Changes in preterm birth during the COVID-19 pandemic by duration of exposure and race and ethnicity

OBJECTIVE

We aimed to determine whether coronavirus-disease-2019 (COVID-19) pandemic exposure duration was associated with PTB and if the pandemic modified racial disparities.

STUDY DESIGN

We analyzed Philadelphia births and replicated in New Haven. Compared to matched months in two prior years, we analyzed overall PTB, specific PTB phenotypes, and stillbirth.

RESULTS

Overall, PTB was similar between periods with the following exceptions. Compared to pre-pandemic, early pregnancy (<14 weeks') pandemic exposure was associated with lower risk of PTB < 28 weeks' (aRR 0.60 [0.30-1.10]) and later exposure with higher risk (aRR 1.77 [0.78-3.97]) (interaction p = 0.04). PTB < 32 weeks' among White patients decreased during the pandemic, resulting in non-significant widening of the Black-White disparity from aRR 2.51 (95%CI: 1.53-4.16) to aRR 4.07 (95%CI: 1.56-12.01) (interaction P = 0.41). No findings replicated in New Haven.

CONCLUSION

We detected no overall pandemic effects on PTB, but potential indirect benefits for some patients which could widen disparities remains possible.

The Uptake of Telemedicine in Obstetric Care During the Early Acute Phase of the Coronavirus 2019 Pandemic

Introduction: The early acute phase of the coronavirus disease 2019 pandemic created rapid adaptation in health care delivery. Methods: Using electronic medical record data from two different institutions located in two different states, we examined how telemedicine was integrated into obstetric care. Results: With no telemedicine use prior, both institutions rapidly incorporated telemedicine into prenatal care (PNC). There were significant patient-level and institutional-level differences in telemedicine use. Telemedicine users initiated PNC earlier and had more total visits, earlier timing of ultrasounds, and earlier diabetes screening during pregnancy compared with nonusers. There were no significant differences in delivery mode or stillbirth associated with telemedicine use at either institution. Conclusions: Rapid adoption of obstetric telemedicine maintained adequate prenatal care provision during the early pandemic, but implementation varied across institutions.

Growth failure in infants with neonatal abstinence syndrome in the neonatal intensive care unit

OBJECTIVE

To assess if infants with neonatal abstinence syndrome (NAS) are smaller at birth and have decreased growth parameters between birth and discharge from the neonatal intensive care unit (NICU).

METHODS

Retrospective data analysis of term/late-preterm neonates with NAS at a single-center NICU between September 2006 and May 2018. Growth parameters (weight, length, HC) were measured at birth and discharge. Z scores and percentiles were calculated using WHO standard growth curves.

RESULTS

A total of 864 infants ≥35 weeks were admitted for NAS. At birth, median percentiles were weight 30%, HC 23%, and length 37%; these decreased significantly (p < 0.001) at discharge to 12%, 6.5%, and 13%, respectively. The percentage of infants <3rd percentile increased significantly (p < 0.001) in all growth parameters from birth to discharge.

CONCLUSION

Infants with NAS are smaller at birth and have significant growth retardation in all growth parameters at discharge. An ongoing long-term growth follow-up study will discern the impact of growth restriction in NAS infants.

Birth Hospital Length of Stay and Rehospitalization During COVID-19

OBJECTIVES

To determine if birth hospitalization length of stay (LOS) and infant rehospitalization changed during the coronavirus disease 2019 (COVID-19) era among healthy, term infants.

METHODS

Retrospective cohort study using Epic's Cosmos data from 35 health systems of term infants discharged ≤5 days of birth. Short birth hospitalization LOS (vaginal birth <2 midnights; cesarean birth <3 midnights) and, secondarily, infant rehospitalization ≤7 days after birth hospitalization discharge were compared between the COVID-19 (March 1 to August 31, 2020) and prepandemic eras (March 1 to August 31, 2017, 2018, 2019). Mixed-effects models were used to estimate adjusted odds ratios (aORs) comparing the eras.

RESULTS

Among 202 385 infants (57 110 from the COVID-19 era), short birth hospitalization LOS increased from 28.5% to 43.0% for all births (vaginal: 25.6% to 39.3%, cesarean: 40.1% to 61.0%) during the pandemic and persisted after multivariable adjustment (all: aOR 2.30, 95% confidence interval [CI] 2.25-2.36; vaginal: aOR 2.12, 95% CI 2.06-2.18; cesarean: aOR 3.01, 95% CI 2.87-3.15). Despite shorter LOS, infant rehospitalizations decreased slightly during the pandemic (1.2% to 1.1%); results were similar in adjusted analysis (all: aOR 0.83, 95% CI 0.76-0.92; vaginal: aOR 0.82, 95% CI 0.74-0.91; cesarean: aOR 0.87, 95% CI 0.69-1.10). There was no change in the proportion of rehospitalization diagnoses between eras.

CONCLUSIONS

Short infant LOS was 51% more common in the COVID-19 era, yet infant rehospitalization within a week did not increase. This natural experiment suggests shorter birth hospitalization LOS among family- and clinician-selected, healthy term infants may be safe with respect to infant rehospitalization, although examination of additional outcomes is needed.

Changes in prenatal testing during the COVID-19 pandemic

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare delivery, including prenatal care. The study objective was to assess if timing of routine prenatal testing changed during the COVID-19 pandemic.

METHODS

Retrospective observational cohort study using claims data from a regional insurer (Highmark) and electronic health record data from two academic health systems (Penn Medicine and Yale New Haven) to compare prenatal testing timing in the pre-pandemic (03/10/2018-12/31/2018 and 03/10/2019-12/31/2019) and early COVID-19 pandemic (03/10/2020-12/31/2020) periods. Primary outcomes were second trimester fetal anatomy ultrasounds and gestational diabetes (GDM) testing. A secondary analysis examined first trimester ultrasounds.

