Impact on Neonatal Outcomes with Late Preterm and Early Term Delivery in Women with Diabetes.

OBJECTIVE: Late preterm and early term deliveries are common in pregnancies complicated by diabetes due to higher rates of obstetric complications including increased stillbirth risk. However, early delivery is associated with multiple neonatal adverse outcomes, which may be further increased by maternal diabetes. We examined whether there is an additive effect on adverse neonatal outcomes in the setting of maternal diabetes in the late preterm and early term periods. STUDY DESIGN: This was a retrospective cohort study of women with a singleton, nonanomalous pregnancy delivering at a single academic medical center in the late preterm (340/7-366/7 weeks) or early term (370/7-386/7 weeks) period between 2010 and 2019. Women were categorized by diabetes status: no diabetes, type 1 (T1DM), type 2 (T2DM), or gestational diabetes (GDM). Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for risk of both mild and severe composite neonatal outcome with delivery in the late preterm or early term period using pregnancies without diabetes as the referent. RESULTS: A total of 8,072 pregnancies were included with T1DM, T2DM, and GDM complicating 1.8, 5.6, and 9.9% of pregnancies, respectively. Expected demographic differences were seen among groups including higher rates of non-Hispanic Black race, chronic hypertension, and higher body mass index in women with T2DM. The probability of severe composite adverse neonatal outcome was significantly increased in women with T1DM in the late preterm (aOR: 4.4; CI: 2.4-8.1) and early term (aOR: 1.6; CI: 1.1-2.3) periods, largely driven by the need for mechanical ventilation. The mild composite outcome was increased among all women with diabetes with early term delivery but highest in women with T1DM. CONCLUSION: Pregnancies complicated by diabetes, particularly T1DM, have higher rates of neonatal adverse outcomes independent of gestational age at delivery, which is an important consideration when late preterm or early term delivery is planned. KEY POINTS: · Diabetes in pregnancy increases risk of early delivery.. · Adverse neonatal outcomes are higher with diabetes, especially T1DM.. · Adverse neonatal outcomes are independent of gestational age..

Latency of late preterm steroid administration to delivery and risk of neonatal hypoglycemia.

BACKGROUND: Late preterm antenatal corticosteroid administration has been associated with an increased risk of neonatal hypoglycemia. The mechanism is thought to be secondary to transient fetal hyperinsulinemia, which may be more likely if delivery occurs during peak antenatal corticosteroid levels. OBJECTIVE: This study aimed to investigate whether there is a latency interval between antenatal corticosteroid administration and delivery that places neonates at the greatest risk of hypoglycemia. STUDY DESIGN: This was a retrospective matched cohort study of pregnant women who received antenatal corticosteroid vs unexposed women between 34 0/7 and 36 6/7 weeks of gestation from 2016 to 2019. Unexposed women were those who did not receive antenatal corticosteroid matched according to gestational age at delivery, diabetes mellitus status, and maternal body mass index from 2010 to 2015. Latency periods from initial steroid administration to delivery were defined in grouped intervals until ≥72 hours. The primary outcome was neonatal hypoglycemia, defined as a neonatal glucose level of <40 mg/dL within 24 hours of life. Poisson regression was used to generate an adjusted relative risk of hypoglycemia for each latency period adjusting for confounders. RESULTS: A total of 812 women were included in the analysis (406 exposed and 406 unexposed). Women who received antenatal corticosteroids were more likely to be nulliparous (P=.009); moreover, the women were well matched on pregnancy complications and baseline demographics. Neonatal hypoglycemia was more frequently identified in women receiving antenatal corticosteroids than in women not receiving antenatal corticosteroids (42% vs 26%; P<.001). Severe hypoglycemia, defined as a glucose level of <20 mg/dL, was significantly more common in patients receiving antenatal corticosteroids than in patients not receiving antenatal corticosteroids (8.4% vs 2.7%; P<.001). Latency time intervals of 12 to 71 hours from antenatal corticosteroid administration were significantly associated with neonatal hypoglycemia in exposed women compared with unexposed women after adjustment; within this time frame, the highest risk was 24 to 47 hours after antenatal corticosteroid administration (adjusted relative risk, 2.09; 95% confidence interval, 1.29-3.38). CONCLUSION: In the late preterm period, the risk of neonatal hypoglycemia is the greatest in the latency period of 12 to 71 hours between steroid administration and delivery. Neonates exposed to antenatal corticosteroids were more likely to experience severe hypoglycemia within 24 hours of life than unexposed neonates.

A predictive model for preterm babies born < 30 weeks gestational age who will not attain full oral feedings.

