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Belcher RH, Patel K, Goudy S, Gelbard A, Hatch LD, Morris EA, Golinko M, Phillips JD, Scott A. Cost Analysis of Avoiding Gastrostomy Tube in Robin Sequence Neonates that Undergo Mandibular Distraction. Laryngoscope 2024. [PMID: 39360516 DOI: 10.1002/lary.31810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/25/2024] [Accepted: 09/17/2024] [Indexed: 10/04/2024]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate costs associated with perioperative gastrostomy tube (G-tube) placement for neonates with Robin sequence (PRS) that undergo mandibular distraction osteogenesis (MDO). METHODS Retrospective chart review was performed to examine the medical records of neonates with RS who received treatment at our institution between 2012 and 2021. Patients under 6 months of age that underwent MDO for RS were included. Billing records of hospital costs over a 2-year period were analyzed. RESULTS The study included 26 total patients with 11 in the MDO-only group, 9 in G-tube after MDO group, and 6 in G-tube before MDO group. There was a significant difference (p < 0.001) in total hospital costs between groups with MDO-only group averaging $119,532 (SD± $$ \pm $$ 33,503), the G-tube after MDO group averaging $245,315 (SD± $$ \pm $$ 102,327), and G-tube before MDO group averaging $252,300 (SD± $$ \pm $$ 84,990). Multiple linear regression was performed controlling for genetic syndrome and birth weight, which still showed a statistically significant difference in total cost between the MDO-only group and G-tube after MDO (p = 0.006), and between the MDO-only group and G-tube prior to MDO (p = 0.01). There was a significant difference in costs between all three groups for total inpatient/outpatient costs with MDO-only group averaging $78,502 (SD± $$ \pm $$ 30,953), the G-tube after MDO group averaging $176,125 (SD± $$ \pm $$ 84,315), and the G-tube prior to MDO group averaging $156,309 (SD± $$ \pm $$ 95,746). CONCLUSIONS MDO performed without perioperative G-tube placement may reduce charges by >$100,000. The associated improvement of dysphagia after MDO surgery and potential for avoiding a G-tube has tremendous downstream cost and social benefits for families. LEVEL OF EVIDENCE NA Laryngoscope, 2024.
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Affiliation(s)
- Ryan H Belcher
- Vanderbilt Division of Pediatric Otolaryngology - Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
- Vanderbilt Cleft and Craniofacial Team, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
| | - Kalpana Patel
- Surgical Outcomes for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
| | - Steven Goudy
- Department of Pediatric Otolaryngology, Emory University, Atlanta, Georgia, U.S.A
| | - Alexander Gelbard
- Vanderbilt Department of Otolaryngology - Head and Neck Surgery, Nashville, Tennessee, U.S.A
| | - L Dupree Hatch
- Departemnt of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Emily A Morris
- Departemnt of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Michael Golinko
- Vanderbilt Cleft and Craniofacial Team, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
- Division of Pediatric Plastic Surgery, Vanderbilt Department of Plastic Surgery, Nashville, Tennessee, U.S.A
| | - James D Phillips
- Vanderbilt Division of Pediatric Otolaryngology - Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
- Vanderbilt Cleft and Craniofacial Team, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
| | - Andrew Scott
- Dr. Elie E. Rebeiz Department of Otolaryngology - Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
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Miller C, Plummer E, Platek J, Arneson S. Use of technology in neonatal nutrition. Nutr Clin Pract 2024; 39:1094-1101. [PMID: 38884603 DOI: 10.1002/ncp.11176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/17/2024] [Accepted: 05/23/2024] [Indexed: 06/18/2024] Open
Abstract
There have been rapidly expanding uses of technology to enhance and improve nutrition in our smallest patients. Optimized nutrition in the neonatal patient is linked to improved outcomes, specifically neurodevelopmental outcomes and decreased length of stay. Despite advances in neonatal care that have improved survival, many patients being discharged from the neonatal intensive care unit are doing so with poor postnatal growth. Because the neonatal brain doubles in size from 20 weeks gestation to term, it is essential to focus care efforts on nutrition to optimize brain growth and development. This review focuses on three exciting areas of neonatal research, including the analysis of macronutrients in breast milk, measurement of body composition, and use of telemedicine.
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Affiliation(s)
- Cristina Miller
- Department of Neonatology, Children's Minnesota, St Paul, Minnesota, USA
| | - Erin Plummer
- Department of Neonatology, Children's Minnesota, St Paul, Minnesota, USA
| | - Jenna Platek
- Department of Clinical Nutrition, Children's Minnesota, St Paul, Minnesota, USA
| | - Steffi Arneson
- Department of Clinical Nutrition, Children's Minnesota, St Paul, Minnesota, USA
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Mitchell MB, Callans K, Erdei C, Patrizi S, Fiechtner L, Kelleher C, Goldstein AM, Lerou P, Turcu R, Fracchia M, Radano M, Dodrill P, Sorbo J, Hersh C, Warren M, Hartnick C. Multi-institutional quality improvement algorithm for home nasogastric tube care for neonates. Int J Pediatr Otorhinolaryngol 2024; 185:112083. [PMID: 39217866 DOI: 10.1016/j.ijporl.2024.112083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/25/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND High-risk neonates continuing to need enteral nutrition, but otherwise medically ready for discharge home from the NICU, are often offered ongoing hospitalization for nasogastric tube (NGT) feeding, versus discharge after placement of gastrostomy tube. Our group developed an interdisciplinary algorithm to support a third option-discharge home with enteral nutrition via NGT. Our objective was to develop a cross-institutional and interdisciplinary pathway to optimize outcomes for neonates discharged with NGTs. METHODS A program to support home NGT feeding use was created, "Passport Home Program," based upon feedback from parents, nurses, speech-language pathologists, otolaryngologists, and neonatal intensivists, amongst others, spanning four hospitals across our health system. RESULTS Standardized educational materials for caregivers of neonates requiring ongoing NGT feeding on discharge were created and consist of an in-hospital curriculum with specific competency thresholds, including demonstrating NGT replacement and confirmation with pH test strips. A discharge kit, including a QR code for a video reviewing safe techniques for home NGT placement, is distributed, along with support staff contact information. Members of an emergency department were trained in neonatal NGT replacement in case of issues after business hours. Each patient is followed in a dedicated outpatient multi-disciplinary clinic. DISCUSSION This is an interdisciplinary and multi-institutional effort to standardize a pathway for neonates discharged home from the NICU with NGTs. This has the potential to lead to earlier discharge, better outcomes for patients and families, as well as lower costs. This best practice algorithm serves as an example pathway applicable across fields of medicine.