RESULTS

The three datasets included 31,474 pregnant patients. Mean gestational age for second trimester anatomy ultrasounds increased from the pre-pandemic to COVID-19 period (Highmark 19.4 vs. 19.6 weeks; Penn: 20.1 vs. 20.4 weeks; Yale: 18.8 vs. 19.2 weeks, all p < 0.001). There was a detectable decrease in the proportion of patients who completed the anatomy survey <20 weeks' gestation across datasets, which did not persist at <23 weeks' gestation. There were no consistent changes in timing of GDM screening. There were significant reductions in the proportion of patients with first trimester ultrasounds in the academic institutions (Penn: 57.7% vs. 40.6% and Yale: 78.7% vs. 65.5%, both p < 0.001) but not Highmark. Findings were similar with multivariable adjustment.

CONCLUSION

While some prenatal testing happened later in pregnancy during the pandemic, pregnant patients continued to receive appropriately timed testing. Despite disruptions in care delivery, prenatal screening remained a priority for patients and providers during the COVID-19 pandemic.

Coronavirus Disease 2019 (COVID-19) Pandemic and Pregnancy Outcomes in a U.S. Population

OBJECTIVE

To examine whether the coronavirus disease 2019 (COVID-19) pandemic altered risk of adverse pregnancy-related outcomes and whether there were differences by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection status among pregnant women.

METHODS

In this retrospective cohort study using Epic's Cosmos research platform, women who delivered during the pandemic (March-December 2020) were compared with those who delivered prepandemic (matched months 2017-2019). Within the pandemic epoch, those who tested positive for SARS-CoV-2 infection were compared with those with negative test results or no SARS-CoV-2 diagnosis. Comparisons were performed using standardized differences, with a value greater than 0.1 indicating meaningful differences between groups.

RESULTS

Among 838,489 women (225,225 who delivered during the pandemic), baseline characteristics were similar between epochs. There were no significant differences in adverse pregnancy outcomes between epochs (standardized difference<0.10). In the pandemic epoch, 108,067 (48.0%) women had SARS-CoV-2 testing available; of those, 7,432 (6.9%) had positive test results. Compared with women classified as negative for SARS-CoV-2 infection, those who tested positive for SARS-CoV-2 infection were less likely to be non-Hispanic White or Asian or to reside in the Midwest and more likely to be Hispanic, have public insurance, be obese, and reside in the South or in high social vulnerability ZIP codes. There were no significant differences in the frequency of preterm birth (8.5% vs 7.6%, standardized difference=0.032), stillbirth (0.4% vs 0.4%, standardized difference=-0.002), small for gestational age (6.4% vs 6.5%, standardized difference=-0.002), large for gestational age (7.7% vs 7.7%, standardized difference=-0.001), hypertensive disorders of pregnancy (16.3% vs 15.8%, standardized difference=0.014), placental abruption (0.5% vs 0.4%, standardized difference=0.007), cesarean birth (31.2% vs 29.4%, standardized difference=0.039), or postpartum hemorrhage (3.4% vs 3.1%, standardized difference=0.019) between those who tested positive for SARS-CoV-2 infection and those classified as testing negative.

CONCLUSION

In a geographically diverse U.S. cohort, the frequency of adverse pregnancy-related outcomes did not differ between those delivering before compared with during the pandemic, nor between those classified as positive compared with negative for SARS-CoV-2 infection during pregnancy.

Management of infants born to mothers with chorioamnionitis: A retrospective comparison of the three approaches recommended by the committee on fetus and newborn

BACKGROUND

Based on the most recently published recommendations from the Committee on the Fetus and Newborn (COFN), three approaches currently exist for the use of risk factors to identify infants who are at increased risk of early-onset sepsis (EOS). Categorical risk factor assessments recommend laboratory testing and empiric antibiotic therapy for all infants born to mothers with a clinical diagnosis of chorioamnionitis. Risk assessments based on clinical condition recommend frequent examinations and close vital sign monitoring for infants born to mothers with chorioamnionitis. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, multivariate risk assessments. The aim of our study was to compare the three risk stratification approaches recommended by the COFN for management of chorioamnionitis-exposed infants.

METHODS

Retrospective study of 1,521 infants born ≥35 weeks to mothers with chorioamnionitis. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition (CCA).

RESULTS

Hypothetical application of SRC and CCA resulted in 79.6% and 76.8-85.1% respectively fewer infants allocated empiric antibiotic therapy. While CCA recommended enhanced observation for all chorioamnionitis-exposed infants, SRC recommended routine care without enhanced observation in 44.3% infants. For the six infants (0.39%) with EOS, SRC and CCA recommended empiric antibiotics only for three symptomatic infants.

CONCLUSION

The SRC and CCA can reduce antibiotic use but potentially delay antibiotic treatment. The SRC does not recommend enhanced observation with frequent and prolonged vital signs for >44% of chorioamnionitis-exposed infants.

