Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network.

BACKGROUND: Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown. METHODS: The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program. RESULTS: Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine. CONCLUSIONS: The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.

Atypical Presentation of Infantile Hepatic Hemangioma: A Case Study.

Infantile hepatic hemangioma (IHH) is the most common benign hepatic tumor of infancy. It is characterized by rapid proliferation in the first year of life, followed by slow involution during childhood. Presentation can range from asymptomatic to severe, high-output congestive heart failure (CHF). The purpose of this article is to review the case of an infant with an atypical presentation of IHH. It also addresses pathophysiology, diagnosis, management, and multidisciplinary team care.

Parents are interested in newborn genomic testing during the early postpartum period.

PURPOSE: We surveyed parents to ascertain interest in newborn genomic testing and determine whether these queries would provoke refusal of conventional state-mandated newborn screening. METHODS: After a brief genetics orientation, parents rated their interest in receiving genomic testing for their healthy newborn on a 5-point Likert scale and answered questions about demographics and health history. We used logistic regression to explore factors associated with interest in genomic testing and tracked any subsequent rejection of newborn screening. RESULTS: We queried 514 parents within 48 hours after birth while still in hospital (mean age (SD) 32.7 (6.4) years, 65.2% female, 61.2% white, 79.3% married). Parents reported being not at all (6.4%), a little (10.9%), somewhat (36.6%), very (28.0%), or extremely (18.1%) interested in genomic testing for their newborns. None refused state-mandated newborn screening. Married participants and those with health concerns about their infant were less interested in newborn genomic testing (P = 0.012 and P = 0.030, respectively). Degree of interest for mothers and fathers was discordant (at least two categories different) for 24.4% of couples. CONCLUSION: Interest in newborn genomic testing was high among parents of healthy newborns, and the majority of couples had similar levels of interest. Surveying parents about genomic sequencing did not prompt rejection of newborn screening.Genet Med 17 6, 501-504.

Potential sources of bisphenol A in the neonatal intensive care unit.

OBJECTIVES: To determine whether nutritional intake and medical devices are bisphenol A (BPA) exposure sources among premature infants in the NICU. METHODS: Mothers and their premature infants cared for in the NICU for the past 3 days were recruited for this exposure assessment study. Forty-three mothers contributed 1 nutrition sample (breast milk or formula) to characterize the infant's intake. Two urine samples (before and after feeding) were collected from each of 55 infants. Medical device use was categorized as "low" or "high" based on the number and invasiveness of devices used. BPA urinary concentrations used as a biomarker to estimate BPA exposure were measured by online solid-phase extraction, high performance liquid chromatography, isotope dilution, tandem mass spectrometry. Nonparametric equivalence tests, intraclass correlations, and hierarchical linear mixed-effects models were conducted. RESULTS: Breast milk and formula samples did not differ in total BPA concentration nor did infants' median urinary concentration of total BPA before or after feedings. However, the median urinary total BPA concentration among infants who required the use of 4 or more medical devices in the past 3 days was significantly higher (36.6 µg/L) than among infants who required the use of 0 to 3 devices (13.9 µg/L). The calculated BPA exposures are lower than the US Environmental Protection Agency reference dose, but considerably higher (16- to 32-fold) than among infants or children from the general population. CONCLUSIONS: The number of medical devices used in the past 3 days, but not nutritional intake, was positively associated with exposure to BPA.

Neonatal stabilization and postresuscitation care.

Neonatal mortality is a major health care concern worldwide. Neonatal resuscitation alone does not address most causes of neonatal mortality; caregivers need to be trained in both neonatal resuscitation and stabilization. Neonatal stabilization requires caregivers to evaluate whether babies are at-risk or unwell, to decide what interventions are required, and to act on those decisions. Several programs address neonatal stabilization in a variety of levels of care in both well-resourced and limited health care environments. This article suggests a shift in clinical, educational, and implementation science from a focus on resuscitation to one on the resuscitation-stabilization continuum.