OBJECTIVE: Develop a model to predict gastrostomy tube (GT) for feeding at discharge in infants born < 30 weeks' (w) gestational age (GA). STUDY DESIGN: A single-center retrospective study at academic NICU. Total of 391 (78 GT, 313 non-GT) infants < 30 w GA admitted in 2015-2018 split into test (15-16) and validation (17-18) cohorts. Classification and regression tree analysis was used to identify predictive factors for GT. RESULTS: Several factors were associated with GT requirements. Four factors included in the model were postmenstrual age (PMA) at first oral feeding, birth GA, high-frequency ventilation exposure, necrotizing enterocolitis stage II/III. Area under the receiver operator characteristic curve was 0.944 in the test cohort, 0.815 in the validation cohort. Implementation plan based on the model was developed. CONCLUSIONS: We developed a predictive model to risk-stratify infants born < 30 w GA for failing full oral feeding. We hope implementation at 38 w PMA will result in earlier placement of needed GT and discharge.

Emanuel syndrome and congenital diaphragmatic hernia: A systematic review.

BACKGROUND: Emanuel Syndrome (ES), a rare chromosomal disorder caused by a supernumerary chromosome 22 derivative (der(22)t(11;22)), was identified in a fetus with congenital diaphragmatic hernia (CDH) at our fetal center. We aimed to identify a precedent for clinical care and patient outcomes to guide family decision-making. METHODS: This non-funded and non-registered study queried the entire CDH Registry (CDHR) including >10,000 patients since 1995 and conducted a systematic literature review for patients with concomitant ES and CDH. RESULTS: Literature review captured 12 citations and identified 9 patients with CDH+ES from over 400 known ES cases. Given the rarity of the disease and to reduce bias, there were no exclusion criteria aside from non-English language. Of these 9, two underwent surgical CDH repair with neither surviving. The CDHR identified 6 patients with ES, all reported after 2013 and prenatally diagnosed. Median estimated gestational age was 39 weeks (range 37-40) and median birth weight was 2.72 kg (range 2.4-3.4 kg). 3 patients died within the first few postnatal days; surgical repair was not offered due to "anomalies" and "pulmonary hypertension" in two and one family chose comfort measures. The other 3 patients underwent surgical repair, and 2 were supported with ECMO. Two patients survived to discharge, incurring surgical comorbidities associated with severe CDH including gastrostomy dependence, tracheostomy, and CDH recurrence. CONCLUSIONS: ES patients with CDH have potential to tolerate repair and survive to discharge, however with significant additional morbidity combined with severe challenges inherent to ES. This represents the largest series of patients with CDH and ES to date. LEVEL OF EVIDENCE: IV (Case series with no comparison group).

Severity of respiratory disease is correlated with time of first oral feeding and need for a gastrostomy tube at discharge in premature infants born at <30 weeks of gestation.

BACKGROUND: Premature infants who cannot achieve full oral feeds may need a gastrostomy tube (GT) to be discharged from the neonatal intensive care unit (NICU). We previously developed a model to predict which infants born <30 weeks (w) gestational age (GA) will require a GT before discharge. Here we report the detailed respiratory variable data to describe the general respiratory course for infants in the NICU < 30 w GA at birth and the association between different levels of respiratory support with postmenstrual age (PMA) at the time of first oral feeding attempt (PMAff), including later need for GT for discharge. METHODS: Retrospective chart review of 391 NICU admissions comprising test (2015-2016) and validation (2017-2018) cohorts. Data, including respiratory support, were collected on 204 infants, 41 GT and 163 non-GT, in the test cohort, and 187 infants, 37 GT, and 150 non-GT, in the validation cohort. RESULTS: Respiratory data were significantly different between GT and non-GT infants. Infants who required GT for discharge were on significantly higher respiratory support at 30 days of age, 32 w PMA, and 36 w PMA. Respiratory parameters were highly correlated with PMAff. CONCLUSION: Respiratory status predicts PMAff, which was the variable in our previously described model that was most predictive of failure to achieve full oral feeding. These data provide a catalyst to develop strategies for improving oral feeding outcome for infants requiring prolonged respiratory support in the NICU.

NICU infants who require a feeding gastrostomy for discharge.

OBJECTIVE: To determine population data for infants receiving a gastrostomy tube (GT) in our Neonatal Intensive Care Unit (NICU) to better understand the premature infant population at risk for GT prior to discharge. STUDY DESIGN: We identified all NICU infants born 2015-2016 who received a GT and determined the birth gestational age below which GTs were placed due to oral feeding failure secondary to prematurity-related comorbidities, rather than anomalies or other reasons. Aggregate data were used to compare infants born <30 weeks (w) gestation who received a GT with those who did not. RESULTS: GTs were placed in 117 infants. More than half of the NICU patients who receive GTs were actually >32 weeks gestation; a cut-off of <30w was a good identifier for those who failed achieving full oral feeds due to prematurity-related problems. Infants born <30w (n = 282) not receiving GTs were discharged at a significantly lower postmenstrual age (36w) and lower weight (2.3 kg) compared with infants who received a GT (49w, 5 kg). CONCLUSIONS: The population of premature infants born <30w gestation constitute the population of infants at risk for a GT based solely on prematurity. LEVELS OF EVIDENCE: III.

Neonatal Thyroid Function and Disorders.

