Examining the Validity of Pediatric Resident Self-Assessment in the Delivery Room.

OBJECTIVE: The validity of resident self-assessment of competence in neonatal resuscitation skills has not been studied. This study was designed to test the hypothesis that residents are accurate in self-assessment of basic delivery room resuscitation and bag-and-mask ventilation (BMV) skills by comparing resident self-assessed performance with assessment by observers. STUDY DESIGN: We conducted a prospective repeated measures observational study. After each delivery residents and observers completed 13-question standardized assessments evaluating resident performance. RESULTS: A total of 99 paired assessments were completed by 36 residents. Residents competently performed and identified correct versus incorrect performance of basic resuscitation steps. Residents were less competent in recognizing the need for BMV and were unable to self-assess BMV-associated performance accurately. In multivariable analysis, only basic resuscitation steps versus BMV were significantly associated with accurate self-assessment. CONCLUSION: Pediatric residents are less competent at performing advanced neonatal resuscitation skills and are unable to accurately self-assess performance of skills essential for neonatal resuscitation. KEY POINTS: · Pediatric residents can competently identify and perform basic neonatal resuscitation steps.. · Pediatric residents are less competent at performing advanced neonatal resuscitation skills.. · Self-assessment is not a valid method for determining resident competence in neonatal resuscitation..

Effect of maternal voice on proportion of oral feeding in preterm infants.

OBJECTIVE: To determine the impact of maternal voice exposure on oral feeding in preterm infants. STUDY DESIGN: Prospective, unblinded, 2-center intervention study of infants born 28 0/7-34 6/7 weeks gestation. Infants were exposed twice daily to maternal voice for 20 min before attempting oral feeding. Feedings were divided into groups consisting of Baseline, Intervention, and Follow-up feeds. The study was registered at clinicaltrials.gov (NCT05181020). RESULT: 29/37 (78%) mother-infant dyads consented for the study. 25 infants with 2051 feedings were included. Compared to the preceding Baseline, Intervention feeds were associated with an adjusted 7.1 percentage-point increase in oral intake (p = 0.036) and in post-hoc analysis a 71% increased likelihood of having the highest feeding readiness score (p = 0.003). CONCLUSION: Exposure to maternal voice prior to enteral feeding is feasible and was associated with significantly improved oral feeding proportions in preterm infants. CLINICAL TRIAL REGISTRY: clinicaltrials.gov (NCT05181020).

Covariation of changing patent ductus arteriosus management and preterm infant outcomes in Pediatrix neonatal intensive care units.

OBJECTIVE: To test the hypothesis that NICU-specific preterm infant outcomes co-vary with changes in local patent ductus arteriosus (PDA) management. STUDY DESIGN: This retrospective multicenter study examined NICU-specific aggregated data for infants born 400-1499 g (VLBW) in the Pediatrix Clinical Data Warehouse. For each NICU and each year 2006-2016 we calculated proportion of infants receiving cyclooxygenase inhibitor (COXI) and/or PDA ligation and determined NICU-specific changes in these therapies between consecutive years. We examined relationships between NICU-specific changes in COXI/ligation and concurrent changes in local adjusted in-hospital outcomes. RESULTS: In 5678 observations of change at 259 NICUs summarizing 78,105 infants, between-year decreases in NICU-specific proportion treated with COXI/ligation were associated with concurrent increases in local mortality and decreases in BPD among infants 400-749 g, and with decreased pulmonary hemorrhage in larger infants. CONCLUSIONS: NICU-specific adjusted mortality, BPD, and pulmonary hemorrhage rates co-vary with changes in local COXI/ligation rates in some VLBW infant subgroups.

Sample Size, Power, and Risk of Misclassification in Pediatric Urology Hospital Rankings.

