Utilizing a line maintenance team to reduce central-line-associated bloodstream infections in a neonatal intensive care unit.

OBJECTIVE: To determine the association of a central-line maintenance team on the incidence of central-line-associated bloodstream infections (CLABSIs) in the neonatal intensive care unit (NICU). STUDY DESIGN: Central line maintenance in the NICU was limited to a line team starting in March 2008. CLABSI rates were determined before (December 2006 to February 2008) and after implementation of the line team ( March 2008 to August 2010) utilizing consistent National Healthcare Safety Network definitions. Rates were calculated by birth weight categories and overall. Data analysis was performed by two-proportion t test using Minitab. RESULT: Overall CLABSI decreased by 65% after implementation of the line team. Pre intervention, mean overall CLABSI rate was 11.6 /1000, as compared with 4.0/1000 after intervention (P<0.001). Birth-weight-specific CLABSI rates also decreased significantly. Decreased infection rates were sustained over time. CONCLUSION: A line team provided for standardized, consistent central-line maintenance care leading to a significant, sustained decrease in CLABSI in a NICU.

International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines.

The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: * Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. * Preventing heat loss: Hyperthermia should be avoided. * Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO(2) detection can be useful in the secondary confirmation of endotracheal intubation. * Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. * Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. * Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.

Feeding, medical factors, and developmental outcome in premature infants.

This is a prospective, longitudinal study of premature infants investigating whether the length of time needed to reach full enteral feedings (FEF) or full nipple feedings (FNF) is related to medical complications and/or developmental outcome at 24 months corrected age. Premature infants (n = 161) from three institutions with birth weights less than 1,600 grams were followed up from birth to 24 months corrected age. The infants were stratified into groups by the severity of medical complications. Bayley Scales of Infant Development were performed at 24 months corrected age. Multiple linear regression was used to analyze the association between feeding milestones, medical complications, and developmental outcomes. Our results show that when controlling for birth weight and gestational age (GA), the severity of respiratory complications was significantly related to reaching FEF (p = 0.024) and FNF (p = 0.0014). Furthermore, when controlling for the severity of respiratory complications, GA, and socioeconomic status, an increased length of time to FEF was significantly associated with a poorer mental outcome (p = 0.0013). We conclude that there is an association between the length of time to reach FEF and mental developmental outcome at 24 months corrected age. Infants who reach full enteral feedings at an earlier age appear to have a better developmental outcome despite their GA and severity of respiratory complications.

Prediction of developmental patterns through 40 months from 6- and 12-month neurologic examinations in very low birth weight infants.

This study examines whether neurologic examinations at 6 and 12 months of age can predict developmental patterns in very low birth weight infants and fullterm controls through 40 months of age. We performed neurologic examinations at 6 and 12 months; the Bayley Scales of Infant Development at 6, 12, and 24 months; and the Stanford-Binet and the McCarthy Motor scale at 40 months. The very low birth weight infants were categorized on the basis of socioeconomic status and high or low risk for early medical complications. More abnormal neurologic scores predicted greater deceleration of cognitive development for high-risk infants only. The 12-month neurologic examination predicted the degree of deceleration in motor development. Medical risk was an independent predictor of curvature of the psychomotor development curve. We conclude that neurologic examinations during the 1st year of life might be used with other factors in decision concerning referrals to early-intervention programs.

Effects of medical risk and socioeconomic status on the rate of change in cognitive and social development for low birth weight children.

