Trends and challenges in United States neonatal intensive care units follow-up clinics

Neonatologist at the Well-Child Clinic: A High-Risk Infant Follow-up Pilot Study

OBJECTIVE

 High-risk infant follow-up (HRIF) is a complex process lacking standardization. We present a simple, single-provider model that proved effective and is well-received by caregivers.

STUDY DESIGN

 In this study, we measured caregiver use and satisfaction with an HRIF visit attended by an experienced neonatologist in a well-care setting, soon after discharge.

RESULTS

 One hundred parents participated in the survey. Among the infants of these parents, 78% of infants were seen in the first 3 months of life and 39% within 1 month of discharge. Nutrition (98%) and development (97%) were the most commonly discussed topics, followed by general health (95%), iron supplementation (93%), and head size (90%). Using a 5-point Likert's scale, with 5 being the highest rating, parents responded that the meeting answered their questions (4.7, n = 93), organized their infants' needs (4.6, n = 90), and increased their confidence in caring for their infants (4.65, n = 92).

CONCLUSION

 HRIF with an experienced neonatologist is an effective means of increasing parents' understanding of their infants' medical needs and confidence in caring for their infants.

KEY POINTS

· Meeting with a neonatologist after discharge addressed many crucial aspects of patient care.. · Meeting with a neonatologist after discharge was met with a high level of caregiver satisfaction.. · Neonatal consultation in the community may promote caregiver confidence in caring for their infant.. · Neonatal consultation reduced parental anxiety, especially regarding growth and development..

Variation in follow-up for children born very preterm in Europe

BACKGROUND

Children born very preterm (<32 weeks of gestation) face high risks of neurodevelopmental and health difficulties compared with children born at term. Follow-up after discharge from the neonatal intensive care unit is essential to ensure early detection and intervention, but data on policy approaches are sparse.

METHODS

We investigated the characteristics of follow-up policy and programmes in 11 European countries from 2011 to 2022 using healthcare informant questionnaires and the published/grey literature. We further explored how one aspect of follow-up, its recommended duration, may be reflected in the percent of parents reporting that their children are receiving follow-up services at 5 years of age in these countries using data from an area-based cohort of very preterm births in 2011/12 (N = 3635).

RESULTS

Between 2011/12 and 22, the number of countries with follow-up policies or programmes increased from 6 to 11. The policies and programmes were heterogeneous in eligibility criteria, duration and content. In countries that recommended longer follow-up, parent-reported follow-up rates at 5 years of age were higher, especially among the highest risk children, born <28 weeks' gestation or with birthweight <1000 g: between 42.1% and 70.1%, vs. <20% in most countries without recommendations.

CONCLUSIONS

Large variations exist in follow-up policies and programmes for children born very preterm in Europe; differences in recommended duration translate into cross-country disparities in reported follow-up at 5 years of age.

Implementing neurodevelopmental follow-up care for children with congenital heart disease: A scoping review with evidence mapping

AIM

To identify and map evidence describing components of neurodevelopmental follow-up care for children with congenital heart disease (CHD).

METHOD

This was a scoping review of studies reporting components of neurodevelopmental follow-up programmes/pathways for children with CHD. Eligible publications were identified through database searches, citation tracking, and expert recommendations. Two independent reviewers screened studies and extracted data. An evidence matrix was developed to visualize common characteristics of care pathways. Qualitative content analysis identified implementation barriers and enablers.

RESULTS

The review included 33 studies. Twenty-one described individual care pathways across the USA (n = 14), Canada (n = 4), Australia (n = 2), and France (n = 1). The remainder reported surveys of clinical practice across multiple geographical regions. While heterogeneity in care existed across studies, common attributes included enrolment of children at high-risk of neurodevelopmental delay; centralized clinics in children's hospitals; referral before discharge; periodic follow-up at fixed ages; standardized developmental assessment; and involvement of multidisciplinary teams. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness. Multi-level stakeholder engagement and integration with other services were key drivers of success.

INTERPRETATION

Defining components of effective neurodevelopmental follow-up programmes and care pathways, along with enhancing and expanding guideline-based care across regions and into new contexts, should continue to be priorities.

WHAT THIS PAPER ADDS

Twenty-two different neurodevelopmental follow-up care pathways/programmes were published, originating from four countries. Twelve additional publications described broad practices for neurodevelopmental follow-up across regions Common attributes across eligibility, service structure, assessment processes, and care providers were noted. Studies reported programme acceptability, uptake, cost, and effectiveness. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness.

Ensuring Optimal Outcomes for Preterm Infants after NICU Discharge: A Life Course Health Development Approach to High-Risk Infant Follow-Up

Children born prematurely (<37 weeks' gestation) have an increased risk for chronic health problems and developmental challenges compared to their term-born peers. The threats to health and development posed by prematurity, the unintended effects of life-sustaining neonatal intensive care, the associated neonatal morbidities, and the profound stressors to families affect well-being during infancy, childhood, adolescence, and beyond. Specialized clinical programs provide medical and developmental follow-up care for preterm infants after hospital discharge. High-risk infant follow-up, like most post-discharge health services, has many shortcomings, including unclear goals, inadequate support for infants, parents, and families, fragmented service provisions, poor coordination among providers, and an artificially foreshortened time horizon. There are well-documented inequities in care access and delivery. We propose applying a life course health development framework to clinical follow-up for children born prematurely that is contextually appropriate, developmentally responsive, and equitably deployed. The concepts of health development, unfolding, complexity, timing, plasticity, thriving, and harmony can be mapped to key components of follow-up care delivery to address pressing health challenges. This new approach envisions a more effective version of clinical follow-up to support the best possible functional outcomes and the opportunity for every premature infant to thrive within their family and community environments over their life course.

Pediatric Sepsis Requiring Intensive Care Admission: Potential Structured Follow-Up Protocols to Identify and Manage New or Exacerbated Medical Conditions

Pediatric sepsis is a leading cause of morbidity and mortality in children globally. Children who require the pediatric intensive care unit (PICU) are at high risk for new or worsening co-morbidities, as well as readmission. This review describes the current state of protocolized follow-up after pediatric sepsis requiring PICU admission. We searched Medline and EMBASE databases for studies published in English from 2005 to date. Duplicates, review articles, abstracts and poster presentations were excluded; neonatal intensive care unit (NICU) patients were also excluded since neonatal sepsis is variably defined and differs from the pediatric consensus definition. The search yielded 418 studies of which 55 were duplicates; the subsequent 363 studies were screened for inclusion criteria, yielding 31 studies for which full article screening was completed. Subsequently, 23 studies were excluded due to wrong population (9), wrong publication type (10), duplicate data (3) or wrong outcome (1). In total, nine studies were included for which we described study design, setting, population, sample size, outcomes, PICU core outcome domain, and results. There were 4 retrospective cohort studies, 4 prospective cohort studies, 1 retrospective case series and no prospective trials. These studies show the varying trajectories of recovery after discharge, with the common finding that new or worsening morbidities are worse within months of discharge, but may persist. Sepsis survivors may have distinct needs and a different post-PICU trajectory compared to other critically ill children, particularly in quality of life and neurocognitive outcomes. Future research should focus on developing screening protocols and studying protocolized follow-up trials to reduce morbidity after pediatric sepsis.

