Continuous improvement of non-emergent neonatal intubations in a level IV NICU.

OBJECTIVE: We sought to improve practices and outcomes related to non-emergent neonatal intubations in a level IV academic Neonatal Intensive Care Unit. STUDY DESIGN: A multidisciplinary team created guidelines for non-emergent neonatal intubations. In period 1, premedication practices were standardized. In period 2, paralytic use and video laryngoscope use were recommended. Premedication and video laryngoscopy practices were assessed along with number of intubation attempts and frequency of bradycardia and desaturation. RESULTS: 636 intubations performed by neonatology fellows and neonatal advanced practice providers were reviewed over six academic years. Two academic years were included in each of the following study periods: baseline, period 1, and period 2. In our unit, compliance with recommended premedication practices and administration of paralytic medication has increased considerably, and video laryngoscopy is now utilized in most of our procedures. The frequency of intubation success on the first attempt has increased, and the frequency of both bradycardia and desaturation during intubation has decreased. In our analysis, paralytic use (AOR 2.41, 95 CI (1.53, 3.81)) and the combination of paralytic and video laryngoscopy (AOR 4.07, 95 CI (2.09, 7.92)) are associated with increased odds of intubating successfully on the first attempt. CONCLUSIONS: This initiative increased the use of standardized premedication, paralytic medication and video laryngoscopy for non-emergent neonatal intubations with temporally associated improvement in patient outcomes including fewer intubation attempts and reduction in physiologic instability.

Time to positivity of blood cultures in a level IV NICU varies based on organism category and population subgroups: is a 36-hour rule out safe?

BACKGROUND: Time to positivity (TTP) of blood cultures and organism characteristics may be different in a Level IV NICU population. METHODS: Retrospective study of 309 Level IV NICU positive blood cultures between January 2012 to December 2018 describing TTP and organism characteristics. RESULTS: Median TTP [IQR] was 21.1 [14.3, 25.2] hours, with 91.2% positive at 36 h, and 96.1% positive at 48 h. Gram negative definite pathogens had the shortest TTP (13.0 [11.4, 15.4] hours) compared to gram positive definite pathogens (16.3 [13.0, 22.4] hours). TTP for treated gram positive commensal organisms (22.3 [20.1, 30.4] hours) and those considered contaminants (23.6 [21.4, 26.0] hours), was significantly longer than both gram positive and negative definite pathogens. CONCLUSION: When antimicrobials are initiated due to concern for bacteremia and blood cultures have not identified a causative pathogen at 36 h, antimicrobials may be safely discontinued in the majority of Level IV NICU patients.

Prevalence and Predictors of Early Intervention Referral Among Substance-Exposed Newborns.

OBJECTIVES: Substance-exposed newborns (SENs) are at risk for developmental delay(s). Early intervention (EI) access, key to addressing these risks, is inequitable. Objectives were to: 1. determine prevalence of EI referral in the Colorado Hospitals Substance-Exposed Newborn Quality Improvement Collaborative; and 2. evaluate predictors of referral. METHODS: Within participating Colorado Hospitals Substance-Exposed Newborn hospitals, maternal-infant dyads with exposure to medications for opioid use disorder (MOUD), illicit/prescription opioids, and/or nonopioid substances were included on the basis of electronic medical record documentation. χ2, Fisher's exact, and analysis of variance tests evaluated differences in maternal/infant characteristics by referral. Multivariable Poisson regression models assessed the independent association of characteristics with referral. RESULTS: Among 1222 dyads, 504 (41%) SENs received EI referral. Infants born to mothers with non-MOUD (adjusted risk ratio [aRR] 2.15, 95% confidence interval [CI] 1.67-2.76) and polysubstance (aRR 1.58, 95% CI 1.26-1.97) exposure were less likely to receive referral compared with infants born to mothers with MOUD exposure. Those with private (aRR 1.26, 95% CI 1.03-1.55) or self-pay/no insurance (aRR 12.32, 95% CI 10.87-13.96) were less likely to receive referral compared with infants with public insurance. CONCLUSIONS: Less than half of identified SENs received EI referral, with variation by substance exposure and maternal insurance status. Systems to ensure equitable access to services are crucial.

