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Background: Postmenstrual age for surviving infants without congenital anomalies born at 24–29 weeks’ gestational age from 2005 to 2018 in the USA increased 8 days, discharge weight increased 316 grams, and median discharge weight z-score increased 0.19 standard units. We asked whether increases were observed in other countries. Methods: We evaluated postmenstrual age, weight, and weight z-score at discharge of surviving infants without congenital anomalies born at 24–29 weeks’ gestational age admitted to Vermont Oxford Network member hospitals in Austria, Ireland, Italy, Switzerland, the UK, and the USA from 2012 to 2020. Results: After adjustment, the median postmenstrual age at discharge increased significantly in Austria (3.6 days, 99% CI [1.0, 6.3]), Italy (4.0 days [2.3, 5.6]), and the USA (5.4 days [5.0, 5.8]). Median discharge weight increased significantly in Austria (181 grams, 99% CI [95, 267]), Ireland (234 [143, 325]), Italy (133 [83, 182]), and the USA (207 [194, 220]). Median discharge weight z-score increased in Ireland (0.24 standard units, 99% CI [0.12, 0.36]) and the USA (0.15 [0.13, 0.16]). Discharge on human milk increased in Italy, Switzerland, and the UK, while going home on cardiorespiratory monitors decreased in Austria, Ireland, and USA and going home on oxygen decreased in Ireland. Conclusions: In this international cohort of neonatal intensive care units, postmenstrual discharge age and weight increased in some, but not all, countries. Processes of care at discharge did not change in conjunction with age and weight increases.

BACKGROUND The microbiologic etiologies, clinical manifestations, and antimicrobial treatment of neonatal infections differ substantially from infections in adult and pediatric patient populations. In 2019, the Centers for Disease Control and Prevention developed neonatal-specific (Standardized Antimicrobial Administration Ratios SAARs), a set of risk-adjusted antimicrobial use metrics that hospitals participating in the National Healthcare Safety Network’s (NHSN’s) antimicrobial use surveillance can use in their antibiotic stewardship programs (ASPs). METHODS The Centers for Disease Control and Prevention, in collaboration with the Vermont Oxford Network, identified eligible patient care locations, defined SAAR agent categories, and implemented neonatal-specific NHSN Annual Hospital Survey questions to gather hospital-level data necessary for risk adjustment. SAAR predictive models were developed using 2018 data reported to NHSN from eligible neonatal units. RESULTS The 2018 baseline neonatal SAAR models were developed for 7 SAAR antimicrobial agent categories using data reported from 324 neonatal units in 304 unique hospitals. Final models were used to calculate predicted antimicrobial days, the SAAR denominator, for level II neonatal special care nurseries and level II/III, III, and IV NICUs. CONCLUSIONS NHSN’s initial set of neonatal SAARs provides a way for hospital ASPs to assess whether antimicrobial agents in their facility are used at significantly higher or lower rates compared with a national baseline or whether an individual SAAR value is above or below a specific percentile on a given SAAR distribution, which can prompt investigations into prescribing practices and inform ASP interventions.

BACKGROUND AND OBJECTIVES High-risk infant follow-up programs (HRIFs) are a recommended standard of care for all extremely low birth weight (ELBW) infants to help mitigate known risks to long-term health and development. However, participation is variable, with known racial and ethnic inequities, though hospital-level drivers of inequity remain unknown. We conducted a study using a large, multicenter cohort of ELBW infants to explore within- and between-hospital inequities in HRIF participation. METHODS Vermont Oxford Network collected data on 19 503 ELBW infants born between 2006 and 2017 at 58 US hospitals participating in the ELBW Follow-up Project. Primary outcome was evaluation in HRIF at 18 to 24 months’ corrected age. The primary predictor was infant race and ethnicity, defined as maternal race (non-Hispanic white, non-Hispanic Black, Hispanic, Asian American, Native American, other). We used generalized linear mixed models to test within- and between-hospital variation and inequities in HRIF participation. RESULTS Among the 19 503 infants, 44.7% (interquartile range 31.1–63.3) were seen in HRIF. Twenty six percent of the total variation in HRIF participation rates was due to between-hospital variation. In adjusted models, Black infants had significantly lower odds of HRIF participation compared with white infants (adjusted odds ratio, 0.73; 95% confidence interval, 0.64–0.83). The within-hospital effect of race varied significantly between hospitals. CONCLUSIONS There are significant racial inequities in HRIF participation, with notable variation within and between hospitals. Further study is needed to identify potential hospital-level targets for interventions to reduce this inequity.

OBJECTIVES To determine the epidemiology, microbiology, and associated outcomes of late-onset sepsis among very preterm infants using a large and nationally representative cohort of NICUs across the United States. METHODS Prospective observational study of very preterm infants born 401 to 1500 g and/or 22 to 29 weeks’ gestational age (GA) from January 1, 2018, to December 31, 2020, who survived >3 days in 774 participating Vermont Oxford Network centers. Late-onset sepsis was defined as isolation of a pathogenic bacteria from blood and/or cerebrospinal fluid, or fungi from blood, obtained >3 days after birth. Demographics, clinical characteristics, and outcomes were compared between infants with and without late-onset sepsis. RESULTS Of 118 650 infants, 10 501 (8.9%) had late-onset sepsis for an incidence rate of 88.5 per 1000 (99% confidence interval [CI] [86.4–90.7]). Incidence was highest for infants born ≤23 weeks GA (322.0 per 1000, 99% CI [306.3–338.1]). The most common pathogens were coagulase negative staphylococci (29.3%) and Staphylococcus aureus (23.0%), but 34 different pathogens were identified. Infected infants had lower survival (adjusted risk ratio [aRR] 0.89, 95% CI [0.87–0.90]) and increased risks of home oxygen (aRR 1.32, 95% CI [1.26–1.38]), tracheostomy (aRR 2.88, 95% CI [2.47–3.37]), and gastrostomy (aRR 2.09, 95% CI [1.93–2.57]) among survivors. CONCLUSIONS A substantial proportion of very preterm infants continue to suffer late-onset sepsis, particularly those born at the lowest GAs. Infected infants had higher mortality, and survivors had increased risks of technology-dependent chronic morbidities. The persistent burden and diverse microbiology of late-onset sepsis among very preterm infants underscore the need for innovative and potentially organism-specific prevention strategies.

