A mini review of what matters in the management of NAS, is ESC the best care?

As the use of opioids and polysubstance by pregnant women has increased over the years, there has also been a sharp increase in cases of neonatal abstinence syndrome (NAS). Classically, infants affected by NAS have been cared for in neonatal intensive care units resulting in an increase of healthcare expenditure and resource utilization as well as separation from the families. Consequently, the Eat, Sleep, and Console (ESC) tool was developed and promoted as a novel method that focuses on maternal/infant dyad during hospital stay while decreasing the use of pharmacological interventions and therefore decreasing the length of stay and healthcare expenditure. Thus, it has been implemented in several hospitals in the United States. Although the training of staff has been proposed and the interventions of sleep, eat, and console are defined, there still exists a lack of standardization of this practice specifically in regard to the type of associated non-pharmacological practices as well as the reports of its short- and long-term outcomes.

Association of a Simplified Finnegan Neonatal Abstinence Scoring Tool With the Need for Pharmacologic Treatment for Neonatal Abstinence Syndrome.

Importance: Observer-rated scales, such as the Finnegan Neonatal Abstinence Scoring Tool (FNAST), are used to quantify the severity of neonatal abstinence syndrome (NAS) and guide pharmacologic therapy. The FNAST, a comprehensive 21-item assessment tool, was developed for research and subsequently integrated into clinical practice; a simpler tool, designed to account for clinically meaningful outcomes, is urgently needed to standardize assessment. Objectives: To identify FNAST items independently associated with the decision to use pharmacologic therapy and to simplify the FNAST while minimizing loss of information for the treatment decision. Design, Setting, and Participants: This multisite cohort study included 424 neonates with opioid exposure who had a gestational age of at least 36 weeks with follow-up from birth to hospital discharge in the derivation cohort and 109 neonates with opioid exposure from the Maternal Opioid Treatment: Human Experimental Research Study in the validation cohort. Neonates in the derivation cohort were included in a medical record review at the Universities of Louisville and Kentucky or in a randomized clinical trial and observational study conducted at Tufts University (2014-2018); the Maternal Opioid Treatment: Human Experimental Research was conducted from 2005 to 2008. Data analysis was conducted from May 2017 to August 2019. Exposures: Prenatal opioid exposure. Main Outcomes and Measures: All FNAST items were dichotomized as present or not present, and logistic regression was used to identify binary items independently associated with pharmacologic treatment. The final model was validated with an independent cohort of neonates with opioid exposure. Results: Among 424 neonates (gestational age, ≥36 weeks; 217 [51%] female infants), convulsions were not observed, and high-pitched cry and hyperactive Moro reflex had extremely different frequencies across cohorts. Therefore, these 3 FNAST items were removed from further analysis. The 2 tremor items were combined, and 8 of the remaining 17 items were independently associated with pharmacologic treatment, with an area under the curve of 0.86 (95% CI, 0.82-0.89) compared with 0.90 (95% CI, 0.87-0.94) for the 21-item FNAST. External validation of the 8 items resulted in an area under the curve of 0.86 (95% CI, 0.79-0.93). Thresholds of 4 and 5 on the simplified scale yielded the closest agreement with FNAST thresholds of 8 and 12 (weighted κ = 0.55; 95% CI, 0.48-0.61). Conclusions and Relevance: The findings of this study suggest that 8 signs of NAS may be sufficient to assess whether a neonate meets criteria for pharmacologic therapy. A focus on these signs could simplify the FNAST tool and may enhance its clinical utility.

Blood transfusions in preterm infants: changes on perfusion index and intermittent hypoxemia.