Previous missed visits and independent risk of loss to follow-up in the high-risk neonatal follow-up clinic

BACKGROUND

Neonatal intensive care unit (NICU) patients are at high risk for developmental delays. As a result, many are seen in neonatal follow-up (NFU) clinics. Disparities in NFU follow-up rates by social determinants of health exist.

AIMS

Determine how the number of missed visits (composed of patient-canceled visits and no-show visits) relates to risk of loss to follow-up in the NFU clinic.

STUDY DESIGN

Retrospective cohort study at a regional specialty center in the United States.

SUBJECTS

262 patients born between January 1, 2014, and December 31, 2017, who were referred to the NFU clinic.

OUTCOME MEASURES

Logistic binomial regression was used to model risk ratio of loss to follow-up over two years, defined as not attending a recommended follow-up visit and not informing the clinic of a reason for discontinued care.

RESULTS

Of 262 infants, 220 patients (84 %) were seen for at least one visit and 143 (65 %) completed follow-up. Younger maternal age, maternal smoking during pregnancy, maternal drug use during pregnancy, and public insurance were all associated with missing more visits. For each additional missed visit, the risk of loss to follow-up was 1.73 times higher unadjusted (95 % CI: 1.33, 2.26) and 1.81 times higher (95 % CI: 1.36, 2.40) after adjusting for confounders. The risk ratio of loss to follow-up for no-show visits was three times higher than that for patient-canceled visits.

CONCLUSIONS

Each missed visit was independently associated with higher risk of loss to follow-up from NFU clinic, even after adjusting for other risk factors.

Ethics Considerations Regarding Artificial Womb Technology for the Fetonate

Since the early 1980's, with the clinical advent of in vitro fertilization resulting in so-called "test tube babies," a wide array of ethical considerations and concerns regarding artificial womb technology (AWT) have been described. Recent breakthroughs in the development of extracorporeal neonatal life support by means of AWT have reinitiated ethical interest about this topic with a sense of urgency. Most of the recent ethical literature on the topic, however, pertains not to the more imminent scenario of a physiologically improved method of neonatal care through AWT, but instead to the remote scenario of "complete ectogenesis" that imagines human gestation occurring entirely outside of the womb. This scoping review of the ethical literature on AWT spans from more abstract concerns about complete ectogenesis to more immediate concerns about the soon-to-be-expected clinical life support of what we term the fetal neonate or fetonate. Within an organizing framework of different stages of human gestational development, from conception to the viable premature infant, we discuss both already identified and newly emerging ethical considerations and concerns regarding AWT and the care of the fetonate.

Implementation of Early Detection and Intervention for Cerebral Palsy in High-Risk Infant Follow-Up Programs: U.S. and Global Considerations

Early detection and intervention for cerebral palsy is best practice for all high-risk infants according to international guidelines, consensus statements and research-supported evidence. It allows support for families and optimization of developmental trajectories into adulthood. All phases of implementation of CP early detection can be found across the world in high-risk infant follow-up programs, demonstrating feasibility and acceptability through standardized implementation science. The largest clinical network for CP early detection and intervention in the world has now sustained an average age at detection less than 12 months corrected age for more than 5 years. Targeted referrals and interventions for CP can now be offered to patients in optimal periods of neuroplasticity, and new therapies researched as the age of detection decreases. Implementation of guidelines and incorporation of rigorous CP research studies both allow high-risk infant follow-up programs to fulfill their mission of improving outcomes of those with the most vulnerable developmental trajectories from birth.

Outcomes of Preterm Infants: Shifting Focus, Extending the View

Advances in perinatal care have led to remarkable long-term survival for infants who are born preterm. This article reviews the broader context of follow-up care, highlighting the need to reenvision some areas, such as improving parental support by embedding parental involvement in the neonatal intensive care unit, incorporating parental perspectives about outcomes into follow-up care models and research, supporting their mental health, addressing social determinants of health and disparities, and advocating for change. Multicenter quality improvement networks allow identification and implementation of best practices for follow-up care.

High-Risk Infant Follow-Up After NICU Discharge: Current Care Models and Future Considerations

Preterm infants are at heightened risk for chronic health problems and developmental delays compared with term-born peers. High-risk infant follow-up programs provide surveillance and support for problems that may emerge during infancy and early childhood. Although considered standard of care, program structure, content, and timing are highly variable. Families face challenges accessing recommended follow-up services. Here, the authors review common models of high-risk infant follow-up, describe novel approaches, and outline considerations for improving the quality, value, and equity of follow-up care.

Prematurity, birth weight, and access to a medical home among school-aged children in the US: A cross-sectional survey

Introduction

Prematurity and low birth weight (LBW) are associated with higher health care needs and higher health care utilization in the first few years of life. The aim of this cross-sectional study was to determine how prematurity and LBW were correlated with access to a medical home later in childhood, at ages 6–17 years.

Methods

Data were analyzed from the 2016–2018 National Survey of Children's Health. Non-institutionalized US children 6–17 years of age who had been born preterm were classified as very low birth weight (VLBW, <1500 g), LBW (1500–2500 g), and normal weight (NBW, >2500 g). Term-born NBW children were included as a reference group. Medical home access was determined according to caregiver report.

Results

The analysis included 64,597 infants (preterm VLBW n  =  737; preterm LBW n  =  2869; preterm NBW n  =  3942; and term NBW n  =  57,049). Based on this sample, 44% of children ages 6–17 years were estimated to receive care meeting the criteria of a medical home. On multivariable analysis, none of the preterm groups had higher likelihood of receiving care in a medical home compared to children born at term and NBW (odds ratios ranging from 0.75 to 0.95).

Conclusions

School-aged children born preterm and LBW were equally or less likely to receive care meeting the criteria of a medical home than children born at term and NBW. Although prematurity and LBW are associated with increased health care use early in the life course, this does not appear sufficient to help children establish and maintain access to a medical home.

Care Intensity and Palliative Care in Chronically Critically Ill Infants

CONTEXT

Increasingly, chronically critically ill (CCI) infants survive to discharge from Neonatal Intensive Care Units (NICUs). Little is known about their care intensity and the primary and specialty palliative care families receive at and following discharge.

OBJECTIVES

To describe care intensity and primary and specialty palliative care received by NICU CCI infants at discharge and one year.

