Search

Objective: Clinical decision support tools (CDSTs) are common in neonatology, but utilization is rarely examined. We examined the utilization of four CDSTs in newborn care. Study Design: A 72-field needs assessment was developed. It was distributed to listservs encompassing trainees, nurse practitioners, hospitalists, and attendings. At the conclusion of data collection, responses were downloaded and analyzed. Results: We received 339 fully completed questionnaires. BiliTool and the EOS tool were used by > 90% of respondents, the BPD tool by 39%, and the EPB tool by 72%. Common reasons CDSTs did not impact clinical care included lack of electronic health record (EHR) integration, lack of confidence in prediction accuracy, and unhelpful predictions. Conclusion: From a national sample of neonatal care providers, there is frequent but variable use of four CDSTs. Understanding the factors that contribute to tool utility is vital prior to development and implementation.

Objective To characterize demographics and trends in length of stay (LOS), morbidities, and mortality in late preterm infants. Study design Cohort study of infants born between 34 0/7 and 36 6/7 weeks gestation between 1999 and 2018 without major congenital anomalies at Pediatrix Medical Group neonatal intensive care units (NICUs). Results 307 967 infants from 410 NICUs met inclusion criteria. The median (25th -75th percentile) LOS was 11 (8–16) days in the entire period. Postmenstrual age (PMA) at discharge increased over time for all gestational ages (p

ObjectivesTo ascertain parental perceptions of the impact of restricted visiting policies to neonatal intensive care units during the current COVID-19 pandemic.DesignCross-sectional survey of parents impacted by visitation policies.SettingSix tertiary level neonatal units, four from the UK and two from the USA, participated in the study.ParticipantsParents and families of infants hospitalised in the participating centres between 1 May 2020 and 21 August 2020.MethodsOnline-based and/or paper-based survey, querying the visitation policies and their impact on parents’ ability to visit, care for and bond with their infants.ResultsA total of 231 responses were received. Visitation limited to a single visitor with no restrictions on duration was the most frequently reported policy; 140/217 (63%). Visitation policies were perceived as being restrictive by 62% (138/219) of the respondents with 37% (80/216) reporting being able to visit less often than desired, 41% (78/191) reporting being unable to bond enough and 27% (51/191) reporting not being able to participate in their baby’s daily care. Mild to severe impact on breast feeding was reported by 36% (75/209) of respondents. Stricter policies had a higher impact on families and were significantly associated with a lack of bonding time, inability to participate in care and an adverse impact on breast feeding.ConclusionsVisitation policies during the COVID-19 pandemic varied between centres and over time with stricter restrictions implemented earlier on in the pandemic. Parents reported significant impacts on their ability to visit, care for and bond with their infants with perceived severity of impact worse with stricter restrictions.

Objective Identify the progression of specific signs of multiorgan dysfunction among infants with fatal sepsis. Study Design Cohort study of 679 infants who died within 3 days of the start of a late-onset sepsis (LOS) episode in neonatal intensive care units from 1997 to 2012. We extracted clinical and laboratory data on the day of death (day 0) and the preceding 5 days (days −5 to −1). Results Median (25th percentile–75th percentile) gestational age was 25 (24–28) weeks. Compared with day −1, day 0 was characterized by an increased requirement for mechanical ventilation and higher mean fraction of inspired oxygen. Measures of cardiorespiratory support and the proportion of infants with neutropenia began to rise on day −2. Conclusion Hospitalized infants with fatal LOS manifest respiratory, cardiovascular, renal, immune, and hematologic dysfunction. Knowledge of these factors and their timing may be important for the development and testing of novel therapeutics to reduce sepsis mortality.

