Maternal, neonatal, and nutritional risk factors for medical and surgical necrotizing enterocolitis.

OBJECTIVE: To identify maternal and neonatal risk factors associated with progression to surgery or death after diagnosis of NEC. STUDY DESIGN: Forty-seven demographic and clinical factors were evaluated across 216 validated cases of NEC occurring between 2010-2020. Nutrition at NEC onset was evaluated in 149 cases. The binary outcome of surgical NEC (progressing to surgery or death) vs. medical NEC (resolved with antibiotic/bowel rest) was compared across variables. RESULTS: Elevated CRP, rapidly decreasing platelet counts, inotropic medication, intubation, and positive blood cultures within 24 h of diagnosis were associated with progression to surgery/death. Infants with surgical NEC had higher abdominal circumferences at birth. Maternal milk intake and receipt of human milk fortifiers were associated with medical NEC, and infants receiving fortified, maternal milk showed the lowest progression to surgery/death. CONCLUSION: The index of suspicion should be heightened for surgical NEC when these risk factors are present.

Incidence, Risk Factors, and Outcomes Associated With Recurrent Neonatal Acute Kidney Injury in the AWAKEN Study.

Importance: The incidence and associated outcomes of recurrent acute kidney injury (rAKI) in neonates remain largely unknown. Objective: To determine the incidence, risk factors, and clinical outcomes associated with rAKI in critically ill neonates. Design, Setting, and Participants: This cohort study was a secondary analysis of the multicenter, international Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates retrospective study. Comparisons were made among neonates with no AKI, a single AKI episode (sAKI), and rAKI. All neonates younger than 14 days who were admitted between January 1 and March 31, 2014, to 24 participating level II to IV neonatal intensive care units and received intravenous fluids for at least 48 hours were considered for inclusion. Neonates with congenital heart disease requiring surgery within the first week of life, lethal chromosomal anomalies, death within 48 hours of admission, or severe congenital kidney abnormalities were excluded. Data were analyzed from May 23, 2022, to December 8, 2023. Exposure: Recurrent AKI using the neonatal Kidney Disease: Improving Global Outcomes criteria. Determination of each rAKI required a complete return to the baseline serum creatinine level that defined the prior AKI episode. Main Outcomes and Measures: Incidence and risk factors of rAKI and associations of rAKI with length of stay (LOS; ie, birth to hospital discharge) and mortality. Results: The study cohort (n = 2162) included 1233 male neonates (57.0%). Gestational age distribution was less than 29 weeks for 276 neonates (12.8%), 29 to less than 36 weeks for 958 (44.3%), and 36 weeks or older for 928 (42.9%). Of 605 neonates with AKI, 133 (22.0%) developed rAKI with risk factors including younger gestational age, lower birthweight, and higher stage of initial AKI. Infants with rAKI experienced longer median LOS (no AKI, 17 [IQR, 8-34] days; sAKI, 18 [IQR, 9-45] days; rAKI, 60 [IQR, 25-109] days; P < .001). Time-varying Cox proportional hazards regression models suggest rAKI is independently associated with a lower hazard of discharge (adjusted hazard ratio, 0.7 [95% CI, 0.6-0.9]; P = .01) when compared with sAKI, but mortality did not differ between groups (adjusted hazard ratio, 1.4 [95% CI, 0.6-3.0]; P = .44). Conclusions and Relevance: In this cohort study, neonatal rAKI was independently associated with longer LOS when compared with sAKI, suggesting that rAKI in neonates may be an important clinical distinction warranting further study and careful monitoring after an initial AKI episode.

Recurrent neonatal acute kidney injury: incidence, predictors, and outcomes in the neonatal intensive care unit.

OBJECTIVE: Determine recurrent neonatal acute kidney injury (rAKI) incidence, risk factors, and associated outcomes. STUDY DESIGN: Single-center retrospective cohort of neonates admitted to the NICU 1/1/20-6/30/21. Comparisons were made between those with no AKI, single AKI episode (sAKI), and rAKI. Multivariable linear and logistic regression models were used to assess associations between rAKI and length of mechanical ventilation (LMV), length of hospitalization stay (LOS), mortality, and hypertension (HTN) at discharge. RESULTS: The incidence of AKI in the cohort of 869 infants was 19%: 705 (81%) no AKI, 100 (12%) sAKI, 64 (7%) rAKI. Both sAKI and rAKI were independently associated with longer LMV and LOS. sAKI was independently associated with almost 4x higher odds of mortality than rAKI. CONCLUSION: In this single center cohort of neonates, sAKI independently predicts mortality, however rAKI is independently associated with increased LMV and LOS suggesting rAKI is clinically important and warrants further study.

British Congenital Cardiac Association Fetal Cardiology Standards: impact of Patient and Public involvement exercise on the development of clinical standards.

