Identifying the essential knowledge and skills for Neonatal-Perinatal Medicine: a systematic analysis of practice.

The knowledge and skills expected for board certification in Neonatal-Perinatal Medicine (NPM) should reflect the clinical practice of neonatology. First, a 14-member panel of practicing neonatologists, convened by the American Board of Pediatrics (ABP), drafted a practice analysis document which identified the practice domains, tasks, knowledge, and skills deemed essential for clinical practice. NPM fellowship program directors provided feedback via online survey resulting in revisions to the document. During the second phase of the project, the panel organized testable knowledge areas into content domains and subdomains to update the existing ABP NPM content outline. All ABP board-certified neonatologists were asked to review via online survey, and results were used to guide final revisions to the content outline. The NPM practice analysis document and the updated NPM content outline should serve as helpful resources for educators, trainees, and practicing neonatologists.

Racial differences in parental satisfaction with neonatal intensive care unit nursing care.

OBJECTIVE: Nurses provide parental support and education in the neonatal intensive care unit (NICU), but it is unknown if satisfaction and expectations about nursing care differ between racial groups. STUDY DESIGN: A prospective cohort was constructed of families with a premature infant presenting to primary care between 1 January 2010 and 1 January 2013 (N=249, 52% white, 42% black). Responses to questions about satisfaction with the NICU were analyzed in ATLAS.ti using the standard qualitative methodology. RESULTS: One hundred and twenty (48%) parents commented on nursing. Fifty-seven percent of the comments were positive, with black parents more negative (58%) compared with white parents (33%). Black parents were most dissatisfied with how nurses supported them, wanting compassionate and respectful communication. White parents were most dissatisfied with inconsistent nursing care and lack of education about their child. CONCLUSIONS: Racial differences were found in satisfaction and expectations with neonatal nursing care. Accounting for these differences will improve parental engagement during the NICU stay.

Effect of prophylactic CPAP in very low birth weight infants in South America.

OBJECTIVE: The objective of this study was to examine the effect of prophylactic continuous positive airway pressure (CPAP) on infants born in 25 South American neonatal intensive care units affiliated with the Neocosur Neonatal Network using novel multivariate matching methods. STUDY DESIGN: A prospective cohort was constructed of infants with a birth weight 500 to 1500 g born between 2005 and 2011 who clinically were eligible for prophylactic CPAP. Patients who received prophylactic CPAP were matched to those who did not on 23 clinical and sociodemographic variables (N=1268). Outcomes were analyzed using the McNemar's test. RESULTS: Infants not receiving prophylactic CPAP had higher mortality rates (odds ratio (OR)=1.69, 95% confidence interval (CI) 1.17, 2.46), need for any mechanical ventilation (OR=1.68, 95% CI 1.33, 2.14) and death or bronchopulmonary dysplasia (BPD) (OR=1.47, 95% CI 1.09, 1.98). The benefit of prophylactic CPAP varied by birth weight and gender. CONCLUSIONS: The implementation of this process was associated with a significant improvement in survival and survival free of BPD.

Factors associated with high-risk rural women giving birth in non-NICU hospital settings.

OBJECTIVE: To identify risk factors for childbirth in a facility without neonatal intensive care unit (NICU) capacity among high-risk rural women. STUDY DESIGN: Using data on all maternal hospitalizations for rural residents in nine states (2010, 2012), we performed logit regression, focusing on women with multiple gestation and preterm birth. We defined a 'local' hospital as any maternity hospital within 30 miles (or the nearest hospital). RESULTS: Rural women with preterm births and multiple gestation pregnancies were less likely to give birth in a hospital with NICU capacity if no local hospital had this capacity. Adjusted odds of giving birth in a NICU hospital were lower among women ⩽age 20 (AOR 0.87 (95% CI 0.77, 0.98)), Medicaid beneficiaries (0.81 (0.75, 0.89)), uninsured women (0.44 (0.32, 0.61)) and black women (0.60 (0.50, 0.71)). CONCLUSIONS: Among high-risk rural pregnant women without local NICU access, younger, low-income, and black women had lower odds of using NICU hospitals.

Variation in treatment of neonatal abstinence syndrome in US children's hospitals, 2004-2011.

