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Objective Compare delivery room practices and outcomes of infants born at less than 32 weeks' gestation or less than 1,500 g who have plastic wrap/bag placement simultaneously during placental transfusion to those receiving plastic wrap/bag placement sequentially following placental transfusion. Study Design Retrospective analysis of data from a multisite quality improvement initiative to refine stabilization procedures pertaining to placental transfusion and thermoregulation using a plastic wrap/bag. Delivery room practices and outcome data in 590 total cases receiving placental transfusion were controlled for propensity score matching and hospital of birth. Results The simultaneous and sequential groups were similar in demographic and most outcome metrics. The simultaneous group had longer duration of delayed cord clamping compared with the sequential group (42.3 ± 14.8 vs. 34.1 ± 10.3 seconds, p < 0.001), and fewer number of times cord milking was performed (0.41 ± 1.26 vs. 0.86 ± 1.92 seconds, p < 0.001). The time to initiate respiratory support was also significantly shorter in the simultaneous group (97.2 ± 100.6 vs. 125.2 ± 177.6 seconds, p = 0.02). The combined outcome of death or necrotizing enterocolitis in the simultaneous group was more frequent than in the sequential group (15.3 vs. 9.3%, p = 0.038); all other outcomes measured were similar. Conclusion Timing of plastic wrap/bag placement during placental transfusion did affect duration of delayed cord clamping, number of times cord milking was performed, and time to initiate respiratory support in the delivery room but did not alter birth hospital outcomes or respiratory care practices other than the combined outcome of death or necrotizing enterocolitis. Key Points Plastic bag placement during placental transfusion is effective in stabilization of preterms. Plastic bag placement after placental transfusion is effective in stabilization of preterms. Plastic bag placement during placental transfusion and risk of death or necrotizing enterocolitis needs additional study. [ABSTRACT FROM AUTHOR]

OBJECTIVE. We tested whether NICU teams trained in benchmarking and quality improvement would change practices and improve rates of survival without bronchopulmonary dysplasia in inborn neonates with birth weights of < 1250 g. METHODS. A cluster-randomized trial enrolled 4093 inborn neonates with birth weights of RESULTS. Intervention centers implemented potentially better practices successfully; changes included reduced oxygen saturation targets and reduced exposure to mechanical ventilation. Five of 7 intervention centers and 2 of 7 control centers implemented use of high-saturation alarms to reduce oxygen exposure. Lower oxygen saturation targets reduced oxygen levels in the first week of life. Despite these changes, rates of survival free of bronchopulmonary dysplasia were all similar between intervention and control groups and remained significantly less than the rate achieved in the best-performing centers (73.3%). CONCLUSIONS. In this cluster-randomized trial, benchmarking and multimodal quality improvement changed practices but did not reduce bronchopulmonary dysplasia rates. www.pediatrics.org/cgi/doi/10.1542/peds.2006-2656 doi:10.1542/peds.2006-2656 Key Words quality improvement, randomized trial, bronchopulmonary dysplasia Abbreviations QI--quality improvement BPD--bronchopulmonary dysplasia PMA--postmenstrual age CPAP--continuous positive airway pressure OR--odds ratio CI--confidence interval, IN 2000, PUBLICATION of the seminal report To Err Is Human by the Institute of Medicine rocked the medical world and shook the confidence of patients in the health care [...]

