"It's hard to wait": Provider Perspectives on Current Genomic Care in Safety-Net NICUs.

PURPOSE: Critically ill infants from marginalized populations disproportionately receive care in neonatal intensive care units (NICUs) that lack access to state-of-the-art genomic care, leading to inequitable outcomes. We sought provider perspectives to inform our implementation study (VIGOR) providing rapid genomic sequencing within these settings. METHODS: We conducted semi-structured focus groups with neonatal and genetics providers at five NICUs at safety-net hospitals, informed by the Promoting Action on Research Implementation in Health Services framework, which incorporates evidence, context, and facilitation domains. We iteratively developed codes and themes until thematic saturation was reached. RESULTS: Regarding evidence, providers felt that genetic testing benefits infants and families. Regarding context, the major barriers identified to genomic care were genetic testing cost, lack of genetics expertise for disclosure and follow-up, and navigating the complexity of selecting and ordering genetic tests. Providers had negative feelings about the current status quo and inequity in genomic care across NICUs. Regarding facilitation, providers felt that a virtual support model like VIGOR would address major barriers and foster family-centered care and collaboration. CONCLUSION: NICU providers at safety-net hospitals believe that access to state-of-the-art genomic care is critical for optimizing infant outcomes, yet substantial barriers exist that the VIGOR study may address.

Implementation of rapid genomic sequencing in safety-net neonatal intensive care units: protocol for the VIrtual GenOme CenteR (VIGOR) proof-of-concept study.

INTRODUCTION: Rapid genomic sequencing (rGS) in critically ill infants with suspected genetic disorders has high diagnostic and clinical utility. However, rGS has primarily been available at large referral centres with the resources and expertise to offer state-of-the-art genomic care. Critically ill infants from racial and ethnic minority and/or low-income populations disproportionately receive care in safety-net and/or community settings lacking access to state-of-the-art genomic care, contributing to unacceptable health equity gaps. VIrtual GenOme CenteR is a 'proof-of-concept' implementation science study of an innovative delivery model for genomic care in safety-net neonatal intensive care units (NICUs). METHODS AND ANALYSIS: We developed a virtual genome centre at a referral centre to remotely support safety-net NICU sites predominantly serving racial and ethnic minority and/or low-income populations and have limited to no access to rGS. Neonatal providers at each site receive basic education about genomic medicine from the study team and identify eligible infants. The study team enrols eligible infants (goal n of 250) and their parents and follows families for 12 months. Enrolled infants receive rGS, the study team creates clinical interpretive reports to guide neonatal providers on interpreting results, and neonatal providers return results to families. Data is collected via (1) medical record abstraction, (2) surveys, interviews and focus groups with neonatal providers and (3) surveys and interviews with families. We aim to examine comprehensive implementation outcomes based on the Proctor Implementation Framework using a mixed methods approach. ETHICS AND DISSEMINATION: This study is approved by the institutional review board of Boston Children's Hospital (IRB-P00040496) and participating sites. Participating families are required to provide electronic written informed consent and neonatal provider consent is implied through the completion of surveys. The results will be disseminated via peer-reviewed publications and data will be made accessible per National Institutes of Health (NIH) policies. TRIAL REGISTRATION NUMBER: NCT05205356/clinicaltrials.gov.

Unconditional cash transfers for preterm neonates: evidence, policy implications, and next steps for research.

To address socioeconomic disparities in the health outcomes of preterm infants, we must move beyond describing these disparities and focus on the development and implementation of interventions that disrupt the factors contributing to them. Unconditional cash transfers (UCTs), which provide unrestricted payments to individuals or households, can help mitigate income disparities and improve health outcomes. While UCTs have been utilized for other vulnerable populations, their full potential has yet to be realized for low-income families with preterm infants, who face significant financial strain. In this perspective, we review evidence supporting UCTs as an intervention for children in the U.S. (including those born term and preterm), discuss the potential benefits of recurring UCTs to low-income families of preterm infants, and propose a conceptual model through which UCTs may improve outcomes for preterm infants. We conclude with potential policy levers for implementing UCTs and key unanswered questions for researchers.

Parent and grandparent neonatal intensive care unit visitation for preterm infants.

OBJECTIVE: Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes. STUDY DESIGN: Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared. RESULTS: Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%). CONCLUSION: Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up.

Evaluation of putative signatures of consciousness using specific definitions of responsiveness, connectedness, and consciousness.

