Increased incidence of severe breastfeeding malnutrition and hypernatremia in a metropolitan area.

OBJECTIVE: To identify common characteristics among infants with breastfeeding malnutrition in a region with an increasing incidence of breastfeeding malnutrition. DESIGN: Retrospective case series. SETTING: A 361-bed regional tertiary care children's hospital in a 1.7 million population metropolitan area. CASE SERIES: five infants with severe breastfeeding malnutrition and hypernatremia admitted to a tertiary care children's hospital over a 5-month period. Retrospective case review: 166 infants admitted between 1990 and 1994 with the diagnosis of dehydration, hypernatremia, or malnutrition. MAIN OUTCOME MEASURES: Maternal characteristics, age at presentation, percent loss from birth weight, serum sodium, average age at birth hospital discharge, neurologic, or cardiovascular complications. RESULTS: Five infants were admitted to a children's hospital over a 5-month period with severe breastfeeding malnutrition and hypernatremia. The average weight loss at time of readmission was 23% (+/- 8%) from birth weight. The average presenting sodium was 186 +/- 19 mmol/L. Three suffered significant complications. From 1990 through 1994, there was a statistically significant (P < .05) annual increase in the number of infants admitted with breastfeeding malnutrition and hypernatremia. CONCLUSIONS: While breastfeeding malnutrition and hypernatremia is not a new problem, this cluster of infants represents an increase in frequency and severity of the problem and could be a consequence of several factors, including inadequate parent education about breastfeeding problems and inadequate strategies for infant follow-up.

Use of health care services by inner-city infants in an early discharge program.

OBJECTIVE: To assess the use of health care services by inner-city infants enrolled in an early discharge program who received care in tertiary care children's hospital primary care clinic. DESIGN: Retrospective cohort study. SETTING: Large, metropolitan university hospital and a children's hospital. PATIENTS: Term infants cared for in a single full-term nursery, before and after implementation of a coordinated early discharge program, who received primary care at the children's hospital. INTERVENTION: The coordinated Early Discharge Program was characterized by in-hospital visits by hospital-based coordinating nurses, home visits by nurses from a home nursing agency, and communication with physicians for necessary adjustments in postdischarge care. METHODS: After linking birth hospital records and the children's hospital medical records, a retrospective chart review was performed to obtain maternal demographic information and birth hospital length of stay, as well as the infants' attendance at primary care clinic, immunizations, emergency department visits, and rehospitalization. MAIN OUTCOME MEASURES: Number of primary care visits in the first 3 months of life, completion of one series of immunizations by 3 months of life, and number of emergency department visits and rehospitalization during the first 3 months of life. RESULTS: The early discharge group (n = 253) had a significantly shorter birth hospital length of stay (35 +/- 24 hours, mean +/- SD) when compared with the control group (n = 212) (52 +/- 14 hours). The early discharge group was also younger than the control group at the first primary care visit, with significantly more infants visiting the primary care clinic in the first month of life. There was also a significant difference between the groups in the mean number of emergency department visits (early discharge = .61 visits/patient, control = .79 visits/patient) and the proportion of patients with no emergency department visits during the first 3 months of life (early discharge = 57%, control = 43%). There was no difference between the two groups in the proportion of infants completing one series of immunizations or in the number of infants rehospitalized during the study period. CONCLUSIONS: Coordinated early discharge with home nursing visits for inner-city infants may result in earlier use of primary care services. Furthermore, there is a significant decrease in use of the emergency department during the first 3 months of life, and no increase in rehospitalization.

Control of methicillin-resistant Staphylococcus aureus in a neonatal intensive-care unit: use of intensive microbiologic surveillance and mupirocin.