METHODS

Chart abstraction of CCI infants at three academic centers discharged at ≥42 weeks corrected gestational age with medical technology between 2016 and 2019, including demographics, care intensity, and primary and specialty palliative care received at discharge and one year.

RESULTS

Among 273 infants, NICU median stays were 45 [IQR 23-92] days. Primary diagnoses included congenital and/or genetic conditions (68.5%), prematurity (28.2%), and birth events (3.3%). At discharge, surgical feeding tubes (75.1%) and tracheostomies (24.5%) were the most common technologies. Infants received a median of 6 [IQR 4-9] medications and were followed by a median of 8 [IQR 7-9] providers. At one year, 91.4% continued with one or more technologies, similar numbers of medications and specialty providers. In the NICU, nearly all families had social work involvement, 78.8% had chaplaincy and 53.8% child life; 19.8% received specialty palliative care consultation. At one year, only 13.2% were followed by palliative care.

CONCLUSIONS

CCI infants receive intensive medical care including multiple medical technologies, medications, and specialty follow up at discharge and remain complex at one year of life. Most receive primary interprofessional palliative care in the NICU, however these infants and their families may have limited access to specialty palliative care in the short- and long-term.

Insurance coverage and respiratory morbidities in bronchopulmonary dysplasia

INTRODUCTION

Preterm infants and young children with bronchopulmonary dysplasia (BPD) are at increased risk for acute care utilization and chronic respiratory symptoms during early life. Identifying risk factors for respiratory morbidities in the outpatient setting could decrease the burden of care. We hypothesized that public insurance coverage was associated with higher acute care usage and respiratory symptoms in preterm infants and children with BPD after initial neonatal intensive care unit (NICU) discharge.

METHODS

Subjects were recruited from BPD clinics at 10 tertiary care centers in the United States between 2018 and 2021. Demographics and clinical characteristics were obtained through chart review. Surveys for clinical outcomes were administered to caregivers.

RESULTS

Of the 470 subjects included in this study, 249 (53.0%) received employer-based insurance coverage and 221 (47.0%) received Medicaid as sole coverage at least once between 0 and 3 years of age. The Medicaid group was twice as likely to have sick visits (adjusted odd ratio [OR]: 2.06; p = 0.009) and emergency department visits (aOR: 2.09; p = 0.028), and three times more likely to be admitted for respiratory reasons (aOR: 3.04; p = 0.001) than those in the employer-based group. Additionally, those in the Medicaid group were more likely to have nighttime respiratory symptoms (aOR: 2.62; p = 0.004).

CONCLUSIONS

Children with BPD who received Medicaid coverage were more likely to utilize acute care and have nighttime respiratory symptoms during the first 3 years of life. More comprehensive studies are needed to determine whether the use of Medicaid represents a barrier to accessing care, lower socioeconomic status, and/or a proxy for detrimental environmental exposures.

ezPreemie study protocol: a randomised controlled factorial trial testing web-based parent training and coaching with parents of children born very preterm

INTRODUCTION

Children born very preterm (VPT; gestational age <32 weeks) are twice as likely to demonstrate behaviour problems such as aggression, non-compliance, temper tantrums and irritability compared with their term-born peers. While behavioural parent training (BPT), also referred to as behaviour therapy is a gold standard for prevention and treatment of childhood problem behaviours, there are limited accessible and effective BPT interventions for families with children born VPT. The purpose of this paper is to describe a multicentre, randomised controlled protocol for a factorial design trial evaluating the independent and combined effects of the ezParent BPT intervention plus brief, weekly coaching calls on parent and child outcomes for families with toddlers born VPT.

METHODS AND ANALYSIS

The study employs a 2×2 factorial randomised design. Parents (n=220) of children aged 20-30 months corrected age who were born VPT (<32 weeks) will be recruited from two large metropolitan Neonatal Intensive Care Units follow-up clinics and randomised to one of four conditions: (1) ezParent (2) ezParent +coach, (3) Active control or (4) Active Control +coach. Data on parenting and child behaviour outcomes will be obtained from all participants at baseline and 3, 6 and 12 months postbaseline. All analyses will use an intention-to-treat approach, independent of their actual dose of each intervention.

ETHICS AND DISSEMINATION

The study protocol has been approved by The Ohio State University Institutional Review Board (IRB) using a single IRB. Study results will be disseminated through presentations at regional and national conferences, publications in peer-reviewed journals, and sharing research reports with participating families and recruiting sites.

TRIAL REGISTRATION NUMBER

NCT05217615.

Impact of the Coronavirus Pandemic on High-Risk Infant Follow-Up (HRIF) Programs: A Survey of Academic Programs

Objective: The impact of the COVID-19 pandemic on the functioning and services of academic high-risk infant follow-up (HRIF) clinics throughout North America. Study Design: Prospective 25-question questionnaire survey through REDCAP links that was sent over 10 weeks, to 105 US and 10 Canadian programs. Finally, 59 of 105 US programs and 5 of 10 Canadian responses were analyzed using SAS version 9.4. Results: In the US, 67% of programs reported closures between 1–5 months, whereas in Canada 80% of programs closed for 1–3 months. In the US 86% of programs provided telemedicine visits and only 42.5% provided multidisciplinary HRIF telemedicine visits. We enumerated innovative approaches specifically for the conduct of Telemedicine visits, the need for the standardization of various tests and services in a telemedicine setting, and to emphasize the urgent need for more government funding to improve follow-up and developmental services to this fragile group of newborns.

Influences of environmental exposures on preterm lung disease

Introduction: Environmental factors play a critical role in the progression or resolution of chronic respiratory diseases. However, studies are limited on the impact of environmental risk factors on individuals born prematurely with lung disease after they leave the neonatal intensive care unit and are discharged into the home environment.Areas covered: In this review, we cover current knowledge of environmental exposures that impact outcomes of preterm respiratory disease, including air pollution, infections, and disparities. The limited data do suggest that certain exposures should be avoided and there are potential preventative strategies for other exposures. There is a need for additional research outside the neonatal intensive care unit that focuses on individual and community-level factors that affect long-term outcomes.Expert opinion: Preterm respiratory disease can impose a significant burden on infants, children, and young adults born prematurely, but may improve for many individuals over time. In this review, we outline the exposures that may potentially hasten, delay, or prevent resolution of lung injury in preterm children.

