Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn.

Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..

Use of a Quality Scorecard to Enhance Quality and Safety in Community Hospital Newborn Nurseries.

OBJECTIVE: To implement a quality improvement (QI) scorecard as a tool for enhancing quality and safety efforts in level 1 and 2 community hospital nurseries affiliated with Nationwide Children's Hospital. STUDY DESIGN: A QI scorecard was developed for data collection, analytics, and reporting of neonatal quality metrics and cross-sector collaboration. Newborn characteristics were included for risk stratification, as were clinical and process measures associated with neonatal morbidity and mortality. Quality and safety activities took place in community hospital newborn nurseries in Ohio, and education was provided in both online and in-person collaborations, followed by local team sessions at partner institutions. Baseline (first 12 months) and postbaseline comparisons of clinical and process measures were analyzed by logistic regression, adjusting for potential confounders. RESULTS: In logistic regression models, at least 1 center documented improvements in each of the 4 process measures, and 3 of the 4 centers documented improvements in compliance with glucose checks obtained within 90 minutes of birth among at-risk infants. CONCLUSION: Collaborative QI projects led to improvements in perinatal metrics associated with important outcomes. Formation of a center-driven QI scorecard is feasible and provides community hospitals with a framework for collecting, analyzing, and reporting neonatal QI metrics.

Quality Improvement Initiative in the NICU for Improved Practice of Cuff Blood Pressure Measurements.

BACKGROUND: Extreme preterm infants face lengthy hospitalizations and are often subjected to painful stimuli. These stimuli may be related to routine caregiving that may negatively impact long-term developmental outcomes. Frequently obtained cuff blood pressure (BP) measurements are an example of a potentially noxious stimulus to preterm infants that may have a cumulating impact on development. PURPOSE: The primary aim was to explore the frequency of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the neonatal intensive care unit (NICU). Our secondary aim was to reduce the number of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the NICU. METHODS: Quality improvement methodologies per the Institute for Healthcare Improvement were used combined with a multidisciplinary approach. Participants were infants born less than 27 weeks of gestation and discharged home. The baseline period was 2015 through Q2-2018 and the intervention period was Q3-2018 through Q1-2020. The electronic medical record was used to collect data and Minitab Statistical Software was used for data analysis. FINDINGS/RESULTS: A baseline of 5.0% of eligible patients received the desired number of cuff BP measurements and increased to 63.2% after the intervention period. IMPLICATIONS FOR PRACTICE: Findings demonstrate that using quality improvement methodology can improve clinical care. Findings suggest the feasibility and safety of reducing the number of cuff BP measurements obtained on hemodynamically stable infants in the NICU. IMPLICATIONS FOR RESEARCH: Future endeavors should aim to reduce the quantity of painful stimuli in the NICU. Long-term developmental outcomes should be correlated in these patients.

Acetaminophen and Acetylsalicylic Acid Exposure in a Preterm Infant after Maternal Overdose.

Here, we review the case of a 26 1/7 weeks' gestation premature female infant born to a mother who intentionally ingested a large quantity of Tylenol, aspirin, quetiapine, and prenatal vitamins. The neonate subsequently had markedly elevated levels of both Tylenol and aspirin when checked on the first day of life. While overall clinically stable, the neonate did demonstrate coagulopathy as evidenced by abnormal coagulation studies. Both poison control and a pediatric gastroenterologist/hepatologist were consulted. She successfully tolerated a course of N-acetylcysteine; her subsequent Tylenol level was markedly decreased and the neonate exhibited no further effects of toxicity. The salicylate level decreased on its own accord. To our knowledge, this is the first report of a neonate at 26 weeks' gestation that has been successfully managed for supratherapeutic concentrations of acetaminophen and acetylsalicylic acid secondary to maternal ingestion. While rare, this case may serve as a reference for the effectiveness of N-acetylcysteine in premature infants in such instances.

Neonatologists and vitamin K hesitancy.

Hemorrhagic disease of the newborn, more aptly termed "Vitamin K Deficiency Bleeding (VKDB)," has long been recognized as a cause of significant morbidity and mortality in early infancy. A single intramuscular dose of vitamin K administered at birth has virtually eliminated VKDB, and this prophylactic regimen has been recommended by the American Academy of Pediatrics since 1961. Although most newborns in the United States receive vitamin K at birth, a growing number of parents are hesitant about this intervention, citing concerns about harm from the injection, preservatives contained in the medication, and clashes with personal belief systems. Ultimately, there is distrust in the medical establishment as many of these parents also opt out of newborn ophthalmic prophylaxis and importantly, childhood vaccinations, establishing a dangerous public health precedent that will lead to resurgence of vaccine-preventable diseases. Various shared decision making models and educational efforts can assist newborn health care professionals in addressing these parental concerns so that VKDB can be effectively prevented in all newborns.

Development of a small baby unit to improve outcomes for the extremely premature infant.

Survival and outcomes for extremely premature (EP) infants have improved and even infants born at 23 and 24 weeks that were previously considered non-viable are now routinely surviving. This review describes our particular institution's basis for and process of creating and sustaining a small baby program for a quaternary, referral-based neonatal intensive care unit. Through multi-disciplinary collaboration, small baby guidelines were developed that established uniform care and optimized evidence-based practice for the care of this unique patient population. A focus on parent-centered care while removing noxious stimuli for the patient has improved neurodevelopmental outcomes. Data collection, quality improvement, and ongoing research are incorporated in the small baby program to establish and sustain best practices and outcomes for the EP patient. Through the establishment of a small baby unit, we have improved survival, decreased short-term morbidities, and improved neurodevelopmental outcomes for the EP infant in our region.

Perspectives on developing and sustaining a small baby program.