ImportanceFor neonates with very low birth weight (VLBW), randomized clinical trials (RCTs) indicate that probiotic treatment decreases the risk of necrotizing enterocolitis (NEC), with smaller decreases in the risk of sepsis and death. There is little evidence on the rate of probiotic adoption in US neonatal intensive care units (NICUs) and whether the benefits seen in trials have materialized in practice.ObjectiveTo estimate changes in probiotic use among neonates with VLBW and to test whether neonates with VLBW treated at NICUs adopting routine probiotic use experience better outcomes compared with neonates treated at nonadopting NICUs.Design, Setting, and ParticipantsThis cohort study used Vermont Oxford Network data on neonates with VLBW in US NICUs from January 1, 2012, to December 31, 2019. Data were analyzed from January 2022 through February 2023.ExposureProbiotics adoption vs nonadoption. Adopting NICUs were defined as those that currently or previously treated at least 20% of neonates with VLBW with probiotics.Main OutcomesThe primary outcomes were rates of NEC, in-hospital mortality, and sepsis, defined as bacterial or fungal infection occurring after day 3 from birth. A difference-in-differences analysis compared changes in VLBW infant outcomes between adopting and nonadopting NICUs before and after hospital-level adoption of probiotics. Additional analyses used the proportion of neonates treated with probiotics in each neonate’s birth NICU and year.ResultsThe analysis included 307 905 neonates with VLBW (mean [SD] gestational age, 28.4 [2.9] weeks; 50.0% male) at 807 US hospitals. The rate of probiotic treatment of neonates with VLBW rose from 1572 of 38 296 neonates (4.1%) in 2012 to 4788 of 37 910 (12.6%) in 2019. Only 123 of 745 NICUs (16.5%) adopted probiotics by 2019, with 4591 of 6017 neonates with VLBW (76.3%) receiving probiotics in 2019 at adopting NICUs. Incidence of NEC declined by 18% at adopting NICUs (odds ratio [OR], 0.82; 95% CI, 0.70-0.95; P = .10) compared with nonadopting NICUs. Probiotic adoption was not associated with a significant reduction in sepsis (OR, 1.11; 95% CI, 0.98-1.25; P = .09) or mortality (OR, 0.93; 95% CI, 0.80-1.08; P = .33).Conclusion and RelevanceIn this cohort study, adoption of routine use of probiotics increased slowly in US NICUs and was associated with lower NEC risk but not with sepsis or mortality among neonates with VLBW. The findings for probiotic adoption and NEC, sepsis, and mortality were smaller than would have been predicted by the totality of RCT evidence but are consistent with a meta-analysis restricted to studies at low risk of bias.

The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity.We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network.Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios.A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location.

BACKGROUND Summary measures are used to quantify a hospital’s quality of care by combining multiple metrics into a single score. We used Baby-MONITOR, a summary quality measure for NICUs, to evaluate quality by race and ethnicity across and within NICUs in the United States. METHODS Vermont Oxford Network members contributed data from 2015 to 2019 on infants from 25 to 29 weeks’ gestation or of 401 to 1500 g birth weight who were inborn or transferred to the reporting hospital within 28 days of birth. Nine Baby-MONITOR measures were individually risk adjusted, standardized, equally weighted, and averaged to derive scores for African American, Hispanic, Asian American, and American Indian infants, compared with white infants. RESULTS This prospective cohort included 169 400 infants at 737 hospitals. Across NICUs, Hispanic and Asian American infants had higher Baby-MONITOR summary scores, compared with those of white infants. African American and American Indian infants scored lower on process measures, and all 4 minority groups scored higher on outcome measures. Within NICUs, the mean summary scores for African American, Hispanic, and Asian American NICU subsets were higher, compared with those of white infants in the same NICU. American Indian summary NICU scores were not different, on average. CONCLUSIONS With Baby-MONITOR, we identified differences in NICU quality by race and ethnicity. However, the summary score masked within-measure quality gaps that raise unanswered questions about the relationships between race and ethnicity and processes and outcomes of care.

A statewide Maryland Perinatal Neonatal Quality Collaborative, facilitated by the Maryland Patient Safety Center (MPSC), identified the three specific, measurable, attainable, relevant, and time-limited (SMART) aims to improve outcomes of neonatal abstinence syndrome (NAS) care as follows: (1) to reduce hospital length of stay (LOS), (2) to reduce interhospital transfers, and (3) to reduce 30-day readmission rates of infants with NAS. The Maryland collaborative developed a bundle of best practices for care of infants with NAS. MPSC partnered with Vermont Oxford Network (VON) to utilize the VON NAS toolkit and provided its standardized NAS educational curriculum to address the three objectives for participating birthing hospitals. Efforts began in quarter 4 (Q4) of 2016 and continued for 2 years. Thirty-one of Maryland's 32 delivery hospitals (97%) participated in the 2-year collaborative. Additionally, one specialty pediatric hospital with an NAS unit participated in the group learnings. Participating facilities implemented components of the MPSC NAS bundle and provided their staff caring for infants with NAS and their mothers access to the VON standardized educational curriculum. MPSC partnered with VON to conduct two audits of implementation of policies and procedures in Q1 of 2016 and Q3 of 2018. The Maryland Department of Health supplied quarterly aggregate hospital information on LOS, interhospital transfers, and 30-day readmissions of infants with a discharge diagnosis of the International Classification of Disease, 10th Revision (ICD-10), P96.1. Among term infants with NAS with total hospital stay greater than 5 days, we observed a nonsignificant reduction in both mean and median LOS of 1.5 days. In this same group, the rate of interhospital transfers fell significantly from 20.1% in 2016 to 13.8 and 11.0% in 2017 and 2018, respectively. The best practice bundle created by the Maryland collaborative was associated with a reduction in the percentage of infants with NAS who required interhospital transfer, thereby reducing family disruption.· A state NAS collaborative engaged 97% of delivery hospitals in education and standardization of care.. · The collaborative witnessed a 1.5-day decrease in length of stay, similar to that observed in other state collaboratives.. · The unique outcome of our collaborative was a 50% decrease in the rate of interhospital transfer..