OBJECTIVE: Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by opioid-exposed infants. There is no standard treatment for NAS and surveys suggest wide variation in pharmacotherapy for NAS. Our objective was to determine whether different pharmacotherapies for NAS are associated with differences in outcomes and to determine whether pharmacotherapy and outcome vary by hospital. STUDY DESIGN: We used the Pediatric Health Information System Database from 2004 to 2011 to identify a cohort of infants with NAS requiring pharmacotherapy. Mixed effects hierarchical negative binomial models evaluated the association between pharmacotherapy and hospital with length of stay (LOS), length of treatment (LOT) and hospital charges, after adjusting for socioeconomic variables and comorbid clinical conditions. RESULT: Our cohort included 1424 infants with NAS from 14 children's hospitals. Among hospitals in our sample, six used morphine, six used methadone and two used phenobarbital as primary initial treatment for NAS. In multivariate analysis, when compared with NAS patients initially treated with morphine, infants treated with methadone had shorter LOT (incidence rate ratio (IRR) = 0.55; P < 0.0001) and LOS (IRR = 0.60; P < 0.0001). Phenobarbital as a second-line agent was associated with increased LOT (IRR = 2.09; P<0.0001), LOS (IRR = 1.78; P < 0.0001) and higher hospital charges (IRR = 1.84; P < 0.0001). After controlling for case-mix, hospitals varied in LOT, LOS and hospital charges. CONCLUSION: We found variation in hospital in treatment for NAS among major US children's hospitals. In analyses controlling for possible confounders, methadone as initial treatment was associated with reduced LOT and hospital stay.

Neonatal intensive care unit to home: the transition from parent and pediatrician perspectives, a prospective cohort study.

OBJECTIVES: To describe the experience of a low-income population during the transition from the neonatal intensive care unit (NICU) to home and to compare these experiences with pediatrician perspectives. STUDY DESIGN: A prospective cohort study in a Level III, 40-bed NICU at a county hospital in Northern California affiliated with seven outpatient pediatric clinics. We surveyed parents in English or Spanish at discharge (n=79) and two weeks after discharge (n=49), along with outpatient pediatricians (n=17). Parents assessed experiences with discharge and the frequency with which barriers were encountered after discharge. We compared parent experiences with pediatrician estimates on four of these barriers. RESULT: Spanish survey participants had more difficulty finding a NICU doctor (P=0.05) or nurse (P=0.001) to answer their questions. After discharge, 16% of families experienced significant challenges with two or more barriers. In contrast, the majority of pediatricians estimated that 50% or more families had significant challenges with all four barriers. CONCLUSION: Communication difficulties were the most commonly reported barriers during the NICU stay and physicians overestimated the frequency that families experienced challenges after discharge. Parent input is important to create effective interventions aimed at improving care and limiting disparities.

The impact of growth curve changes in assessing premature infant growth.

OBJECTIVE: To assess the impact of using the recently published WHO growth standard, based on healthy, breastfed infants in multiple countries that excluded prematurely born infants, versus the Infant Health Development Program (IHDP) growth reference constructed from premature infants, on the interpretation of the growth of premature infants after hospital discharge. STUDY DESIGN: A retrospective cohort was constructed of infants born at gestational age ≤35 weeks who initially presented for care at one of the 32 outpatient sites between 2006 and 2008 (N=2297). Kappa statistics measured overall agreement and agreement in ever classifying infants <5th percentile or ≥ 95th percentile for age between the WHO and IHDP. Logistic regression models identified factors associated with growth curve disagreement in classifying infants at the extremes of growth. RESULT: The WHO and IHDP growth curves showed moderate agreement for all measurements (κ=0.40-0.52). When the curves disagreed on whether an infant was <5th percentile for weight (8.3% of cohort) or length (13.6% of cohort), the WHO curve classified the infant in this category over 90% of the time. For head circumference, the IHDP curve classified more infants below the 5th percentile. Gestational age <30 weeks was associated with growth curve disagreement for weight and length <5th percentile. CONCLUSION: Choice of growth curve affects the assessment of growth and the classification of underweight status. Longitudinal studies are needed to determine which assessment identifies the greatest number of premature infants at risk for long-term growth issues.

The impact of certificate of need programs on neonatal intensive care units.