DNA Methylation Profile in Human Cord Blood Mononuclear Leukocytes From Term Neonates: Effects of Histological Chorioamnionitis

Background: Histological chorioamnionitis (HCA) is an infection/inflammation of fetal membranes and complicates 5.2-28.5% of all live births. Exposure to HCA can have long-term consequences including abnormal neurodevelopment and an increased risk for allergic disorders and asthma later in childhood. HCA may incite epigenetic changes, which have the potential to modulate both the immune and neurological systems as well as increase the risk of related disorders later in life. However, there is limited data on the impact of HCA on epigenetics, in particular DNA methylation, and changes to immune and neurological systems in full-term human neonates. Objective: To determine differential DNA methylation in cord blood mononuclear leukocytes from neonates exposed to HCA. Methods: Cord blood was collected from 10 term neonates (5 with HCA and 5 controls without HCA) and mononuclear leukocytes were isolated. Genome-wide DNA methylation screening was performed on Genomic DNA extracted from mononuclear leukocytes. Results: Mononuclear leukocytes from cord blood of HCA-exposed neonates showed differential DNA methylation of 68 probe sets compared to the control group (44 hypermethylated, 24 hypomethylated) with a p ≤ 0.0001. Several genes involved in immune modulation and nervous system development were found to be differentially methylated. Important canonical pathways as revealed by Ingenuity Pathway Analysis (IPA) were CREB Signaling in Neurons, FcγRIIB Signaling in B Lymphocytes, Cell Cycle: G1/S Checkpoint Regulation, Interleukin-1, 2, 3, 6, 8, 10, 17, and 17A signaling, p53 signaling, dopamine degradation, and serotonin degradation. The diseases and disorders picked up by IPA were nervous system development and function, neurological disease, respiratory disease, immune cell trafficking, inflammatory response, and immunological disease. Conclusions: HCA induces differential DNA methylation in cord blood mononuclear leukocytes. The differentially methylated genes may contribute to inflammatory, immunological and neurodevelopmental disorders in neonates exposed to HCA.

Influence of Patient Characteristics on Antibiotic Use Rates Among Preterm Infants

BACKGROUND

The antibiotic use rate (AUR) has emerged as a potential metric for neonatal antibiotic use, but reported center-level AURs are limited by differences in case mix. The objective of this study was to identify patient characteristics associated with AUR among a large cohort of preterm infants.

METHODS

Retrospective observational study using the Optum Neonatal Database, including infants born from January 1, 2010 through November 30, 2016 with gestational age 23-34 weeks admitted to neonatal units across the United States. Exposures were patient-level characteristics including length of stay, gestational age, sex, race/ethnicity, bacterial sepsis, necrotizing enterocolitis, and survival status. The primary outcome was AUR, defined as days with ≥ 1 systemic antibiotic administered divided by length of stay. Descriptive statistics, univariable comparative analyses, and generalized linear models were utilized.

RESULTS

Of 17 910 eligible infants, 17 836 infants (99.6%) from 1090 centers were included. Median gestation was 32.9 (interquartile range [IQR], 30.3-34) weeks. Median length of stay was 25 (IQR, 15-46) days and varied by gestation. Overall median AUR was 0.13 (IQR, 0-0.26) and decreased over time. Gestational age, sex, and race/ethnicity were independently associated with AUR (P < .01). AUR and gestational age had an unexpected inverse parabolic relationship, which persisted when only surviving infants without bacterial sepsis or necrotizing enterocolitis were analyzed.

CONCLUSIONS

Neonatal AURs are influenced by patient-level characteristics besides infection and survival status, including gestational age, sex, and race/ethnicity. Neonatal antibiotic use metrics that account for patient-level characteristics as well as morbidity case mix may allow for more accurate comparisons and better inform neonatal antibiotic stewardship efforts.

Use of a Modified Early-Onset Sepsis Risk Calculator for Neonates Exposed to Chorioamnionitis

OBJECTIVE

To validate the recently modified Kaiser Permanente early-onset sepsis (EOS) calculator with a higher baseline incidence in chorioamnionitis exposed neonates.

STUDY DESIGN

This is a retrospective study of chorioamnionitis-exposed neonates born at ≥35 weeks of gestation with a known EOS incidence of 4.3/1000. The risk and management categories were calculated using the calculator with an incidence of 4/1000. The results were compared with a previous analysis of the same cohort that used an EOS incidence of 0.5/1000.

RESULTS

In our sample, the EOS calculator recommends at least a blood culture in 834 of 896 (93.1%) and empiric antibiotics in 533 of 896 (59.5%) chorioamnionitis-exposed neonates when using an EOS incidence of 4/1000. This captures 5 of 5 neonates (100%) with EOS. When using a baseline EOS incidence of 0.5/1000, the calculator recommends at least a blood culture in only 289 of 896 (32.2%) and empiric antibiotics in only 209 of 896 (23.3%) neonates, but fails to recommend empiric antibiotics in 2 of 5 neonates with EOS (40%).

CONCLUSIONS

When using an EOS risk of 4 of 1000 in infants exposed to mothers with chorioamnionitis, the EOS calculator has the ability to capture an increased number of neonates with culture-positive EOS. However, this change also leads to nearly a 3-fold increase in the use of empiric antibiotics and an evaluation with blood culture in almost all infants born to mothers with chorioamnionitis.

Hypertensive disorders during pregnancy are associated with reduced severe intraventricular hemorrhage in very-low-birth-weight infants

OBJECTIVE

To determine differences in severe intraventricular hemorrhage (IVH) between very-low-birth-weight (≤1500 g, VLBW) infants born to mothers with and without hypertensive disorders (HD).

DESIGN/METHODS

Retrospective analysis from the Optum Neonatal Database. The primary outcome of interest was severe IVH (grade 3 or 4). Secondary outcomes included other neonatal morbidities, mortality, and length of hospitalization. Outcomes were compared between VLBW infants born to mothers with and without HD.

RESULTS

A total of 5456 infants met inclusion criteria. After multivariable regression analysis, risks of severe IVH and bronchopulmonary dysplasia (BPD) were lower ([OR 0.42, 95% CI 0.33-0.89, p = 0.01] and [OR 0.75, 95% CI 0.58-0.97, p = 0.03], respectively) and median length of hospitalization was decreased in the HD group (49 versus 61 days, p < 0.001).

