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Sayeed S, Reeves BC, Theriault BC, Hengartner AC, Ahsan N, Sadeghzadeh S, Elsamadicy EA, DiLuna M, Elsamadicy AA. Reduced racial disparities among newborns with intraventricular hemorrhage. Childs Nerv Syst 2024; 40:2051-2059. [PMID: 38526575 DOI: 10.1007/s00381-024-06369-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/17/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Intraventricular hemorrhage (IVH) can ensue permanent neurologic dysfunction, morbidity, and mortality. While previous reports have identified disparities based on patient gender or weight, no prior study has assessed how race may influence in neonatal or infantile IVH patients. The aim of this study was to investigate the impact of race on adverse event (AE) rates, length of stay (LOS), and total cost of admission among newborns with IVH. METHODS Using the 2016-2019 National Inpatient Sample database, newborns diagnosed with IVH were identified using ICD-10-CM codes. Patients were stratified based on race. Patient characteristics and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of race on extended LOS and exorbitant cost. RESULTS Of 1435 patients, 650 were White (45.3%), 270 African American (AA) (18.8%), 300 Hispanic (20.9%), and 215 Other (15.0%). A higher percentage of AA and Other patients than Hispanic and White patients were < 28 days old (p = 0.008). Each of the cohorts had largely similar presenting comorbidities and symptoms, although AA patients did have significantly higher rates of NEC (p < 0.001). There were no observed differences in rates of AEs, rates of mortality, mean LOS, or mean total cost of admission. Similarly, on multivariate analysis, no race was identified as a significant independent predictor of extended LOS or exorbitant cost. CONCLUSIONS Our study found that in newborns with IVH, race is not associated with proxies of poor healthcare outcomes like prolonged LOS or excessive cost. Further studies are needed to validate these findings.
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Affiliation(s)
- Sumaiya Sayeed
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Brianna C Theriault
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Nabihah Ahsan
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Emad A Elsamadicy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Vanderbilt University, Nashville, TN, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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Edwards EM, Ehret DEY, Horbar JD. Potentially Better Practices for Follow Through in Neonatal Intensive Care Units. Pediatrics 2024:e2023065530. [PMID: 38872618 DOI: 10.1542/peds.2023-065530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 06/15/2024] Open
Abstract
OBJECTIVE To ascertain how NICU teams are undertaking action to follow through, involving teams, families, and communities as partners to address health-related social needs of infants and families. METHODS Nineteen potentially better practices (PBPs) for follow through first published in 2020 were reported and analyzed as a sum, overall, and by safety-net hospital status, hospital ownership, and NICU type, among US NICUs that finalized Vermont Oxford Network data collection in 2023. RESULTS One hundred percent of 758 eligible hospitals completed the annual membership survey, of which 57.5% reported screening for social risks. Almost all NICUs offered social work, lactation support, and translation services, but only 16% included a lawyer or paralegal on the team. Overall, 90.2% helped families offset financial costs while their infants were in the hospital, either with direct services or vouchers. At discharge, 94.0% of NICUs connected families with appropriate community organizations and services, 52.9% provided telemedicine after discharge, and 11.7% conducted home visits. The median number of PBPs at each hospital was 10 (25th percentile: 8, 75th percentile: 12). The number of PBPs reported differed by hospital control or ownership and level of NICU care. There were no differences by safety-net hospital status. CONCLUSIONS Despite concerns about time and resources, a diverse set of US NICUs reported adopting potentially better practices for follow through. However, the marked variation among NICUs and the lower rates at for-profit and lower-level NICUs suggest there is substantial opportunity for improvement.
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Affiliation(s)
- Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, Vermont
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, Burlington, Vermont
| | - Danielle E Y Ehret
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, Vermont
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, Vermont
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Vesoulis ZA, Diggs S, Brackett C, Sullivan B. Racial and geographic disparities in neonatal brain care. Semin Perinatol 2024:151925. [PMID: 38897830 DOI: 10.1016/j.semperi.2024.151925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
In this review, we explore race-based disparities in neonatology and their impact on brain injury and neurodevelopmental outcomes. We discuss the historical context of healthcare discrimination, focusing on the post-Civil War era and the segregation of healthcare facilities. We highlight the increasing disparity in infant mortality rates between Black and White infants, with premature birth being a major contributing factor, and emphasize the role of prenatal factors such as metabolic syndrome and toxic stress in affecting neonatal health. Furthermore, we examine the geographic and historical aspects of racial disparities, including the consequences of redlining and limited access to healthcare facilities or nutritious food options in Black communities. Finally, we delve into the higher incidence of brain injuries in Black neonates, as well as disparities in adverse neurodevelopmental outcome. This evidence underscores the need for comprehensive efforts to address systemic racism and provide equitable access to healthcare resources.
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Affiliation(s)
- Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Stephanie Diggs
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Cherise Brackett
- Department of Pediatrics, Division of Neonatology, University of Virginia, USA
| | - Brynne Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia, USA
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Taneri PE, Devane D, Kirkham J, Molloy E, Daly M, Branagan A, Suguitani D, Wynn JL, Kissoon N, Kawaza K, Simons SHP, Bonnard LN, Giannoni E, Strunk T, Ohaja M, Mugabe K, Quirke F, Bazilio K, Biesty L. Outcomes of interventions in neonatal sepsis: A systematic review of qualitative research. Int J Gynaecol Obstet 2024. [PMID: 38842248 DOI: 10.1002/ijgo.15725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/23/2024] [Accepted: 05/26/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND While a systematic review exists detailing neonatal sepsis outcomes from clinical trials, there remains an absence of a qualitative systematic review capturing the perspectives of key stakeholders. OBJECTIVES Our aim is to identify outcomes from qualitative research on any intervention to prevent or improve the outcomes of neonatal sepsis that are important to parents, other family members, healthcare providers, policymakers, and researchers as a part of the development of a core outcome set (COS) for neonatal sepsis. SEARCH STRATEGY A literature search was carried out using MEDLINE, EMBASE, CINAHL, and PsycInfo databases. SELECTION CRITERIA Publications describing qualitative data relating to neonatal sepsis outcomes were included. DATA COLLECTION AND ANALYSIS Drawing on the concepts of thematic synthesis, texts related to outcomes were coded and grouped. These outcomes were then mapped to the domain headings of an existing model. MAIN RESULTS Out of 6777 records screened, six studies were included. Overall, 19 outcomes were extracted from the included studies. The most frequently reported outcomes were those in the domains related to parents, healthcare workers and individual organ systemas such as gastrointestinal system. The remaining outcomes were classified under the headings of general outcomes, miscellaneous outcomes, survival, and infection. CONCLUSIONS The outcomes identified in this review are different from those reported in neonatal sepsis clinical trials, thus highlighting the importance of incorporating qualitative studies into COS development to encapsulate all relevant stakeholders' perspectives.
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Affiliation(s)
- Petek Eylul Taneri
- HRB-Trials Methodology Research Network, University of Galway, Galway, Ireland
- School of Nursing & Midwifery, University of Galway, Galway, Ireland
| | - Declan Devane
- HRB-Trials Methodology Research Network, University of Galway, Galway, Ireland
- School of Nursing & Midwifery, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland & Cochrane Ireland, University of Galway, Galway, Ireland
| | - Jamie Kirkham
- Centre for Biostatistics, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Eleanor Molloy
- Department of Neonatology, Coombe Hospital, Dublin, Ireland
- Department of Paediatrics and Child Health &Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
- Neonatology, Children's Health Ireland, Dublin, Ireland
| | - Mandy Daly
- Advocacy and Policymaking, Irish Neonatal Health Alliance, Bray, Ireland
| | - Aoife Branagan
- Department of Neonatology, Coombe Hospital, Dublin, Ireland
- Department of Paediatrics and Child Health &Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
| | - Denise Suguitani
- Brazilian Parents of Preemies' Association, Porto Alegre, Brazil
| | - James L Wynn
- Department of Paediatrics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Niranjan Kissoon
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kondwani Kawaza
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatric and Neonatal Intensive Care, Erasmus UMC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Eric Giannoni
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Tobias Strunk
- Neonatal Directorate, Child and Adolescent Health Service; Wesfarmers' Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Magdalena Ohaja
- School of Nursing & Midwifery, University of Galway, Galway, Ireland
| | - Kenneth Mugabe
- Mbale Regional Referral Hospital, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Fiona Quirke
- HRB-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | | | - Linda Biesty
- School of Nursing & Midwifery, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland & Cochrane Ireland, University of Galway, Galway, Ireland
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Mohamed TH, Mpody C, Nafiu O. Perioperative Neonatal Acute Kidney Injury Is Common: Risk Factors for Poor Outcomes. Am J Perinatol 2024; 41:e2818-e2823. [PMID: 37643826 DOI: 10.1055/a-2161-7663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Perioperative acute kidney injury (AKI) is associated with poor patient outcomes. The epidemiology of perioperative AKI is characterized in children and to a lesser extent in neonates with cardiac disease. We hypothesized that the prevalence of noncardiac perioperative AKI in neonates is higher than in older children. We also hypothesized that certain neonatal characteristics and comorbidities increase the risk of perioperative AKI and hospital mortality. We aimed to characterize the epidemiology and risk factors of perioperative AKI in neonates undergoing noncardiac surgeries and outline the associated mortality risk factors. STUDY DESIGN We performed a retrospective study of neonates ≤28 days old who underwent inpatient noncardiac surgery in 46 U.S. children's hospitals participating in the Pediatric Hospital Information System between 2016 and 2021. AKI was evaluated throughout the surgical admission encounter. AKI was defined using the International Classification of Diseases (ICD) versions 9 and 10 codes. Comorbid risk factors are chronic and longstanding diagnoses and were selected using ICD-9 and ICD-10 diagnostic and procedure codes. RESULTS Perioperative AKI occurred in 10% of neonates undergoing noncardiac surgeries. Comorbidities associated with high risk of perioperative AKI included metabolic, hematologic/immunologic, cardiovascular, and renal disorders. The relative risk of mortality in perioperative AKI was highest in infants with low birthweight (relative risk = 1.49, 1.14-1.94) and those with hematologic (1.46, 1.12-1.90), renal (1.24, 1.01-1.52), and respiratory comorbidities (1.35, 1.09-1.67). CONCLUSION Perioperative AKI is common in neonates undergoing noncardiac surgeries. Infants with high-risk comorbidity profiles for the development of perioperative AKI and mortality may benefit from close surveillance of their kidney function in the perioperative period. Although retrospective, the findings of our study could inform clinicians to tailor neonatal perioperative kidney care to improve short- and long-term outcomes. KEY POINTS · AKI is common in neonates undergoing noncardiac surgeries.. · Extremely preterm and very low birth weight neonates have the highest rates of perioperative AKI.. · Renal, hematologic, and respiratory comorbidities increase mortality risk in neonates with perioperative AKI..