Improving preterm ophthalmologic care in the era of accountable care organizations.

OBJECTIVES To understand retinopathy of prematurity (ROP) follow-up care for preterm very low-birth-weight infants (VLBW; <1500 g) in the context of the chronic care model and identify opportunities for improvement under accountable care organizations. METHODS We conducted focus groups and interviews with parents (N = 47) of VLBW infants and interviews with neonatal intensive care unit and ophthalmologic providers (N = 28) at 6 sites in Massachusetts and South Carolina. Themes are reported according to consolidated criteria for reporting qualitative research guidelines. RESULTS Respondents perceived that legal liability and low reimbursement contributed to shortages of ROP providers. Some neonatal intensive care units offered subsidies to attract ophthalmologic providers or delayed transfers to institutions that could not provide ROP examinations and/or treatment. Sites used variable practices for coordinating ROP care. Even at sites with a tracking database and a dedicated ROP coordinator, significant time was required to ensure that examinations and treatment occurred as scheduled. Parents' ability to manage their children's health care was limited by parental understanding of ROP, feeling overwhelmed by the infant's care, and unmet needs for resources to address social stressors. CONCLUSIONS Under accountable care organizations, hospitals and ophthalmology practices should share responsibility for ensuring coordinated ROP care to mitigate liability concerns. To promote integrated care, reimbursement for ROP care should be bundled to include screening, diagnosis, treatment, and appropriate follow-up. Clinical information systems should be enhanced to increase efficiency and limit lapses in care. Self-management tools and connections to community resources could help promote families' attendance of follow-up appointments.

Intrapartum temperature elevation, epidural use, and adverse outcome in term infants.

OBJECTIVES: To examine the association of intrapartum temperature elevation with adverse neonatal outcome among low-risk women receiving epidural analgesia and evaluate the association of epidural with adverse neonatal outcome without temperature elevation. METHODS: We studied all low-risk nulliparous women with singleton pregnancies ≥37 weeks delivering at our hospital during 2000, excluding pregnancies where infants had documented sepsis, meningitis, or a major congenital anomaly. Neonatal outcomes were compared between women receiving (n = 1538) and not receiving epidural analgesia (n = 363) in the absence of intrapartum temperature elevation (≤99.5°F) and according to the level of intrapartum temperature elevation within the group receiving epidural (n = 2784). Logistic regression was used to evaluate neonatal outcome while controlling for confounders. RESULTS: Maternal temperature >100.4°F developed during labor in 19.2% (535/2784) of women receiving epidural compared with 2.4% (10/425) not receiving epidural. In the absence of intrapartum temperature elevation (≤99.5°F), no significant differences were observed in adverse neonatal outcomes between women receiving and not receiving epidural. Among women receiving epidural, a significant linear trend was observed between maximum maternal temperature and all neonatal outcomes examined including hypotonia, assisted ventilation, 1- and 5-min Apgar scores <7, and early-onset seizures. In regression analyses, infants born to women with fever >101°F had a two- to sixfold increased risk of all adverse outcomes examined. CONCLUSIONS: The proportion of infants experiencing adverse outcomes increased with the degree of epidural-related maternal temperature elevation. Epidural use without temperature elevation was not associated with any of the adverse outcomes we studied.

Exposure to biological maternal sounds improves cardiorespiratory regulation in extremely preterm infants.