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Affiliation(s)
- Margaret B Mitchell
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Kevin Callans
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, MA, USA
| | - Carmina Erdei
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
| | - Siliva Patrizi
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA; Department of Neonatology, Newton-Wellesley Hospital, Boston, MA, USA
| | - Lauren Fiechtner
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Mass General for Children, Boston, MA, USA
| | - Cassandra Kelleher
- Harvard Medical School, Boston, MA, USA; Department of Pediatric Surgery, Mass General for Children, Boston, MA, USA
| | - Allan M Goldstein
- Harvard Medical School, Boston, MA, USA; Department of Pediatric Surgery, Mass General for Children, Boston, MA, USA
| | - Paul Lerou
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Mass General for Children, Boston, MA, USA
| | - Rodica Turcu
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Mass General for Children, Boston, MA, USA
| | - Mary Fracchia
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Mass General for Children, Boston, MA, USA
| | - Marcella Radano
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Mass General for Children, Boston, MA, USA
| | - Pamela Dodrill
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
| | - Jessica Sorbo
- Department of Pediatrics, Mass General for Children, Boston, MA, USA; Pediatric Aerodigestive Center, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl Hersh
- Department of Pediatrics, Mass General for Children, Boston, MA, USA; Pediatric Aerodigestive Center, Massachusetts General Hospital, Boston, MA, USA
| | - Mollie Warren
- Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA.
| | - Christopher Hartnick
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye & Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Bourque SL, Murthy K, Grover TR, Berman L, Riddle S. Cutting into the NICU: Improvements in Outcomes for Neonates with Surgical Conditions. Neoreviews 2024; 25:e634-e647. [PMID: 39349417 DOI: 10.1542/neo.25-10-e634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/04/2024] [Accepted: 06/03/2024] [Indexed: 10/02/2024]
Abstract
The Children's Hospitals Neonatal Consortium (CHNC), established in 2010, seeks to improve care for infants with medically and surgically complex conditions who are cared for in level IV regional children's hospital NICUs across North America. Through patient-level individual data collection, comparative benchmarking, and multicenter quality improvement work, CHNC has contributed to knowledge and improved outcomes, leveraging novel collaborations between and across institutions. Focusing on antenatal and inpatient care for infants with surgical conditions including congenital diaphragmatic hernia, gastroschisis, and necrotizing enterocolitis, we summarize the progress made in these infants' care. We highlight the ways in which CHNC has enabled multidisciplinary and multicenter collaborations through the facilitation of diagnosis-specific focus groups, which enable comparative observations of outcomes through quality improvement and research initiatives. Finally, we review the importance of postbirth hospitalization needs of these infants and the application of telemedicine in this population.
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Affiliation(s)
- Stephanie L Bourque
- Department of Pediatrics, University of Colorado School of Medicine; Children's Hospital Colorado, Aurora, CO
| | - Karna Murthy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Theresa R Grover
- Department of Pediatrics, University of Colorado School of Medicine; Children's Hospital Colorado, Aurora, CO
| | - Loren Berman
- Nemours Children's Health, Department of Surgery, Wilmington, DE
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stefanie Riddle
- Department of Pediatrics, University of Cincinnati School of Medicine; Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Quinn M, Banta-Wright S, Warren JB. Influences of a Remote Monitoring Program of Home Nasogastric Tube Feeds on Transition from NICU to Home. Am J Perinatol 2024. [PMID: 38889888 DOI: 10.1055/a-2347-4015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVE The transition from the neonatal intensive care unit (NICU) to the home is complex and multifaceted for families and infants, particularly those with ongoing medical needs. Our hospital utilizes a remote monitoring program called Growing @ Home (G@H) to support discharge from the NICU with continued nasogastric tube (NGT) feeds. We aim to describe the experience of the transition from NICU to home for families enrolled in G@H. STUDY DESIGN Using a semistructured interviewing technique, parents of infants discharged on G@H were interviewed at NICU discharge, at 1 month, and at 6 months after NICU discharge. Interviews were recorded and transcribed into data analysis software. Conventional content analysis was used to analyze qualitative data. Codes were assigned to describe key elements of the interviews and used to identify major themes. RESULTS Parents (n = 17) identified three major themes when discussing the effect of G@H on the transition to home. The program provided a means of escape from the NICU, allowing families to stop living split lives between their homes and the NICU. It acted as a middle ground between the restrictive yet supportive NICU environment, and the normal yet isolated home environment. G@H served as a safety net for families, providing a continued connection to the NICU for their still-fragile infants. CONCLUSION G@H utilizes telehealth to positively support the complex transition from NICU to home for families and infants discharged with NGT feeds. KEY POINTS · G@H program supported parents in their transition from NICU to home.. · G@H program provided a means of escape from the NICU.. · G@H program was a middle ground between the NICU and home.. · G@H program created a safety net after discharge.. · Follow-up with a consistent provider was essential to a positive parent experience..