The Small Baby Program at Nationwide Children's Hospital was launched in 2004 in response to a need for better care for infants born extremely preterm. Standardization of care, decreased variability, multidisciplinary support, and robust research and quality improvement have allowed us to greatly improve our outcomes. In addition to the numerous medical and technological advances during this time, a strong commitment to kangaroo care and family-centered care have been integral to the growth and success of our program. The following review of the program aims to highlight the above areas while detailing the specific processes that have contributed to its ongoing success. Key areas of focus have been on respiratory management, neurodevelopmental care, and nutritional optimization. The implementation and continued refinement of the Small Baby Program has allowed us to improve the survival of extremely preterm infants, decrease certain morbidities, and improve long-term neurodevelopmental outcomes.

Near-Infrared Spectroscopy in Extremely Preterm Infants.

With advances in neonatal care, survival of premature infants at the limits of viability has improved significantly. Despite these improvement in mortality, infants born at 22-24 weeks gestation are at a very high risk for short- and long-term morbidities associated with prematurity. Many of these diseases have been attributed to abnormalities of tissue oxygenation and perfusion. Near-infrared spectroscopy utilizes the unique absorption properties of oxyhemoglobin and deoxyhemoglobin to provide an assessment of regional tissue oxygen saturation, which can be used to calculate the fractional tissue oxygen extraction. This allows for a non-invasive way to monitor tissue oxygen consumption and enables targeted hemodynamic management. This mini-review provides a brief and complete overview of the background and physiology of near-infrared spectroscopy, practical use in extremely preterm infants, and potential applications in the neonatal intensive care unit. In this mini-review, we aim to summarize the three primary application sites for near-infrared spectroscopy, disease-specific indications, and available literature regarding use in extremely preterm infants.

Predicting survival in infants born at <27 weeks gestation admitted to an all referral neonatal intensive care unit: a pilot study.

BACKGROUND: There are no available predictive models for survival in extremely preterm (EP) infants admitted to a referral Level IV neonatal intensive care unit (NICU) after the first day of life (DOL). OBJECTIVE: To determine if there are clinical variables present at admission that are associated with survival in an outborn EP population. STUDY DESIGN: Data were analyzed from EP infants admitted before DOL 100 from 2008 to 2016 (n = 744). RESULTS: We found that prophylactic indomethacin (OR 1.98 (1.20-3.25) p = 0.007), admit DOL (OR 1.05 (1.02-1.08) p < 0.001), and birth in Franklin County, (OR 2.02 (95% CI, 1.04-3.90) p = 0.04) were all associated with survival. Using ROC analysis, the area under the curve for the provisional survival score was 0.69 (95% CI, 0.64-0.75; p < 0.0001). CONCLUSIONS: There are factors on admission to a referral Level IV NICU associated with survival in EP patients.

Revert to the original: time to re-establish delayed umbilical cord clamping as the standard approach for preterm neonates.

Delayed cord clamping, the common term used to denote placental-to-newborn transfusion at birth, is a practice now endorsed by the major governing bodies affiliated with maternal-newborn care. Despite considerable evidence, delayed cord clamping, not early cord clamping, continues to be viewed as the "experimental" intervention category when discussed in research studies. We provide a brief overview of placental-to-newborn transfusion in relation to birth transitional physiology and discuss areas where we may need to modify our interpretation of "normal" vital signs and laboratory values as delayed cord clamping becomes standardized. We also assert that delayed cord clamping should now be viewed as the standard of care approach, especially given that multiple randomized controlled trials have revealed that early cord clamping, which lacks evidence-based support, is associated with a greater risk for morbidity and mortality than delayed cord clamping.

Handheld, point-of-care laser speckle imaging.

Laser speckle imaging (LSI) enables measurement of relative changes in blood flow in biological tissues. We postulate that a point-of-care form factor will lower barriers to routine clinical use of LSI. Here, we describe a first-generation handheld LSI device based on a tablet computer. The coefficient of variation of speckle contrast was < 2% after averaging imaging data collected over an acquisition period of 5.3 s. With a single, experienced user, handheld motion artifacts had a negligible effect on data collection. With operation by multiple users, we did not identify any significant difference (p > 0.05) between the measured speckle contrast values using either a handheld or mounted configuration. In vivo data collected during occlusion experiments demonstrate that a handheld LSI is capable of both quantitative and qualitative assessment of changes in blood flow. Finally, as a practical application of handheld LSI, we collected data from a 53-day-old neonate with confirmed compromised blood flow in the hand. We readily identified with LSI a region of diminished blood flow in the thumb of the affected hand. Our data collectively suggest that handheld LSI is a promising technique to enable clinicians to obtain point-of-care measurements of blood flow.

Quality of life in patients with cutaneous leishmaniasis.

BACKGROUND: Leishmaniasis is a zoonotic infection caused by a protozoa belonging to the genus Leishmania. Its clinical manifestations range from a self-healing cutaneous leishmaniasis (CL) to lethal visceral leishmaniasis. We aim to examine the quality of life of patients with CL in Kerman, Iran.  METHODS: In this cross-sectional study we evaluated 124 patients with CL. The Dermatology Life Quality Index (DLQI) questionnaire was used for measuring quality of life. Data on demographics and characteristics of the lesions also were collected. Mann-Whitney U-test and Kruskal-Wallis were used for data analyses. RESULTS: The mean DLQI score was 5.87 ± 5.96. We observed the highest effect in the symptoms and feelings domains; the lowest effect was seen in the treatment domain of the DLQI. There was no significant difference in DLQI scores between men and women. Patients with ulcerated lesions had lower quality of life (P < 0.05).  CONCLUSION: CL significantly affects the quality of life of patients. Further studies are suggested to examine the effect of its treatment on the quality of life in these patients.