Extremely long hospitalizations of newborns in the United States: data, descriptions, dilemmas

Perspectives on non-emergent neonatal intensive care unit to pediatric intensive care unit care transfers in the United States

BACKGROUND

There is a substantial population of long-stay patients who non-emergently transfer directly from the neonatal intensive care unit (NICU) to the pediatric intensive care unit (PICU) without an interim discharge home. These infants are often medically complex and have higher mortality relative to NICU or PICU-only admissions. Given an absence of data surrounding practice patterns for non-emergent NICU to PICU transfers, we hypothesized that we would encounter a broad spectrum of current practices and a high proportion of dissatisfaction with current processes.

AIM

To characterize non-emergent NICU to PICU transfer practices across the United States and query PICU providers’ evaluations of their effectiveness.

METHODS

A cross-sectional survey was drafted, piloted, and sent to one physician representative from each of 115 PICUs across the United States based on membership in the PARK-PICU research consortium and membership in the Children’s Hospital Association. The survey was administered via internet (REDCap). Analysis was performed using STATA, primarily consisting of descriptive statistics, though logistic regressions were run examining the relationship between specific transfer steps, hospital characteristics, and effectiveness of transfer.

RESULTS

One PICU attending from each of 81 institutions in the United States completed the survey (overall 70% response rate). Over half (52%) indicated their hospital transfers patients without using set clinical criteria, and only 33% indicated that their hospital has a standardized protocol to facilitate non-emergent transfer. Fewer than half of respondents reported that their institution’s non-emergent NICU to PICU transfer practices were effective for clinicians (47%) or patient families (38%). Respondents evaluated their centers’ transfers as less effective when they lacked any transfer criteria (P = 0.027) or set transfer protocols (P = 0.007). Respondents overwhelmingly agreed that having set clinical criteria and standardized protocols for non-emergent transfer were important to the patient-family experience and patient safety.

CONCLUSION

Most hospitals lacked any clinical criteria or protocols for non-emergent NICU to PICU transfers. More positive perceptions of transfer effectiveness were found among those with set criteria and/or transfer protocols.

Characteristics and Outcomes of Intrahospital Transfers from Neonatal Intensive Care to Pediatric Intensive Care Units

OBJECTIVE

Critically ill children may be transferred from the neonatal intensive care unit (NICU) to the pediatric intensive care unit (PICU) for further critical care, but the frequency and outcomes of this patient population are unknown. The aims of this study are to describe the characteristics and outcomes in patients transferred from NICU to PICUs. We hypothesized that a higher-than-expected mortality would be present for patients with respiratory or cardiovascular diagnoses that underwent a NICU to PICU transition and that specific factors (timing of transfer, illness severity, and critical care interventions) are associated with a higher risk of mortality in the cardiovascular group.

STUDY DESIGN

Retrospective analysis of Virtual Pediatric Systems, LLC (2011-2019) deidentified cardiovascular and respiratory NICU to PICU subject data. We evaluated demographics, PICU length of stay, procedures, disposition, and mortality scores. Pediatric Index of Mortality 2 (PIM2) score was utilized to determine the standardized mortality ratio (SMR).

RESULTS

SMR of 4,547 included subjects (3,607 [79.3%] cardiovascular and 940 [20.7%] respiratory) was 1.795 (95% confidence interval: 1.62-1.97, p < 0.0001). Multivariable logistic regression analysis demonstrated transfer age (cardiovascular: odds ratio, 1.246 [1.10-1.41], p = 0.0005; respiratory: 1.254 [1.07-1.47], p = 0.0046) and PIM2 scores (cardiovascular: 1.404 [1.25-1.58], p < 0.0001; respiratory: 1.353 [1.08-1.70], p = 0.0095) were significantly associated with increased odds of mortality.

CONCLUSION

In this present study, we found that NICU to PICU observed deaths were high and various factors, particularly transfer age, were associated with increased odds of mortality. While the type of patients evaluated in this study likely influenced mortality, further investigation is warranted to determine if transfer timing is also a factor.

KEY POINTS

· NICU patients may be transitioned to the PICU.. · NICU to PICU observed deaths were high.. · Transfer timing may be a factor..

Caregiver Engagement During Pediatric Post-Acute Care Hospitalization

OBJECTIVES

Caregiver engagement during acute inpatient hospitalizations has been demonstrated to provide developmental and behavioral benefits for children, decrease readmissions and length of stay, and improve caregiver confidence. Caregiver engagement has been examined in acute care settings; however, there is a gap in information regarding caregiver engagement in a pediatric post-acute care hospital (pPACH). The objective of this study was to explore caregiver engagement in a pPACH.

