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Objective To identify racial/ethnic disparities in postnatal growth by year and gestational age among very low birth weight infants. Study design Total 37,122 infants, with birth weight 500–1500 g or gestational age 23–34 weeks in the California Perinatal Quality Care Collaborative in 2008–2016. Postnatal growth failure (PGF) was defined as change in weight Z-score from birth to discharge below −1.28. Multivariable regression analysis with birth hospital as random effect was used to estimate odds ratios (OR). Results Infants born to Hispanic mothers had highest risk of PGF at 30%, compared to white (24%, OR 1.33), Black (22%, OR 1.50), or Asian/Pacific Islander mothers (23%, OR 1.38). PGF incidence decreased from 2008 (27.4%) to 2016 (22.8%) with differences in trends by race. Each increasing gestational age week was associated with decreasing risk for PGF (OR 0.73, 95% confidence interval 0.72–0.74). Conclusion Targeted interventions addressing PGF are needed to address disparities.

A recent shift in public attention to racism, racial disparities, and health equity have resulted in an abundance of calls for relevant papers and publications in academic journals. Peer-review for such articles may be susceptible to bias, as subject matter expertise in the evaluation of social constructs, like race, is variable. From the perspective of researchers focused on neonatal health equity, we share our positive and negative experiences in peer-review, provide relevant publicly available data regarding addressing bias in peer-review from 12 neonatology-focused journals, and give recommendations to address bias and knowledge gaps in the peer review process of health equity research.

To investigate whether hospital rates of active treatment for infants born at 22-23 weeks is associated with survival of infants born at 24-27 weeks.We included all liveborn infants 22-27 weeks of gestation delivered at California Perinatal Quality Care Collaborative hospitals from 2015 to 2019. We assessed (1) the correlation of active treatment (e.g., endotracheal intubation, epinephrine) in 22-23 week infants and survival until discharge for 24-27 week infants and (2) the association of active treatment with survival using multilevel models.The 22-23 week active treatment rate was associated with infant outcomes at 22-23 weeks but not 24-27 weeks. A 10% increase in active treatment did not relate to 24-25 week (adjusted OR: 1.00 [95% CI: 0.95-1.05]), or 26-27 week survival (aOR: 1.02 [0.95-1.09]).The hospital rate of active treatment for infants born at 22-23 weeks was not associated with improved survival for 24-27 week infants.

Objective This study examines comprehensive patient and process factors that influence breast milk use in the NICU setting. Study design We examined the association of maternal, neonatal, and family factors and lactation support systems to identify gaps in breast milk use in a retrospective study of 865 infants born in 23–41 weeks gestation admitted to the NICU. Results Breast milk at discharge for all infants was 89.3%, for extremely preterm 82.3%, moderately preterm 91.4%, late preterm 86.5%, and term 92.7%. Prematurity (OR 0.31 [0.17–0.56]), low birth weight, morbidities, Black maternal race (OR 0.20 [0.07–0.57]) and public insurance (OR 0.54 [0.34–0.85]) were associated with decreased breast milk use. Early initiation of feeds was associated with increased breast milk use. Conclusions There is a need to increase social as well as hospital support systems to address gaps in breast milk use in the NICU.

Objective Test web-based implementation for the science of enhancing resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) burnout. Design RCT using two cohorts of HCWs of four NICUs each, to improve HCW well-being (primary outcome: burnout). Cohort 1 received WISER while Cohort 2 acted as a waitlist control. Results Cohorts were similar, mostly female (83%) and nurses (62%). In Cohorts 1 and 2 respectively, 182 and 299 initiated WISER, 100 and 176 completed 1-month follow-up, and 78 and 146 completed 6-month follow-up. Relative to control, WISER decreased burnout (−5.27 (95% CI: −10.44, −0.10), p = 0.046). Combined adjusted cohort results at 1-month showed that the percentage of HCWs reporting concerning outcomes was significantly decreased for burnout (−6.3% (95%CI: −11.6%, −1.0%); p = 0.008), and secondary outcomes depression (−5.2% (95%CI: −10.8, −0.4); p = 0.022) and work-life integration (−11.8% (95%CI: −17.9, −6.1); p Conclusion WISER appears to durably improve HCW well-being. Clinical Trials Number NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133