OBJECTIVE: To describe the epidemiology and the interventions used to control two methicillin-resistant Staphylococcus aureus (MRSA) epidemics involving 46 infants with two fatalities in a neonatal intensive care unit (NICU). SETTING: A 50-bed, level III NICU in a university hospital. INTERVENTIONS: After traditional interventions failed to stop the first epidemic, an intensive microbiologic surveillance (IMS) program was developed. Cultures were obtained on all infants each week, and those colonized with MRSA were isolated. When an infant was found to be colonized with MRSA, cultures immediately were obtained on all surrounding infants. This was continued until no MRSA-colonized infants were found in the area. During the first epidemic, mupirocin was used in an attempt to eradicate the organism from the unit. RESULTS: All infants, colonized and noncolonized, and parents of and personnel working with colonized infants were treated simultaneously with 5 days of mupirocin. This failed to eradicate MRSA in colonized infants. The spread of MRSA ceased in the unit, but a second epidemic occurred 4 months later. This time, IMS alone was successful in quickly containing the epidemic, and MRSA disappeared from the unit after all colonized infants were discharged. Plasmid analysis demonstrated that the same strain was responsible for both outbreaks. CONCLUSIONS: IMS and isolation are effective in containing the spread of MRSA in an NICU. The use of mupirocin failed to eradicate the organism.

Management of sore throats in children: a cost-effectiveness analysis.

OBJECTIVE: To perform a cost-effectiveness analysis of treatment management strategies for children older than 3 years who present with signs or symptoms of pharyngitis. DESIGN: Decision model with 7 strategies, including neither testing for streptococcus nor treating with antibiotics; treating empirically with penicillin V; basing treatment on results of a throat culture (Culture); and basing treatment on results of enzyme immunoassay or optical immunoassay rapid tests, performed alone or in combination with throat cultures. In these 7 strategies, all tests are performed in a local reference laboratory. In a sensitivity analysis, we examined the cost-effectiveness of 4 strategies involving office-based testing. We obtained data on event probabilities and test characteristics from our hospital's clinical laboratory and the literature; costs for the analysis were based on resource use. RESULTS: At a baseline prevalence of 20.8% for streptococcal pharyngitis, the Culture strategy was the least expensive and most effective, with an average cost of $6.85 per patient. The outcome was sensitive to the prevalence of streptococcal pharyngitis, the rheumatic fever attack rate, the cost of the enzyme immunoassay test, and the cost of culturing and reporting culture results. The Culture strategy was also preferred if amoxicillin was substituted for oral penicillin. For office-based testing, Culture was the least costly strategy, but treatment based on results of the optical immunoassay test alone had an incremental cost-effectiveness ratio of $1.6 million per additional life saved. CONCLUSION: In a setting with adherent patients, children with sore throats should generally get throat cultures in lieu of rapid streptococcus antigen tests.

Inpatient care for uncomplicated bronchiolitis: comparison with Milliman and Robertson guidelines.

CONTEXT: Bronchiolitis is the most common lower respiratory tract infection in infancy. A recent Centers for Disease Control and Prevention report confirmed that hospitalization rates for bronchiolitis have increased 2.4-fold from 1980 to 1996. Controversies exist about optimal treatment plans. Milliman and Robertson recommend ambulatory care management; in case of hospitalization, the recommended length of stay is 1 day. OBJECTIVES: To relate actual practice variation for infants admitted with uncomplicated bronchiolitis to Milliman and Robertson's recommendations. DESIGN: Prospective observational study. SETTING: General care wards of 8 pediatric hospitals of the Child Health Accountability Initiative during the winter of 1998-1999. PATIENTS: First-time admissions for uncomplicated bronchiolitis in patients not previously diagnosed as having asthma and who were younger than 1 year. MAIN OUTCOME MEASURES: Respiratory rate, monitored interventions, attainment of discharge criteria goals, and length of stay. RESULTS: Eight hundred forty-six patients were included in the final analysis: 85.7% were younger than 6 months, 48.5% were nonwhite, and 64.1% were Medicaid recipients or self-pay. On admission to the hospital, 18.3% of the infants had respiratory rates higher than higher than 80 breaths per minute, 53.8% received supplemental oxygen therapy, and 52.6% received intravenous fluids. These proportions decreased to 1.9%, 33.8%, and 20.3%, respectively, 1 day after admission, and to 0.7%, 20.1%, and 8.6%, respectively, 2 days after admission. The average length of stay was 2.8 days (SD, 2.3 days). CONCLUSIONS: Milliman and Robertson's recommendations do not correspond to practice patterns observed at the hospitals participating in this study; no hospital met the Milliman and Robertson recommended 1-day goal length of stay. Administration of monitored intervention persisted past the second day of hospitalization.