Implementation of a Follow-Up System for Pediatric Sepsis Survivors in a Large Academic Pediatric Intensive Care Unit

Background: Survivors of pediatric sepsis often develop new morbidities and deterioration in quality of life after sepsis, leading to a need for improved follow-up for children who survive sepsis. Objective: To implement a follow-up system for pediatric sepsis survivors in a pediatric health system. Methods: We performed a retrospective case series of patients treated for sepsis from October 2018 through October 2019 in a pediatric intensive care unit in a quaternary children's hospital, and describe implementation of a follow-up system for sepsis survivors. Program planning started in 2017 with multidisciplinary meetings including physical, occupational, and speech therapists, teachers, neuropsychologists, and coordinators from other survivorship programs (neonatology, stroke, and oncology). In 2018, a workshop was held to consult with local and national experts. The Pediatric Sepsis Survivorship Program launched in October 2018 led by a nurse coordinator who met with families to educate about sepsis and offer post-discharge follow-up. Patients with high pre-existing medical complexity or established subspecialty care were referred for follow-up through existing care coordination or subspecialty services plus guidance to monitor for post-sepsis morbidity. For patients with low-moderate medical complexity, the nurse coordinator administered a telephone-based health-assessment 2-3 months after discharge to screen for new physical or psychosocial morbidity. Patients flagged with concerns were referred to their primary physician and/or to expedited neuropsychological evaluation to utilize existing medical services. Results: Of 80 sepsis patients, 10 died, 20 were referred to care coordination by the program, and 13 had subspecialty follow-up. Five patients were followed in different health systems, four were adults not appropriate for existing follow-up programs, four remained hospitalized, and four were missed due to short stay or unavailable caregivers. The remaining 20 patients were scheduled for follow-up with the Pediatric Sepsis Program. Nine patients completed the telephone assessment. Four patients were receiving new physical or occupational therapy, and one patient was referred for neuropsychology evaluation due to new difficulties with attention, behavior, and completion of school tasks. Conclusions: Implementation of an efficient, low-cost pediatric sepsis survivorship program was successful by utilizing existing systems of care, when available, and filling a follow-up gap in screening for select patients.

Respiratory Monitoring: Current State of the Art and Future Roads

In this article, we present current methodologies, available technologies, and demands for monitoring various respiratory parameters. We discuss the importance of noninvasive techniques for remote and continuous monitoring and challenges involved in the current "smart and connected health" era. We conducted an extensive literature review on the medical significance of monitoring respiratory vital parameters, along with the current methods and solutions with their respective advantages and disadvantages. We discuss the challenges of developing a noninvasive, wearable, wireless system that continuously monitors respiration parameters and opportunities in the field and then determines the requirements of a state-of-the-art system. Noninvasive techniques provide a significant amount of medical information for a continuous patient monitoring system. Contact methods offer more advantages than non-contact methods; however, reducing the size and power of contact methods is critical for enabling a wearable, wireless medical monitoring system. Continuous and accurate remote monitoring, along with other physiological data, can help caregivers improve the quality of care and allow patients greater freedom outside the hospital. Such monitoring systems could lead to highly tailored treatment plans, shorten patient stays at medical facilities, and reduce the cost of treatment.

Developmental and medical factors associated with parenting stress in mothers of toddlers born very preterm in a neonatal follow-up clinic

The purpose of this exploratory, cross-sectional study was to identify child-related factors associated with maternal parenting stress in toddlers born very preterm and followed in a neonatal follow-up (NFU) clinic. The study aimed to describe the associations of current medical complications and presence of developmental delays with total parenting stress. Participants were 53 mother-child dyads presenting in a NFU clinic. Mothers completed the Parenting Stress Index-Short Form (PSI-SF), and children were administered the Brigance Early Head Start Screen II. Medical variables were also collected from the child's medical record. Approximately 24% of mothers had at least one elevated subscale score on the PSI-SF. Regression analyses indicated that receipt of early intervention services was associated with increased parenting stress among mothers of toddlers born very preterm, though number of current medical complications was not. Parents of children born very preterm are at increased risk for parenting stress that extends beyond discharge from the neonatal intensive care unit . Clinicians working in NFU clinics are positioned to monitor for increased parenting stress, particularly among families of children with emerging signs of developmental delay.

Telemedicine, a tool for follow-up of infants discharged from the NICU? Experience from a pilot project

OBJECTIVE

Follow-up of infants from the NICU by neonatologist is limited to premature and complicated infants although parents of infants with advanced gestation may have concerns as well. We compared parental questions of infants < 35 weeks gestation (group A), during virtual telemedicine visits, to ≥35 week infants (group B).

STUDY DESIGN

In a retrospective cohort study, questions asked by parents were extracted from the electronic medical record of all infants post discharge from the NICU, after their pediatrician visit.

RESULTS

Gestation and birth weight of infants in group A were significantly lower than group B but their stay was longer. There were no significant differences in the number of parents who had questions, between the groups (A 68.1% vs B 67.3%, p = 0.91, 95% CI 0.46-1.99, OR = 0.96).

CONCLUSIONS

Telemedicine is a feasible tool for follow-up of NICU infants post discharge. Parents of infants with advanced gestation and weight may benefit from NICU follow-up.

Optimizing High-risk Infant Follow-up in Nonresearch-based Paradigms: The New England Follow-up Network

Supplemental Digital Content is available in the text.

Objectives:

To establish the first regional quality improvement collaborative solely dedicated to follow-through care of high-risk infants after Neonatal intensive care unit (NICU) discharge and to characterize extremely low birth weight (ELBW) follow-up in New England.

Methods:

Eleven of 14 follow-up programs in New England partnered with the Vermont Oxford Network (VON) ELBW project for an initial data collection project. We collected information about the health status and developmental outcomes of infants born ≤1,000 g or younger than 28 weeks 2014–2016 at the 18–24 months corrected for gestational age (CGA) follow-up visit. VON collected and compiled the data.

Results:

Of 993 eligible infants, 516 (52.0%) had follow-up visits. The rehospitalization rate was 33.9%, mostly respiratory illness. Ninety-six children (19.3%) had weight less than 10th percentile and 44 (8.9%) had weight less than third percentile at 18–24 months. Only 170 (61.4%) children had recommended hearing screening after NICU discharge. Forty-six (9.1%) had cerebral palsy; 81 of the 441 infants that completed all 3 sections of the Bayley Scales of Infant Development, third edition (18.4%) had any composite score less than 70. Over half of the social and demographic data were missing.

Conclusion:

Most quality initiatives in neonatology stop at NICU discharge. This first project by the New England Follow-up Network showed a low rate for clinical follow-up. It demonstrated many opportunities to improve postdischarge follow-through specific to NICU-based care. Future projects will aim to improve the quality of follow-through services through collaborative learning, data sharing, and comparative outcomes.

Social disparities negatively impact neonatal follow-up clinic attendance of premature infants discharged from the neonatal intensive care unit

OBJECTIVE

Neonatal neurodevelopmental follow-up clinic provides continued surveillance and assessment of high-risk premature infants. We hypothesized that attrition is associated with race and social factors.