PURPOSE: We investigated 2019 and 2020 U.S. News & World Report methodologies of assessing pediatric urology surgical revision rates for distal hypospadias, pyeloplasty, and ureteral reimplantation to evaluate statistical power and misclassification risks. MATERIALS AND METHODS: Median annual volumes of distal hypospadias, pyeloplasty, and ureteral reimplantation procedures by hospital from 2016 to 2018 were calculated using the Pediatric Health Information System® database. U.S. News & World Report 2019 and 2020 methodologies were assessed to calculate power required to detect differences between hospitals and risk of hospital misclassifications. RESULTS: Median (IQR) annual hospital procedure volume was 72 (43-97) for distal hypospadias procedures, 19 (9-34) for pyeloplasties, and 35 (19-50) for ureteral reimplantations. Based on 2019 methodology, in order to achieve 80% power 764 cases/hospital are required to distinguish between a 1% vs 3% surgical revision rate, 1,500 cases/hospital are required to distinguish between a 3% vs 5% revision rate, and 282 cases/hospital are required to distinguish between a 1% vs 5% revision rate. Based on 2020 methodology, 98.0% of hospitals do not have adequate ureteral reimplantation volume to achieve full points even when reporting no revisions; similarly, 66.0% do not have adequate pyeloplasty volume, and 10.9% do not have adequate distal hypospadias volume. Risks of misclassification exceed 50% in several instances among hospitals reporting distal hypospadias and pyeloplasty revisions using both 2019 and 2020 methodology. CONCLUSIONS: Based on median-volume hospitals, current U.S. News & World Report methods for classifying revision rates for distal hypospadias, pyeloplasty, and ureteral reimplantation have insufficient power and are at high risk for misclassification.

High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants.

BACKGROUND: In-hospital growth of preterm infants remains a challenge in clinical practice. The high nutrient demands of preterm infants often lead to growth faltering. For preterm infants who cannot be fed maternal or donor breast milk or may require supplementation, preterm formulas with fat in the form of medium chain triglycerides (MCTs) or long chain triglycerides (LCTs) may be chosen to support nutrient utilization and to improve growth. MCTs are easily accessible to the preterm infant with an immature digestive system, and LCTs are beneficial for central nervous system development and visual function. Both have been incorporated into preterm formulas in varying amounts, but their effects on the preterm infant's short-term growth remain unclear. This is an update of a review originally published in 2002, then in 2007. OBJECTIVES: To determine the effects of formula containing high as opposed to low MCTs on early growth in preterm infants fed a diet consisting primarily of formula.  SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 8), in the Cochrane Library; Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R); MEDLINE via PubMed for the previous year; and Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 16 September 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA: We included all randomized and quasi-randomized trials comparing the effects of feeding high versus low MCT formula (for a minimum of five days) on the short-term growth of preterm (< 37 weeks' gestation) infants. We defined high MCT formula as 30% or more by weight, and low MCT formula as less than 30% by weight. The infants must be on full enteral diets, and the allocated formula must be the predominant source of nutrition. DATA COLLECTION AND ANALYSIS: The review authors assessed each study's quality and extracted data on growth parameters as well as adverse effects from included studies. All data used in analysis were continuous; therefore, mean differences with 95% confidence intervals were reported. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We identified 10 eligible trials (253 infants) and extracted relevant growth data from 7 of these trials (136 infants). These studies were found to provide evidence of very low to low certainty. Risk of bias was noted, as few studies described specific methods for random sequence generation, allocation concealment, or blinding. We found no evidence of differences in short-term growth parameters when high and low MCT formulas were compared. As compared to low MCT formula, preterm infants fed high MCT formula showed little to no difference in weight gain velocity (g/kg/d) during the intervention, with a typical mean difference (MD) of -0.21 g/kg/d (95% confidence interval (CI) -1.24 to 0.83; 6 studies, 118 infants; low-certainty evidence). The analysis for weight gain (g/d) did not show evidence of differences, with an MD of 0.00 g/d (95% CI -5.93 to 5.93; 1 study, 18 infants; very low-certainty evidence), finding an average weight gain of 20 ± 5.9 versus 20 ± 6.9 g/d for high and low MCT groups, respectively. We found that length gain showed no difference between low and high MCT formulas, with a typical MD of 0.10 cm/week (95% CI -0.09 to 0.29; 3 studies, 61 infants; very low-certainty evidence). Head circumference gain also showed little to no difference during the intervention period, with an MD of -0.04 cm/week (95% CI -0.17 to 0.09; 3 studies, 61 infants; low-certainty evidence). Two studies reported skinfold thickness with different measurement definitions, and evidence was insufficient to determine if there was a difference (2 studies, 32 infants; very low-certainty evidence). There are conflicting data (5 studies) as to formula tolerance, with 4 studies reporting narrative results of no observed clinical difference and 1 study reporting higher incidence of signs of gastrointestinal intolerance in high MCT formula groups. There is no evidence of effect on the incidence of necrotizing enterocolitis (NEC), based on small numbers in two trials. Review authors found no studies addressing long-term growth parameters or neurodevelopmental outcomes. AUTHORS' CONCLUSIONS: We found evidence of very low to low certainty suggesting no differences among short-term growth data for infants fed low versus high MCT formulas. Due to lack of evidence and uncertainty, neither formula type could be concluded to improve short-term growth outcomes or have fewer adverse effects. Further studies are necessary because the results from included studies are imprecise due to small numbers and do not address important long-term outcomes. Additional research should aim to clarify effects on formula tolerance and on long-term growth and neurodevelopmental outcomes, and should include larger study populations to better evaluate effect on NEC incidence.

