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Rostas SE, McPherson C. Acid Suppression for Gastroesophageal Reflux Disease in Infants. Neonatal Netw 2018; 37:33-41. [PMID: 29436357 DOI: 10.1891/0730-0832.37.1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Gastroesophageal reflux is a normal physiologic occurrence that is common throughout infancy and usually resolves on its own. Infrequently, reflux causes complications and turns into gastroesophageal reflux disease (GERD), which may warrant intervention. Available interventions vary in invasiveness and supporting data may be lacking for efficacy and safety. Nonpharmacologic interventions are first-line therapy for GERD in infants, whereas pharmacologic and surgical approaches are controversial. Efficacy data are limited for pharmacologic strategies for infantile GERD and safety data have demonstrated serious risks, especially in younger infants. Utilization of these medications should be approached cautiously in this population, if appropriate diagnostic techniques determine acid suppression could be beneficial. A robust monitoring plan with frequent reassessment of need for therapy may optimize benefit and minimize risk.
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Smith PB. Use of Reflux Medications in Premature Infants After Hospital Discharge. Pediatrics 2016; 138:e20162849. [PMID: 27940724 PMCID: PMC5127077 DOI: 10.1542/peds.2016-2849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- P Brian Smith
- Duke University Medical Center, Durham, North Carolina
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Quality use of medicines in neonatal care: a review of measures of quality used to evaluate the appropriateness and rational use of medication within the NICU. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0313-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Romaine A, Ye D, Ao Z, Fang F, Johnson O, Blake T, Benjamin DK, Cotten CM, Testoni D, Clark RH, Chu VH, Smith PB, Hornik CP. Safety of histamine-2 receptor blockers in hospitalized VLBW infants. Early Hum Dev 2016; 99:27-30. [PMID: 27390109 PMCID: PMC4969147 DOI: 10.1016/j.earlhumdev.2016.05.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/20/2016] [Accepted: 05/24/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Histamine-2 receptor (H2) blockers are often used in very low birth weight infants despite lack of population specific efficacy and safety data. AIMS We sought to describe safety and temporal trends in histamine-2 receptor (H2) blocker use in hospitalized very low birth weight (VLBW) infants. STUDY DESIGN We conducted a retrospective cohort study using a clinical database populated by an electronic health record shared by 348 neonatal intensive care units in the United States. SUBJECTS We included all VLBW infants without major congenital anomalies. OUTCOME MEASURES We used multivariable logistic regression with generalizing estimating equations to evaluate the association between days of H2 blocker exposure and risk of: 1) death or necrotizing enterocolitis (NEC); 2) death or sepsis; and 3) death, NEC, or sepsis. RESULTS Of 127,707 infants, 20,288 (16%) were exposed to H2 blockers for a total of 6,422,352days. Median gestational age for infants exposed to H2 blockers was 27weeks (25th 75th percentile 26, 29). H2 blocker use decreased from 18% of infants in 1997 to 8% in 2012 (p<0.001). On multivariable analysis, infants were at increased risk of the combined outcome of death, NEC, or sepsis on days exposed to H2 blockers (odds ratio=1.14) (95% confidence interval 1.08, 1.19). CONCLUSIONS H2 blocker use is associated with increased risk of the combined outcome of death, NEC, or sepsis in hospitalized VLBW infants.
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Affiliation(s)
| | - Daniel Ye
- Duke Clinical Research Institute, Durham, NC, USA.
| | - Zachary Ao
- Duke Clinical Research Institute, Durham, NC, USA.
| | - Francia Fang
- Duke Clinical Research Institute, Durham, NC, USA.
| | | | - Taylor Blake
- Duke Clinical Research Institute, Durham, NC, USA.
| | | | | | | | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL,USA.
| | - Vivian H Chu
- Duke Clinical Research Institute, Durham, NC, USA.