BACKGROUND: Red blood cell (RBC) transfusion decreases intermittent hypoxemia (IH) events beyond the first week of life. This benefit may be related to improved perfusion to the respiratory control network. Perfusion index (PI) is a perfusion measure provided by the pulse oximeter. We hypothesized that the benefit in IH after RBC transfusion is associated with an increase in PI. In addition, we assessed the value of PI and clinical measures in predicting the effect of RBC transfusion on IH. STUDY DESIGN AND METHODS: We prospectively enrolled infants less than 30 weeks' gestation age. PI and oxygen saturation (SpO2 ) were monitored with high-resolution pulse oximeters 24 hours before and after RBC transfusion. Data were analyzed at three postnatal periods: Epoch 1, first week of life (1 to 7 days of life); Epoch 2, 2 to 4 weeks of life (8 to 28 days of life); and Epoch 3, 4 to 8 weeks of life. RESULTS: A total of 118 transfusions were analyzed. IH measures significantly decreased after transfusion in Epochs 2 and 3. PI significantly increased after transfusion, but it did not correlate with the decrease in IH measures. Mechanical ventilation, fraction of inspired oxygen (FiO2 ), and IH measures influenced the effects on oxygenation. CONCLUSIONS: RBC transfusion improved IH after the first week of life. The benefit in IH did not correlate with PI increase after transfusion. Pretransfusion respiratory support and IH measures predicted the effect of transfusion on oxygenation.

The Epidemic of Neonatal Abstinence Syndrome, Historical References of Its' Origins, Assessment, and Management.

Neonatal abstinence syndrome (NAS) refers to a constellation of signs that are present in some newborn infants resulting from the abrupt cessation of passive transfer of maternal opioids used during pregnancy. The classic NAS refers to infants born to mothers who used opioids during pregnancy, but the term has broadened to include infants whose mothers have used or abused other psychoactive substances during pregnancy that contribute to the expression of the syndrome. Pregnant women who use opioids do so illicitly, and/or as medically prescribed for pain relief, and/or as medication assisted treatment for opioid dependence. The first case of NAS in infants and the subsequent treatment (or lack thereof) was reported in 1875 and was called Congenital Morphinism. By 2012, the incidence of NAS increased to more than 30 per 1,000 hospital live births, along with an increase in the number of infants being treated pharmacologically for NAS, resulting in an increase in the length of stay and healthcare expenses. We present historical references on NAS, the various factors and events that led to its increasing prevalence and today's current epidemic. We also review the current tools to assess infants with NAS and treatment options in its management.

The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature.

There is no doubt regarding the multiple benefits of breastfeeding for infants and society in general. Therefore, the World Health Organization (WHO) in a conjoint effort with United Nations International Children's Emergency Fund (UNICEF) developed the "Ten Steps to Successful Breastfeeding" in 1992, which became the backbone of the Baby Friendly Hospital Initiative (BFHI). Following this development, many hospitals and countries intensified their position towards creating a "breastfeeding oriented" practice. Over the past two decades, the interest increased in the BFHI and the Ten Steps. However, alongside the implementation of the initiative, extensive research continues to evaluate the benefits and dangers of the suggested practices. Hence, it is our intention to make a critical evaluation of the current BFHI and the Ten Steps recommendations in consideration of the importance of providing an evidence-based breastfeeding supported environment for our mothers and infants.

Bronchopulmonary Dysplasia: Comparison Between the Two Most Used Diagnostic Criteria.

Objectives: To compare the Shennan's and the consensus definition of Bronchopulmonary Dysplasia (BPD) from the National Institutes of Health (NIH) workshop and analyze specific risk factors associated with each definition. Study design: Retrospective analysis of records of 274 infants admitted to a level IV intensive care unit. Infants were classified as having BPD or no BPD by both definitions. Differences in incidence and risk factors were analyzed. Statistical methods included descriptive statistics, comparative tests, and marginal logistic regression modeling. Results: The estimated difference in prevalence was 32% [95% CI: (26%, 37%), (p < 0.0001)] between both criteria. The prevalence of BPD was 80% higher based on the NIH criteria [RR = 1.80; 95% CI: (1.58, 2.06)]. Infants with no BPD by the Shennan definition were breathing room air with or without positive or continuous pressure support and were most likely to be discharged home on oxygen [OR = 4.47, 95% CI: (1.20, 16.61), p = 0.03]. Gestational age, birth weight, and 1-min Apgar score predicted BPD by both definitions. Chorioamnionitis increased the risk of BPD by the Shennan definition but was associated with lower risk by the NIH criteria. IUGR was associated with BPD by the Shennan definition and with severe BPD by the NIH criteria. Conclusion: Compared to the Shennan's definition, the NIH consensus identified 80% more infants with BPD and is a better predictor of oxygen requirement at discharge. Until a new better criteria is develop, the NIH consensus definition should be used across centers.