Maternal H-antigen secretor status is an early biomarker for potential preterm delivery.

OBJECTIVE: Pre-pregnancy or first trimester biomarkers predicting preterm delivery are lacking. The purpose of this study was to determine whether maternal H-antigen (secretor status) is a potential biomarker for preterm delivery. METHODS: This cohort study examined maternal saliva samples and birth data gathered by the National Children's Study Vanguard pilot phase (2009-2014) and included 300 women who were ≥18 years old and provided birth data and saliva samples. The maternal secretor status phenotype was determined by quantifying H-antigen in saliva using enzyme-linked immunoassay. Mothers were stratified by secretor status and multivariable analysis estimated adjusted associations with preterm delivery. RESULTS: Maternal lack of H-antigen production was an independent risk factor for preterm delivery after adjusting for known confounders (aOR 4.53; 95% CI: 1.74, 11.81; P = 0.002). CONCLUSIONS: Maternal H-antigen may be a biomarker identifying women at-risk for preterm delivery. Prospective cohort studies validating these findings are needed.

Demographics and Geographic Distribution of Mothers Donating to a Nonprofit Milk Bank.

Background: The Human Milk Banking Association of North America (HMBANA) is a nonprofit association that standardizes and facilitates the establishment and operation of nonprofit donor human milk banks in North America. Few studies have examined milk donor characteristics and geographic distribution, and little is known about how donor characteristics change with time. Materials and Methods: We performed a retrospective cohort study of mothers who donated to Mothers' Milk Bank Northeast (MMBNE) between January 1, 2011 and September 1, 2019. Data collected from MMBNE donor surveys and collection procedures were analyzed using descriptive and comparative statistics. Donor characteristics were examined for secular trends. Results: Donors (n = 3,764) were of mean age 32.5 years (median 32; IQR 30-35) and most donated more than once (median 2; IQR 1-3; range 1-41). The majority of donors gave birth to term infants and resided in New England; however, MMBNE donors were located in 39 states at the time of donation. Median total volume donated per donor was median 11,396 mL (380 Oz); IQR 6,020-24,242 mL. Mothers of preterm compared with term infants were more likely to be bereaved (p < 0.01) and donated larger volumes (p < 0.01). Over time, number of first-time donors increased, although donors became less likely to have preterm infants or to reside in Massachusetts or New England. Conclusions: Donors to MMBNE varied greatly in age and were broadly distributed geographically. Donor characteristics changed substantially over time. Enhanced understanding of the characteristics of donors may improve the efficiency of efforts to promote milk donation.

Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk.