Sustaining the implementation of an evidence-based guideline for bronchiolitis.

OBJECTIVE: To describe the changes occurring over a 3-year period after implementation of an evidence-based clinical practice guideline for the care of infants with bronchiolitis. DESIGN: Before and after study. SETTING: Children's Hospital Medical Center, Cincinnati, Ohio. PATIENTS: Infants 1 year or younger admitted to the hospital with a first-time episode of typical bronchiolitis. INTERVENTION: The guideline was implemented January 15, 1997. Data on all patients discharged from the hospital with bronchiolitis, from January 15 through March 27, in 1997, 1998, and 1999, were stratified by year and compared with data on similar patients discharged from the hospital in the same periods in the years 1993 through 1996. MAIN OUTCOME MEASURES: Patient volumes, length of stay for admissions, and use of specific laboratory and therapeutic resources ancillary to bed occupancy. RESULTS: After implementation of the guideline, admissions decreased 30% and mean length of stay decreased 17% (P<.001). Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients (P<.001); 14% fewer chest x-ray films were ordered (P<.001). There were significant reductions in the use of all respiratory therapies, with a 17% decrease in the use of at least 1 beta(2)-agonist inhalation therapy (P<.001). In addition, 28% fewer repeated inhalations were administered (P<.001); mean costs for all resources ancillary to bed occupancy fell 41% (P<.001); and mean costs for respiratory care services fell 72% (P<.001). CONCLUSIONS: An evidence-based clinical practice guideline for the care of patients encountered in major pediatric care facility has been successfully sustained beyond the initial year of its introduction to practitioners in southwest Ohio.

Preservation of cerebral autoregulation in the unanesthetized hypoxemic newborn dog.

Studies were conducted to determine the effects of hypoxemia on cerebral blood flow and the influence of hyperoxia and hypoxemia on autoregulation of cerebral blood flow in the unanesthetized newborn dog. Twenty-one newborn dogs less than 2 weeks of age were studied. Cerebral blood flow was measured using radioactive microspheres during successive periods of normotension, hypotension (produced by blood withdrawal) and normotension (produced by infusion of previously withdrawn blood). In the hyperoxic animals, arterial pO2 was maintained above 250 torr by having the animal breathe 100% oxygen, while in the hypoxemic animals arterial pO2 was maintained between 30 and 35 torr by having the animal breathe 12% O2. Cerebral blood flow increased significantly with hypoxemia. In both hypoxemic and hyperoxic animals cerebral blood flow was maintained constant in spite of a large fall in arterial blood pressure and cardiac output, demonstrating the presence of autoregulation. Calculated oxygen transport to the brain was constant during hypoxemia and hypotension in all animals. Thus autoregulation of cerebral blood flow is present in newborn animals and is preserved under conditions of moderate hypoxemia.

The effect of metabolic acidosis upon autoregulation of cerebral blood flow in newborn dogs.