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Affiliation(s)
- Tahagod H Mohamed
- The Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Olubukola Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Brumbaugh JE, Bann CM, Bell EF, Travers CP, Vohr BR, McGowan EC, Harmon HM, Carlo WA, Hintz SR, Duncan AF. Social Determinants of Health and Redirection of Care for Infants Born Extremely Preterm. JAMA Pediatr 2024; 178:454-464. [PMID: 38466268 PMCID: PMC10928542 DOI: 10.1001/jamapediatrics.2024.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/17/2024] [Indexed: 03/12/2024]
Abstract
Importance Redirection of care refers to withdrawal, withholding, or limiting escalation of treatment. Whether maternal social determinants of health are associated with redirection of care discussions merits understanding. Objective To examine associations between maternal social determinants of health and redirection of care discussions for infants born extremely preterm. Design, Setting, and Participants This is a retrospective analysis of a prospective cohort of infants born at less than 29 weeks' gestation between April 2011 and December 2020 at 19 National Institute of Child Health and Human Development Neonatal Research Network centers in the US. Follow-up occurred between January 2013 and October 2023. Included infants received active treatment at birth and had mothers who identified as Black or White. Race was limited to Black and White based on service disparities between these groups and limited sample size for other races. Maternal social determinant of health exposures were education level (high school nongraduate or graduate), insurance type (public/none or private), race (Black or White), and ethnicity (Hispanic or non-Hispanic). Main Outcomes and Measures The primary outcome was documented discussion about redirection of infant care. Secondary outcomes included subsequent redirection of care occurrence and, for those born at less than 27 weeks' gestation, death and neurodevelopmental impairment at 22 to 26 months' corrected age. Results Of the 15 629 infants (mean [SD] gestational age, 26 [2] weeks; 7961 [51%] male) from 13 643 mothers, 2324 (15%) had documented redirection of care discussions. In unadjusted comparisons, there was no significant difference in the percentage of infants with redirection of care discussions by race (Black, 1004/6793 [15%]; White, 1320/8836 [15%]) or ethnicity (Hispanic, 291/2105 [14%]; non-Hispanic, 2020/13 408 [15%]). However, after controlling for maternal and neonatal factors, infants whose mothers identified as Black or as Hispanic were less likely to have documented redirection of care discussions than infants whose mothers identified as White (Black vs White adjusted odds ratio [aOR], 0.84; 95% CI, 0.75-0.96) or as non-Hispanic (Hispanic vs non-Hispanic aOR, 0.72; 95% CI, 0.60-0.87). Redirection of care discussion occurrence did not differ by maternal education level or insurance type. Conclusions and Relevance For infants born extremely preterm, redirection of care discussions occurred less often for Black and Hispanic infants than for White and non-Hispanic infants. It is important to explore the possible reasons underlying these differences.
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Affiliation(s)
- Jane E. Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Carla M. Bann
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | | | - Colm P. Travers
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Betty R. Vohr
- Department of Pediatrics, Women & Infants Hospital of Rhode Island and Warren Albert Medical School of Brown University, Providence
| | - Elisabeth C. McGowan
- Department of Pediatrics, Women & Infants Hospital of Rhode Island and Warren Albert Medical School of Brown University, Providence
| | | | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Andrea F. Duncan
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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7
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Shukla VV, Youngblood EM, Tindal RR, Carlo WA, Travers CP. Persistent disparities in black infant mortality across gestational ages in the United States. J Perinatol 2024; 44:584-586. [PMID: 38160225 DOI: 10.1038/s41372-023-01863-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA.
| | - Emily M Youngblood
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
| | - Rachel R Tindal
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
| | - Waldemar A Carlo
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
| | - Colm P Travers
- University of Alabama at Birmingham, Division of Neonatology, Birmingham, AL, USA
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Dail RB, Everhart KC, Iskersky V, Chang W, Fisher K, Warren K, Steflik HJ, Hardin JW. Prenatal and Postnatal Disparities in Very-Preterm Infants in a Study of Infections between 2018-2023 in Southeastern US. Trop Med Infect Dis 2024; 9:70. [PMID: 38668531 PMCID: PMC11054784 DOI: 10.3390/tropicalmed9040070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND The birthrate of Black preterm (BPT) infants is 65% higher than White preterm (WPT) infants with a BPT mortality that is 2.3 times higher. The incidence of culture-positive late-onset sepsis is as high as 41% in very-preterm infants. The main purpose of this study was to examine thermal gradients and the heart rate in relation to the onset of infection. This report presents disparities in very-preterm infection incidence, bacteria, and mortality data amongst BPT and WPT infants. METHODS 367 preterms born at <32 weeks gestational age (GA) between 2019-2023 in five neonatal intensive care units (NICUs) were enrolled to study the onset of infections and dispositions; REDCap data were analyzed for descriptive statistics. RESULTS The 362 infants for analyses included 227 BPTs (63.7%) and 107 WPTs (29.6%), with 28 infants of other races/ethnicities (Hispanic, Asian, and other), 50.6% female, mean GA of 27.66 weeks, and 985.24 g birthweight. BPT infants averaged 968.56 g at birth (SD 257.50), and 27.68 (SD 2.07) weeks GA, compared to WPT infants with a mean birthweight of 1006.25 g (SD 257.77, p = 0.2313) and 27.67 (SD 2.00, p = 0.982) weeks GA. Of the 426 episodes of suspected infections evaluated across all the enrolled infants, the incidence of early-onset sepsis (EOS) was 1.9%, with BPT infants having 2.50 times higher odds of EOS than WPT infants (p = 0.4130, OR (odds ratio) = 2.50, p_or = 0.408). The overall incidence of late-onset sepsis (LOS) was 10.8%, with LOS in 11.9% of BPT infants versus 9.3% (p = 0.489, OR = 1.21, p_or = 0.637) of WPT infants. BPT infants made up 69.2% of the 39 infants with Gram-positive infections vs. 25.6% for WPT infants; 16 infants had Gram-negative culture-positive infections, with 81.2% being BPT infants versus 18.8% being WPT infants. Of the 27 urinary tract infections, 78% were in BPTs. The necrotizing enterocolitis incidence was 6.9%; the incidence in BPT infants was 7.5% vs. 6.5% in WPT infants. The overall mortality was 8.3%, with BPTs at 8.4% vs. WPT infants at 9.3%, (p = 0.6715). CONCLUSIONS BPTs had a higher rate of positive cultures, double the Gram-negative infections, a much higher rate of urinary tract infections, and a higher rate of mortality than their WPT counterparts. This study emphasizes the higher risk of morbidity and mortality for BPTs.
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Affiliation(s)
- Robin B. Dail
- Department of Biobehavioral Health & Nursing Science, University of South Carolina, Columbia, SC 29208, USA; (K.C.E.); (K.W.)
| | - Kayla C. Everhart
- Department of Biobehavioral Health & Nursing Science, University of South Carolina, Columbia, SC 29208, USA; (K.C.E.); (K.W.)
| | - Victor Iskersky
- Department of Neonatology, Prisma Health Midlands, Columbia, SC 29203, USA;
| | - Weili Chang
- Department of Pediatrics/Neonatology, East Carolina University, Greenville, NC 27834, USA;
| | - Kimberley Fisher
- Department of Pediatrics/Neonatology, Duke University, Durham, NC 27705, USA;
| | - Karen Warren
- Department of Biobehavioral Health & Nursing Science, University of South Carolina, Columbia, SC 29208, USA; (K.C.E.); (K.W.)
| | - Heidi J. Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - James W. Hardin
- Department of Epidemiology & Biostatistics, University of South Carolina, Columbia, SC 29208, USA;
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9
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Galloway I, Roehr CC, Tan K. Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?-a narrative review. Transl Pediatr 2024; 13:459-473. [PMID: 38590374 PMCID: PMC10998991 DOI: 10.21037/tp-23-468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/07/2024] [Indexed: 04/10/2024] Open
Abstract
Background and Objective The morbidity and mortality of infants born extremely preterm varies substantially across networks, within countries and throughout the globe. Most of the literature tends to focus on the management at birth and choices around active resuscitation of extremely preterm infants. Withdrawal and withholding of life sustaining treatment (WWLST) is an important and central process in the neonatal intensive care unit (NICU) and practices vary substantially. As such, our objective in this review was to explore whether end of life decisions also contribute to variations in the morbidity and mortality of periviable infants. Methods This narrative literature review is based on studies from the last 15 years found using several searches of medical databases (OVID Medline, Scopus and Cochrane Systematic Reviews) performed between March 2021 and December 2023. Key Content and Findings Just as outcomes in periviable infants vary, the rates of and processes behind WWLST differ in the periviable population. Variation increases as gestational age decreases. Parental involvement is crucial to share decision making but the circumstances and rates of parental involvement differ. Strict guidelines in end-of-life care may not be appropriate, however there is a need for more targeted guidance for periviable infants as a specific population. The current literature available relating to periviable infants or WWLST is minimal, with many datasets rapidly becoming outdated. Conclusions Further research is needed to establish the role of WWLST in variation of periviable infants' outcomes. The unification of data, acquisition of more recent datasets and inclusion of variables relating to end-of-life decisions in data collection will aid in this process.
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Affiliation(s)
- Isobel Galloway
- Department of Paediatrics, School of Clinical Sciences, Monash University, Victoria, Australia
| | - Charles Christoph Roehr
- Women’s and Children’s, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
- Faculty of Health Sciences, University of Bristol, Bristol, UK
- National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Kenneth Tan
- Department of Paediatrics, School of Clinical Sciences, Monash University, Victoria, Australia
- Monash Newborn, Monash Children’s Hospital, Victoria, Australia
- School of Medicine, Taylor’s University, Selangor, Malaysia
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10
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ElSeed Peterson EE, Roeckner JT, Deall TW, Karn M, Duncan JR, Flores-Torres J, Kumar A, Randis TM. Need for Gastrostomy Tube in Periviable Infants. Am J Perinatol 2024. [PMID: 38513690 DOI: 10.1055/s-0044-1781461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
OBJECTIVE We sought to identify clinical and demographic factors associated with gastrostomy tube (g-tube) placement in periviable infants. STUDY DESIGN We conducted a single-center retrospective cohort study of live-born infants between 22 and 25 weeks' gestation. Infants not actively resuscitated and those with congenital anomalies were excluded from analysis. RESULTS Of the 243 infants included, 158 survived until discharge. Of those that survived to discharge, 35 required g-tube prior to discharge. Maternal race/ethnicity (p = 0.006), intraventricular hemorrhage (p = 0.013), periventricular leukomalacia (p = 0.003), bronchopulmonary dysplasia (BPD; p ≤ 0.001), and singleton gestation (p = 0.009) were associated with need for gastrostomy. In a multivariable logistic regression, maternal Black race (Odds Ratio [OR] 2.88; 95% confidence interval [CI] 1.11-7.47; p = 0.029), singleton gestation (OR 3.99; 95% CI 1.28-12.4; p = 0.017) and BPD (zero g-tube placement in the no BPD arm; p ≤ 0.001) were associated with need for g-tube. CONCLUSION A high percentage of periviable infants surviving until discharge require g-tube at our institution. In this single-center retrospective study, we noted that maternal Black race, singleton gestation, and BPD were associated with increased risk for g-tube placement in infants born between 22 and 25 weeks' gestation. The finding of increased risk with maternal Black race is consistent with previous reports of racial/ethnic disparities in preterm morbidities. Additional studies examining factors associated with successful achievement of oral feedings in preterm infants are necessary and will inform future efforts to advance equity in newborn health. KEY POINTS · BPD, singleton birth, and Black race are associated with need for g-tube in periviable infants.. · Severe intraventricular hemorrhage is associated with increased mortality or g-tube placement in periviable infants.. · Further investigation into the relationship between maternal race and g-tube placement is warranted..
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Affiliation(s)
- Erica E ElSeed Peterson
- Division of Neonatology, Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Jared T Roeckner
- Division of Maternal-Fetal Medicine, Florida Perinatal Associates, Pediatrix, Tampa, Florida
| | - Taylor W Deall
- Division of Neonatology, Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Michele Karn
- Department of Pediatrics, Johns Hopkins All Children Hospital, St. Petersburg, Florida
| | - Jose R Duncan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Jaime Flores-Torres
- Division of Neonatology, Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Ambuj Kumar
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Tara M Randis
- Division of Neonatology, Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, Florida
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11
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Ponnapakkam A, Carr NR, Comstock BA, Perez K, O'Shea TM, Tolia VN, Clark RH, Heagerty PJ, Juul SE, Ahmad KA. Factors Associated with Outpatient Therapy Utilization in Extremely Preterm Infants. Am J Perinatol 2024; 41:458-469. [PMID: 34753183 DOI: 10.1055/a-1692-0544] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Factors influencing utilization of outpatient interventional therapies for extremely low gestational age newborns (ELGANs) after discharge remain poorly characterized, despite a significant risk of neurodevelopmental impairment. We sought to assess the effects of maternal, infant, and environmental characteristics on outpatient therapy utilization in the first 2 years after discharge using data from the Preterm Erythropoietin Neuroprotection (PENUT) Trial. STUDY DESIGN This is a secondary analysis of 818, 24 to 27 weeks gestation infants enrolled in the PENUT trial who survived through discharge and completed at least one follow-up call or in-person visit between 4 and 24 months of age. Utilization of a state early intervention (EI) program, physical therapy (PT), occupational therapy (OT), and speech therapy (ST) was recorded. Odds ratios and cumulative frequency curves for resource utilization were calculated for patient characteristics adjusting for gestational age, treatment group, and birth weight. RESULTS EI was not accessed by 37% of infants, and 18% did not use any service (PT/OT/ST/EI). Infants diagnosed with severe morbidities (intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis), discharged with home oxygen, or with gastrostomy placement experienced increased utilization of PT, OT, and ST compared with peers. However, substantial variation in service utilization occurred by the state of enrollment and selected maternal characteristics. CONCLUSIONS ELGANs with severe medical comorbidities are more likely to utilize services after discharge. Therapy utilization may be impacted by maternal characteristics and state of enrollment. Outpatient therapy services remain significantly underutilized in this high-risk cohort. Further research is required to characterize and optimize the utilization of therapy services following NICU discharge of ELGANs. KEY POINTS · Outpatient therapy is underutilized in ELGANs.. · Medical comorbidities may impact therapy use.. · Maternal characteristics may impact therapy use.. · State of enrollment may impact therapy use..
