Neurodevelopmental Outcomes of Extremely Preterm Infants Fed Donor Milk or Preterm Infant Formula: A Randomized Clinical Trial.

Importance: Maternal milk feeding of extremely preterm infants during the birth hospitalization has been associated with better neurodevelopmental outcomes compared with preterm formula. For infants receiving no or minimal maternal milk, it is unknown whether donor human milk conveys similar neurodevelopmental advantages vs preterm formula. Objective: To determine if nutrient-fortified, pasteurized donor human milk improves neurodevelopmental outcomes at 22 to 26 months' corrected age compared with preterm infant formula among extremely preterm infants who received minimal maternal milk. Design, Setting, and Participants: Double-blind, randomized clinical trial conducted at 15 US academic medical centers within the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants younger than 29 weeks 0 days' gestation or with a birth weight of less than 1000 g were enrolled between September 2012 and March 2019. Intervention: Preterm formula or donor human milk feeding from randomization to 120 days of age, death, or hospital discharge. Main Outcomes and Measures: The primary outcome was the Bayley Scales of Infant and Toddler Development (BSID) cognitive score measured at 22 to 26 months' corrected age; a score of 54 (score range, 54-155; a score of ≥85 indicates no neurodevelopmental delay) was assigned to infants who died between randomization and 22 to 26 months' corrected age. The 24 secondary outcomes included BSID language and motor scores, in-hospital growth, necrotizing enterocolitis, and death. Results: Of 1965 eligible infants, 483 were randomized (239 in the donor milk group and 244 in the preterm formula group); the median gestational age was 26 weeks (IQR, 25-27 weeks), the median birth weight was 840 g (IQR, 676-986 g), and 52% were female. The birthing parent's race was self-reported as Black for 52% (247/478), White for 43% (206/478), and other for 5% (25/478). There were 54 infants who died prior to follow-up; 88% (376/429) of survivors were assessed at 22 to 26 months' corrected age. The adjusted mean BSID cognitive score was 80.7 (SD, 17.4) for the donor milk group vs 81.1 (SD, 16.7) for the preterm formula group (adjusted mean difference, -0.77 [95% CI, -3.93 to 2.39], which was not significant); the adjusted mean BSID language and motor scores also did not differ. Mortality (death prior to follow-up) was 13% (29/231) in the donor milk group vs 11% (25/233) in the preterm formula group (adjusted risk difference, -1% [95% CI, -4% to 2%]). Necrotizing enterocolitis occurred in 4.2% of infants (10/239) in the donor milk group vs 9.0% of infants (22/244) in the preterm formula group (adjusted risk difference, -5% [95% CI, -9% to -2%]). Weight gain was slower in the donor milk group (22.3 g/kg/d [95% CI, 21.3 to 23.3 g/kg/d]) compared with the preterm formula group (24.6 g/kg/d [95% CI, 23.6 to 25.6 g/kg/d]). Conclusions and Relevance: Among extremely preterm neonates fed minimal maternal milk, neurodevelopmental outcomes at 22 to 26 months' corrected age did not differ between infants fed donor milk or preterm formula. Trial Registration: ClinicalTrials.gov Identifier: NCT01534481.

Fundamentals of designing high-quality surveys: revisiting neonatal perinatal medicine survey applications.

Surveys in neonatal perinatal medicine are practical instruments for gathering information about medical practices, and outcomes related to the care of newborns and infants. This includes research for identifying needs, assessing requirements, analyzing the effects of change, creating policies, and developing curriculum initiatives. Surveys also provide useful data for enhancing the provision of healthcare services, assessing medical specialties, and evaluating training programs. However, creating a high-quality survey can be difficult for many practitioners, particularly when deciding how to formulate the right questions, whether to utilize various types of questions and how best to arrange or format the survey tool for effective responses. Problems with design principles have been evident in many surveys submitted for dissemination to the members of the Section of Neonatal Perinatal Medicine (SoNPM). To prevent potential measurement errors and increase the quality of surveys, it is crucial to follow a systematic approach in developing surveys by adhering to the principles of effective survey design. This review article provides a brief summary of survey use within the SoNPM, and offers guidance for creating high-quality surveys, including identifying important factors to consider in survey development and characteristics of well-written and effective questions. We briefly note techniques that optimize survey design for distribution through digital media.

Early neurodevelopmental follow-up in the NICHD neonatal research network: Advancing neonatal care and outcomes, opportunities for the future.