Vitamin E in the Preterm Infant: A Forgotten Cause of Hemolytic Anemia.

OBJECTIVE: Vitamin E deficiency in premature infants has been associated with hemolytic anemia. Its incidence decreased after the supplementation of preterm formulas and parenteral nutrition with vitamin E. Despite this, some infants still develop hemolytic anemia and receive vitamin E. STUDY DESIGN: Retrospective analysis of 70 infants admitted to a level IV intensive care unit and who developed hemolytic anemia and were treated with vitamin E. Infants were classified into two groups based on whether or not they responded to vitamin E therapy. Statistical methods included the use of descriptive statistics and marginal logistic regression models. RESULTS: Low hematocrit and reticulocytosis before vitamin E administration were associated with adequate response to treatment. Thrombocytosis, iron treatment (duration and dose), gestational age, birth weight, and type of feedings were not. Infants who received a short duration of parenteral nutrition and were on oxygen responded to vitamin E therapy. Infants with a hematocrit ≤ 26% and reticulocyte of 36.1% were more likely to respond to vitamin E. CONCLUSION: Although formulas and parenteral nutrition are supplemented with vitamin E; some preterm infants may still develop hemolytic anemia. Those with anemia, reticulocytosis, and oxygen requirement may benefit from additional vitamin E.

Judging the Neonatal Abstinence Syndrome Assessment Tools to Guide Future Tool Development: The use of Clinimetrics as Opposed to Psychometrics.

In the face of the current Neonatal Abstinence Syndrome (NAS) epidemic, there is considerable variability in the assessment and management of infants with NAS. In this manuscript, we particularly focus on NAS assessment, with special attention given to the popular Finnegan Neonatal Abstinence Score (FNAS). A major instigator of the problem of variable practices is that multiple modified versions of the FNAS exist and continue to be proposed, including shortened versions. Furthermore, the validity of such assessment tools has been questioned, and as a result, the need for better tools has been suggested. The ultimate purpose of this manuscript, therefore, is to increase researchers' and clinicians' understanding on how to judge the usefulness of NAS assessment tools in order to guide future tool development and to reduce variable practices. In short, we suggest that judgment of NAS assessment tools should be made on a clinimetrics viewpoint as opposed to psychometrically. We provide examples, address multiple issues that must be considered, and discuss future tool development. Furthermore, we urge researchers and clinicians to come together, utilizing their knowledge and experience, to assess the utility and practicality of existing assessment tools and to determine if one or more new or modified tools are needed with the goal of increased agreement on the assessment of NAS in practice.

Simplification of the Finnegan Neonatal Abstinence Scoring System: retrospective study of two institutions in the USA.

OBJECTIVE: To develop a simplified Finnegan Neonatal Abstinence Scoring System (sFNAS) that will highly correlate with scores ≥8 and ≥12 in infants being assessed with the FNAS. DESIGN, SETTING AND PARTICIPANTS: This is a retrospective analysis involving 367 patients admitted to two level IV neonatal intensive care units with a total of 40 294 observations. Inclusion criteria included neonates with gestational age ≥37 0/7 weeks, who are being assessed for neonatal abstinence syndrome (NAS) using the FNAS. Infants with a gestational age <37 weeks were excluded. METHODS: A linear regression model based on the original FNAS data from one institution was developed to determine optimal values for each item in the sFNAS. A backward elimination approach was used, removing the items that contributed least to the Pearson's correlation. The sFNAS was then cross-validated with data from a second institution. RESULTS: Pearson's correlation between the proposed sFNAS and the FNAS was 0.914. The optimal treatment cut-off values for the sFNAS were 6 and 10 to predict FNAS scores ≥8 and ≥12, respectively. The sensitivity and specificity of these cut-off values to detect FNAS scores ≥8 and ≥12 were 0.888 and 0.883 for a cut-off of 6, and 0.637 and 0.992 for a cut-off of 10, respectively. The sFNAS cross-validation resulted in a Pearson's correlation of 0.908, sensitivity and specificity of 0.860 and 0.873 for a cut-off of 6, and 0.525 and 0.986 for a cut-off of 10, respectively. CONCLUSION: The sFNAS has a high statistical correlation with the FNAS, and it is cross-validated for the assessment of infants with NAS. It has excellent specificity and negative predictive value for identifying infants with FNAS scores ≥8 and ≥12.