BACKGROUND: Understanding the neural correlates of consciousness has important ramifications for the theoretical understanding of consciousness and for clinical anaesthesia. A major limitation of prior studies is the use of responsiveness as an index of consciousness. We identified a collection of measures derived from unresponsive subjects and more specifically their association with consciousness (any subjective experience) or connectedness (specific experience of environmental stimuli). METHODS: Using published data generated through the UNderstanding Consciousness Connectedness and Intra-Operative Unresponsiveness Study (NCT03284307), we evaluated 10 previously published resting-state EEG-based measures that were derived using unresponsiveness as a proxy for unconsciousness. Measures were tested across dexmedetomidine and propofol sedation and natural sleep. These markers represent the complexity, connectivity, cross-frequency coupling, graph theory, and power spectrum measures. RESULTS: Although many of the proposed markers were associated with consciousness per se (reported subjective experience), none were specific to consciousness alone; rather, each was also associated with connectedness (i.e. awareness of the environment). In addition, multiple markers showed no association with consciousness and were associated only with connectedness. Of the markers tested, loss of normalised-symbolic transfer entropy (front to back) was associated with connectedness across all three experimental conditions, whereas the transition from disconnected consciousness to unconsciousness was associated with significant decreases in permutation entropy and spectral exponent (P<0.05 for all conditions). CONCLUSIONS: None of the proposed EEG-based neural correlates of unresponsiveness corresponded solely to consciousness, highlighting the need for a more conservative use of the term (un)consciousness when assessing unresponsive participants. CLINICAL TRIAL REGISTRATION: NCT03284307.

Prescription for Cash? Cash Support to Low-Income Families in Maternal and Pediatric Health Care Settings.

Policy Points Pregnancy and childhood are periods of heightened economic vulnerability, but current policies for addressing health-related social needs, including screening and referral programs, may be insufficient because of persistent gaps, incomplete follow-up, administrative burden, and limited take-up. To bridge gaps in the social safety net, direct provision of cash transfers to low-income families experiencing health challenges during pregnancy, infancy, and early childhood could provide families with the flexibility and support to enable caregiving, increase access to health care, and improve health outcomes.

Early Bloomers: A Nursing-Driven Program to Support Human Milk Feeding Among Late Preterm Infants in the Mother-Baby Unit.

Late preterm infants have lower breastfeeding rates than term infants, yet few published interventions or guidelines exist to guide hospitals in managing them in the non-intensive nursery setting. Here we describe the development and implementation of an interdisciplinary, hospital-based, breastfeeding support program among late preterm infants not requiring intensive care. The Early Bloomer Program includes an order set applied at birth, immediate lactation consultation, availability of donor milk, parent education on late preterm infants, hand expression teaching and kit including spoon and video link, and daily interdisciplinary team huddles. The program was developed with staff input using Diffusion of Innovation Theory, and implemented first among early adopters before expanding to all postpartum nurses. Nursing staff received education on late preterm infant physiology and feeding, and trainings on the Early Bloomers program through various learning modalities during the year leading up to implementation. To further understand the strengths and weakness of the program, we surveyed nurses (n = 43). Nurses reported that they were more attentive to the needs of late preterm infants, more confident in their care, and more aware of possible complications and feeding needs. Areas noted in need of improvement included lack of overnight lactation consults and little involvement of labor and delivery staff in the program. The Early Bloomers program increased confidence in care and was well received by nurses. Well-designed clinical studies are needed to identify effective breastfeeding support practices for late preterm infants.

Variation in Hospital Practices Regarding Marijuana Use in Pregnancy and Lactation.

Background and Objectives: Evidence is lacking on the safety of marijuana (MJ) exposure on the fetus and neonate, and current guidelines vary across professional organizations. We examined variation in hospital practices regarding use of mother's own milk (MOM) in the setting of perinatal MJ exposure based on hospital location and state MJ legal designation. Methods: We conducted a cross-sectional electronic survey of U.S. perinatal health care workers on hospital policies and clinical practice regarding maternal MJ use from November 2021 to April 2022. We analyzed responses from those working in states with legal recreational MJ (REC), MJ legal for medical use only (MED), and illegal MJ (NON), based on legalization status as of 2021. Results: Two thousand six hundred eighty-three surveys were analyzed from 50 states and the District of Columbia, with 1,392 respondents from REC states, 524 from NON states, and 668 from MED states. Hospital policies and practices showed significant differences between facilities from REC and NON states. REC states were more likely to have policies allowing use of MOM from mothers using MJ after delivery and less likely to routinely include cannabinoids in toxicology testing. Hospital policies also varied within individual hospitals between well baby nurseries and neonatal intensive care units. Conclusions: Hospital practices vary widely surrounding provision of MOM in the presence of maternal MJ use, based on state legalization status and hospital unit of care. Clear guidelines across professional organizations regarding perinatal MJ exposure, regardless of legality, are warranted to improve consistency of care and patient education.

