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Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach. Life (Basel) 2021; 11:life11020171. [PMID: 33671771 PMCID: PMC7926945 DOI: 10.3390/life11020171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/15/2022] Open
Abstract
Unexpected events of breath, tone, and skin color change in infants are a cause of considerable distress to the caregiver and there is still debate on their appropriate management. The aim of this study is to survey the trend in prevention, decision-making, and management of brief resolved unexplained events (BRUE)/apparent life-threatening events (ALTE) and to develop a shared protocol among hospitals and primary care pediatricians regarding hospital admission criteria, work-up and post-discharge monitoring of patients with BRUE/ALTE. For the study purpose, a panel of 54 experts was selected to achieve consensus using the RAND/UCLA appropriateness method. Twelve scenarios were developed: one addressed to primary prevention of ALTE and BRUE, and 11 focused on hospital management of BRUE and ALTE. For each scenario, participants were asked to rank each option from ‘1’ (extremely inappropriate) to ‘9’ (extremely appropriate). Results derived from panel meeting and discussion showed several points of agreement but also disagreement with different opinion emerged and the need of focused education on some areas. However, by combining previous recommendations with expert opinion, the application of the RAND/UCLA appropriateness permitted us to drive pediatricians to reasoned and informed decisions in term of evaluation, treatment and follow-up of infants with BRUE/ALTE, reducing inappropriate exams and hospitalisation and highlighting priorities for educational interventions.
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Abstract
OBJECTIVES To compare duration and changes over time in length of hospital stay for very preterm and extremely preterm infants in 10 European regions. DESIGN Two area-based cohort studies from the same regions in 2003 and 2011/2012. SETTING Ten regions from nine European countries. PATIENTS Infants born between 22 + 0 and 31 + 6 weeks of gestational age and surviving to discharge (Models of Organising Access to Intensive Care for Very Preterm Births cohort in 2003, n = 4,011 and Effective Perinatal Intensive Care in Europe cohort in 2011/2012, n = 4,336). INTERVENTIONS Observational study, no intervention. MEASUREMENTS AND MAIN RESULTS Maternal and infant characteristics were abstracted from medical records using a common protocol and length of stay until discharge was adjusted for case-mix using negative binomial regression. Mean length of stay was 63.6 days in 2003 and varied from 52.4 to 76.5 days across regions. In 2011/2012, mean length of stay was 63.1 days, with a narrower regional range (54.0-70.1). Low gestational age, small for gestational age, low 5-minute Apgar score, surfactant administration, any surgery, and severe neonatal morbidities increased length of stay. Infant characteristics explained some of the differences between regions and over time, but large variations remained after adjustment. In 2011/2012, mean adjusted length of stay ranged from less than 54 days in the Northern region of the United Kingdom and Wielkopolska, Poland to over 67 days in the Ile-de-France region of France and the Eastern region of the Netherlands. No systematic decrease in very preterm length of stay was observed over time after adjustment for patient case-mix. CONCLUSIONS A better understanding of the discharge criteria and care practices that contribute to the wide differences in very preterm length of stay across European regions could inform policies to optimize discharge decisions in terms of infant outcomes and health system costs.
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Chandrasekharan P, Rawat M, Reynolds AM, Phillips K, Lakshminrusimha S. Apnea, bradycardia and desaturation spells in premature infants: impact of a protocol for the duration of 'spell-free' observation on interprovider variability and readmission rates. J Perinatol 2018; 38:86-91. [PMID: 29120450 PMCID: PMC5775039 DOI: 10.1038/jp.2017.174] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/02/2017] [Accepted: 09/25/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To study the impact of implementing a protocol to standardize the duration of observation in preterm infants with apnea/bradycardia/desaturation spells before hospital discharge on length of stay (LOS) and readmission rates. STUDY DESIGN A protocol to standardize the duration of in-hospital observation for preterm infants with apnea, bradycardia and desaturation spells who were otherwise ready for discharge was implemented in December 2013. We evaluated the impact of this protocol on the LOS and readmission rates of very low birth weight infants (VLBW). Data on readmission for apnea and an apparent life-threatening event (ALTE) within 30 days of discharge were collected. The pre-implementation epoch (2011 to 2013) was compared to the post-implementation period (2014 to 2016). RESULTS There were 426 and 368 VLBW discharges before and after initiation of the protocol during 2011 to 2013 and 2014 to 2016, respectively. The LOS did not change with protocol implementation (66±42 vs 64±42 days before and after implementation of the protocol, respectively). Interprovider variability on the duration of observation for apneic spells (F-8.8, P=0.04) and bradycardia spells (F-17.4, P<0.001) decreased after implementation of the protocol. The readmission rate for apnea/ALTE after the protocol decreased from 12.1 to 3.4% (P=0.01). CONCLUSION Implementing an institutional protocol for VLBW infants to determine the duration of apnea/bradycardia/ desaturation spell-free observation period as recommended by the American Academy of Pediatrics clinical report did not prolong the LOS but effectively reduced interprovider variability and readmission rates.