BACKGROUND: Human milk as compared to formula reduces morbidity in preterm infants but requires fortification to meet their nutritional needs and to reduce the risk of extrauterine growth failure. Standard fortification methods are not individualized to the infant and assume that breast milk is uniform in nutritional content. Strategies for individualizing fortification are available; however it is not known whether these are safe, or if they improve outcomes in preterm infants. OBJECTIVES: To determine whether individualizing fortification of breast milk feeds in response to infant blood urea nitrogen (adjustable fortification) or to breast milk macronutrient content as measured with a milk analyzer (targeted fortification) reduces mortality and morbidity and promotes growth and development compared to standard, non-individualized fortification for preterm infants receiving human milk at < 37 weeks' gestation or at birth weight < 2500 grams. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 9), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on September 20, 2019. We also searched clinical trials databases and the reference lists of retrieved articles for pertinent randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA: We considered randomized, quasi-randomized, and cluster-randomized controlled trials of preterm infants fed exclusively breast milk that compared a standard non-individualized fortification strategy to individualized fortification using a targeted or adjustable strategy. We considered studies that examined any use of fortification in eligible infants for a minimum duration of two weeks, initiated at any time during enteral feeding, and providing any regimen of human milk feeding. DATA COLLECTION AND ANALYSIS: Data were collected using the standard methods of Cochrane Neonatal. Two review authors evaluated the quality of the studies and extracted data. We reported analyses of continuous data using mean differences (MDs), and dichotomous data using risk ratios (RRs). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: Data were extracted from seven RCTs, resulting in eight publications (521 total participants were enrolled among these studies), with duration of study interventions ranging from two to seven weeks. As compared to standard non-individualized fortification, individualized (targeted or adjustable) fortification of enteral feeds probably increased weight gain during the intervention (typical mean difference [MD] 1.88 g/kg/d, 95% confidence interval [CI] 1.26 to 2.50; 6 studies, 345 participants), may have increased length gain during the intervention (typical MD 0.43 mm/d, 95% CI 0.32 to 0.53; 5 studies, 242 participants), and may have increased head circumference gain during the intervention (typical MD 0.14 mm/d, 95% CI 0.06 to 0.23; 5 studies, 242 participants). Compared to standard non-individualized fortification, targeted fortification probably increased weight gain during the intervention (typical MD 1.87 g/kg/d, 95% CI 1.15 to 2.58; 4 studies, 269 participants) and may have increased length gain during the intervention (typical MD 0.45 mm/d, 95% CI 0.32 to 0.57; 3 studies, 166 participants). Adjustable fortification probably increased weight gain during the intervention (typical MD 2.86 g/kg/d, 95% CI 1.69 to 4.03; 3 studies, 96 participants), probably increased gain in length during the intervention (typical MD 0.54 mm/d, 95% CI 0.38 to 0.7; 3 studies, 96 participants), and increased gain in head circumference during the intervention (typical MD 0.36 mm/d, 95% CI 0.21 to 0.5; 3 studies, 96 participants). We are uncertain whether there are differences between individualized versus standard fortification strategies in the incidence of in-hospital mortality, bronchopulmonary dysplasia, necrotizing enterocolitis, culture-proven late-onset bacterial sepsis, retinopathy of prematurity, osteopenia, length of hospital stay, or post-hospital discharge growth. No study reported severe neurodevelopmental disability as an outcome. One study that was published after our literature search was completed is awaiting classification. AUTHORS' CONCLUSIONS: We found moderate- to low-certainty evidence suggesting that individualized (either targeted or adjustable) fortification of enteral feeds in very low birth weight infants increases growth velocity of weight, length, and head circumference during the intervention compared with standard non-individualized fortification. Evidence showing important in-hospital and post-discharge clinical outcomes was sparse and of very low certainty, precluding inferences regarding safety or clinical benefits beyond short-term growth.

Improving the quality of quality metrics in neonatology.

This article examines approaches for improving the efficiency and effectiveness of quality metrics currently in use in neonatal care. Desirable characteristics of quality metrics are discussed, the criteria and process for their development are presented, and the uses and limitations of current neonatal outcome and process metrics are explored together with approaches for improving metric performance. Discussion includes enhancing quality metrics through optimizing improvement readiness, sustaining improvements once achieved, and use of improvement science methods to improve metric validity.

The Nutritional Composition and Energy Content of Donor Human Milk: A Systematic Review.