In cases of severe respiratory failure, cardiopulmonary bypass has been used as support until cardiac and pulmonary recovery occurs. We report the Wilford Hall USAF Medical Center experience with extracorporeal membrane oxygenation (ECMO) and its associated complications. From July 1985 to March 1989, 57 neonates were placed on membrane oxygenators. The overall survival was 79%. Technical complications encountered included catheter-related problems, mechanical complications of the pump apparatus, and hemorrhage. Hemorrhagic complications were the most frequent and devastating complications encountered. Intracranial hemorrhage accounted for six deaths associated with bypass. Extracorporeal membrane oxygenation is successful in significantly improving survival of neonates whose predicted mortality approaches 100% with conventional treatment. The rate of infant mortality using the membrane oxygenator is not affected by technical complications related to catheter position, mechanical problems with the circuit, or hemorrhage, excluding intracranial hemorrhage. The major cause of death of infants receiving extracorporeal membrane oxygenation is the underlying disease process leading to cardiopulmonary failure.

Objective Preterm rupture of membranes (PROM) is associated with an increased risk of preterm birth and neonatal morbidity. Prophylactic 17-hydroxyprogesterone caproate (17OHP-C) reduces the risk of preterm birth in some women who are at risk for preterm birth. We sought to test whether 17OHP-C would prolong pregnancy or improve perinatal outcome when given to mothers with preterm rupture of the membranes. Study Design This is a multicenter, double-blind, placebo-controlled, randomized clinical trial. The study included singleton pregnancies with gestational ages from 23 0/7 to 30 6/7 weeks at enrollment, documented PROM, and no contraindication to expectant management. Consenting women were assigned randomly to receive weekly intramuscular injections of 17OHP-C (250 mg) or placebo. The primary outcome was continuation of pregnancy until a favorable gestational age, which was defined as either 34 0/7 weeks of gestation or documentation of fetal lung maturity at 32 0/7 to 33 6/7 weeks of gestation. The 2 prespecified secondary outcomes were interval from randomization to delivery and composite adverse perinatal outcome. The planned sample size was 222 total women. Results From October 2011 to April 2014, 152 women were enrolled; 74 women were allocated randomly to 17OHP-C, and 78 were allocated randomly to placebo. The trial was stopped when results of a planned interim analysis suggested that continuation was futile. The primary outcome was achieved in 3% of the 17OHP-C group and 8% of the placebo group ( P = .18). There was no significant between-group difference in the prespecified secondary outcomes, randomization-to-delivery interval (17.1 ± 16.1 vs 17.0 ± 15.8 days, respectively; P = .76) or composite adverse perinatal outcome (63% vs 61%, respectively; P = .93). No significant differences were found in other outcomes, which included rates of chorioamnionitis, postpartum endometritis, cesarean delivery, individual components of the composite outcome, or prolonged neonatal length of stay. Conclusion Compared with placebo, weekly 17OHP-C injections did not prolong pregnancy or reduce perinatal morbidity in patients with PROM in this trial.

Background. In biophysical and animal testing, Infasurf develops lower surface tension and restores total surfactant activity better than Survanta. Methods. We performed 2 prospective, randomized, masked clinical trials; 1 trial used a prophylactic strategy aimed at prevention of respiratory distress syndrome (prophylaxis trial) for infants who were born between 23 weeks, 0 days and 29 weeks, 6 days of gestation, and the second trial used a treatment strategy (treatment trial) for intubated infants with a birth weight of 401 to 2000 g who required fractional inspired oxygen of >0.4 to maintain an arterial oxygen saturation of >90% (or an arterial/alveolar oxygen ratio of 0.30 to maintain an arterial oxygen saturation of >90% (or an arterial/alveolar oxygen ratio of 0.33) and the infant remained intubated for respiratory distress syndrome. Results. Both trials were halted for not meeting enrollment targets after a 32-month recruitment period. The decision to end recruitment was made after the interim analysis of the treatment trial. We enrolled 749 infants in the prophylaxis trial and 1361 infants in the treatment trial. The primary outcome (alive and not receiving supplemental oxygen at 36 weeks' postmenstrual age) rate in the prophylaxis trial was 52.1% for group 1 and 52.4% for group 2. In the treatment trial, the primary outcome rate was 58.7% in group 1 and 56.8% in group 2. Based on sample-size requirements for a conclusion of similarity, and the lack of statistical significance to the differences noted in the primary outcome, we have chosen not to break the investigator blind but to report the results as groups 1 and 2. Conclusion. Early trial closure prevents us from either accepting or rejecting our null hypothesis.