ObjectiveCreate a prioritization framework for value-based improvement in neonatal care.Study designA retrospective cohort study of very low birth weight (ResultsResource categories with the greatest cost, patient exposure, and inter-hospital variability were parenteral nutrition, hematology (lab testing), and anticoagulation (for central venous access and therapy), respectively. Based on our prioritization score, parenteral nutrition was identified as the highest priority overall.ConclusionsWe report the development of a prioritization score for potential value-based improvement in neonatal care. Our findings suggest that parenteral nutrition, central venous access, and high-volume laboratory and imaging modalities should be priorities for future comparative effectiveness and quality improvement efforts.

To evaluate associations between pre-pregnancy body mass index (BMI), gestational weight gain (GWG), and postnatal growth in preterm infants. A cohort study of 14,962 births

There is a large body of evidence demonstrating that delaying clamping of the umbilical cord provides benefits for term and preterm infants. These benefits include reductions in mortality in preterm infants and improved developmental scores at 4 years of age in term infants. However, non-breathing or non-vigorous infants at birth are excluded due to the perceived need for immediate resuscitation. Recent studies have demonstrated early physiological benefits in both human and animal models if resuscitation is performed with an intact cord, but this is still an active area of research. Given the large number of ongoing and planned trials, we have brought together an international group that have been intimately involved in the development or use of resuscitation equipment designed to be used while the cord is still intact. In this review, we will present the benefits and limitations of devices that have been developed or are in use. Published trials or ongoing studies using their respective devices will also be reviewed.

Objective To determine the rates of high-risk infant follow-up (HRIF) attendance and the characteristics associated with follow-up among infants with hypoxic-ischemic encephalopathy (HIE) in California. Study design Using population-based datasets, 1314 infants with HIE born in 2010-2016 were evaluated. The characteristics associated with follow-up were identified through multivariable logistic regression. Results 73.9% of infants attended HRIF by age 1. Follow-up rates increased and variation in follow-up by clinic decreased over time. Female infants; those born to African-American, single, less than college-educated, or publicly insured caregivers; and those referred to high-volume or regional programs had lower follow-up rates. In multivariable analysis, Asian and Pacific Islander race/ethnicity had lower odds of follow-up; infants with college- or graduate school-educated caregivers or referred to mid-volume HRIF programs had greater odds. Conclusion Sociodemographic and program-level characteristics were associated with lack of follow-up among HIE infants. Understanding these characteristics may improve the post-discharge care of HIE infants.

To rank clinician-driven tests and treatments (CTTs) by their total cost during the birth hospitalization for preterm infants. Retrospective cohort of very low birth weight (

Objective To examine interhospital variation in admissions to neonatal intensive care units (NICU) and reasons for the variation. Study design 2010–2012 linked birth certificate and hospital discharge data from 35 hospitals in California on live births at 35–42 weeks gestation and ≥1500 g birth weight were used. Hospital variation in NICU admission rates was assessed by coefficient of variation. Patient/hospital characteristics associated with NICU admissions were identified by multivariable regression. Results Among 276,489 newborns, 6.3% were admitted to NICU with 34.5% of them having mild diagnoses. There was high interhospital variation in overall risk-adjusted rate of NICU admission (coefficient of variation = 26.2) and NICU admission rates for mild diagnoses (coefficient of variation: 46.4–74.0), but lower variation for moderate/severe diagnoses (coefficient of variation: 8.8–14.1). Births at hospitals with more NICU beds had a higher likelihood of NICU admission. Conclusion Interhospital variation in NICU admissions is mostly driven by admissions for mild diagnoses, suggesting potential overuse.