Objective. Oxygen delivery through nasal cannulae to convalescent preterm infants is a common but largely unstudied practice. To learn more about current nasal cannula oxygen delivery practices, we examined the variations in oxygen delivery through nasal cannulae among the centers of the Neonatal Research Network, the frequency of prescription of low levels of oxygen, and the success of weaning to room air. We hypothesized that some infants treated with oxygen through nasal cannulae were receiving oxygen levels equivalent to those of room air. Methods. This was a descriptive, nested, cohort study of nasal cannula oxygen prescription among 187 infants with birth weights of Results. Fifty-two infants (27.8%) were receiving oxygen concentrations and flow rates through nasal cannulae that delivered an effective FI[O.sub.2] of Conclusions. Prescription of oxygen with combinations of flow rates and oxygen concentrations that delivered a low effective FI[O.sub.2] was common. We speculate that some of this, including the inadvertent prescription of an effective FI[O.sub.2] equivalent to that of room air, is related to lack of knowledge of the effective FI[O.sub.2]. Routine calculation of effective FI[O.sub.2] values may prompt earlier trials of room air and thus reduce unnecessary days of oxygen therapy. ABBREVIATIONS. FI[O.sub.2], fraction of inspired oxygen; STOP-ROP, Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity., Oxygen delivery through nasal cannulae to convalescent preterm infants is a common but largely unstudied practice. There are no existing criteria regarding when personnel attempt to wean infants from oxygen [...]

Objective. Chorioamnionitis complicates 1% to 10% of pregnancies and increases the risk of neonatal infection. Women with chorioamnionitis receive intrapartum antibiotics, often resulting in inconclusive neonatal blood cultures. Peripheral neutrophil values are used frequently to assist in the diagnosis of neonatal infection and to determine duration of antibiotics; we sought to determine the utility of this approach. Methods. A prospective observational study was performed in 856 near-term/term neonates who were exposed to suspected chorioamnionitis. Each received antibiotics for 48 hours unless clinical infection or positive blood cultures occurred. Peripheral neutrophils were measured serially and analyzed using the reference ranges of Manroe et al; an additional analysis of only the initial neutrophil values used the normal ranges of Schelonka et al. Results of neutrophil analyses were not used to determine duration of therapy. Fifty percent of asymptomatic neonates were seen postdischarge to ascertain recurrent infection. Local patient charges were examined. Results. Ninety-six percent of neonates were asymptomatic and had negative cultures, and antibiotics were discontinued at 48 hours. A total of 2427 neutrophil counts were analyzed. Although abnormal neutrophil values were more frequent in infected or symptomatic neonates, 99% of asymptomatic neonates had [greater than or equal to] 1 abnormal value. The specificity and negative predictive values for abnormal neutrophil values ranged between 0.12 and 0.95 and 0.91 and 0.97, respectively; sensitivity was 0.27 to 0.76. Significant differences in interpretation of the initial neutrophil values were noted, depending on the normal values used. Follow-up was performed for 373 asymptomatic neonates until 3 weeks&apos; postnatal age. Eight required rehospitalization; none had evidence of bacterial infection. If neutrophil values had been used to determine duration of antibiotics, then local costs would have increased by $76 000 to $425 000 per year. Conclusions. Single or serial neutrophil values do not assist in the diagnosis of early-onset infection or determination of duration of antibiotic therapy in asymptomatic, culture-negative neonates who are [greater than or equal to] 35 weeks&apos; gestation and are delivered of women with suspected chorioamnionitis. Pediatrics 2004;113:1173-1180; intraamniotic infection, neutrophil values, complete blood count, early-onset infection, antibiotic therapy, length of stay, resource utilization. ABBREVIATIONS. CDC, Centers for Disease Control and Prevention; CBC, complete blood cell count; ATN, absolute total neutrophil count; ATI, immature neutrophil count; I:T, immature neutrophil count:absolute total neutrophil count proportion; NBN, normal newborn nursery; GBS, group B streptococcus., Intrapartum maternal fever [greater than or equal to] 38[degrees]C has been reported to occur in 1% to 10% of pregnancies, resulting in a diagnosis of suspected chorioamnionitis in 40 000 [...]