STUDY DESIGN

We performed a retrospective cohort study of neonates born at 26-32 weeks gestation who were admitted to a level IV neonatal intensive care unit. Maternal and neonatal characteristics and follow-up attendance were collected. Statistical analysis was performed with significance set at p value < 0.05.

RESULTS

In total, 237 neonates met study criteria. There was a 62% loss to follow-up over 2 years. Factors associated with loss to follow-up included older gestational age, African American race, and maternal cigarette smoking. Protective factors included older maternal age, a neonatal diagnosis of bronchopulmonary dysplasia, and longer hospital length of stay.

CONCLUSIONS

Social disparities negatively impact neonatal follow-up clinic attendance. Efforts to identify and target high-risk populations must be started during initial hospitalization before infants are lost to follow-up.

Development of a Multidisciplinary Medical Home Program for NICU Graduates

OBJECTIVE

Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population.

METHODS

This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs.

RESULTS

The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down.

DISCUSSION

Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

Neonatal Abstinence Syndrome and Childhood Mental Health Conditions, 2009-2015: Commercial Versus Medicaid Populations

OBJECTIVE

This study aimed to examine mental health conditions of children diagnosed with neonatal abstinence syndrome (NAS) in a commercially insured population and compare them with a multistate Medicaid-insured population identified in prior research.

METHODS

Data from the IBM MarketScan Commercial Database from January 1, 2009, to September 30, 2015, were used to identify mental health conditions among children ages 1-5 both with and without NAS. Frequency analyses were conducted to ascertain intrapopulation differences and differences between the commercially insured and Medicaid populations.

RESULTS

The NAS rate in the Medicaid population was 28.7 times higher than in the commercially insured population. Although the sample of children with NAS was small, and the results must be interpreted with caution, elevated rates of childhood mental health conditions observed in the commercially insured population were comparable to the Medicaid population.

CONCLUSIONS

This analysis emphasizes the difference in rates of NAS between commercially insured and Medicaid populations.

Neonatal follow-up programs in Canada: A national survey

Background

A 2006 Canadian survey showed a large variability in neonatal follow-up practices. In 2010, all 26 tertiary level Neonatal Follow-Up clinics joined the Canadian Neonatal Follow-Up Network (CNFUN) and agreed to implement a standardized assessment (including the Bayley Scales of Infant and Toddler Development-III (Bayley-III) at 18 months corrected age for children born < 29 weeks' gestation. It is unknown whether the variability in follow-up practices lessened as a result.

Objectives

To describe the current status of neonatal follow-up services in Canada and changes over time.

Methods

A comprehensive online survey was sent to all tertiary level CNFUN Follow-up programs. Questions were based on previous survey results, current literature, and investigator expertise and consensus.

Results

Respondents included 23 of 26 (88%) CNFUN programs. All sites provide neurodevelopmental screening and referrals in a multidisciplinary setting with variations in staffing. CNFUN programs vary with most offering five to seven visits. Since 2006, assessments at 18 months CA increased from 84% to 91% of sites, Bayley-III use increased from 21% to 74% (P=0.001) and eligibility for follow-up was expanded for children with stroke, congenital diaphragmatic hernia and select anomalies detected in utero. Audit data is collected by > 80% of tertiary programs.

Conclusion

Care became more consistent after CNFUN; 18-month assessments and Bayley-III use increased significantly. However, marked variability in follow-up practices persists.

Promoting developmental supportive care in preterm infants and families in a level III neonatal intensive care unit (NICU) setting in India

Despite evidence of short- and long-term benefits of developmental care, several studies have documented nurses' lack of knowledge and skills related to developmental care concepts. This study aims to enhance neonatal nurses' abilities to acquire care practices (knowledge and skills) regarding Developmental Supportive Care (DSC). A nonrandomized before and after intervention design was adopted to improve the knowledge and skills of staff nurses in DSC practices for preterm infants in Level III B NICU. The study included 50 level III B NICU nurses (25 in interventional group, 25 in control group) located within a tertiary care hospital in India. A significant increase in the mean knowledge score was seen among participants in the intervention group (pre-test: 16.6 ± 3.1, post-test: 29.9 ± 4.1, p = 0.01) but not in the control group (pre: 16.4 ± 2.2, post: 18.6 ± 3.6, p = 0.98). The improvement in the skills of providing DSC among neonatal nurses was also higher in the intervention group (106.4 ± 7.4) relative to the control group (65.8 ± 3.6), p < 0.01, at 0.05 level of significance. The Developmental Supportive Care Program (DSCP) had a significant impact in improving the knowledge and skills of nurses in providing care and preventing complications in preterm infants.

Spanish survey on follow-up programmes for children born very preterm

AIM

To describe variations in practice between follow-up programmes for very preterm children born at less than 32 weeks' gestation or with very low birth weight of less than 1,500 g.

METHODS

A survey on follow-up practices was electronically distributed to level II and III units among hospitals of the Spanish National Health Service in 2016. The survey included 70 questions covering issues such as follow-up organisation and resources, routine assessments, relationships with other services and families, information management and training.

RESULTS

The response rate was 91.5% (141/154). Among respondents, 70.9% (100/141) reported that they do provide follow-up and 42% do so up to six years of age. Routine neurological and ophthalmological follow-up is not performed in 60% and 37% of hospitals, respectively, and a second hearing assessment is not given in 62%. Just 38% of units have psychologist. In 41% of hospitals, training in follow-up skills is not included in Paediatric Residency training programme.

CONCLUSION

Although Spain has a nationwide health system that provides universal health coverage, we found that follow-up care for children born very preterm/very low birth weight is not equitable. Nearly half of paediatric residents receive no training in follow-up for this high-risk population.

PICU-Based Rehabilitation and Outcomes Assessment: A Survey of Pediatric Critical Care Physicians

OBJECTIVES

Characterize current practices for PICU-based rehabilitation, and physician perceptions and attitudes, barriers, resources, and outcome assessment in contemporary PICU settings.

DESIGN

International, self-administered, quantitative, cross-sectional survey.

SETTING

Online survey distributed from March 2017 to April 2017.

PATIENTS OR SUBJECTS

Pediatric critical care physicians who subscribed to email distribution lists of the Pediatric Acute Lung Injury and Sepsis Investigators, the Pediatric Neurocritical Care Research Group, or the Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment study group, and visitors to the World Federation of Pediatric Intensive and Critical Care Societies website.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 170 subjects who began the survey, 148 completed it. Of those who completed the optional respondent information, most reported working in an academic medical setting and were located in the United States. The main findings were 1) a large majority of PICU physicians reported working in institutions with no guidelines for PICU-based rehabilitation, but expressed interest in developing and implementing such guidelines; 2) despite this lack of guidelines, an overwhelming majority of respondents reported that their current practices would involve consultation of multiple rehabilitation services for each case example provided; 3) PICU physicians believed that additional research evidence is needed to determine efficacy and optimal implementation of PICU-based rehabilitation; 4) PICU physicians reported significant barriers to implementation of PICU-based rehabilitation across centers; and 5) low routine assessment of long-term functional outcomes of PICU patients, although some centers have developed multidisciplinary follow-up programs.