Objective Assess practices supporting care transitions for infants and families in the neonatal intensive care unit (NICU) using a model of four key drivers: communication, teamwork, family integration, and standardization. Study design Single-day audit among NICUs in the Vermont Oxford Network Critical Transitions collaborative addressing policies and practices supporting the four key drivers during admission, discharge, shift-to-shift handoffs, within hospital transfers, and select changes in clinical status. Results Among 95 NICUs, the median hospital rate of audited policies in place addressing the four key drivers were 47% (inter-quartile range (IQR) 35–65%) for communication, 67% (IQR 33–83%) for teamwork, 50% (IQR 33–61%) for family integration, and 70% (IQR 56–85%) for standardization. Of the 2462 infants included, 1066 (43%) experienced ≥1 specified transition during the week prior to the audit. Conclusions We identified opportunities for improving NICU transitions in areas of communication, teamwork, family integration, and standardization.

Objective To examine whether there are: 1) regional differences in three perinatal interventions that reflect active treatment among periviable gestations and 2) racial-ethnic differences in the receipt of these perinatal interventions after accounting for hospital region. Methods We conducted a retrospective study on neonates born at 776 U.S. centers that participated in the Vermont Oxford Network (2006-2017) with a gestational age of 22-25 weeks. The primary outcome was postnatal life support. Secondary outcomes included maternal administration of antenatal corticosteroids and cesarean delivery. We examined rates and 99% CI of the three outcomes by region. We also calculated the adjusted relative risks (aRRs) and 99% CIs for the three outcomes by race and ethnicity within each region using modified Poisson regression models with robust variance estimation. Results Major regional variation exists in the use of the three interventions at 22 and 23 weeks of gestation but not at 24 and 25 weeks. For example, at 22 weeks of gestation, rates of life support in the South (38.3%; 99% CI 36.3-40.2) and the Midwest (32.7%; 99% CI 30.4-35.0) were higher than in the Northeast (20.2%; 99% CI 17.6-22.8) and the West (22.2%; 99% CI 20.0-24.4). Particularly in the Northeast, black and Hispanic neonates born at 22 or 23 weeks of gestation had a higher provision of postnatal life support than white neonates (at 22 weeks: black: aRR 1.84 [99% CI 1.33-2.56], Hispanic: aRR 1.80 [1.23-2.64]; at 23 weeks: black: aRR 1.14 [99% CI 1.08-1.20], Hispanic: aRR 1.12 [1.05-1.19]). In the West, black and Hispanic neonates born at 23 weeks of gestation also had a higher provision of life support (black: aRR 1.11 [99% CI 1.03-1.19]; Hispanic: aRR 1.10 [1.04-1.16]). Conclusion Major regional variation exists in perinatal interventions when managing 22- and 23-week neonates. In the Northeast and the West regions, minority neonates born at 22 and 23 weeks of gestation had higher provision of postnatal life support.

OBJECTIVES To examine the prevalence, characteristics, clinical course, and length of stay (LOS) among 4 groups of infants who were transferred for convalescence and subsequently discharged from the hospital; failed transfer for convalescence and were (a) either readmitted, or (b) transferred again; and were not transferred for convalescence. METHODS Among very low birth weight infants hospitalized at US Vermont Oxford Network centers between 2006 and 2020, we examined the distribution of characteristics, delivery room and NICU usage measures, outcomes, and LOS among the 4 groups of infants. RESULTS Among 641 712 infants, a total of 28 985 (4.5%) infants were transferred for convalescent care; of 28 186 infants, 182 (0.65%) died before hospital discharge and 2551 (9.1%) failed the transfer (1771 [6.3%] were readmitted and 780 [2.8%] were transferred again). There were major regional and NICU variations in the practice of the transfer for convalescence; New England (18.8%) had the highest whereas East South Central (2.2%) had the lowest percentage of transfer for convalescence. Infants who transferred for convalescence and were discharged from the hospital had a similar LOS and similar distribution of NICU usage measures and outcomes to infants who were not transferred for convalescence. Infants who failed the transfer for convalescence had a longer LOS than infants who were transferred for convalescence and then discharged from the hospital. CONCLUSIONS The rates of transfer for convalescence and transfer for convalescence failure were low. Future studies should weigh the risks and benefits of transfer for convalescence, which might differ on the basis of geography.

This study aims to quantify mortality rates and hospital lengths of stay (LOS) in neonates with esophageal atresia and tracheoesophageal fistula (EA/TEF), and to characterize the effects of birth weight (BW) and associated congenital anomalies upon these.Data regarding patients with EA/TEF were prospectively collected (2013-2019) at 298 North American centers. The primary outcome was mortality and secondary outcome was LOS. Risk factors affecting mortality and LOS were assessed.EA/TEF was diagnosed in 3290 infants with a median BW of 2476 g (IQR 1897,2970). In-hospital mortality was 12.7%. Mortality was inversely correlated with BW. After adjustment, the risk of mortality decreased by approximately 11% with every 100 g increase in BW. A significant congenital anomaly other than EA/TEF was diagnosed in 37.9% of patients. Risk of mortality increased in patients with associated congenital anomalies, most notably in those with a severe cardiac anomaly. Lower BW was associated with an increased mean LOS among survivors. Similar to mortality risk, additional anomalies were associated with prolonged LOS.This study demonstrates an in-hospital mortality of over 10%. Both increased mortality and prolonged LOS are highly associated with lower birth weight and the presence of concomitant congenital anomalies.