At the inception of the Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN), provision of care for extremely preterm (EPT) infants was considered experimental. The NRN Follow-up Study Group, initiated in 1993, developed infrastructure with certification processes and standards, allowing the NRN to assess 2-year outcomes for EPT and to provide important metrics for randomized clinical trials. This chapter will review the NRN Follow-up Study Group's contributions to understanding factors related to improved neurodevelopmental, behavioral, and social-emotional outcomes of EPT infants. We will also discuss follow up challenges, including reassessing which outcomes are most meaningful for parents and investigators. Finally, we will explore how outcome studies have informed clinical decisions and ethical considerations, given limitations of prediction of complex later childhood outcomes from early neurodevelopmental findings.

Hydrocortisone to Improve Survival without Bronchopulmonary Dysplasia.

BACKGROUND: Bronchopulmonary dysplasia is a prevalent complication after extremely preterm birth. Inflammation with mechanical ventilation may contribute to its development. Whether hydrocortisone treatment after the second postnatal week can improve survival without bronchopulmonary dysplasia and without adverse neurodevelopmental effects is unknown. METHODS: We conducted a trial involving infants who had a gestational age of less than 30 weeks and who had been intubated for at least 7 days at 14 to 28 days. Infants were randomly assigned to receive either hydrocortisone (4 mg per kilogram of body weight per day tapered over a period of 10 days) or placebo. Mandatory extubation thresholds were specified. The primary efficacy outcome was survival without moderate or severe bronchopulmonary dysplasia at 36 weeks of postmenstrual age, and the primary safety outcome was survival without moderate or severe neurodevelopmental impairment at 22 to 26 months of corrected age. RESULTS: We enrolled 800 infants (mean [±SD] birth weight, 715±167 g; mean gestational age, 24.9±1.5 weeks). Survival without moderate or severe bronchopulmonary dysplasia at 36 weeks occurred in 66 of 398 infants (16.6%) in the hydrocortisone group and in 53 of 402 (13.2%) in the placebo group (adjusted rate ratio, 1.27; 95% confidence interval [CI], 0.93 to 1.74). Two-year outcomes were known for 91.0% of the infants. Survival without moderate or severe neurodevelopmental impairment occurred in 132 of 358 infants (36.9%) in the hydrocortisone group and in 134 of 359 (37.3%) in the placebo group (adjusted rate ratio, 0.98; 95% CI, 0.81 to 1.18). Hypertension that was treated with medication occurred more frequently with hydrocortisone than with placebo (4.3% vs. 1.0%). Other adverse events were similar in the two groups. CONCLUSIONS: In this trial involving preterm infants, hydrocortisone treatment starting on postnatal day 14 to 28 did not result in substantially higher survival without moderate or severe bronchopulmonary dysplasia than placebo. Survival without moderate or severe neurodevelopmental impairment did not differ substantially between the two groups. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01353313.).

Neurodevelopmental outcome of preterm infants enrolled in myo-inositol randomized controlled trial.

OBJECTIVE: This study evaluates the 24-month follow-up for the NICHD Neonatal Research Network (NRN) Inositol for Retinopathy Trial. STUDY DESIGN: Bayley Scales of Infants Development-III and a standardized neurosensory examination were performed in infants enrolled in the main trial. Moderate/severe NDI was defined as BSID-III Cognitive or Motor composite score <85, moderate or severe cerebral palsy, blindness, or hearing loss that prevents communication despite amplification were assessed. RESULTS: Primary outcome was determined for 605/638 (95%). The mean gestational age was 25.8 ± 1.3 weeks and mean birthweight was 805 ± 192 g. Treatment group did not affect the risk for the composite outcome of death or survival with moderate/severe NDI (60% vs 56%, p = 0.40). CONCLUSIONS: Treatment group did not affect the risk of death or survival with moderate/severe NDI. Despite early termination, this study represents the largest RCT of extremely preterm infants treated with myo-inositol with neurodevelopmental outcome data.

What Are We Measuring as Outcome? Looking Beyond Neurodevelopmental Impairment.

Outcomes of neonatal intensive care unit (NICU) graduates have been categorized by rates of neurodevelopmental impairment at 2 years old. Although useful as metrics for research, these early childhood assessments may underestimate or overestimate later functional capabilities. Often overlooked are less severe but more prevalent neurobehavioral dysfunctions seen later in childhood, and chronic health concerns that may impact the child's quality of life (QoL). Comprehensive NICU follow-up should include measures of less severe cognitive/learning delays, physical/mental well-being, and the promotion of resilience in children and families. Studies are needed to identify QoL measures that will optimize children's assessments and outcomes.