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Affiliation(s)
- Megan Quinn
- Oregon Health and Science University School of Nursing, Portland, Oregon
| | | | - Jamie B Warren
- Department of Pediatrics, Oregon Health and Science University School of Medicine, Doernbecher Children's Hospital, Portland, Oregon
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McBride EB, Lasarev MR, O'Connell DM, Limjoco JJ. Clinical Outcomes of Neonatal Intensive Care Unit Graduates with Bridled Nasogastric Feeding Tubes. Am J Perinatol 2024; 41:1171-1177. [PMID: 35580625 DOI: 10.1055/s-0042-1748161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The aim of this study was to describe clinical outcomes of bridled nasogastric tube (NGT) program implementation for infants requiring assisted home feeding (AHF) to discharge from the neonatal intensive care unit (NICU). STUDY DESIGN This was a descriptive prospective analysis of a pilot cohort of infants after implementation of a bridled NGT AHF program to facilitate discharge from level III and IV NICUs from March 2019 to October 2020. RESULTS Of 29 attempts in infants, 22 infants were discharged with bridled NGTs over 18 months. Bridle placement was unsuccessful in three patients, and four bridles were removed before discharge. Bridle use ranged from 7 to 125 days, with a median duration of 37 days. Dislodgement rate was 0.69 per 100 days. Seventeen infants (77%) achieved full oral feeds, while five (23%) discharged with bridled NGTs later converted to gastrostomy tubes. CONCLUSION Implementation of a bridled NGT program is feasible for level III and IV NICUs to facilitate discharging infants who require feeding support to transition home. KEY POINTS · Bridled NGT use after NICU is typically 1 month.. · Infants have low bridle NGT dislodgement.. · Most bridled NGT NICU grads attain full oral feeds..
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Affiliation(s)
- Elizabeth B McBride
- Division of Neonatology, Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel M O'Connell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Jamie J Limjoco
- Division of Neonatology, Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
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7
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Fisher A, Ermarth A, Ling CY, Brinker K, DuPont TL. Method of home tube feeding and 2-3-year neurodevelopmental outcome. J Perinatol 2024:10.1038/s41372-024-02013-2. [PMID: 38811755 DOI: 10.1038/s41372-024-02013-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 05/08/2024] [Accepted: 05/16/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE To describe the Bayley Scales of Infant Development 3rd Edition (Bayley-III) of infants discharged home receiving tube feeds. STUDY DESIGN Retrospective review of infants discharged with nasogastric or gastrostomy tube feeds and completed a Bayley-III assessment at 2-3-years of age through a neonatal follow-up program. Results were reported using descriptive statistics. RESULTS Of infants discharged with nasogastric feeds, median Bayley-III scores were in the low-average to average range, and full oral feeds were achieved in 75%. Of infants discharged with gastrostomy tube feeds, median Bayley-III scores were in the extremely low range, and full oral feeds were achieved in 36%. Our data set did not demonstrate a distinct patient demographic that correlated to the type of feeding tube at discharge. CONCLUSION Neurodevelopmental outcome at 2-3 years does not appear to be negatively impacted by the decision to discharge an infant from the NICU with home NG feedings.
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Affiliation(s)
- Allison Fisher
- Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City, UT, USA
| | - Anna Ermarth
- Department of Pediatrics, Division of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Con Yee Ling
- Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City, UT, USA
| | | | - Tara L DuPont
- Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City, UT, USA.
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Sloan P, Johng S, Daniel JM, Rhee CJ, Mahmood B, Gravari E, Marshall S, Downey AG, Braski K, Gowda SH, Fernandes CJ, Dariya V, Haberman BE, Seabrook R, Makkar A, Gray BW, Cookson MW, Najaf T, Rintoul N, Hedrick HL, DiGeronimo R, Weems MF, Ades A, Chapman R, Grover TR, Keene S. A clinical consensus guideline for nutrition in infants with congenital diaphragmatic hernia from birth through discharge. J Perinatol 2024; 44:694-701. [PMID: 38627594 DOI: 10.1038/s41372-024-01965-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/28/2024] [Accepted: 04/08/2024] [Indexed: 05/15/2024]
Abstract
OBJECTIVE To develop a consensus guideline to meet nutritional challenges faced by infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN The CDH Focus Group utilized a modified Delphi method to develop these clinical consensus guidelines (CCG). Topic leaders drafted recommendations after literature review and group discussion. Each recommendation was sent to focus group members via a REDCap survey tool, and members scored on a Likert scale of 0-100. A score of > 85 with no more than 25% outliers was designated a priori as demonstrating consensus among the group. RESULTS In the first survey 24/25 recommendations received a median score > 90 and after discussion and second round of surveys all 25 recommendations received a median score of 100. CONCLUSIONS We present a consensus evidence-based framework for managing parenteral and enteral nutrition, somatic growth, gastroesophageal reflux disease, chylothorax, and long-term follow-up of infants with CDH.