CONCLUSIONS

VLBW infants born to mothers with HD have a decreased risk of severe IVH, BPD, and a shorter duration of hospitalization.

Apgar Scores at 10 Minutes and Outcomes in Term and Late Preterm Neonates with Hypoxic-Ischemic Encephalopathy in the Cooling Era

OBJECTIVE

To determine the short-term outcomes (abnormal brain magnetic resonance imaging [MRI]/death) in infants born with a 10-minute Apgar score of 0 who received therapeutic hypothermia and compare them with infants with higher scores.

STUDY DESIGN

This is a retrospective review of 293 neonates (gestational age ≥ 35 weeks) born between November 2006 and October 2015 admitted with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. Results of brain MRIs were assessed by the basal ganglia/watershed scoring system. Short-term outcomes were compared between infants with Apgar scores of 0, 1 to 4, and ≥5 at 10 minutes.

RESULTS

Eight of 17 infants (47%) with an Apgar of 0 at 10 minutes survived, having 4 (24%) without abnormalities on the brain MRI and 7 (41%) without severe abnormalities. There was no significant difference in the combined outcomes of "death/abnormal MRI" and "death/severe abnormalities on the MRI" between infants with Apgar scores of 0 and 1 to 4. Follow-up data were available for six of eight surviving infants, and none had moderate or severe neurodevelopmental impairment.

CONCLUSION

In the cooling era, 47% of infants with no audible heart rate at 10 minutes and who were admitted to the neonatal intensive care unit survived; 24% without abnormalities on the brain MRI and 41% without severe abnormalities.

Exclusive breast feeding and dehydration fever in newborns during the first days of life

Objectives: To determine the prevalence of dehydration fever in infants admitted to the Neonatal Intensive Care Unit (NICU) from the well newborn nursery with fever in the first days of life.Study design: Retrospective data analysis of term infants admitted to the NICU from the well newborn nursery with fever (n = 75). Infants were divided into two groups based on hydration status using clinical and laboratory signs of dehydration. Clinical and laboratory variables were compared between the two groups.Results: Fifty-three of the 75 infants admitted to the NICU with fever had clinical and laboratory signs of dehydration (71%). Infants with dehydration were more likely to be exclusively breast fed and present with fever at >24 h of age. There were no positive blood or cerebrospinal fluid cultures in infants with dehydration. The incidence of dehydration fever increased after implementation of an "Exclusive Breast Feeding" policy from 1.4/1000 to 3.5/1000 live births (p ≤ .01).Conclusions: Dehydration is associated with fever in exclusively breast fed infants during the first several days of life. There were no cases of serious bacterial or viral infections in the cohort of febrile infants with clinical and laboratory signs of dehydration.

Association between early antibiotic exposure and bronchopulmonary dysplasia or death

OBJECTIVE

To characterize the independent association between antibiotic exposure in the first week of life and the risk of bronchopulmonary dysplasia (BPD) or death among very preterm infants without culture-confirmed sepsis.

METHODS

Retrospective cohort study using the Optum Neonatal Database. Infants without culture-confirmed sepsis born less than 1500 g and less than 32 weeks gestation between 1/2010 and 11/2016 were included. The independent association between antibiotic therapy during the first week of life and BPD or death prior to 36 weeks postmenstrual age (PMA) was assessed by multivariable logistic regression.

RESULTS

Of 4950 infants, 3946 (79.7%) received antibiotics during the first week of life. Rates of BPD or death (41.5% vs. 31.1%, p < 0.001) and the two individual outcomes were significantly higher among antibiotic treated infants. After adjusting for potential confounding variables, antibiotic use in the first week of life was not associated with increased risk of BPD or death (OR 0.96, 95% CI [0.76,1.21]) or BPD among survivors (OR 0.86, 95% CI [0.67,1.09]). Antibiotic use was associated with increased risk of death prior to 36 weeks PMA (OR 3.01, 95% CI [1.59,5.71]), however, secondary analyses suggested this association may be confounded by unmeasured illness severity.

CONCLUSIONS

Antibiotic exposure in the first week of life among preterm infants without culture-confirmed sepsis was not independently associated with increased risk of BPD or death.

Utility of Early-Onset Sepsis Risk Calculator for Neonates Born to Mothers with Chorioamnionitis

OBJECTIVES

To evaluate the performance of the early-onset sepsis (EOS) risk calculator in a cohort of neonates born to mothers with clinical chorioamnionitis, and to compare the diagnostic utility of the EOS calculator, clinical signs, and laboratory evaluations for correctly identifying EOS in this cohort.

STUDY DESIGN

This was a retrospective study of neonates born at ≥35 weeks of gestation to mothers with chorioamnionitis. The risk and management categories for all neonates were calculated using the EOS calculator, and these results were analyzed and compared with laboratory data and clinical signs.

RESULTS

Of the 1159 neonates born to mothers with chorioamnionitis, 5 (0.43%) had culture-proven EOS. Data for calculation of EOS risk were available for 896 neonates, including the 5 neonates with culture-proven EOS. The management recommendation based on the calculator was no empiric antibiotic treatment for 67% of the neonates, including 2 of the 5 with EOS. All neonates with culture-proven EOS had abnormal complete blood counts and C-reactive protein levels at 6-12 hours. Three of the 5 neonates with EOS had clinical signs of sepsis.

CONCLUSIONS

The risk of EOS in neonates born to mothers with chorioamnionitis is low. The use of an EOS calculator may reduce the use of empiric antibiotics in chorioamnionitis-exposed neonates, but in our cohort, some neonates with culture-confirmed EOS would have been missed. A larger study is needed to evaluate whether limiting antibiotics to chorioamnionitis-exposed neonates with clinical and/or laboratory signs of infection can safely decrease antibiotic use.