CONCLUSIONS

Physicians lack PICU-based rehabilitation guidelines despite great interest and current practices involving a high degree of PICU-based rehabilitation consultation. Data are needed to identify best practices and necessary resources in the delivery of ICU-based multidisciplinary rehabilitation and long-term functional outcomes assessment to optimize recovery of children and families affected by critical illness.

NICU Discharge Feeding Bundle Improves Accuracy of Postdischarge Feeding Preparation and Potentially Prevents Readmission

BACKGROUND

Hospitalized infants often need fortified human milk and formulas for growth in the neonatal intensive care unit and postdischarge. Parents must learn how to properly mix infant feedings.At the initial Children's Hospital Colorado follow-up visit, baseline data revealed a 50% rate of mixing inaccuracy of discharge feeding recipes and identified the readmission of 2 infants with life-threatening hypernatremia. A gap in discharge teaching was identified. A quality improvement project was implemented at 2 affiliated neonatal intensive care units.

PURPOSE/AIM

The aim of this study was to improve parental comfort and efficacy in infant feeding preparation during hospitalization, reduce mixing inaccuracy postdischarge, and prevent readmission. The primary aim was to improve the accuracy rate at follow-up to 75% within 12 months and the sustain mixing accuracy rate at follow-up to above 95% for an additional 24 months.

METHODS/INTERVENTIONS

A literature review was conducted; potential barriers were identified and strategies developed to recognize the relationships between the aim and the changes to be tested. Implementation of standardized teaching focused on the teach-back technique. Education included mixing demonstration and written instructions. Parents were expected to correctly mix the recipe 3 times before discharge.

RESULTS

Mixing accuracy at the initial clinic follow-up visit improved to 97%. No readmissions were reported from inaccurately prepared feedings.

IMPLICATIONS FOR PRACTICE

Collaborative quality improvement project with standardized teaching provided improved feeding safety and parental comfort with accuracy of discharge instructions. Primary care providers need to be aware of the importance of accurate formula or fortified human milk preparation and verify accuracy of the specific discharge recipes at the initial visit.

Neuroprotective Care of Extremely Preterm Infants in the First 72 Hours After Birth

Birth at extremely low gestational ages presents a significant threat to infants' survival, health, development, and future well-being. After birth, a critical period of brain development must continue outside the womb. Neuro-supportive and neuroprotective family centered developmental care for and standardized care practices for extremely preterm infants have been shown to improve outcomes. Neuroprotective interventions must include a focus on the emotional connections of infants and their families. Being in skin-to-skin contact with the mother is the developmentally expected environment for all mammals and is especially important for supporting physiologic stability and neurodevelopment of preterm infants.

Profile of at-risk newborns attended by nurses in outpatient follow-up clinic: a retrospective cohort study

OBJECTIVE

to analyze the cohort profile of at-risk newborns attended by nurses in a multidisciplinary follow-up clinic, with emphasis on the type of feeding and weight gain, after hospital discharge.

METHOD

retrospective cohort, whose population is composed of at-risk newborns attended in a 4-year period. Data came from medical records and attendance report, later exported to R Program. The outcome variables were number of the nursing consultation, type of feeding, daily weight gain and main guidelines. We used descriptive statistics, frequency distribution and applied Mann-Whitney, Chi-Square, Spearman correlation, Variance and Tukey analysis, with p <0.05 being significant.

RESULTS

a total of 882 consultations with 629 infants and families were analyzed. The frequencies of exclusive breastfeeding and weight gain increased as the consultations progressed. The infants who needed more consultations and with lower weight gain were those with lower gestational age (p = 0.001) and birth weight (p = 0.000), longer length of hospital stay (p <0.005), and diagnoses related to extreme prematurity (p <0.05), among others.

CONCLUSION

nurses verified the importance of outpatient follow-up of at-risk newborns, especially in promoting breastfeeding and healthy growth.

Very Preterm Infants with Technological Dependence at Home: Impact on Resource Use and Family

OBJECTIVE

To examine the impact of medical complexity among very preterm infants on health care resource use, family, and neurodevelopmental outcomes at 18 months' corrected age.

METHODS

This observational cohort study of Canadian infants born < 29 weeks' gestational age in 2009-2011 compared infants with and those without medical complexity defined as discharged home with assistive medical technology. Health care resource use and family outcomes were collected. Children were assessed for cerebral palsy, deafness, blindness, and developmental delay at 18 months. Logistic regression analysis was performed for group comparisons.

RESULTS

Overall, 466/2,337 infants (20%) needed assistive medical technology at home including oxygen (79%), gavage feeding (21%), gastrostomy or ileostomy (20%), CPAP (5%), and tracheostomy (3%). Children with medical complexity were more likely to be re-hospitalized (OR 3.6, 95% CI 3.0-4.5) and to require ≥2 outpatient services (OR 4.4, 95% CI 3.5-5.6). Employment of both parents at 18 months was also less frequent in those with medical complexity compared to those without medical complexity (52 vs. 60%, p < 0.01). Thirty percent of children with medical complexity had significant neurodevelopmental impairment compared to 13% of those without medical complexity (p < 0.01). Lower gestational age, lower birth weight, bronchopulmonary dysplasia, sepsis, and surgical necrotizing enterocolitis were associated with a risk of medical complexity.

CONCLUSION

Medical complexity is common following very preterm birth and has a significant impact on health care use as well as family employment and is more often associated with neurodevelopmental disabilities. Efforts should be deployed to facilitate care coordination upon hospital discharge and to support families of preterm children with medical complexity.

Bereaved mothers' and fathers' perceptions of a legacy intervention for parents of infants in the NICU

BACKGROUND

Legacy-making, actions or behaviors aimed at being remembered, may be one strategy to enhance coping and improve grief outcomes for bereaved parents and siblings. While legacy interventions have been developed and tested in pediatric and adult populations, legacy activities specific to bereaved parents in the neonatal intensive care unit remain unexplored. This study explored bereaved parents' perceptions of a digital storytelling legacy-making intervention for parents after the death of an infant.

METHODS

Six bereaved mothers and fathers participated in a focus group interview three to 12 months after the death of an infant in the NICU. A semi-structured interview guide with open-ended questions was used to obtain parent self-reports. Qualitative content analysis identified emerging themes.

RESULTS

Four major themes emerged regarding participants' perceptions of a legacy intervention: (a) parents' willingness to participate in a legacy intervention, (b) parents' suggestions for a feasible intervention, (c) parents' suggestions for an acceptable intervention, and (d) parents' perceived benefits of legacy-making.