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Affiliation(s)
- Patrick Sloan
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA.
| | - Sandy Johng
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - John M Daniel
- Department of Pediatrics, Division of Neonatology, University of Missouri Kansas School of Medicine, Kansas City, MO, USA
| | - Christopher J Rhee
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Burhan Mahmood
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Evangelia Gravari
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Ann G Downey
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katie Braski
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sharada H Gowda
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Vedanta Dariya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Beth E Haberman
- Department of Pediatrics, Division of Neonatology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ruth Seabrook
- Department of Pediatrics, Division of Neonatology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Abhishek Makkar
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Michael W Cookson
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Tasnim Najaf
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA
| | - Natalie Rintoul
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Department of Pediatric General Thoracic and Fetal Surgery Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mark F Weems
- Division of Neonatology and Le Bonheur Children's Hospital, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anne Ades
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Chapman
- Department of Pediatrics, USC Keck School of Medicine, Fetal & Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Theresa R Grover
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah Keene
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Ascencio A, Fingland S, Diaz-Miron J, Weber N, Hills-Dunlap J, Partrick D, Acker SN. Operative Complications Following Gastrostomy Tube Placement After Cardiac Surgery During Infancy. J Surg Res 2024; 296:203-208. [PMID: 38281355 DOI: 10.1016/j.jss.2023.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 11/27/2023] [Accepted: 12/23/2023] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Gastrostomy tube (GT) placement is common in infants following repair of congenital heart defects. We aimed to determine rate of operative complications and predictors of short-term GT use to counsel parents regarding the risks and benefits of GT placement. METHODS We reviewed infants aged <1 y with congenital heart disease who underwent GT placement after cardiac surgery between 2018 and 2021. Demographics and clinical data were collected and analyzed. Comparisons were made between infants who required the GT for more than 1 y and those who required the GT for less than 1 y. RESULTS One hundred thirty three infants were included; 35 (26%) suffered one or more complication including wound infection (4, 3%), granulation tissue (3, 2%), tube dislodgement (10), leakage from the tube (9), unplanned emergency department visit (15), and unplanned readmission (1). Thirty-four infants used the GT for feeds for 1 y or less (26%) including 17 (13%) who used it for 3 mo or less. Fifty-six infants had their GT removed during the study period (42%), 20 of whom required gastrocutaneous fistula closure (36%). Thirty-three infants had a GT placed on or before day of life 30, 17 (52%) used the GT for less than 1 y, and 10 (31%) used it for 3 mo or less. CONCLUSIONS GT placement is associated with a relatively high complication and reoperation rate. GT placement in infants aged less than 30 d is associated with shorter duration of use. Risks, benefits, and alternatives such as nasogastric tube feeds should be discussed in the shared decision-making process for selected infants.
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Affiliation(s)
- Andy Ascencio
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Stephanie Fingland
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jose Diaz-Miron
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Nell Weber
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jonathan Hills-Dunlap
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - David Partrick
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
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Berber Çiftci H, Topbaş S, Taştekin A. Effect of Nonnutritive Sucking on Oral Feeding in Neonates With Perinatal Asphyxia: A Randomized Controlled Trial. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:406-417. [PMID: 38039979 DOI: 10.1044/2023_ajslp-23-00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
AIMS The effect of nonnutritive sucking (NNS) stimulation is unclear in infants with perinatal asphyxia. Thus, the aim of this study was to assess the effect of NNS stimulation on oral intake, discharge time, and early feeding skills in infants with perinatal asphyxia. DESIGN A randomized controlled study was conducted. METHOD Of the 94 infants, 47 were included in the experimental group and given NNS stimulation once a day before tube feeding by a speech-language therapist (SLT) in addition to hypothermia treatment. Infants' feeding performances on the days of first oral intake and discharge were evaluated with the Early Feeding Skills Scale (EFS). RESULTS The time from tube feeding to oral intake was significantly lower in the experimental group compared to the control group (p < .05). EFS scores at discharge were significantly higher in the experimental group than in the control group (p < .05). There was no significant difference between the experimental and control groups in terms of discharge and weight gain (p > .05). CONCLUSIONS The findings indicated that the NNS stimulation positively affected oral intake and early feeding skills in infants with perinatal asphyxia, as in preterms. However, NNS stimulation had no significant effect on discharge and weight gain in infants with asphyxia. This finding may be attributed to other factors. It is recommended to use NNS by an SLT in a neonatal intensive care unit within a multidisciplinary team to accelerate the transition to oral feeding and improve feeding skills in infants with perinatal asphyxia. Further studies on the effect of NNS stimulation in infants with perinatal asphyxia are needed to corroborate its effects on discharge time and weight gain.
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Affiliation(s)
- Hilal Berber Çiftci
- Department of Speech and Language Therapy, Graduate School of Health Sciences, Istanbul Medipol University, Turkey
- Department of Speech and Language Therapy, School of Health Sciences, Tarsus University, Mersin, Turkey
| | - Seyhun Topbaş
- Department of Speech and Language Therapy, Graduate School of Health Sciences, Istanbul Medipol University, Turkey
| | - Ayhan Taştekin
- Department of Neonatology, International School of Medicine, İstanbul Medipol University, Turkey
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11
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Ermarth A, Brinker K, Ostrander B. Feeding dysfunction in NICU patients with cramped synchronized movements. Early Hum Dev 2023; 187:105879. [PMID: 37875030 DOI: 10.1016/j.earlhumdev.2023.105879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 10/26/2023]
Abstract
Patients admitted to the neonatal intensive care unit (NICU) have higher association for neurodevelopment deficits, specifically cerebral palsy (CP). We identified patients with risk for CP using abnormal Pretchl's General Movement Assessment (GMA) and sub-category of cramped synchronized movements (CSM) and reported their feeding outcomes at discharge. Over 75 % of these patients required either nasogastric (NGT) or gastrostomy tube (GT) at discharge. Of these, 57 % weaned off their NGT or GT at home and 43 % of patients still needed a GT one year after discharge. Of those that could not wean off their NGT or GT, these patients had longer hospital stay, took lower percentage by mouth, and an older post-menstrual age at discharge. We did not find a difference in NGT or GT use between patients with IVH, ELBW, nor between their birthweight or gestation age at birth. This study provides further clinical characteristics in NICU patients who have higher risk of CP, and supports the need for skilled feeding therapy and resources both during and after NICU admission.
