Comparison of a dichotomous versus trichotomous checklist for neonatal intubation.

BACKGROUND: To compare validity evidence for dichotomous and trichotomous versions of a neonatal intubation (NI) procedural skills checklist. METHODS: NI skills checklists were developed utilizing an existing framework. Experts were trained on scoring using dichotomous and trichotomous checklists, and rated recordings of 23 providers performing simulated NI. Videolaryngoscope recordings of glottic exposure were evaluated using Cormack-Lehane (CL) and Percent of Glottic Opening scales. Internal consistency and reliability of both checklists were analyzed, and correlations between checklist scores, airway visualization, entrustable professional activities (EPA), and global skills assessment (GSA) were calculated. RESULTS: During rater training, raters gave significantly higher scores on better provider performance in standardized videos (both p < 0.001). When utilized to evaluate study participants' simulated NI attempts, both dichotomous and trichotomous checklist scores demonstrated very good internal consistency (Cronbach's alpha 0.868 and 0.840, respectively). Inter-rater reliability was higher for dichotomous than trichotomous checklists [Fleiss kappa of 0.642 and 0.576, respectively (p < 0.001)]. Sum checklist scores were significantly different among providers in different disciplines (p < 0.001, dichotomous and trichotomous). Sum dichotomous checklist scores correlated more strongly than trichotomous scores with GSA and CL grades. Sum dichotomous and trichotomous checklist scores correlated similarly well with EPA. CONCLUSIONS: Neither dichotomous or trichotomous checklist was superior in discriminating provider NI skill when compared to GSA, EPA, or airway visualization assessment. Sum scores from dichotomous checklists may provide sufficient information to assess procedural competence, but trichotomous checklists may permit more granular feedback to learners and educators. The checklist selected may vary with assessment needs.

Intubation Competence During Neonatal Fellowship Training.

OBJECTIVES: To characterize neonatal-perinatal medicine fellows' progression toward neonatal intubation procedural competence during fellowship training. METHODS: Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows' intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success. RESULTS: There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07-1.14). CONCLUSIONS: The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees' progression toward intubation competence is warranted.

Current training in percutaneously inserted central catheter (PICC) placement and maintenance for neonatal-perinatal medicine fellows.

OBJECTIVE: To describe the current educational status of percutaneously inserted central catheter (PICC) insertion/ maintenance training for neonatal-perinatal medicine (NPM) fellows in the United States. STUDY DESIGN: A cross-sectional 34-question survey was electronically distributed to NPM fellowship training program directors (PDs) in the United States. RESULTS: The response rate was 81.8% (81/99 PD). Most PDs (68.5%) reported that their neonatal intensive care unit has a PICC team. Fellows were PICC team members in 72%. Only 52% of programs offer formal training in PICC placement to fellows; 61.5% of these utilize a standardized curriculum. Dedicated PICC team existence was negatively associated with formal training for PICC insertion and maintenance for fellows (42.0% with PICC team vs. 73.91% without, p = 0.01). CONCLUSIONS: Wide variation exists in fellow's exposure, education, and competency assessment in PICC-related activities nationally. Development of a standardized curriculum would be beneficial.

Umbilical catheter-associated complications in a level IV neonatal intensive care unit.

OBJECTIVE: To assess complication rates and risks associated with the use of umbilical catheters. STUDY DESIGN: An observational cohort study was conducted in a level IV neonatal intensive care unit over 11 years. Any neonate with an umbilical catheter placed during this period was included. Complication event rates over time were assessed via Poisson and Cox regressions. RESULTS: Fifty one of 2035 umbilical arterial catheters (2.5%) and 269 of 2017 umbilical venous catheters placed (13.3%) developed a complication. Positional issues comprised most umbilical venous catheter-associated complications (86.2%) and breaks/ruptures the majority in umbilical arterial catheters (41.2%). The cumulative incidence of a complication increased most notably after 10 days of umbilical arterial catheter use and 16 days of umbilical venous catheter use. CONCLUSIONS: Complications occurred in a relatively low percentage of umbilical catheters placed in our neonatal intensive care unit. Extended catheter dwell time remains a significant risk of developing a complication.

Impact of a dedicated nursing team on central line-related complications in neonatal intensive care unit.