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Affiliation(s)
- Adharsh Ponnapakkam
- Department of Pediatrics, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Nicholas R Carr
- Department of Pediatrics, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Bryan A Comstock
- Center for Biomedical Statistics, University of Washington, Seattle, Washington
| | - Krystle Perez
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - T Michael O'Shea
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Veeral N Tolia
- Pediatrix Medical Group, Dallas TX
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, FL
| | - Reese H Clark
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, FL
| | - Patrick J Heagerty
- Center for Biomedical Statistics, University of Washington, Seattle, Washington
| | - Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Kaashif A Ahmad
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, FL
- Pediatrix Medical Group of San Antonio, San Antonio, TX
- Department of Pediatrics, Baylor College of Medicine, San Antonio, TX
- Pediatrix and Obstetrix Specialists of Houston, Houston, TX
- Department of Clinical Sciences, University of Houston, Houston, TX
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12
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Mays EJ, Diggs S, Vesoulis ZA, Warner B. The Effects of Health Disparities on Neonatal Outcomes. Crit Care Nurs Clin North Am 2024; 36:11-22. [PMID: 38296368 DOI: 10.1016/j.cnc.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
The history of racism in the United States was established with slavery, and the carry-over effect continues to impact health care through structural and institutional racism. Racial segregation and redlining have impacted access to quality health care, thereby impacting prematurity and infant mortality rates. Health disparities also impact neonatal morbidities such as intraventricular hemorrhage and necrotizing enterocolitis and the family care experience including the establishment of breastfeeding and health care provider interactions.
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Affiliation(s)
- Erin J Mays
- St. Louis Children's Hospital NICU, 1 Childrens Place, St Louis, MO 63110, USA.
| | - Stephanie Diggs
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, 1 Childrens Place, #8116-NWT 8, St Louis, MO 63110, USA
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, 1 Childrens Place, #8116-NWT 8, St Louis, MO 63110, USA
| | - Barbara Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, 1 Childrens Place, #8116-NWT 8, St Louis, MO 63110, USA
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13
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Gould JB, Bennett MV, Profit J, Lee HC. Cohort selection and the estimation of racial disparity in mortality of extremely preterm neonates. Pediatr Res 2024; 95:792-801. [PMID: 37580552 PMCID: PMC10899100 DOI: 10.1038/s41390-023-02766-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/19/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Racial disparities in preterm neonatal mortality are long-standing. We aimed to assess how cohort selection influences mortality rates and racial disparity estimates. METHODS With 2014-2018 California data, we compared neonatal mortality rates among Black and non-Hispanic White very low birth weight (VLBW, <1500 g) or very preterm infants (22-29 weeks gestational age). Relative risks were estimated by different cohort selection criteria. Blinder-Oaxaca decomposition quantified factors contributing to mortality differential. RESULTS Depending upon standard selection criteria, mortality ranged from 6.2% (VLBW infants excluding first 12-h deaths) to 16.0% (22-29 weeks' gestation including all deaths). Black observed neonatal mortality was higher than White infants only for delivery room deaths in VLBW infants (5.6 vs 4.2%). With risk adjustment accounting for higher rate of low gestational age, low Apgar score and other factors, White infant mortality increased from 15.9 to 16.6%, while Black infant mortality decreased from 16.7 to 13.7% in the 22-29 weeks cohort. Across varying cohort selection, risk adjusted survival advantage among Black infants ranged from 0.70 (CL 0.61-0.80) to 0.84 (CL 0.76-0.93). CONCLUSIONS Standard cohort selection can give markedly different mortality estimates. It is necessary to reduce prematurity rates and perinatal morbidity to improve outcomes for Black infants. IMPACT In this population-based observational cohort study that encompassed very low birth weight infant hospitalizations in California, varying standard methods of cohort selection resulted in neonatal mortality ranges from 6.2 to 16.0%. Across all cohorts, the only significant observed Black-White disparity was for delivery room deaths in Very Low Birth Weight births (5.6 vs 4.2%). Across all cohorts, we found a 16-30% survival advantage for Black infants. Cohort selection can result in an almost three-fold difference in estimated mortality but did not have a meaningful impact on observed or adjusted differences in neonatal mortality outcomes by race and ethnicity.
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Affiliation(s)
- Jeffrey B Gould
- Department of Pediatrics (Neonatology), Stanford University, Stanford, CA, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, USA
| | - Mihoko V Bennett
- Department of Pediatrics (Neonatology), Stanford University, Stanford, CA, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, USA
| | - Jochen Profit
- Department of Pediatrics (Neonatology), Stanford University, Stanford, CA, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, USA
| | - Henry C Lee
- California Perinatal Quality Care Collaborative, Stanford, CA, USA.
- University of California San Diego, La Jolla, CA, USA.
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14
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Slopen N, Chang AR, Johnson TJ, Anderson AT, Bate AM, Clark S, Cohen A, Jindal M, Karbeah J, Pachter LM, Priest N, Suglia SF, Bryce N, Fawcett A, Heard-Garris N. Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:147-158. [PMID: 38242597 DOI: 10.1016/s2352-4642(23)00251-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 08/02/2023] [Accepted: 09/08/2023] [Indexed: 01/21/2024]
Abstract
Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.
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Affiliation(s)
- Natalie Slopen
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Center on the Developing Child, Harvard University, Boston, MA, USA.
| | - Andrew R Chang
- Harvard Medical School, Harvard University, Boston, MA, USA
| | | | - Ashaunta T Anderson
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Aleha M Bate
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA
| | - Shawnese Clark
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alyssa Cohen
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Monique Jindal
- Department of Clinical Medicine, University of Illinois, Chicago, IL, USA
| | - J'Mag Karbeah
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Lee M Pachter
- Institute for Research on Equity and Community Health, ChristianaCare, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; School of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Naomi Priest
- Centre for Social Research and Methods, Australian National University, Canberra, ACT, Australia; Population Health, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nessa Bryce
- Department of Psychology, Harvard University, Boston, MA, USA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Chicago, IL, USA
| | - Nia Heard-Garris
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Department of Pediatrics, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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15
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Higgins BV, Baer RJ, Steurer MA, Karvonen KL, Oltman SP, Jelliffe-Pawlowski LL, Rogers EE. Resuscitation, survival and morbidity of extremely preterm infants in California 2011-2019. J Perinatol 2024; 44:209-216. [PMID: 37689808 PMCID: PMC10844092 DOI: 10.1038/s41372-023-01774-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 08/21/2023] [Accepted: 08/31/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE To describe changes over time in resuscitation, survival, and morbidity of extremely preterm infants in California. STUDY DESIGN This population-based, retrospective cohort study includes infants born ≤28 weeks. Linked birth certificates and hospital discharge records were used to evaluate active resuscitation, survival, and morbidity across two epochs (2011-2014, 2015-2019). RESULTS Of liveborn infants, 0.6% were born ≤28 weeks. Active resuscitation increased from 16.9% of 22-week infants to 98.1% of 25-week infants and increased over time in 22-, 23-, and 25-week infants (p-value ≤ 0.01). Among resuscitated infants, survival to discharge increased from 33.2% at 22 weeks to 96.1% at 28 weeks. Survival without major morbidity improved over time for 28-week infants (p-value < 0.01). CONCLUSION Among infants ≤28 weeks, resuscitation and survival increased with gestational age and morbidity decreased. Over time, active resuscitation of periviable infants and morbidity-free survival of 28-week infants increased. These trends may inform counseling around extremely preterm birth.
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Affiliation(s)
- Brennan V Higgins
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, CA, USA
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Martina A Steurer
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Kayla L Karvonen
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Scott P Oltman
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Laura L Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Elizabeth E Rogers
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
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16
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Cheng TC, Lo CC. Factors Contributing to the Health of 0- to 5-Year-Old Low-Birth-Weight Children in the United States: Application of the Multiple Disadvantage Model. Eur J Investig Health Psychol Educ 2024; 14:203-214. [PMID: 38248133 PMCID: PMC10814834 DOI: 10.3390/ejihpe14010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
This secondary data analysis of 1731 low-birth-weight children and their parents in the United States investigated children's health and its associations with social disorganization, social structural factors, social relationships, health/mental health, and access to health insurance/services. The study drew on data from the 2021 National Survey of Children's Health. Logistic regression yielded results showing low-birth-weight children's excellent/very good/good health to be associated positively with parents' education and health. In turn, child health was associated negatively with being Black, having a family income at or below the 100% federal poverty level, difficulty parenting the child, child chronic health condition(s), parent mental health, and substance use in the family. The implications of the present findings in terms of interventions promoting maternal and child health as well as participation in government assistance programs for low-income families are discussed.
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Affiliation(s)
- Tyrone C. Cheng
- School of Social Work, University of Alabama, Little Hall, Tuscaloosa, AL 35401, USA
| | - Celia C. Lo
- Peraton, Defense Personnel and Security Research Center, Seaside, CA 93955, USA;
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17
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Sullivan BA, Beam K, Vesoulis ZA, Aziz KB, Husain AN, Knake LA, Moreira AG, Hooven TA, Weiss EM, Carr NR, El-Ferzli GT, Patel RM, Simek KA, Hernandez AJ, Barry JS, McAdams RM. Transforming neonatal care with artificial intelligence: challenges, ethical consideration, and opportunities. J Perinatol 2024; 44:1-11. [PMID: 38097685 PMCID: PMC10872325 DOI: 10.1038/s41372-023-01848-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023]
Abstract
Artificial intelligence (AI) offers tremendous potential to transform neonatology through improved diagnostics, personalized treatments, and earlier prevention of complications. However, there are many challenges to address before AI is ready for clinical practice. This review defines key AI concepts and discusses ethical considerations and implicit biases associated with AI. Next we will review literature examples of AI already being explored in neonatology research and we will suggest future potentials for AI work. Examples discussed in this article include predicting outcomes such as sepsis, optimizing oxygen therapy, and image analysis to detect brain injury and retinopathy of prematurity. Realizing AI's potential necessitates collaboration between diverse stakeholders across the entire process of incorporating AI tools in the NICU to address testability, usability, bias, and transparency. With multi-center and multi-disciplinary collaboration, AI holds tremendous potential to transform the future of neonatology.