Using Hierarchical Linear Models (HLM) analysis, this study evaluated the effects of medical risk at birth and socioeconomic status (SES) on the rate of change in cognitive and social development over the first three years of life in premature children with low birth weight (LBW). Children with LBW (n = 79) with both high (HR) (n = 37) and low (LR) (n = 42) medical risk were compared to healthy full-term (FT) (n = 49) children. Children were assessed longitudinally at 6, 12, 24, and 36 months for cognitive development with the Bayley Scales of Infant Development and the McCarthy Scales for Children's Abilities, and for social initiative and responsiveness with observational measures. The HR LBW group had slower rates of increases in cognitive scores than did the LR LBW and FT groups and showed more deceleration in cognitive development by 36 months of age. Children with LBW, regardless of medical risk, had lower social initiating scores and slower rates of increase in initiating across the first 36 months than did FT children. As predicted, the groups did not show different rates of change for measures of social responsiveness. Higher SES was predictive of better cognitive and social development for all children. The difficulties encountered by children with LR and HR LBW in developing social initiating skills are discussed in relation to the link between learning to take initiative and early executive function skills.

Physical growth of low birthweight infants in the first year of life: impact of maternal behaviors.

Physical growth of preterm infants relates to many medical factors, such as birthweight, severity of medical illnesses, and nutritional status. We previously reported that maternal behaviors influence developmental outcomes in low birthweight infants (birthweight < 1600 g); we now hypothesize that maternal behaviors also influence physical somatic growth in low birthweight (LBW) infants. We serially followed 218 mother-infant pairs from birth through 12 months of age. One-hundred thirteen LBW infants were categorized based on severity of early medical complications. Low Risk infants (LR, n = 71) had acute respiratory distress and/or grade 1-2 intraventricular hemorrhage (IVH), or grade 3 IVH without hydrocephalus. High Risk infants (HR, n = 42) had chronic lung disease, grade 3 IVH with hydrocephalus or grade 4 IVH, and/or periventricular leukomalacia. We also studied 105 socioeconomic (SES) matched Full Term (FT) controls. Maternal behaviors were assessed during home visits with global ratings of Warm Sensitivity and Punitiveness. Infant weight was measured at birth and at 38 weeks, 6 months and 12 months corrected gestational age. We examined alternative expressions of weight growth across the three groups by developing the Weight Quotient (WQ), which is the ratio of actual measured weight to the median weight for age. For each infant the regression of the WQ ratio against correct gestational age was analyzed. We used a General Linear Model to compare the relation of the maternal variables to the weight quotients for the three groups. We determined the catch up growth as the slope of each regression. Results indicated that higher levels of maternal Punitiveness were related to slower rates of growth for High Risk (R2 = 0.36), but not Low Risk or Full Term. For maternal Warm Sensitivity (R2 = 0.36), there were significant (P < 0.05) inverse relations with weight gain growth for the Full Term infants. These data suggest that some maternal behaviors are related to the growth of term and premature infants, although the mechanisms through which this occurs is unclear.

The relation of medical risk and maternal stimulation with preterm infants' development of cognitive, language and daily living skills.

High-risk (HR) and low-risk (LR) preterm infants (N = 212) and full-term infants (FT, N = 128) from low socio-economic homes were studied with their mothers in the home at 6 and 12 months of age. Infants' cognitive, language and daily living skills were evaluated in relation to mothers' warm sensitivity, use of strategies which maintained the infants' attention and directiveness. Higher levels of maternal attention-maintaining were positively related to infant development for all groups. During toy play, attention-maintaining was most strongly related to expressive language skills for the HR infants; during toy play and daily activities, this maternal behavior was more strongly related to cognitive and language skills for both preterm groups than for the FT infants.

Severity of medical and neurologic complications as a determinant of neurodevelopmental outcome at 6 and 12 months in very low birth weight infants.

Very low birth weight (n = 154) and term infants (n = 119) had neurologic and developmental assessment at 6 and 12 months of age. Preterm infants with severe neonatal complications were considered to be at high risk, and those with milder complications were considered to be at low risk, for neurodevelopmental abnormality. Compared to term infants, high- and low-risk infants had abnormalities at 6 months in total neurologic score, cranial nerves, motor tone, motor coordination, and reflexes (P < .001). At 12 months, all groups had improved. However, high-risk infants had persistent abnormalities in the same subcategories (P < .001), whereas low-risk infants differed from term infants only in motor tone (P < .001). Bayley developmental scores were different for all groups at 6 months (P < .001), but at 12 months only high-risk infants differed from term infants (P < .01). These results demonstrate improvement in neurologic and developmental scores over time in very low birth weight infants. The degree of neurodevelopmental abnormality and improvement over time is related to severity of neonatal complications in preterm infants.