Aim: To evaluate the impact of a dedicated nursing team on central line insertion success and catheter-related complications.Methods: Five nurses were trained in central line insertion and maintenance practices and replaced a team primarily comprised of neonatal-perinatal medicine fellows. A prospective observational cohort study with pre/post-intervention analysis was designed to compare certain aspects of central line insertion and related complications between the two models.Results: Six hundred and twenty peripherally inserted central catheters were attempted preintervention (period 1) in 325 infants, and 630 were attempted in 406 infants postintervention (period 2). Successful central line placement on the first attempt increased significantly from 56.6% in period 1-71.4% in period 2 (p < .001), and needle sticks per attempt decreased (3.5 versus 3; p = .03). All central line-related complications decreased from 12.8 per 1000 line days in period 1 to 5.5 in period 2 (rate ratio = 0.40; 95% confidence interval: 0.29, 0.65). The most significant reduction was noted in phlebitis (4.9-0.5 per 1000 line days; rate ratio = 0.10; 95% confidence interval: 0.03, 0.30)Conclusion: Implementation of a dedicated nursing-based central line team, skilled in insertion and certain aspects of catheter maintenance, significantly improved insertion rates and reduced line-related complications.

Utility of Fetal Cardiac Axis and Cardiac Position Assessment in Predicting Neonatal Respiratory Morbidity in Fetal Congenital Lung Lesions.

OBJECTIVES: To assess the diagnostic performance of the fetal cardiac axis (CA) and/or cardiac position (CP) versus the congenital pulmonary malformation volume ratio (CVR) in predicting any and severe neonatal respiratory morbidity in fetal congenital lung lesions. METHODS: This work was an 11-year retrospective cohort study. The sensitivity, specificity, positive predictive value, and negative predictive value of CA and/or CP assessment in prediction of respiratory morbidity were calculated before 24 weeks' gestation and between 24 and 32 weeks and compared to CVR cutoffs obtained from the literature. RESULTS: Fifty-three patients were included. CA and/or CP abnormalities were present in 45% and 38% of patients before 24 weeks and between 24 and 32 weeks and were significantly more common in left- versus right-sided lesions (60% versus 17%; P = .003). The sensitivity, specificity, positive predictive value, and negative predictive value of an abnormal CA and/or CP for any and severe respiratory morbidity were 0.67, 0.61, 0.33, and 0.86 and 0.8, 0.58, 0.17, and 0.97 before 24 weeks and 0.75, 0.73, 0.45, and 0.91 and 0.8, 0.67, 0.20, and 0.97 between 24 and 32 weeks, respectively. An abnormal CA and/or CP had higher sensitivity for any respiratory morbidity compared to the CVR at 0.5 and 0.8 cutoffs both before 24 weeks and between 24 and 32 weeks (P < .05). CONCLUSIONS: An abnormal CA and/or CP before 24 weeks and between 24 and 32 weeks has higher sensitivity for the detection of any respiratory morbidity at birth compared to the CVR at both 0.5 and 0.8 cutoffs. A normal CA and CP have a high negative predictive value for excluding any respiratory morbidity at birth both before 24 weeks and between 24 and 32 weeks.

Neonatal Intubation Competency Assessment Tool: Development and Validation.

BACKGROUND: Neonatal tracheal intubation (NTI) is an important clinical skill. Suboptimal performance is associated with patient harm. Simulation training can improve NTI performance. Improving performance requires an objective assessment of competency. Competency assessment tools need strong evidence of validity. We hypothesized that an NTI competency assessment tool with multisource validity evidence could be developed and be used for formative and summative assessment during simulation-based training. METHODS: An NTI assessment tool was developed based on a literature review. The tool was refined through 2 rounds of a modified Delphi process involving 12 subject-matter experts. The final tool included a 22-item checklist, a global skills assessment, and an entrustable professional activity (EPA) level. The validity of the checklist was assessed by having 4 blinded reviewers score 23 videos of health care providers intubating a neonatal simulator. RESULTS: The checklist items had good internal consistency (overall α = 0.79). Checklist scores were greater for providers at greater training levels and with more NTI experience. Checklist scores correlated with global skills assessment (ρ = 0.85; P < .05), EPA levels (ρ = 0.87; P < .05), percent glottic exposure (r = 0.59; P < .05), and Cormack-Lehane scores (ρ = 0.95; P < .05). Checklist scores reliably predicted EPA levels. CONCLUSIONS: We developed an NTI competency assessment tool with multisource validity evidence. The tool was able to discriminate NTI performance based on experience. The tool can be used during simulation-based NTI training to provide formative and summative assessment and can aid with entrustment decisions.

Two-Year Neurodevelopment and Growth Outcomes for Preterm Neonates Who Received Low-Dose Intravenous Soybean Oil.