Thyroid hormone is essential for normal fetal brain development in utero and for the first 2 years of life. The developing fetus is initially reliant upon maternal thyroid hormones that cross the placenta, until the fetal thyroid begins to supply thyroid hormone for the fetus. Maternal thyroid status affects fetal thyroid function and maternal thyroid dysfunction can have a significant impact on the fetus and neonate. There are also several neonatal factors that can influence thyroid function. Here, we describe thyroid function in the fetus and neonate and discuss the most common thyroid disorders seen in neonates.

Case Studies in Thyroid Dysfunction and Pregnancy.

This chapter represents a selection of 8 clinical scenarios that may commonly be encountered. They help summarize some of the literature and teaching points of the previous chapters. They are not meant to represent every possible presentation of thyroid disease, but rather to present common symptoms and findings that may aid a clinician in making a diagnosis or in selecting initial treatment.

Implementation of computerized provider order entry in a neonatal intensive care unit: Impact on admission workflow.

OBJECTIVE: The study objective was to determine if computerized provider order entry (CPOE) systems impaired or enhanced workflow in the neonatal intensive care unit (NICU) by comparing the timing of administration of the first dose of antibiotics before and after CPOE system implementation. METHODS: We conducted a pre-post intervention comparative study of the length of time between admission and administration of initial antibiotics in neonates before and after a CPOE system was implemented. Clinical information and timing of antibiotic administration were collected on all inborn infants, who were admitted to the NICU in the first 4h of life and treated with antibiotics, for one year prior to the implementation of computerized order entry and for one year after the implementation. RESULTS: Infants admitted to the NICU were similar in both periods (mean birth weight 2183 g vs. 2091 g, gestational age 33.3 weeks vs. 33.0 weeks). There was no significant difference in mean length of time from admission to antibiotic administration in the pre-CPOE group (131 min [CI 124-139]) compared to the post-CPOE group (125 min [CI 116-133]) (p=0.07). The mean time to pharmacy verification for a subset of patients was significantly shorter for patients in the post-CPOE group (61 ± 58 min) compared to the pre-CPOE group (88 ± 76 min) (p=<0.001). CONCLUSIONS: While the introduction of a CPOE system in the NICU did not significantly improve antibiotic administration times, the timeliness of an important aspect of the medication process, time to pharmacy verification, was improved. These findings imply other factors are impeding workflow. Further studies are needed to evaluate how CPOE systems combined with patient care activities affect workflow and overall patient care.

A randomised crossover trial to compare the potential of stannous fluoride and essential oil mouth rinses to induce tooth and tongue staining.

This study compared the staining potential of two experimental amine fluoride/stannous fluoride mouth rinses (A and B), a phenolic/essential oil rinse (C) and a negative control, water, rinse (D). The study was a single centre, randomized, single-blind, four treatment crossover study design among healthy participants. Prior to each study period, participants received a dental prophylaxis. On the Monday of each period, subjects suspended oral hygiene, and under supervision, rinsed with the allocated mouth rinse immediately followed by a warm black tea solution at hourly intervals eight times a day for 4 days. On Friday, the area and intensity of staining on the teeth, the primary outcome measure and dorsum of tongue were assessed. This regimen was repeated for all the three subsequent treatment periods. Rinse B produced less stain than rinse A, but the difference was not significant (p = 0.20). Rinse B produced significantly more stain than rinse C (p < 0.05) and D (p < 0.001). For tongue staining, rinse B produced significantly more staining than D (p < 0.01) but not A or C. Overall, all test rinses produced more staining than placebo with an overall pattern for more staining with stannous formulations. Individuals using stannous or phenolic/essential oil mouth rinse formulations should be advised of the possible staining side effect and that this can be easily removed by a professional dental cleaning.

Greening critical care.

Climate change and environmental stewardship are phrases that have been defining the past few decades and promoting change in our societies. The sensitivities of intensive care as a specialty make the process of greening an intensive care unit a challenge, but not one that is insurmountable. This paper discusses opportunities for critical care to reduce its environmental impact and provide a framework change. The article includes suggestions of what can be done as an individual, as a unit and as a hospital. Generally, practices in critical care are accepted without questioning the environmental consequences. We believe it is time for change, and critical care should give environmental stewardship a higher priority.

Intensity-modulated radiation therapy: not a dry eye in the house.

Inverse planned intensity-modulated radiation therapy (IMRT) has been applied to patients in a conformal fashion in order to avoid the lacrimal gland. In the present study, we report a patient in which a potential planned dose of 63 Gy to the lacrimal gland for a conventional plan was reduced to 12 Gy to the lacrimal gland for the IMRT plan. Dose objective inverse planning was provided using a Pinnacle treatment planning computer and treatment was delivered using a Varian dynamic multileaf collimator (MLC) on a Varian linear accelerator. Because multiple MLC segments are used to deliver the modulated treatment, conventional dose checks by manual calculation are not practical. To aid in an alternative dosimetric verification process, the Pinnacle planning computer has two unique dose tools, which provide axial and beams eye view doses on user-specified check phantoms. The combined field axial dose tool matched our ion chamber dose checks within +/- 2.4% at the isocentre. The individual beams eye view dose tool matched film dose maps within +/- 3% in the umbra.