Relationship between perfusion index and patent ductus arteriosus in preterm infants.

BACKGROUND: Perfusion index (PI) is a noninvasive measure of perfusion. ΔPI (difference between pre- and postductal PI) may identify hemodynamically significant PDA. However, studies are limited to brief and intermittent ΔPI sampling. Our objective is to assess the value of continuous high resolution ΔPI monitoring in the diagnosis of PDA. METHODS: Continuous ΔPI monitoring in preterm infants was prospectively performed using two high-resolution pulse oximeters. Perfusion Index measures (ΔPI mean and variability, pre- and postductal PI) were analyzed over a 4-h period prior to echocardiography. A cardiologist blinded to the results evaluated for PDA on echocardiography. Linear mixed regression models were utilized for analyses. RESULTS: We obtained 31 echocardiography observations. Mean ΔPI (-0.23 vs. 0.16; P < 0.05), mean pre-PI (0.86 vs. 1.26; P < 0.05), and ΔPI variability (0.39 vs. 0.61; P = 0.05) were lower in infants with PDA compared to infants without PDA at the time of echocardiography. CONCLUSION: Mean ΔPI, ΔPI variability, and mean pre-PI measured 4 h prior to echocardiography detect PDA in preterm infants. PI is dynamic and should be assessed continuously. Perfusion index is a promising bedside measurement to identify PDA in preterm infants.

Continuous training and certification in neonatal resuscitation in remote areas using a multi-platform information and communication technology intervention, compared to standard training: A randomized cluster trial study protocol.

Background: About 10% of all newborns may have difficulty breathing and require support by trained personnel. In Peru, 90% of deliveries occur in health facilities. However, there is not a national neonatal resuscitation and certification program for the public health sector. In addition, the Andes and the Amazon regions concentrate large rural remote areas, which further limit the implementation of training programs and the accomplishment of continuous certification. Neonatal resuscitation training through the use of Information, Communication and Technology (ICT) tools, running on computers, tablets or mobile phones, may overcome such limitations. This strategy allows online and offline access to educational resources, paving the way to more frequent and efficient training, and certification processes. Objective: To evaluate the effects of a neonatal resuscitation training and certification program that uses a Multi-Platform ICT (MP-ICT) strategy on neonatal health care in remote areas. Methods: We propose to conduct the study through a cluster-randomized trial, where the study and analysis unit is the health care facility. Eligible facilities will include primary and secondary health care level facilities that are located in provinces with neonatal mortality rates higher than 15 per 1,000 live births. We will compare the proportion of newborns with a heart rate ≥100 beats per minute at two minutes after birth in health care facilities that receive MP-ICT training and certification implementation, with those that receive standard training and certification. Discussion: We expect that the intervention will be shown as more effective than the current standard of care. We are prepared to include it within a national neonatal resuscitation training and certification program to be implemented at national scale together with policymakers and other key stakeholders.  Trial registration: ClinicalTrials.gov Nº NCT03210194 Status of the study: This study is ongoing. Study protocol version 1.1 - March 31st, 2017.