NICU Visitation Time and Adherence to Safe Sleep Practices Among Mothers of Very Preterm Infants.

BACKGROUND: Sleep-associated infant death is the leading cause of postneonatal mortality in the United States. Preterm infants are at higher risk for sleep-associated death, but maternal adherence to safe sleep practices is lower than for mothers of full-term infants. Data are lacking on whether maternal neonatal intensive care unit (NICU) visitation time impacts safe sleep compliance after hospital discharge. PURPOSE: For mothers of preterm infants, to investigate the association of time days per week spent in the NICU and adherence to safe sleep practices after discharge. METHODS: A prospective observational study of 109 mothers with infants born at less than 32 weeks from 4 Colorado NICUs who completed a survey at 6 weeks after discharge about infant sleep practices. Maternal time spent in the NICU was defined as the average number of days spent in the NICU per week of infant hospitalization, as documented in the electronic medical record. Multivariable logistic regression models assessed the relationship between time in the NICU and safe sleep adherence. Covariates included maternal/infant characteristics significant at P < .2 level in bivariate analysis. RESULTS: Predictors of compliance with all safe infant sleep practices included public/no insurance compared with private insurance (adjusted odds ratio [AOR] 0.29; 95% confidence interval [CI] 0.09-0.96), some college/associate-level education versus bachelor's degree (AOR 5.88; 95% CI 1.21-28.67), and depression/anxiety symptoms (AOR 0.37; 95% CI 0.14-0.97). NICU visitation days was not associated with adherence to safe sleep practices. IMPLICATIONS FOR PRACTICE AND RESEARCH: Maternal visitation days was not associated with adherence to safe infant sleep practices after discharge, highlighting the need to identify barriers and facilitators to engaging families about SUID risk-reducing behaviors.

Association of Rural and Frontier Residence with Very Preterm and Very Low Birth Weight Delivery in Nonlevel III NICUs.

OBJECTIVE: Delivery of very preterm and very low birth weight neonates (VPT/VLBW) in a nonlevel III neonatal intensive care unit (NICU) increases risk of morbidity and mortality. Study objectives included the following: (1) Determine incidence of VPT/VLBW delivery (<32 weeks gestational age and/or birth weight <1,500 g), in nonlevel III units in Colorado; (2) Evaluate the independent association between residence and nonlevel III unit delivery; (3) Determine the incidence of and factors associated with postnatal transfer. STUDY DESIGN: This retrospective cohort study used 2007 to 2016 Colorado birth certificate data. Demographic and clinical characteristics by VPT/VLBW delivery in level III NICUs versus nonlevel III units were compared using Chi-square analyses. Multivariable logistic regression was used to estimate the independent association between residence and VPT/VLBW delivery. RESULTS: Among patients, 897 of 10,015 (8.96%) VPT/VLBW births occurred in nonlevel III units. Compared with infants born to pregnant persons in urban counties, infants born to those residing in rural (adjusted odds ratio [AOR] = 1.58, 95% confidence interval [CI]: 1.33, 1.88) or frontier (AOR = 3.19, 95% CI: 2.14, 4.75) counties were more likely to deliver in nonlevel III units and to experience postnatal transfer within 24 hours (rural AOR = 2.24, 95% CI: 1.60, 3.15; frontier AOR = 3.91, 95% CI: 1.76, 8.67). Compared with non-Hispanic Whites, Hispanics were more likely to deliver VPT/VLBW infants in nonlevel III units (AOR = 1.36, 95% CI: 1.15, 1.61). CONCLUSION: A significant number of VPT/VLBW neonates were born in nonlevel III units with associated disparities by race/ethnicity and nonurban residence. KEY POINTS: · Preterm delivery in a nonlevel III NICU increases risk of neonatal morbidity and mortality.. · A significant number of preterm deliveries in Colorado occur in hospitals with nonlevel III NICUs.. · Disparities in preterm delivery by race/ethnicity and nonurban residence exist..