OBJECTIVE: To examine the impact of a Patient and Public Involvement exercise on the development of British Congenital Cardiac Association Fetal Cardiology Standards 2021. DESIGN: Open-ended, semi-structured interviews were undertaken to inform the design of a study to improve the quality of parents' experiences during antenatal and perinatal care of their child with CHD. This Patient and Public Involvement exercise was used to inform the final version of the drafted 'Standards'. SETTING: One-on-one interviews with parents who responded to a request on the closed Facebook page of the user group "Little Hearts Matter": "Would you be interested in helping us to design a study about parents' experience on learning that their child had CHD"? PATIENTS: Parents of children with single ventricle CHD. RESULTS: Twenty-one parents (18 mothers, 3 fathers) participated. Parents responses were reported to have variably reinforced, augmented, and added specificity in the later stages of drafting to six of the seven subsections of Section C Information and Support for Parents including: "At the time of the Scan"; "Counselling following the identification of an abnormality"; "Written information/resources"; "Parent support"; "Communication with other teams and ongoing care"; and "Bereavement support". CONCLUSIONS: This Patient and Public Involvement exercise successfully informed the development of Standards after the initial drafting. It contributed to the establishment of face validity of the 'Standards', especially when consistent with what is reported in the literature. Further research is needed to explore approaches to involving and standardising Patient and Public Involvement in the development of clinical standards.

Impact of Delayed Time to Antibiotics in Medical and Surgical Necrotizing Enterocolitis.

This study investigated whether delayed receipt of antibiotics in infants with necrotizing enterocolitis (NEC) is associated with disease severity. In this retrospective, single-center cohort study of infants diagnosed with NEC over 4 years, we compared the timing of antibiotic administration in infants (time order placed to time of receipt) in medical and surgical NEC. Cases were independently reviewed, then various clinical factors were compared. Of 46 suspected cases, 25 were confirmed by a panel of radiologists with good interrater reliability (ICC 0.657; p < 0.001). Delays in antibiotic receipt were 1.7× greater in surgical than medical NEC cases (p = 0.049). Every hour after order entry increased the adjusted odds of surgical NEC by 2.4 (1.08−5.23; p = 0.032). Delayed antibiotic receipt was more common in infants with surgical than medical NEC. Larger studies will be needed to investigate if optimizing antibiotic expediency could improve intestinal outcomes.

Urinary Tract Dilation in the Fetus and Neonate.

Urinary tract dilation (UTD), previously known as hydronephrosis, is the most common congenital condition identified on prenatal ultrasonography. UTD can be physiologic and resolve spontaneously or can be caused by various congenital anomalies of the urinary tract, which can lead to renal failure if not treated properly. In 2014, a multidisciplinary consensus group established UTD definitions, a classification system, and a standardized scheme for perinatal evaluation. Various imaging modalities are available to help diagnose the cause of UTD in fetuses and neonates and to help identify those patients who may benefit from fetal or early postnatal intervention. In this article, we will review the diagnosis and quantification of antenatal and postnatal UTD based on the UTD classification system, outline the imaging studies available to both evaluateUTD and determine its cause, briefly review the most common causes of UTD in the fetus and neonate, outline management strategies for UTD including the role for fetal intervention and prophylactic antibiotics, and report on the outcome and prognosis in patients with UTD.

Improving the identification of acute kidney injury in the neonatal ICU: three centers' experiences.

OBJECTIVE: To describe three different standardized approaches to improving neonatal acute kidney injury (AKI) identification and the impact on AKI identification, incidence, and nephrology consultation and referral. STUDY DESIGN: A retrospective cohort study in three academic NICUs. We compared AKI identification, AKI incidence, nephrology consultation, and nephrology follow-up before and after implantation of local protocols to standardize neonatal AKI identification. RESULT: Neonatal AKI identification improved in all three NICUs following protocol implementation (26-85%, P < 0.0001). Each center also saw increases in nephrology consultation (15-83%, P < 0.0001) and nephrology follow-up (7-73%, P < 0.0001). AKI incidence decreased significantly (21-12%, P < 0.0001). CONCLUSION: Multiple strategies can be successfully operationalized to improve neonatal AKI identification. While different in approach, each strategy resulted in increased AKI identification and nephrology involvement. This study emphasizes the importance of local standardized approaches to AKI to improve AKI identification and nephrology involvement in the NICU.

Using different methods for calculating frontal alpha asymmetry to study its development from infancy to 3 years of age in a large longitudinal sample.

Frontal electroencephalography (EEG) alpha asymmetry (FAA), defined as the difference in frontal alpha power observed over the right and left frontal scalp regions, has been widely used in developmental research as a measure of multiple aspects of child behavior, such as temperament. Studies have used different equations to calculate FAA, which renders comparison of results across studies challenging. Furthermore, few studies have examined FAA's longitudinal stability across infancy and early childhood, which is a desirable feature of a temperament measure. We investigated the cross-sectional and the longitudinal correlations of FAA values from four different equations to calculate FAA used in the literature. We used baseline EEG data from a longitudinal sample of 321 infants and 168 3-year-old children (149 of whom had data at both timepoints). Consistent with previous work, FAA values calculated using two commonly used equations were highly correlated with each other cross-sectionally but not with values from a different equation that used log-transformed relative power. The log-transformed relative power FAA values were the only values that showed significant longitudinal stability. These findings suggest that researchers interested in FAA as a trait-like measure in children should consider using the relative power equation that renders stability across ages.