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Ellsbury DL, Clark RH, Ursprung R, Handler DL, Dodd ED, Spitzer AR. A Multifaceted Approach to Improving Outcomes in the NICU: The Pediatrix 100 000 Babies Campaign. Pediatrics 2016; 137:peds.2015-0389. [PMID: 26936860 DOI: 10.1542/peds.2015-0389] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Despite advances in neonatal medicine, infants requiring neonatal intensive care continue to experience substantial morbidity and mortality. The purpose of this initiative was to generate large-scale simultaneous improvements in multiple domains of care in a large neonatal network through a program called the "100,000 Babies Campaign." METHODS Key drivers of neonatal morbidity and mortality were identified. A system for retrospective morbidity and mortality review was used to identify problem areas for project prioritization. NICU system analysis and staff surveys were used to facilitate reengineering of NICU systems in 5 key driver areas. Electronic health record-based automated data collection and reporting were used. A quality improvement infrastructure using the Kotter organizational change model was developed to support the program. RESULTS From 2007 to 2013, data on 422 877 infants, including a subset with birth weight of 501 to 1500 g (n = 58 555) were analyzed. Key driver processes (human milk feeding, medication use, ventilator days, admission temperature) all improved (P < .0001). Mortality, necrotizing enterocolitis, retinopathy of prematurity, bacteremia after 3 days of life, and catheter-associated infection decreased. Survival without significant morbidity (necrotizing enterocolitis, severe intraventricular hemorrhage, severe retinopathy of prematurity, oxygen use at 36 weeks' gestation) improved. CONCLUSIONS Implementation of a multifaceted quality improvement program that incorporated organizational change theory and automated electronic health record-based data collection and reporting program resulted in major simultaneous improvements in key neonatal processes and outcomes.
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Affiliation(s)
- Dan L Ellsbury
- The Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - Reese H Clark
- The Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - Robert Ursprung
- The Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - Darren L Handler
- The Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - Elizabeth D Dodd
- The Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - Alan R Spitzer
- The Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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Gordon PV, Swanson JR, Clark R, Spitzer A. The complete blood cell count in a refined cohort of preterm NEC: the importance of gestational age and day of diagnosis when using the CBC to estimate mortality. J Perinatol 2016; 36:121-5. [PMID: 26562369 DOI: 10.1038/jp.2015.162] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The value of the white blood cell count (WBC) in necrotizing enterocolitis (NEC) is controversial. One reason for this confusion may be that the various WBC lineages change substantially with increasing gestational age and thereby age of NEC onset. This study postulated that if a data set was large enough and the diagnosis of NEC clean enough, absolute WBC counts would facilitate prediction of NEC mortality. The objective of this study was to determine whether absolute WBC counts enhance the prediction of NEC mortality. STUDY DESIGN A de-identified data subset from the Pediatrix national data set specific to the diagnoses of NEC in patients who had a CBC drawn on the day of diagnosis (exclusive of the diagnoses of spontaneous intestinal perforations and congenital anomalies) was the target for analysis. Values of primary interest included: gestation, day of diagnosis, absolute WBC count, platelet count, hematocrit, mortality and the day of diagnosis. Stepwise regression analysis was used to predict mortality. RESULT A total of 4059 (79%) survivors and 1107 (21%) infants who died with a diagnosis of medical or surgical NEC were included in the data set. Associations with mortality were found with low gestational age, low platelet count, low hematocrit, high band/segmented neutrophil ratio, earlier day of diagnosis, high birth weight z-score, non-white race, no antenatal steroids in gestations above 24 weeks, absolute lymphocyte count adjusted for gestational age, and absolute monocyte count high and low values. A stepwise regression analysis yielded a receiver-operator curve of 0.819 with a sensitivity of 65% and specificity of 84%. CONCLUSION Absolute WBC values enhance prediction of NEC survival when used in combination with readily available data on the day of NEC diagnosis.
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Affiliation(s)
- P V Gordon
- Sacred Heart Women's and Children's Hospital, Pensacola, FL, USA.,Pediatrix Corporation, Sunrise, FL, USA
| | - J R Swanson
- Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, VA, USA
| | - R Clark
- Pediatrix Corporation, Sunrise, FL, USA
| | - A Spitzer
- Pediatrix Corporation, Sunrise, FL, USA
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Ericson JE, Arnold C, Cheeseman J, Cho J, Kaneko S, Wilson E, Clark RH, Benjamin DK, Chu V, Smith PB, Hornik CP. Use and Safety of Erythromycin and Metoclopramide in Hospitalized Infants. J Pediatr Gastroenterol Nutr 2015; 61:334-9. [PMID: 25806675 PMCID: PMC4553109 DOI: 10.1097/mpg.0000000000000792] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Prokinetic medications are used in premature infants to promote motility and decrease time to full enteral feeding. Erythromycin and metoclopramide are the most commonly used prokinetic medications in the neonatal intensive care unit (NICU), but their safety profile is not well defined. METHODS We conducted a large retrospective cohort study using data from 348 NICUs managed by the Pediatrix Medical Group. All of the infants exposed to ≥1 dose of erythromycin, metoclopramide, or both, from a cohort of 8,87,910 infants discharged between 1997 and 2012 were included. We collected laboratory and clinical information while infants were exposed to erythromycin or metoclopramide and described the frequency of laboratory abnormalities and clinical adverse events (AEs). RESULTS Metoclopramide use increased from 1997 to 2005 and decreased from 2005 to 2012, whereas erythromycin use remained stable. Erythromycin use was most often associated with a diagnosis of feeding problem (40%), whereas metoclopramide was most often associated with a diagnosis of gastroesophageal reflux (59%). The most common laboratory AE during exposure to erythromycin or metoclopramide was hyperkalemia (8.6/1000 infant days on erythromycin and 11.0/1000 infant days on metoclopramide). Incidence of pyloric stenosis was greater with erythromycin than with metoclopramide (10/1095, 0.9% vs 76/19,001, 0.4%; P = 0.01), but odds were not significantly increased after adjusting for covariates (odds ratio 0.52, 95% confidence interval [CI] 0.26-1.02, P = 0.06). More infants experienced an AE while treated with metoclopramide than with erythromycin (odds ratio 1.21, 95% CI 1.03-1.43). CONCLUSIONS Metoclopramide was associated with increased risk of AEs compared with erythromycin. Studies are needed to confirm safety and effectiveness of both the drugs in infants.