OBJECTIVE: Preterm infants experience frequent cardiorespiratory events (CREs) including multiple episodes of apnea and bradycardia per day. This physiological instability is due to their immature autonomic nervous system and limited capacity for self-regulation. This study examined whether systematic exposure to maternal sounds can reduce the frequency of CREs in NICU infants. METHODS: Fourteen preterm infants (26-32 weeks gestation) served as their own controls as we measured the frequency of adverse CREs during exposure to either Maternal Sound Stimulation (MSS) or Routine Hospital Sounds (RHS). MSS consisted of maternal voice and heartbeat sounds recorded individually for each infant. MSS was provided four times per 24-h period via a micro audio system installed in the infant's bed. Frequency of adverse CREs was determined based on monitor data and bedside documentation. RESULTS: There was an overall decreasing trend in CREs with age. Lower frequency of CREs was observed during exposure to MSS versus RHS. This effect was significantly evident in infants ≥ 33 weeks gestation (p=0.03), suggesting an effective therapeutic window for MSS when the infant's auditory brain development is most intact. CONCLUSION: This study provides preliminary evidence for short-term improvements in the physiological stability of NICU infants using MSS. Future studies are needed to investigate the potential of this non-pharmacological approach and its clinical relevance to the treatment of apnea of prematurity.

Effectiveness of a guideline to reduce vancomycin use in the neonatal intensive care unit.

BACKGROUND: The Centers for Disease Control and Prevention recommend hospitals develop guidelines for the appropriate use of vancomycin as part of comprehensive antimicrobial stewardship. The objective of this study was to evaluate the effectiveness and safety of a guideline to restrict vancomycin use in the neonatal intensive care unit (NICU). METHODS: A vancomycin use guideline was introduced in 2 tertiary care NICUs with low incidences of methicillin-resistant Staphylococcus aureus infections. We compared all infants >72 hours of age who were evaluated for late-onset infection before and after implementation of this guideline. RESULTS: Vancomycin start rates were reduced from 6.9 to 4.5 per 1000 patient-days (35% reduction; P = 0.01) at Brigham and Women's Hospital, and from 17 to 6.4 per 1000 patient-days (62% reduction; P < 0.0001) at Massachusetts General Hospital. The number of infants exposed to vancomycin decreased from 5.2 to 3.1 per 1000 patient-days (40% reduction; P = 0.008) at Brigham and Women's Hospital, and 10.8 to 5.5 per 1000 patient-days (49% reduction; P = 0.009) at Massachusetts General Hospital. Causes of infection, duration of bacteremia, and incidence of complications or deaths attributable to late-onset infection did not change significantly at either institution. CONCLUSIONS: Implementation of a NICU vancomycin use guideline significantly reduced exposure of newborns to vancomycin without adversely affecting short-term patient safety. Further studies are required to evaluate the long-term effect of vancomycin restriction on NICU patient safety and microbial ecology, particularly among institutions with higher rates of methicillin-resistant Staphylococcus aureus infections.

Premature infant swallowing: patterns of tongue-soft palate coordination based upon videofluoroscopy.

Coordination between movements of individual tongue points, and between soft palate elevation and tongue movements, were examined in 12 prematurely born infants referred from hospital NICUs for videofluoroscopic swallow study (VFSS) due to poor oral feeding and suspicion of aspiration. Detailed post-evaluation kinematic analysis was conducted by digitizing images of a lateral view of digitally superimposed points on the tongue and soft palate. The primary measure of coordination was continuous relative phase of the time series created by movements of points on the tongue and soft palate over successive frames. Three points on the tongue (anterior, medial, and posterior) were organized around a stable in-phase pattern, with a phase lag that implied an anterior to posterior direction of motion. Coordination between a tongue point and a point on the soft palate during lowering and elevation was close to anti-phase at initiation of the pharyngeal swallow. These findings suggest that anti-phase coordination between tongue and soft palate may reflect the process by which the tongue is timed to pump liquid by moving it into an enclosed space, compressing it, and allowing it to leave by a specific route through the pharynx.

Fetal placental thrombosis and neonatal implications.

We present the neonatal complications of two premature newborn infants whose placentas demonstrated placental thrombosis in the fetal circulation. Both mothers presented with a 3-day history of decreased fetal movements before delivery. The first infant presented with thrombocytopenia and disseminated intravascular coagulation. The second infant had extended bilateral extended hemorrhagic venous infarctions. Severe fetal placental vascular lesions seem to be a predisposing factor for some adverse neonatal outcomes. We present these two cases with a brief review of the literature.