OBJECTIVE: To determine the impact of state certificate of need programs (CON) on the number of hospitals with neonatal intensive care units (NICU) and the number of NICU beds. STUDY DESIGN: The presence of a CON program was verified from each state's department of health. Multivariable regression models determined the association between the absence of a CON program and each outcome after controlling for socioeconomic and demographic differences between states. RESULT: A total of 30 states had CON programs that oversaw NICUs in 2008. Absence of such programs was associated with more hospitals with a NICU (Rate Ratio (RR) 2.06, 95% CI 1.74 to 2.45) and NICU beds (RR 1.96, 95% CI 1.89 to 2.03) compared with states with CON legislation, and increased all-infant mortality rates in states with a large metropolitan area. CONCLUSION: There has been an erosion of CON programs that oversee NICUs. CON programs are associated with more efficient delivery of neonatal care.

Clinical Predictors of Urinary Tract Infection in the Neonatal Intensive Care Unit.

OBJECTIVE: To identify clinical predictors associated with urinary tract infections (UTI) in patients in a referral neonatal intensive care unit (NICU). STUDY DESIGN: We performed a nested case control study of all NICU patients with urine cultures obtained as part of late-onset sepsis evaluations from January 1, 2007 through December 31, 2007 (N=266). Clinical factors and laboratory results were compared between subjects with positive urine cultures (cases, N= 27) and randomly selected subjects with negative cultures (controls, N= 54). RESULTS: Cases were significantly older than controls at the time of urine culture (75 days vs. 29 days, p=0.003). Maximal peripheral white blood cell (WBC) count and C-reactive protein (CRP) did not differ between cases and controls. Only 24% of cases had a simultaneously positive blood culture. In multivariable analysis, only increased chronological age was statistically associated with a positive culture (OR 3.02, 95% CI 1.09, 8.39). CONCLUSION: Limited clinical factors exist to identify NICU patients at increased risk for UTI. Peripheral WBC count and CRP do not help discriminate between patients with and without UTI. Clinicians should evaluate chronologically older NICU patients for infection like other young infants, including a urine culture, to adequately identify potential sources of infection.

Pediatric care for preterm infants after NICU discharge: high number of office visits and prescription medications.

OBJECTIVE: To determine the frequency and risk factors for clinic and pharmacy use in preterm infants during the first year after neonatal intensive care unit (NICU) discharge. STUDY DESIGN: We analyzed clinic visits and prescriptions in a cohort of 23 to 32 weeks infants. We constructed multivariable regression models to determine risk factors for high use. RESULT: The 892 preterm infants experienced 18 346 pediatric visits (mean 20 visits per infant per year) and filled 2100 prescriptions (mean 5.5 prescriptions per year among infants taking medications). Most visits were non-well child care visits to pediatric primary care providers. Prematurity and bronchopulmonary dysplasia (BPD) are important risk factors: infants at 23 to 26 weeks gestation or infants with BPD had an average 29 visits per year and 9 prescriptions per year among infants taking medication. However, half of the highest using infants were relatively healthy infants at 27 to 32 weeks gestation who escaped BPD, NEC or grade 3 to 4 intraventricular hemorrhage. CONCLUSION: Premature infants had frequent pediatric visits and prescription medications. Extreme prematurity and neonatal morbidities are important risk factors; however, half of the highest using infants are moderately preterm without neonatal morbidities.

Immunohistochemical localization of protein 3-nitrotyrosine and S-nitrosocysteine in a murine model of inhaled nitric oxide therapy.

Inhaled nitric oxide (INO) therapy is currently used clinically to selectively dilate the pulmonary vasculature and to help treat persistent pulmonary hypertension and bronchopulmonary dysplasia in the neonate. However, in the presence of oxygen or superoxide, nitric oxide forms potentially harmful reactive nitrogen species. Using an experimental mice model, we examined the effects of concurrent hyperoxia and INO on protein tyrosine nitration and cysteine S-nitrosylation in pulmonary tissue. Data showed enhanced 3-nitrotyrosine staining within the airway epithelium and alveolar interstitium of mice lungs treated with hyperoxia, which did not increase significantly with INO administration. Within the alveolar interstitium, 3-nitrotyrosine staining was localized to macrophages. S-Nitrosocysteine staining in airway epithelium was significantly enhanced with INO administration regardless of oxygen content. These data suggest that the formation of protein S-nitrosocysteine is the major protein modification during administration of INO.