CONCLUSIONS

Participants reported that a legacy-making intervention via digital storytelling would be feasible, acceptable, and beneficial for NICU parents. Study results support the need and desire for legacy-making services to be developed and offered in the NICU.

The predictors for the non-compliance to follow-up among very low birth weight infants in the Korean neonatal network

The critical need to emphasize preterm infant follow-up after neonatal intensive care unit (NICU) discharge assures early identification of and intervention for neurodevelopmental disability. The aims of this study were to observe the follow-up rates in high-risk follow-up clinics, and analyze factors associated with non-compliance to follow-up among very low birth weight (VLBW) infants. The data was prospectively collected for 3063 VLBW infants between January 2013 and December 2014 from 57 Korean neonatal network (KNN) centers at a corrected age of 18–24 months. Correlations among demographic data, clinical variables, and neonatal intensive care unit (NICU) volume (divided into 4 quartiles) with the occurrence of non-compliance were analyzed. The overall follow-up rate at the corrected age of 18–24 month was 65.4%. The follow-up rates were inversely related to birth weight and gestational age. Apgar score, hospital stay, maternal age, and maternal education were significantly different between the compliance and non-compliance groups. The follow-up rate was higher for mothers with chorioamnionitis, abnormal amniotic fluid, multiple pregnancy, and in vitro fertilization. Infants with respiratory distress syndrome, bronchopulmonary dysplasia, patent ductus arteriosus ligation, periventricular leukomalacia, and retinopathy of prematurity were more common in the compliance group. Follow-up rates showed significant differences according to NICU volume. Using multivariate logistic regression, high birth weight, low NICU volume, siblings, foreign maternal nationality and high 5 min APGAR scores were significant independent factors associated with the non-compliance of VLBW infants for follow-up at 18–24 months of age. This is the first nation-wide analysis of follow-up for VLBW infants in Korea. Understanding factors associated with failure of compliance could help improve the long-term follow-up rates and neurodevelopmental outcomes through early intervention.

Health-care spending and utilization for children discharged from a neonatal intensive care unit

OBJECTIVES

To describe health-care spending and utilization for infants discharged from the neonatal intensive care unit (NICU).

STUDY DESIGN

Retrospective cohort analysis of 4973 NICU graduates in the Truven MarketScan Medicaid database, with follow-up to the third birthday. Health-care spending and utilization after NICU discharge were assessed. Using logistic regression, we assessed clinical characteristics associated with hospitalization and emergency department (ED) visits.

RESULTS

Most (69.5%) post-NICU spending occurred within the first year [$33,276 per member per year]. Inpatient care accounted for most (71.6%) of the 3-year spending. The percentages of infants with a 1-year readmission or ED visit were 36.8% and 63.7%, respectively. Medical technology was associated with the highest likelihoods of hospital [aOR 17.8 (95%CI 12.2-26.0)] and ED use [aOR 2.3 (95%CI 1.8-3.0)].

CONCLUSIONS

Hospital care accounts for the majority of spending for NICU graduates. Infants with medical technology have the highest risk of hospital and ED use.

[Follow-up protocol for newborns of birthweight less than 1500 g or less than 32 weeks gestation]

The mortality of children with a birthweight of less than 1500g or with a gestational age of less than 32 weeks (<1500<32) has decreased significantly in the last 20 years or so. Given the higher risk of disability in these children, follow-up after hospital discharge is considered essential. In this document, the Follow-Up Group of the Spanish Society of Neonatology, in collaboration with the Spanish Society of Paediatric Primary Care, propose a follow-up protocol specific for the<1500<32, which has as its aim to standardise the activities and evaluations according to good practice criteria.

The NICU Environment: Infusing Single-Family Room Benefits into the Open-Bay Setting

Two distinct architectural designs are found in today's NICUs-the open-bay (OPBY) and the single-family room (SFR) designs. When neonatology was recognized as a medical subspecialty in the 1970s, the OPBY design was the only platform offered to neonates and families. The OPBY design facilitated communication between staff, collegiality, and interprofessional collaboration among members of the neonatal team. Over time, pitfalls to the design were recognized, including increased transmission of sound and light. As a result, the SFR design emerged offering a family-centered, customizable environment. Through recognition and adoption of best practices, the neurodevelopmental benefits to SFRs can be infused within the OPBY unit. This article aims to identify best practices to infuse the benefits of SFR design (such as low light, low sound, and less overstimulation) into the OPBY NICU to reduce negative stimulation and optimize developmental outcomes for vulnerable neonates.

ASQ3 and/or the Bayley-III to support clinicians' decision making

Background

Appropriate tools are essential to support a clinician’s decision to refer very preterm infants to developmental resources. Streamlining the use of developmental assessment or screening tools to make clinical decisions offers an alternative methodology to help to choose the most effective way to assess this very high-risk population.

Objective

To examine the influence of the Ages and Stages Questionnaire-3^rd edition (ASQ3) and the Bayley Scales of Infant Development-3^rd edition (Bayley-III) scores within a clinically-based decision-making process.

Methods

This retrospective cohort study includes children born at less than 29 weeks gestation who had completed both psychologist-administered Bayley-III and physician-observed ASQ3 assessments at 18 months corrected age. Theoretical referral decisions (TRDs) based on each assessment results were formulated, using cut-off scores between the lower first and second standard deviation values and below the lower second standard deviation values. TRDs to refer to developmental resources were evaluated in light of the multidisciplinary team’s actual final integrated decisions (FID).

Results

Complete data was available for 67 children. The ASQ3 and the Bayley-III had similar predictive value for the FID, with comparable kappa values. Comparisons of the physicians’ and psychologists’ TRDs with the FIDs demonstrated that the ASQ3 in conjunction with the medical and socio-familial findings predicted 93% of referral decisions.

Conclusion

Taking into consideration potential methodological biases, the results suggest that either ASQ3 or Bayley-III, along with socio-environmental, medical and neurological assessment, are sufficient to guide the majority of clinicians’ decisions regarding referral for specialty services. This retrospective study suggests that the physician-supervised ASQ3 may be sufficient to assess children who had been extremely preterm infants for referral purposes. The findings need to be confirmed in a larger, well-designed prospective study to minimize and account for potential sources of bias.

Part C early intervention utilization in preterm infants: Opportunity for referral from a NICU follow-up clinic

OBJECTIVE

Early Intervention (EI) services promote development for preterm infants. In the state of Illinois, Child and Family Connections (CFC) is the intake agency that determines qualification for EI services. In Illinois, all extremely low birth weight (ELBW) infants are eligible for and referred to CFC at discharge from the Neonatal Intensive Care Unit (NICU). This study investigated: (1) patterns of CFC and EI enrollment, and; (2) predictors of CFC enrollment, need for CFC referral, and high EI therapy use among preterm infants seen in a NICU follow-up clinic.

