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Objective: To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs).Study Design: We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation.Results: Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death.Conclusions: From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency. [ABSTRACT FROM AUTHOR]

Objective: To estimate the association between the mode of respiratory support administered at 36 weeks' post-menstrual age (PMA) with time-to-liberation from respiratory support (LRS) in infants with grade 2/3 bronchopulmonary dysplasia (BPD)., Study Design: Daily respiratory support data were abstracted for infants born <32 weeks' gestation with grade 2/3 BPD enrolled in the Children's Hospitals Neonatal Database between 2017 and 2022. The main exposure was the mode of respiratory support received at 36 weeks' PMA: high flow nasal cannula >2 L/min (HFNC), continuous positive airway pressure (CPAP), non-invasive positive pressure ventilation (NIPPV), or mechanical ventilation (MV). The primary outcome was time-to-LRS, defined as the PMA when infants weaned to nasal cannula <2 L/min or room air for >2 days. The independent association between the main exposure and time-to-LRS was estimated using restricted mean survival time analysis., Results: Among 3,483 included infants from 41 centers, 17% received HFNC, 36% CPAP, 16% NIPPV, and 32% MV at 36 weeks' PMA. After censoring those who died (4.2%), survived with tracheostomy (7.6%), or were transferred to another facility (7.5%), the median (IQR) time-to-LRS differed between groups: HFNC 37 [37, 39]; CPAP 39 [37, 41] NIPPV 41[39, 45]; and MV 44 [40, 48] weeks' PMA (P<0.001). Across centers, a 10-fold difference in time-to-LRS was observed after adjustment for clinical risk factors., Conclusions: For infants with grade 2/3 BPD, the mode of respiratory support prescribed at 36 weeks' PMA and center of care were each associated with time-to-LRS independent of patient and clinical characteristics., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To estimate the association of ZIP code-level social determinants of health (SDoH), specifically household income, education level, and unemployment rate, with postmenstrual age (PMA) at tracheostomy placement in patients with severe bronchopulmonary dysplasia., Study Design: This was a retrospective observational study of infants born <32 weeks' gestation and discharged from a Children's Hospitals Neonatal Consortium newborn intensive care unit. Patients were diagnosed with severe bronchopulmonary dysplasia and received tracheostomies before discharge. Maternal ZIP code at admission was linked to that ZIP code's SDoH via the 2021 US Census Bureau 5-year data. Unadjusted and adjusted analyses were completed with separate models fit for each SDoH marker., Results: There were 877 patients who received tracheostomies at a median of 48 weeks PMA (IQR, 44-53 weeks PMA). In multivariable models, patients in the highest education groups received tracheostomies earlier (OR, 0.972; 95% CI, 0.947-0.997; P = .031), and non-Hispanic Black patients received tracheostomies later compared with non-Hispanic White patients (OR, 1.026; 95% CI, 1.005-1.048; P = .017). For household income and unemployment, the PMA at tracheostomy did not differ by SDoH or race. For all 3 models, male sex, small for gestation status, and later PMA at admission were associated with later PMA at tracheostomy. For each SDoH marker, significant intercenter variation was noted; several centers had independently increased PMA at tracheostomy., Conclusions: Education at the ZIP code level influenced PMA at tracheostomy after adjusting for patient and clinical factors. Adjusted for each SDoH studied, significant differences were noted among centers. Factors leading to the decision and timing of neonatal tracheostomy need further evaluation., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Repair of type C esophageal atresia with tracheo-esophageal fistula (EA/TEF) may be complicated by esophageal anastomotic leak. Risk factors associated with leak and the impact of leak on inpatient outcomes remains uncertain. Our objectives are to estimate the associations between clinical factors and esophageal anastomotic leak and quantify the association of leak with length of stay (LOS) in infants who underwent repair of type C EA/TEF., Methods: Using the Children's Hospitals Neonatal Database (CHND), we identified infants with type C EA/TEF from 2021 to 2023. The main outcomes were anastomotic leak and LOS. Multivariable associations between patient and clinical factors and these outcomes were quantified using logistic regression (leak) and Cox proportional hazards modelling (LOS)., Results: Among 365 infants at 36 centers, anastomotic leak occurred in 55 (15.1 %) infants, and thoracoscopic approach, lower birthweight, small for gestational age less than 10th percentile, male sex, staged repair, ventricular septal defect, and center were independently associated with leak (area under receiver operating curve = 0.853). Also, LOS was increased in infants with leak compared to those without [hazard ratio (HR): 0.655, 95 % CI = 0.431-0.996, p = 0.044], independent of birth weight, surgical approach, male sex, or VSD. The adjusted LOS demonstrated a 11-fold inter-center variation (p = 0.034)., Conclusions: Several clinical and operative factors are associated with esophageal anastomotic leak in infants after type C EA/TEF repair. Leak significantly prolongs LOS. The