The radioactive microsphere technique was used in 13 newborn dogs to determine the effect of a metabolic (lactic)acidosis upon cardiac output (CO), cerebral blood flow (CBF), and autoregulation of cerebral blood flow. The animals were mechanically ventilated with supplemental oxygen to ensure normocarbia and hyperoxia throughout the experiments. Baseline cardiac output and cerebral blood flow measurements were made, followed by a lactic acid infusion to maintain pH less than 7.25. Metabolic acidosis produced a 27% fall in cardiac output and no change in cerebral blood flow (19 ml/100 g/min). Autoregulation was tested in 6 of the acidemic puppies by acute volume depletion to reduce blood pressure by 30% of baseline, followed by rapid volume re-expansion of the withdrawn blood. With volume depletion, CO decreased by 38%, and with volume re-expansion CO returned to baseline. The CBF remained at baseline levels with volume depletion but was slightly increased after rapid volume re-expansion. Five acidemic controls maintained CO and CBF constant with time. Thus cerebral autoregulation is preserved in the newborn dogs during metabolic acidosis, although cerebral blood flow was slightly increased following volume re-expansion.

Physician variations and the ancillary costs of neonatal intensive care.

OBJECTIVE: To determine to what degree attending physicians contribute to cost variations in the care of ventilator-dependent newborns. DATA SOURCES: Clinical data were merged with hospital financial data describing daily ancillary care costs during the first two weeks of life for 132 extremely low-birthweight newborns. In addition, each patient's chart was reviewed and illness severity graded using both SNAP and CRIB scores. STUDY DESIGN: This was a retrospective cohort of infants with birth weights of less than 1,001 grams and respiratory distress syndrome requiring mechanical ventilation in the first day of life. From birth up to two weeks of life, each received care directed by only one of 11 faculty neonatologists in a single university hospital. Data were analyzed stratified by these physicians. t-Test, ANOVA, and chi-square were used to assess bivariate data. For continuous data, log linear regressions were used. PRINCIPAL FINDINGS: After controlling for illness severity, when stratified by physicians, there were significant variances in the costs of ancillary resources for the study infants (p < .0001). Twenty-nine percent of the variance was attributable to whether or not the hospital day included the use of a ventilator. Physician identity explained only 5.6 percent (p < .0001). CONCLUSIONS: Physician identity was significant but explained less than 6 percent of the total variance in ancillary costs. Whether or not a ventilator was used during care was far more important. We conclude that for very sick babies during the first two weeks of care, reducing variations in ancillary services utilization among neonatologists will yield only modest savings.

The influence of day of life in predicting the inpatient costs for providing care to very low birth weight infants.

The purpose of this study was to test, refine, and extend a statistical model that adjusts neonatal intensive care costs for a very low birth weight infant's day of life and birth weight category. Subjects were 62 infants with birth weights below 1,501 g who were born and cared for in a university hospital until discharged home alive. Subjects were stratified into 250-g birth weight categories. Clinical and actual daily room and ancillary-resource costs for each day of care of each infant were tabulated. Data were analyzed by using a nonlinear regression procedure specifying two separate for modeling. The modeling was performed with data sets that both included and excluded room costs. The former set of data were used for generating a model applicable for comparing interhospital performances and the latter for comparing interphysician performances. The results confirm the existence of a strong statistical relationship between an infant's day of life and both total hospital costs and the isolated costs for ancillary-resource alone (P < 0.0001). A refined series of statistical models have been generated that are applicable to the assessment of either interhospital or interphysician costs associated with providing inpatient care to very low birth weight infants.

Outcomes and resource utilization for newborns with major congenital malformations: the initial NICU admission.

HYPOTHESIS: Newborns with major congenital malformations (MCM) have contributed to a significant proportion of resource utilization in a regional referral neonatal intensive care unit (NICU). SETTING: The Children's Hospital Medical Center NICU, Cincinnati, OH. SUBJECTS: Newborns with and without MCM admitted from August 1, 1993 through July 31, 1994. Total patients studied were 572; 147 with and 385 without MCM. No intervention was performed in this observational study. STATISTICS: Statistics were t test, chi-squared, and rank sum analysis. RESULTS: MCM accounted for 27.6% of NICU referrals, 32.4% of total NICU days, and 39.6% of NICU costs. Both median cost per patient and length of stay were significantly (p < 0.01) higher for patients with MCM than those without MCM. Surgery was more frequent in MCM than non-MCM cases. Thirty-three percent of the newborns with MCM received ongoing medical support at discharge. CONCLUSION: Patients with MCM remain as one of the largest and costliest groups hospitalized in a referral NICU.