Effect of Depth and Duration of Cooling on Death or Disability at Age 18 Months Among Neonates With Hypoxic-Ischemic Encephalopathy: A Randomized Clinical Trial.

IMPORTANCE: Hypothermia for 72 hours at 33.5°C for neonatal hypoxic-ischemic encephalopathy reduces death or disability, but rates continue to be high. OBJECTIVE: To determine if cooling for 120 hours or to a temperature of 32.0°C reduces death or disability at age 18 months in infants with hypoxic-ischemic encephalopathy. DESIGN, SETTING, AND PARTICIPANTS: Randomized 2 × 2 factorial clinical trial in neonates (≥36 weeks' gestation) with hypoxic-ischemic encephalopathy at 18 US centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network between October 2010 and January 2016. INTERVENTIONS: A total of 364 neonates were randomly assigned to 4 hypothermia groups: 33.5°C for 72 hours (n = 95), 32.0°C for 72 hours (n = 90), 33.5°C for 120 hours (n = 96), or 32.0°C for 120 hours (n = 83). MAIN OUTCOMES AND MEASURES: The primary outcome was death or moderate or severe disability at 18 to 22 months of age adjusted for center and level of encephalopathy. Severe disability included any of Bayley Scales of Infant Development III cognitive score less than 70, Gross Motor Function Classification System (GMFCS) level of 3 to 5, or blindness or hearing loss despite amplification. Moderate disability was defined as a cognitive score of 70 to 84 and either GMFCS level 2, active seizures, or hearing with amplification. RESULTS: The trial was stopped for safety and futility in November 2013 after 364 of the planned 726 infants were enrolled. Among 347 infants (95%) with primary outcome data (mean age at follow-up, 20.7 [SD, 3.5] months; 42% female), death or disability occurred in 56 of 176 (31.8%) cooled for 72 hours and 54 of 171 (31.6%) cooled for 120 hours (adjusted risk ratio, 0.92 [95% CI, 0.68-1.25]; adjusted absolute risk difference, -1.0% [95% CI, -10.2% to 8.1%]) and in 59 of 185 (31.9%) cooled to 33.5°C and 51 of 162 (31.5%) cooled to 32.0°C (adjusted risk ratio, 0.92 [95% CI, 0.68-1.26]; adjusted absolute risk difference, -3.1% [95% CI, -12.3% to 6.1%]). A significant interaction between longer and deeper cooling was observed (P = .048), with primary outcome rates of 29.3% at 33.5°C for 72 hours, 34.5% at 32.0°C for 72 hours, 34.4% at 33.5°C for 120 hours, and 28.2% at 32.0°C for 120 hours. CONCLUSIONS AND RELEVANCE: Among term neonates with moderate or severe hypoxic-ischemic encephalopathy, cooling for longer than 72 hours, cooling to lower than 33.5°C, or both did not reduce death or moderate or severe disability at 18 months of age. However, the trial may be underpowered, and an interaction was found between longer and deeper cooling. These results support the current regimen of cooling for 72 hours at 33.5°C. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01192776.

Safety and Effectiveness of Whole Body Cooling Therapy for Neonatal Encephalopathy on Transport.

OBJECTIVE: The purpose of this study was to evaluate the safety and effectiveness of a transport protocol using active and passive methods for therapeutic whole body cooling of the neonate with hypoxic-ischemic encephalopathy. METHODS: A retrospective study of neonates who received whole body cooling during transport by our pediatric/neonatal transport team between December 2008 and April 2012 was conducted. RESULTS: Sixty-three of 66 (95%) neonates arrived within a safety temperature range of 33.0°C-37°C, and 3 (5%) were hypothermic (31.9°C-32.8°C). No clinical complications of cooling during transport were identified. Twenty-five (38%) and 57(86%) achieved therapeutic cooling upon admission and ≤ 6 hours after birth, respectively. Factors associated with cooling > 6 hours included a later time of initial referral (2.44 vs. 1.07 hours, P = .01), a later rendezvous time (4.17 vs. 1.92 hours, P = .002), and a later admission time (6.46 vs. 3.99 hours, P = .001). CONCLUSION: Whole body cooling of neonates with hypoxic-ischemic encephalopathy can be effectively and safely performed during interfacility transport.

Findings and patterns on MRI and MR spectroscopy in neonates after therapeutic hypothermia for hypoxic ischemic encephalopathy treatment.

