Incidence of Neonatal Hypothermia in the Newborn Nursery and Associated Factors.

Importance: Thermoregulation is a key component of well-newborn care. There is limited epidemiologic data on hypothermia in late preterm and term infants admitted to the nursery. Expanding on these data is essential for advancing evidence-based care in a population that represents more than 3.5 million births per year in the US. Objective: To examine the incidence and factors associated with hypothermia in otherwise healthy infants admitted to the newborn nursery following delivery. Design, Setting, and Participants: A retrospective cohort study using electronic health record data from May 1, 2015, to August 31, 2021, was conducted at a newborn nursery at a university-affiliated children's hospital. Participants included 23 549 infants admitted to the newborn nursery, from which 321 060 axillary and rectal temperature values were analyzed. Exposures: Infant and maternal clinical and demographic factors. Main Outcomes and Measures: Neonatal hypothermia was defined according to the World Health Organization threshold of temperature less than 36.5 °C. Hypothermia was further classified by severity (mild: single episode, temperature 36.0-36.4 °C; moderate/severe: persistent or recurrent hypothermia and/or temperature <36.0 °C) and timing (early: all hypothermic episodes occurred within the first 24 hours after birth; late: any episode extended beyond the first 24 hours). Results: Of 23 549 included infants (male, 12 220 [51.9%]), 5.6% were late preterm (35-36 weeks' gestation) and 4.3% were low birth weight (≤2500 g). The incidence of mild hypothermia was 17.1% and the incidence of moderate/severe hypothermia was 4.6%. Late hypothermia occurred in 1.8% of infants. Lower birth weight and gestational age and Black and Asian maternal race and ethnicity had the highest adjusted odds across all classifications of hypothermia. The adjusted odds ratios of moderate/severe hypothermia were 5.97 (95% CI 4.45-8.00) in infants with a birth weight less than or equal to 2500 vs 3001 to 3500 g, 3.17 (95% CI 2.24-4.49) in 35 week' vs 39 weeks' gestation, and 2.65 (95% CI 1.78-3.96) in infants born to Black mothers and 1.94 (95% CI 1.61-2.34) in infants born to Asian mothers vs non-Hispanic White mothers. Conclusions and Relevance: In this cohort study of infants in the inpatient nursery, hypothermia was common, and the incidence varied by hypothermia definition applied. Infants of lower gestational age and birth weight and those born to Black and Asian mothers carried the highest odds of hypothermia. These findings suggest that identifying biological, structural, and social determinants of hypothermia is essential for advancing evidence-based equitable thermoregulatory care.

Management of asymptomatic cutaneous lumbosacral findings in newborns: a neurosurgical perspective.

OBJECTIVE: The purpose of this study was to find areas of agreement among pediatric neurosurgeons with respect to the clinical management of asymptomatic newborns with a variety of lumbosacral skin findings. METHODS: An electronic survey containing 18 clinical images and brief vignettes was sent to pediatric neurosurgeons within the American Academy of Pediatrics Section of Neurological Surgery (AAP SONS). In total, 38% (n = 21) of AAP SONS members submitted complete responses to the survey. Respondents were asked if they would advise routine care, watchful waiting, imaging, or subspecialty consultation for each clinical case. Responses were categorized into two groups: 1) watchful waiting and/or routine care, or 2) imaging and/or subspecialty consultation. Consensus was categorized as good (> 90% of responses in the same group), modest (70%-90%), and poor (< 70%). Demographic information, local factors impacting management, and experiences with local referral patterns were also collected. RESULTS: Among the pediatric neurosurgeons within the AAP SONS network, the authors found high levels (> 90%) of agreement that subcutaneous lipomas, faun tail nevi, large skin tags, and deep/atypical lumbosacral dimples in asymptomatic newborns should prompt an imaging study. Similarly, the authors found high agreement that simple coccygeal dimples do not need imaging. The management of some types of lumbosacral vascular marks and gluteal crease deviations had poor agreement (< 70%). When imaging was recommended, there was preference for spinal MRI in most cases (67%). CONCLUSIONS: Pediatric neurosurgeons generally agree that imaging of the spine is indicated for asymptomatic newborns with subcutaneous lipomas, faun tail nevi, large skin tags, or deep/atypical lumbar dimples (deep or atypical appearing). They also agree that imaging is unnecessary for infants with simple coccygeal dimples. There was a notable lack of consensus on the appropriate management of certain gluteal cleft deviations and cutaneous vascular marks.

Sustainability of a Clinical Examination-Based Approach for Ascertainment of Early-Onset Sepsis in Late Preterm and Term Neonates.

We demonstrated the sustained impact over a 5-year period of a clinical examination-based approach to identification of early-onset sepsis in late preterm and term neonates at our hospital. To date, more than 20 000 neonates have been safely managed using this approach, resulting in a 63% reduction in antibiotic use.