PATIENTS AND METHODS

All patients, birth to 23 years of age, in the medical service of an independent pPACH in the Northeastern United States, January 1, 2013, through December 31, 2017, were identified. Retrospective review of electronic health records for patient demographics and caregiver engagement, identified as visit(s) and telephone call(s), was conducted. Descriptive statistics and logistic regression were used to distinguish differences and measure associations of caregiver visits and calls between demographic groups.

RESULTS

The primary mode of caregiver engagement for pPACH patients (n = 614) was by visits, whereas caregiver calls were less frequent. Multivariable logistic regression analysis identified significantly greater odds of caregiver visits among patients ages 1 to 17 years, with private payer, and having a single admission, whereas lower odds of visits were identified among those <1 year or ≥18 years, with ≥2 pPACH admissions, public insurance, Child Protective Services (CPS) involvement, and African American/Black, other, and unknown race/ethnicities.

CONCLUSIONS

Patients who were infants, had ≥2 admissions, had CPS involvement, and were covered under public payer experienced lower caregiver visit rates. Strategies are needed to further identify and address barriers to caregiver engagement.

Predictors of Pediatric Tracheostomy Outcomes in the United States

Objectives

To investigate the outcomes of pediatric tracheostomy as influenced by demographics and comorbidities.

Study Design

Retrospective national database review.

Setting

Fifty-two children’s hospitals across the United States.

Subjects and Methods

Hospitalization records from Pediatric Health Information System database dated 2010 to 2018 with patients younger than 18 years and procedure codes for tracheostomy were extracted. The primary outcome was total length of stay. The secondary outcomes were 30-day readmission, mortality, and posttracheostomy length of stay.

Results

A total of 14,155 children were included in the analysis. The median total length of stay was 77 days and increased from 59 to 103 days between 2010 and 2018 ( P < .001). The median posttracheostomy length of stay was 34 days and also increased from 27 to 49 days ( P < .001). On multivariate regression analyses, the total and posttracheostomy lengths of stay were significantly increased in children younger than 1 year, patients of black race, hospitals in the non-West regions, those discharged to home, and those with comorbidities. Socioeconomic indicators such as insurance type and estimated household income were associated with no difference or small effect sizes. Regions and comorbidities were associated with differences in 30-day readmission (overall 26%), while in-hospital mortality was primarily associated with age and comorbidities (overall 8.6%).

Conclusion

Pediatric tracheostomy requires substantial health care resources with length of stay escalating over recent years. Age, race, region, discharge destination, and comorbidities were associated with differences in length of stay.

Maternal race/ethnicity as a risk factor for cervical insufficiency

BACKGROUND

Preterm birth (PTB) affects 1 in 9 pregnancies in the United States. There are well known but poorly understood racial/ethnic disparities in PTB rates. The role that racial/ethnic disparities in cervical insufficiency (CI) may play in the overall disparities in preterm birth rates is unknown.

OBJECTIVE

The primary objective of this study was to examine racial/ethnic differences in risk of CI.

STUDY DESIGN

We conducted a retrospective cohort study of singleton pregnant women in 2012 who were members of Kaiser Permanente Northern California (KPNC), excluding elective termination, delivery outside KPNC, and loss to follow-up. The primary outcome was CI; the secondary outcomes included stillbirth, PTB, and neonatal intensive care unit (NICU) admission. We compared rates of these outcomes among women of different racial/ethnic background. Multivariable logistic regression modeling was used to assess other potential risk factors for CI, including maternal age, parity, medical co-morbidities, prior cervical procedures, prior pregnancy terminations, and history of PTB.

RESULTS

A total of 34,173 women who were pregnant in 2012 were included in the study. The racial/ethnic makeup of the cohort was 38.6% White, 25.8% Asian, 25.1% Hispanic, 7% Black, and 3.5% other. Approximately 1% (401) of women were diagnosed with CI. Black women had a significantly higher rate of CI (3.2%) compared to White women (0.9%, P < 0.001) as well as higher rates of PTB (9.2%). Infants born to black women had higher rates of NICU care (8.7%) compared to other racial/ethnic groups. Regression analysis showed that Black race/ethnicity was significantly associated with CI compared to Whites (OR 2.89, 95% CI 2.13-3.92) after controlling for other variables associated with CI.

CONCLUSION

Black women had higher odds of CI compared to White women. This disparity may contribute to the significantly higher rate of PTB among Black women nationally. Further investigation of this association may provide important contributions to our understanding of both CI and PTB.

NEC-zero recommendations from scoping review of evidence to prevent and foster timely recognition of necrotizing enterocolitis

BACKGROUND

Although decades have focused on unraveling its etiology, necrotizing enterocolitis (NEC) remains a chief threat to the health of premature infants. Both modifiable and non-modifiable risk factors contribute to varying rates of disease across neonatal intensive care units (NICUs).

PURPOSE

The purpose of this paper is to present a scoping review with two new meta-analyses, clinical recommendations, and implementation strategies to prevent and foster timely recognition of NEC.