OBJECTIVES: The purpose of this study is to describe the findings and patterns of injury on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) after whole-body hypothermia treatment for neonatal hypoxic ischemic encephalopathy. METHODS: A retrospective review of consecutive term neonates treated with whole-body hypothermia was performed. Data recorded included demographics and MRI and MRS findings, and day of life (DOL) studies were performed. Injury patterns were classified on MRI as deep, cortical, mixed, or diffuse. The relative apparent diffusion coefficient (rADC) was plotted against DOL scanned and the presence of lactate was recorded. RESULTS: MRI was performed in 44 infants, 34 of whom also underwent MRS. MRI was abnormal in 32% of neonates, 29.5% of whom were imaged at DOL 4 to 8. rADC values were lowest in neonates scanned on DOL 4 and 5 and remained low up to DOL 8. The deep brain nuclei were involved in hypoxic ischemic encephalopathy in 93% of neonates with abnormal MRIs and lactate was identified on MRS in 18% of neonates between DOL 4 and 8. CONCLUSIONS: MRI performed after therapeutic cooling was abnormal in 29.5% of neonates scanned on DOL 4 to 8. Deep nuclear injury was identified in 93% of neonates. Lactate was present on MRS in 18% of neonates, and rADC values were most reduced on MRI between DOL 4 and 8.

School-age outcome of children with prenatal cocaine exposure following early case management.

The impact of prenatal cocaine exposure on neurodevelopmental outcome in childhood continues to be in question. Objectives of this study were to determine if there are differences in growth, behavioral, cognitive or verbal functioning or caregiver-child dyad interactions for inner-city, school-aged children with and without prenatal cocaine exposure, and if these measures would be affected by early family case management. From an initial sample of 118 cocaine-exposed children who were evaluated to 36 months of age, 47 were able to be contacted and 39 (83%) completed a follow-up evaluation at 84 +/- 11 months of age. Subjects had been assigned at birth to early case management (CM, 24) and routine care (RC, 15). Eighteen children from the initial non-cocaine-exposed comparison sample of 41 children were able to be contacted and 12 (67%) were evaluated at 85 +/- 16 months of age. Evaluation included growth measurements, Stanford-Binet IQ, receptive and expressive language quotients, parent-reported Child Behavior Checklists (CBCL), and assessment of caregiver-child interactions by scored videotaped free-play sessions. No differences were found in growth, mean IQ, language quotients, CBCL scores or videotaped caregiver-child play interactions as a function of cocaine exposure. Within the cocaine-exposed group, there were no outcome differences between CM and RC children. However, during the play sessions, CM caregivers had more positive affect in interactions with the child than RC. Within the RC dyads, birthmothers had significantly more positive interactions than non-birthmothers. In summary, no differences in growth, behavioral, cognitive, or language function were evident for inner-city, school-aged children related to prenatal cocaine exposure or early case management. CM caregivers demonstrated more positive interactions during a play session than RC; within the RC group, non birthmothers had the least positive affective interactions. Further study of influences on caregiver-child interactions may lead to effective intervention strategies for drug-exposed infants.

Perinatal outcome and later implications of intrauterine growth restriction.

This chapter reviews outcomes for children who have intrauterine growth retardation (IUGR) or small-for-gestation-age (SGA) status at birth. Such infants are at risk for increased perinatal mortality, birth adaptation complications, including perinatal acidosis, hypoglycemia, hypothermia, coagulation abnormalities, and selected immunologic deficiencies. IUGR infants also appear to be at great risk for complications of prematurity, including chronic lung disease and necrotizing enterocolitis. Childhood implications for IUGR include an increased risk for short stature, cognitive delays with decreased academic achievement, and a small but significant increased risk of neurologic disorders, including cerebral palsy. Low socioeconomic status is correlated with the occurrence of IUGR and is significantly related to long-term disabilities. Morbidities associated with preterm delivery appear to be additive to those associated with fetal growth restriction so IUGR, preterm infants may be at great risk for poor neurodevelopmental outcome.

Can an alternative umbilical arterial catheter solution and flush regimen decrease iatrogenic hemolysis while enhancing nutrition? A double-blind, randomized, clinical trial comparing an isotonic amino acid with a hypotonic salt infusion.