Differences in morbidities between spontaneous intestinal perforation (SIP) and necrotizing enterocolitis (NEC) are unknown.Prospectively collected multicenter data regarding very low birth weight (VLBW) infants 2015-2019 were analyzed. Diagnosis of SIP or NEC was laparotomy-confirmed in all patients. Multivariable regression modeling was used to assess adjusted length of stay (LOS; primary outcome) and adjusted risk ratios (ARR) for weight10th percentile at discharge, and supplemental oxygen requirement at discharge.Of 201,300 VLBW infants at 790 hospitals, 1523 had SIP and 2601 had NEC. Adjusted LOS was similar for SIP and NEC (92 vs 88 days, p = 0.08561), but significantly higher than seen without SIP or NEC (68 days, p0.0001). The risk of growth morbidity at discharge was similar between SIP and NEC (74.2% vs 75.3%; ARR:1.00;0.94,1.06), but higher than infants without SIP or NEC (47.7%; ARR:0.50;0.47,0.53). Infants with NEC were less likely to require supplemental oxygen at discharge than infants with SIP (24.4% vs 34.9%; ARR:0.80; 0.71,0.89).Although mortality is known to be lower in VLBW infants with SIP than NEC, this study highlights the similarly high morbidity experienced by both groups of infants. These benchmark data can help align counseling of families with expected outcomes.Level II.Prognosis study (Cohort Study).

OBJECTIVES To determine the epidemiology and microbiology of early-onset sepsis (EOS) among very preterm infants using a nationally representative cohort from academic and community hospitals to inform empirical antibiotic guidance, highlight risk factors for infection, and aid in prognostication for infected infants. METHODS Prospective observational study of very preterm infants born weighing 401 to 1500 g or at 22 to 29 weeks’ gestational age from January 2018 to December 2019 in 753 Vermont Oxford Network centers. EOS was defined as a culture-confirmed bacterial infection of the blood or cerebrospinal fluid in the 3 days after birth. Demographics, clinical characteristics, and outcomes were compared between infants with and without EOS. RESULTS Of 84 333 included infants, 1139 had EOS for an incidence rate of 13.5 per 1000 very preterm births (99% confidence interval [CI] 12.5–14.6). Escherichia coli (538 of 1158; 46.5%) and group B Streptococcus (218 of 1158; 18.8%) were the most common pathogens. Infected infants had longer lengths of stay (median 92 vs 66 days) and lower rates of survival (67.5% vs 90.4%; adjusted risk ratio 0.82 [95% CI 0.79–0.85]) and of survival without morbidity (26.1% vs 59.4%; adjusted risk ratio 0.66 [95% CI 0.60–0.72]). CONCLUSIONS In a nationally representative sample of very preterm infants with EOS from 2018 to 2019, approximately one-third of isolates were neither group B Streptococcus nor E coli. Three-quarters of all infected infants either died or survived with a major medical morbidity. The profoundly negative impact of EOS on very preterm infants highlights the need for novel preventive strategies.

BACKGROUND Patent ductus arteriosus (PDA) treatment is common among very low birth weight (VLBW) infants. Given limitations in evidence, controversy exists regarding treatment risks and benefits. In this study, we describe PDA treatment trends and variation in a large, US, multicenter VLBW infant cohort. METHODS Data were collected through Vermont Oxford Network on 291 292 VLBW infants born 2012–2019 at 806 US NICUs. PDA diagnosis and treatment rates, further categorized as pharmacologic, invasive, or combined, were determined. NICUs were classified as capable versus noncapable of invasive PDA treatment. Infant and hospital characteristics were examined by NICU type and treatment quartile. Geographic NICU distribution and treatment rates were described in 9 US census divisions. RESULTS Of all infants, 24.6% were diagnosed with and 20.5% were treated for PDA. Diagnosis and treatment rates decreased over the study period. Treatment was predominantly pharmacologic. Treatment rates varied widely among NICUs (0% to 67%) despite similar infant characteristics. The median treatment rate was higher at NICUs capable of pharmacologic and invasive treatment (20.3%, interquartile range 13.3–28.6) than at NICUs capable of only pharmacologic treatment (8.9%, interquartile range 2.9–14.8). Treatment rates were highest in the northeast and lowest in the west. Invasive treatment was more common in the west. CONCLUSIONS PDA diagnosis and treatment rates are trending downward. Wide variation exists in PDA treatment despite a largely uniform VLBW infant population. This variation correlates with differences in hospital treatment capabilities and geography. Further understanding of the effects of treatment disparity could aid in guiding clinical management.

BACKGROUND AND OBJECTIVESThe Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary dysplasia (BPD). This study provides the first benchmark epidemiological data applying this definition.METHODSRetrospective cohort study of infants born from 22 to 29 weeks’ gestation in 2018 at 715 US hospitals in the Vermont Oxford Network. Rates of BPD, major neonatal morbidities, and common respiratory therapies, stratified by BPD severity, were determined.RESULTSAmong 24 896 infants, 2574 (10.3%) died before 36 weeks’ postmenstrual age (PMA), 12 198 (49.0%) did not develop BPD, 9192 (36.9%) developed grade 1 or 2 BPD, and 932 (3.7%) developed grade 3 BPD. Rates of mortality before 36 weeks’ PMA and grade 3 BPD decreased from 52.7% and 9.9%, respectively, among infants born at 22 weeks’ gestation to 17.3% and 0.8% among infants born at 29 weeks’ gestation. Grade 1 or 2 BPD peaked in incidence (51.8%) among infants born at 25 weeks’ gestation. The frequency of severe intraventricular hemorrhage or cystic periventricular leukomalacia increased from 4.8% among survivors without BPD to 23.4% among survivors with grade 3 BPD. Similar ranges were observed for late onset sepsis (4.8%–31.4%), surgically treated necrotizing enterocolitis (1.4%–17.1%), severe retinopathy of prematurity (1.2%–23.0%), and home oxygen therapy (2.0%–67.5%).CONCLUSIONSMore than one-half of very preterm infants born in the United States died before 36 weeks’ PMA or developed BPD. Greater BPD severity was associated with more frequent development of major neonatal morbidities, in-hospital mortality, and use of supplemental respiratory support at discharge.