NICU patients are disproportionately affected by any disaster due to their vulnerability and highly specialized care needs that require a multitude of resources. Research in disaster preparedness and its effect on NICU patients is limited. From March to May 2018, NICUs across California participated in a survey designed to assess their preparedness for a disaster. Of the 84 responding units, 99% were urban, 73% were nonprofit, and 65% were community NICUs. As for NICU participation in hospital training exercises for disaster preparedness, 10% did not participate in annual drills, 44% did once a year, 36% did twice a year, and 10% did more than two times per year. We showed that many NICUs had redundant systems in place and plans for various disasters; however, there is not consistent participation by NICUs in hospital training exercises for disaster preparedness.

Objective. To understand factors associated with care and survival among babies with congenital diaphragmatic hernia (CDH). Study design. We used data on California births (2006–2011) to examine birth hospital level of care, hospital transfer before repair, and survival. Result. Among 577 infants, 25% were born at lower-level hospitals, 62% were transferred, and 31% died during infancy. Late or no prenatal care had the strongest association with birth at lower-level hospitals (adjusted Relative Risk (ARR)=1.9, 95% confidence interval (CI)=1.0–3.6). Birth at lower-level hospitals was associated with transfer (ARR=1.2, CI=1.1–1.4), and transferred infants tended to be less clinically complex. Infants with low birthweight, other birth defects, low Apgar scores, and late or no prenatal care had 2–4-fold higher risk of mortality than their comparison groups. Conclusions. These data support the importance of prenatal care and delivery planning into higher-level hospitals for optimal care and outcomes for newborns with CDH.

Objective Identify clinical factors, transport characteristics and transport time intervals associated with clinical deterioration during neonatal transport in California. Study design Population-based database was used to evaluate 47,794 infants transported before 7 days after birth from 2007 to 2016. Log binomial regression was used to estimate relative risks. Results 30.8% of infants had clinical deterioration. Clinical deterioration was associated with prematurity, delivery room resuscitation, severe birth defects, emergent transports, transports by helicopter and requests for delivery room attendance. When evaluating transport time intervals, time required for evaluation by the transport team was associated with increased risk of clinical deterioration. Modifiable transport intervals were not associated with increased risk. Conclusion Our results suggest that high-risk infants are more likely to be unstable during transport. Coordination and timing of neonatal transport in California appears to be effective and does not seem to contribute to clinical deterioration despite variation in the duration of these processes.

Objective To identify characteristics of neonatal transport in California and which factors influence team performance. Study design We led focus group discussions with 19 transport teams operating in California, interviewing 158 neonatal transport team members. Transcripts were analyzed using a thematic analysis approach. Result The composition of transport teams varied widely. There was strong thematic resonance to suggest that the nature of emergent neonatal transports is unpredictable and poses several significant challenges including staffing, ambulance availability, and administrative support. Teams reported dealing with this unpredictability by engaging in teamwork, gathering experience with staff at referral hospitals, planning for a wide variety of circumstances, specialized training, debriefing after events, and implementing quality improvement strategies. Conclusion Our findings suggest potential opportunities for improvement in neonatal transport. Future research can explore the cost and benefits of strategies such as dedicated transport services, transfer centers, and telemedicine.

Objective: Examine the adoption and presence of preterm, neuro-centric care practices across Neonatal Intensive Care Units (NICUs). Study Design: Statewide, cross-sectional survey of California NICUs. Data were collected surrounding the timing of adoption and presence of delivery room practices, nursing protocols, provider management practices and quality improvement initiatives. Result: Among the 95 NICUs completing the survey (65%), adoption of all surveyed practices increased between 2005 and 2016, though rates of uptake changed over time and varied by practice. Adoption of indomethacin prophylaxis increased 1.8-fold whereas delayed cord clamping increased 78-fold. Adoption of premedication for intubation and a patent ductus arteriosus management algorithm differed by unit level. Additionally, two underlying practice domains were identified; adoption of delivery room practices and adoption of any preterm practice. Conclusion: Adoption of preterm, neuro-centric care practices across California NICUs has increased, though uptake patterns vary by practice and level.