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Affiliation(s)
- Anna Ermarth
- University of Utah School of Medicine, Salt Lake City, UT, USA; Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, USA.
| | - Kristin Brinker
- Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Betsy Ostrander
- University of Utah School of Medicine, Salt Lake City, UT, USA; Division of Pediatric Neurology, Department of Pediatrics, USA
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12
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Fisher C, Haag M, Douglas A, Kayhani A, Warren JB. Remote monitoring for neonates requiring continued nasogastric tube feeding: implementation, patient characteristics, and early outcomes. J Perinatol 2023; 43:1125-1130. [PMID: 37468613 DOI: 10.1038/s41372-023-01732-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/27/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Our neonatal intensive care unit utilizes remote patient monitoring to facilitate hospital discharge with nasogastric tube (NGT) feeds. Program implementation, patient characteristics, and initial outcomes are described. STUDY DESIGN Data was collected prospectively in this implementation study. Descriptive statistics define weight gain, number of NGT feed days, number of days on monitoring, and physician time spent. Patient characteristics, readmissions, and implementation details are described. RESULTS One-hundred and four babies consented to and completed data collection. Average weight gain on monitoring was 31.4 g/day (SD 10.2). Eighty-nine babies (85.6%) achieved full oral feeds while on the program, requiring a median 5 NGT feed days (IQR 2-13) and a median 15 days on monitoring (IQR 11-27). Average physician time spent was 9.1 min per day (SD 3.7). Six babies (5.8%) had unscheduled readmissions while on the program. CONCLUSION Remote monitoring programs can facilitate discharge for babies with continued NGT needs.
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Affiliation(s)
- Christina Fisher
- Department of Pediatrics, Oregon Health & Science University School of Medicine, Doernbecher Children's Hospital, Portland, OR, USA
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Meredith Haag
- Department of Pediatrics, Oregon Health & Science University School of Medicine, Doernbecher Children's Hospital, Portland, OR, USA
| | - Angela Douglas
- Department of Pediatrics, Oregon Health & Science University School of Medicine, Doernbecher Children's Hospital, Portland, OR, USA
| | | | - Jamie B Warren
- Department of Pediatrics, Oregon Health & Science University School of Medicine, Doernbecher Children's Hospital, Portland, OR, USA.
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13
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Marquart JP, Mukherjee D, Canales BN, Flynn-O'Brien KT, Szabo A, Wagner AJ. Factors Associated with Hospital Readmission One Year Post-Discharge in Infants with Gastroschisis. Fetal Diagn Ther 2023; 50:344-352. [PMID: 37285815 DOI: 10.1159/000531449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Gastroschisis is the most common congenital abdominal wall defect with a rising prevalence. Infants with gastroschisis are at risk for multiple complications, leading to a potential increased risk for hospital readmission after discharge. We aimed to find the frequency and factors associated with an increased risk of readmission. METHODS A retrospective analysis of infants born with gastroschisis between 2013 and 2019 who received initial surgical intervention and follow-up care in the Children's Wisconsin health system was performed. The primary outcome was the frequency of hospital readmission within 1 year of discharge. We also compared maternal and infant clinical and demographic variables between those readmitted for reasons related to gastroschisis, and those readmitted for other reasons or not readmitted. RESULTS Forty of 90 (44%) infants born with gastroschisis were readmitted within 1-year of the initial discharge date, with 33 (37%) of the 90 infants being readmitted due to reasons directly related to gastroschisis. The presence of a feeding tube (p < 0.0001), a central line at discharge (p = 0.007), complex gastroschisis (p = 0.045), conjugated hyperbilirubinemia (p = 0.035), and the number of operations during the initial hospitalization (p = 0.044) were associated with readmission. Maternal race/ethnicity was the only maternal variable associated with readmission, with Black race being less likely to be readmitted (p = 0.003). Those who were readmitted were also more likely to be seen in outpatient clinics and utilize emergency healthcare resources. There was no statistically significant difference in readmission based on socioeconomic factors (all p > 0.084). CONCLUSION Infants with gastroschisis have a high hospital readmission rate, which is associated with a variety of risk factors including complex gastroschisis, multiple operations, and the presence of a feeding tube or central line at discharge. Improved awareness of these risk factors may help stratify patients in need of increased parental counseling and additional follow-up.
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Affiliation(s)
- John P Marquart
- Department of Pediatric Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Bethany N Canales
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy J Wagner
- Department of Pediatric Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
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14
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Enteral tube feeding selection at NICU discharge and resource utilization. J Perinatol 2022; 43:647-652. [PMID: 36435925 DOI: 10.1038/s41372-022-01566-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 11/05/2022] [Accepted: 11/11/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate resource utilization in infants discharged with different forms of feeding access. STUDY DESIGN Retrospective chart review of neonates discharged from 2012 to 2018. Data were collected from the medical record and relevant outcomes were compared. RESULTS 300 patients were sampled. 196 (65%) were discharged on NG feeds, 95 (32%) via GT, and 9 gastrojejunal (GJ 3%). NG-fed infants discharged sooner (mean DOL: NG = 85.4 vs GT = 122.8, p < 0.001). More GT/GJ patients required emergency department (ED) visits for tube complications (GT = 61 vs GJ = 7 vs NG = 42, p < 0.001) and more frequently (mean visits: GT = 1.63 ± 2.33 vs GJ = 4.22 ± 4.44 vs NG = 0.48 ± 1.40, p < 0.001). However, 44 (24%) of the patients discharged on NG later had a GT placed. CONCLUSIONS Many patients discharged from the NICU can be supported with NG feeds. This may shorten hospital stays and decrease ED visits but select patients will later merit surgical tube placement.
