Oral Clonidine-Based Strategy to Reduce Opiate Use During Cooling for Neonatal Encephalopathy: An Observational Study.

OBJECTIVE: To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy would decrease opiate use while maintaining similar short-term safety and efficacy profiles to a morphine-based strategy (MOR). STUDY DESIGN: This was a single-center, observational study conducted at a level IV neonatal intensive care unit from January 1, 2017, to October 1, 2021. From April 13, 2020, to August 13, 2020, we transitioned from MOR to CLON. Thus, patients receiving TH for hypoxic-ischemic encephalopathy were grouped to MOR (before April 13, 2020) and CLON (after August 13, 2020). We calculated the total and rescue morphine milligram equivalent/kg (primary outcome) and frequency of hemodynamic changes (secondary outcome) for both groups. RESULTS: The MOR and CLON groups (74 and 25 neonates, respectively) had similar baseline characteristics and need for rescue sedative intravenous infusion (21.6% MOR and 20% CLON). Both morphine milligram equivalent/kg and need for rescue opiates (combined bolus and infusions) were greater in MOR than CLON (P < .001). As days in TH advanced, a lower percentage of patients receiving CLON needed rescue opiates (92% on day 1 to 68% on day 3). Patients receiving MOR received a greater cumulative dose of dopamine and more frequently required a second inotrope and hydrocortisone for hypotension. MOR had a lower respiratory rate during TH (P = .01 vs CLON). CONCLUSIONS: Our CLON protocol is noninferior to MOR, maintaining perceived effectiveness and hemodynamic safety, with an apparently reduced need for opiates and inotropes.

Evaluation of the clinical impact of decreasing the maximum osmolarity of neonatal peripheral parenteral nutrition.

OBJECTIVE: To describe the clinical impact of lowering the peripheral parenteral nutrition (PPN) maximum osmolarity limit from 1000 to 900 mOsm/L in patients in two neonatal intensive care units (NICUs). METHODS: This was a retrospective cohort study including inborn neonates that received PPN for at least 3 consecutive days within the first 14 days of life. Data were evaluated to compare the ability of PPN with a maximum osmolarity limit of 1000 to 900 mOsm/L to provide daily recommended macronutrient doses, and daily recommended goal calories, as well as to compare the incidence of significant peripheral intravenous (PIV) infiltrates. RESULTS: A total of 200 PPN orders representing 57 patients were included for analysis, with 100 PPN orders in each osmolarity cohort. Baseline characteristics were similar between the two cohorts. Significantly more PPN orders met goal amino acid doses (45% vs. 24%, p = 0.003) and goal intravenous fat emulsion (IVFE) doses (61% vs. 37%, p = 0.001) in the 1000 mOsm/L osmolarity limit cohort compared to the 900 mOsm/L osmolarity limit cohort. A total of three patients received hyaluronidase for PN infiltration, two in the 1000 mOsm/L osmolarity limit and one in the 900 mOsm/L osmolarity limit cohort (p = 0.6). CONCLUSION: A lower PPN osmolarity limit of 900 mOsm/L significantly limited the ability to provide goal amino acid and IVFE doses to NICU patients compared to the previous osmolarity limit of 1000 mOsm/L without reducing the incidence of PIV infiltration or extravasation.

Improving On-time Administration of the Initial Hepatitis B Vaccine in the NICU.

Introduction: Despite the updated American Academy of Pediatrics recommendation for universal administration of the hepatitis B vaccine for newborns, delays in routine prophylaxis are common in the Neonatal Intensive Care Unit (NICU). Delayed immunization can increase perinatal acquisition risks and lead to subsequent delays in routine childhood immunization. This study aimed to increase the on-time administration of the birth dose of the hepatitis B vaccine from 46% to ≥70% at a level III and level IV NICU within the same health system. Methods: The stakeholder group developed project interventions using quality improvement methods, including implementing unit guidelines and a prompt in the progress note template. The outcome measure was the percent on-time administration of the initial hepatitis B vaccine for inborn NICU patients born to hepatitis B-negative mothers. The process measure was the percent on-time administration or a valid reason to delay immunization following the guidelines. Statistical process control P-charts graphically represented the measures to assess for change from January 2019 to May 2021. Results: In total, 2192 patients were included. The percent on-time administration improved from 48% to 57%. The percentage of on-time administration or valid reason to delay increased from 76% to 80%. Conclusions: Quality improvement methodology facilitated the identification of barriers to on-time hepatitis B prophylaxis in the NICU and the improvement of the timeliness of administration across 2 sites. Guidelines tailored to this population and changes to the progress note template successfully created and sustained change and may benefit other NICUs.

Insulin Glargine Dose and Weight Changes in Underweight, Normal Weight, and Overweight Children Newly Diagnosed with Type 1 Diabetes Mellitus.

STUDY OBJECTIVE: Newly diagnosed pediatric patients with type 1 diabetes mellitus (T1D) can be underweight, overweight, or normal weight at presentation. Study objectives were to determine if, across weight categories, admission body weight (ABW)-based initial insulin glargine dosing resulted in similar fasting blood glucose responses on day of discharge, how initial ABW-based doses differed from doses at outpatient follow-up, and whether an ideal body weight (IBW) would provide a better estimate of body weight after discharge. DESIGN: Retrospective chart review. SETTING: Urban tertiary academic medical center. PATIENTS: Eighty-one pediatric patients newly diagnosed with T1D who started therapy with subcutaneous insulin glargine between October 2014 and October 2016; patients were categorized by weight using body mass index (BMI) percentiles (underweight, normal weight, or overweight/obese). MEASUREMENTS AND MAIN RESULTS: Data on patient parameters from hospitalization to outpatient physician follow-up were collected. The McLaren, Moore, and BMI IBW methods were used to calculate IBW for each patient; these IBWs were compared with weights at outpatient follow-up. Initial insulin glargine doses were similar among all weight groups: median (range) 0.299 (0.227-0.4), 0.297 (0.204-0.421), and 0.291 (0.194-0.394) units/kg/dose, respectively, for the underweight, normal weight, and overweight/obese groups. No significant differences in discharge fasting glucose level or insulin glargine dose change from admission to first outpatient follow-up visit were noted. Underweight patients gained significantly more weight within 60 days after discharge compared with normal and overweight/obese patients, (median 16.3% vs 7.7% and 5.7%, respectively; p=0.002), aligning closest with the McLaren IBW. ABW was the best estimate of weight at outpatient follow-up in the overweight/obese patient group. CONCLUSION: For children who presented underweight, the McLaren IBW method was the best predictor of outpatient dose and body weight, whereas ABW was the best estimate in overweight and obese patients. Further investigation of the role of IBW- or ABW-based dosing methods in underweight pediatric patients with T1D may assist in optimal dosing.