Prediction of 12-month neurodevelopmental outcome from a 6-month neurologic examination in premature infants.

This study examined whether a neurologic examination at 6 months of age is predictive of neurodevelopmental outcome at 12 months in very-low-birth-weight (VLBW) infants. A neurologic examination and the Bayley Scales of Infant Development were performed at 6 and 12 months with VLBW infants and full-term (FT) controls. VLBW infants were categorized based on early medical complications. High-risk (HR) infants had diagnoses of bronchopulmonary dysplasia, pulmonary immaturity, grade III or IV intraventricular hemorrhage, and/or periventricular leukomalacia. VLBW infants with other diagnoses were placed in the low-risk (LR) group. Total neurologic scores (NS) improved over time for all three groups but improved more for HR infants, who had more abnormal NS at both time points; NS at 6 months predicted neurologic and developmental scores at 12 months for all three groups, but the relation between 6- and 12-month outcomes was strongest for the HR infants. The neurologic examination may be helpful in assessing VLBW infants' need for referral to early childhood intervention programs.

Current issues in Texas neonatology.

Since almost 10% of the births in the United States occur in Texas, issues that affect neonatal care in Texas are important for both the state and the nation. Although overall statistics are similar for the state and nation, closer examination reveals a need for improvement in specific areas, namely prenatal care, black and Hispanic mortality, and low birth-weight rates. Lay midwifery regulation has been an important concern in Texas. Surfactant use and education to prevent birth asphyxia have had a positive impact on perinatal health, contributing to public health efforts to improve perinatal outcome.

Low birth weight (LBW) infants' exploratory behavior at 12 and 24 months: effects of intraventricular hemorrhage and mothers' attention directing behaviors.

Medically high-risk (HR), low birth weight (LBW) preterm infants (n = 11) with significant degrees of intraventricular hemorrhage (IVH) were seen at 12 and 24 months of age. This HR group was compared with a low-risk (LR) LBW preterm group (n = 16) with respiratory distress syndrome or mild grades of IVH, and a normal full-term (FT) group (n = 12). Infants and their mothers were observed in a 10-min toy-centered play interaction to determine if more advanced exploratory play occurred in association with specific maternal attention-directing behaviors. Results showed that the FT infants were able to respond with advanced exploratory play to unstructured as well as structured strategies, but that higher level play for the LR infants was associated with structured strategies. The HR infants showed fewer play responses than the other two infant groups regardless of whether mothers used structured or unstructured strategies. All infant groups showed more exploratory play behavior in relation to mothers' maintaining versus redirecting behavior.

Longitudinal outcome for low birth weight infants: effects of intraventricular hemorrhage and bronchopulmonary dysplasia.

This study addresses the mental and motor development of 78 low birth weight infants (LBW) classified into five groups according to early medical complications: (1) respiratory distress syndrome (RDS); (2) intraventricular hemorrhage (IVH Grades I-II); (3) IVH (Grade III); (4) IVH (Grade IV) with hydrocephalus; and (5) bronchopulmonary dysplasia (BPD) with or without IVH. Each child received an assessment of mental and motor development at 6, 12, 24 and 36 months of age. Results of mental scores revealed clear effects of group and age, but no interaction of group and age. The RDS and IVH (Grades I-III) groups generally had higher scores on indices of mental development than did IVH (Grade IV) and BPD infants with or without IVH. Although most groups had higher mental scores at the older ages, rates of growth were essentially parallel across the five groups. There was some support for differential rates of motor development, with the IVH (Grade IV) group showing acceleration between 24 and 36 months of age while the BPD group continued to show motor delay at 36 months. These results call into question the common practice of correcting psychology test scores of LBW infants for gestational age.

