Standardizing documentation and the clinical approach to apnea of prematurity reduces length of stay, improves staff satisfaction, and decreases hospital cost.

BACKGROUND: Apnea of prematurity, a common disorder, can severely compromise an infant's condition unless correctly diagnosed and treated. Infants with a history of apnea of prematurity can be discharged home but then be rehospitalized for an apneic event, an apparent life-threatening event, or sudden infant death syndrome. The definition of a clinically significant cardiopulmonary event, such events' documentation, and the treatment approach were standardized, and discharge criteria were refined. METHODS: A prospective, single-center comparison was conducted between a group of premature infants before and after implementation of the standard approach. Data were collected prospectively from August 1, 2005, through July 21, 2006, for the prestandard-approach group and from August 1, 2006, through September 16, 2007, for the standard-approach group. RESULTS: Twenty-two (35%) of the 63 infants in the prestandard-approach group experienced discharge delays because of poor documentation, whereby the clinician could not determine the safety of discharge. This resulted in 59 additional hospital days (mean length-of-stay [LOS] increase, 5.7 days). The standard-approach group of 72 infants experienced no discharge delays and no additional hospital days, and LOS decreased (all p < .0001). Annual charges were reduced by more than $58,000 in avoiding unnecessary hospital days. Readmission to the hospital for apnea of prematurity occurred for 5 (7.9%) of the prestandard-approach group but none of the standard-approach group (p = .0203). Overall compliance with the standardization process has been maintained at > or = 96%. CONCLUSION: Implementation of a standard approach to the definition of apnea of prematurity and its treatment and documentation decreases LOS and reduces cost.

Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study.

OBJECTIVES: To evaluate the generalizability of stringent protocol-driven weaning in improving total duration of opioid treatment and length of inpatient hospital stay after treatment of neonatal abstinence syndrome (NAS). METHODS: We conducted a retrospective cohort analysis of 981 infants who completed pharmacologic treatment of NAS with methadone or morphine from January 2012 through August 2014. Before July 2013, 3 of 6 neonatology provider groups (representing Ohio's 6 children's hospitals) directed NAS nursery care by using group-specific treatment protocols containing explicit weaning guidelines. In July 2013, a standardized weaning protocol was adopted by all 6 groups. Statistical analysis was performed to identify effects of adoption of the multicenter weaning protocol on total duration of opioid treatment and length of hospital stay at the protocol-adopting sites and at the sites with preexisting protocol-driven weaning. RESULTS: After adoption of the multicenter protocol, infants treated by the 3 groups previously without stringent weaning guidelines experienced shorter duration of opioid treatment (23.0 vs 34.0 days, P < .001) and length of inpatient hospital stay (23.7 vs 31.6 days, P < .001). Protocol-adopting sites also experienced a lower rate of adjunctive drug therapy (5% vs 21%, P = .004). Outcomes were sustained by the 3 groups who initially had specific weaning guidelines after multicenter adoption (duration of treatment = 17.0 days and length of hospital stay = 23.3 days). CONCLUSIONS: Adoption of a stringent weaning protocol resulted in improved NAS outcomes, demonstrating generalizability of the protocol-driven weaning approach. Opportunity remains for additional protocol refinement.

Neonatal sinovenous thrombosis associated with homozygous thermolabile methylenetetrahydrofolate reductase in both mother and infant.

The C677T mutation in 5,10-methylenetetrahydrofolate reductase (MTHFR) predicts substitution of valine for alanine at residue 223 (A223V). This thermolabile form of MTHFR has 50% reduced activity, has been associated with hyperhomocystinemia, and is a described risk factor for thrombosis in adults.(1-3) In addition, it has been associated with birth defects in the infants of affected mothers and with recurrent fetal losses.(4-6) We report the occurrence of sinovenous thrombosis in a newborn infant who presented with seizures. Both infant and mother were subsequently identified as having homozygous C677T alleles for MTHFR.

Intraparenchymal brain hemorrhage and remote soft tissue arteriovenous malformation in a newborn infant.

Congenital arteriovenous malformations (AVMs) often present with congestive heart failure. Such pathologic vascular structures typically occur in cranial, hepatic, or pulmonary locations and are usually associated with overlying external visible, tactile, or audible abnormalities. These vascular anomalies may also be associated with such complications as thromboembolic events, coagulopathy, and localized hemorrhage. We present a newborn infant with an occult but hemodynamically significant parascapular AVM who presented with an intraparenchymal brain hemorrhage, which we suspect to be a remote complication of the AVM.

Pathogenesis of hypoxic-ischemic cerebral injury in the term infant: current concepts.

Multiple, biochemical cascades contribute to the pathogenesis of neonatal hypoxic-ischemic brain injury. This article summarizes experimental evidence that supports the role of excitatory amino acids, calcium, free radicals, nitric oxide, proinflammatory cytokines, and bioactive lipids. Specific vulnerabilities that distinguish the response of the immature brain from that of the mature brain are highlighted. These include increased susceptibility to excitotoxicity and free radical injury, greater tendency to apoptotic death, and heightened vulnerability of developing oligodendrocytes. Available supportive evidence from human studies is also included. Implications for clinical neuroprotective strategies are discussed.

A multicenter cohort study of treatments and hospital outcomes in neonatal abstinence syndrome.