OBJECTIVE: In the process of sampling blood through an umbilical arterial catheter (UAC), infant blood comes into stagnant contact with infusion solution in the "waste syringe" before being reinfused. We have previously demonstrated in vitro that this process is associated with less hemolysis of red blood cells (RBCs) with use of an isotonic solution compared with a hypotonic 0.25 normal saline (NS) solution. The objective of this study was to compare the in vivo effect on hemolysis of 2 UAC infusion/flush regimens (an isotonic regimen vs a hypotonic regimen) and to assess the early nutritional benefit of an amino acid solution as the isotonic UAC infusion solution. METHODS: Infants who had a birth weight of < or =1.5 kg and were expected to have a UAC for > or =3 days were enrolled within 24 hours of life into this prospective, double-blind, randomized, clinical trial of 2 UAC infusion solution/flush regimens. Power analysis demonstrated that 40 infants were needed to determine differences in hemolysis quantified by plasma-free hemoglobin (PFH) level. Nutrition from glucose was evaluated by measurement of daily dextrose calories. C-peptide was measured to evaluate endogenous insulin production. Adverse events and protein tolerance were tracked. RESULTS: Twenty-two infants (mean gestational age: 27 weeks; 945 g birth weight) were enrolled in each group, for an average of 4.2 days (range: 2.5-8 days). There were no group differences in demographics. PFH levels were lower for infants who received isotonic amino acid (IAA) in comparison with 0.25 NS (33 +/- 14 mg/dL vs 62 +/- 27 mg/dL, respectively). C-peptide was higher in those who received IAA, as were nonprotein calories received on days 4 to 6 of the study (51 +/- 11 kcal/kg/day vs 44 +/- 12 kcal/kg/day, IAA vs 0.25 NS, respectively). CONCLUSIONS: Lower PFH levels in IAA versus 0.25 NS group were consistent with our hypothesis of decreased hemolysis with an isotonic infusion/flush regimen. IAA use may also allow greater early glucose nutrition, as indicated by the higher level of endogenous insulin production and improved glucose tolerance. IAA seems to be a superior UAC solution to 0.25 NS in that it is associated with less hemolysis and improved nutrition.

Preschool outcome of less than 801-gram preterm infants compared with full-term siblings.

OBJECTIVE: Extremely low birth weight (ELBW) infants are at greater risk for neurodevelopmental delay than full-term infants. Outcomes may be compromised secondary to abnormal brain development associated with complications of prematurity. Long-term cognitive outcome has also been reported to be significantly influenced by postnatal factors. The objective of this study was to clarify the effects of prematurity separate from environmental factors on growth and neurodevelopmental outcomes by comparing ELBW children with their full-term siblings. METHODS: The study consisted of 25 ELBW children, a subset selected from a larger population of infants who were <801 g birth weight and enrolled in a longitudinal follow-up project from birth and their 25 full-term, full-weight siblings. Twenty-three sets of siblings were evaluated at 5 years of age and 2 sets at 3 years of age with standardized medical, social, cognitive, motor, and language testing. Physical and neurodevelopmental outcomes were compared between groups, controlling for gender and socioeconomic status (SES). RESULTS: At follow-up, ELBW children were lighter, were shorter, and had smaller head circumference. The ELBW children had lower Stanford-Binet IQs (85 +/- 12 [mean +/- SD] and 95 +/- 11), with lower Stanford-Binet subtests except short-term memory and quantitative reasoning, lower spelling scores on the Wide Range Achievement Test, and lower Peabody motor quotients (79 +/- 11 and 92 +/- 17). Preschool Language Scale quotients were not different, but other receptive language measures were lower for ELBW children. High SES seemed to modify the impact of preterm status on cognitive and language but not motor scores. The mean IQ for high-SES ELBW children was equivalent to that of the low-SES term siblings. CONCLUSIONS: Preschool-age cognitive and language functioning in ELBW children seemed to be affected by both prenatal and birth influences (preterm status) and postnatal influences (SES variables). Motor scores were significantly related to preterm status but not to SES.

Pulmonary function and exercise capacity for ELBW survivors in preadolescence: effect of neonatal chronic lung disease.