METHODS

Using the Translating Research into Practice (TRIP) framework, we conducted a stakeholder-engaged scoping review to classify strength of evidence and form implementation recommendations using GRADE criteria across subgroup areas: 1) promoting human milk, 2) feeding protocols and transfusion, 3) timely recognition strategies, and 4) medication stewardship. Sub-groups answered 5 key questions, reviewed 11 position statements and 71 research reports. Meta-analyses with random effects were conducted on effects of standardized feeding protocols and donor human milk derived fortifiers on NEC.

RESULTS

Quality of evidence ranged from very low (timely recognition) to moderate (feeding protocols, prioritize human milk, limiting antibiotics and antacids). Prioritizing human milk, feeding protocols and avoiding antacids were strongly recommended. Weak recommendations (i.e. "probably do it") for limiting antibiotics and use of a standard timely recognition approach are presented. Meta-analysis of data from infants weighing <1250 g fed donor human milk based fortifier had reduced odds of NEC compared to those fed cow's milk based fortifier (OR = 0.36, 95% CI 0.13, 1.00; p = 0.05; 4 studies, N = 1164). Use of standardized feeding protocols for infants <1500 g reduced odds of NEC by 67% (OR = 0.33, 95% CI 0.17, 0.65, p = 0.001; 9 studies; N = 4755 infants). Parents recommended that NEC information be shared early in the NICU stay, when feedings were adjusted, or feeding intolerance occurred via print and video materials to supplement verbal instruction.

DISCUSSION

Evidence for NEC prevention is of sufficient quality to implement. Implementation that addresses system-level interventions that engage the whole team, including parents, will yield the best impact to prevent NEC and foster its timely recognition.

Defining Pediatric Chronic Critical Illness for Clinical Care, Research, and Policy

Chronically critically ill pediatric patients represent an emerging population in NICUs and PICUs. Chronic critical illness has been recognized and defined in the adult population, but the same attention has not been systematically applied to pediatrics. This article reviews what is currently known about pediatric chronic critical illness, highlighting the unique aspects of chronic critical illness in infants and children, including specific considerations of prognosis, outcomes, and decision-making. We propose a definition that incorporates NICU versus PICU stays, recurrent ICU admissions, dependence on life-sustaining technology, multiorgan dysfunction, underlying medical complexity, and the developmental implications of congenital versus acquired conditions. We propose a research agenda, highlighting existing knowledge gaps and targeting areas of improvement in clinical care, research, and policy.

Professional Responsibility, Consensus, and Conflict: A Survey of Physician Decisions for the Chronically Critically Ill in Neonatal and Pediatric Intensive Care Units

OBJECTIVE

To describe neonatologist and pediatric intensivist attitudes and practices relevant to high-stakes decisions for children with chronic critical illness, with particular attention to physician perception of professional duty to seek treatment team consensus and to disclose team conflict.

DESIGN

Self-administered online survey.

SETTING

U.S. neonatal ICUs and PICUs.

SUBJECTS

Neonatologists and pediatric intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We received 652 responses (333 neonatologists, denominator unknown; 319 of 1,290 pediatric intensivists). When asked about guiding a decision for tracheostomy in a chronically critically ill infant, only 41.7% of physicians indicated professional responsibility to seek a consensus decision, but 73.3% reported, in practice, that they would seek consensus and make a consensus-based recommendation; the second most common practice (15.5%) was to defer to families without making recommendations. When presented with conflict among the treatment team, 63% of physicians indicated a responsibility to be transparent about the decision-making process and reported matching practices. Neonatologists more frequently reported a responsibility to give decision making fully over to families; intensivists were more likely to seek out consensus among the treatment team.

CONCLUSIONS

ICU physicians do not agree about their responsibilities when approaching difficult decisions for chronically critically ill children. Although most physicians feel a professional responsibility to provide personal recommendations or defer to families, most physicians report offering consensus recommendations. Nearly all physicians embrace a sense of responsibility to disclose disagreement to families. More research is needed to understand physician responsibilities for making recommendations in the care of chronically critically ill children.

Does diagnosis influence end-of-life decisions in the neonatal intensive care unit?

OBJECTIVE

To determine the influence of physiological status and diagnosis at the time of death on end-of-life care.

STUDY DESIGN

Retrospective descriptive study in a regional referral level IV neonatal intensive care unit (NICU) of infants who died from 1 January 1999 to 31 December 2008. Infants were categorized based on diagnosis (very preterm, congenital anomalies or other) and level of stability. Primary outcome was level of clinical service provided at end of life (care withheld, care withdrawn or full resuscitation).