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Affiliation(s)
- Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, UBMD, Women and Children’s Hospital of Buffalo, NY
| | - Munmun Rawat
- Division of Neonatology, Department of Pediatrics, UBMD, Women and Children’s Hospital of Buffalo, NY
| | - Anne Marie Reynolds
- Division of Neonatology, Department of Pediatrics, UBMD, Women and Children’s Hospital of Buffalo, NY
| | | | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, UBMD, Women and Children’s Hospital of Buffalo, NY
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Piumelli R, Davanzo R, Nassi N, Salvatore S, Arzilli C, Peruzzi M, Agosti M, Palmieri A, Paglietti MG, Nosetti L, Pomo R, De Luca F, Rimini A, De Masi S, Costabel S, Cavarretta V, Cremante A, Cardinale F, Cutrera R. Apparent Life-Threatening Events (ALTE): Italian guidelines. Ital J Pediatr 2017; 43:111. [PMID: 29233182 PMCID: PMC5728046 DOI: 10.1186/s13052-017-0429-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/22/2017] [Indexed: 02/07/2023] Open
Abstract
Five years after the first edition, we have revised and updated the guidelines, re-examining the queries and relative recommendations, expanding the issues addressed with the introduction of a new entity, recently proposed by the American Academy of Pediatrics: BRUE, an acronym for Brief Resolved Unexplained Events. In this manuscript we will use the term BRUE only to refer to mild, idiopathic cases rather than simply replace the acronym ALTE per se.In our guidelines the acronym ALTE is used for severe cases that are unexplainable after the first and second level examinations.Although the term ALTE can be used to describe the common symptoms at the onset, whenever the aetiology is ascertained, the final diagnosis may be better specified as seizures, gastroesophageal reflux, infection, arrhythmia, etc. Lastly, we have addressed the emerging problem of the so-called Sudden Unexpected Postnatal Collapse (SUPC), that might be considered as a severe ALTE occurring in the first week of life.
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Affiliation(s)
- Raffaele Piumelli
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy.
| | - Riccardo Davanzo
- Department of Perinatal Medicine, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Niccolò Nassi
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy
| | | | - Cinzia Arzilli
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Firenze, Italy
| | - Marta Peruzzi
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy
| | - Massimo Agosti
- Neonatal Intensive Care Unit, Del Ponte Hospital, Varese, Italy
| | - Antonella Palmieri
- SIDS Center, Pediatric Emergency Department, "G. Gaslini" Children's Hospital, Genova, Italy
| | - Maria Giovanna Paglietti
- Pneumology Unit - University Hospital Pediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Luana Nosetti
- Paediatric Department, University of Insubria, Varese, Italy
| | - Raffaele Pomo
- SIDS/ALTE Center, Buccheri la Ferla Hospital, Palermo, Italy
| | | | | | | | - Simona Costabel
- Emergency Department of Paediatrics, G. Gaslini Children's Hospital, Genova, Italy
| | | | - Anna Cremante
- National Neurological Institute IRCCS C, Mondino, Pavia, Italy
| | | | - Renato Cutrera
- Pneumology Unit - University Hospital Pediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
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Mitchell A, Hall RW, Erickson SW, Yates C, Lowery S, Hendrickson H. Systemic Absorption of Cyclopentolate and Adverse Events After Retinopathy of Prematurity Exams. Curr Eye Res 2016; 41:1601-1607. [PMID: 27159349 DOI: 10.3109/02713683.2015.1136419] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Preterm infants undergoing Retinopathy of Prematurity Eye Exams (ROPEE) may experience adverse events, possibly from systemic absorption of cyclopentolate. The purpose of this study was to analyze the association between adverse events and drug levels found in neonates undergoing ROPEE. MATERIALS AND METHODS 25 infants were randomized into two groups during routine ROP screening: 5 infants for blood collection before mydriatic drops and 20 for blood collection 1 h after eye drops. Blood was collected onto dried blood spot cards, extracted, and analyzed for cyclopentolate and phenylephrine using liquid chromatography and mass spectrometry. Relationships between drug levels and adverse events were assessed. RESULTS Cyclopentolate (range 6-53 ng/ml) was observed in 15 of 18 infants, while phenylephrine was not detected. Levels of cyclopentolate were significantly higher in infants who were on oxygen (p = 0.01). There was a significant association between cyclopentolate levels and gastric residuals in tube-fed infants not receiving oxygen (p = 0.01). CONCLUSIONS Cyclopentolate levels varied among preterm infants after ROPEE. Cyclopentolate was positively associated with increased gastric residuals. Underlying medical conditions requiring oxygen administration may affect absorption and metabolism of cyclopentolate. There is a need to predict infants at risk for high blood levels of cyclopentolate in order to prevent or treat adverse events after ROPEE.