Differential markers for regionalization.

OBJECTIVE: To examine the site of delivery for very low birth weight (VLBW) infants and infants with major congenital malformations (MCM) within an established system of perinatal regionalization. STUDY DESIGN: A retrospective study of site of delivery for VLBW infants and infants born with MCM (tracheoesophageal fistula/esophageal atresia, diaphragmatic hernia, or gastroschisis/omphalocele) from 1990 through 1995 in Ohio. RESULTS: A total of 59.8% of VLBW infants and 36.1% of MCM infants were born in a level III hospital. There was a significant trend toward a decrease in VLBW infants (p < 0.01) and an increase in MCM infants (p < 0.05) born in a level III hospital between 1990 and 1995. There were significant regional variations among the six perinatal regions in Ohio in the proportion of both VLBW and MCM infants born in a tertiary center. CONCLUSION: Using the traditional marker of VLBW to assess regionalization in one state, we found significant variation in site of delivery among the perinatal regions and over the time course of the study. The delivery of infants with MCM at level III centers may be an alternative measure of regionalization.

An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost.

BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.

Hepatitis B vaccine use in Cincinnati: a community's response to the AAP recommendation of universal hepatitis B immunization.

The Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) recently recommended universal immunization of infants against hepatitis B virus (HBV). We surveyed all pediatricians and family practitioners with admitting privileges to our institution to determine their degree of approval of the AAP recommendation and the anticipated compliance with the recommendation. A questionnaire was sent to 86 family practitioners and 205 pediatricians; the response rate was 38% and 47%, respectively. The survey sought information regarding prior HBV immunization practices, planned HBV immunization strategies in the physician's office and hospital nursery, and the individual's opinion of the AAP recommendation. Only 21% of pediatricians and 12.5% of family practitioners anticipated giving HBV vaccine to all infants. An additional 22% of pediatricians and 28% of family practitioners planned to give HBV vaccine to infants who had the means to pay for the vaccine. Only a minority of physicians, 42.6% of pediatricians and 36.4% of family practitioners, approved of the AAP recommendation. We conclude that in our community there is widespread concern about the financial practicality and scientific merit of universal HBV immunization, and many practitioners will not comply with the AAP recommendation.

Effect of acute polycythemia on newborn renal hemodynamics and function.

The present study investigates the effects of polycythemia on renal hemodynamics and function in 15 anesthetized newborn dogs, 2-10 days of age. Microspheres were used to study renal blood flow. Experimental animals received an exchange transfusion with adult dog packed red blood cells resulting in an increase in hematocrit from 38% +/- 2.1% to 69% +/- 2.1%. Control animals received an exchange transfusion with adult dog whole blood so that there was no change in hematocrit. Polycythemia resulted in a marked increase in blood viscosity, a 40% fall in cardiac output from 251.8 +/- 14 ml/kg/min to 150.7 +/- 9 ml/kg/min and a 98% increase in total vascular resistance from 0.32 +/- 0.02 mmHg/ml/kg/min to 0.63 +/- 0.07 mmHg/ml/kg/min. Nevertheless, renal blood flow was not significantly altered indicating renal vasodilation (1.4 +/- 0.06 ml/g/min initial versus 1.2 +/- 0.09 ml/g/min final). Although renal blood flow was well preserved, renal plasma flow decreased by 63% as the hematocrit increased from 0.86 +/- 0.03 ml/g/min to 0.38 +/- 0.04 ml/g/min, resulting in a 53% fall in glomerular filtration rate from 0.21 +/- 0.02 ml/min/g kidney weight to 0.09 +/- 0.02 ml/min/g kidney weight. There was also a large drop in urine output and Na and K excretion following polycythemia. This was due primarily to the decreased filtered load, because fractional Na reabsorption remained constant. Thus, in spite of well-preserved renal blood flow, polycythemia markedly affected renal function, resulting in water and salt retention.

