Prenatal marijuana exposure and neonatal outcomes: a retrospective cohort study.

OBJECTIVES: Previous literature on the effects of marijuana exposure on neonatal outcomes has been limited by the reliance on maternal self-report. The objective of this study was to examine the relationship of prenatal marijuana exposure on neonatal outcomes in infants with marijuana exposure confirmed with meconium drug testing. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Meconium drug screens obtained on infants born in a hospital system in the Pacific Northwest in the USA over a 2.5-year period. 1804 meconium drug screens were initially obtained, with 1540 drug screens included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: Neonates with meconium drug screens positive for delta-9-tetrahydrocannabinol (THC) only were compared with neonates with negative drug screens. The following neonatal outcomes were examined: gestational age, preterm birth (<37 weeks), birth weight, low birth weight (defined as birth weight <2.5 kg), length, head circumference, Apgar scores and admission to the neonatal intensive care unit (NICU). Using multivariable logistical and linear regression, we controlled for confounding variables. RESULTS: 1540 meconium drug screens were included in the analysis, with 483 positive for delta-9-THC only. Neonates exposed to delta-9-THC had significantly lower birth weight, head circumference and length (p<0.001). Neonates with THC exposure had 1.9 times the odds (95% CI 1.3 to 2.7, p=0.001) of being defined as low birth weight. Birth weight was on average 0.16 kg lower (95% CI 0.10 to 0.22, p<0.001) in those exposed to THC. CONCLUSIONS: Prenatal marijuana exposure was significantly associated with decreases in birth weight, length and head circumference, and an increased risk of being defined as low birth weight. These findings add to the previous literature demonstrating possible negative effects of prenatal marijuana use on neonatal outcomes.

Do Standardized Scripts Improve Interpreter Use by Spanish-Speaking Patients?

Patients with limited English-proficiency (LEP) who need but do not receive interpreters have lower satisfaction and poorer understanding. A knowledge gap remains regarding the optimal way to offer interpreters. Using standardized scripts, we will determine whether the questions we use to offer interpreters increase utilization. Pilot prospective cohort study of postpartum mothers with LEP. Subjects were assigned one of three unique scripted question offering an interpreter. Data were analyzed using ANOVA, chi-square test, and Fisher's exact test. Fifty-five LEP patients were randomized into three study arms with similar sociodemographics. Overall interpreter use was 80% (44/55). There was a significant difference in interpreter utilization: 82.4%, 63.6%, 100%, respectively by arm (p = 0.015). Highest interpreter utilization occurred with "In what language do you prefer to receive your medical care?". There is opportunity for providers to refine the way they offer interpreters to optimize utilization.

Ethical and Public Health Implications of Targeted Screening for Congenital Cytomegalovirus.

Congenital cytomegalovirus (cCMV) is the most common congenital infection and is associated with sensorineural hearing loss, developmental delays, and visual impairment. The clinical presentation of cCMV is variable, and the majority (80%-90%) of newborns will never manifest any clinical symptoms. Given the clinical heterogeneity of cCMV infection, it is challenging to identify which newborns may benefit from testing. Recently, certain states have implemented a targeted screening program in which newborns who fail the newborn hearing screen are tested for cCMV. Clinicians and legislative bodies have been propelled into debates about the ethical and moral permissibility of a targeted cCMV screening approach. Those who oppose this screening approach describe undue burden on patients, families, and the health care system because the majority of newborns who fail the newborn hearing screen and have cCMV will not go on to have any sequelae related to cCMV, including hearing loss. However, those who support this screening approach cite the importance of early detection and ongoing surveillance for hearing loss and developmental delays in this high-risk group of newborns. This debate will be considered by experts in the field.

Pulmonary Function and Systolic Blood Pressure in Very Low Birth Weight Infants at 34 - 36 Weeks of Corrected Age.