Continuous Positive Airway Pressure versus Mechanical Ventilation on the First Day of Life in Very Low-Birth-Weight Infants

Objective The objective of this study was to determine differences in the incidence of bronchopulmonary dysplasia (BPD) or death in very low-birth-weight (VLBW) infants managed successfully on continuous positive airway pressure (CPAP) versus mechanical ventilation on the first day of life (DOL). Study Design This is a retrospective analysis of the Alere neonatal database for infants born between January 2009 and December 2014, weighing ≤ 1,500 g. Baseline demographics, clinical characteristics, and outcomes were compared between the two groups. Multivariable regression analysis was performed to control the variables that differ in bivariate analysis. Results In this study, 4,629 infants (birth weight 1,034 ± 290 g, gestational age 28.1 ± 2.5 weeks) met the inclusion criteria. The successful use of early CPAP was associated with a significant reduction in BPD or death (p < 0.001), as well as days to room air, decreased oxygen use at discharge, lower risk for severe intraventricular hemorrhage, and patent ductus arteriosus requiring surgical ligation (p < 0.001 for all outcomes). Conclusion Successful use of early CPAP on the first DOL in VLBW infants is associated with a reduced risk of BPD or death.

Development of children born to mothers with cancer during pregnancy: comparing in utero chemotherapy-exposed children with nonexposed controls

OBJECTIVE

Cancer is diagnosed in approximately 1 per 1000 pregnant women. Lifesaving cancer therapy given to the mother during pregnancy appears in conflict with the interest of the developing fetus. Often, termination of pregnancy is suggested but has not been proven in any type of cancer to improve maternal prognosis, while very few studies have documented the long-term effects of in utero chemotherapy exposure on child outcome. To counsel patients about the risk of continuing a pregnancy while undergoing cancer treatment, we performed developmental testing to provide more detailed follow-up on children exposed in utero to chemotherapy.

STUDY DESIGN

Mother-infant pairs, enrolled in the Cancer and Pregnancy Registry, were offered developmental testing for children who were ≥18 months of age. Based on age, the Bayley Scales of Infant Development-Third Edition, the Wechsler Preschool and Primary Scale of Intelligence-Revised, the Wechsler Intelligence Scale for Children, Third Edition, or the Wechsler Individual Achievement Test was administered. All parents or primary caregivers completed the Child Behavior Checklist, a parent questionnaire to assess behavior and emotional issues. Results of children exposed to chemotherapy before delivery were compared with children whose mothers were also diagnosed with cancer during pregnancy but did not receive chemotherapy before delivery.

RESULTS

No significant differences were noted in cognitive skills, academic achievement, or behavioral competence between the chemotherapy-exposed group and the unexposed children. Of children, 95% scored within normal limits on cognitive assessments; 71% and 79% of children demonstrated at or above age equivalency in mathematics and reading scores, respectively; and 79% of children scored within normal limits on measures of behavior. Older children had significantly higher rates of internalizing behavior problems.

CONCLUSION

We could not demonstrate a significant difference in cognitive ability, school performance, or behavioral competence for children exposed to chemotherapy in utero compared with nonexposed controls. The majority of these children scored within normal limits on all developmental measures. Premature birth was more prevalent in the chemotherapy-exposed group yet did not predict developmental outcome. Older children in the sample demonstrated higher rates of internalizing behavior problems.

Pediatric vancomycin use in 421 hospitals in the United States, 2008

BACKGROUND

Recommendations to prevent the spread of vancomycin resistance have been in place since 1995 and include guidelines for inpatient pediatric use of vancomycin. The emergence of large databases allows us to describe variation in pediatric vancomycin across hospitals. We analyzed a database with hospitalizations for children under 18 at 421 hospitals in 2008.

METHODOLOGY/PRINCIPAL FINDINGS

The Premier hospital 2008 database, consisting of records for 877,201 pediatric hospitalizations in 421 hospitals, was analyzed. Stratified analyses and logistic mixed effects models were used to calculate the probability of vancomycin use while considering random effects of hospital variation, hospital fixed effects and patient effects, and the hierarchical structure of the data. Most hospitals (221) had fewer than 10 hospitalizations with vancomycin use in the study period, and 47 hospitals reported no vancomycin use in 17,271 pediatric hospitalizations. At the other end of the continuum, 21 hospitals (5.6% of hospitals) each had over 200 hospitalizations with vancomycin use, and together, accounted for more than 50% of the pediatric hospitalizations with vancomycin use. The mixed effects modeling showed hospital variation in the probability of vancomycin use that was statistically significant after controlling for teaching status, urban or rural location, size, region of the country, patient ethnic group, payor status, and APR-mortality and severity codes.

CONCLUSIONS/SIGNIFICANCE

The number and percentage of pediatric hospitalizations with vancomycin use varied greatly across hospitals and was not explained by hospital or patient characteristics in our logistic models. Public health efforts to reduce vancomycin use should be intensified at hospitals with highest use.

Implementing medication reconciliation in outpatient pediatrics

OBJECTIVE

To describe the implementation of a system-wide, electronic medical record (EMR)-based quality improvement intervention targeting medication reconciliation (MedRec) in outpatient pediatrics and to test variables associated with the performance of MedRec.

METHODS

This was a retrospective study using serial cross-sections of outpatient pediatric visits over a 5-year period set in a multispecialty children's integrated health care network in Florida, Delaware, Pennsylvania, and New Jersey. We reviewed 2 745 523 outpatient pediatric visits between 2005 and 2010. In 2007, the performance of MedRec was identified as critical to improving patient safety at our organization. A comprehensive intervention involved changes in the EMR, automated generation of medication lists, educational modules, and provider compliance reports. In 2009, quality-based financial incentives to physicians to perform MedRec were added. The outcome measure was documentation of MedRec performance.