Experience with 17 open lung biopsies in critically ill premature neonates was reviewed. Despite their small size, prematurity, and near maximal ventilator requirements, the infants suffered no significant complications. In three cases, an infectious agent was identified. In one case end-stage lung fibrosis associated with persistent (>3 months), severe respiratory failure prompted termination of support. In the remainder of the cases, definitively ruling out infection allowed the confident trial of a course of steroids in an attempt to treat bronchopulmonary dysplasia. Unlike older patients, the definitive diagnosis of no infection in the premature neonate is just as informative as the diagnosis of an infection. Used judiciously, open lung biopsy can be performed in the premature infant with acceptable morbidity and mortality.

Previous studies using repetitive courses of antenatal corticosteroids (ACS) have demonstrated marginal or no benefit and concern over potential risk. No prior prospective or randomized studies have evaluated the option of a single rescue course of ACS on neonatal outcome.A multicenter randomized double-blind placebo-controlled trial was performed from May 2003 through February 2008 in 18 private (15) and university (3) medical centers. Patients with singletons or twins33 weeks who had completed a single course of ACS before 30 weeks and at least 14 days before inclusion, and were judged to have a recurring threat of preterm delivery in the coming week, were included. Patients were randomized to receive a single rescue course of betamethasone, 2 12-mg doses 24 hours apart, or placebo. Exclusion criteria included: premature rupture of membranes, advanced dilation (5 cm), chorioamnionitis, and other steroid use.In all, 437 patients were randomized (223 rescue steroid group and 214 placebo group). A total of 55% of patients in each group delivered at34 weeks. There was a significant reduction in the primary outcome of composite neonatal morbidity34 weeks in the rescue steroid group vs placebo (43.9% vs 63.6%; odds ratio, 0.45; 95% confidence interval, 0.27-0.75; P = .002) and significantly decreased respiratory distress syndrome, ventilator support, and surfactant use. Perinatal mortality and other morbidities were similar in each group. Including all neonates in the analysis (regardless of gestational age at delivery) still demonstrated a significant reduction in composite morbidity in the rescue course group (32.1% vs 42.6%, odds ratio, 0.65; 95% confidence interval, 0.44-0.97; P = .0034) and improvement in respiratory morbidities.Administration of a single rescue course of ACS before 33 weeks improves neonatal outcome without apparent increased short-term risk.

OBJECTIVE: To determine the immunologic effects of oropharyngeal colostrum administration in extremely premature infants. METHODS: We conducted a double-blind, randomized, placebo-controlled trial involving 48 preterm infants born before 28 weeks’ gestation. Subjects received 0.2 mL of their mother’s colostrum or sterile water via oropharyngeal route every 3 hours for 3 days beginning at 48 to 96 hours of life. To measure concentrations of secretory immunoglobulin A, lactoferrin, and several immune substances, urine and saliva were obtained during the first 24 hours of life and at 8 and 15 days. Clinical data during hospitalization were collected. RESULTS: Urinary levels of secretory immunoglobulin A at 1 week (71.4 vs 26.5 ng/g creatinine, P = .04) and 2 weeks (233.8 vs 48.3 ng/g creatinine, P = .006), and lactoferrin at 1 week (3.5 vs 0.9 μg/g creatinine, P = .01) were significantly higher in colostrum group. Urine interleukin-1β level was significantly lower in colostrum group at 2 weeks (55.3 vs 91.8 μg/g creatinine, P = .01). Salivary transforming growth factor-β1 (39.2 vs 69.7 μg/mL, P = .03) and interleukin-8 (1.2 vs 4.9 ng/mL, P = .04) were significantly lower at 2 weeks in colostrum group. A significant reduction in the incidence of clinical sepsis was noted in colostrum group (50% vs 92%, P = .003). CONCLUSIONS: This study suggests that oropharyngeal administration of colostrum may decrease clinical sepsis, inhibit secretion of pro-inflammatory cytokines, and increase levels of circulating immune-protective factors in extremely premature infants. Larger studies to confirm these findings are warranted.