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Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kristyn Beam
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Khyzer B Aziz
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Ameena N Husain
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lindsey A Knake
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Alvaro G Moreira
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Thomas A Hooven
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elliott M Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, WA, USA
| | - Nicholas R Carr
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - George T El-Ferzli
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ravi M Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelsey A Simek
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Antonio J Hernandez
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - James S Barry
- Division of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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18
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Cucka B, Biglione B, Xia J, Tan AJ, Chand S, Rrapi R, El Saleeby C, Kroshinsky D. Complicated Cellulitis is an Independent Predictor for Increased Length of Stay in the Neonatal Intensive Care Unit. J Pediatr 2023; 262:113581. [PMID: 37353147 DOI: 10.1016/j.jpeds.2023.113581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 05/23/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To assess cellulitis in the neonatal intensive care unit (NICU) setting and identify risk factors for its disease severity and whether cellulitis influences length of stay (LOS). STUDY DESIGN In this retrospective study, patients with cellulitis were identified using the electronic health record while admitted to the NICU at Massachusetts General for Children from January 2007 to December 2020. Demographic and clinical data were extracted from patient records. Two multivariable logistic regression models were constructed to assess for independent predictors for increased LOS (≥30 days) and complicated cellulitis in the hospital. RESULTS Eighty-four patients met the study criteria; 46.4% were older than 14 days at the time of diagnosis of cellulitis, 61.9% were non-White, and 83.3% were born prematurely; 48.8% had complicated cellulitis as defined by overlying hardware (41.7%), sepsis (7.1%), requirement for broadened antibiotic coverage (7.1%), bacteremia (4.8%), and/or abscess (3.6%). The mean hospital LOS was 58.5 ± 36.1 days SD, with 72.6% having a LOS greater than 30 days. Independent predictors of increased LOS were extreme prematurity (<28 weeks' gestation) (OR: 14.7, P = .03), non-White race (OR: 5.7, P = .03), and complicated cellulitis (OR: 6.4, P = .03). No significant predictors of complicated cellulitis were identified. CONCLUSIONS This study identifies complicated cellulitis in the NICU as an independent predictor of increased hospital LOS in neonates. Implementation of strategies to mitigate the development of cellulitis may decrease LOS among this high-risk population.
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Affiliation(s)
- Bethany Cucka
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Bianca Biglione
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Joyce Xia
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Alice J Tan
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Sidharth Chand
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Renajd Rrapi
- Department of Dermatology, Massachusetts General Hospital, Boston, MA
| | - Chadi El Saleeby
- Divisions of Hospital Medicine and Infectious Disease, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA; Harvard Medical School, Boston, MA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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19
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Johnson DL, Carlo WA, Rahman AKMF, Tindal R, Trulove SG, Watt MJ, Travers CP. Health Insurance and Differences in Infant Mortality Rates in the US. JAMA Netw Open 2023; 6:e2337690. [PMID: 37831450 PMCID: PMC10576209 DOI: 10.1001/jamanetworkopen.2023.37690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023] Open
Abstract
Importance Health insurance status is associated with differences in access to health care and health outcomes. Therefore, maternal health insurance type may be associated with differences in infant outcomes in the US. Objective To determine whether, among infants born in the US, maternal private insurance compared with public Medicaid insurance is associated with a lower infant mortality rate (IMR). Design, Setting, and Participants This cohort study used data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research expanded linked birth and infant death records database from 2017 to 2020. Hospital-born infants from 20 to 42 weeks of gestational age were included if the mother had either private or Medicaid insurance. Infants with congenital anomalies, those without a recorded method of payment, and those without either private insurance or Medicaid were excluded. Data analysis was performed from June 2022 to August 2023. Exposures Private vs Medicaid insurance. Main Outcomes and Measures The primary outcome was the IMR. Negative-binomial regression adjusted for race, sex, multiple birth, any maternal pregnancy risk factors (as defined by the CDC), education level, and tobacco use was used to determine the difference in IMR between private and Medicaid insurance. The χ2 or Fisher exact test was used to compare differences in categorical variables between groups. Results Of the 13 562 625 infants included (6 631 735 girls [48.9%]), 7 327 339 mothers (54.0%) had private insurance and 6 235 286 (46.0%) were insured by Medicaid. Infants born to mothers with private insurance had a lower IMR compared with infants born to those with Medicaid (2.75 vs 5.30 deaths per 1000 live births; adjusted relative risk [aRR], 0.81; 95% CI, 0.69-0.95; P = .009). Those with private insurance had a significantly lower risk of postneonatal mortality (0.81 vs 2.41 deaths per 1000 births; aRR, 0.57; 95% CI, 0.47-0.68; P < .001), low birth weight (aRR, 0.90; 95% CI, 0.85-0.94; P < .001), vaginal breech delivery (aRR, 0.80; 95% CI, 0.67-0.96; P = .02), and preterm birth (aRR, 0.92; 95% CI, 0.88-0.97; P = .002) and a higher probability of first trimester prenatal care (aRR, 1.24; 95% CI, 1.21-1.27; P < .001) compared with those with Medicaid. Conclusions and Relevance In this cohort study, maternal Medicaid insurance was associated with increased risk of infant mortality at the population level in the US. Novel strategies are needed to improve access to care, quality of care, and outcomes among women and infants enrolled in Medicaid.
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Affiliation(s)
- Desalyn L. Johnson
- University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | | | | | - Sarah G. Trulove
- University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Mykaela J. Watt
- University of Alabama School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Colm P. Travers
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
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20
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Venkatesan T, Rees P, Gardiner J, Battersby C, Purkayastha M, Gale C, Sutcliffe AG. National Trends in Preterm Infant Mortality in the United States by Race and Socioeconomic Status, 1995-2020. JAMA Pediatr 2023; 177:1085-1095. [PMID: 37669025 PMCID: PMC10481321 DOI: 10.1001/jamapediatrics.2023.3487] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 06/07/2023] [Indexed: 09/06/2023]
Abstract
Importance Inequalities in preterm infant mortality exist between population subgroups within the United States. Objective To characterize trends in preterm infant mortality by maternal race and socioeconomic status to assess how inequalities in preterm mortality rates have changed over time. Design, Setting, and Participants This was a retrospective longitudinal descriptive study using the US National Center for Health Statistics birth infant/death data set for 12 256 303 preterm infant births over 26 years, between 1995 and 2020. Data were analyzed from December 2022 to March 2023. Exposures Maternal characteristics including race, smoking status, educational attainment, antenatal care, and insurance status were used as reported on an infant's US birth certificate. Main Outcomes and Measures Preterm infant mortality rate was calculated for each year from 1995 to 2020 for all subgroups, with a trend regression coefficient calculated to describe the rate of change in preterm mortality. Results The average US preterm infant mortality rate (IMR) decreased from 33.71 (95% CI, 33.71 to 34.04) per 1000 preterm births per year between 1995-1997, to 23.32 (95% CI, 23.05 to 23.58) between 2018-2020. Black non-Hispanic infants were more likely to die following preterm births than White non-Hispanic infants (IMR, 31.09; 95% CI, 30.44 to 31.74, vs 21.81; 95% CI, 21.43 to 22.18, in 2018-2020); however, once born, extremely prematurely Black and Hispanic infants had a narrow survival advantage (IMR rate ratio, 0.87; 95% CI, 0.84 to 0.91, in 2018-2020). The rate of decrease in preterm IMR was higher in Black infants (-0.015) than in White (-0.013) and Hispanic infants (-0.010); however, the relative risk of preterm IMR among Black infants compared with White infants remained the same between 1995-1997 vs 2018-2020 (relative risk, 1.40; 95% CI, 1.38 to 1.44, vs 1.43; 95% CI, 1.39 to 1.46). The rate of decrease in preterm IMR was higher in nonsmokers compared with smokers (-0.015 vs -0.010, respectively), in those with high levels of education compared with those with intermediate or low (-0.016 vs - 0.010 or -0.011, respectively), and in those who had received adequate antenatal care compared with those who did not (-0.014 vs -0.012 for intermediate and -0.013 for inadequate antenatal care). Over time, the relative risk of preterm mortality widened within each of these subgroups. Conclusions and Relevance This study found that between 1995 and 2020, US preterm infant mortality improved among all categories of prematurity. Inequalities in preterm infant mortality based on maternal race and ethnicity have remained constant while socioeconomic disparities have widened over time.
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Affiliation(s)
- Tim Venkatesan
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Philippa Rees
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Julian Gardiner
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Department of Education, University of Oxford, Oxford, United Kingdom
| | - Cheryl Battersby
- Department of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Mitana Purkayastha
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Chris Gale
- Department of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Alastair G. Sutcliffe
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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21
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Fraiman YS, Guyol G, Acevedo-Garcia D, Beck AF, Burris H, Coker TR, Tiemeier H. A Narrative Review of the Association between Prematurity and Attention-Deficit/Hyperactivity Disorder and Accompanying Inequities across the Life-Course. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1637. [PMID: 37892300 PMCID: PMC10605109 DOI: 10.3390/children10101637] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/26/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023]
Abstract
Preterm birth is associated with an increased risk of neurodevelopmental and neurobehavioral impairments including attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioral disorder of childhood. In this narrative review, we examine the known associations between prematurity and ADHD and highlight the impact of both prematurity and ADHD on multiple domains across the pediatric life-course. We develop a framework for understanding the health services journey of individuals with ADHD to access appropriate services and treatments for ADHD, the "ADHD Care Cascade". We then discuss the many racial and ethnic inequities that affect the risk of preterm birth as well as the steps along the "ADHD Care Cascade". By using a life-course approach, we highlight the ways in which inequities are layered over time to magnify the neurodevelopmental impact of preterm birth on the most vulnerable children across the life-course.
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Affiliation(s)
- Yarden S. Fraiman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Genevieve Guyol
- Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02218, USA
| | - Dolores Acevedo-Garcia
- Heller School of Social Policy and Management, Brandeis University, Waltham, MA 02453, USA
| | - Andrew F. Beck
- Cincinnati Children’s, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Heather Burris
- Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tumaini R. Coker
- Seattle Children’s, University of Washington School of Medicine, Seattle, WA 98105, USA
| | - Henning Tiemeier
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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22
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Dawson AE, Ray Bignall ON, Spencer JD, McLeod DJ. A Call to Comprehensively Understand Our Patients to Provide Equitable Pediatric Urological Care. Urology 2023; 179:126-135. [PMID: 37393019 DOI: 10.1016/j.urology.2023.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Anne E Dawson
- Division of Psychology and Neuropsychology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio; The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio
| | - O N Ray Bignall
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio; Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - John David Spencer
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio; Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Daryl J McLeod
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio; Department of Urology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio.
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23
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Sullivan BA, Hochheimer CJ, Chernyavskiy P, King WE, Fairchild KD. Impact of race on heart rate characteristics monitoring in very low birth weight infants. Pediatr Res 2023; 94:575-580. [PMID: 36650306 PMCID: PMC10350468 DOI: 10.1038/s41390-023-02470-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND A multicenter RCT showed that displaying a heart rate characteristics index (HRCi) predicting late-onset sepsis reduced mortality for VLBW infants. We aimed to assess whether HRCi display had a differential impact for Black versus White infants. METHODS We performed secondary data analysis of Black and White infants enrolled in the HeRO RCT. We evaluated the predictive performance of the HRCi for infants with Black or White maternal race. Using models adjusted for birth weight, we assessed outcomes and interventions for a race × randomization interaction. RESULTS Among 2607 infants, Black infants had lower birth weight, gestational age, length of stay, and ventilator days, while sepsis and mortality were similar. The HRCi performed equally for sepsis prediction in Black and White infants. We found no differential effect of randomization by race on sepsis, mortality, antibiotic days, length of stay, or ventilator days. However, there was a differential randomization effect by race for blood cultures per patient: White RR 1.11 (95% CrI 1.04-1.18), Black RR 1.00 (0.93-1.07). CONCLUSIONS The HRCi performed similarly for sepsis prediction in Black and White infants. Randomization to HRCi display increased blood cultures in White but not in Black infants, while the impact on other outcomes or interventions was similar. IMPACT Predictive analytics, such as heart rate characteristics (HRC) monitoring for late-onset neonatal sepsis, should have equal impact among patients of different race. Infants with Black or White maternal race randomized to HRC display had similar outcomes, but randomization to the study arm increased a related clinical intervention, blood cultures, in White but not in Black infants. This study provides evidence of a differential effect of predictive models on clinical care by race. The work will promote consideration and analysis of equity in the implementation of predictive analytics.