RESULTS

MedRec improved consistently over time, from a nadir of 0% in 2005 to a maximum of 71% in 2010. Performance of MedRec varied according to practice location as the intervention was rolled out. Throughout the study period, documentation of MedRec was consistently less likely for sick visits (adjusted odds ratio [aOR] for each year ranged from 0.44 to 0.68) but more likely if the provider placed a medication order during the visit (aOR: 1.70-2.15). Beginning in 2009, visits with providers eligible for the quality-based financial incentive were more likely to have had MedRec performed (aOR: 2.02 [2009] and 2.31 [2010]).

CONCLUSIONS

A system-wide, EMR-based, outpatient pediatric quality improvement intervention was successful in improving documentation of the performance of MedRec, a national patient safety goal.

Do premature female infants really do better than their male counterparts?

We compared survival and outcomes in process of care in female versus male infants born ≤32 weeks gestational age (GA). Data were obtained from the Alere database for infants born ≤32 weeks GA. Females were compared with males for demographics, complications, and care processes. Univariate and multivariate analysis was conducted using chi-square analysis, analysis of variance, or logistic regression. Of the infants included, 6086 female and 6721 males were included. Mean GA did not differ, males were born larger than females, and females were more likely to be born SGA. Males received more surfactant, developed more CLD, received more steroids, and more often required oxygen at discharge. Females were more likely to develop a patent ductus arteriosus. After controlling for body weight, GA, and small-for-GA status, females were more likely to survive (95.4% versus 93.6%, odds ratio 1.63, P < 0.01). Male sex did not play a role in other processes of care except for weaning to a crib. Male infants born ≤32 weeks GA have a decreased rate of survival and an increased rate of respiratory morbidity in spite of higher birth weight distributions. Sex did not play a role in other processes of care.

Do premature female infants really do better than their male counterparts?

We compared survival and outcomes in process of care in female versus male infants born ≤32 weeks gestational age (GA). Data were obtained from the Alere database for infants born ≤32 weeks GA. Females were compared with males for demographics, complications, and care processes. Univariate and multivariate analysis was conducted using chi-square analysis, analysis of variance, or logistic regression. Of the infants included, 6086 female and 6721 males were included. Mean GA did not differ, males were born larger than females, and females were more likely to be born SGA. Males received more surfactant, developed more CLD, received more steroids, and more often required oxygen at discharge. Females were more likely to develop a patent ductus arteriosus. After controlling for body weight, GA, and small-for-GA status, females were more likely to survive (95.4% versus 93.6%, odds ratio 1.63, P < 0.01). Male sex did not play a role in other processes of care except for weaning to a crib. Male infants born ≤32 weeks GA have a decreased rate of survival and an increased rate of respiratory morbidity in spite of higher birth weight distributions. Sex did not play a role in other processes of care.

Incubator weaning in preterm infants and associated practice variation

OBJECTIVE

To evaluate the relationship of weight of preterm infants when first placed into an open crib with days to full oral feedings, growth velocity and length of stay (LOS), and to identify unwarranted variation in incubator weaning after adjusting for severity indices.

STUDY DESIGN

A retrospective study using the ParadigmHealth neonatal database from 2003 to 2006 reviewed incubator weaning to an open crib in appropriate-for-gestational-age (AGA) infants from 22 to weeks gestation. Primary outcome measurements included days to full oral (PO) feeding, weight gain from open crib to discharge and length of stay. Models were severity adjusted. To understand hospital practice variation, we also used a regression model to estimate the weight at open crib for the top 10 volume hospitals.

RESULT

In all 2908 infants met the inclusion criteria for the study. Their mean weight at open crib was 1850 g. On average every additional 100 g an infant weighed at the open crib was associated with increased time to full PO feeding by 0.8 days, decreased weight gained per day by 1 gram and increased LOS by 0.9 days. For the top 10 volume hospitals, severity variables alone accounted for 9% of the variation in weight at open crib, whereas the hospital in which the baby was treated accounted for an additional 19% of the variation.

CONCLUSION

Even after controlling for severity, significant practice variation exists in weaning to an open crib, leading to potential delays in achieving full-volume oral feeds, decreased growth velocity and prolonged LOS.

Effect of HAART on salivary gland function in the Women's Interagency HIV Study (WIHS)

OBJECTIVE

To determine the impact of highly active antiretroviral therapy (HAART) on salivary gland function in human immunodeficiency virus (HIV) positive women from the Women's Interagency HIV Study (WIHS).

DESIGN

Longitudinal cohort study.

SUBJECTS AND METHODS

A total of 668 HIV positive women from the WIHS cohort with an initial and at least one follow-up oral sub-study visit contributed 5358 visits. Salivary gland function was assessed based on a dry mouth questionnaire, whole unstimulated and stimulated salivary flow rates, salivary gland enlargement or tenderness and lack of saliva on palpation of the major salivary glands.

MAIN OUTCOME MEASURES

Changes in unstimulated and stimulated flow rates at any given visit from that of the immediate prior visit (continuous variables). The development of self-reported dry mouth (present/absent), enlargement or tenderness of salivary glands (present/absent), and absence of secretion on palpation of the salivary glands were binary outcomes (yes/no).

RESULTS

Protease Inhibitor (PI) based HAART was a significant risk factor for developing decreased unstimulated (P = 0.01) and stimulated (P = 0.0004) salivary flow rates as well as salivary gland enlargement (P = 0.006) as compared with non-PI based HAART.

CONCLUSIONS

PI-based HAART therapy is a significant risk factor for developing reduced salivary flow rates and salivary gland enlargement in HIV positive patients.