BACKGROUND: In some studies, the dose of intravenous soybean oil (SO) has been associated with a decreased incidence of intestinal failure-associated liver disease. The effect of lipid sparing on neurodevelopment (ND) and growth remains unknown. This study investigated the impact of SO dose on ND and growth over the first 2 years of age in preterm neonates. MATERIALS AND METHODS: This is a single-site prospective follow-up study. Neonates with a gestational age ≤29 weeks were randomized to low-dose (LOW) or standard-dose (CON) SO. Bayley Scales of Infant Development III and anthropometric measurements were collected at approximately 6, 12, and 24 months corrected gestational age. RESULTS: Subjects were premature, with a mean (±SD) gestational age of 28 ± 1 and 27 ± 1 weeks (P = .3) for LOW and CON, respectively. Thirty subjects completed follow-up (LOW = 15, CON = 15). There were no differences for ND and growth outcomes when LOW was compared with CON, with the exception of a higher 12-month follow-up cognitive scaled score in the LOW group (P = .02). CONCLUSION: A reduced SO dose did not adversely affect ND or growth in this cohort of preterm neonates. However, larger studies are needed to determine the long-term safety of SO dose reduction before this strategy can be adopted.

Risk factors for tracheostomy requirement in extremely low birth weight infants.

AIM: To identify variables that affect the risk of tracheostomy in a population of extremely low birth weight (ELBW) infants. METHODS: A retrospective matched case-control study was conducted. ELBW infants with a tracheostomy were compared with controls without tracheostomy. Data collection included demographics, detailed information about each intubation and extubation attempt, the use of steroids and the presence of comorbidities. Statistical analyses include conditional logistic regression and Poisson regression for clustered observations. RESULTS: Twenty-eight ELBW infants with a tracheostomy were identified. Mean gestational age for both cases and controls was 25 weeks (22-29) and 67.9% were males. Tracheostomy was performed on average on day of life 118 (95%CI: 107-128) and weight at tracheostomy was 2877 g (95%CI: 2657-3098). In the final model, cumulative days with an endotracheal tube (ETT) and total number of intubation episodes were associated with a tracheostomy. For each additional day of intubation, odds of tracheostomy increased by 11% (OR = 1.11, 95%CI: 1.01, 1.23) and with each new intubation episode/failed extubation episode, odds of tracheostomy increased by 150% from the previous episode (OR = 2.5, 95%CI: 1.2, 5.2). CONCLUSIONS: Greater cumulative exposure to ETT ventilation and number of intubations is associated with having a tracheostomy.

Low-Dose Intravenous Soybean Oil Emulsion for Prevention of Cholestasis in Preterm Neonates.

BACKGROUND: Premature infants depend on intravenous fat emulsions to supply essential fatty acids and calories. The dose of soybean-based intravenous fat emulsions (S-IFE) has been associated with parenteral nutrition (PN)-associated liver disease. This study's purpose was to determine if low-dose S-IFE is a safe and effective preventive strategy for cholestasis in preterm neonates. MATERIALS AND METHODS: This is a multicenter randomized controlled trial in infants with a gestational age (GA) ≤29 weeks. Patients <48 hours of life were randomized to receive a low (1 g/kg/d) or control dose (approximately 3 g/kg/d) of S-IFE. The primary outcome was cholestasis, defined as a direct bilirubin ≥15% of the total bilirubin at 28 days of life (DOL) or full enteral feeds, whichever was later, after 14 days of PN. Secondary outcomes included growth, length of hospital stay, death, and major neonatal morbidities. RESULTS: In total, 136 neonates (67 and 69 in the low and control groups, respectively) were enrolled. Baseline characteristics were similar for the 2 groups. When the low group was compared with the control group, there was no difference in the primary outcome (69% vs 63%; 95% confidence interval, -0.1 to 0.22; P = .45). While the low group received less S-IFE and total calories over time compared with the control group (P < .001 and P = .03, respectively), weight, length, and head circumference at 28 DOL, discharge, and over time were not different (P > .2 for all). CONCLUSION: Compared with the control dose, low-dose S-IFE was not associated with a reduction in cholestasis or growth.

Systematic use of the RAM nasal cannula in the Yale-New Haven Children's Hospital Neonatal Intensive Care Unit: a quality improvement project.