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Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | | | - Pavel Chernyavskiy
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - William E King
- Medical Predictive Sciences Corporation, Charlottesville, VA, USA
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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24
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Sullivan BA, Doshi A, Chernyavskiy P, Husain A, Binai A, Sahni R, Fairchild KD, Moorman JR, Travers CP, Vesoulis ZA. Neighborhood Deprivation and Association With Neonatal Intensive Care Unit Mortality and Morbidity for Extremely Premature Infants. JAMA Netw Open 2023; 6:e2311761. [PMID: 37166800 PMCID: PMC10176121 DOI: 10.1001/jamanetworkopen.2023.11761] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/20/2023] [Indexed: 05/12/2023] Open
Abstract
Importance Socioeconomic status affects pregnancy and neurodevelopment, but its association with hospital outcomes among premature infants is unknown. The Area Deprivation Index (ADI) is a validated measure of neighborhood disadvantage that uses US Census Bureau data on income, educational level, employment, and housing quality. Objective To determine whether ADI is associated with neonatal intensive care unit (NICU) mortality and morbidity in extremely premature infants. Design, Setting, and Participants This retrospective cohort study was performed at 4 level IV NICUs in the US Northeast, Mid-Atlantic, Midwest, and South regions. Non-Hispanic White and Black infants with gestational age of less than 29 weeks and born between January 1, 2012, and December 31, 2020, were included in the analysis. Addresses were converted to census blocks, identified by Federal Information Processing Series codes, to link residences to national ADI percentiles. Exposures ADI, race, birth weight, sex, and outborn status. Main Outcomes and Measures In the primary outcome, the association between ADI and NICU mortality was analyzed using bayesian logistic regression adjusted for race, birth weight, outborn status, and sex. Risk factors were considered significant if the 95% credible intervals excluded zero. In the secondary outcome, the association between ADI and NICU morbidities, including late-onset sepsis, necrotizing enterocolitis (NEC), and severe intraventricular hemorrhage (IVH), were also analyzed. Results A total of 2765 infants with a mean (SD) gestational age of 25.6 (1.7) weeks and mean (SD) birth weight of 805 (241) g were included in the analysis. Of these, 1391 (50.3%) were boys, 1325 (47.9%) reported Black maternal race, 498 (18.0%) died before NICU discharge, 692 (25.0%) developed sepsis or NEC, and 353 (12.8%) had severe IVH. In univariate analysis, higher median ADI was found among Black compared with White infants (77 [IQR, 45-93] vs 57 [IQR, 32-77]; P < .001), those who died before NICU discharge vs survived (71 [IQR, 45-89] vs 64 [IQR, 36-86]), those with late-onset sepsis or NEC vs those without (68 [IQR, 41-88] vs 64 [IQR, 35-86]), and those with severe IVH vs those without (69 [IQR, 44-90] vs 64 [IQR, 36-86]). In a multivariable bayesian logistic regression model, lower birth weight, higher ADI, and male sex were risk factors for mortality (95% credible intervals excluded zero), while Black race and outborn status were not. The ADI was also identified as a risk factor for sepsis or NEC and severe IVH. Conclusions and Relevance The findings of this cohort study of extremely preterm infants admitted to 4 NICUs in different US geographic regions suggest that ADI was a risk factor for mortality and morbidity after adjusting for multiple covariates.
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Affiliation(s)
- Brynne A. Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville
| | - Ayush Doshi
- currently a medical student at University of Virginia School of Medicine, Charlottesville
| | - Pavel Chernyavskiy
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville
| | - Ameena Husain
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Alexandra Binai
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Rakesh Sahni
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Karen D. Fairchild
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - J. Randall Moorman
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville
| | - Colm P. Travers
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | - Zachary A. Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
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25
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Jensen EA, Wiener LE, Rysavy MA, Dysart KC, Gantz MG, Eichenwald EC, Greenberg RG, Harmon HM, Laughon MM, Watterberg KL, Walsh MC, Yoder BA, Lorch SA, DeMauro SB. Assessment of Corticosteroid Therapy and Death or Disability According to Pretreatment Risk of Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants. JAMA Netw Open 2023; 6:e2312277. [PMID: 37155165 PMCID: PMC10167571 DOI: 10.1001/jamanetworkopen.2023.12277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/24/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Meta-analyses suggest that corticosteroids may be associated with increased survival without cerebral palsy in infants at high risk of bronchopulmonary dysplasia (BPD) but are associated with adverse neurologic outcomes in low-risk infants. Whether this association exists in contemporary practice is uncertain because most randomized clinical trials administered corticosteroids earlier and at higher doses than currently recommended. Objective To evaluate whether the pretreatment risk of death or grade 2 or 3 BPD at 36 weeks' postmenstrual age modified the association between postnatal corticosteroid therapy and death or disability at 2 years' corrected age in extremely preterm infants. Design, Setting, and Participants This cohort study analyzed data on 482 matched pairs of infants from 45 participating US hospitals in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database (GDB). Infants were included in the cohort if they were born at less than 27 weeks' gestation between April 1, 2011, and March 31, 2017; survived the first 7 postnatal days; and had 2-year death or developmental follow-up data collected between January 2013 and December 2019. Corticosteroid-treated infants were propensity score matched with untreated controls. Data were analyzed from September 1, 2019, to November 30, 2022. Exposure Systemic corticosteroid therapy to prevent BPD that was initiated between day 8 and day 42 after birth. Main Outcomes and Measures The primary outcome was death or moderate to severe neurodevelopmental impairment at 2 years' corrected age. The secondary outcome was death or moderate to severe cerebral palsy at 2 years' corrected age. Results A total of 482 matched pairs of infants (mean [SD] gestational age, 24.1 [1.1] weeks]; 270 males [56.0%]) were included from 656 corticosteroid-treated infants and 2796 potential controls. Most treated infants (363 [75.3%]) received dexamethasone. The risk of death or disability associated with corticosteroid therapy was inversely associated with the estimated pretreatment probability of death or grade 2 or 3 BPD. The risk difference for death or neurodevelopmental impairment associated with corticosteroids decreased by 2.7% (95% CI, 1.9%-3.5%) for each 10% increase in the pretreatment risk of death or grade 2 or 3 BPD. This risk transitioned from estimated net harm to benefit when the pretreatment risk of death or grade 2 or 3 BPD exceeded 53% (95% CI, 44%-61%). For death or cerebral palsy, the risk difference decreased by 3.6% (95% CI, 2.9%-4.4%) for each 10% increase in the risk of death or grade 2 or 3 BPD and transitioned from estimated net harm to benefit at a pretreatment risk of 40% (95% CI, 33%-46%). Conclusions and Relevance Results of this study suggested that corticosteroids were associated with a reduced risk of death or disability in infants at moderate to high pretreatment risk of death or grade 2 or 3 BPD but with possible harm in infants at lower risk.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Laura Elizabeth Wiener
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas McGovern Medical School, Houston
| | - Kevin C. Dysart
- Neonatal/Perinatal Medicine, Nemours Children’s Hospital, Wilmington, Delaware
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Eric C. Eichenwald
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Rachel G. Greenberg
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Heidi M. Harmon
- Stead Family Department of Pediatrics, University of Iowa, Iowa City
| | - Matthew M. Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Scott A. Lorch
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Sara B. DeMauro
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
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26
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Racial Disparities in Breastmilk Receipt and Extremely Low Gestational Age Neonatal Morbidities in an Asian Pacific Islander Population. J Racial Ethn Health Disparities 2023; 10:952-960. [PMID: 35297496 DOI: 10.1007/s40615-022-01283-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Racial disparities in breastmilk provision and neonatal morbidities of extreme prematurity have been documented in previous studies but are not as well-documented in Asian and Pacific Islander (API) infants. The objectives of this study were to evaluate a predominantly API neonatal intensive care unit (NICU) population for racial disparities in (1) the receipt of breastmilk within 24 h of admission and at discharge and (2) neonatal morbidities among infants ≤ 28 weeks gestational age. METHODS A retrospective chart review of 2528 infants from 2018 to 2020 born at the largest level 3 NICU in Honolulu, Hawai'i, was conducted. Multivariable logistic regression analysis was performed on NICU outcomes to calculate adjusted odds ratios (aOR) and confidence intervals (CI). RESULTS Native Hawaiian (NH) (aOR 0.73 [0.54, 0.98]), Pacific Islander (PI) (aOR 0.57 [0.41, 0.79]), and Filipino infants (aOR 0.66 [0.49, 0.89]) were less likely to receive breastmilk at discharge compared to Asian infants. PI infants were also more likely to experience necrotizing enterocolitis (aOR 7.89 [1.07, 58.10]) and intraventricular hemorrhage (aOR 3.86 [1.15, 13.02]) compared to Asian infants. CONCLUSION In a predominantly API population, disparities in breastmilk receipt and neonatal morbidities exist among NH, PI, and Filipino infants in the NICU. Our findings call for better understanding of the underlying inequities to guide directed efforts, including standardization of care through staff trainings on implicit biases and trauma-informed care, as well as provision of culturally sensitive education and lactation support for these patients.
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27
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Steurer MA, Ryckman KK, Baer RJ, Costello J, Oltman SP, McCulloch CE, Jelliffe-Pawlowski LL, Rogers EE. Developing a resiliency model for survival without major morbidity in preterm infants. J Perinatol 2023; 43:452-457. [PMID: 36220984 PMCID: PMC10079534 DOI: 10.1038/s41372-022-01521-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Develop and validate a resiliency score to predict survival and survival without neonatal morbidity in preterm neonates <32 weeks of gestation using machine learning. STUDY DESIGN Models using maternal, perinatal, and neonatal variables were developed using LASSO method in a population based Californian administrative dataset. Outcomes were survival and survival without severe neonatal morbidity. Discrimination was assessed in the derivation and an external dataset from a tertiary care center. RESULTS Discrimination in the internal validation dataset was excellent with a c-statistic of 0.895 (95% CI 0.882-0.908) for survival and 0.867 (95% CI 0.857-0.877) for survival without severe neonatal morbidity, respectively. Discrimination remained high in the external validation dataset (c-statistic 0.817, CI 0.741-0.893 and 0.804, CI 0.770-0.837, respectively). CONCLUSION Our successfully predicts survival and survival without major morbidity in preterm babies born at <32 weeks. This score can be used to adjust for multiple variables across administrative datasets.
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Affiliation(s)
- Martina A Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Kelli K Ryckman
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Jean Costello
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Scott P Oltman
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Laura L Jelliffe-Pawlowski
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
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28
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Abstract
Long-standing health disparities in maternal reproductive health, infant morbidity and mortality, and long-term developmental outcomes are rooted in a foundation of structural racism. Social determinants of health profoundly affect reproductive health outcomes of Black and Hispanic women disproportionately; they have higher rates of death during pregnancy and preterm birth. Their infants are also more likely to be cared for in poorer quality neonatal intensive care units (NICUs), receive poorer quality of NICU care, and are less likely to be referred to an appropriate high-risk NICU follow-up program. Interventions that mitigate the impact of racism will help to eliminate health disparities.
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Affiliation(s)
- Yvette R Johnson
- Texas Christian University, Burnett School of Medicine, Cook Children's Medical Center, N.E.S.T. Developmental Follow-up Clinic, 1500 Cooper Street, Fort Worth, TX 76104, USA.
| | - Charleta Guillory
- Baylor College of Medicine, Texas Children's Hospital, Section of Neonatology, 6621 Fannin, Houston, TX 77030, USA
| | - Sonia Imaizumi
- Newtown Square, MultiPlan.com, 18 Campus Boulevard, Suite 200, Newtown Square, PA 19073, USA
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29
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Sullivan BA, Kausch SL, Fairchild KD. Artificial and human intelligence for early identification of neonatal sepsis. Pediatr Res 2023; 93:350-356. [PMID: 36127407 DOI: 10.1038/s41390-022-02274-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
Artificial intelligence may have a role in the early detection of sepsis in neonates. Machine learning can identify patterns that predict high or increasing risk for clinical deterioration from a sepsis-like illness. In developing this potential addition to NICU care, careful consideration should be given to the data and methods used to develop, validate, and evaluate prediction models. When an AI system alerts clinicians to a change in a patient's condition that warrants a bedside evaluation, human intelligence and experience come into play to determine an appropriate course of action: evaluate and treat or wait and watch closely. With intelligently developed, validated, and implemented AI sepsis systems, both clinicians and patients stand to benefit. IMPACT: This narrative review highlights the application of AI in neonatal sepsis prediction. It describes issues in clinical prediction model development specific to this population. This article reviews the methods, considerations, and literature on neonatal sepsis model development and validation. Challenges of AI technology and potential barriers to using sepsis AI systems in the NICU are discussed.
