Standardized Evaluation of Cord Gases in Neonates at Risk for Hypoxic Ischemic Encephalopathy.

BACKGROUND: Umbilical-cord acidemia may indicate perinatal asphyxia and places a neonate at increased risk for hypoxic ischemic encephalopathy (HIE). Our specific aim was to develop a standardized clinical care pathway, ensuring timely identification and evaluation of neonates with umbilical-cord acidemia at risk for HIE. METHODS: A standardized clinical care pathway to screen inborn neonates ≥36 weeks with abnormal cord blood gases (a pH of ≤7.0 or base deficit of ≥10) for HIE was implemented in January 2016. Abnormal cord blood gases resulted in a direct notification from the laboratory to an on-call physician. Evaluation included a modified Sarnat examination, postnatal blood gas, and standardized documentation. The percentage of neonates in which physician notification, documented Sarnat examination, and postnatal blood gas occurred was examined for 6 months before and 35 months after implementation. RESULTS: Of 203 neonates with abnormal cord gases in the post-quality improvement (QI) period, physician notification occurred in 92%. In the post-QI period, 94% had a documented Sarnat examination, and 94% had postnatal blood gas, compared with 16% and 11%, respectively, of 87 neonates in the pre-QI period. In the post-QI period, of those evaluated, >96% were documented within 4 hours of birth. In the post-QI period, 15 (7.4%) neonates were cooled; 13 were in the NICU at time of identification, but 2 were identified in the newborn nursery and redirected to the NICU for cooling. CONCLUSIONS: A standardized screening pathway in neonates with umbilical-cord acidemia led to timely identification and evaluation of neonates at risk for HIE.

Community Pediatric Hospitalist Workload: Results from a National Survey.

As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.

Current Practices and Perspectives on Peer Observation and Feedback: A National Survey.

OBJECTIVE: Peer observation and feedback (POF) is the direct observation of an activity performed by a colleague followed by feedback with the goal of improved performance and professional development. Although well described in the education literature, the use of POF as a tool for development beyond teaching skills has not been explored. We aimed to characterize the practice of POF among pediatric hospitalists to explore the perceived benefits and barriers and to identify preferences regarding POF. METHODS: We developed a 14-item cross-sectional survey regarding divisional expectations, personal practice, perceived benefits and barriers, and preferences related to POF. We refined the survey based on expert feedback, cognitive interviews, and pilot testing, distributing the final survey to pediatric hospitalists at 12 institutions across the United States. RESULTS: Of 357 eligible participants, 198 (56%) responded, with 115 (58%) practicing in a freestanding children's hospital. Although 61% had participated in POF, less than one half (42%) reported divisional POF expectation. The most common perceived benefits of POF were identifying areas for improvement (94%) and learning about colleagues' teaching and clinical styles (94%). The greatest perceived barriers were time (51%) and discomfort with receiving feedback from peers (38%), although participation within a POF program reduced perceived barriers. Most (76%) desired formal POF programs focused on improving teaching skills (85%), clinical management (83%), and family-centered rounds (82%). CONCLUSIONS: Although the majority of faculty desired POF, developing a supportive environment and feasible program is challenging. This study provides considerations for improving and designing POF programs.

Temporal Relationship of Onset of Necrotizing Enterocolitis and Introduction of Enteric Feedings and Powdered Milk Fortifier.

OBJECTIVE: This article evaluates temporal relationships between onset of necrotizing enterocolitis (NEC) in preterm infants and introduction of enteral feedings or powdered human milk fortifier (HMF). STUDY DESIGN: This is a Poisson regression analysis of NEC cases at a single children's hospital between 1999 and 2009, using the self-controlled case series method to estimate adjusted daily event rate ratios (DERR) during postexposure intervals. RESULTS: Of 139 patients with a clinical diagnosis of NEC, 26 had early disease onset prior to initiation of feeding and were considered to be cases of spontaneous intestinal perforation (SIP). For the remaining 113 infants, the DERR for NEC onset were significantly greater on days for which infants were <14 days of age (DERR, 2.15; 95% confidence interval [CI], 1.22-3.79) or ≥31 weeks postmenstrual age (2.94; 95% CI, 1.51-5.83) or which fell within 14 days after initiation of enteric feeding (8.29; 95% CI, 4.73-14.53) or 4 days after introduction of HMF (12.32; 95% CI, 7.13-21.29). CONCLUSION: There are strong temporal associations between onset of NEC and initiation of enteral feeding or powdered HMF in preterm infants.