"We Don't Want to Screen for the Sake of Screening": A Qualitative Evaluation of a Social Needs Screening and Referral Intervention in the NICU.

BACKGROUND: Low uptake of social determinants of health (SDH) screening and referral interventions within neonatal intensive care units (NICUs) is partly due to limited understanding of the best procedures to integrate this practice into routine clinical workflows. PURPOSE: To examine the feasibility and acceptability of an SDH screening and referral intervention in the NICU from the perspective of neonatal nurses; and to identify factors affecting implementation outcomes. METHODS: We conducted 25 semistructured interviews with NICU nurses. We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to guide interview questions and codebook development for directed content analysis. Themes were mapped onto the 3 PARiHS domains of context, evidence, and facilitation. FINDINGS: Analysis yielded 8 themes. Context: Nurses felt that stressors experienced by NICU families are magnified in a safety net environment. Nurses shared varying viewpoints of the roles and responsibilities for social care in the NICU, and feared that scarcity of community resources would make it difficult to address families' needs. Evidence: The intervention was perceived to increase identification of adverse SDH and provision of resources; and to potentially jump-start better caregiver and infant health trajectories. Facilitation: Procedures that improved acceptability included dynamic training and champion support, regular feedback on intervention outcomes, and strategies to reduce stigma and bias. CONCLUSION: We identified contextual factors, concrete messaging, and training procedures that may inform implementation of SDH screening and referral in NICU settings.

Resolution of elevated interleukin-6 after surgery is associated with return of normal cognitive function.

BACKGROUND: Unresolved surgical inflammation might induce chronic cognitive decline in older adults. Although inflammatory biomarkers have been correlated with perioperative cognitive impairment and delirium, the effects of prolonged inflammation on cognition are not well studied. This prospective cohort study investigated 1-yr dynamics in plasma interleukin-6 levels and executive function. METHODS: Patients undergoing major surgery (n=170) aged ≥65 yr completed Trail Making Test B and other neuropsychological assessments with plasma interleukin-6 levels collected on postoperative days 1-9 and 90, and at 1-yr. Mixed-effects analyses were conducted for Trail Making Test B (and other assessments), including interleukin-6 levels, time, and additional confounders (fixed effects), and a random effect for participant. RESULTS: Changes in interleukin-6 levels were associated with changes in Trail Making Test B over 1 yr in a generalised additive model (ß=0.074, P<0.001) supporting that unresolved inflammation impaired executive function. This result was robust to confounders, outlier rejection, and fitting to non-linear models. Changes in interleukin-6 levels also correlated with changes in Trail Making Test A and Controlled Oral Word Association Test. Sensitivity analyses conducted on binary definitions of cognitive decline (>1, >1.5, or >2 standard deviations from baseline) were also associated with interleukin-6 changes. CONCLUSIONS: Delayed resolution of inflammation is associated with cognitive impairment after surgery. Monitoring interleukin-6 might provide an opportunity to intervene with anti-inflammatory therapies in vulnerable patients. CLINICAL TRIAL REGISTRATION: NCT01980511, NCT03124303.

The Reviewer Academy of the Society of Critical Care Medicine: Key Principles and Strategic Plan.

The Society of Critical Care Medicine (SCCM) Reviewer Academy seeks to train and establish a community of trusted, reliable, and skilled peer reviewers with diverse backgrounds and interests to promote high-quality reviews for each of the SCCM journals. Goals of the Academy include building accessible resources to highlight qualities of excellent manuscript reviews; educating and mentoring a diverse group of healthcare professionals; and establishing and upholding standards for insightful and informative reviews. This manuscript will map the mission of the Reviewer Academy with a succinct summary of the importance of peer review, process of reviewing a manuscript, and the expected ethical standards of reviewers. We will equip readers to target concise, thoughtful feedback as peer reviewers, advance their understanding of the editorial process and inspire readers to integrate medical journalism into diverse professional careers.

Drivers of decision-making regarding infant sleep practices among mothers with opioid use disorder.