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Affiliation(s)
- Brynne A Sullivan
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Sherry L Kausch
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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30
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Abstract
Significant racial and ethnic disparities exist in birth outcomes and complications related to prematurity. However, little is known about racial and ethnic variations in health outcomes after premature infants are discharged from the neonatal intensive care unit (NICU). We propose a novel, equity-focused conceptual model to guide future evaluations of post-discharge outcomes that centers on a multi-dimensional, comprehensive view of health, which we call thriving. We then apply this model to existing literature on post-discharge inequities, revealing a need for rigorous analysis of drivers and strength-based, longitudinal outcomes.
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Affiliation(s)
- Daria C Murosko
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia PA.
| | - Michelle-Marie Peña
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia PA; Department of Pediatrics, Division of Neonatology, Emory University School of Medicine and Children's Healthcare of Atlanta
| | - Scott A Lorch
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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31
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Karvonen KL, Goronga F, McKenzie-Sampson S, Rogers EE. Racial disparities in the development of comorbid conditions after preterm birth: A narrative review. Semin Perinatol 2022; 46:151657. [PMID: 36153273 DOI: 10.1016/j.semperi.2022.151657] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite recognition and attempts to reduce racial disparities in perinatal outcomes, Black infants are still disproportionately represented among those who are born preterm. Postnatal investigations of racial disparities in comorbidities and outcomes after preterm birth are increasing, although their results and interpretations are conflicting. In the present review, we 1.) identify important methodological limitations of that literature 2.) summarize the conflicting literature investigating racial disparities, specifically Black-white differences, in postnatal comorbidities and outcomes after preterm birth 3.) describe mechanisms by which racism operates to contextualize our understanding to inform future work to actively reduce disparities in preterm birth and subsequently, its complications.
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Affiliation(s)
- Kayla L Karvonen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States; California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, United States.
| | - Faith Goronga
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States
| | - Safyer McKenzie-Sampson
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, United States; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States; California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, United States
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32
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Fraiman YS, Barrero-Castillero A, Litt JS. Implications of racial/ethnic perinatal health inequities on long-term neurodevelopmental outcomes and health services utilization. Semin Perinatol 2022; 46:151660. [PMID: 36175260 DOI: 10.1016/j.semperi.2022.151660] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Infants born preterm and with low birth weight have increased risk for neurodevelopmental challenges later in life compared to term-born peers. These include functional motor impairment, cognitive and speech delays, neurobehavioral disorders, and atypical social development. There are well-documented inequities in the population distributions of preterm birth and associated short-term morbidities by race, ethnicity, language, and nativity. Far less is known about how these inequities affect long-term outcomes, though the impact of unequal access to post-discharge support services for preterm infants raises concerns about widening gaps in health, development, and functioning. In this review, we describe what is currently known about the impact of race, ethnicity, nativity, and language on long-term outcomes. We provide a framework for understanding inequities in social, political, and historical context. And we offer guidance for next steps to delineate mechanistic pathways and to identify interventions to eliminate inequities in long-term neurodevelopmental outcomes through research, intervention, and advocacy.
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Affiliation(s)
- Yarden S Fraiman
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Alejandra Barrero-Castillero
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jonathan S Litt
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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Profit J, Edwards EM, Pursley D. Getting to health equity in NICU care in the USA and beyond. Arch Dis Child Fetal Neonatal Ed 2022:archdischild-2021-323533. [PMID: 36379698 DOI: 10.1136/archdischild-2021-323533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022]
Abstract
Differences in race/ethnicity, gender, income and other social factors have long been associated with disparities in health, illness and premature death. Although the terms 'health differences' and 'health disparities' are often used interchangeably, health disparities has recently been reserved to describe worse health in socially disadvantaged populations, particularly members of disadvantaged racial/ethnic groups and the poor within a racial/ethnic group. Infants receiving disparate care based on race/ethnicity, immigration status, language proficiency, or social class may be discomforting to healthcare workers who dedicate their lives to care for these patients. Recent literature, however, has documented differences in neonatal intensive care unit (NICU) care quality that have contributed to racial and ethnic differences in mortality and significant morbidity. We examine the within-NICU and between-NICU mechanisms of disparate care and recommend approaches to address these disparities.
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Affiliation(s)
- Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA .,California Perinatal Quality Care Collaborative, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont, USA.,Department of Pediatrics, Robert Larner MD College of Medicine, University of Vermont, Burlington, Vermont, USA.,Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, Vermont, USA
| | - DeWayne Pursley
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Ramachandran S, Foglia EE, DeMauro SB, Chawla S, Brion LP, Wyckoff MH. Perinatal management: Lessons learned from the neonatal research network. Semin Perinatol 2022; 46:151636. [PMID: 35835614 PMCID: PMC10894037 DOI: 10.1016/j.semperi.2022.151636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Recent contributions of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) regarding obstetrical perinatal interventions and neonatal delivery room practices include the following: the impact of multiple antepartum factors including maternal diabetes, hypertension, obesity and mode of delivery on outcomes of extremely preterm newborns, effects of delayed delivery interval for extremely preterm multiples, effects of antenatal steroids on preterm newborn outcomes and the impact of antenatal magnesium sulfate therapy on neurodevelopmental outcomes for extremely preterm infants. NRN studies also contribute important evidence for neonatal delivery room resuscitation guidelines including umbilical cord management and maintenance of euthermia immediately after birth. The updated NRN outcome calculator helps better counsel families regarding possible outcomes for the most immature newborns if resuscitation is attempted at birth. Thus, the NRN provides substantial information regarding effects of perinatal management on newborn infants.
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Affiliation(s)
- Shalini Ramachandran
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara B DeMauro
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sanjay Chawla
- Departments of Pediatrics, Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Luc P Brion
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX, USA
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, TX, USA.
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Kilbride HW, Vohr BR, McGowan EM, Peralta-Carcelen M, Stringer K, Das A, Archer SW, Hintz SR. Early neurodevelopmental follow-up in the NICHD neonatal research network: Advancing neonatal care and outcomes, opportunities for the future. Semin Perinatol 2022; 46:151642. [PMID: 35842320 PMCID: PMC11068160 DOI: 10.1016/j.semperi.2022.151642] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
At the inception of the Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN), provision of care for extremely preterm (EPT) infants was considered experimental. The NRN Follow-up Study Group, initiated in 1993, developed infrastructure with certification processes and standards, allowing the NRN to assess 2-year outcomes for EPT and to provide important metrics for randomized clinical trials. This chapter will review the NRN Follow-up Study Group's contributions to understanding factors related to improved neurodevelopmental, behavioral, and social-emotional outcomes of EPT infants. We will also discuss follow up challenges, including reassessing which outcomes are most meaningful for parents and investigators. Finally, we will explore how outcome studies have informed clinical decisions and ethical considerations, given limitations of prediction of complex later childhood outcomes from early neurodevelopmental findings.
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Affiliation(s)
- Howard W Kilbride
- Department of Pediatrics, Children's Mercy-Kansas City and the University of Missouri-Kansas City, 2401 Gillham Road, 3rd Floor Annex, Kansas City, MO.
| | - Betty R Vohr
- Department of Pediatrics, Women and Infants Hospital of Rhode Island and Brown University, Providence, RI
| | - Elisabeth M McGowan
- Department of Pediatrics, Women and Infants Hospital of Rhode Island and Brown University, Providence, RI
| | | | - Kimberlly Stringer
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Stephanie Wilson Archer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Susan R Hintz
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Torr C. Culturally competent care in the neonatal intensive care unit, strategies to address outcome disparities. J Perinatol 2022; 42:1424-1427. [PMID: 35241768 DOI: 10.1038/s41372-022-01360-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 11/09/2022]
Abstract
In the past two years, we have witnessed social unrest, the unequal effects of a pandemic across our society, and a focus on how systems in the United States produce unequal outcomes along racial and cultural divides. With increased national awareness, there has also been a call for change in healthcare, specifically racial inequities in Neonatal Intensive Care Unit (NICU) outcomes (1). While race may be a data point used to classify outcomes, it has no basis in biology, and merely identifying it does not make it simple to address. To address these inequities we need to look past the social construct of race and to the social aspects of our care in the NICU. Focusing on small and large changes that we can make as individuals, units, and as a specialty that can improve the care and outcomes of this at-risk patient population. This perspective focuses on culturally congruent care, trauma-informed care, and other approaches to reduce disparities in neonatal outcomes.
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Affiliation(s)
- Carrie Torr
- University of Utah School of Medicine, Salt Lake City, UT, USA.
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Bamat NA, Vereen RJ, Montoya-Williams D. Disparities in Lung Disease of Prematurity-When Does Exposure to Racism Begin? JAMA Pediatr 2022; 176:845-847. [PMID: 35913709 PMCID: PMC10016617 DOI: 10.1001/jamapediatrics.2022.2671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nicolas A Bamat
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheda J Vereen
- Brooke Army Medical Center, Department of Pediatrics, Fort Sam Houston, San Antonio, Texas
| | - Diana Montoya-Williams
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Venkatesh KK, Lynch CD, Costantine MM, Backes CH, Slaughter JL, Frey HA, Huang X, Landon MB, Klebanoff MA, Khan SS, Grobman WA. Trends in Active Treatment of Live-born Neonates Between 22 Weeks 0 Days and 25 Weeks 6 Days by Gestational Age and Maternal Race and Ethnicity in the US, 2014 to 2020. JAMA 2022; 328:652-662. [PMID: 35972487 PMCID: PMC9382444 DOI: 10.1001/jama.2022.12841] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Birth in the periviable period between 22 weeks 0 days and 25 weeks 6 days' gestation is a major source of neonatal morbidity and mortality, and the decision to initiate active life-saving treatment is challenging. OBJECTIVE To assess whether the frequency of active treatment among live-born neonates in the periviable period has changed over time and whether active treatment differed by gestational age at birth and race and ethnicity. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional descriptive study using National Center for Health Statistics natality data from 2014 to 2020 for 61 908 singleton live births without clinical anomalies between 22 weeks 0 days and 25 weeks 6 days in the US. EXPOSURES Year of delivery, gestational age at birth, and race and ethnicity of the pregnant individual, stratified as non-Hispanic Asian/Pacific Islander, non-Hispanic Black, Hispanic/Latina, and non-Hispanic White. MAIN OUTCOMES AND MEASURES Active treatment, determined by whether there was an attempt to treat the neonate and defined as a composite of surfactant therapy, immediate assisted ventilation at birth, assisted ventilation more than 6 hours in duration, and/or antibiotic therapy. Frequencies, mean annual percent change (APC), and adjusted risk ratios (aRRs) were estimated. RESULTS Of 26 986 716 live births, 61 908 (0.2%) were periviable live births included in this study: 5% were Asian/Pacific Islander, 37% Black, 24% Hispanic, and 34% White; and 14% were born at 22 weeks, 21% at 23 weeks, 30% at 24 weeks, and 34% at 25 weeks. Fifty-two percent of neonates received active treatment. From 2014 to 2020, the overall frequency (mean APC per year) of active treatment increased significantly (3.9% [95% CI, 3.0% to 4.9%]), as well as among all racial and ethnic subgroups (Asian/Pacific Islander: 3.4% [95% CI, 0.8% to 6.0%]); Black: 4.7% [95% CI, 3.4% to 5.9%]; Hispanic: 4.7% [95% CI, 3.4% to 5.9%]; and White: 3.1% [95% CI, 1.1% to 4.4%]) and among each gestational age range (22 weeks: 14.4% [95% CI, 11.1% to 17.7%] and 25 weeks: 2.9% [95% CI, 1.5% to 4.2%]). Compared with neonates born to White individuals (57.0%), neonates born to Asian/Pacific Islander (46.2%; risk difference [RD], -10.81 [95% CI, -12.75 to -8.88]; aRR, 0.82 [95% CI, [0.79-0.86]), Black (51.6%; RD, -5.42 [95% CI, -6.36 to -4.50]; aRR, 0.90 [95% CI, 0.89 to 0.92]), and Hispanic (48.0%; RD, -9.03 [95% CI, -10.07 to -7.99]; aRR, 0.83 [95% CI, 0.81 to 0.85]) individuals were significantly less likely to receive active treatment. CONCLUSIONS AND RELEVANCE From 2014 to 2020 in the US, the frequency of active treatment among neonates born alive between 22 weeks 0 days and 25 weeks 6 days significantly increased, and there were differences in rates of active treatment by race and ethnicity.