Changing use of surfactant over 6 years and its relationship to chronic lung disease

OBJECTIVES

Our goals were to identify the trend of surfactant use over a 6-year period and to determine whether a relationship exists between the incidence of chronic lung disease in infants born weighing <1000 g who receive surfactant and those who do not.

METHODOLOGY

Data regarding surfactant use, incidence of chronic lung disease, nasal continuous positive airway pressure use and duration, and demographic data were collected from the Alere (formerly ParadigmHealth) database from 2001 to 2006 (n = 3086). Groups were compared by using chi(2) test, analysis of variance, or Student's t test.

RESULTS

Use of surfactant has decreased over time from 67% in 2001 to 59.9% in 2006. Infants who received surfactant were more likely to develop chronic lung disease. Those who received >1 dose of surfactant were more likely to develop chronic lung disease when compared with infants treated with only 1 dose. Chronic lung disease rates have risen over time from 47.8% in 2001 to 57.8% in 2006. There was no difference in survival between groups.

CONCLUSIONS

Despite the findings that surfactant use decreased during the study period and the rate of chronic lung disease increased, the data do not support a connection. Infants who receive surfactant are more likely to develop chronic lung disease, and chronic lung disease rates are stable in those infants not treated with surfactant. It is concerning, however, that 60% of infants not receiving surfactant developed chronic lung disease.

A prospective, randomized pilot trial of perfluorocarbon-induced lung growth in newborns with congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Initial laboratory and clinical data suggest that partial liquid ventilation (PLV) can enhance pulmonary function and that lung growth can be induced via distension of the newborn lung using perfluorocarbon in patients with congenital diaphragmatic hernia (CDH). The authors, therefore, performed a prospective, randomized pilot study evaluating PLV and perfluorocarbon-induced lung growth (PILG) in newborns with CDH on extracorporeal life support (ECLS) at 6 medical centers.

METHODS

Patients were selected randomly using a permuted block design to PLV/PILG (n = 8) or conventional mechanical ventilation (CMV/control, n = 5). Patients in the PILG group received daily doses which filled the lungs with perflubron for up to 7 days and were placed on continuous positive airway pressure of 5 to 8 cm H2O. CMV patients were treated with standard mechanical ventilation while on extracorporeal membrane oxygenation (ECMO).

RESULTS

A total of 13 patients were evaluated in this study. All 3 patients enrolled without being on ECLS rapidly transitioned to ECLS. The study, therefore, effectively evaluated PILG (n = 8) versus standard ventilation (control, n = 5) on ECLS. Mean (+/- SE) gestational age was 37 +/- 1 weeks and weight was 3.1 +/- 0.1 kg. Time on ECMO was 9.8 +/- 2.3 days in the PILG and 14.5 +/- 3.5 days (P =.58) in the control group. Survival rate in the PILG group was 6 of 8 (75%), whereas survival rate was 2 of 5 (40%) in the control group (P =.50). The number of days free from the ventilator in the first 28 days (VFD) was 6.3 +/- 3.3 days with PILG and 4.6 +/- 4.6 days with control (P =.9). Causes of death in the PILG group included sepsis and renal failure in one patient and pulmonary hypertension in the other. There were no safety issues, and the deaths in the PILG group did not appear to be related to the administration of perflubron.

CONCLUSIONS

These data show that PILG can be performed safely. The survival rate, VFD, and time on ECMO data, although not conclusive, are encouraging and indicate the need for a definitive trial of this novel intervention in these neonates with high mortality.

Pennsylvania's early discharge legislation: effect on maternity and infant lengths of stay and hospital charges in Philadelphia

OBJECTIVE

To assess the effect of maternal length of stay (LOS) legislation on LOS and hospital charges associated with Philadelphia resident live births from 1994 through 1997.

DATA SOURCE/STUDY SETTING

This was a descriptive epidemiological study involving secondary data analyses of linked birth record and hospital discharge data pertaining to all Philadelphia resident live births occurring between January 1, 1994 and December 31, 1997.

STUDY DESIGN

Using these linked data, trends in median and mean maternal and infant LOS and hospital charges were described for three distinct time periods: (1) a "prelegislative" period (January 1, 1994 through June 30, 1995); (2) a one-year period during which LOS legislation was introduced, debated, modified, and eventually passed by Pennsylvania lawmakers (July 1, 1995 through June 30, 1996); and (3) a "post-LOS law" period immediately following enactment of Act 85 mandating minimum LOS for mothers and their newborns (July 1, 1996 through December 31, 1997). LOS variables for both mothers and infants were calculated based on the actual number of hours elapsing between birth and discharge; hospital charges were obtained directly from information available in the Hospital Discharge Survey data.

PRINCIPAL FINDINGS

Maternal median charges and LOS per delivery for vaginal births rose from 5,270 dollars to 6,333 dollars and from 35 to 47 hours following the enactment of Pennsylvania maternal minimum LOS legislation. Median infant cost and LOS per delivery mirrored these trends.

CONCLUSIONS

Pennsylvania LOS legislation had a profound effect on maternal and infant discharge practices in Philadelphia. As much as $20 million may have been added to annual health care costs associated with Philadelphia resident births.