OBJECTIVE: To assess pulmonary function and exercise capacity of apparently asymptomatic children who were born extremely preterm. STUDY DESIGN: Pulmonary function and treadmill testing were performed on 50 children 9 to 15 years old who had birth weight <801 g (extremely low birth weight [ELBW]) and without apparent neurodevelopmental or pulmonary disabilities, compared with 25 children born at term with normal birth weight (NBW). Medical history and physical activity levels were assessed by parent questionnaire. Group differences were determined by two-sample t test. Secondary analysis was performed to assess significant influence of neonatal chronic lung disease (CLD) on outcome measures. RESULTS: Twenty percent of ELBW subjects but no subjects with NBW had clinically abnormal pulmonary function (>2 SD from norms, P=.026). All significant pulmonary function differences except peak expiratory flow rate percentages were accounted for by ELBW subjects who had CLD. Oxygen consumption measurements were significantly lower for subjects with ELBW (30.3+/-6.9 and 38.5+/-5.2 mL/kg/min, P=.000), independent of CLD status. CONCLUSION: Pulmonary function abnormalities consistent with obstructive lung disease were more frequently detected in ELBW children who had neonatal CLD. Low oxygen consumption measurements suggest a lower level of fitness for ELBW children compared with children with NBW.

Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia.

OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. The objective of this study was to develop strategies to decrease nosocomial infection rates in NICUs. METHODS: The process included a comprehensive literature review, internal practice analyses, benchmark studies, and development of practical experience through rapid-cycle changes, subsequent analysis, and feedback. This process led to 3 summary statements on potentially better practices in handwashing, approach to nosocomial sepsis evaluations, and central venous catheter management. RESULTS: These statements provide a basis for an evidence-based approach to lowering neonatal intensive care unit nosocomial infection rates. CONCLUSIONS: The 2-year process also led to changes in the culture and habits of the institutions involved, which should in turn have long-term effects on other aspects of quality improvement.

Implementation of evidence-based potentially better practices to decrease nosocomial infections.

OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. Nosocomial infection is a significant area for improvement in most NICUs. METHODS: Six NICUs participating in the Vermont Oxford Network made clinical changes to address 3 areas of consensus: handwashing, line management, and accuracy of diagnosis. The summary statements were widely communicated. Review of the literature, internal assessments, and benchmarking visits all contributed to ideas for change. RESULTS: The principle outcome was the incidence of coagulase-negative staphylococcus bacteremia. There was an observed reduction from 24.6% in 1997 to 16.4% in 2000. CONCLUSIONS: The collaborative process for clinical quality improvement can result in effective practice changes.

Evidence-based approach to change in clinical practice: introduction of expanded nasal continuous positive airway pressure use in an intensive care nursery.

OBJECTIVE: Recent studies provide evidence that nasal intermittent positive pressure ventilation (NIPPV) may stabilize the airway of extremely low birth weight infants after endotracheal extubation. The objective of this project was to introduce the use of NIPPV into a busy level 3 intensive care nursery. METHODS: This report describes the process of NIPPV introduction using a series of rapid-cycle improvement projects, as proposed by the Vermont Oxford Network. RESULTS: In the first cycle, 7 (88%) of 8 infants were successfully extubated with NIPPV after meeting criteria for reintubation on nasal continuous positive airway pressure alone. Proper positioning of the prongs in the nasopharynx was found to be an important determinant of success. In a second cycle, shorter 2.5-cm nasopharyngeal prongs were more effective than standard 4-cm prongs in 12 recently extubated infants as assessed by objective measurements and subjective nursing reports. A third cycle confirmed the acceptance of this technique in our unit and demonstrated an associated decrease in markers of chronic lung disease in extremely low birth weight infants during the 22 months after its introduction. CONCLUSION: This experience supports the role for the rapid-cycle change model in achieving effective evidence-based medical practices in a neonatal intensive care setting.

Functional outcome at adolescence for infants less than 801 g birth weight: perceptions of children and parents.

OBJECTIVE: To compare functional, emotional, and academic status of adolescents who had been extremely low birth weight (ELBW) with those who were full term. STUDY DESIGN: Twenty-six adolescents who were born in 1983 to 1984 at less than 801 g birth weight were compared with 26 adolescents born at term. Adolescent-perceived status was assessed using the Behavior Assessment System for Children (BASC-SR) and the Self-Perception Profile. Parents' perceptions were assessed using BASC Parent Report, Family Impact Questionnaire, and Functional Status Measure. Health status was obtained through written requests to primary care providers and parent interviews. Academic and attendance information was obtained through school records. RESULTS: Compared to the term adolescents, the ELBW group had significantly lower function related to health status, increased need for special education, and tended to score lower on academic performance measures. However, ELBW adolescents' perceptions regarding their scholastic, athletic, or social competencies did not differ from the term group or national normative data. Parents of ELBWs reported lower adaptive skills, but no other behavioral differences from the term group. CONCLUSION: ELBW survivors and their parents perceived outcome at adolescence positively in spite of evident limitations. Mechanisms that ELBW families use to cope may be important determinants for successful, long-term outcome.