with acidosis (r = -0.6, P < 0.01). CONCLUSIONS: Strong inter-rater reliability for the modified Sarnat was observed except for tone and Moro in preterm infants. Experience of the examiners resulted in improved reliability in tone, while for the Moro agreement improved only beyond 35 weeks. Findings suggest the need of adjustment of the examination form specific for preterm infants.

Weaning of Moderately Preterm Infants from the Incubator to the Crib: A Randomized Clinical Trial.

OBJECTIVE: To assess whether length of hospital stay is decreased among moderately preterm infants weaned from incubator to crib at a lower vs higher weight. STUDY DESIGN: This trial was conducted in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants with gestational ages 29-33 weeks, birthweight <1600 g, and in an incubator were randomly assigned to a weaning weight of 1600 or 1800 g. Within 60 to 100 g of weaning weight, the incubator temperature was decreased by 1.0°C to 1.5°C every 24 hours until 28.0°C. The infants were weaned to the crib following stable temperature at 36.5°C to 37.4°C for 8 to 12 hours. Clothing and bedcoverings were standardized. The primary outcome was length of hospital stay from birth to discharge; secondary outcomes included length of stay and growth velocity from weaning to discharge. Adverse events were monitored. RESULTS: Of 1565 infants screened, 885 were eligible, and 366 enrolled-187 to the 1600-g and 179 to the 1800-g group. Maternal and neonatal characteristics did not differ among weight groups. Length of hospital stay was a median of 43 days in the lower and 41 days in the higher weight group (P = .12). Growth velocity from completion of weaning to discharge was higher in the lower weight group, 13.7 g/kg/day vs 12.8 g/kg/day (P = .005). Groups did not differ in adverse events. CONCLUSIONS: Among moderately preterm neonates, weaning from incubator to crib at a lower weight did not decrease length of stay, but was safe and was accompanied by higher weight gain after weaning. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02160002.

Decrease in the frequency of treatment for patent ductus arteriosus after implementation of consensus guidelines: a 15-year experience.

BACKGROUND: Patent ductus arteriosus (PDA) management varies widely among neonatologists. LOCAL PROBLEM: Lack of institution-specific evidence-based guidelines for therapeutic closure of PDA. METHODS: Quality improvement project among infants <30 weeks gestational age (GA) designed to determine whether the odds of therapy for closing the PDA, adjusted for GA, decreased after implementing evidence-based guidelines. INTERVENTION: Implementation of guidelines with conservative approach to PDA management. RESULTS: The frequency of PDA treatment decreased from 446/1125 (40%) in Epoch 1 to 96/482 (20%) in Epoch 2. PDA treatment was more frequent in neonates 23-26 weeks GA than those of 27-29 weeks GA (43% vs. 28%, respectively). Among 542 infants receiving indomethacin for PDA, 25% had subsequent ligation; the odds of ligation after indomethacin were lower in neonates 27-29 weeks GA and decreased during Epoch 2. CONCLUSIONS: The frequency of medical and surgical treatment for therapeutic closure of PDA decreased after implementing evidence-based treatment guidelines.

Valid serial length measurements in preterm infants permit characterization of growth patterns.

BACKGROUND: The lack of a valid and safe method for measuring length in critically ill preterm neonates has led to a primary focus on weight gain. LOCAL PROBLEM: Paucity of valid length measurements, precluding the accurate analysis of growth patterns. METHODS: Quality improvement project among infants < 29 weeks or small for gestational age < 35 weeks with embedded validation of (1) a caliper (infantometer) for length measurements and (2) length measurements during the first week to estimate birth length. INTERVENTION: Implementation of valid methods to measure length. RESULTS: We validated infantometer measurements and first week length measurements. The percentage of neonates with valid measurements during the first week rose from 10% to 78%, resulting in increased identification of classifiable growth patterns from < 10% to 89%. CONCLUSIONS: By increasing the percentage of neonates with valid length measurements in the first week postnatal, we identified an increased number of neonates with classifiable growth abnormalities.