The inequalities in income, wealth, and opportunity so deeply ingrained in our society's history of enslavement, genocide, racism, and discrimination are root causes of health disparities. Follow through is a comprehensive approach that begins before birth and continues into childhood, where health professionals, families, and communities partner to meet the social as well as medical needs of infants and families to achieve health equity. This article discusses potentially better practices for follow through, offering neonatal care providers tangible ways to address social determinants of health, the conditions in which people are born, grow, work, live, and age and the systems that creates these conditions.

Examine whether the quality of Black and Hispanic serving (BHS) compared with not BHS (NBHS) NICUs has changed differentially over time. Infants 24–29 weeks’ gestation born at U.S. Vermont Oxford Network centers (2006–2018) were studied. We calculated adjusted hospital quality scores as the predicted probabilities of composite in-hospital mortality and morbidities from a logistic model. We regressed hospital quality scores on birth year to estimate the linear temporal slope by BHS-serving status for hospitals within each Census division. Hospital quality improved similarly over time for BHS and NBHS hospitals across all divisions except West South Central where a mean change in the composite score was −18.8 (95% CI: −24.1, −13.5) for NBHS and −9.3 (95% CI: −14.1, −4.6) for BHS hospitals (p-value = 0.009). Hospital quality improved similarly for BHS and NBHS hospitals across most divisions. Variation within and between divisions should be a focus for quality improvement.

BACKGROUND: A complex set of medical, social, and financial factors underlie decisions to discharge very preterm infants. As care practices change, whether postmenstrual age and weight at discharge have changed is unknown. METHODS: Between 2005 and 2018, 824 US Vermont Oxford Network member hospitals reported 314 811 infants 24 to 29 weeks’ gestational age at birth without major congenital abnormalities who survived to discharge from the hospital. Using quantile regression, adjusting for infant characteristics and complexity of hospital course, we estimated differences in median age, weight, and discharge weight z score at discharge stratified by gestational age at birth and by NICU type. RESULTS: From 2005 to 2018, postmenstrual age at discharge increased an estimated 8 (compatibility interval [CI]: 8 to 9) days for all infants. For infants initially discharged from the hospital, discharge weight increased an estimated 316 (CI: 308 to 324) grams, and median discharge weight z score increased an estimated 0.19 (CI: 0.18 to 0.20) standard units. Increases occurred within all birth gestational ages and across all NICU types. The proportion of infants discharged home from the hospital on human milk increased, and the proportions of infants discharged home from the hospital on oxygen or a cardiorespiratory monitor decreased. CONCLUSIONS: Gestational age and weight at discharge increased steadily from 2005 to 2018 for survivors 24 to 29 weeks’ gestation with undetermined causes, benefits, and costs.

* Abbreviations: COVID-19 — : coronavirus disease 2019 SARS-CoV-2 — : severe acute respiratory syndrome coronavirus 2 SONPM — : Section on Neonatal-Perinatal Medicine VON — : Vermont Oxford Network Although few newborns infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported,1 the pandemic has affected how hospitals provide care to pregnant women, infants, and families. The severity and variability of this impact are unknown. Vermont Oxford Network (VON), in partnership with the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine (SONPM), conducted an audit in April 2020 to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of newborn infants and families. ### Recruitment and Participation Hospitals were recruited via e-mail. Any hospitals caring for newborn infants was eligible to participate regardless of membership in VON. Each hospital conducted an audit on a single day of their choice using an online tool.2 ### Audit Contents Part 1 identified the census of infants admitted within 28 days of birth, confirmed infant cases, and suspected infant cases on the day of … Address correspondence to Erika M. Edwards, PhD, MPH, Vermont Oxford Network, 33 Kilburn St, Burlington, VT 05401. E-mail: eedwards{at}vtoxford.org

We develop an approach to risk classification based on quantile contours and allometric modelling of multivariate anthropometric measurements. We propose the definition of allometric direction tangent to the directional quantile envelope, which divides ratios of measurements into half-spaces. This in turn provides an operational definition of directional quantile that can be used as cutoff for risk assessment. We show the application of the proposed approach using a large dataset from the Vermont Oxford Network containing observations of birthweight (BW) and head circumference (HC) for more than 150,000 preterm infants. Our analysis suggests that disproportionately growth-restricted infants with a larger HC-to-BW ratio are at increased mortality risk as compared to proportionately growth-restricted infants. The role of maternal hypertension is also investigated., 31 pages, 3 figures, 8 tables

BACKGROUND:Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown.METHODS:The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (RESULTS:Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine.CONCLUSIONS:The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows’ exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.

* Abbreviations: PBP — : potentially better practice QI — : quality improvement In America, health and well-being are, to a large extent, determined by a person’s race, ethnicity, income, immigration status, and neighborhood of residence. Racism, segregation, and inequality of income, opportunity, and wealth cause disparities in health outcomes across the life course.1 The effects are particularly pronounced for infants requiring neonatal intensive care and their families because of the already significant risk for neurodevelopmental disabilities and need for specialized services. As health professionals, pediatricians, and neonatal health care providers, we have the responsibility to address these social determinants of health. We must learn to practice social as well as technical medicine2 and follow-through, accepting that our responsibility to the infants and families we serve extends beyond the hospital or clinic walls. Although in this article we focus on follow-through in the neonatal intensive care setting, the ideas for practicing social medicine we present have wider application in pediatrics, obstetrics, and beyond. We have proposed the term “follow-through” to distinguish our proposal from the more typical neonatal practice of “follow-up” in which the services and staffing of clinics are focused, primarily, on medical conditions and assessment of neurodevelopment after discharge from the NICU. Only 70% of follow-up clinics provide any social services, for example, and

Importance The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals. Objective To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States. Design, Setting, and Participants This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks’ 0 days’ to 25 weeks’ 6 days’ gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45 179 in VON for 2006 to 2012, and 25 969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019. Exposures Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids. Main Outcomes and Measures The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months’ corrected age and measures of hospital resource use (days of hospitalization and ventilator use). Results Among 4176 actively treated infants in the NRN cohort (48% female; mean [SD] gestational age, 24.2 [0.8] weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean [SD] gestational age, 24.2 [0.8] weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45 179 actively treated infants (47% female; mean [SD] gestational age, 24.1 [0.8] weeks) and 70% among 25 969 infants from 2013 to 2016 (48% female; mean [SD] gestational age, 24.1 [0.8] weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age–only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%). Conclusions and Relevance An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.