OBJECTIVE: To evaluate the clinical efficacy of the RAM nasal cannula (NC) with different modes of non-invasive ventilation (NIV) in the neonatal intensive care unit (NICU). METHODS: A single center prospective, observational study of infants placed on RAM NC. A small trial (Study 1) was completed in 16 infants on NIV via the RAM NC over a 48-h period to create Summary Statement recommendations. Next, over a 10-month period (Study 2), data were prospectively collected for the outcome of all infants receiving respiratory support with the RAM NC. Outcomes were compared between different modes of NIV and whether the recommendations were followed. RESULTS: The Study 2 population consisted of 88 infants of whom 67 infants received nasal continuous positive airway pressure ventilation (NCPAP) and 21 received nasal intermittent positive pressure ventilation (NIPPV) via the RAM NC. The NIPPV group tended to be younger, smaller and stayed on the RAM NC longer. The overall success rate in weaning off the RAM NC, if our guidelines were followed, was 63%. CONCLUSION: RAM NC use with NIV was well tolerated in the neonatal population with the use of our guidelines. We speculate that use of our guidelines will lead to a more systematic use of the RAM NC in the NICU.

Is a haptic simulation interface more effective than computer mouse-based interface for neonatal intubation skills training?

Objective: To compare the efficacy of a three-dimensional (3D) haptic interface to a two-dimensional (2D) mouse interface for a screen-based simulation (SBS) neonatal intubation (NI) training intervention. Primary hypothesis: a haptic interface is more effective than a mouse interface for SBS training intervention for NI. Secondary hypothesis: SBS training, regardless of interface, will result in improved NI performance on a neonatal airway simulator. Methods: 45 participants were randomised to either a haptics or a mouse interface to complete an identical SBS training intervention for NI over a five-month period. Participants completed pre- and post-training surveys to assess demographics, experience, knowledge and attitudes. The primary outcome of participants' NI skills performance was assessed on a neonatal manikin simulator. Skills were measured pre- and post- training by number of attempts and time to successfully intubate, and airway visualization. Results: The demographics, training and experience were similar between groups. There was no difference in the improvement in skills, knowledge, attitudes or satisfaction ratings pre- and post-training between the groups. There was a significant decrease in number of attempts to intubate a neonatal airway simulator (2.89 vs 1.96, p<0.05) and improvement in the percent of subjects intubating in <30 seconds (22% vs 27%, p=0.02) from pre- to post-training in the study population overall. Conclusion: Using a haptic interface did not have an advantage over a mouse interface in improving NI skills, knowledge, attitudes, or satisfaction. Overall, a SBS training intervention for NI improved skills measured on a neonatal airway simulator.

Do you see what I see? A randomised pilot study to evaluate the effectiveness and efficiency of simulation-based training with videolaryngoscopy for neonatal intubation.

Introduction: Direct laryngoscopy (DL) and airway intubation are critical for neonatal resuscitation. A challenge in teaching DL is that the instructor cannot assess the learners' airway view. Videolaryngoscopy (VL), which allows display of a patient's airway on a monitor, enables the instructor to view the airway during the procedure. This pilot study compared deliberate practice using either VL with instruction (I-VL) or traditional DL. We hypothesised that I-VL would improve the efficiency and effectiveness of neonatal intubation (NI) training. Methods: Participants (students, paediatric interns and neonatal fellows) were randomised to I-VL or DL. Baseline technical skills were assessed using a skills checklist and global skills assessment. Following educational sessions, deliberate practice was performed on mannequins using the Storz C-MAC. With I-VL, the instructor could guide training using a real-time airway monitor view. With DL, feedback was based solely on technique or direct visual confirmation, but the instructor and learner views were not concurrent. During summative assessment, procedural skills checklists were used to evaluate intubation ability on a neonatal airway trainer. The duration of attempts was recorded, and recorded airway views were blindly reviewed for airway grade. 'Effectiveness' reflected achievement of the minimum passing score (MPS). 'Efficiency' was the duration of training for learners achieving the MPS. Results: 58 learners were randomised. Baseline demographics were similar. All participants had a significant improvement in knowledge, skills and comfort/confidence following training. There were no significant differences between randomised groups in efficiency or effectiveness, but trends towards improvement in each were noted. Fellows were more likely to achieve 'competency' postinstruction compared to non-fellows (p<0.001). Conclusions: This educational intervention to teach NI increased the learner's knowledge, technical skills and confidence in procedural performance in both groups. I-VL did not improve training effectiveness. The small sample size and participant diversity may have limited findings, and future work is indicated.

Clinical and laboratory factors that predict death in very low birth weight infants presenting with late-onset sepsis.