Comparison of three dosing procedures for administration of bovine surfactant to neonates with respiratory distress syndrome.

A multicenter, randomized, double-blind, controlled trial compared three beractant (Survanta) administration procedures in the treatment of neonatal respiratory distress syndrome. Infants weighing > or = 600 gm with respiratory distress syndrome who required assisted ventilation were treated within 8 hours of birth with beractant administered intratracheally. Procedure A required administration in two fractional doses after removal of the infant from the ventilator. Procedure B required administration in two fractional doses through a neonatal suction valve and did not require removal of the infant from the ventilator, and procedure C required administration in four fractional doses during removal from the ventilator. Procedure C is the method used in all previous beractant studies. Of the 299 infants enrolled, 103 were randomly assigned to procedure A, 100 to procedure B, and 96 to procedure C. The results indicate no significant differences among the treatment groups in the clinical outcome measures of fractional inspired oxygen, mean airway pressure, and arterial-alveolar ratio of partial pressure of oxygen at 72 hours of life, or in the incidences of air leaks, pulmonary interstitial emphysema, or death through 72 hours of life. There were no significant differences in the lowest heart rates recorded during administration of doses, but there was less oxygen desaturation during administration of dose 1 with procedure B than with procedure A (p = 0.001), and more reflux of beractant after procedure B than after procedure C (p = 0.007). We conclude that the three procedures are equally effective and can be used to administer beractant safely and effectively. Procedure B has the advantage of allowing administration without interrupting mechanical ventilation.

Reduction of neonatal mortality after multiple doses of bovine surfactant in low birth weight neonates with respiratory distress syndrome.

To determine if outcomes of low birth weight neonates with respiratory distress syndrome can be improved by the administration of multiple doses of bovine surfactant, we conducted two identical multicenter, controlled trials, and the results were combined for analysis. Seven hundred and ninety-eight neonates weighing 600 to 1750 g at birth who had developed respiratory distress syndrome within 6 hours of birth were assigned randomly to receive either 100 mg of phospholipid/kg of Survanta, a modified bovine surfactant (n = 402), or a sham dosing procedure (n = 396). Neonates whose respiratory distress persisted could be given up to three more doses, with all doses to be given in the first 48 hours after birth. Dosing was performed by investigators not involved in the clinical care of the neonates; nursery staff were kept blinded as to the treatment assignment. Fewer Survanta-treated neonates died of any cause (18.4% vs 27.3%, P = .002), died of respiratory distress syndrome (9.0% vs 20.3%, P less than .001), and either died or developed bronchopulmonary dysplasia due to respiratory distress syndrome (51.2% vs 64.6%, P less than .001). Neonates who received Survanta also had greater improvement in their oxygenation and ventilatory status from baseline to 72 hours than did control neonates. Survanta-treated neonates were at lowered risk for developing pulmonary interstitial emphysema (18.6% vs 39.3%, P less than .001) and other pulmonary air leaks (11.5% vs 25.9%, P less than .001). We conclude that multiple doses of Survanta given after diagnosis of respiratory distress syndrome reduce mortality and morbidity.

Twenty-four hour in-house coverage for neonatal intensive care units in academic centers: who, how, and why?

Twenty-four-hour in-house coverage by attending physicians is becoming more common in academic centers in certain subspecialties in pediatrics. The actual percentage of programs providing this coverage in most subspecialties is not documented. We report the results of a survey of in-house coverage by attending physicians in neonatal intensive care units at academic centers in the United States. Of the 238 surveys distributed, 204 (86%) were returned and completed. At the time of the survey, 47 of 204 programs (23%) provided 24-hour in-house coverage for their neonatal intensive care units. These programs had more manpower than those programs not providing this coverage. If this trend continues, it will significantly alter projections for neonatal manpower needs in the United States.