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15
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Ahearn MA, Stephens JR, Zwemer EK, Hall M, Ahuja A, Chatterjee A, Coletti H, Fuchs J, Lewis E, Liles EA, Reade E, Sutton AG, Sweeney A, Weinberg S, Harrison WN. Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes. Hosp Pediatr 2022; 12:969-980. [PMID: 36285567 DOI: 10.1542/hpeds.2022-006627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization. METHODS Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement. RESULTS We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year. CONCLUSIONS Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.
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Affiliation(s)
- M Alex Ahearn
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John R Stephens
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Eric K Zwemer
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matt Hall
- Department of Analytics, Children's Hospital Association, Overland Park, Kansas
| | - Arshiya Ahuja
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ashmita Chatterjee
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hannah Coletti
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jennifer Fuchs
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emilee Lewis
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - E Allen Liles
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Reade
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ashley G Sutton
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Alison Sweeney
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Steven Weinberg
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Wade N Harrison
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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16
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Morbidity and mortality in neonates with Down Syndrome based on gestational age. J Perinatol 2022; 43:445-451. [PMID: 36131096 DOI: 10.1038/s41372-022-01514-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/23/2022] [Accepted: 09/07/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Greater than 50% of neonates with Down Syndrome (DS) have perinatal complications that require admission to the neonatal intensive care unit (NICU) at birth. Previous studies have shown increased morbidity and mortality rates in neonates without DS delivered prior to 39 weeks of completed gestation. OBJECTIVE To determine if an association exists between gestational age at delivery and adverse outcomes in neonates with DS. STUDY DESIGN Neonates with DS admitted to a large, tertiary care center NICU from 2010 to 2020 were evaluated. Gestational age (GA) was stratified into 4 groups: <34 (preterm), 34-36 (late-preterm), 37-38 (early-term) and ≥39 (term + post-term) completed weeks. Fisher's exact tests were used to evaluate morbidity and mortality rates between groups. RESULT Of the 314 neonates with DS, 10% (N = 31) were <34 weeks, 22% (N = 68) 34-36 weeks, 40% (N = 127) 37-38 weeks, and 28% (N = 88) ≥39 completed weeks at birth. Baseline characteristics were similar between groups. GA at birth <34 weeks was associated with a higher in-hospital mortality rate when compared to those born 37-38 (19% vs. 0%, P < 0.001) and ≥39 (19% vs. 3%, P = 0.01). Neonates with DS born <34 weeks had a higher likelihood of oxygen requirement at time of discharge compared to 34-36, 37-38, and ≥39 groups (P = 0.01; P < 0.001; P < 0.001 respectively). Neonates with DS < 34 weeks were more likely to develop necrotizing enterocolitis (P = 0.02) and require nitric oxide (P = 0.014) compared to neonates with DS ≥ 39. We observed no differences in the need for surgical interventions between groups aside from the rate of gastrostomy/jejunostomy tube placement between 34-36 weeks and 37-38 weeks GA. CONCLUSION Neonates with DS born preterm (<34 weeks) represent a highly vulnerable subgroup. Multidisciplinary strategies are needed to address their higher rates of morbidity and mortality.
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17
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Bardach SH, Perry AN, Kapadia NS, Richards KE, Cogswell LK, Hartman TK. Redesigning care to support earlier discharge from a neonatal intensive care unit: a design thinking informed pilot. BMJ Open Qual 2022; 11:bmjoq-2021-001736. [PMID: 35613830 PMCID: PMC9134166 DOI: 10.1136/bmjoq-2021-001736] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background Preterm infants may remain in neonatal intensive care units (NICUs) to receive proper nutrition via nasogastric tube feedings. However, prolonged NICU stays can have negative effects for the patient, the family and the health system. Aim To demonstrate how a patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. Method We report on our design thinking-empathy building approach to programme design, initial outcomes and considerations for ongoing study. Results Through the use of design thinking methods, we identified unique needs, preferences and concerns that guided the development of our novel early discharge programme. We found that stable, preterm infants unable to feed by mouth and requiring nasogastric tubes can be cared for at home with remote patient monitoring and telehealth support. In addition, novel feeding strategies can help address parental preferences without compromising infant growth. Conclusion A patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. The programme resulted in a reduced length of stay, thereby increasing NICU bed capacity and limiting hospital turn-aways.