Prevalence and Predictors of Pediatric COVID-19 Vaccine Acceptance.

OBJECTIVE: As pediatric COVID-19 vaccine eligibility expands, understanding predictors of vaccine intent is critical to effectively address parental concerns. Objectives included: (1) Evaluate maternal COVID-19 vaccine intent for child(ren) and associated predictors of stated intent; (2) Describe attitudes related to hypothetical vaccination policies; (3) Summarize themes associated with intention to vaccinate child(ren) for COVID-19. STUDY DESIGN: Mothers enrolled in Heath eMoms, a longitudinal survey project, were recruited for this electronic COVID-19 survey. Chi-square analysis was used to compare proportions of respondent characteristics based on vaccination intent. Population survey logistic regression was used for multivariable modeling to assess the independent association between vaccine intent and demographics. RESULTS: The response rate was 65.3% (n = 1884); 44.2% would choose vaccination, 20.3% would not choose vaccination, and 35.5% are unsure whether to have their child(ren) vaccinated for COVID-19. Black mothers (AOR 0.26, 95% CI 0.13, 0.54), respondents with less than high school education (AOR 0.26, 95% 0.12, 0.56) and those in rural areas (AOR 0.28, 95% CI 0.16, 0.48) were less likely to choose vaccination. Commonly cited reasons for vaccine hesitancy include the belief that the vaccine was not tested enough, is not safe, and there are concerns regarding its side effects. CONCLUSION: Over 50% of respondents do not intend or are unsure about their intent to vaccinate their child(ren) for COVID-19 with variability noted by demographics. Opportunities exist for perinatal and pediatric providers to educate pregnant people, parents, and caregivers with a focus on addressing concerns regarding vaccine safety and efficacy. KEY POINTS: · COVID-19 vaccination rates remain suboptimal, especially in the pediatric population, with variation across states.. · We found that the prevalence of vaccine acceptance for young children is low.. · We highlight opportunities for providers to educate parents, focusing on addressing vaccine safety and efficacy..

Defining an Infant's Race and Ethnicity: A Systematic Review.

CONTEXT: Infant race and ethnicity are used ubiquitously in research and reporting, though inconsistent approaches to data collection and definitions yield variable results. The consistency of these data has an impact on reported findings and outcomes. OBJECTIVE: To systematically review and examine concordance among differing race and ethnicity data collection techniques presented in perinatal health care literature. DATA SOURCES: PubMed, CINAHL, and Ovid were searched on June 17, 2021. STUDY SELECTION: English language articles published between 1980 and 2021 were included if they reported on the United States' infant population and compared 2 or more methods of capturing race and/or ethnicity. DATA EXTRACTION: Two authors independently evaluated articles for inclusion and quality, with disagreements resolved by a third reviewer. RESULTS: Our initial search identified 4329 unique citations. Forty articles passed title/abstract review and were reviewed in full text. Nineteen were considered relevant and assessed for quality and bias, from which 12 studies were ultimately included. Discordance in infant race and ethnicity data were common among multiple data collection methods, including those frequently used in perinatal health outcomes research. Infants of color and those born to racially and/or ethnically discordant parents were the most likely to be misclassified across data sources. LIMITATIONS: Studies were heterogeneous in methodology and populations of study and data could not be compiled for analysis. CONCLUSIONS: Racial and ethnic misclassification of infants leads to inaccurate measurement and reporting of infant morbidity and mortality, often underestimating burden in minoritized populations while overestimating it in the non-Hispanic/Latinx white population.

Parental leave during pediatric fellowship training: A national survey.