Improved care and growth outcomes by using hybrid humidified incubators in very preterm infants.

OBJECTIVE: To identify changes in temperature, fluid and electrolyte management, growth, and short-term outcome in extremely low birth weight (ELBW) infants nursed in humidified hybrid incubators (HI group) compared with a cohort of patients cared for in nonhumidified conventional incubators (CI group). METHODS: Body temperature (BT), fluid and electrolyte balance, and growth velocity (GV) were collected retrospectively on 182 ELBW infants. The CI group included ELBW infants cared for with radiant warmers followed by an incubator without humidity. The HI group included ELBW infants cared for in the radiant warmer mode in a Giraffe OmniBed, followed by the incubator mode using high humidity. RESULTS: The CI group included more multiple births (50.6%) than the HI group (35.8%; P < .05), but there was no difference in demographic characteristics. BT was similar during the first week. The HI group had less fluid intake, urine output, and insensible water loss, less maximum weight loss, and a lower incidence of hypernatremia during the first week than did the CI group (P < .05). The HI group also had a lower frequency of electrolyte sampling and packed red cell transfusion (P < .05), a higher incidence of hyponatremia on postnatal day 1 than the CI group (P < .05), and a higher GV than the CI group (15.2 +/- 5.0 vs 13.5 +/- 4.8 g/kg per day), especially among those with a birth weight of

Exposure to bisphenol A and other phenols in neonatal intensive care unit premature infants.

OBJECTIVE: We previously demonstrated that exposure to polyvinyl chloride plastic medical devices containing di(2-ethylhexyl) phthalate (DEHP) was associated with higher urinary concentrations of several DEHP metabolites in 54 premature infants in two neonatal intensive care units than in the general population. For 42 of these infants, we evaluated urinary concentrations of several phenols, including bisphenol A (BPA), in association with the use of the same medical devices. MEASUREMENTS: We measured the urinary concentrations of free and total (free plus conjugated) species of BPA, triclosan, benzophenone-3, methyl paraben, and propyl paraben. RESULTS: The percentage of BPA present as its conjugated species was > 90% in more than three-quarters of the premature infants. Intensity of use of products containing DEHP was strongly associated with BPA total concentrations but not with any other phenol. Adjusting for institution and sex, BPA total concentrations among infants in the group of high use of DEHP-containing products were 8.75 times as high as among infants in the low use group (p < 0.0001). Similarly, after adjusting for sex and DEHP-containing product use category, BPA total concentrations among infants in Institution A were 16.6 times as high as those among infants in Institution B (p < 0.0001). CONCLUSION: BPA geometric mean urinary concentration (30.3 microg/L) among premature infants undergoing intensive therapeutic medical interventions was one order of magnitude higher than that among the general population. Conjugated species were the primary urinary metabolites of BPA, suggesting that premature infants have some capacity to metabolize BPA. The differences in exposure to BPA by intensity of use of DEHP-containing medical products highlight the need for further studies to determine the specific source(s) of exposure to BPA.

Cerebral hemodynamic changes during intensive care of preterm infants.