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Affiliation(s)
- Shoshana H Bardach
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire, USA
| | - Amanda N Perry
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire, USA.,Dartmouth-Hitchcock Medical Center, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Kathryn E Richards
- Dartmouth-Hitchcock Medical Center, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Laura K Cogswell
- Dartmouth-Hitchcock Medical Center, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Tyler K Hartman
- Dartmouth-Hitchcock Medical Center, Dartmouth Health, Lebanon, New Hampshire, USA
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18
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Abstract
Premature infants or infants born with complex medical problems are at increased risk of having delayed or dysfunctional oral feeding ability. These patients typically require assisted enteral nutrition in the form of a nasogastric tube (NGT) during their NICU hospitalization. Historically, once these infants overcame their initial reason(s) for admission, they were discharged from the NICU only after achieving full oral feedings or placement of a gastrostomy tube. Recent programs show that these infants can be successfully discharged from the hospital with partial NGT or gastrostomy tube feedings with the assistance of targeted predischarge education and outpatient support. Caregiver opinions have also been reported as satisfactory or higher with this approach. In this review, we discuss the current literature and outcomes in infants who are discharged with an NGT and provide evidence for safe practices, both during the NICU hospitalization, as well as in the outpatient setting.
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Affiliation(s)
- Anna Ermarth
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Con Yee Ling
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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19
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Gehle DB, Chapman A, Gregoski M, Brunswick M, Anderson E, Ramakrishnan V, Muhammad LN, Head W, Lesher AP, Ryan RM. A predictive model for preterm babies born < 30 weeks gestational age who will not attain full oral feedings. J Perinatol 2022; 42:126-131. [PMID: 34628479 PMCID: PMC8501923 DOI: 10.1038/s41372-021-01219-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/17/2021] [Accepted: 09/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Develop a model to predict gastrostomy tube (GT) for feeding at discharge in infants born < 30 weeks' (w) gestational age (GA). STUDY DESIGN A single-center retrospective study at academic NICU. Total of 391 (78 GT, 313 non-GT) infants < 30 w GA admitted in 2015-2018 split into test (15-16) and validation (17-18) cohorts. Classification and regression tree analysis was used to identify predictive factors for GT. RESULTS Several factors were associated with GT requirements. Four factors included in the model were postmenstrual age (PMA) at first oral feeding, birth GA, high-frequency ventilation exposure, necrotizing enterocolitis stage II/III. Area under the receiver operator characteristic curve was 0.944 in the test cohort, 0.815 in the validation cohort. Implementation plan based on the model was developed. CONCLUSIONS We developed a predictive model to risk-stratify infants born < 30 w GA for failing full oral feeding. We hope implementation at 38 w PMA will result in earlier placement of needed GT and discharge.
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Affiliation(s)
| | - Alison Chapman
- Department of Pediatrics (Neonatology), Charleston, SC USA
| | | | - Meghan Brunswick
- grid.16416.340000 0004 1936 9174Department of Pediatrics (Gastroenterology), University of Rochester, Rochester, NY USA
| | - Emily Anderson
- grid.410427.40000 0001 2284 9329Augusta University Medical College of Georgia, AU/UGA Medical Partnership, Athens, GA USA
| | | | - Lutfiyya N. Muhammad
- grid.16753.360000 0001 2299 3507Department of Preventive Medicine (Division of Biostatistics), Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - William Head
- grid.259828.c0000 0001 2189 3475Department of Surgery (Pediatric Surgery), Medical University of South Carolina, Charleston, SC USA
| | - Aaron P. Lesher
- grid.259828.c0000 0001 2189 3475Department of Surgery (Pediatric Surgery), Medical University of South Carolina, Charleston, SC USA
| | - Rita M. Ryan
- Department of Pediatrics (Neonatology), Charleston, SC USA ,grid.415629.d0000 0004 0418 9947Department of Pediatrics (Neonatology), Case Western Reserve University, Rainbow Babies & Children’s Hospital, Cleveland, OH USA
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20
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Mago-Shah DD, Malcolm WF, Greenberg RG, Goldstein RF. Discharging Medically Complex Infants with Supplemental Nasogastric Tube Feeds: Impact on Neonatal Intensive Care Unit Length of Stay and Prevention of Gastrostomy Tubes. Am J Perinatol 2021; 38:e207-e214. [PMID: 32498094 DOI: 10.1055/s-0040-1709497] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the feasibility, safety, and efficacy of discharge with supplemental nasogastric tube (NGT) feeds in medically complex infants. STUDY DESIGN Cohort study of 400 infants enrolled in the Transitional Medical Home (TMH) program at Duke University Level IV neonatal intensive care unit from January 2013 to 2017. RESULTS Among 400 infants enrolled in the TMH, 57 infants were discharged with an NGT. A total of 45 infants with a variety of diagnoses and comorbidities were included in final analysis. Among 45 infants, 5 obtained a gastrostomy tube (GT) postdischarge. Median (25-75th percentile) length of use of NGT in 40 infants was 12 days (4-37). Excluding four outliers who used NGT for ≥140 days, the median length of use was 8 days (3-24). This extrapolates to a median of 288 hospital days saved for the remaining 36 infants. There were only three emergency room visits related to parental concern for incorrect NGT placement. There was no statistically significant difference in percent oral feeding predischarge or growth in first month postdischarge between infants who orally fed versus those who obtained GTs. CONCLUSION Discharge with supplemental NGT feeds is safe and feasible utilizing a standardized protocol and close postdischarge follow-up. This practice can decrease length of stay and prevent need for GT. KEY POINTS · Discharge with nasogastric tube (NGT) supplementation is safe.. · Discharge with NGT supplementation decreases cost.. · Discharge with NGT can decrease neonatal intensive care unit length of stay.. · Medical home model facilitates safe discharge..