OBJECTIVES: To compare pharmacologic treatment strategies for neonatal abstinence syndrome (NAS) with respect to total duration of opioid treatment and length of inpatient hospital stay. METHODS: We conducted a cohort analysis of late preterm and term neonates who received inpatient pharmacologic treatment of NAS at one of 20 hospitals throughout 6 Ohio regions from January 2012 through July 2013. Physicians managed NAS using 1 of 6 regionally based strategies. RESULTS: Among 547 pharmacologically treated infants, we documented 417 infants managed using an established NAS weaning protocol and 130 patients managed without protocol-driven weaning. Regardless of the treatment opioid chosen, when we accounted for hospital variation, infants receiving protocol-based weans experienced a significantly shorter duration of opioid treatment (17.7 vs. 32.1 days, P < .0001) and shorter hospital stay (22.7 vs. 32.1 days, P = .004). Among infants receiving protocol-based weaning, there was no difference in the duration of opioid treatment or length of stay when we compared those treated with morphine with those treated with methadone. Additionally, infants treated with phenobarbital were treated with the drug for a longer duration among those following a morphine-based compared with methadone-based weaning protocol. (P ≤ .002). CONCLUSIONS: Use of a stringent protocol to treat NAS, regardless of the initial opioid chosen, reduces the duration of opioid exposure and length of hospital stay. Because the major driver of cost is length of hospitalization, the implications for a reduction in cost of care for NAS management could be substantial.

Management of high-order multiple births: application of lessons learned because of participation in Vermont Oxford Network collaboratives.

OBJECTIVES: The delivery and care of sextuplets is complex. Potentially better practices that were developed as part of the Vermont Oxford Network improvement collaboratives were used to prepare for a sextuplet delivery at Akron Children's Hospital. METHODS: The team used potentially better practices that were learned from the Neonatal Intensive Care Quality Improvement Collaborative 2002 using multidisciplinary teams. There was extensive media coverage of the delivery. RESULTS: The goal was to use nearly all potentially better practices that focused on the goals of reducing nosocomial infection, reducing chronic lung disease, reducing radiograph use, reducing length of stay, reducing blood gas use, promoting nutrition, reducing intraventricular hemorrhage, and enriching family-centered care. The center aimed to use these 97 potentially better practices. Of the 97 possible potential better practices as set by the Neonatal Intensive Care Quality Improvement Collaborative 2002, 96 (99%) were used. CONCLUSIONS: This is a blueprint that any center that is faced with high-order multiple births could use as a reference point to begin planning. The team created a benchmark to achieve in every birth of very low birth weight infants and not just a special situation of high-order multiple births.

A local perspective on the initial management of children with cleft lip and palate by primary care physicians.

OBJECTIVE: To evaluate the frequency and referral patterns, need for continuing education, and information given to parents of children with cleft lip and palate by local primary care physicians. STUDY DESIGN: A survey was sent to primary care physicians from the pediatrics, family practice, and internal medicine/pediatrics specialties in six surrounding counties of a regional craniofacial center located within northeastern Ohio with a population base of 1.5 million people. Particular aspects of care evaluated included protocols of care, information for parents, referral patterns, conferences attended, and literature read. RESULTS: Nearly 30% of physicians had standard protocols when children are born with clefts. Eighty-seven percent of physicians referred children within 2 weeks of diagnosis, yet only 48% gave referrals to a multidisciplinary team. Physicians providing team referrals were nearly three times as likely to attend related conferences and approximately four times as likely to have a set plan at the time of diagnosis of the cleft. Forty-nine percent of physicians gave oral information, 35% gave oral and written information, and 10% did not give parents information. Ninety-four percent of physicians gave parents the option to call with concerns. Pediatricians were approximately four times as likely to attend cleft conferences and desire continuing education updates. However, family practitioners were over three times as likely to give proper referrals, compared with pediatricians. CONCLUSION: There is a necessity to educate local primary care physicians who manage children with cleft lip and palate regarding cleft information for parents, referral guidelines, the cleft team concept, and the role of primary physicians.

Can lateralizing sensorimotor deficits be identified after neonatal cerebral hypoxia-ischemia in rats?

The neonatal rat model of unilateral cerebral hypoxia-ischemia (HI) is commonly used to test the efficacy of therapeutic strategies for prevention or treatment of stroke in the immature brain. Traditionally neuroprotection has been defined as reduction in tissue injury; there is growing interest in complementary functional assessment. Our objectives were to determine whether lateralizing performance deficits could be detected in two sensorimotor tests not previously used after neonatal HI, and to determine whether performance reflected the extent of tissue damage. Seven-day-old rats that underwent right carotid ligation followed by 1.5 h in 8% O2 and age-matched controls were tested for sensorimotor performance on postnatal day 35 (P35). We evaluated initial forepaw placement on the wall of a cylinder, and time taken to contact and remove adhesive stickers from the dorsum of each forepaw. Cortical, striatal and hippocampal damage severity was evaluated on P36 by calculating the contralateral-ipsilateral percent difference in regional areas. There was an inverse relationship between cortical and striatal damage severity and percent contralateral forepaw initiation in the cylinder. There was a direct linear relationship between damage severity and the delay from contact to removal of the contralateral sticker. These two tests revealed quantifiable contralateral sensorimotor deficits 4 weeks after unilateral neonatal cerebral HI in animals with cortical and striatal damage.