OBJECTIVES: The objectives of this study were to examine the circulatory changes experienced by the immature systemic and cerebral circulations during routine events in the critical care of preterm infants and to identify clinical factors that are associated with greater hemodynamic-oxygenation changes during these events. METHODS: We studied 82 infants who weighed <1500 g at birth and required intensive care management and continuous blood pressure monitoring from an umbilical arterial catheter. Continuous recording of cerebral and systemic hemodynamic and oxygenation changes was performed. We studied 6 distinct types of caregiving events during 10-minute epochs: (1) quiet baseline periods; (2) minor manipulation; (3) diaper changes; (4) endotracheal tube suctioning; (5) endotracheal tube repositioning; and (6) complex events. Each event was matched with a preceding baseline. We examined the effect of specific clinical factors and cranial ultrasound abnormalities on the systemic and cerebral hemodynamic oxygenation changes that were associated with the various event types. RESULTS: There were highly significant differences in hemodynamics and oxygenation between events overall and baseline epochs. The magnitude of these circulatory changes was greatest during endotracheal tube repositioning and complex caregiving events. Lower gestational age, higher illness severity, chorioamnionitis, low Apgar scores, and need for pressor-inotropes all were associated with circulatory changes of significantly lower magnitude. Cerebral hemodynamic changes were associated with early parenchymal ultrasound abnormalities. CONCLUSIONS: Routine caregiving procedures in critically ill preterm infants are associated with major circulatory fluctuations that are clinically underappreciated and underdetected by current bedside monitoring. Our data underscore the importance of continuous cerebral hemodynamic monitoring in critically ill preterm infants.

Positive screening for autism in ex-preterm infants: prevalence and risk factors.

OBJECTIVE: The survival of very low birth weight infants has increased markedly in recent years. Unfortunately, the prevalence of significant and lifelong motor, cognitive, and behavioral dysfunction has remained a major problem confronting these children. The objective of this study was to perform screening tests for early autistic features in children with a history of very low birth weight and to identify risk factors associated with a positive screening result. METHODS: We studied 91 ex-preterm infants < or = 1500 g at birth. Infants underwent conventional MRI studies at preterm and/or term-adjusted age. We collected pertinent demographic, prenatal, intrapartum, acute postnatal, and short-term outcome data for all infants. Follow-up assessments were performed at a mean age of 21.9 +/- 4.7 months, using the Modified Checklist for Autism in Toddlers, the Vineland Adaptive Behavior Scale, and the Child Behavior Checklist. RESULTS: Twenty-six percent of ex-preterm infants had a positive result on the autism screening tool. Abnormal scores correlated highly with internalizing behavioral problems on the Child Behavior Checklist and socialization and communication deficits on the Vineland Scales. Lower birth weight, gestational age, male gender, chorioamnionitis, acute intrapartum hemorrhage, illness severity on admission, and abnormal MRI studies were significantly associated with an abnormal autism screening score. CONCLUSIONS: Early autistic behaviors seem to be an underrecognized feature of very low birth weight infants. The results from this study suggest that early screening for signs of autism may be warranted in this high-risk population followed by definitive autism testing in those with positive screening results.

Current definitions of hypotension do not predict abnormal cranial ultrasound findings in preterm infants.

OBJECTIVE: Hypotension is a commonly treated complication of prematurity, although definitions and management guidelines vary widely. Our goal was to examine the relationship between current definitions of hypotension and early abnormal cranial ultrasound findings. METHODS: We prospectively measured mean arterial pressure in 84 infants who were < or = 30 weeks' gestational age and had umbilical arterial catheters in the first 3 days of life. Sequential 5-minute epochs of continuous mean arterial pressure recordings were assigned a mean value and a coefficient of variation. We applied to our data 3 definitions of hypotension in current clinical use and derived a hypotensive index for each definition. We examined the association between these definitions of hypotension and abnormal cranial ultrasound findings between days 5 and 10. In addition, we evaluated the effect of illness severity (Score for Neonatal Acute Physiology II) on cranial ultrasound findings. RESULTS: Acquired lesions as shown on cranial ultrasound, present in 34 (40%) infants, were not predicted by any of the standard definitions of hypotension or by mean arterial pressure variability. With hypotension defined as mean arterial pressure < 10th percentile (< 33 mmHg) for our overall cohort, mean value for mean arterial pressure and hypotensive index predicted abnormal ultrasound findings but only in infants who were > or = 27 weeks' gestational age and those with lower illness severity scores. CONCLUSIONS: Hypotension as diagnosed by currently applied thresholds for preterm infants is not associated with brain injury on early cranial ultrasounds. Blood pressure management directed at these population-based thresholds alone may not prevent brain injury in this vulnerable population.