METHODS

405 preterm infants, including 169 ELBW infants, were seen in a NICU follow-up clinic at 4-, 8- and 20-months corrected age. CFC/EI data were collected at each visit. Multiple regression analyses adjusted for the effect of medical, sociodemographic and neurodevelopmental risk factors on CFC/EI outcome.

RESULTS

Despite the high rate of EI utilization and routine care by primary pediatricians, up to 28% of ELBW infants required a CFC referral from a NICU follow-up clinic. Medical and neurodevelopmental risk factors were associated with CFC enrollment while medical, sociodemographic and neurodevelopmental risk factors were associated with need for CFC referral.

CONCLUSION

NICU follow-up clinics facilitate appropriate CFC/EI services for preterm infants.

Natural Language Processing for Cohort Discovery in a Discharge Prediction Model for the Neonatal ICU

OBJECTIVES

Discharging patients from the Neonatal Intensive Care Unit (NICU) can be delayed for non-medical reasons including the procurement of home medical equipment, parental education, and the need for children's services. We previously created a model to identify patients that will be medically ready for discharge in the subsequent 2-10 days. In this study we use Natural Language Processing to improve upon that model and discern why the model performed poorly on certain patients.

METHODS

We retrospectively examined the text of the Assessment and Plan section from daily progress notes of 4,693 patients (103,206 patient-days) from the NICU of a large, academic children's hospital. A matrix was constructed using words from NICU notes (single words and bigrams) to train a supervised machine learning algorithm to determine the most important words differentiating poorly performing patients compared to well performing patients in our original discharge prediction model.

RESULTS

NLP using a bag of words (BOW) analysis revealed several cohorts that performed poorly in our original model. These included patients with surgical diagnoses, pulmonary hypertension, retinopathy of prematurity, and psychosocial issues.

DISCUSSION

The BOW approach aided in cohort discovery and will allow further refinement of our original discharge model prediction. Adequately identifying patients discharged home on g-tube feeds alone could improve the AUC of our original model by 0.02. Additionally, this approach identified social issues as a major cause for delayed discharge.

CONCLUSION

A BOW analysis provides a method to improve and refine our NICU discharge prediction model and could potentially avoid over 900 (0.9%) hospital days.

NICU discharge planning and beyond: recommendations for parent psychosocial support

Parents will interact with a multitude of teams from various disciplines during their child's admission to the neonatal intensive care unit. Recognition of the emotional stressors experienced by these parents is a first step in working to provide the crucial support and parenting skills needed for bonding and caring for their infant from admission through discharge and beyond. Family-centered care involves time-sensitive two-way communication between parents and the multidisciplinary team members who coordinate care transition by providing emotional, educational, medical and home visitor support for these families. To do this well, a thoughtful exchange of information between team members and parents is essential to identify psychosocial stress and ameliorate family concerns. Parents will need emotional and educational support and follow-up resources. Establishing individualized, flexible but realistic, pre- and post-discharge plans with parents is needed to start their healthy transition to home and community.

Newborn intensive care survivors: a review and a plan for collaboration in Texas

BACKGROUND

Neonatal intensive care is a remarkable success story with dramatic improvements in survival rates for preterm newborns. Significant efforts and resources are invested to improve mortality and morbidity but much remains to be learned about the short and long-term effects of neonatal intensive care unit (NICU) interventions. Published guidelines recommend that infants discharged from the NICU be in an organized follow-up program that tracks medical and neurodevelopmental outcomes. Yet, there are no standardized guidelines for provision of follow-up services for high-risk infants. The National Institute of Child Health and Human Development Neonatal Research Network and the Vermont Oxford Network have made strides toward standardizing practices and conducting outcomes research, but only include a subset of developmental follow-up programs with a focus on extremely preterm infants. Several studies have been conducted to gain a better understanding of current practices in developmental follow-up. Some of the major themes in these studies are the lack of personnel and funding to provide comprehensive follow-up care; feeding difficulties as a primary issue for NICU survivors, families, and programs; wide variability in referral and follow-up care practices; and calls for standardized, systematic developmental surveillance to improve outcomes.

FINDINGS

We convened a one-day summit to discuss developmental follow-up practices in Texas involving four academic and three nonacademic centers. All seven centers described variable age and weight criteria for follow-up of NICU patients and a unique set of developmental practices, including duration of follow-up, types and timing of developmental assessments administered, education and communication with families and other health care providers, and referrals for services. Needs identified by the centers focused on two main themes: resources and comprehensive care. Participants identified key challenges for developmental follow-up, generated recommendations to address these challenges, and outlined components of a quality program.

CONCLUSIONS

The long-term goal is to ensure that all children maximize their potential; a goal supported through quality, comprehensive developmental follow-up care and outcomes research to continuously improve evidence-based practices. We aim to contribute to this goal through a statewide working group collaborating on research to standardize practices and inform policies that truly benefit children and their families.

Predicting Discharge Dates From the NICU Using Progress Note Data

BACKGROUND AND OBJECTIVES

Discharging patients from the NICU may be delayed for nonmedical reasons including the need for medical equipment, parental education, and children's services. We describe a method to predict which patients will be medically ready for discharge in the next 2 to 10 days, providing lead time to address nonmedical reasons for delayed discharge.

METHODS

A retrospective study examined 26 features (17 extracted, 9 engineered) from daily progress notes of 4693 patients (103,206 patient-days) from the NICU of a large, academic children's hospital. These data were used to develop a supervised machine learning problem to predict days to discharge (DTD). Random forest classifiers were trained by using examined features and International Classification of Diseases, Ninth Revision-based subpopulations to determine the most important features.

RESULTS

Three of the 4 subpopulations (premature, cardiac, gastrointestinal surgery) and all patients combined performed similarly at 2, 4, 7, and 10 DTD with area under the curve (AUC) ranging from 0.854 to 0.865 at 2 DTD and 0.723 to 0.729 at 10 DTD. Patients undergoing neurosurgery performed worse at every DTD measure, scoring 0.749 at 2 DTD and 0.614 at 10 DTD. This model was also able to identify important features and provide "rule-of-thumb" criteria for patients close to discharge. By using DTD equal to 4 and 2 features (oral percentage of feedings and weight), we constructed a model with an AUC of 0.843.

CONCLUSIONS

Using clinical features from daily progress notes provides an accurate method to predict when patients in the NICU are nearing discharge.

Referral of very low birth weight infants to high-risk follow-up at neonatal intensive care unit discharge varies widely across California

OBJECTIVES

To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative.

STUDY DESIGN

Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral.

RESULTS

In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ≤ 750 g vs 1251-1499 g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment.

CONCLUSIONS

There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.