Transcutaneous bilirubin measurements (TcBs) provide a noninvasive method for screening infants for hyperbilirubinemia and have been used extensively in term and late preterm newborns in well baby nurseries, offices, and outpatient clinics. Several studies have also demonstrated the utility of TcBs as a screening tool for infants 28 weeks' gestation and their ability to reduce the need for blood sampling. The objectives of this study are to identify how often TcBs are used among California Newborn Intensive Care Units (NICUs) in preterm, late preterm and term infants, and other aspects of jaundice management.We conducted a survey on TcB use and practices relating to jaundice management in 150 California NICUs between April and October 2016.TcB screening is routinely used in 28% (42/150) of NICUs. Only 7% (11/150) of NICUs use TcB in preterm infants 28 weeks. Practice varied similarly across NICU levels of care. Among the subset of NICUs that responded to questions related to phototherapy and screening practices, prophylactic phototherapy was used in 38% (23/59) and 90% (55/61) screened for glucose-6-phosphate dehydrogenase deficiency based on race, ethnicity, and/or family history.Despite studies validating the accuracy of TcB in preterm infants 28 weeks, only 28% of California NICUs routinely use TcB devices. TcB screening in infants 28 weeks gestation is not widely used and no recommendation can be made in this regard until there is more experience with its application using a standardized protocol in these infants and on a large scale.

To assess the accuracy of different sonographic estimated fetal weight (EFW) cutoffs, and combinations of EFW and biometric measurements for predicting small for gestational age (SGA) in fetal gastroschisis.Gastroschisis cases from two centers were included. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated for different EFW cutoffs, as well as EFW and biometric measurement combinations.Seventy gastroschisis cases were analyzed. An EFW10% had 94% sensitivity, 43% specificity, 33% PPV and 96% NPV for SGA at delivery. Using an EFW cutoff of5% improved the specificity to 63% and PPV to 41%, but decreased the sensitivity to 88%. Combining an abdominal circumference (AC) or femur length (FL) z-score less than -2 with the total EFW improved the specificity and PPV but decreased the sensitivity.A combination of a small AC or FL along with EFW increases the specificity and PPV, but decreases the sensitivity of predicting SGA.

To describe the current scope of neonatal inter-facility transports. California databases were used to characterize infants transported in the first week after birth from 2009 to 2012. Transport of the 22 550 neonates was classified as emergent 9383 (41.6%), urgent 8844 (39.2%), scheduled 2082 (9.2%) and other 85 (0.4%). In addition, 2152 (9.5%) were initiated for delivery attendance. Most transports originated from hospitals without a neonatal intensive care unit (68%), with the majority transferred to regional centers (66%). Compared with those born and cared for at the birth hospital, the odds of being transported were higher if the patient’s mother was Hispanic

Objective To assess frequency of very low birth weight (VLBW) births at non-level III hospitals. Study design Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500 g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models. Results Of the 1 508 143 births, 13 919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24 h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively. Conclusion Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.

The aim of this study was to investigate the effect of maternal magnesium sulfate (MgSO4) exposure for eclampsia prophylaxis on neonatal intensive care unit (NICU) admission rates for term newborns. A secondary analysis of the Maternal–Fetal Medicine Unit Network Cesarean Registry, including primary and repeat cesarean deliveries, and failed and successful trials of labor after cesarean was conducted. Singleton pregnancies among women with preeclampsia and >37 weeks of gestation were included. Pregnancies with uterine rupture, chorioamnionitis and congenital malformations were excluded. Logistic regression analysis was used to determine associations between MgSO4 exposure and NICU admission. P

To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women.Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24 h, mode of delivery and maternal and fetal outcomes.A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9 h, P0.0001) and were more likely to deliver vaginally in24 h (47% vs 64%, P=0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes.Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.