magnitude of inter-center variability in LOS also suggests that identifying best practices could aid in improving patient care in this patient population., Type of Study: Retrospective Comparative Study., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Acute kidney injury (AKI) occurs in up to half of infants admitted to the neonatal intensive care unit (NICU) and is associated with increased risks of death and more days of mechanical ventilation, hospitalization, and vasopressor drug support. Our objective was to build a granular relational database to study the impact that AKI has on infants admitted to Level-IV NICUs., Methods: A relational database was created by linking data from the Children's Hospitals Neonatal Database with AKI-focused data from electronic health records from 9 centers., Results: The current cohort consists of 24,870 infants with a median (IQR) gestational age of birth of 37 weeks (32 weeks, 39 weeks), and a median birth weight of 2.720 kg (1.750 kg, 3.310 kg). There was a male predominance with 14,214 (57%) males. In all, 2434 (9.8%) of the mothers were of Hispanic ethnicity. The maternal race breakdown of the cohort was as follows: 741 (3.0%) Asian, 5911 (24%) Black, and 14,945 (60%) White. Overall mortality was 5.8%., Conclusion: The ADVANCE relational database is an innovative research tool to rigorously study the epidemiology of AKI in a large national cohort of infants admitted to Level-IV NICUs involved in the Children's Hospital Neonatal Consortium., Impact: We used a biomedical informatics approach to build a relational database to study acute kidney injury in infants. We highlight our methodology linking Children's Hospital Neonatal Consortium and electronic health record data from nine neonatal intensive care units. The ADVANCE relational database is a granular and innovative research tool to study risk factors and in-hospital outcomes of acute kidney injury and mortality in a vulnerable patient population., (© 2024. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Multidisciplinary bronchopulmonary dysplasia (BPD) programs provide improved and consistent medical management, care of the developing infant, family support, and smoother transitions in care resulting in improved survival, pulmonary, and extra-pulmonary outcomes. This review summarizes the benefits of interdisciplinary BPD management, as well as strategies for initial programmatic development, program growth, and maintenance at centers across the United States factoring in institutional, provider, and parent reported goals that were derived from a consensus conference on BPD management., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Purpose: Quantify short-term outcomes associated with initial surgery [laparotomy (LAP) vs. peritoneal drain (PD)] for necrotizing enterocolitis (NEC) in extremely-low-birth-weight (ELBW) infants., Methods: Using the Children's Hospitals Neonatal Database, we identified ELBW infants <32 weeks' gestation with surgical NEC (sNEC). Unadjusted and multivariable regression analyses were used to estimate the associations between LAP (or PD) and death/short bowel syndrome (SBS) and length of stay (LOS)., Results: LAP was the more common initial procedure for sNEC (n = 359/528, 68%). Infants receiving LAP were older and heavier. Initial procedure was unrelated to death/SBS in both bivariate (LAP: 43% vs PD: 46%, p = 0.573) and multivariable analyses (OR = 0.89, 95% CI = 0.57, 1.38, p = 0.6). LAP was inversely related to mortality (29% vs. 41%, p < 0.007) in bivariate analysis, but not significant in multivariable analysis accounting for markers of preoperative illness severity. However, the association between LAP and SBS (14% vs. 5%, p = 0.012) remained significant in multivariable analyses (adjusted OR = 2.25, p = 0.039). LOS among survivors was unrelated to the first surgical procedure in multivariable analysis., Conclusion: ELBW infants who undergo LAP as the initial operative procedure for sNEC may be at higher risk for SBS without a clear in-hospital survival advantage or shorter hospitalization., Level of Evidence: Level II., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/purpose: The optimal surgical approach in infants with gastroschisis (GS) is unknown. The purpose of this study was to estimate the association between staged closure and length of stay (LOS) in infants with GS., Design/methods: We used the Children's Hospital Neonatal Database to identify surviving infants with GS born ≥34 weeks' gestation referred to participating NICUs. Infants with complex GS, bowel atresia, or referred after 2 days of age were excluded. The primary outcome was LOS; multivariable linear regression was used to quantify the relationship between staged closure and LOS., Results: Among 442 eligible infants, staged closure occurred in 68.1% and was associated with an increased median LOS relative to odds ration (OR):primary closure (37 vs. 28 days, p<0.001). This association persisted in the multivariable equation (β=1.35, 95% CI: 1.21, 1.52, p<0.001) after adjusting for the presence of necrotizing enterocolitis, short bowel syndrome, and central-line associated bloodstream infections., Conclusions: In this large, multicenter cohort of infants with GS, staged closure was independently associated with increased LOS. These data can be used to enhance antenatal and pre-operative counseling and also suggest that some infants who receive staged closure may benefit from primary repair., (Copyright © 2014 Elsevier Inc. All rights reserved.)