OBJECTIVES: In this study, we benchmark outcomes and identify factors associated with tracheostomy placement in infants of very low birth weight (VLBW). METHODS: Data were prospectively collected on infants of VLBW (401–1500 g or gestational age of 22–29 weeks) born between 2006 and 2016 and admitted to 796 North American centers. Length of stay (LOS), mortality, associated surgical procedures, and comorbidities were assessed, and infants who received tracheostomy were compared with those who did not. Multivariable logistic regressions were performed to identify risk factors for tracheostomy placement and for mortality in those receiving tracheostomy. RESULTS: Of 458 624 infants of VLBW studied, 3442 (0.75%) received tracheostomy. Infants with tracheostomy had a median (interquartile range) LOS of 226 (168–304) days and a mortality rate of 18.8%, compared with 58 (39–86) days and 8.3% for infants without tracheostomy. Independent risk factors associated with tracheostomy placement included male sex, birth weight CONCLUSIONS: Infants of VLBW receiving tracheostomy had twice the risk of mortality and nearly 4 times the initial LOS of those without tracheostomy. CLD and congenital anomalies were the strongest predictors of tracheostomy placement and mortality. These benchmark data on tracheostomy in infants of VLBW should guide discussions with patient families and inform future studies and interventions.

We sought to describe changes in the incidence and mortality of necrotizing enterocolitis (NEC) and associated surgical management strategies for very low birth weight (VLBW) infants.Data were prospectively collected on VLBW infants (≤1500 g or 29 weeks) born 2006 to 2017 and admitted to 820 U.S. centers. NEC was defined by the presence of at least one clinical and one radiographic finding. Trends analyses were performed to assess changes in incidence and mortality over time.Of 473,895 VLBW infants, 36,130 (7.6%) were diagnosed with NEC, of which 21,051 (58.3%) had medical NEC and 15,079 (41.7%) had surgical NEC. Medical NEC decreased from 5.3% to 3.0% (p 0.0001). Surgical NEC decreased from 3.4% to 3.1% (p = 0.06). Medical NEC mortality decreased from 20.7% to 16.8% (p = 0.003), while surgical NEC mortality decreased from 36.6% to 31.6% (p 0.0001). In the surgical cohort, the use of primary peritoneal drainage (PPD) versus initial laparotomy rose from 23.2% to 46.8%.The incidence and mortality of both medical and surgical NEC have decreased over time. Changes in surgical management during this time period included the increased utilization of primary peritoneal drainage.Prognosis study.Level II.

OBJECTIVES: To determine if NICU teams participating in a multicenter quality improvement (QI) collaborative achieve increased compliance with the Centers for Disease Control and Prevention (CDC) core elements for antibiotic stewardship and demonstrate reductions in antibiotic use (AU) among newborns. METHODS: From January 2016 to December 2017, multidisciplinary teams from 146 NICUs participated in Choosing Antibiotics Wisely, an Internet-based national QI collaborative conducted by the Vermont Oxford Network consisting of interactive Web sessions, a series of 4 point-prevalence audits, and expert coaching designed to help teams test and implement the CDC core elements of antibiotic stewardship. The audits assessed unit-level adherence to the CDC core elements and collected patient-level data about AU. The AU rate was defined as the percentage of infants in the NICU receiving 1 or more antibiotics on the day of the audit. RESULTS: The percentage of NICUs implementing the CDC core elements increased in each of the 7 domains (leadership: 15.4%–68.8%; accountability: 54.5%–95%; drug expertise: 61.5%–85.1%; actions: 21.7%–72.3%; tracking: 14.7%–78%; reporting: 6.3%–17.7%; education: 32.9%–87.2%; P < .005 for all measures). The median AU rate decreased from 16.7% to 12.1% (P for trend < .0013), a 34% relative risk reduction. CONCLUSIONS: NICU teams participating in this QI collaborative increased adherence to the CDC core elements of antibiotic stewardship and achieved significant reductions in AU.

Very low birth weight (VLBW) infants require specialized care in neonatal intensive care units. In the United States (U.S.), such infants frequently are transferred between hospitals. Although these neonatal transfer networks are important, both economically and for infant morbidity and mortality, the national level pattern of neonatal transfers is largely unknown. Using data from Vermont Oxford Network on 44,753 births, 2122 hospitals, and 9722 interhospital infant transfers from 2015, we performed the largest analysis to date on the interhospital transfer network for VLBW infants in the U.S. We find that transfers are organized around regional communities, but that despite being largely within state boundaries, most communities often contain at least two hospitals in different states. To classify the structural variation in transfer pattern amongst these communities, we applied a spectral measure for regionalization and found an association between a community’s degree of regionalization and their infant transfer rate, which was not utilized in detecting communities. We also demonstrate that the established measures of network centrality and hierarchy, e.g., the community-wide entropy in PageRank or betweenness centrality and number of distinct “layers,” within a community, correlate weakly with our regionalization index and were not significantly associated with metrics on infant transfer rate. Our results suggest that the regionalization index captures novel information about the structural properties of VLBW infant transfer networks, have the practical implication of characterizing neonatal care in the U.S., and may apply more broadly to the role of centralizing forces in organizing complex adaptive systems.

This study characterizes neurodevelopmental outcomes and healthcare needs of extremely low birth weight (ELBW) survivors of necrotizing enterocolitis (NEC) compared to ELBW infants without NEC.Data were collected prospectively on neonates born 22-27weeks' gestation or 401-1000g at 47 Vermont Oxford Network member centers from 1999 to 2012. Detailed neurodevelopmental evaluations were conducted at 18-24months corrected age. Information regarding rehospitalizations, postdischarge surgeries, and feeding was also collected. "Severe neurodevelopmental disability" was defined as: bilateral blindness, hearing impairment requiring amplification, inability to walk 10 steps with support, cerebral palsy, and/or Bayley Mental or Psychomotor Developmental Index70. Diagnosis of NEC required both clinical and radiographic findings.There were 9063 children without NEC, 417 with medical NEC, and 449 with surgical NEC evaluated. Significantly higher rates of morbidity were observed among infants with a history of NEC. Those with surgical NEC were more frequently affected across all outcome measures at 18-24months corrected age: 38% demonstrated severe neurodevelopmental disability, nearly half underwent postdischarge operations, and a quarter required tube feeding at home.At 18-24months, extremely low birth weight survivors of necrotizing enterocolitis were at markedly increased risk (p0.001) for severe neurodevelopmental disability, postdischarge surgery, and tube feeding.II (prospective cohort study with80% follow-up rate).

