Mother-Infant Dyads with COVID-19 at an Urban, Safety-Net Hospital: Clinical Manifestations and Birth Outcomes.

OBJECTIVE: This study aimed to describe maternal characteristics and clinical outcomes of infants born to mothers with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests during pregnancy at an urban, safety-net hospital in Boston. STUDY DESIGN: We abstracted electronic chart data from 75 pregnant women with positive SARS-CoV-2 tests at any stage of gestation until 72 hours after birth who delivered consecutively between March 31 and August 6, 2020 at our center. We collected clinical data on maternal and infant characteristics, including testing, signs, and symptoms of coronavirus disease 2019 (COVID-19), delivery outcomes, newborn care practices (skin-to-skin care, location of care, and breastfeeding) and 30-day postdischarge infant emergency room visits and readmissions. We described categorical characteristics as percentages for this case series. RESULTS: Among 75 pregnant women, 47 (63%) were Hispanic, 10 (13%) had hypertension, 23 (30%) had prepregnancy obesity, and 57 (76%) had symptomatic SARS-CoV-2 infection. Regarding birth outcomes, 32 (41%) had cesarean delivery and 14 (19%) had preterm birth. Among 75 infants, 5 (7%) had positive SARS-CoV-2 polymerase chain reaction tests in the first week of life, all of whom were born to Hispanic mothers with symptomatic SARS-CoV-2 infection and had clinical courses consistent with gestational age. Six (8%) infants visited the emergency department within 30 days of discharge; one was admitted with a non-COVID-19 diagnosis. CONCLUSION: At our urban, safety-net hospital among pregnant women with positive SARS-CoV-2 tests, 41% had a cesarean delivery and 19% had a preterm birth. Seven percent of infants had one or more positive SARS-CoV-2 tests and all infants had clinical courses expected for gestational age. KEY POINTS: · Among 75 pregnant women with SARS-CoV-2 positive testing at our center, five infants (7%) had one or more SARS-CoV-2 positive tests in the first week of life.. · Infants with positive SARS-CoV-2 tests had clinical courses expected for gestational age..

A Quality Improvement Project to Increase Mother's Milk Use in an Inner-City NICU.

Mother's milk is recommended for preterm infants due to numerous health benefits. At our inner-city hospital, >80% of mothers of infants younger than 34 weeks' gestation initiated milk production, but fewer continued until discharge. Among infants younger than 34 weeks' gestation, we aimed to (1) increase any mother's milk use in the 24 hours before discharge/transfer to >75%; (2) increase exclusive mother's milk use in the 24 hours before discharge/transfer to >50%; and (3) reduce racial/ethnic disparities in mother's milk use. METHODS: We conducted a quality improvement project from January 2015 to December 2017 focused on prenatal education, first milk expression ≤6 hours after birth, and skin-to-skin care in the first month. We tracked process measures and main outcomes with run and control charts among 202 infants younger than 34 weeks' gestation eligible to receive mother's milk born at our hospital; We tracked results according to maternal race/ethnicity subgroups. RESULTS: Forty-seven percent of mothers were non-Hispanic black, 28% were Hispanic, and 13% were non-Hispanic white. We improved the rate of first milk expression ≤6 hours after birth and skin-to-skin care in the first month but did not improve rates of any/exclusive mother's milk use at discharge/transfer. Eight-five percent of infants had mothers that initiated milk production, but only 55% received any mother's milk at discharge/transfer. CONCLUSIONS: Our single-center quality improvement effort focused on infants younger than 34 weeks' gestation whose mothers were predominately Hispanic and non-Hispanic blacks. We successfully increased first milk expression ≤6 hours after birth and skin-to-skin care but did not increase mother's milk use at discharge/transfer.

Improving Respiratory Support Practices to Reduce Chronic Lung Disease in Premature Infants.

INTRODUCTION: We implemented a bundle of respiratory care practices and optimized delivery of continuous positive airway pressure (CPAP) to reduce the incidence of chronic lung disease (CLD) among very low birth weight (VLBW) infants born before 33 weeks gestation. METHODS: Our multidisciplinary task force utilized 6 plan-do-study-act cycles to test our interventions. The primary outcome was the quarterly percentage of infants diagnosed with CLD; other outcomes included the percentage of infants initially managed with CPAP, intubation <72 hours of age, use of a nasal cannula, and days of ventilation, oxygen, and/or CPAP. Process measures included compliance with each of the 5 components of the bundle; balancing measures included mortality and complications of prematurity. RESULTS: Demographics were similar in the 55 infants born before and 76 infants born after the task force interventions, except for gestational age, which was lower before. CLD decreased by 55.5% (from 37.5% to 16.7%). Quarterly percentage of infants requiring intubation decreased from 87.5% to 40.8%. Quarterly average days of ventilation decreased from 11.2 to 6.1, and days of supplemental oxygen declined from 44.1 to 25.4, while the use of CPAP increased. There were no differences in adverse events including mortality, pneumothorax, use of postnatal steroids, or any retinopathy of prematurity. The incidence of patent ductus arteriosus declined from 60% to 33% (P < 0.01). CONCLUSIONS: We reduced the incidence of CLD among our very low birth weight infants born before 33 weeks gestation by over 50% without increasing any measured adverse outcomes. The incidence of patent ductus arteriosus declined.

Implementation of a pilot program of Reach Out and Read® in the neonatal intensive care unit: a quality improvement initiative.