Variation in Management of Cutaneous Lumbosacral Findings in Newborns.

BACKGROUND: Cutaneous lumbosacral findings in neonates are common in the newborn nursery but may also be associated with occult spinal dysraphism. Variation in management of lumbosacral findings by neonatal clinicians has not been previously described. METHODS: Clinicians in the Better Outcomes through Research for Newborns (BORN) Network were invited to participate in an electronic survey. Participants reviewed 18 photographs of lumbosacral findings in asymptomatic neonates and selected 1 or more initial management step(s): routine care, watchful waiting, imaging, and/or subspecialty consultation. Additional data collected include ease of access to imaging and subspecialty consultants and characteristics of respondents. RESULTS: Of 407 BORN Network clinicians, 206 (51%) completed the survey. Respondents were in >90% agreement in initial management approach of 8 of 18 cases. The most common initial actions were spinal ultrasound (53%), neurosurgery evaluation (18%), and MRI (13%). Anomalies of the gluteal crease had the lowest proportion of agreement. In 2 cases, there were differences in respondents' choice to image or consult a subspecialist depending on their percent clinical full time equivalent spent taking care of neonates <1 month of age: (1) coccygeal hair (P = .02) and (2) deviated gluteal crease (P = .02). CONCLUSIONS: Variation in initial management of neonatal lumbosacral findings by clinicians in the BORN Network was seen most often for deviations of the gluteal crease, flat vascular macules, and coccygeal hair.

Management of Chorioamnionitis-Exposed Infants in the Newborn Nursery Using a Clinical Examination-Based Approach.

BACKGROUND: Antibiotic use in well-appearing late preterm and term chorioamnionitis-exposed (CE) infants was reduced by 88% after the adoption of a care approach that was focused on clinical monitoring in the intensive care nursery to determine the need for antibiotics. However, this approach continued to separate mothers and infants. We aimed to reduce maternal-infant separation while continuing to use a clinical examination-based approach to identify early-onset sepsis (EOS) in CE infants. METHODS: Within a quality improvement framework, well-appearing CE infants ≥35 weeks' gestation were monitored clinically while in couplet care in the postpartum unit without laboratory testing or empirical antibiotics. Clinical monitoring included physician examination at birth and nurse examinations every 30 minutes for 2 hours and then every 4 hours until 24 hours of life. Infants who developed clinical signs of illness were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, and clinical outcomes were collected. RESULTS: Among 319 initially well-appearing CE infants, 15 (4.7%) received antibiotics, 23 (7.2%) underwent laboratory testing, and 295 (92.5%) remained with their mothers in couplet care throughout the birth hospitalization. One infant had group B Streptococcus EOS identified and treated at 24 hours of age based on new-onset tachypnea and had an uncomplicated course. CONCLUSIONS: Management of well-appearing CE infants by using a clinical examination-based approach during couplet care in the postpartum unit maintained low rates of laboratory testing and antibiotic use and markedly reduced mother-infant separation without adverse events. A framework for repeated clinical assessments is an essential component of identifying infants with EOS.

Identification of risk for neonatal haemolysis.

AIM: To identify neonates at risk of haemolytic hyperbilirubinaemia through near-concurrent measurements of total serum/plasma bilirubin (TB) or transcutaneous bilirubin (TcB) and end-tidal breath carbon monoxide (CO), corrected for ambient CO (ETCOc), an index of bilirubin production and haemolysis. METHODS: Paired TB/TcB (mg/dL) and ETCOc (ppm) measurements were obtained in newborns (n = 283) at 20 to <60 hours of age in five nurseries. TB/TcB values were assigned TB/TcB percentile risk values using the Bhutani hour-specific nomogram. In infants having two serial TB/TcB measurements (n = 76), TB rate of rise (ROR, mg/dL/h) was calculated. RESULTS: For the entire cohort (n = 283), 67.1% and 32.9% had TB/TcB<75th and ≥75th percentile, respectively. TB/TcB (5.79 ± 1.84 vs 9.14 ± 2.25 mg/dL) and ETCOc (1.61 ± 0.45 vs 2.02 ± 1.35 ppm, p = 0.0002) were different between the groups. About 36.6% of infants with TB/TcB ≥75th percentile had ETCOc ≥ 2.0 ppm. In the subcohort of infants with serial TB/TcB measurements (n = 76), 44.7% and 55.3% had TB/TcB<75th and ≥75th percentile, respectively. TB/TcB (5.28 ± 1.97 vs 9.53 ± 2.78 mg/dL), ETCOc (1.72 ± 0.48 vs 2.38 ± 1.89 ppm, p = 0.05) and TB ROR (0.011 ± 0.440 vs 0.172 ± 0.471 mg/dL/h) were different between the groups. CONCLUSION: The combined use of TB/TcB percentile risk assessments and ETCOc measurements can identify infants with haemolytic hyperbilirubinaemia. The addition of TB ROR can identify those infants with elimination disorders.

Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis.

BACKGROUND: The risk of early-onset sepsis is low in well-appearing late-preterm and term infants even in the setting of chorioamnionitis. The empirical antibiotic strategies for chorioamnionitis-exposed infants that are recommended by national guidelines result in antibiotic exposure for numerous well-appearing, uninfected infants. We aimed to reduce unnecessary antibiotic use in chorioamnionitis-exposed infants through the implementation of a treatment approach that focused on clinical presentation to determine the need for antibiotics. METHODS: Within a quality-improvement framework, a new treatment approach was implemented in March 2015. Well-appearing late-preterm and term infants who were exposed to chorioamnionitis were clinically monitored for at least 24 hours in a level II nursery; those who remained well appearing received no laboratory testing or antibiotics and were transferred to the level I nursery or discharged from the hospital. Newborns who became symptomatic were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, culture results, and clinical outcomes were collected. RESULTS: Among 277 well-appearing, chorioamnionitis-exposed infants, 32 (11.6%) received antibiotics during the first 15 months of the quality-improvement initiative. No cases of culture result-positive early-onset sepsis occurred. No infant required intubation or inotropic support. Only 48 of 277 (17%) patients had sepsis laboratory testing. The implementation of the new approach was associated with a 55% reduction (95% confidence interval 40%-65%) in antibiotic exposure across all infants ≥34 weeks' gestation born at our hospital. CONCLUSIONS: A management approach using clinical presentation to determine the need for antibiotics in chorioamnionitis-exposed infants was successful in reducing antibiotic exposure and was not associated with any clinically relevant delays in care or adverse outcomes.

A Cross-Sectional Assessment of Cutaneous Lumbosacral and Coccygeal Physical Examination Findings in a Healthy Newborn Population.

Objective. The purpose of this study is to describe the range and frequency of cutaneous lumbosacral and coccygeal findings encountered during the newborn examination in a population of apparently healthy babies, to determine if the prevalence of these findings is associated with race/ethnicity, and to report the frequency of co-occurrence of low-risk cutaneous findings. Methods. Lumbosacral physical findings of 1121 infants were documented on well newborns at least 35 weeks or greater gestational age under the authors' care. The overall frequency of each physical finding was tabulated in addition to determining whether frequencies varied by race/ethnicity. Co-occurrence of the most common physical findings was also examined. Results. Of 1096 infants included in the study, 24.8% had deviated or duplicated gluteal creases, 15.6% had dimples, and 24.7% had lumbosacral and/or coccygeal hairiness. All racial/ethnic groups had double to quadruple the risk of lumbosacral hair when compared with Caucasians. A total of 44.1% of study infants had lumbosacral/coccygeal slate-grey patches, which were least common in Caucasians. Seven infants had coccygeal skin tags, and 14 infants had lumbosacral vascular macules. Thirty-one percent had more than 1 cutaneous lumbosacral finding present, 24.8% had 2 findings, and 6.2% had 3 or more findings. Conclusion. Coccygeal dimples, increased lumbosacral and/or coccygeal hair, deviations and/or duplications of the gluteal crease, and lumbosacral slate-grey patches are common in healthy newborns and vary by race/ethnicity. Eleven percent of study infants had 2 or more low-risk cutaneous findings excluding slate-grey patches. Distinction between low-risk and common versus high-risk findings is important when deciding which patients need further evaluation.

The Superior Labial Frenulum in Newborns: What Is Normal?

Introduction and Objectives: There has been an emergence of procedures to release the superior labial frenula in infants, yet little is known about the normal appearance or incidence of severe attachment, or "lip-tie." The objective of this article was to develop a classification system for superior labial frenula and to estimate the incidence of different degrees of attachment. Methods: A prospective cross-sectional study. Newborns were examined and had photographs taken of their upper frenula. Relevant medical professionals rated the appearance of the labial frenula using a previously described Kotlow classification system. The raters assessed each photograph twice and were blinded to their previous rating and to other raters' scores. Results: All newborns have a labial frenula, with most attached at the gingival margins (83%). Raters had poor intra- and interrater reliability (64% to 74% and 8%, respectively), using the Kotlow classification system, which improved when the classification system was simplified. Conclusions: The Kotlow classification of lip-tie fails to be reproducible by relevant experts. The majority of infants had a significant level of attachment of the labial frenulum. As more procedures are done to release the upper lip frenulum, it is important to understand what degree of attachment is normal, or more common.

Identification of neonatal haemolysis: an approach to predischarge management of neonatal hyperbilirubinemia.