The American Academy of Pediatrics recommends donor human milk (DHM) as the preferred feeding strategy for preterm infants when the milk of the mother is unavailable, based on conclusive evidence of lower rates of necrotizing enterocolitis with DHM feedings compared with preterm infant formula. The nutritional composition of DHM may differ from maternal milk for many reasons including differences in maternal characteristics, milk collection methods, and the impact of donor milk banking practices. The purpose of this systematic review is to examine the literature regarding research on the fat, protein, carbohydrate, vitamin, and mineral composition of DHM obtained through nonprofit milk banks or commercial entities. PubMed, CINAHL, and Scopus databases were searched for articles published between 1985 and 30 April, 2019. In total, 164 abstracts were screened independently by 2 investigators, and 14 studies met all inclusion criteria. Studies were predominantly small (<50 samples) and measured macronutrients. Few studies assessed vitamins and minerals. Information bias was prevalent due to the use of a variety of analytical methods which influence accuracy and cross-study comparisons. Other sources of information bias included missing information regarding methods for protein and calorie assessment. Despite these limitations, existing research suggests the potential for 2-fold and greater differences in the fat, protein, and energy composition of DHM, with mean values for energy and fat often below clinical reference values expected for human milk. Further research is warranted regarding the nutritional composition of DHM, with a prioritization on measuring macronutrients and micronutrients using established reference methods.

Macronutrient analysis of donor human milk labelled as 24 kcal/oz.

OBJECTIVE: To measure the macronutrient content (MNC) of donor human milk labelled as 24 kcal/oz ("high-calorie DHM," hcDHM), compare to bank-labelled MNC, and examine variability of hcDHM MNC among milk banks. STUDY DESIGN: MNC was measured with near-infrared spectroscopy for 75 convenience samples from five milk banks collected during September 2016-July 2017. Concordance of measured MNC with labelled values was evaluated using three different thresholds: within ±20%, similar to FDA labelling standards for class II nutrients in foods; ±10%; and ±5%. RESULTS: Protein and caloric content differed significantly between measured and labelled values and varied significantly among milk banks. Measured caloric content ranged from 16.50 to 30.27 kcal/oz, with 89.3% of hcDHM samples within ±20%, 58.7% within ±10%, and 18.7% within ±5% of labelled content. CONCLUSIONS: MNC of hcDHM used in clinical practice shows variation that may result in differences from desired diet. The clinical implications of such differences are unexplored.

Delayed Achievement of Oral Feedings Is Associated with Adverse Neurodevelopmental Outcomes at 18 to 26 Months Follow-up in Preterm Infants.

OBJECTIVE: This study aimed to compare neurodevelopmental outcomes in preterm infants at 18 to 26 months corrected age (CA) who did versus did not achieve full oral feedings at 40 weeks postmenstrual age (PMA). STUDY DESIGN: This retrospective study included infants born between 2010 and 2015 with gestational age <32 weeks and followed between 18 and 26 months CA. Achievement of full oral feedings was defined as oral intake >130 mL/kg/d for >72 hours by 40 weeks PMA. Incidence of cognitive, language, or motor delay, or cerebral palsy at 18 to 26 months CA was compared in multivariable analyses for infants in the two feeding groups. RESULTS: Of 372 included infants, those achieving full oral feedings had lower incidence of any adverse neurodevelopmental outcome (p < 0.001) compared with those who did not achieve full oral feedings. In multivariable analyses, achievement of full oral feedings by 40 weeks PMA was associated with decreased odds of cognitive, language, and motor delays, cerebral palsy, and any adverse neurodevelopmental outcome at follow-up. CONCLUSION: Achievement of full oral feedings by 40 weeks PMA was associated with better adjusted neurodevelopmental outcomes at 18 to 26 months CA. Inability to fully feed orally at 40 weeks PMA may be a simple, clinically useful marker for risk of adverse neurodevelopmental outcomes.

Preterm infant gut microbial patterns related to the development of necrotizing enterocolitis.

