Early Weight Loss Percentile Curves and Feeding Practices in Opioid-Exposed Infants.

OBJECTIVE: We examined weight loss patterns and feeding practices of infants hospitalized for neonatal opioid withdrawal syndrome (NOWS) managed by the eat, sleep, console approach, which emphasizes nonpharmacologic treatment. Although feeding practices during hospitalization vary widely, weight loss patterns for infants managed under this approach have not yet been described. METHODS: Of 744 infants with NOWS born from 2014 to 2019 at our institution, 330 met inclusion criteria (≥35 weeks' gestation and no NICU transfer). We examined maximum weight loss and created weight loss percentile curves by delivery type using mixed effects quantile modeling with spline effect for hour of life; 95% confidence intervals (CI) were compared to published early weight loss nomograms. RESULTS: In the cohort, the mean gestational age was 39.2 weeks, mean birth weight was 3.1 kg, and mean length of stay was 6.5 days; 94.6% did not require pharmacologic treatment. Median percent weight loss was significantly more compared to early weight loss nomograms for both vaginally-delivered infants at 48 hours (6.9% [95% CI: 5.8-8.5] vs 2.9%) and cesarean-delivered infants at 48 hours (6.5% [95% CI: 4.1-9.1] vs 3.7%) and 72 hours (7.2% [95%CI 4.7-9.9] vs 3.5%), all P < .001. Overall, 27.9% lost >10% birth weight. CONCLUSIONS: We demonstrate weight loss patterns of infants with NOWS managed by the eat, sleep, console approach at a single center. Infants with NOWS lose significantly more weight than nonopioid exposed infants and are at increased risk of morbidity and health care use. Studies to address optimal feeding methods in these infants are warranted.

More Than Meets the Eye: Idiopathic Orbital Inflammation Mimicking Orbital Cellulitis.

An 18-year-old female presented with left eye periorbital swelling, erythema, and pain for three days. Computed tomographic images showed swelling of the medial rectus muscle, and she was diagnosed with orbital cellulitis and initiated on empiric antibiotics. Over the next 48 hours, she did not clinically improve, resulting in an MRI and further workup of infectious, oncologic, endocrinologic, and rheumatologic etiologies was unrevealing and ruled-out malignancy, sarcoidosis, Wegner's, and thyroid eye disease. Given the negative workup, the presentation was determined to be consistent with idiopathic orbital inflammation (orbital myositis variant) via a diagnosis of exclusion. Therefore, the patient was empirically treated with intravenous steroids that produced pronounced improvement within 24 hours. The patient was discharged in improved condition with a prednisone taper and rheumatology follow-up. Idiopathic orbital inflammation is a rare diagnosis of exclusion in pediatrics that merits prompt consideration and work-up if treatment for orbital cellulitis does not progress as expected.

The Effect of Sitting Versus Standing on Family Perceptions of Family-Centered Rounds.

OBJECTIVE: Previous studies reveal improved perception of time spent, as well as overall experience, for patients when their inpatient provider is seated during an encounter. With our study, we aim to establish whether family experience and perception of time is improved when a pediatric inpatient provider team sits for patient and family-centered rounds. PATIENTS AND METHODS: From February 2017 to November 2017, 99 inpatient encounters were randomly assigned to either a sitting or standing rounding team. Mean total time spent on rounds, family perception of time spent on rounds, and overall family experience with rounds (by using top-box analysis of physician communication questions) were compared between the 2 groups. RESULTS: Total time spent on rounds was similar between the 2 groups (14.2 minutes in the sitting group and 12.7 minutes in the standing group; P = .23), and families in general overestimated the time spent with physicians in both groups (15.9 minutes in sitting group and 14.8 minutes in the standing group; P = .45). There were no significant differences in top-box experience responses (62% in sitting and 55% in standing; P = .12). CONCLUSIONS: Sitting during the patient and family-centered rounds encounter did not affect actual or perceived time spent during rounds. Families may have a slightly more positive experience with seated rounds, but the difference in this study did not reach a level of statistical significance.

Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome.

OBJECTIVES: This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. STUDY DESIGN: We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. RESULTS: The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates. CONCLUSIONS: Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.

Neonatal abstinence syndrome.

Neonates exposed prenatally to opioids will often develop a collection of withdrawal signs known as neonatal abstinence syndrome (NAS). The incidence of NAS has substantially increased in recent years placing an increasing burden on the healthcare system. Traditional approaches to assessment and management have relied on symptom-based scoring tools and utilization of slowly decreasing doses of medication, though newer models of care focused on non-pharmacologic interventions and rooming-in have demonstrated promise in reducing length of hospital stay and medication usage. Data on long-term outcomes for both traditional and newer approaches to care of infants with NAS is limited and an important area of future research. This review will examine the history, incidence and pathophysiology of NAS. We will also review diagnostic screening approaches, scoring tools, differing management approaches and conclude with recommendations for continued work to improve the care of infants with NAS.