AIM: Relative contributions of increased production [by end-tidal carbon monoxide concentrations (ETCOc)] and decreased elimination of bilirubin to predischarge hour-specific total bilirubin (TB) levels were assessed in healthy late-preterm and term newborns. Secondly, we report predischarge ETCOc ranges to guide clinical management of hyperbilirubinemia. METHODS: TB and ETCOc (≤3 timepoints) determinations of newborns aged between six hours and <6 days (n = 79) were stratified by postnatal age epochs. Hyperbilirubinemia risk was assessed by plotting TB values as a function of ETCOc. RESULTS: Stratifications of ETCOc (in ppm, mean, median and interquartile ranges) by postnatal age epochs (0-24, 24-48 and 48-72) were as follows: 2.0, 1.9, 1.8-2.2 (n = 11); 1.6, 1.5, 1.1-2.0 (n = 58); and 2.0, 1.8, 1.6-2.3 (n = 9), respectively. Infants with ETCOc ≥ 2.5 were at high risk, between 1.5 and 2.5 at moderate risk and ≤1.5 were at low risk. Risk due to haemolysis alone was not independent (p < 0.01). For infants with TB >75th percentile (n = 31), 23% had ETCO ≤1.5, and 77% had ETCOc > 1.5 (p < 0.00003). CONCLUSION: Near-simultaneous ETCOc and TB measurements in infants with TB >75th percentile accurately identify haemolytic hyperbilirubinemia.

Salivary gland choristoma (heterotopic salivary gland tissue) on the anterior chest wall of a newborn.

Salivary gland choristoma (heterotopic salivary gland tissue) is a rare condition typically seen in the newborn period. This developmental heterotopia is generally nonprogressive, with little risk of malignant transformation. We present the second known reported case of a salivary gland choristoma located on the anterior chest wall. Knowledge of this rare entity will allow for accurate diagnosis and management of this benign anatomic variant.

Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT.

BACKGROUND AND OBJECTIVES: Recent public health efforts focus on reducing formula use for breastfed infants during the birth hospitalization. No previous randomized trials report the effects of brief early formula use. The objective of the study was to determine if small formula volumes before the onset of mature milk production might reduce formula use at 1 week and improve breastfeeding at 3 months for newborns at risk for breastfeeding problems. METHODS: We randomly assigned 40 exclusively breastfeeding term infants, 24 to 48 hours old, who had lost ≥5% birth weight to early limited formula (ELF) intervention (10 mL formula by syringe after each breastfeeding and discontinued when mature milk production began) or control (continued exclusive breastfeeding). Our outcomes were breastfeeding and formula use at 1 week and 1, 2, and 3 months. RESULTS: Among infants randomly assigned to ELF during the birth hospitalization, 2 (10%) of 20 used formula at 1 week of age, compared with 9 (47%) of 19 control infants assigned during the birth hospitalization to continue exclusive breastfeeding (P = .01). At 3 months, 15 (79%) of 19 infants assigned to ELF during the birth hospitalization were breastfeeding exclusively, compared with 8 (42%) of 19 controls (P = .02). CONCLUSIONS: Early limited formula may reduce longer-term formula use at 1 week and increase breastfeeding at 3 months for some infants. ELF may be a successful temporary coping strategy for mothers to support breastfeeding newborns with early weight loss. ELF has the potential for increasing rates of longer-term breastfeeding without supplementation based on findings from this RCT.

Development of the breast milk expression experience measure.

Exclusive breastfeeding provides optimal nutrition through 6 months. Recent research has shown that milk expression may affect breastfeeding duration. A woman's experience with milk expression might mediate the effect of milk expression on breastfeeding duration. The objective of this study was to develop a measure to evaluate women's experiences of expressing milk. Based on the available literature, we developed a brief measure of the Breast Milk Expression Experience (BMEE) assessing three dimensions: (1) social support for milk expression; (2) ease of learning how to express milk; and (3) personal experiences of milk expression. All items used 1-5 Likert scales, with higher scores indicating better experiences. We administered the items immediately after expression to 68 mothers who expressed milk post-partum. We evaluated this measure for reliability using Cronbach's alpha. Mothers completing the BMEE were 57% primiparous with 75% vaginal births. The BMEE demonstrated appropriate reliability with a Cronbach's alpha of 0.703 for the summary index and 0.719-0.763 for social support, learning experience and personal experience subscales. The BMEE also indicated good predictive validity; of the six mothers who had a mean score <3 on the 11-item scale post-partum, two (33.3%) were expressing breast milk at 1 month, compared with 37 (80.4%) of the 46 mothers who had a mean score ≥3 on the 11-item scale post-partum (P = 0.012). The BMEE is a promising measure of milk expression experience in this population. Use of this measure may allow improved understanding of women's experiences expressing milk.