Objectives: To define gut microbial patterns in preterm infants with and without necrotizing enterocolitis (NEC) and to characterize clinical factors related to the composition of the preterm intestinal microbiome.Methods: Fecal samples were collected at one-week intervals from infants with gestational ages <30 weeks at a single level IV neonatal intensive care unit. Using 16S rRNA gene sequencing, the composition and diversity of microbiota were determined in samples collected from five NEC infants and five matched controls. Hierarchical linear regression was used to identify clinical factors related to microbial diversity and specific bacterial signatures.Results: Low levels of diversity were demonstrated in samples obtained from all preterm infants and antibiotic exposure further decreased diversity among both NEC cases and controls. Fecal microbial composition differed between NEC cases and controls, with a greater abundance of Proteobacteria and bacteria belonging to the class Gammaproteobacteria among NEC infants. Control infants demonstrated a greater abundance of bacteria belonging to the phylum Firmicutes.Conclusion: These findings indicate that an association exists between intestinal Proteobacteria and NEC, and strengthens the notion that an overly exuberant response to Gram-negative products, particularly lipopolysaccharide, in the preterm intestine is involved in NEC pathogenesis. Cumulative exposure to antibiotics corresponded to a reduction in microbial diversity in both NEC cases and controls.

Predicting Maintenance of Any Breastfeeding from Exclusive Breastfeeding Duration: A Replication Study.

OBJECTIVES: To predict the duration of any breastfeeding using the duration of exclusive breastfeeding in a socioeconomically heterogeneous sample of mothers using receiver operator characteristic (ROC) analysis. STUDY DESIGN: The Mother Baby Health Survey, a birth certificate-linked cross-sectional survey was sent at 4-5 months postpartum to a stratified random sample of socioeconomically and racially diverse women in upstate New York; 797 mothers who initiated exclusive breastfeeding were included in this study. Split-sample validation was employed; eligible subjects were divided into training or test samples at random (80% and 20%, respectively). ROC curves were constructed using the training sample and optimal exclusive breastfeeding duration thresholds were tested using the remaining test sample. Logistic regression using the training sample provided estimates of the predictive ability (sensitivity, specificity, positive predictive value) of thresholds in both unadjusted and adjusted analyses (covariates: age, education, parity, marital status, and race). RESULTS: The ROC analysis in this sample demonstrated that 9 weeks of exclusivity was required for maintenance of breastfeeding at 3 months, and 14.9 weeks of exclusivity was required for maintenance at 20 weeks. Unadjusted and adjusted models yielded similar results; women who exclusively breastfed for at least 9 weeks had 2.2 times the risk (95% CI 1.7-2.8) of maintaining any breastfeeding at 3 months. CONCLUSIONS: These results are similar to our previous results, from a less diverse cohort, and support that these thresholds may be useful in clinical settings for helping mothers achieve breastfeeding duration goals.

Covariation of Neonatal Intensive Care Unit-Level Patent Ductus Arteriosus Management and In-Neonatal Intensive Care Unit Outcomes Following Preterm Birth.

OBJECTIVE: To test the hypothesis that neonatal intensive care unit (NICU)-specific changes in patent ductus arteriosus (PDA) management are associated with changes in local outcomes in preterm infants. STUDY DESIGN: This retrospective repeated-measures study of aggregated data included infants born 400-1499 g admitted within 2 days of delivery to NICUs participating in the California Perinatal Quality Care Collaborative. The period 2008-2015 was divided into four 2-year epochs. For each epoch and NICU, we calculated proportions of infants receiving cyclooxygenase inhibitor (COXI) or PDA ligation and determined NICU-specific changes in these therapies between consecutive epochs. Generalized estimating equations were used to examine adjusted relationships between NICU-specific changes in PDA management and contemporaneous changes in local outcomes. RESULTS: We included 642 observations of interepoch change at 119 hospitals summarizing 32 094 infants. NICU-specific changes in COXI use and ligation showed significant dose-response associations with contemporaneous changes in adjusted local outcomes. Each percentage point decrease in NICU-specific proportion treated with either COXI or ligation was associated with a 0.21 percentage point contemporaneous increase in adjusted local in-hospital mortality (95% CI 0.06, 0.33; P = .005) among infants born 400-749 g. In contrast, decreasing NICU-specific ligation rate among infants 1000-1499 g was associated with decreasing adjusted local bronchopulmonary dysplasia (P = .009) and death or bronchopulmonary dysplasia (P = .01). CONCLUSIONS: NICU-specific outcomes of preterm birth co-vary with local PDA management. Treatment for PDA closure may benefit some infants born 400-749 g. Decreasing NICU-specific rates of COXI use or ligation were not associated with increases in local adjusted rates of examined adverse outcomes in larger preterm infants.