Background. Recent studies of preterm neonates have indicated that antenatal dexamethasone (ADX) may have adverse effects on cranial ultrasound findings at the time of hospital discharge, including periventricular leukomalacia. Furthermore, both ADX and postnatal dexamethasone (PDX) may have adverse effects on subsequent neurodevelopmental outcome. Objectives. 1) To assess the effects of ADX exposure on cranial ultrasound findings at the time of hospital discharge and 2) to evaluate the individual effects of ADX and/or PDX exposure on subsequent neurodevelopmental outcome in extremely low birth weight (ELBW) neonates in whom confounding risk factors known to influence outcome were controlled. Methods. One hundred seventy-three ELBW ([less than or equal to] 1000 g) neonates were studied using a prospectively collected database and hospital and clinic records. Study patients were assigned to 1 of 4 groups according to dexamethasone exposure: group I, no dexamethasone exposure; group II, ADX exposure to hasten fetal lung maturity; group III, PDX exposure for chronic lung disease; group IV, both ADX and PDX exposure. The 4 groups were compared using multinomial logistic regression or analysis of covariance to control for confounding variables. Primary outcome variables were cranial ultrasound findings at hospital discharge and results of developmental testing at 18 to 22 months&apos; corrected age (Bayley Scales of Infant Development). Results. Cranial ultrasound results as well as Bayley Scales of Infant Development scores were similar in groups I and II and in groups III and IV. The likelihood of abnormal cranial ultrasound studies and lower scores on neurodevelopmental testing was greater in groups III and IV versus groups I and II. In this study, ADX did not seem to increase the risk of periventricular leukomalacia. Conclusions. ADX exposure is not associated with an increase in abnormal cranial ultrasound findings in ELBW neonates. PDX exposure, but not ADX exposure, is associated with worse neurodevelopmental outcome in this population. These results are supportive of the recent statement by the American Academy of Pediatrics (Committee on Fetus and Newborn) and the Canadian Paediatric Society (Fetus and Newborn Committee) and emphasize that PDX should be used with caution in ELBW neonates. Pediatrics 2002;110:275-279; preterm neonate, corticosteroids, chronic lung disease, neurodevelopment, analysis of variance, ANCO VA, multinomial regression, Bayley, head ultrasound., ABBREVIATIONS. ADX, antenatal dexamethasone; RDS, respiratory distress syndrome; PDX, postnatal dexamethasone; CLD, chronic lung disease; ELBW, extremely low birth weight; PVL, periventricular leukomalacia; BSID II, Bayley Scales of Infant Development; [...]

Objective. To compare estimates of serum bilirubin as determined by a transcutaneous device (BiliChek IBC]) with laboratory-measured total serum bilirubin (TSB) in a predominately Hispanic population in which a significant number of TSB values [greater than or equal to] 15 mg/dL was anticipated. Methods. A total of 248 Hispanic and 56 non-Hispanic neonates were studied. Transcutaneous measurements were performed by 1 investigator within 30 minutes of blood sampling for TSB; TSB was determined in a large clinical laboratory using the diazo Jendrassik-Grof with blank method. Agreement between BC and TSB determinations was assessed using Bland-Altman plots and the Bradley-Blackwood test. Interdevice comparisons were made among the BC devices. Predictive indices for TSB >10 mg/dL and >15 mg/dL were determined using various BC cutoff values. Results. TSB was [greater than or equal to] 15 mg/dL in 31% of the Hispanic neonates. BC generally tended to underestimate TSB determinations, and this trend was more pronounced when TSB was >10 mg/dL. Very high sensitivities were observed only when relatively low BC cutoff values were used to predict TSB >10 mg/dL or >15 mg/L. Relatively small numbers of infants had BC values in these low ranges. Conclusions. The tendency of BC to underestimate TSB limits its usefulness in neonates with relatively high TSB. In this population, most infants would have required additional evaluation to ensure that TSB was not >10 mg/dL or >15 mg/dL. It seems that the discrepancy between this study and previous studies of BC is related to our relatively large number of TSB values [greater than or equal to] 15 mg/dL. Pediatrics 2002;110:61-67; neonate, jaundice, hyperbilirubinemia, transcutaneous device, Bili-Chek., The management of jaundice in term and near-term neonates is a challenging clinical problem, complicated by increased prevalence of breastfeeding, early hospital discharge, and difficulty in ensuring prompt postdischarge follow-up. [...]