Through standardized data collection, benchmark reporting, clinical trials, and quality improvement, neonatal networks play important roles in prevention, screening, and treatment efforts for retinopathy of prematurity.

Family involvement in newborn intensive care quality improvement dates back to the 1980s. In recent years, there has been an evolution of support for family partnerships at the bedside, transforming parents from being passively present to being active and engaged caregivers and team members. Through those same efforts, a transformational understanding of the power of the family perspective in system design and improvement has occurred. Even with the progression and deepening of this involvement, opportunities exist to learn from families and to improve the quality of neonatal care as a result of the unique family perspective.

To assess progress of neonatal intensive care units (NICUs) participating in the Vermont Oxford Network iNICQ 2015: Alarm Safety Collaborative in achieving Joint Commission 2014 alarm safety goals with respect to oximeters, and to compare patient-level oxygen saturation (SpO2) and oximeter alarm data to local policies. Prospective multicenter audits in February and August 2015 assessed implementation of policies addressing Joint Commission 2014 Alarm Safety goals, and ascertained SpO2 targets, oximeter alarm settings and compliance with policy-specified SpO2 targets and alarms. Eighty-six NICUs completed both audits. Of 13 policies addressing mandated goals, median (interquartile range) 8 (5, 9) policies were implemented at audit 1 and 9 (6, 11) at audit 2 (P=0.004). At audit 1, 28 NICUs had implemented ⩾9 policies versus 47 at audit 2. For 794 infants 97% was less frequent than when high alarm was not set to policy (10.1% vs 21.5%, P=0.006). Participating NICUs showed significant progress between audits in their implementation of Joint Commission Alarm Safety goals for oximeter monitoring. Oximeter high alarm not set per local policy is associated with increased hyperoxemia in preterm infants. Recommendations to standardize oxygen saturation targets for infants at risk for oxygenation-related outcomes have not been widely adopted.

Importance Human milk confers important health benefits to very low-birth-weight (VLBW) infants (≤1500 g). The extent to which the use of human milk has changed over time and the factors associated with human milk use nationally in this population are poorly understood. Objectives To describe US trends in the provision of human milk at hospital discharge for VLBW infants during the past decade according to census region and maternal race/ethnicity, quantify associations of census region and maternal race/ethnicity with the provision of human milk at hospital discharge, and examine regional and state variations in any provision of human milk at hospital discharge among racial/ethnic groups. Design, Setting, and Participants A cohort study was conducted of 346 248 infants, born at 23 to 29 weeks’ gestation or with a birth weight of 401 to 1500 g, who were cared for at 802 US hospitals in the Vermont Oxford Network from January 1, 2008, to December 31, 2017. The US census region was categorized as West, Midwest, Northeast, and South (reference). Maternal race/ethnicity was categorized as non-Hispanic white (reference), non-Hispanic black, Hispanic, Asian and Pacific Islanders, and Native American. Main Outcomes and Measures Any provision of human milk at hospital discharge, defined as the use of human milk as the only enteral feeding or the use of human milk in combination with fortifier or formula. Results Of the 346 248 infants in the study (172 538 boys and 173 710 girls), 46.2% were non-Hispanic white, 30.1% were non-Hispanic black, 18.3% were Hispanic of any race, 4.7% were Asian and Pacific Islanders, and 0.8% were Native American. Any provision of human milk at hospital discharge increased steadily among all infants, from 44% in 2008 to 52% in 2017. There were increases across all US census regions and racial/ethnic groups. Any provision of human milk at hospital discharge was higher in the West (among singleton births: adjusted prevalence ratio, 1.32; 95% CI, 1.25-1.39; among multiple births: adjusted prevalence ratio, 1.28; 95% CI, 1.21-1.35) and Northeast (among singleton births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19; among multiple births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19), compared with the South, and was higher among Asian mothers (among singleton births: adjusted prevalence ratio, 1.21; 95% CI, 1.18-1.25; among multiple births: adjusted prevalence ratio, 1.12; 95% CI, 1.09-1.15) and lower among Hispanic (among singleton births: adjusted prevalence ratio, 0.98; 95% CI, 0.96-1.01; among multiple births: adjusted prevalence ratio, 0.88; 95% CI, 0.86-0.91), Native American (among singleton births: adjusted prevalence ratio, 0.64; 95% CI, 0.59-0.70; among multiple births: adjusted prevalence ratio, 0.59; 95% CI, 0.50-0.69), and non-Hispanic black mothers (among singleton births: adjusted prevalence ratio, 0.67; 95% CI, 0.65-0.70; among multiple births: adjusted prevalence ratio, 0.57; 95% CI, 0.54-0.60), compared with non-Hispanic white mothers. These results were robust to adjustment for birth year and infant characteristics. Wide regional and state variations were found in any provision of human milk at hospital discharge. Conclusions and Relevance Overall prevalence of any provision of human milk at hospital discharge among VLBW infants has steadily increased during the past decade. Disparities by US region and race/ethnicity in the provision of human milk exist and have not diminished over time.

A health care learning community engages providers and families in a collaborative environment to improve outcomes. Vermont Oxford Network (VON), a voluntary organization dedicated to improving the quality, safety and value of care through a coordinated program of data-driven quality improvement, education, and research, is a worldwide learning community in newborn medicine. Through collection of pragmatic structured data items and benchmarking reports, quality improvement collaboratives, pragmatic trials, and observational research, VON facilitates quality improvement by multidisciplinary teams and families in neonatal intensive care units (NICU) in low, middle, and high resource countries. By bringing health professionals and families together across disciplines and geographies to enable shared learning and knowledge dissemination, VON empowers individuals, organizations, and systems to meet the shared vision that every infant around the world can and should achieve their full potential.