Parents' responses to prognostic disclosure at diagnosis of a child with a high-risk brain tumor: Analysis of clinician-parent interactions and implications for clinical practice.

BACKGROUND: Previous studies have found that parents of children with cancer desire more prognostic information than is often given even when prognosis is poor. We explored in audio-recorded consultations the kinds of information they seek. METHODS: Ethnographic study including observation and audio recording of consultations at diagnosis. Consultations were transcribed and analyzed using an interactionist perspective including tools drawn from conversation and discourse analysis. RESULTS: Enrolled 21 parents and 12 clinicians in 13 cases of children diagnosed with a high-risk brain tumor (HRBT) over 20 months at a tertiary pediatric oncology center. Clinicians presented prognostic information in all cases. Through their questions, parents revealed what further information they desired. Clinicians made clear that no one could be absolutely certain what the future held for an individual child. Explicit communication about prognosis did not satisfy parents' desire for information about their own child. Parents tried to personalize prognostic information and to apply it to their own situation. Parents moved beyond prognostic information presented and drew conclusions, which could change over time. Parents who were present in the same consultations could form different views of their child's prognosis. CONCLUSION: Population level prognostic information left parents uncertain about their child's future. The need parents revealed was not for more such information but rather how to use the information given and how to apply it to their child in the face of such uncertainty. Further research is needed on how best to help parents deal with uncertainty and make prognostic information actionable.

Acute Kidney Injury Guidelines Are Associated With Improved Recognition and Follow-up for Neonatal Patients.

BACKGROUND: Studies demonstrate that neonatal acute kidney injury (AKI) is associated with increased morbidity and mortality. Acute kidney injury survivors are at risk for renal dysfunction and chronic kidney disease and require long-term follow-up. PURPOSE: To maximize identification of AKI and ensure referral, we created guidelines for diagnosis, evaluation, and management of AKI. METHODS/SEARCH STRATEGY: Retrospective cohort study of neonatal intensive care unit patients treated before guideline implementation (cohort 1; n = 175) and after (cohort 2; n = 52). Outcome measures included AKI incidence, documented diagnosis, and pediatric nephrology consultation. Statistical methods included t tests, Fisher exact tests, and Wilcoxon rank sum tests. FINDINGS/RESULTS: We found 68 AKI episodes in 52 patients in cohort 1 and 15 episodes in 12 patients in cohort 2. Diagnosis and documentation of AKI improved after guideline implementation (C1:24/68 [35%], C2: 12/15 [80%]; P = .003) as did pediatric nephrology consultation (C1:12/68 [18%]; C2: 12/15 [80%]; P < .001) and outpatient referral (C1: 3/47 [6%], C2:5/8 [63%]; P < .01). IMPLICATIONS FOR PRACTICE: Neonatal AKI guideline implementation was associated with improvements in recognition, diagnosis, and inpatient and outpatient nephrology consultation. Early recognition and diagnosis along with specialist referral may improve outcomes among neonatal AKI survivors, ensuring appropriate future monitoring and long-term follow-up. IMPLICATIONS FOR RESEARCH: Future research should continue to determine the long-term implications of early diagnosis of AKI and appropriate subspecialty care with follow-up.

Insights into the perception that research ethics committees are a barrier to research with seriously ill children: A study of committee minutes and correspondence with researchers studying seriously ill children.

BACKGROUND: Research ethics committees are commonly perceived as a 'barrier' to research involving seriously ill children. Researchers studying seriously ill children often feel that committees view their applications more harshly compared to applications for research with other populations. Whether or not this is the case in practice is unknown. AIM: The aim of this study was to explore committees' concerns, expectations and decisions for research applications involving seriously ill children submitted for review in the United Kingdom. DESIGN: Content analysis of committee meeting minutes, decision letters and researcher response letters. SETTING/PARTICIPANTS: Chief investigators for National Institute of Health Research portfolio studies involving seriously ill children were contacted for permission to review their study documents. RESULTS: Of the 77 applications included in this study, 57 received requests for revisions at first review. Committee expectations and concerns commonly related to participant information sheets, methodology, consent, recruitment or formatting. Changes were made to 53 of these studies, all of which were subsequently approved. CONCLUSION: Our findings suggest that committees review applications for research involving seriously ill children with the same scrutiny as applications for research with other populations. Yet, the perception that committees act as a barrier to this type of research persists. We suggest that this perception remains due to other factors including, but not limited to, the high levels of formatting or administrative revisions requested by committees or additional study requirements needed for research involving children, such as multiple versions of consent forms or participant information sheets.