BACKGROUND: Until recently, no uniform requirements for parental leave (PL) existed in graduate medical education. We implemented a national survey, with the objective of ascertaining fellows' perceptions of PL policies and their impact. This is the first study to focus exclusively on pediatric subspecialty fellows. METHODS: An online survey instrument was created targeting pediatric fellows. RESULTS: The survey was accessed by 1003 (25%) of the estimated 4078 pediatric subspecialty fellows and 853 (21%) submitted surveys. Respondent demographic data paralleled the data reported by the American Board of Pediatrics. Half of respondents did not know whether their program had a written PL policy. Over 40% reported ≥ 5 weeks of paid PL. Most indicated that fellows use vacation, sick leave, and unpaid time for PL. Almost half of respondents (45%) indicated that their program's PL policy increases the stress of having a child. Fellows chose establishing/extending paid leave and intentionally fostering a more supportive program culture as the most crucial candidate improvements. The importance of equitable PL polices between parent fellows and co-fellows was an important theme of our qualitative data. Fellows feel there is a moral misalignment between the field of pediatrics' dedication to maternal and child health and current PL policies governing pediatric trainees. CONCLUSIONS: PL policies vary widely among pediatric fellowship programs and are often not known by fellows. Fellows are not satisfied with PL policies, which often exacerbate stress for new parents and burden their co-fellows. Targeted modification of several aspects of PL policies may improve their acceptance.

Comparisons of Three Measures of Maternal Engagement Activities in the Neonatal Intensive Care Unit.

BACKGROUND: Mothers' engagement with their hospitalized preterm infant(s) is recognized as an important aspect of treatment in neonatal intensive care units (NICUs). However, no gold standard exists for measuring maternal engagement, and the various methods used to measure mothers' time have documented limitations. OBJECTIVES: This study sought to compare three measurement methods of maternal engagement (a five-item maternal cross-sectional survey, time use diaries, and electronic health records [EHRs]) to identify whether these methods capture consistent data and patterns in detected differences in measures of engagement. METHODS: Maternal engagement was defined as time spent visiting the infant in the NICU (presence), holding (blanket holding in the mother's arms or by kangaroo care [KC]), and caregiving (e.g., bathing and changing diapers). The survey estimating daily maternal engagement was administered in two Level III NICUs and one Level IV NICU at study enrollment, at least 2 weeks after admission. Mothers then completed the daily time use diaries until infant discharge. Data were also collected from participants' EHRs, charted by nursing staff. Wilcoxon signed-rank tests were used for pairwise analysis of the three measures for maternal engagement activities. RESULTS: A total of 146 participants had data across all three measurement types and were included in the analysis. In the Level III NICUs (n = 101), EHR data showed significantly more time spent with all engagement activities than the diary data. In the Level IV data, only differences in time holding were significant when comparing EHR data with survey data, with mothers reporting more time doing KC and less time blanket holding. Comparison of EHR data with diary data showed more time in all activities except KC. DISCUSSION: In most cases, time spent in engagement activities measured in the EHR was higher than in the surveys or time use diaries. Accuracy of measurements could not be determined because of limitations in data collection, and there is no gold standard for comparison. Nevertheless, findings contribute to ongoing efforts to develop the most valuable and accurate strategies for measuring maternal engagement-a significant predictor of maternal and infant health.

Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes.

OBJECTIVE: We sought to standardize and improve compliance with evidence-based premedication for non-emergent neonatal intubations in two academic-affiliated Neonatal Intensive Care Units. STUDY DESIGN: A multidisciplinary team created guidelines and electronic medical record order sets for intubation. Compliance with recommended premedication, number of intubation attempts, and frequency of bradycardia and desaturation were assessed. RESULTS: 387 intubation procedures were reviewed. Provision of recommended premedication increased by 36% and 75% at the level III and IV units, respectively. Decreased frequency of bradycardia during intubation (p = 0.0003) occurred in the level III unit. A reduction in number of intubation attempts (p ≤ 0.001), improvement in first-attempt intubation success (p ≤ 0.001), and decreased frequency of bradycardia (p = 0.01) and desaturation (p = 0.02) during intubation occurred in the level IV unit. CONCLUSIONS: This quality improvement initiative improved standardized premedication compliance and decreased adverse events associated with non-emergent neonatal intubations in two separate units.