OBJECTIVE: To understand the perspectives and perceived facilitators of and barriers to following safe infant sleeping practices among mothers with opioid use disorder (OUD). STUDY DESIGN: Using the Theory of Planned Behavior (TPB) framework, we conducted qualitative interviews with mothers with OUD regarding infant sleep practices. We created codes and generated themes, concluding data collection upon achieving thematic saturation. RESULTS: Twenty-three mothers with infants 1-7 months of age were interviewed from 08/2020 to 10/2021. Mothers chose sleeping practices they perceived made their infants safer, more comfortable, and minimized infant withdrawal symptoms. Mothers in residential treatment facilities were influenced by facility infant sleep rules. Hospital sleep modeling and varied advice by providers, friends and family influenced maternal decisions. CONCLUSIONS: Mothers reported factors unique to their experience with OUD that influenced their decisions about infant sleep that should be considered when developing tailored interventions to promote safe infant sleep in this population.

Understanding cigarette smoking among mothers with opioid use disorder.

BACKGROUND: Cigarette smoking is highly prevalent among mothers with opioid use disorder (OUD). Organizations such as the American College of Obstetrics and Gynecology recommend cessation of cigarettes during the pre- and postnatal periods. Factors that inform decisions to continue or stop smoking cigarettes among pregnant and postpartum mothers with OUD are unclear. AIMS: This study aimed to understand (1) the lived experience of mothers with OUD regarding cigarette smoking and (2) barriers and facilitators to reduction of cigarette smoking during the pre- and postnatal periods. METHODS: Guided by the Theory of Planned Behavior (TPB) framework, we completed semi-structured, in-depth interviews with mothers with OUD with infants 2-7 months of age. We used an iterative approach to analysis by conducting interviews and developing and revising codes and themes until we reached thematic saturation. RESULTS: Fifteen of 23 mothers reported smoking cigarettes prenatally and postnatally, 6 of 23 smoked cigarettes during the prenatal period only, and 2 mothers were non-smokers. We found that mothers: 1) believed that smoke exposure had negative health consequences and may exacerbate withdrawal symptoms for their infants; 2) implemented risk mitigation practices, which were dictated both by themselves and by outside rules, to reduce the harmful effects of smoke around infants; 3) were motivated to quit or cut-down on smoking because of the desire to optimize the health and well-being of their infants; 4) continued to smoke because they felt that the stress related to caregiving and their own recovery were a higher priority than quitting smoking; and 5) were influenced by exposure to smokers with whom they lived, as well as by the varied advice of medical providers, family, and friends. CONCLUSION: While mothers with OUD acknowledged the negative health impact of cigarette smoke exposure to their infants, many experienced stressors related to recovery and caregiving unique to those with OUD that impacted their cigarette smoking behaviors.

Breastfeeding Decision-Making Among Mothers with Opioid Use Disorder: A Qualitative Study.

Background: Factors that contribute to low initiation and continuation of breastfeeding among mothers with opioid use disorder (OUD) are poorly understood. Objective: To understand barriers and facilitators to breastfeeding initiation and continuation beyond the birth hospitalization for mothers with OUD. Materials and Methods: We conducted 23 in-depth, semistructured interviews with mothers with OUD who cared for their infants at home 1-7 months after birth. Our interview guide was informed by the Theory of Planned Behavior (TPB) framework, which has been used to understand decision-making regarding breastfeeding. An iterative approach was used to develop codes and themes. Results: Among 23 participants, 16 initiated breastfeeding, 10 continued after hospital discharge, and 4 continued beyond 8 weeks. We identified factors influencing breastfeeding decisions in the four TPB domains. Regarding attitudes, feeding intentions were based on beliefs of the healthiness of breastfeeding particularly pertaining to infant withdrawal or exposure to mothers' medications. Regarding social norms, breastfeeding was widely recommended, but mothers had varying levels of trust in medical professional advice. Regarding perceived control, infant withdrawal and maternal pain caused breastfeeding to be difficult, with decisions to continue modulated by level of outside support. Regarding self-efficacy, mothers weighed their own recovery and well-being against the constant demands of breastfeeding, impacting decisions to continue. Conclusion: Mothers with OUD face unique barriers to breastfeeding related to their infants' withdrawal as well as their own health, recovery, and social context. Overcoming these barriers may serve as future intervention targets for breastfeeding promotion among this high-risk population.

Pediatric Critical Care in the Twenty-first Century and Beyond.

Pediatric critical care addresses prevention, diagnosis, and treatment of organ dysfunction in the setting of increasingly complex patients, therapies, and environments. Soon burgeoning data science will enable all aspects of intensive care: driving facilitated diagnostics, empowering a learning health-care environment, promoting continuous advancement of care, and informing the continuum of critical care outside the intensive care unit preceding and following critical illness/injury. Although novel technology will progressively objectify personalized critical care, humanism, practiced at the bedside, defines the essence of pediatric critical care now and in the future.