PURPOSE: Preterm infants are at increased risk of systemic hypertension compared to term infants. Bronchopulmonary dysplasia (BPD) has been shown to be associated with hypertension in preterm infants albeit with no causation reported. BPD is characterized by abnormal pulmonary function tests (PFTs), specifically elevated passive respiratory resistance (Rrs), decreased passive respiratory compliance (Crs) and decreased functional residual capacity (FRC). There have been no studies comparing PFTs in very low birth weight (VLBW) infants with and without hypertension. We hypothesized that stable VLBW infants with hypertension will have altered PFTs. PATIENTS AND METHODS: Retrospective cohort study of infants < 1500 grams at birth (VLBW) who had PFTs performed near 34-36 weeks of corrected gestational age (CGA). We excluded infants with congenital anomalies, known hypertensive disorders or those at risk of medication-induced hypertension. Data obtained included PFT parameters (Rrs, Crs, FRC) and mean systolic blood pressure (SBP). RESULTS: 59 VLBW infants were identified for analysis, 14 with and 45 without hypertension. Hypertensive and normotensive patients were similar in terms of mean gestational age (26.6 vs 27.4 weeks), mean CGA at PFTs (36.1 vs 34.6 weeks) and proportion of BPD (36% vs 36%). The Rrs was significantly higher in hypertensive versus normotensive patients [median Rrs of 0.080 (0.069, 0.090) versus 0.066 (0.054, 0.083) cmH2O/mL/sec; p = 0.04]. There was no difference in systolic blood pressure in the infants with and without BPD. CONCLUSION: In this cohort of contemporary VLBW infants, those with hypertension had increased Rrs. This finding warrants a prospective study with a larger sample size and long-term follow-up.

Implementation of the sepsis risk score for chorioamnionitis-exposed newborns.

BACKGROUND: To prevent early onset sepsis (EOS), ~10% of neonates receive antibiotics based on CDC recommendations regarding chorioamnionitis exposure. A sepsis risk score (SRS) predicts EOS and spares unnecessary evaluation and treatment. LOCAL PROBLEM: Chorioamnionitis-exposed neonates utilize significant resources. METHODS: An SRS algorithm was implemented to decrease resource utilization in chorioamnionitis-exposed neonates ≥35 weeks'. Outcome measures included antibiotic exposure, time in NICU, laboratory evaluations, and length of stay (LOS). Balancing measures were missed cases of EOS and readmissions. Data were assessed using run charts. INTERVENTIONS: Plan-Do-Study-Act cycles were utilized to process map, implement and reinforce the algorithm. RESULTS: A number of 356 patients met inclusion criteria. After algorithm implementation, antibiotic exposure reduced from 95 to 9%, laboratory evaluation from 96 to 22%, NICU observation from 73 to 10%. LOS remained unchanged. No missed cases of EOS, nor sepsis readmissions. CONCLUSIONS: Algorithm implementation decreased antibiotic and resource utilization without missing cases of EOS.

Characteristics of hypertension in premature infants with and without chronic lung disease: a long-term multi-center study.

BACKGROUND: Many causes for neonatal hypertension in premature infants have been described; however in some cases no etiology can be attributed. Our objectives are to describe such cases of unexplained hypertension and to compare hypertensive infants with and without chronic lung disease (CLD). METHODS: We reviewed all cases of hypertension in premature infants referred from 18 hospitals over 16 years. Inclusion criteria were hypertension occurring at <6 months of age and birth at <37 weeks gestation; the main exclusion criterion was known secondary hypertension. Continuous variables were compared using analysis of variance. Nominal variables were compared using chi-square tests. RESULTS: A total of 97 infants met the inclusion criteria, of whom 37 had CLD. Among these infants, hypertension presented at a mean of 11.3 ± 3.2 chronological weeks of age and a postmenstrual age of 39.6 ± 3.6 weeks. Diagnostic testing was notable for plasma renin activity (PRA) being <11 ng/mL/h in 98% of hypertensive infants. Spironolactone was effective monotherapy in 51 of 56 cases of hypertension. Hypertension resolved in all infants, with an average treatment duration of 25 weeks. Significant differences between the two groups of infants were a 0.4 kg lower birthweight and a 2.5 weeks younger gestational age at birth in those with CLD (p < 0.01, p < 0.01, respectively). Hypertension presented in those with CLD 1.8 weeks later, but at the same postmenstrual age as those without CLD (p < 0.01, p = 0.45, respectively). CONCLUSION: Premature infants with unexplained hypertension, with and without CLD, presented at a postmenstrual age of 40 weeks with low PRA, transient time course, and a favorable response to spironolactone treatment.