Comparative analysis of the expression of the Epstein-Barr virus (EBV) anti-apoptotic gene BHRF1 in nasopharyngeal carcinoma and EBV-related lymphoid diseases

Epstein-Barr virus (EBV) has been identified in a wide range of neoplastic and non-neoplastic disorders. The EBV open reading frame BHRF1 encodes a protein with partial sequence and functional homology to the anti-apoptotic onco-protein Bcl-2 and may therefore have a role in the proliferation of EBV positive cells. We have developed a rat monoclonal antibody against pBHRF1, which can detect BHRF1 in paraffin sections. While a number of mutant versions of BHRF1 were recognised, the monoclonal did not detect the BHRF1 homologue encoded by Herpesvirus papio or two mutants with deletions in the BH2 region. This novel rat monoclonal antibody (6A9) was used to examine tissue sections from 39 cases of non-keratinising undifferentiated nasopharyngeal carcinoma (NPC), 6 cases of metastatic NPC, 7 cases of EBV-positive NPC with squamous differentiation from Chinese patients, 15 cases of EBV-positive post-transplant lymphoproliferative disorder (PTLD), 6 EBV-containing lymphoblastoid cell lines, and 2 cases of oral hairy leukoplakia (OHL). In 11 cases of undifferentiated NPC, RT-PCR data were available for comparison with the immunohistochemistry. Both cases of OHL and two cases of LCL were positive for BHRF1 but none of the PTLD showed positive staining. All cases of undifferentiated NPC were positive for Bcl-2 but only one BHRF1 positive cell was identified in 1 of 39 cases of primary undifferentiated NPC. The 6A9 antibody produced less background staining and no nuclear positivity compared with the commercially available mouse monoclonal 5B11. It is concluded that BHRF1 can not be detected by immunohistochemistry in NPC and therefore it appears not to play a significant anti-apoptotic role in the progression of this EBV-associated tumour. The 6A9 monoclonal appears to be superior to 5B11 for the detection of pBHRF1 in tissue sections.

Effect of nonviable infants on the infant mortality rate in Philadelphia, 1992

OBJECTIVES

This report measured the effect of births at 22 weeks' gestation or earlier on infant mortality in Philadelphia, Pa.

METHODS

The proportion of live-born deliveries at 22 weeks or earlier was calculated. Overall and race-specific infant mortality was calculated after excluding live-born deliveries at 22 weeks' gestation or earlier.

RESULTS

Of all deliveries, 1.5% were at 22 weeks or earlier. Of these, 68% were stillborn and 32% were live-born. Large hospital-to-hospital variation in the proportion of live-born deliveries at 22 weeks' gestation or earlier was noted. When nonviable births were excluded, overall infant mortality decreased 40%.

CONCLUSIONS

The development of a standardized birth certificate policy is needed and will facilitate comparisons of infant mortality across spatial boundaries and racial/ethnic groups.

Congenital diaphragmatic hernia survival and use of extracorporeal life support at selected level III nurseries with multimodality support

BACKGROUND

Congenital diaphragmatic hernia (CDH) has been cited to have a mortality rate of 50%. There have been multiple studies at individual institutions demonstrating potential benefits from various strategies including extracorporeal life support (ECLS), delayed repair, and lower levels of ventilator support. There has been no multicenter survey of institutions offering these modalities to describe the current use of ECLS and survival of these infants. In addition, the relationship between the number of patients with CDH managed at an individual institution and outcome has not been evaluated.

METHODS

We queried 16 level III neonatal intensive care centers on the use of ECLS and survival of infants with CDH who were treated during 2 consecutive years (1993 to 1995). Data are presented as mean +/- SEM, median, and range.

RESULTS

Data were collected on 411 patients. Of these, 71% +/- 8% were outborn and 8% +/- 3% were considered nonviable. Overall survival of CDH infants was 69% +/- 4% (range, 39% to 95%). The survival rate of infants on ECLS was 55% +/- 4%, whereas survival of infants not requiring ECLS was significantly increased at 81% +/- 5% (p = 0.005). The mean rate of ECLS use was 46% +/- 2%. There was no correlation between the number of cases per year at an individual institution and overall survival, ECLS survival, or ECLS use (r = 0.341, 0.305, and 0.287, respectively). There was also no correlation between case volume at an individual institution and ECLS survival (r = 0.271).

CONCLUSIONS

The current survival rate and rate of ECLS use in infants with CDH at level III neonatal intensive care units in the United States are 69% +/- 4% and 46% +/- 2%, respectively. There is no correlation between the yearly individual center experience with managing CDH and rate of ECLS use or outcome.

Effect of maternal depression on premature infant health during initial hospitalization

This study evaluates the effect of maternal depression on neonatal health status in premature infants during their initial hospitalization. Infants younger than 34 weeks' gestation born to nondrug abusing mothers were enrolled in the study. Thirty-one mother-infant pairs were identified. Maternal depression was evaluated by the Center for Epidemiologic Studies-Depression Scale (CES-D). Scores > or = 16 defined maternal depression. Initial infant physiologic health status was determined by the Score for Neonatal Acute Physiology (SNAP). In-hospital health status was assessed by the following variables: days receiving supplemental oxygen, days on mechanical ventilation (VENT), and days not on enteral feeding (NPO). Health status variables evaluated for long-term outcome included bronchopulmonary dysplasia at 28 days (BPD), BPD at 34 weeks' postmenstrual age (BPD-34), and intraventricular hemorrhage (IVH). Seventeen (55%) of 31 mothers manifested depression on the CES-D. No epidemiologic differences were found between this group and the nondepressed mothers. No differences in gestation or birth weight was detected between the preterm infants of depressed versus nondepressed mothers. The CES-D scores correlated significantly with SNAP (r = .36, P < .02). Infants of depressed mothers experienced significantly worse outcomes in the occurrence of BPD (P = .015), BPD-34 (P = .049), and IVH (P = .055). This study confirms that maternal depression occurs frequently in mothers of preterm infants and adversely affects the presenting neonatal health status of their babies during the initial hospitalization. Maternal depression was related to the severity of the initial neonatal illness and was significantly related to IVH and BPD. These factors may have long-term consequences for subsequent growth, neurodevelopment, and recurrence of related health problems.