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Affiliation(s)
- Deesha D Mago-Shah
- Division of Neonatology, Department of Pediatrics, Duke University Hospital, Durham, North Carolina
| | - William F Malcolm
- Division of Neonatology, Department of Pediatrics, Duke University Hospital, Durham, North Carolina
| | - Rachel G Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University Hospital, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Ricki F Goldstein
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky
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21
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Lagatta JM, Uhing M, Acharya K, Lavoie J, Rholl E, Malin K, Malnory M, Leuthner J, Brousseau D. Actual and Potential Impact of a Home Nasogastric Tube Feeding Program for Infants Whose Neonatal Intensive Care Unit Discharge Is Affected by Delayed Oral Feedings. J Pediatr 2021; 234:38-45.e2. [PMID: 33789159 PMCID: PMC8238833 DOI: 10.1016/j.jpeds.2021.03.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/21/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare healthcare use and parent health-related quality of life (HRQL) in 3 groups of infants whose neonatal intensive care unit (NICU) discharge was delayed by oral feedings. STUDY DESIGN This was a prospective, single-center cohort of infants in the NICU from September 2018 to March 2020. After enrollment, weekly chart review determined eligibility for home nasogastric (NG) feeds based on predetermined criteria. Actual discharge feeding decisions were at clinical discretion. At 3 months' postdischarge, we compared acute healthcare use and parental HRQL, measured by the PedsQL Family Impact Module, among infants who were NG eligible but discharged with all oral feeds, discharged with NG feeds, and discharged with gastrostomy (G) tubes. We calculated NICU days saved by home NG discharges. RESULTS Among 180 infants, 80 were orally fed, 35 used NG, and 65 used G tubes. Compared with infants who had NG-tube feedings, infants who had G-tube feedings had more gastrointestinal or tube-related readmissions and emergency encounters (unadjusted OR 3.97, 95% CI 1.3-12.7, P = .02), and orally-fed infants showed no difference in use (unadjusted OR 0.41, 95% CI 0.1-1.7, P = .225). Multivariable adjustment did not change these comparisons. Parent HRQL at 3 months did not differ between groups. Infants discharged home with NG tubes saved 1574 NICU days. CONCLUSIONS NICU discharge with NG feeds is associated with reduced NICU stay without increased postdischarge healthcare use or decreased parent HRQL, whereas G-tube feeding was associated with increased postdischarge healthcare use.
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Affiliation(s)
- Joanne M. Lagatta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Uhing
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Krishna Acharya
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Julie Lavoie
- Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Erin Rholl
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathryn Malin
- Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Margaret Malnory
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jonathan Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Brousseau
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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22
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Connors J, Havranek T, Campbell D. Discharge of Medically Complex Infants and Developmental Follow-up. Pediatr Rev 2021; 42:316-328. [PMID: 34074718 DOI: 10.1542/pir.2020-000638] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
At the time of discharge from the NICU, many infants have ongoing complex medical issues that will require coordinated, multispecialty follow-up. Discharge planning and transfer of care for infants with medical complexity require a multidisciplinary team effort that begins early during the NICU hospitalization. It is critical that the primary care physician is involved in this process because he or she will serve as the chief communicator and coordinator of care after discharge. Although some infants with medical complexity may be followed in specialized multidisciplinary NICU follow-up clinics, these are not universally available. The responsibility then falls to the primary care physician to coordinate with different subspecialties based on the infant's needs. Many infants with medical complexity are technology-dependent at the time of discharge and may require home oxygen, ventilators, monitors, or tube feeding. Prematurity, critical illness, and prolonged NICU hospitalization that lead to medical complexity also increase the risk of neurodevelopmental delay or impairment. As such, these infants will not only require routine developmental surveillance and screening by the primary care physician but also should be followed longitudinally by a neurodevelopmental specialist, either a developmental-behavioral pediatrician or a neonatologist with experience in neurodevelopmental assessment.
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Affiliation(s)
- Jillian Connors
- Division of Neonatology, Children's Hospital at Montefiore, Bronx, NY.,Albert Einstein College of Medicine, Bronx, NY
| | - Tomas Havranek
- Division of Neonatology, Children's Hospital at Montefiore, Bronx, NY.,Albert Einstein College of Medicine, Bronx, NY
| | - Deborah Campbell
- Division of Neonatology, Children's Hospital at Montefiore, Bronx, NY.,Albert Einstein College of Medicine, Bronx, NY
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23
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NICU infants who require a feeding gastrostomy for discharge. J Pediatr Surg 2021; 56:449-453. [PMID: 32828544 DOI: 10.1016/j.jpedsurg.2020.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/05/2020] [Accepted: 07/18/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine population data for infants receiving a gastrostomy tube (GT) in our Neonatal Intensive Care Unit (NICU) to better understand the premature infant population at risk for GT prior to discharge. STUDY DESIGN We identified all NICU infants born 2015-2016 who received a GT and determined the birth gestational age below which GTs were placed due to oral feeding failure secondary to prematurity-related comorbidities, rather than anomalies or other reasons. Aggregate data were used to compare infants born <30 weeks (w) gestation who received a GT with those who did not. RESULTS GTs were placed in 117 infants. More than half of the NICU patients who receive GTs were actually >32 weeks gestation; a cut-off of <30w was a good identifier for those who failed achieving full oral feeds due to prematurity-related problems. Infants born <30w (n = 282) not receiving GTs were discharged at a significantly lower postmenstrual age (36w) and lower weight (2.3 kg) compared with infants who received a GT (49w, 5 kg). CONCLUSIONS The population of premature infants born <30w gestation constitute the population of infants at risk for a GT based solely on prematurity. LEVELS OF EVIDENCE III.
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Prevalence of Feeding Disorders: A Tough Reality to Swallow. J Pediatr 2021; 228:13-14. [PMID: 32861695 DOI: 10.1016/j.jpeds.2020.08.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 01/08/2023]
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