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MESH Headings
- Clinical Decision-Making
- Cross-Sectional Studies
- Ethnicity/statistics & numerical data
- Female
- Fetal Viability
- Gestational Age
- Humans
- Infant, Extremely Premature
- Infant, Newborn
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/ethnology
- Infant, Premature, Diseases/therapy
- Intensive Care, Neonatal/methods
- Intensive Care, Neonatal/statistics & numerical data
- Intensive Care, Neonatal/trends
- Live Birth/epidemiology
- Live Birth/ethnology
- Patient Care/methods
- Patient Care/statistics & numerical data
- Patient Care/trends
- Pregnancy
- Retrospective Studies
- United States/epidemiology
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Affiliation(s)
- Kartik K. Venkatesh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Courtney D. Lynch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Maged M. Costantine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Carl H. Backes
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Jonathan L. Slaughter
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Heather A. Frey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Xiaoning Huang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark B. Landon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Mark A. Klebanoff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Sadiya S. Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William A. Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
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Travers CP, Hansen NI, Das A, Rysavy MA, Bell EF, Ambalavanan N, Peralta-Carcelen M, Tita AT, Van Meurs KP, Carlo WA. Potential missed opportunities for antenatal corticosteroid exposure and outcomes among periviable births: observational cohort study. BJOG 2022; 129:10.1111/1471-0528.17230. [PMID: 35611472 PMCID: PMC9684347 DOI: 10.1111/1471-0528.17230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Test the hypothesis potential missed opportunities for antenatal corticosteroids increase as gestational age decreases and are associated with adverse outcomes. DESIGN Observational cohort study. SETTING 24 US centers in the Neonatal Research Network. POPULATION Actively treated infants 22-25 weeks' gestation and birth weight 401-1000 grams, without major birth defects, born 2006-2018. METHODS Potential missed opportunity was defined as no antenatal corticosteroids but did have prenatal antibiotics, and/or magnesium sulfate, and/or prolonged rupture of membranes. Poisson regression models adjusted for baseline characteristics. MAIN OUTCOME MEASURES Antenatal corticosteroid exposure, mortality, and severe intracranial hemorrhage or periventricular leukomalacia. RESULTS 6966 (87.5%) were exposed to antenatal corticosteroids, 454 (5.7%) had no exposure but potential missed opportunities for antenatal corticosteroid exposure, and 537 (6.7%) had no exposure and no evidence of potential missed opportunities. Compared with infants born at 25 weeks, potential missed opportunities for antenatal corticosteroid exposure were more likely at 22 weeks (adjusted relative risk (aRR) [95% CI] 11.06 [7.52-16.27]) and 23 weeks (3.24 [2.44-4.29]) but did not differ at 24 weeks (1.08 [0.82-1.42]). Potential missed opportunities for antenatal corticosteroids decreased over time at 22-23 weeks' gestation. Antenatal corticosteroid exposed infants had lower risk of death (31.0% vs 54.8%; 0.77 [0.70-0.84]) and survivors had lower risk of severe brain injury (25.0% v 44.5%; 0.64 [0.55-0.73]) compared with infants with potential missed opportunities. CONCLUSION Potential missed opportunities for antenatal corticosteroid exposure increased with decreasing gestational age and were associated with higher rates of death and severe brain injury among actively treated periviable births.
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Affiliation(s)
- Colm P. Travers
- Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Nellie I. Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, United States
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD, United States
| | | | - Edward F. Bell
- Pediatrics, University of Iowa, Iowa City, IA, United States
| | | | | | - Alan T. Tita
- Obstetrics & Gynecology, and Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Waldemar A. Carlo
- Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
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McKenzie K, Lynch E, Msall ME. Scaffolding Parenting and Health Development for Preterm Flourishing Across the Life Course. Pediatrics 2022; 149:186921. [PMID: 35503323 PMCID: PMC9847416 DOI: 10.1542/peds.2021-053509k] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 01/21/2023] Open
Abstract
Advances in obstetrics and neonatal medicine have resulted in improved survival rates for preterm infants. Remarkably, >75% extremely (<28 weeks) preterm infants who leave the NICU do not experience major neurodevelopmental disabilities, although >50% experience more minor challenges in communication, perception, cognition, attention, regulatory, and executive function that can adversely impact educational and social function resulting in physical, behavioral, and social health issues in adulthood. Even late premature (32-36 weeks) infants have more neurodevelopmental challenges than term infants. Although early intervention and educational programs can mitigate risks of prematurity for children's developmental trajectories, restrictive eligibility requirement and limitations on frequency and intensity mean that many premature infants must "fail first" to trigger services. Social challenges, including lack of family resources, unsafe neighborhoods, structural racism, and parental substance use, may compound biological vulnerabilities, yet existing services are ill-equipped to respond. An intervention system for premature infants designed according to Life Course Health Development principles would instead focus on health optimization from the start; support emerging developmental capabilities such as self-regulation and formation of reciprocal secure early relationships; be tailored to each child's unique neurodevelopmental profile and social circumstances; and be vertically, horizontally, and longitudinally integrated across levels (individual, family, community), domains (health, education), and time. Recognizing the increased demands placed on parents, it would include parental mental health supports and provision of trauma-informed care. This developmental scaffolding would incorporate parenting, health, and developmental interventions, with the aim of improved health trajectories across the whole of the life course.
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Affiliation(s)
- Kamryn McKenzie
- University of Chicago Kennedy Research Center on Intellectual and Neurodevelopmental Disabilities, Chicago, Illinois
| | - Emma Lynch
- University of Chicago Kennedy Research Center on Intellectual and Neurodevelopmental Disabilities, Chicago, Illinois
| | - Michael E. Msall
- Address correspondence to Address correspondence to: Michael E. Msall, MD, Section of Developmental and Behavioral Pediatrics, University of Chicago Kennedy Research Center and Comer Children's Hospital, 936 East 61 St Street, Room 207, Chicago, IL 60637. E-mail:
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Salas AA, Jerome M, Finck A, Razzaghy J, Chandler-Laney P, Carlo WA. Body composition of extremely preterm infants fed protein-enriched, fortified milk: a randomized trial. Pediatr Res 2022; 91:1231-1237. [PMID: 34183770 PMCID: PMC8237544 DOI: 10.1038/s41390-021-01628-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/19/2021] [Accepted: 06/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Critically ill extremely preterm infants fed human milk are often underrepresented in neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes. METHODS Masked randomized trial in which 56 extremely preterm infants 25-28 weeks of gestation were randomized to receive either fortified milk enriched with a fixed amount of extensively hydrolyzed protein (high protein group) or fortified milk without additional protein (standard protein group). RESULTS Baseline characteristics were similar between groups. In a longitudinal analysis, the mean percent body fat (%BF) at 30-32 weeks of postmenstrual age (PMA), 36 weeks PMA, and 3 months of corrected age (CA) did not differ between groups (17 ± 3 vs. 15 ± 4; p = 0.09). The high protein group had higher weight (-0.1 ± 1.2 vs. -0.8 ± 1.3; p = 0.03) and length (-0.8 ± 1.3 vs. -1.5 ± 1.3; p = 0.02) z scores from birth to 3 months CA. The high protein group also had higher fat-free mass (FFM) z scores at 36 weeks PMA (-0.9 ± 1.1 vs. -1.5 ± 1.1; p = 0.04). CONCLUSIONS Increased enteral intake of protein increased FFM accretion, weight, and length in extremely preterm infants receiving protein-enriched, fortified human milk. IMPACT Extremely preterm infants are at high risk of developing postnatal growth failure, particularly when they have low fat-free mass gains. Protein supplementation increases fat-free mass accretion in infants, but several neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes have systematically excluded critically ill extremely preterm infants fed human milk exclusively. In extremely preterm infants fed fortified human milk, higher enteral protein intake increases fat-free mass accretion and promotes growth without causing excessive body fat accretion.
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Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Maggie Jerome
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amber Finck
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jacqueline Razzaghy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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42
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Nephrotoxic medications and associated acute kidney injury in hospitalized neonates. J Nephrol 2022; 35:1679-1687. [PMID: 35167057 DOI: 10.1007/s40620-022-01264-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Hospitalized neonates are often treated with nephrotoxic medications, a known risk factor for acute kidney injury (AKI). Nephrotoxic medications and AKI, especially in periviable neonates, could be detrimental to nephrogenesis. Our objectives were to evaluate the prevalence of neonatal treatment with nephrotoxic medications and its relationship with AKI in in the first 28 days of life, and to delineate the associated demographics and diagnoses. STUDY DESIGN Multicenter retrospective analysis using the national Pediatric Hospital Information System database, including 49 pediatric hospitals. Neonates admitted within the first two postnatal days were included. Treatment with 37 nephrotoxic medications across demographics and clinical variables, and relationship with AKI were evaluated. AKI was determined by using the International Classification of Diseases codes. RESULTS Of 192,229 neonates, 74% were treated with at least one nephrotoxic medication. Incidence of AKI was significantly higher in the treated group (aRR 3.68 [95% CI: 2.85, 4.75]). The aRRs of treatment were increased in infants born < 32-week, and < 2000 g. Nephrotoxic medications were prescribed to 90-95% of neonates born ≤ 28-week gestational age. Most treatments (95-98%) occurred in the first 3 days. Intravascular aminoglycosides were the most frequent type; 28% of neonates were treated for ≥ 4 calendar days. Most common diagnoses were infections (25%) and patent ductus arteriosus (20%). CONCLUSIONS Neonatal treatment with nephrotoxic medications is common, especially among the smallest, most immature preterm neonates and demonstrates a need for initiatives to reduce neonatal exposure to these agents, when feasible. Across all gestational age categories, the prevalence of AKI is higher in the neonates treated with nephrotoxic drugs. The long-term effects of treatment with nephrotoxic medications and subsequent AKI on nephrogenesis and nephron endowment will need to be evaluated.
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Controversies in treatment practices of the mother-infant dyad at the limit of viability. Semin Perinatol 2022; 46:151539. [PMID: 34887106 DOI: 10.1016/j.semperi.2021.151539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In the setting of threatened extreme preterm birth, balancing maternal and fetal risks and benefits in order to choose the best available treatment options is of utmost importance. Inconsistency in treatment practices for infants born between 22 and 24 weeks of gestatotional age may account for inter-hospital variation in survival rates with and without impairment. Most importantly, non-biased and accurate information must be presented to the family as soon as extremely preterm birth is suspected, including counseling on morbidities and mortality associated with delivery at the limits of viability. This review will focus on different therapeutic medical and surgical practices available for threatened extremely preterm birth to improve fetal and maternal outcomes while highlighting the importance of patient-centered approaches.