Evaluación de la consejería pretest para el VIH en un hospital nacional en Lima-Perú / Evaluating HIV pre-test counseling in people attending a national hospital in Lima, Peru

Objetivo Evaluar los conocimientos adquiridos por la consejería pretest para el VIH, en personas que acudieron a un hospital nacional de Lima, Perú. Método Estudio observacional descriptivo de corte transversal, que se realizó en 499 personas que acudieron a la Estrategia Sanitaria Nacional de Prevención y Control de ITS/VIH y SIDA, que fueron seleccionadas de manera probabilística de tipo intencional. Se aplicó una entrevista estructurada que utilizó un cuestionario validado por expertos con preguntas directas. Se definió como variable de conocimiento correcto a un puntaje ≥75 por ciento de respuestas correctas y como variable de conocimiento incorrecto a un puntaje <75 por ciento de respuestas incorrectas. Resultados El 64,1 por ciento (n = 320) de los encuestados fueron mujeres. El grupo de edad con mayor numero de respuestas correctas (40,3 por ciento, n=201) fue el de 22 a 28 años, (p<0,05). Las personas que acudieron por pareja con diagnóstico reciente de VIH/ SIDA, tuvieron mayor cantidad de respuestas correctas (12,3 en promedio). Los hombres alcanzaron un mayor nivel de conocimientos correctos (63,6 por ciento) en comparación con las mujeres (36,4 por ciento), (p<0,05). Solo 4,4 por ciento (n=22) del total, alcanzaron un nivel de conocimiento correcto. Conclusión El nivel de conocimiento adquirido con la consejería pretest en este hospital fue deficiente, no cumpliendo los objetivos de la misma. Se sugiere cambiar la metodología para que pueda aumentar la retención de información por las personas, y de esta manera reducir la morbi-mortalidad en ITS y VIH/ SIDA.

Objective Evaluating the knowledge acquired by the pre-test counselling programme in a national hospital in Lima Peru. Method A cross-sectional descriptive observational study was carried out on 499 patients attending the National STI/HIV Prevention and Control Sanitary Strategy service after they had been counselled. The patients were intentionally selected by probabilistic means. A questionnaire having direct questions was applied; it had been previously validated by experts. ≥75 percent of correct answers was defined as being a variable of correct knowledge and <75 percent of correct answers as incorrect knowledge. Results 64.1 percent (n=320) of the patients were female. The age group having a better level of knowledge after counselling was the 22-28 year old group, 40.3 percent (n=201) (p<0.05). People having a partner diagnosed as having HIV/AIDS answered more questions correctly (12.3 on average). Men showed higher correct knowledge (63.6 percent) related to women (36.4 percent) (p<0.05). Only 4.4 percent (n=22) of the patients had a correct level of knowledge. Conclusion The pre-test counselling programme did not improve knowledge regarding HIV/AIDS. It is thus suggested that the approach and method should be changed so that patients become well-informed, thereby reducing STI and HIV/AIDS-related morbidity and mortality.

[Evaluating HIV pre-test counseling in people attending a national hospital in Lima, Peru]. / Evaluación de la Consejería Pretest para el VIH en un Hospital Nacional en Lima-Perú.

OBJECTIVE: Evaluating the knowledge acquired by the pre-test counselling programme in a national hospital in Lima Peru. METHOD: A cross-sectional descriptive observational study was carried out on 499 patients attending the National STI/HIV Prevention and Control Sanitary Strategy service after they had been counselled. The patients were intentionally selected by probabilistic means. A questionnaire having direct questions was applied; it had been previously validated by experts. > or = 75 % of correct answers was defined as being a variable of correct knowledge and <75 % of correct answers as incorrect knowledge. RESULTS: 64.1 % (n=320) of the patients were female. The age group having a better level of knowledge after counselling was the 22-28 year old group, 40.3 % (n=201) (p<0.05). People having a partner diagnosed as having HIV/AIDS answered more questions correctly (12.3 on average). Men showed higher correct knowledge (63.6 %) related to women (36.4 %) (p<0.05). Only 4.4 % (n=22) of the patients had a correct level of knowledge. CONCLUSION: The pre-test counselling programme did not improve knowledge regarding HIV/AIDS. It is thus suggested that the approach and method should be changed so that patients become well-informed, thereby reducing STI and HIV/AIDS-related morbidity and mortality.