Influence of airway pressure waveform on cardiac output during positive pressure ventilation of healthy newborn dogs.

During positive pressure ventilation, increases in mean airway pressure produced by increases in end expiratory pressure are associated with reductions in cardiac output. Mean airway pressure may be increased not only by increasing end expiratory pressure, but also by increasing the inspiratory pressure or the inspiratory to expiratory time ratio. During positive pressure ventilation of 10 healthy newborn dogs, cardiac output and left ventricular dimensions were measured using radioactive microspheres and echocardiography, respectively. Baseline ventilation was produced using the least inspiratory pressure to maintain normocarbia (rate = 50 min-1, inspiratory to expiratory time ratio = 1:3, end expiratory pressure = 2 cm H2O). The mean airway pressure was increased 3-fold by independently changing the airway pressure waveform through increases in inspiratory pressure, inspiratory to expiratory time ratio, or end expiratory pressure. Despite differences in airway pressure waveform, similar reductions in left ventricular dimension, cardiac output, and stroke volume were seen. We conclude that at a given increased mean airway pressure during positive pressure ventilation, the reduction in cardiac output is independent of the airway pressure waveform.

Cerebrovascular hemodynamics during and after recovery from acute asphyxia in the newborn dog.

Cerebrovascular volume and transmural pressure loads accompanying acute increases in cerebral blood flow are implicated in the pathogenesis of periventricular-intraventricular hemorrhage in preterm infants. An acute increase in cerebral blood flow would be expected during acute recovery from asphyxia. Therefore, cerebrovascular hemodynamics, including flow (microspheres), were studied during and after acute recovery from asphyxia in seven newborn dogs in order to study the determinants of these volume and pressure loads. During the acute recovery phase, cerebral hemispheric blood flow was 69.6 +/- 10 ml/100 g/min (mean +/- SEM) representing a 250% increase from baseline values of 19.9 +/- 1.8 ml/100 g/min (p less than 0.005), while combined cerebellar-brainstem flow was 204.3 +/- 19.3 ml/100 g/min representing a 536% increase from baseline values of 32.0 +/- 1.5 ml/100 g/min (p less than 0.005). Blood flow to both areas had returned to baseline levels 20 min after the onset of recovery. Associated with this cerebral hyperemia was an acute increase in mean arterial pressure from 21.3 +/- 4.5 mm Hg at end asphyxia to 69.5 +/- 6.0 mm Hg at peak recovery (p less than 0.01), and parallel acute increases in sagittal sinus pressure (from 4.0 +/- 0.4 to 14.6 +/- 1.9 mm Hg, p less than 0.01) and cerebrospinal fluid pressure (from 3.8 +/- 0.4 to 14.3 +/- 1.9 mm Hg, p less than 0.01). Central venous pressure fell from 4.3 +/- 0.6 mm Hg at end asphyxia to 1.6 +/- 0.5 mm Hg, and thus is not a determinant of the elevation in sagittal sinus pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute cardiovascular effects of indomethacin in anesthetized newborn dogs.

Cardiac output and regional blood flow distribution were measured in 14 newborn dogs before and 90 min following 0.3 mg/kg of indomethacin and in 4 control animals who received buffer alone using the Radioactive Microsphere Reference Organ Technique. Indomethacin produced no significant change in cardiac output or blood flow to the gastrointestinal tract or kidney. There were no changes in cerebral blood flow in animals over 4 days of age. However, in 3 of 8 puppies less than 3 days of age, indomethacin resulted in a 47% fall in cerebral blood flow. In newborn dogs, indomethacin in the dose employed had no deleterious effects on cardiac output and, with the possible exception of the cerebral circulation, on blood flow distribution.