OBJECTIVE: Language exposure is important for neurodevelopment, but is sparse in the neonatal intensive care unit (NICU). STUDY DESIGN: We introduced Reach Out and Read (ROR) in the NICU as a quality improvement initiative to increase language exposure. Measures included availability of books, accessibility of parents, and enrollment of infants, percent infants read to by their parents, and data from parental surveys. RESULT: 98 infants were included (40 before, 58 after). We obtained books in the mother's language for 95% of infants, 82% eligible infants were enrolled, and 70% read to their infants (mean of 0.45 ± 0.35 times/day). Surveyed parents enjoyed reading, noted positive effect(s), and intended to read post-discharge. CONCLUSION: We launched a well-received pilot ROR program in the NICU and reached our goal of ≥50% infants being read to by their parents. Further study is needed to assess the impact of reading in the NICU on parents and infants.

Low urine vascular endothelial growth factor levels are associated with mechanical ventilation, bronchopulmonary dysplasia and retinopathy of prematurity.

BACKGROUND: Organ-specific vascular endothelial growth factor (VEGF) expression is decreased during the pathogenesis of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) several weeks before either disease can be diagnosed. Early measurement of organ-specific tissue VEGF levels might allow identification of infants at high risk for these diseases, but is not clinically feasible. Urine VEGF is easily measured and useful in early diagnosis of several diseases. OBJECTIVES: Our aims were to assess the correlation of urine VEGF levels measured in the first postnatal month with subsequent BPD or ROP diagnosis and to determine whether various infant characteristics influence urine VEGF levels. METHODS: 106 subjects born at <29 weeks' gestation and surviving to 36 weeks' postmenstrual age were selected from an existing database and biorepository. Urine VEGF and total protein were measured in 2-3 samples per subject. RESULTS: Urine VEGF/protein levels increased by 72% per week (p < 0.0001) during the first postnatal month. In multivariable analysis controlling for postnatal age, lower VEGF/protein was associated with higher levels of mechanical respiratory support (p = 0.006), male gender (p = 0.001) and early sepsis (p = 0.003) but not with fraction of inspired oxygen. Lower urine VEGF/protein and mechanical ventilation were each associated with BPD and ROP. In analyses adjusted for respiratory support, lower urine VEGF/protein and ROP remained associated but urine VEGF/protein and BPD did not. CONCLUSIONS: Low urine VEGF/protein levels in the first postnatal month are associated with mechanical ventilation, BPD, and ROP.

Impact of implementing 5 potentially better respiratory practices on neonatal outcomes and costs.

OBJECTIVE: We implemented 5 potentially better practices to limit mechanical ventilation (MV), supplemental oxygen, and bronchopulmonary dysplasia in newborn infants born before 33 weeks' gestation. METHODS: The methods used in this study included (1) exclusive use of bubble continuous positive airway pressure (bCPAP), (2) provision of bCPAP in the delivery room, (3) strict intubation criteria, (4) strict extubation criteria, and (5) prolonged CPAP to avoid supplemental oxygen. We excluded outborn infants and those with major anomalies and obstetric complications from analysis. RESULTS: Demographics were similar in 61 infants born before and 60 born after implementation. For infants born at 26 to 32(6/7) weeks' gestation, intubation (first 72 hours) decreased from 52% to 11% (P < .0001) and surfactant use decreased from 48% to 14% (P=.0001). In all infants, the mean ± SD fraction of inspired oxygen requirement (first 24 hours) decreased from 0.27 ± 0.08 to 0.24 ± 0.05 (P=.0005), days of oxygen decreased from 23.5 ± 44.5 to 9.3 ± 22.0 (P=.04), and days of MV decreased from 8.8 ± 27.8 to 2.2 ± 6.2 (P=.005). Hypotension decreased from 33% to 15% (P=.03). The percentage of infants with bronchopulmonary dysplasia was 17% before and 8% after (P=.27). Nurse staffing ratios remained unchanged. CONCLUSIONS: Implementation of these potentially better practices reduced the need for MV, surfactant, and supplemental oxygen as well as reduced hypotension among infants born before 33 weeks' gestation without adverse consequences. The costs for equipment and surfactant were lower.

NPAS1 regulates branching morphogenesis in embryonic lung.

Drosophila trachealess (Trl), master regulator of tracheogenesis, has no known functional mammalian homolog. We hypothesized that genes similar to trachealess regulate lung development. Quantitative (Q)RT-PCR and immunostaining were used to determine spatial and temporal patterns of npas1 gene expression in developing murine lung. Immunostaining for alpha-smooth muscle actin demonstrated myofibroblasts, and protein gene product (PGP)9.5 identified neuroendocrine cells. Branching morphogenesis of embryonic lung buds was analyzed in the presence of antisense or sense oligodeoxynucleotides (ODN). Microarray analyses were performed to screen for changes in gene expression in antisense-treated lungs. QRT-PCR was used to validate the altered expression of key genes identified on the microarrays. We demonstrate that npas1 is expressed in murine embryonic lung. npas1 mRNA peaks early at Embryonic Day (E)10.5-E11.5, then drops to low levels. Sequencing verifies the identity of npas1 transcripts in embryonic lung. NPAS1 immunostaining occurs in nuclei of parabronchial mesenchymal cells, especially at the tracheal bifurcation. Arnt, the murine homolog of Tango (the heterodimerization partner for Trl) is also expressed in developing lung but at constant levels. npas1- or arnt-antisense ODN inhibit lung branching morphogenesis, with altered myofibroblast development and increased pulmonary neuroendocrine cells. On microarrays, we identify > 50 known genes down-regulated by npas1-antisense, including multiple genes regulating cell migration and cell differentiation. QRT-PCR confirms significantly decreased expression of the neurogenic genes RBP-Jk and Tle, and three genes involved in muscle development: beta-ig-h3, claudin-11, and myocardin. Npas1 can regulate myofibroblast distribution, branching morphogenesis, and neuroendocrine cell differentiation in murine embryonic lung.