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Affiliation(s)
- Anita Mitchell
- a Department of Nursing Science , College of Nursing, University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Richard W Hall
- b Department of Pediatrics , College of Medicine, University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Stephen W Erickson
- c Department of Biostatistics , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Charlotte Yates
- d Department of Physical Therapy , University of Central Arkansas , Conway , AR , USA
| | | | - Howard Hendrickson
- e Department of Pharmaceutical Sciences , College of Pharmacy, University of Arkansas for Medical Sciences , Little Rock , AR , USA
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Oster ME, Ehrlich A, King E, Petit CJ, Clabby M, Smith S, Glanville M, Anderson J, Darbie L, Beekman RH. Association of Interstage Home Monitoring With Mortality, Readmissions, and Weight Gain: A Multicenter Study from the National Pediatric Cardiology Quality Improvement Collaborative. Circulation 2015; 132:502-8. [PMID: 26260497 DOI: 10.1161/circulationaha.114.014107] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 05/22/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Daily home monitoring of oxygen saturation and weight has been reported to improve outcomes for patients with single-ventricle heart disease during the period between stage I palliation and stage II palliation. However, these studies have been limited to single institutions and used historical control subjects. Our objective was to determine the association of various interstage home monitoring strategies with outcomes using a multicenter cohort with contemporary control subjects. METHODS AND RESULTS We performed a retrospective cohort study using prospectively collected data from the National Pediatric Cardiology Quality Improvement Collaborative from 2008 to 2012. We compared interstage mortality, unscheduled readmissions, and change in weight-for-age Z score for various home monitoring strategies of oxygen saturation (n=494) or weight (n=472), adjusting for sex, syndrome, tricuspid regurgitation, arch obstruction, and shunt type. Overall interstage mortality was 8.1%, and 47% had ≥1 unscheduled readmission. We did not find any associations of home oxygen saturation or weight monitoring with mortality or readmission. Although there was no difference in weight-for-age Z score for daily (0.33±0.12) versus weekly (0.34±0.18, P=0.98) weight monitoring, daily home weight monitoring was superior to no home weight monitoring (-0.15±0.18; P<0.01). CONCLUSIONS Home weight monitoring is associated with improved weight gain during the interstage period, but we did not find any benefits in other clinical outcomes for either home oxygen saturation monitoring or home weight monitoring.
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Affiliation(s)
- Matthew E Oster
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.).
| | - Alexandra Ehrlich
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Eileen King
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Christopher J Petit
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Martha Clabby
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Sherry Smith
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Michelle Glanville
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Jeffrey Anderson
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Lynn Darbie
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
| | - Robert H Beekman
- From Children's Healthcare of Atlanta, GA (M.E.O., A.E., C.J.P., M.E.C., S.S., M.G.); Emory University School of Medicine, Atlanta, GA (M.E.O., C.J.P., M.C.); and Cincinnati Children's Hospital Medical Center, OH (E.K., J.A., L.D., R.H.B.)
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