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Bell EF, Hintz SR, Hansen NI, Bann CM, Wyckoff MH, DeMauro SB, Walsh MC, Vohr BR, Stoll BJ, Carlo WA, Van Meurs KP, Rysavy MA, Patel RM, Merhar SL, Sánchez PJ, Laptook AR, Hibbs AM, Cotten CM, D’Angio CT, Winter S, Fuller J, Das A. Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018. JAMA 2022; 327:248-263. [PMID: 35040888 PMCID: PMC8767441 DOI: 10.1001/jama.2021.23580] [Citation(s) in RCA: 232] [Impact Index Per Article: 116.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/10/2021] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Despite improvement during recent decades, extremely preterm infants continue to contribute disproportionately to neonatal mortality and childhood morbidity. OBJECTIVE To review survival, in-hospital morbidities, care practices, and neurodevelopmental and functional outcomes at 22-26 months' corrected age for extremely preterm infants. DESIGN, SETTING, AND PARTICIPANTS Prospective registry for extremely preterm infants born at 19 US academic centers that are part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. The study included 10 877 infants born at 22-28 weeks' gestational age between January 1, 2013, and December 31, 2018, including 2566 infants born before 27 weeks between January 1, 2013, and December 31, 2016, who completed follow-up assessments at 22-26 months' corrected age. The last assessment was completed on August 13, 2019. Outcomes were compared with a similar cohort of infants born in 2008-2012 adjusting for gestational age. EXPOSURES Extremely preterm birth. MAIN OUTCOMES AND MEASURES Survival and 12 in-hospital morbidities were assessed, including necrotizing enterocolitis, infection, intracranial hemorrhage, retinopathy of prematurity, and bronchopulmonary dysplasia. Infants were assessed at 22-26 months' corrected age for 12 health and functional outcomes, including neurodevelopment, cerebral palsy, vision, hearing, rehospitalizations, and need for assistive devices. RESULTS The 10 877 infants were 49.0% female and 51.0% male; 78.3% (8495/10848) survived to discharge, an increase from 76.0% in 2008-2012 (adjusted difference, 2.0%; 95% CI, 1.0%-2.9%). Survival to discharge was 10.9% (60/549) for live-born infants at 22 weeks and 94.0% (2267/2412) at 28 weeks. Survival among actively treated infants was 30.0% (60/200) at 22 weeks and 55.8% (535/958) at 23 weeks. All in-hospital morbidities were more likely among infants born at earlier gestational ages. Overall, 8.9% (890/9956) of infants had necrotizing enterocolitis, 2.4% (238/9957) had early-onset infection, 19.9% (1911/9610) had late-onset infection, 14.3% (1386/9705) had severe intracranial hemorrhage, 12.8% (1099/8585) had severe retinopathy of prematurity, and 8.0% (666/8305) had severe bronchopulmonary dysplasia. Among 2930 surviving infants with gestational ages of 22-26 weeks eligible for follow-up, 2566 (87.6%) were examined. By 2-year follow-up, 8.4% (214/2555) of children had moderate to severe cerebral palsy, 1.5% (38/2555) had bilateral blindness, 2.5% (64/2527) required hearing aids or cochlear implants, 49.9% (1277/2561) had been rehospitalized, and 15.4% (393/2560) required mobility aids or other supportive devices. Among 2458 fully evaluated infants, 48.7% (1198/2458) had no or mild neurodevelopmental impairment at follow-up, 29.3% (709/2419) had moderate neurodevelopmental impairment, and 21.2% (512/2419) had severe neurodevelopmental impairment. CONCLUSIONS AND RELEVANCE Among extremely preterm infants born in 2013-2018 and treated at 19 US academic medical centers, 78.3% survived to discharge, a significantly higher rate than for infants born in 2008-2012. Among infants born at less than 27 weeks' gestational age, rehospitalization and neurodevelopmental impairment were common at 2 years of age.
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Affiliation(s)
| | - Susan R. Hintz
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Nellie I. Hansen
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Carla M. Bann
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Betty R. Vohr
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | | | | | - Ravi M. Patel
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Pablo J. Sánchez
- Department of Pediatrics, The Ohio State University and Nationwide Children’s Hospital, Columbus
| | - Abbot R. Laptook
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | | | - Carl T. D’Angio
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Sarah Winter
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Janell Fuller
- Department of Pediatrics, University of New Mexico, Albuquerque
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
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45
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Flannery DD, Edwards EM, Puopolo KM, Horbar JD. Early-Onset Sepsis Among Very Preterm Infants. Pediatrics 2021; 148:e2021052456. [PMID: 34493539 PMCID: PMC11151778 DOI: 10.1542/peds.2021-052456] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the epidemiology and microbiology of early-onset sepsis (EOS) among very preterm infants using a nationally representative cohort from academic and community hospitals to inform empirical antibiotic guidance, highlight risk factors for infection, and aid in prognostication for infected infants. METHODS Prospective observational study of very preterm infants born weighing 401 to 1500 g or at 22 to 29 weeks' gestational age from January 2018 to December 2019 in 753 Vermont Oxford Network centers. EOS was defined as a culture-confirmed bacterial infection of the blood or cerebrospinal fluid in the 3 days after birth. Demographics, clinical characteristics, and outcomes were compared between infants with and without EOS. RESULTS Of 84 333 included infants, 1139 had EOS for an incidence rate of 13.5 per 1000 very preterm births (99% confidence interval [CI] 12.5-14.6). Escherichia coli (538 of 1158; 46.5%) and group B Streptococcus (218 of 1158; 18.8%) were the most common pathogens. Infected infants had longer lengths of stay (median 92 vs 66 days) and lower rates of survival (67.5% vs 90.4%; adjusted risk ratio 0.82 [95% CI 0.79-0.85]) and of survival without morbidity (26.1% vs 59.4%; adjusted risk ratio 0.66 [95% CI 0.60-0.72]). CONCLUSIONS In a nationally representative sample of very preterm infants with EOS from 2018 to 2019, approximately one-third of isolates were neither group B Streptococcus nor E coli. Three-quarters of all infected infants either died or survived with a major medical morbidity. The profoundly negative impact of EOS on very preterm infants highlights the need for novel preventive strategies.
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MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Bacterial Infections/complications
- Bacterial Infections/drug therapy
- Datasets as Topic
- Escherichia coli/isolation & purification
- Female
- Humans
- Incidence
- Infant, Extremely Premature
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/microbiology
- Infant, Premature, Diseases/mortality
- Length of Stay
- Male
- Neonatal Sepsis/complications
- Neonatal Sepsis/drug therapy
- Neonatal Sepsis/microbiology
- Neonatal Sepsis/mortality
- Prospective Studies
- Streptococcus agalactiae/isolation & purification
- Survival Analysis
- United States/epidemiology
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erika M Edwards
- Department of Pediatrics, Larner College of Medicine
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, The University of Vermont, Burlington, Vermont
- Vermont Oxford Network, Burlington, Vermont
| | - Karen M Puopolo
- Division of Neonatology
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey D Horbar
- Department of Pediatrics, Larner College of Medicine
- Vermont Oxford Network, Burlington, Vermont
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46
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Bignall ONR, Harer MW, Sanderson KR, Starr MC. Commentary on "Trends and Racial Disparities for Acute Kidney Injury in Premature Infants: the US National Database". Pediatr Nephrol 2021; 36:2587-2591. [PMID: 33829326 DOI: 10.1007/s00467-021-05062-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022]
Affiliation(s)
- O N Ray Bignall
- Division of Nephrology and Hypertension, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Matthew W Harer
- Department of Pediatrics, Division of Neonatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Keia R Sanderson
- Department of Medicine-Pediatrics, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, HITS Building, Suite 2000A, 410 West 10th Street, Indianapolis, IN, 46202, USA.
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47
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Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, Bell EF, Rysavy MA, Conroy S, Backes CH. Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review. J Pediatr 2021; 235:63-74.e12. [PMID: 33894262 PMCID: PMC9348995 DOI: 10.1016/j.jpeds.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation). STUDY DESIGN PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale. RESULTS Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation. CONCLUSIONS The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.
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Affiliation(s)
- Leeann R. Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital
| | - Charles V. Smith
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - Joanie Randle
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Cory Hanlon
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Kristi Small
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Matthew A. Rysavy
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sara Conroy
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University,Biostatistics Resource at Nationwide Children’s Hospital
| | - Carl H. Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH,Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH,Obstetrics and Gynecology, The Ohio State University Wexner Medical Center,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
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48
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Parker MG, Hwang SS. Quality improvement approaches to reduce racial/ethnic disparities in the neonatal intensive care unit. Semin Perinatol 2021; 45:151412. [PMID: 33865628 DOI: 10.1016/j.semperi.2021.151412] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inequities in neonatal care quality and outcomes persist. Current models of neonatal quality improvement (QI) typically involve implementation of standardized approaches to clinical care that seek to provide consistent care to all infants and their families, which may neglect to account for the unique needs of diverse patient populations. Current approaches often fail to track outcome and process measures by important social disparity metrics, such as race/ethnicity and primary language. Despite these shortcomings, use of a QI structure has tremendous potential to address disparities in neonatal care. Crucial components of a QI approach to achieve health equity include: (1) Identifying equity goals from the inception of a project; (2) Inclusion of diverse family members on multidisciplinary teams; (3) Tracking outcome and process measures according to disparity metrics; and (4) Conducting interventions that preferentially address barriers of high-risk social groups. Hospital-system commitment to diversity and inclusion in the healthcare work force, recognition of the impact of unconscious provider bias and advocacy in the greater public health setting are needed to address underlying social inequities that impact neonatal care quality.
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Affiliation(s)
- Margaret G Parker
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, 88 E Newton St, Vose Hall, 3rd Floor, Boston, MA 02118, United States.
| | - Sunah S Hwang
- Department of Pediatrics, Colorado Children's Hospital, University of Colorado School of Medicine, United States
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49
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Arnolds M, Laventhal N. Perinatal Counseling at the Margin of Gestational Viability: Where We've Been, Where We're Going, and How to Navigate a Path Forward. J Pediatr 2021; 233:255-262. [PMID: 33567323 DOI: 10.1016/j.jpeds.2021.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Marin Arnolds
- Division of Neonatology, Department of Pediatrics, Evanston Hospital, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL.
| | - Naomi Laventhal
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
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50
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Mpody C, Willer BL, Minneci PC, Tobias JD, Nafiu OO. Moderating Effects of Race and Preoperative Comorbidity on Surgical Mortality in Infants. J Surg Res 2021; 264:435-443. [PMID: 33848843 DOI: 10.1016/j.jss.2021.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/01/2021] [Accepted: 02/27/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND We sought to investigate the risk of pediatric surgical mortality associated with the combined effects of key preoperative comorbidities and race. METHODS We performed a retrospective study that included infants who underwent inpatient surgical procedures between 2012 and 2017 and were entered into the NSQIP-P registry. We assessed additive moderation by estimating the proportion of mortality risk attributable to the combined effects of race and the presence of a preoperative comorbidity (attributable proportion [AP]). RESULTS The study group was comprised of 58466 surgical cases, of whom 15711(26.9%) were neonates and 42755(73.1%) older infants. Among neonates, a history of prematurity carried a poorer prognosis in black babies than their white peers (OR:1.53, 95%CI:1.20,1.95). Additionally, there was evidence of additive moderation by race on the association between prematurity and postoperative mortality (AP: 23.9%; 95%CI: 3.8,43.9, P value = 0.020). In older infants, presence of preoperative sepsis carried almost two times higher risk of mortality for black patients than their white counterparts (OR:1.81; 95%CI:1.21,2.73). This explained 38.4% of mortality cases in black patients with preoperative sepsis (95%CI:14.0,62.7; P = 0.002). A history of prematurity also carried a greater risk of mortality in older infants of black race (OR:1.69; 95%CI: 1.27, 2.24), accounting for 24.2% of mortality cases (AP:24.2%; 95%CI:0.90, 47.5, P = 0.041). CONCLUSIONS We quantified the surgical burden of mortality resulting from the differential impact of key comorbidities on black neonates and infants. Our data suggest that race-specific interventions to mitigate the incidence of the identified comorbidities could narrow the racial disparities in post surgical mortality.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Brittany L Willer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.
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