Periconceptional changes in weight and risk of delivering offspring with conotruncal heart defects.

BACKGROUND: Maternal nutritional status has been recognized as a contributor to conotruncal heart defects, but there is limited understanding of the specific nutrition-related factors involved. In this California case-control study of 296 conotruncal cases and 695 nonmalformed controls we explored whether weight loss during early pregnancy was associated with an increased risk of d-transposition of the great arteries (dTGA) and tetralogy of Fallot (TOF) conotruncal defects. METHODS: During telephone interviews women were asked whether they were dieting to lose weight or using weight loss remedies during 2 months before or 2 months after conception, and how much weight they gained or lost in the first 2 months of pregnancy or during the year before pregnancy. RESULTS: Odds ratios for dieting to lose weight and use of weight loss remedies for dTGA and TOF were not substantially elevated and all had confidence intervals that included 1.0. Mothers who had a loss of >5 lbs in the first 2 months of pregnancy as well as mothers who lost and gained >5 lbs in the first 2 months of pregnancy also did not show a significant increased risk of delivering case infants when compared with women with no weight change in the year before pregnancy. CONCLUSION: Given current recommendations about limited weight gain for obese pregnant women, these data indicate that dieting may not substantially increase a fetus' risk of having a conotruncal defect.

Red blood cell transfusion is not associated with necrotizing enterocolitis: a review of consecutive transfusions in a tertiary neonatal intensive care unit.

OBJECTIVE: To explore the association between red blood cell transfusion and necrotizing enterocolitis (NEC) in a neonatal intensive care unit with liberal transfusion practices. STUDY DESIGN: A retrospective cohort study was conducted for all infants weighing <1500 g who received at least 1 packed red blood cell transfusion between January 2008 and June 2013 in a tertiary neonatal intensive care unit. The primary outcome was NEC, defined as Bell stage II or greater. The temporal association of NEC and transfusion was assessed using multivariate Poisson regression. RESULTS: The study sample included 414 very low birth weight infants who received 2889 consecutive red blood cell transfusions. Twenty-four infants (5.8%) developed NEC. Four cases of NEC occurred within 48 hours of a previous transfusion event. Using multivariate Poisson regression, we did not find evidence of a temporal association between NEC and transfusion (P = .32). CONCLUSION: There was no association between NEC and red blood cell transfusion. Our results differ from previous studies and suggest that the association between NEC and transfusion may be contextual.

Pilot undergraduate course teaches students about chronic illness in children: an educational intervention study.

BACKGROUND: Recent data question whether medical education adequately prepares physicians to care for the growing number of children with chronic medical conditions. We describe a 10-week course designed to provide undergraduate students with the knowledge and skills required to understand and care for children with chronic or catastrophic illnesses. The course presented the illness experience from the child's perspective and thus presented information in a manner that was efficient, conducive, and memorable. The curriculum was designed like a graduate-level seminar that included workshops, lectures, readings, writing, and lively discussions. METHODS: This is an educational intervention study that used survey data to assess changes in attitudes among and between participants completing this course versus students not exposed to this course. We used Somers' D test and Fisher's z-transformation to perform both pre- and post-nonparametric comparisons. RESULTS: Course participants were more likely to change their attitudes and agree that chronically ill children "feel comfortable talking with their peers about their condition" (P=0.003) and less likely to agree that these children "want to be treated differently," "want more sympathy," or "care less about romantic relationships" (P = 0.003, 0.002 and 0.02, respectively). Controls were more likely to continue to agree that chronically ill children "want to be treated differently" (P = 0.009) and "care less about romantic relationships" (P = 0.02), and less likely to agree that these children "talk openly" or "feel comfortable talking with their peers about their condition" (P = 0.04). CONCLUSIONS: This classroom-based course serves as a feasible and cost-effective model for universities and medical schools to aid in improving student attitudes toward treating chronically ill children. The course provides the unique opportunity to learn directly from those who care for and those who have lived with chronic illness.