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Affiliation(s)
- Jessica E. Ericson
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | | | - Jordan Cho
- Duke Clinical Research Institute, Durham, NC
| | | | | | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Daniel K. Benjamin
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Vivian Chu
- Department of Medicine, Duke University, Durham, NC
| | - P. Brian Smith
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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Drug utilisation profile in the neonatal unit of a university hospital: a prospective observational study in Brazil. Int J Clin Pharm 2015; 37:645-55. [PMID: 25832676 DOI: 10.1007/s11096-015-0109-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 03/20/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Advances in neonatology have contributed to changes in the drug utilisation profile in neonates, both in the number of drugs and the pharmacotherapeutic groups. OBJECTIVE To analyse drug use in the neonatal care unit of a teaching hospital in Brazil and to evaluate the associations among perinatal, clinical care and drug use data. SETTING The neonatal care unit of a teaching hospital in Brazil. METHODS A prospective observational study was conducted. Perinatal, clinical care and pharmacotherapy data were collected from the patients' medical records. Labelling information regarding neonatal use was analysed for prescribed drugs. The data were analysed using univariate descriptive statistics and quasi-Poisson regression. MAIN OUTCOME MEASURE Frequency of drug use by gestational age. RESULTS The study included 187 patients; 157 (84.0 %) received drugs. The mean gestational age was 35.8 weeks. The mean number of drugs prescribed per patient was 6.4. The number of drugs used was inversely correlated to gestational age and birth weight. The most commonly prescribed drugs belonged to the following anatomical therapeutic chemical groups: nervous system drugs, anti-infectives for systemic use, and alimentary tract and metabolism drugs. Information regarding neonatal use was given in the labelling of only 20.5 % of the prescribed drugs. Of these, only 9.5 % had information specific for preterm infants. CONCLUSIONS Drug administration to neonates is frequently and inversely correlated to gestational age and birth weight. Neonates are exposed to different therapeutic classes, reflecting scientific advances in neonatology. In Brazil, the percentage of drugs with neonate-specific labelling information is low. Consequently, there is an evident need for efforts to guarantee effective and safe pharmacotherapy for neonates.
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Reducing necrotizing enterocolitis in very low birth weight infants using quality-improvement methods. J Perinatol 2014; 34:850-7. [PMID: 25010221 PMCID: PMC4216600 DOI: 10.1038/jp.2014.123] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 05/12/2014] [Accepted: 05/14/2014] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Owing to a rise in necrotizing enterocolitis (NEC, stage ⩾ 2) among very low birth weight (VLBW, birth weight <1500 g) infants from 4% in 2005 to 2006 to 10% in 2007 to 2008, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants. STUDY DESIGN In September 2009, we developed an NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ⩾ 2. In May 2010, we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170). RESULT The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%) but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC. CONCLUSION QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.