Impact of Coronavirus Disease-19 "Stay-At-Home" Orders on Preterm Birth in Colorado.

In this retrospective cohort analysis of Colorado birth certificate records from April to December 2015-2020, we demonstrate that Colorado birthing individuals experienced lower adjusted odds of preterm birth after issuance of coronavirus-19 "stay-at-home" orders. However, this positive birth outcome was experienced only by non-Hispanic white and Hispanic mothers.

Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals.

OBJECTIVES: Investigate disparities by Hispanic ethnicity in the care of opioid exposed newborns (OENs) in Colorado birthing hospitals within a statewide quality improvement collaborative. METHODS: This study is a secondary analysis of a quality improvement initiative aimed at standardizing hospital-based care of OENs through implementation of the Eat, Sleep, Console Model. We used statistical process control charts to compare time to special cause variation by Hispanic ethnicity for outcomes including infant length of stay, use of pharmacologic therapy, and breastfeeding eligibility and receipt. Only hospitals that delivered both Hispanic and non-Hispanic OENs during the study period were included, documented maternal ethnicity was required for inclusion. We investigated hospital variation in these outcomes among 4 hospitals that cared for Hispanic OENs for most of the study period. RESULTS: We analyzed 799 mother-OEN dyads, 241 Hispanic and 558 non-Hispanic. Both Hispanic and non-Hispanic OENs experienced decreases in length of stay overall and among those who received postnatal opioids, although Hispanic OENs achieved these decreases 3 annual quarters after non-Hispanic OENs. Pharmacologic therapy use decreased by 55% for Hispanic OENs and 60% for non-Hispanic OENs. Hispanic OENs experienced a 1-quarter delay for this decrease. CONCLUSIONS: Although this quality improvement initiative resulted in positive outcomes for Hispanic and non-Hispanic OENs, improvement was delayed among Hispanic infants, indicating a need to explore and address care practices of Hispanic mothers and infants affected by opioid use disorders.

The Association of Social Factors and Time Spent in the NICU for Mothers of Very Preterm Infants.

OBJECTIVES: Evaluate the association between maternal social factors and maternal time spent in the NICU for very preterm infants admitted to 4 level III and IV NICUs. METHODS: In this prospective observational cohort study, we enrolled mother-infant dyads whose infants were born <32 weeks' gestation. Enrollment occurred after 2 weeks of NICU exposure, when maternal social factors and demographic information was collected. Maternal time spent in the NICU was abstracted from the electronic medical record and was dichotomized into 0 to 6 days and ≥6 days per week. Demographic differences between the 2 groups were compared by using χ2 tests. Logistic regression was used to assess the independent association between maternal social factors and the average number of days per week spent in the NICU. RESULTS: A total of 169 mother-infant dyads were analyzed. Maternal social factors associated with more time spent in the NICU included an annual household income of >$100 000, compared with those with an annual household income of <$50 000 (adjusted odds ratio [aOR]: 5.68; 95% confidence interval [CI] 1.77-18.19), a travel time <30 minutes to the NICU (compared with those who traveled >60 minutes [aOR: 7.85; 95% CI 2.81-21.96]), and the lack of other children in the household, compared with women with other children (aOR: 3.15; 95% CI 1.39-7.11). CONCLUSIONS: Maternal time spent in the NICU during a prolonged birth hospitalization of a very preterm infant differed by socioeconomic status, travel time, and presence of other dependents. Strategies to better identify and reduce these disparities to optimize engagement and, subsequently, improve infant health outcomes is needed.