Objective To develop a length of stay (LOS) model for extremely low birth weight (ELBW) infants. Study Design We included infants from the California Perinatal Quality Care Collaborative with birth weight 401–1,000 grams who were discharged to home. Exclusion criteria were congenital anomalies, surgery, and death. LOS was defined as days from admission to discharge. As patients who died or were transferred to lower level of care were excluded, we assessed correlation of hospital mortality rates and transfers torisk adjusted LOS. Results There were 2,012 infants with median LOS 79 days (range 23–219). Lower birth weight, lack of antenatal steroids, and lower Apgar score were associated with longer LOS. There was negligiblecorrelation between risk-adjusted LOS and hospital mortality rates (r = 0.0207) and transfer-out rates (r = 0.121). Conclusion Particularly because ELBW infants have extended hospital stays, identification of unbiased and informative risk-adjusted LOS for these infants is an important step in benchmarking best practice and improving efficiency in care.

The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria. A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression. In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death. Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.

To conduct a pilot study assessing a neonatologist's accuracy in diagnosing patent ductus arteriosus (PDA) using compact, portable ultrasound after limited training.Prospective study of premature infants scheduled for echocardiography for suspected PDA. A neonatologist with limited training performed study exams before scheduled exams. Sensitivity and specificity were calculated, compared to the scheduled echocardiogram interpreted by a cardiologist.There were 24 exams. Compared to the scheduled exam, the neonatologist's exam had sensitivity 69% (95% confidence interval (CI), 41 to 89%) and specificity 88% (95% CI, 47 to 99%). When a cardiologist interpreted the study exams, the sensitivity was 87% (95% CI, 60 to 98%) and specificity 71% (95% CI, 29 to 96%).A neonatologist with limited training was able to detect PDA with moderate success. A more rigorous training process or real-time transmission with cardiologist interpretation may substantially improve accuracy. Institutions with experienced technicians and on-site pediatric cardiologists may not gain from intensive training of neonatologists, but hospitals where diagnosis and treatment of PDA would be delayed may benefit from such processes.

To determine if there are differential cesarean delivery rates by race and other socio-demographic factors for women with breech infants. We calculated cesarean delivery rates for 186 727 White, African American, Hispanic and Asian women delivering breech singletons with gestational age 26 to 41 weeks born in 1999 and 2000 using data from the National Center for Health Statistics. Multivariable logistic regression was used to determine differences in mode of delivery by race, adjusting for socio-demographic and medical factors. Cesarean rates for breech were >80% in most gestational age groups. In 14 of 18 groups, Whites had higher cesarean delivery rates than African Americans. However, this finding did not persist after risk adjustment. Hispanics were more likely to deliver by cesarean delivery than African Americans and Whites. Breech singleton infants are predominantly born by cesarean delivery. Although African-American women with breech presentation have lower cesarean delivery rates than Whites, this difference is not present after adjusting for socio-demographic and medical factors. Hispanics were more likely to be delivered by cesarean delivery and this difference was amplified after risk adjustment. Asians had slightly lower cesarean rates after risk adjustment, but this varied widely according to Asian subgroup.

We thank Dr Heuchan and Dr Goldman for their interest and comments on our paper as well as their insight in identifying the important role of monitoring and maintaining ambient temperatures of above 25 °C in improving admission temperatures of preterm newborns. We commend Dr Heuchan and her colleagues for their persistence and success in dramatically improving admission temperatures of newborns in their neonatal intensive care unit through their quality improvement programs.

We thank Drs McAdams and Milhoan for their interest and comments on our paper. The circumstances that they describe in which pediatric cardiologists are not readily available in the neonatal intensive care unit are what we had in mind as we embarked on our pilot study. To clarify some of their questions regarding the study design, the study cardiologist reviewed all of the studies performed by the neonatologist on the Acuson Cypress (Siemens USA, Malvern, PA, USA), the portable ultrasound device.1 The cardiologist was aware that they were all performed by the neonatologist. He did not review the studies or reports of the echocardiograms done by the cardiology service until after review of the neonatologists' exams. He then reviewed selected ultrasounds performed by the cardiology service on the Acuson Sequoia (Siemens USA). Comparison of measured ductal size determinations would indeed be of interest for future studies, but this was not the primary outcome of our analysis. Estimated ductal size is not routinely recorded by our cardiology service, and was not recorded by the study neonatologist.

Breast-milk feeding of very low birth weight infants as a function of hospital demographics