BACKGROUND: Late-onset sepsis (LOS) in very low birth weight (VLBW) infants is associated with significant morbidity and mortality. The ability to predict mortality in infants with LOS based on clinical and laboratory factors at presentation of illness remains limited. OBJECTIVES: To identify predictors of sepsis-associated mortality from a composite risk profile that includes demographic data, category of infecting organism, clinical and laboratory data at onset of illness. STUDY DESIGN: Data were collected from VLBW infants with at least 1 episode of LOS admitted to Yale Neonatal Intensive Care Unit from 1989 through 2007. Episodes were categorized as Gram-positive, Gram-negative or fungal. Multivariate logistic regression analysis was used to compare and contrast different types of infections and to assess independent risk factors for death. RESULTS: Four hundred twenty-four cases of LOS were identified in 424 VLBW infants. Of these, 262 (62%) were categorized as Gram-positive, 126 (30%) as Gram-negative and 36 (8%) as fungal. Multivariate analyses revealed that infants with Gram-positive infections had significantly lower odds of death compared to those with Gram-negative (adjusted odds ratio: 0.17; 95% confidence interval: 0.08-0.36) or fungal LOS (adjusted odds ratio: 0.22; 95% confidence interval: 0.07-0.64). Need for intubation, initiation of pressors, hypoglycemia and thrombocytopenia as presenting laboratory signs of infection and necrotizing enterocolitis were independent risk factors for sepsis-related death. CONCLUSIONS: We identified presenting clinical and laboratory factors, including category of infecting organism, which predict the increased risk of LOS-related death. This information can be useful in estimating prognosis shortly after the onset of disease.

The genetic susceptibility to respiratory distress syndrome.

Previous studies to identify a genetic component to RDS have shown conflicting results. Our objectives were to evaluate and quantify the genetic contribution to RDS using data that comprehensively includes known environmental factors in a large sample of premature twins. Data from a retrospective chart review of twins born at < or =32 wk GA were obtained from two neonatal units. Mixed effects logistic regression (MELR) analysis was used to assess the influence of several independent covariates on RDS. A zygosity analysis, including the effects of additive genetic, common environmental and residual effects (ACE) factors, was performed to estimate the genetic contribution. Results reveal that the 332 twin pairs had a mean GA of 29.5 wk and birth weight (BW) of 1372 g. An MELR identified significant nongenetic covariates as male gender (p = 0.04), BW (p < 0.001), 5-min Apgar score (p < 0.001), and treating institution (p = 0.001) as significant predictors for RDS. The ACE model was used to estimate the genetic susceptibility to RDS by adjusting for the above factors. We found 49.7% (p = 0.04) of the variance in liability to RDS was the result of genetic factors alone. We conclude that there is a significant genetic susceptibility to RDS in preterm infants.

New syndrome of simplified gyral pattern, micromelia, dysmorphic features and early death.

We report two sisters with a new syndrome of simplified gyral pattern, normal head circumference at birth but with subsequent development of microcephaly, intractable seizures, and early death. Dysmorphic features included coarse face, hypertrichosis, short nose, paranasal widening, long philtrum, short neck, upper limb micromelia, single transverse palmar lines, and clasp thumbs. The proband had repeated convulsions from shortly after birth and she required continuous artificial ventilation. Neurological examination showed absent sucking, rooting, Moro and grasping reflexes. MRI revealed a diffuse simplified gyral pattern with apparent agyria over the frontal lobes. Biochemical screening gave normal results. Her older sister had bilateral renal pelvic dilatation on prenatal ultrasound. She also developed severe convulsions on the first day of life, and she had to be artificially ventilated for 38 days. She had severe developmental retardation and neurological examination showed absence of spontaneous movements and Moro reflex, weak sucking reflex, and hypertonicity. CT scan of the brain showed a simplified gyral pattern. At 3 months, she developed hypocalcemia and hyperphosphatemia with normal levels of vitamin D and alkaline phosphatase, and parathyroid hormone level was low. Other biochemical tests gave normal results. She died at 5 months due to a massive aspiration event. Based on the unique clinical and radiological features found in our patients, we propose that this is a new syndrome.

Branchial cyst, sensorineural deafness, congenital heart defect, and skeletal abnormalities: Branchio-oto-cardio-skeletal (BOCS) syndrome?

This article describes a boy with an unusual combination of features, namely, intrauterine growth retardation, short stature, branchial cyst, sensorineural hearing loss, congenital heart defect, rib and vertebral abnormalities, micromelia, brachymesophalangia, and absence of phalanges. We suggest that these findings comprise a new entity of combined branchio-oto and cardio-digital developmental field abnormalities, which we termed branchio-oto-cardio-skeletal syndrome. The pattern of inheritance remains uncertain.