Pediatric Chief Residents' Experiences as Inpatient Attending Physicians.

BACKGROUND: Some pediatric chief residents perform supervisory clinical duties during chief residency, but these activities are highly variable and descriptions are limited. Our goals were to characterize inpatient service performed by pediatric chief residents and to explore factors that influence their experiences as inpatient attending physicians. METHODS: Pediatric chief residents at Accreditation Council for Graduate Medical Education-accredited programs in 2016 were invited to complete a 40-item electronic questionnaire about their inpatient service obligation as well as attitudes regarding this experience. Data were analyzed using Chi-square, analysis of variance tests, and logistic regression. Open-ended responses underwent content analysis. RESULTS: There were 116 completed surveys from a national sample of 223 (response rate 52%); 66% served as inpatient attending physicians during chief residency. On average, chief residents spent 5.5 weeks (range 1-16) in this role with a daily census of 11.5 patients (range 5-20). Those entering primary care were significantly less likely to spend time as an inpatient attending compared with chiefs entering fellowship or hospital medicine (45.7 vs 67.3 vs 83.3%, P = .01). Overall, 92% regarded their inpatient clinical experience positively and indicated they would like the same (40%) or more time (52%) in this role. The average favorability rating was 8.2 of 10, and this was not associated with clinical workload or career choice. CONCLUSIONS: Most chief residents serve as inpatient attending physicians during chief residency. They rate their inpatient experience positively despite wide variability in clinical experiences, patient population, and clinical load. Further studies should examine the value of this experience and its impact on chief residents' future practice.

A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome.

OBJECTIVES: Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS. METHODS: We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children's Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine. RESULTS: By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach (P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach (P < .001). There were no readmissions or adverse events reported. CONCLUSIONS: Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay.

An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVES: The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%. METHODS: In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children's Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts. RESULTS: There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from $44 824 to $10 289. No infants were readmitted for treatment of NAS and no adverse events were reported. CONCLUSIONS: Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events.

A Qualitative Analysis of Pediatric Patient Attitudes Regarding Family-Centered Rounds.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends family-centered rounds (FCR) as standard practice for the inpatient setting. To date, there is limited research investigating the attitudes of pediatric patients regarding this shift in practice. The goal of this study was to explore pediatric patients' perspectives of their experiences during FCR. METHODS: We conducted a qualitative descriptive study based on results from 22 semi-structured interviews of school-aged and adolescent inpatients from September 2012 through October 2013. English-speaking patients, aged 7 to 18 years, who participated in FCR were eligible for inclusion. Transcripts were initially analyzed by using a constant comparative method. After completion of this initial analysis, a third reviewer independently reviewed all transcripts to verify the accuracy of the final coding scheme. RESULTS: The final coding scheme consisted of 5 main themes: team size, medical team interactions, content discussed on FCR, setting expectations, and timing and location of FCR. In general, patients expressed a wide array of positive, negative, and neutral impressions within each theme relating to their experiences with FCR. CONCLUSIONS: Patient comments regarding their experience with FCR offer unique perspectives from previously studied participants, including physicians, nurses, students, and parents. Future research aimed at evaluating the bedside rounding process should incorporate patients' views to realize the complete FCR experience.

The utility of inpatient rebound bilirubin levels in infants readmitted after birth hospitalization for hyperbilirubinemia.

BACKGROUND AND OBJECTIVES: There are few data evaluating the role of inpatient rebound bilirubin levels in the management of infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. The goal of the present study was to evaluate the clinical utility of inpatient rebound bilirubin levels within this patient population. METHODS: A retrospective cohort study was conducted of 226 infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. Data from 130 infants with rebound bilirubin levels drawn at a mean of 6.1±2.4 hours after discontinuation of phototherapy were compared with data from 96 infants without rebound bilirubin levels. The primary outcome was readmission to the hospital, and secondary outcomes included length of stay and discharge time. A subgroup analysis compared characteristics of children who required repeat phototherapy versus those who did not. RESULTS: Overall, 5 of 130 patients from the rebound group were readmitted compared with 4 of 96 patients from the no-rebound group (P=.98). Length of stay was significantly longer for patients with rebound bilirubin levels (27.7 vs 23.2 hours; P=.001). Patients with bilirubin levels lowered to ≤14 mg/dL were less likely to receive repeat phototherapy than those with levels>14 mg/dL (2 of 129 vs 12 of 97; P=.001). CONCLUSIONS: Early inpatient rebound bilirubin levels do not successfully predict which patients will require hospital readmission for repeat phototherapy. Children with bilirubin levels lowered to ≤14 mg/dL with phototherapy are unlikely to receive repeat phototherapy.