Reducing Alarm Fatigue in Two Neonatal Intensive Care Units through a Quality Improvement Collaboration.

OBJECTIVE: To reduce nonactionable oximeter alarms by 80% without increasing time infants were hypoxemic (oxygen saturation [SpO2] ≤ 80%) or hyperoxemic (SpO2 > 95% while on supplemental oxygen). STUDY DESIGN: In 2015, a multidisciplinary team at Connecticut Children's Medical Center initiated a quality improvement project to reduce nonactionable oximeter alarms in two referral neonatal intensive care units (NICUs). Changes made through improvement cycles included reduction of the low oximeter alarm limit for specific populations, increased low alarm delay, development of postmenstrual age-based alarm profiles, and updated bedside visual reminders. Manual alarm tallies and electronic SpO2 data were collected throughout the project. RESULTS: Alarm tallies were collected for 158 patient care hours with SpO2 data available for 138 of those hours. Mean number of total nonactionable alarms per patient per hour decreased from 9 to 2 (78% decrease) and the mean number of nonactionable low alarms per patient per hour decreased from 5 to 1 (80% decrease). No change was noted in the balancing measures of percentage time with SpO2 ≤ 80% (mean 4.3%) or SpO2 > 95% (mean 23.7%). CONCLUSION: Through small changes in oximeter alarm settings, including revision of alarm limits, alarm delays, and age-specific alarm profiles, our NICUs significantly reduced nonactionable alarms without increasing hypoxemia.

Dose-response Relationship Between Donor Human Milk, Mother's Own Milk, Preterm Formula, and Neonatal Growth Outcomes.

BACKGROUND: A dose-response relationship between proportions of donor human milk (DHM) intake and in-neonatal intensive care unit (in-NICU) growth rates, if any, remains poorly defined. Objective was to evaluate interrelationships between percentages of DHM, mother's own milk (MOM), and preterm formula (PF) intake and neonatal growth parameters at 36 weeks postmenstrual age or NICU discharge. METHODS: Infants eligible for this single-center retrospective study were inborn at ≤32 weeks gestation or ≤1800 g, stayed in the NICU for ≥7 days, and received enteral nutrition consisting of human milk fortified with Enfamil human milk fortifier acidified liquid. Study exposures were defined as 10% increments in the total volumetric proportions of infant diet provided as MOM, DHM, or PF. Outcomes were growth parameters at 36 weeks postmenstrual age or NICU discharge. Multivariable linear regression modeled the adjusted additive effect of infant diet on individual growth parameters. RESULTS: A total of 314 infants records were eligible for analysis. Using MOM as reference, the adjusted mean growth velocity for weight significantly decreased by 0.17 g ·â€Škg ·â€Šday for every 10% increase in DHM intake, but did not vary with PF intake. The adjusted mean change in weight z score significantly decreased with increasing proportion of DHM intake but significantly improved with increasing PF intake. The adjusted mean head circumference velocity was significantly decreased by 0.01 cm/wk for every 10% increase in DHM intake, in reference to MOM, but did not vary with PF intake. Neither proportion of DHM nor PF intake was associated with length velocity. CONCLUSIONS: When DHM and MOM are fortified interchangeably, preterm infants receiving incremental amounts of DHM are at increased risk of postnatal growth restriction. The dose-response relationship between DHM, MOM, and PF and long-term growth and neurodevelopmental outcomes warrants further research.

Alarm Safety and Alarm Fatigue.

Clinical alarm systems have received significant attention in recent years following warnings from hospital accrediting and health care technology organizations regarding patient harm caused by unsafe practices. Alarm desensitization or fatigue from frequent, false, or unnecessary alarms, has led to serious events and even patient deaths. Other concerns include settings inappropriate to patient population or condition, inadequate staff training, and improper use or disabling. Research on human factors in alarm response and of functionality of medical devices will help clinicians develop appropriate policies, practices, and device settings for clinical alarms in neonatal intensive care units.