Objectives To utilize a large multicenter neonatal cohort to describe survival and clinical outcomes of very low birth weight (VLBW) or preterm infants with ectopia cordis. Study design Data were prospectively collected on 2 211 262 infants (born 2000-2017) from 845 US centers. Both VLBW (401-1500 g or 22-29 weeks of gestation) and non-VLBW (>1500 g and >29 weeks) infants had diagnoses or anatomic descriptors consistent with ectopia cordis and/or pentalogy of Cantrell. The primary outcome was neonatal survival, defined as hospital discharge or initial length of stay of ≥12 months. Results In total, 180 infants had ectopia cordis, 135 (76%) with findings of pentalogy of Cantrell. VLBW infants comprised 52% of the population. VLBW mortality was 96% with 79% dying within 12 hours, compared with 59% and 36%, respectively, for non-VLBW. One-third of VLBW infants received life support compared with 65% of non-VLBW. Surgery was reported for 34% of VLBW and 68% of non-VLBW infants. Congenital heart disease was reported in 8% of VLBW and 36% of non-VLBW, with conotruncal abnormalities most common. Survival exceeded 50% for infants >2500 g and >37 weeks of gestation. Conclusions Survival of VLBW infants with ectopia cordis was poor and substantially worse compared with non-VLBW, with notable discrepancies in resuscitative efforts and surgical interventions. Although gestational age and weight strongly influence current survival, more detailed information regarding the severity of cardiac and noncardiac abnormalities is required to fully determine prognosis and inform counseling.

OBJECTIVES: To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers. METHODS: Infants 22 to 29 weeks’ gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals for African American and Hispanic versus white infants by birth year. We tested temporal differences in mortality and morbidity rates between white and African American or Hispanic infants using a likelihood ratio test on nested binomial regression models. RESULTS: Disparities for certain care practices such as antenatal corticosteroids and for some in-hospital outcomes have narrowed over time for minority infants. Compared with white infants, African American infants had a faster decline for mortality, hypothermia, necrotizing enterocolitis, and late-onset sepsis, whereas Hispanic infants had a faster decline for mortality, respiratory distress syndrome, and pneumothorax. Other morbidities showed a constant rate difference between African American and Hispanic versus white infants over time. Despite the improvements, outcomes including hypothermia, mortality, necrotizing enterocolitis, late-onset sepsis, and severe intraventricular hemorrhage remained elevated by the end of the study period, especially among African American infants. CONCLUSIONS: Racial and ethnic disparities in vital care practices and certain outcomes have decreased. That the quality deficit among minority infants occurred for several care practice measures and potentially modifiable outcomes suggests a critical role for quality improvement initiatives tailored for minority-serving hospitals.

The Textbook of Neonatal Resuscitation, seventh edition, does not suggest routine endotracheal suctioning for non-vigorous infants born through meconium-stained amniotic fluid. We compared 301,150 infants at &ge, 35 weeks&rsquo, gestational age inborn at 311 Vermont Oxford Network member centers in the United States (U.S.) and admitted to neonatal intensive care units (NICU) who were born before (2013 to 2015) and after (2017) the guideline change. Logistic regression models adjusting for clustering of infants within centers were used to calculate risk ratios. NICU admissions for infants with a diagnosis of meconium aspiration syndrome (MAS) decreased from 1.8% to 1.5% (risk ratio: 0.82, 95% confidence interval: 0.68, 0.97) and delivery room endotracheal suctioning in this group decreased from 57.0% to 28.9% (0.51, 0.41, 0.62). Treatment with conventional or high frequency ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation remained unchanged 42.3% vs. 40.3% (0.95, 0.80, 1.13) among infants with MAS and 9.1% vs. 8.2% (0.91, 0.87, 0.95) among infants without MAS. The use of surfactant among infants with MAS increased from 24.6% to 30% (1.22, 1.02, 1.48). Mortality (2.6 to 2.9%, 1.12, 0.74, 1.69) and moderate/severe hypoxic-ischemic encephalopathy (5.4 to 6.8%, 1.24, 0.91, 1.69) increased slightly in 2017. Subgroup analyses of infants with 1 min Apgar scores of &le, 3 found similar results. While NICU admissions for MAS and tracheal suctioning decreased after the introduction of the new guideline with no subsequent increase in severe respiratory distress among infants with and without a MAS diagnosis, limitations in our study preclude inferring that the new guideline is safe or effective.

BACKGROUND: The Antimicrobial Use (AU) Option of the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) is a surveillance resource that can provide actionable data for antibiotic stewardship programs. Such data are used to enable measurements of AU across hospitals and before, during, and after stewardship interventions. METHODS: We used monthly AU data and annual facility survey data submitted to the NHSN to describe hospitals and neonatal patient care locations reporting to the AU Option in 2017, examine frequencies of most commonly reported agents, and analyze variability in AU rates across hospitals and levels of care. We used results from these analyses in a collaborative project with Vermont Oxford Network to develop neonatal-specific Standardized Antimicrobial Administration Ratio (SAAR) agent categories and neonatal-specific NHSN Annual Hospital Survey questions. RESULTS: As of April 1, 2018, 351 US hospitals had submitted data to the AU Option from at least 1 neonatal unit. In 2017, ampicillin and gentamicin were the most frequently reported antimicrobial agents. On average, total rates of AU were highest in level III NICUs, followed by special care nurseries, level II-III NICUs, and well newborn nurseries. Seven antimicrobial categories for neonatal SAARs were created, and 6 annual hospital survey questions were developed. CONCLUSIONS: A small but growing percentage of US hospitals have submitted AU data from neonatal patient care locations to NHSN, enabling the use of AU data aggregated by NHSN as benchmarks for neonatal antimicrobial stewardship programs and further development of the SAAR summary measure for neonatal AU.