Bilirubin Measurement and Phototherapy Use After the AAP 2022 Newborn Hyperbilirubinemia Guideline.

BACKGROUND AND OBJECTIVES: Guidelines for the management of neonatal hyperbilirubinemia have helped to reduce rates of significant hyperbilirubinemia. However, recent evidence suggesting overtreatment and potential harms of phototherapy have informed the American Academy of Pediatrics clinical practice guideline revision and the accompanying increase in phototherapy thresholds. These changes are predicted to safely reduce overuse; however, to date, the exact effect of these guidelines has not been established. METHODS: We conducted a retrospective study of newborns born at ≥35 weeks' gestation across a network of 8 hospitals between January 2022 and June 2023. Outcomes included rates of phototherapy and total serum bilirubin (TSB) measurements before and after guideline publication, as well as clinical outcomes, including length of stay, readmissions, and duration of phototherapy. RESULTS: In our cohort of >22 000 newborns, we observed a 47% decrease in phototherapy utilization, from 3.9% to 2.1% (P < .001). TSB measurements were reduced by 23%, from 712 to 551 measurements per 1000 newborns (P < .001), without an increase in outpatient TSB measurements. We did not observe an increase in readmissions receiving phototherapy, and length of stay increased by only 1 hour (P < .001). CONCLUSIONS: Our study reveals that the publication of the updated American Academy of Pediatrics 2022 hyperbilirubinemia guidelines has likely yielded a significant reduction in phototherapy use and serum bilirubin measurement. Dedicated quality improvement initiatives may help determine which implementation strategies are most effective. Further population-level studies are needed to confirm safety with ongoing guideline uptake.

Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome.

A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.

Assessing the clinical utility of toxicology testing in the peripartum period.

BACKGROUND: Toxicology testing is frequently used as a means of gathering objective data about substance use in pregnancy, but little is known about the clinical utility of testing in the peripartum setting. OBJECTIVE: This study aimed to characterize the utility of obtaining maternal-neonatal dyad toxicology testing at the time of delivery. STUDY DESIGN: We performed a retrospective chart review of all deliveries in a single healthcare system in Massachusetts between 2016 and 2020, and identified deliveries with either maternal or neonatal toxicology testing at delivery. An unexpected result was defined as a positive test for a nonprescribed substance that was not known on the basis of clinical history, self-report, or previous toxicology testing within a week of delivery, excluding results for cannabis. We evaluated the characteristics of maternal-infant dyads with unexpected positive results, unexpected positive results by rationale for testing, changes in clinical management after an unexpected positive test, and maternal outcomes in the year after delivery using descriptive statistics. RESULTS: Of the 2036 maternal-infant dyads with toxicology tests performed during the study period, there were 80 (3.9%) with an unexpected positive result. Diagnosis of substance use disorder with active use in the last 2 years was the clinical rationale for testing that yielded the greatest number of unexpected positive results (10.7% of total tests ordered for this rationale). Inadequate prenatal care (5.8%), maternal use of medication for opioid use disorder (3.8%), maternal medical indications such as hypertension or placental abruption (2.3%), history of substance use disorder in remission (1.7%), or maternal cannabis use (1.6%) yielded lower rates of unexpected results compared with a recent substance use disorder (within the last 2 years). Solely on the basis of findings from unexpected test results, 42% of dyads were referred to child protective services, 30% of dyads had no documentation of maternal counseling during delivery hospitalization, and 31% did not receive breastfeeding counseling after an unexpected test; 22.8% had monitoring for neonatal opioid withdrawal syndrome. Postpartum, 26 (32.5%) were referred to substance use disorder treatment, 31 (38.8%) attended a postpartum mental health visit, and only 26 (32.5%) attended a postpartum visit. Fifteen individuals (18.8%) were readmitted in the year after delivery, all for substance-related medical complications. CONCLUSION: Unexpected positive toxicology results at delivery were uncommon, particularly when tests were sent for frequently used clinical rationales for testing, suggesting a need to revisit guidelines surrounding appropriateness of indications for toxicology testing. The poor maternal outcomes in this cohort highlight a missed opportunity for maternal connection to counseling and treatment in the peripartum period.

Limited Utility of Toxicology Testing at Delivery for Perinatal Cannabis Use.

OBJECTIVES: To describe the characteristics of individuals undergoing toxicology testing at delivery for a sole indication of cannabis use and to evaluate the rate of unexpected positive toxicology testing results among this cohort. METHODS: This retrospective cohort study included dyads with a maternal history of cannabis use who underwent peripartum toxicology testing between 2016 and 2020 at 5 birthing hospitals in Massachusetts. We collected information on maternal demographic characteristics and toxicology test results and reviewed records of dyads with unexpected positive results to identify additional social risk factors and clinical outcomes. RESULTS: Of 60 608 live births reviewed, 1924 dyads underwent toxicology testing, including 614 (31.9%) for a sole indication of cannabis use. Significantly greater percentages of patients in the cannabis cohort were <25 years old (32.4% vs 6.1% of the birthing population, P <.001), non-Hispanic Black (32.4% vs 8.1%, P < .001), Hispanic or Latino (30.5% vs 15.5%), American Indian/Alaskan (0.7% vs 0.1%), and publicly insured (39.9% vs 15.6%, P <.001). Eight of the 614 dyads (1.3%) had an unexpected positive toxicology test result, including 2 (0.3%) unexpectedly positive for opioids. Seven dyads (1.1%) had false positive test results for unexpected substances. Only 1 test result changed clinical management; a urine test positive for opioids prompted monitoring (but not medication) for neonatal opioid withdrawal syndrome. CONCLUSIONS: Toxicology testing of patients for a sole indication of cannabis use, without other risk factors, may be of limited utility in elucidating other substance use and may exacerbate existing disparities in perinatal outcomes.

Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals.

OBJECTIVE: To evaluate for disparities in peripartum toxicology testing among maternal-infant dyads across a hospital network and subsequent child protective services (CPS) involvement. METHODS: Retrospective chart review of 59,425 deliveries at 5 hospitals in Massachusetts between 2016 and 2020. We evaluated associations between maternal characteristics, toxicology testing, and child welfare involvement with disproportionality risk ratios and hierarchical logistical regression. RESULTS: Toxicology testing was performed on 1959 (3.3%) dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use or maternal medical complications compared to white non-Hispanic individuals. Among those without a substance use disorder, age <25 (adjusted odds ratio [aOR] 2.81; 95% confidence interval [CI], 2.43-3.26), race and ethnicity (non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79), and public insurance (Medicaid [aOR 2.61; 95% CI, 2.27-3.00], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) had increased odds of toxicology testing compared to older, white non-Hispanic, and privately insured individuals. The disproportionality ratios in testing were greater than 1.0 for individuals under 25 years old (3.8), Hispanic individuals (1.6), non-Hispanic Black individuals (1.8), individuals of other race (1.2), unavailable race (1.8), and individuals with public insurance (Medicaid 2.6; Medicare 10.6). Among dyads tested, race and ethnicity was not associated with CPS involvement. CONCLUSIONS: Peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.

Improving Timeliness of Hepatitis B Vaccine Birth Dose Administration.

BACKGROUND AND OBJECTIVES: When given within 24 hours of birth, the hepatitis B vaccine is up to 90% effective in preventing perinatal infection. The American Academy of Pediatrics now recommends administration within 24 hours for infants with a birth weight >2 kg, but a national benchmark for compliance with this time frame has not been established. We aimed to increase the monthly average of eligible newborns receiving the vaccine on time from 40% to 80% over a 9-month period. METHODS: A series of plan-do-study-act cycles were conducted to improve timeliness of hepatitis B vaccine birth dose administration among newborns in the level 1 nursery at our academic community hospital. Interventions included staff education, nurse-driven consent and vaccine ordering, and earlier initial newborn assessments performed by nursing staff. Our primary outcome was the monthly percentage of newborns receiving the vaccine within 24 hours of birth, and our secondary outcome was the frequency of nonvaccination events. Statistical process control was used to analyze the effectiveness of interventions. RESULTS: Our mean monthly rate of vaccine administration within the 24-hour time frame increased from 40% to 92%. Predischarge vaccination rate improved from a mean of 13 to 61 cases between infants discharged without vaccination. CONCLUSIONS: Nurse-led interventions, including the ability to obtain consent and incorporation of the vaccine into our nurse-activated admission order set, were significant contributors to improvement in the timeliness of hepatitis B vaccine administration. We propose a mean of 90% compliance with the American Academy of Pediatrics recommendations as a benchmark for other institutions.

Perceived Maternal Behavioral Control, Infant Behavior, and Milk Supply: A Qualitative Study.

OBJECTIVE: Disparities persist in breastfeeding exclusivity and duration despite increases in breastfeeding initiation. The objective of this study was to examine factors that influence maternal decision making surrounding infant feeding practices over time in a diverse inner-city population. METHODS: We conducted a prospective qualitative study with 20 mothers recruited from 2 urban primary care clinics. Participants completed open-ended interviews and demographic questionnaires in English or Spanish administered at approximately 2 weeks and 6 months postpartum. Transcripts were analyzed using a combined technique of inductive (data-driven) and deductive (theory-driven, based on the Theory of Planned Behavior) thematic analysis using 3 independent coders and iterative discussion to reach consensus. RESULTS: All women initiated breastfeeding, and 65% reported perceived insufficient milk (PIM). An association between PIM and behavioral control emerged as the overarching theme impacting early breastfeeding cessation and evolved over time. Early postpartum, PIM evoked maternal distress-strong emotional responses to infant crying and need to control infant behaviors. Later, mothers accepted a perceived lack of control over milk supply with minimal distress or as a natural process. Decisions to stop breastfeeding occurred through an iterative process, informed by trials of various strategies and observations of subsequent changes in infant behavior, strongly influenced by competing psychosocial demands. CONCLUSION: Infant feeding decisions evolve over time and are influenced by perceptions of control over infant behavior and milk supply. Tailored anticipatory guidance is needed to provide time-sensitive strategies to cope with challenging infant behaviors and promote maternal agency over breastfeeding in low-income populations.