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Hawcutt DB, O’Connor O, Turner MA. Adverse drug reactions in neonates: could we be documenting more? Expert Rev Clin Pharmacol 2014; 7:807-20. [DOI: 10.1586/17512433.2014.956090] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Legrand F, Boulkedid R, Elie V, Leroux S, Valls E, Valls-i-Soler A, Van den Anker JN, Jacqz-Aigrain E. A Delphi process to optimize quality and performance of drug evaluation in neonates. PLoS One 2014; 9:e104976. [PMID: 25210742 PMCID: PMC4161344 DOI: 10.1371/journal.pone.0104976] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/16/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Neonatal trials remain difficult to conduct for several reasons: in particular the need for study sites to have an existing infrastructure in place, with trained investigators and validated quality procedures to ensure good clinical, laboratory practices and a respect for high ethical standards. The objective of this work was to identify the major criteria considered necessary for selecting neonatal intensive care units that are able to perform drug evaluations competently. METHODOLOGY AND MAIN FINDINGS This Delphi process was conducted with an international multidisciplinary panel of 25 experts from 13 countries, selected to be part of two committees (a scientific committee and an expert committee), in order to validate criteria required to perform drug evaluation in neonates. Eighty six items were initially selected and classified under 7 headings: "NICUs description-Level of care" (21), "Ability to perform drug trials: NICU organization and processes (15), "Research Experience" (12), "Scientific competencies and area of expertise" (8), "Quality Management" (16), "Training and educational capacity" (8) and "Public involvement" (6). Sixty-one items were retained and headings were rearranged after the first round, 34 were selected after the second round. A third round was required to validate 13 additional items. The final set includes 47 items divided under 5 headings. CONCLUSION A set of 47 relevant criteria will help to NICUs that want to implement, conduct or participate in drug trials within a neonatal network identify important issues to be aware of. SUMMARY POINTS 1) Neonatal trials remain difficult to conduct for several reasons: in particular the need for study sites to have an existing infrastructure in place, with trained investigators and validated quality procedures to ensure good clinical, laboratory practices and a respect for high ethical standards. 2) The present Delphi study was conducted with an international multidisciplinary panel of 25 experts from 13 countries and aims to identify the major criteria considered necessary for selecting neonatal intensive care units (NICUs) that are able to perform drug evaluations competently. 3) Of the 86 items initially selected and classified under 7 headings--"NICUs description-Level of care" (21), "Ability to perform drug trials: NICU organization and processes (15), "Research Experience" (12), "Scientific competencies and area of expertise" (8), "Quality Management" (16), "Training and educational capacity" (8) and "Public involvement" (6)--47 items were selected following a three rounds Delphi process. 4) The present consensus will help NICUs to implement, conduct or participate in drug trials within a neonatal network.
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Affiliation(s)
- Frederic Legrand
- AP-HP (Assistance Publique des Hôpitaux de Paris), Department of Paediatric Pharmacology and Pharmacogenetics, Inserm CIC 9202 (Centre d'Investigation Clinique pédiatrique), University Diderot Paris VII, Hôpital Robert Debré, Paris, France
| | - Rym Boulkedid
- AP-HP (Assistance Publique des Hôpitaux de Paris), Unité de Recherche Clinique (URC), Inserm CIE5 (Centre d'Investigation clinique Epidémiologie clinique), Hôpital Robert Debré, Paris, France
| | - Valery Elie
- AP-HP (Assistance Publique des Hôpitaux de Paris), Department of Paediatric Pharmacology and Pharmacogenetics, Inserm CIC 9202 (Centre d'Investigation Clinique pédiatrique), University Diderot Paris VII, Hôpital Robert Debré, Paris, France
| | - Stephanie Leroux
- AP-HP (Assistance Publique des Hôpitaux de Paris), Department of Paediatric Pharmacology and Pharmacogenetics, Inserm CIC 9202 (Centre d'Investigation Clinique pédiatrique), University Diderot Paris VII, Hôpital Robert Debré, Paris, France
| | - Elizabeth Valls
- University of Basque country, Head Neonatal Intensive care Unit, Cruces University Hospital, Barakaldo-Bilbao, Spain
| | - Adolfo Valls-i-Soler
- University of Basque country, Head Neonatal Intensive care Unit, Cruces University Hospital, Barakaldo-Bilbao, Spain
| | - Johannes N. Van den Anker
- Evan and Cindy Jones Professor of Paediatric Clinical Pharmacology Chief, Division of Clinical Pharmacology, Children's National Health System, Washington, District of Columbia, United States of America
| | - Evelyne Jacqz-Aigrain
- AP-HP (Assistance Publique des Hôpitaux de Paris), Department of Paediatric Pharmacology and Pharmacogenetics, Inserm CIC 9202 (Centre d'Investigation Clinique pédiatrique), University Diderot Paris VII, Hôpital Robert Debré, Paris, France
- * E-mail:
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