RESULT

From 1999 to 2008, there were 414 deaths in the NICU. Congenital anomaly was the leading diagnosis at the time of death, representing 45% of all deaths. Comparing mode of death, very preterm newborns were more likely than infants with congenital anomalies to have received cardio-pulmonary resuscitation (CPR) at the time of death (26% vs 13%, P < 0.01) and were significantly more unstable (75% vs 52%, P < 0.01). Infants aged 22 to 24 weeks were mostly unstable and significantly more likely to receive CPR than infants with any other diagnosis.

CONCLUSION

Over the 10-year period, very preterm infants were more likely to be physiologically unstable and to receive CPR at the time of death than infants with any other diagnosis. This finding was especially true for infants at the edge of viability (22 to 24 weeks). These differences in end-of-life care suggest that the quality of life and medical futility may be viewed differently for the least mature infants.

Time trends and payer differences in lengths of initial hospitalization for preterm infants, Arkansas, 2004 to 2010

OBJECTIVE

The objective of this study was to examine the time trend in length of stay (LOS) and explore potential differences in neonatal LOS by insurance type for preterm infants in Arkansas between 2004 and 2010.

STUDY DESIGN

There were 18,712 preterm infants included in our analyses. Accelerated failure time models were used to model neonatal LOS as a function of insurance type and discharge year while adjusting for key maternal and infant characteristics, and complication/anomaly indicators.

RESULTS

Before adjusting for the complication/anomaly indicators, the LOS for preterm infants delivered to mothers in the Medicaid group was 3.2% shorter than those in the private payer group. Furthermore, each subsequent year was associated with a 1.6% increase in the expected LOS. However, after accounting for complications and anomalies, insurance coverage differences in neonatal LOS were not statistically significant while the trend in LOS persisted at a 0.59% increase for each succeeding year.

CONCLUSION

All of the apparent differences in LOS by insurance type and more than half of the apparent increase in LOS over time are accounted for by higher rates of complications among privately insured preterm infants and increasing rates of complications for all surviving preterm infants between 2004 and 2010.

It’s agony for us as well

Background:

Improved techniques and life sustaining technology in the neonatal intensive care unit have resulted in an increased probability of survival for extremely premature babies. The by-product of the aggressive treatment is iatrogenic pain, and this infliction of pain can be a cause of suffering and distress for both baby and nurse.

Research question:

The research sought to explore the caregiving dilemmas of neonatal nurses when caring for extremely premature babies. This article aims to explore the issues arising for neonatal nurses when they inflict iatrogenic pain on the most vulnerable of human beings – babies ≤24 weeks gestation.

Participants:

Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia.

Ethical consideration:

Ethical processes and procedures set out by the ethics committee have been adhered to by the researchers.

Findings:

A qualitative approach was used to analyse the data. The theme ‘inflicting pain’ comprised three sub-themes: ‘when caring and torture are the same thing’, ‘why are we doing this!’ and ‘comfort for baby and nurse’. The results show that the neonatal nurses were passionate about the need for appropriate pain relief for extremely premature babies.

Conclusion:

The neonatal nurses experienced a profound sense of distress manifested as existential suffering when they inflicted pain on extremely premature babies. Inflicting pain rather than relieving it can leave the nurses questioning their role as compassionate healthcare professionals.

Parental experiences of a developmentally focused care program for infants and children during prolonged hospitalization

This study investigates parental experiences and perceptions of the care received during their child's prolonged hospitalization. It relates this care to the Beanstalk Program (BP), a develop-mentally focused care program provided to these families within an acute care hospital setting. A total of 20 parents (of children hospitalized between 1-15 months) completed the Measures of Processes of Care (MPOC-20) with additional questions regarding the BP. Scores rate the extent of the health-care provider's behaviour as perceived by the family, ranging from 'to a great extent' (7) to 'never' (1). Parents rated Respectful and Supportive Care (6.33) as highest, while Providing General Information (5.65) was rated lowest. Eleven parents participated in a follow-up, qualitative, semi-structured interview. Interview data generated key themes: (a) parents strive for positive and normal experiences for their child within the hospital environment; (b) parents value the focus on child development in the midst of their child's complex medical care; and (c) appropriate developmentally focused education helps parents shift from feeling overwhelmed with a medically ill child to instilling feelings of confidence and empowerment to care for their child and transition home. These results emphasize the importance of enhancing child development for hospitalized infants and young children through programs such as the BP.

Estimating the impact of smoking cessation during pregnancy: the San Bernardino County experience

We examined the relation between maternal smoking and adverse infant outcomes [low birth weight (LBW), and preterm birth (PTB)] during 2007-2008 in San Bernardino County, California-the largest county in the contiguous United States which has one of the highest rates of infant mortality in California. Using birth certificate data, we identified 1,430 mothers in 2007 and 1,355 in 2008 who smoked during pregnancy. We assessed the effect of never smoking and smoking cessation during pregnancy relative to smoking during pregnancy for the 1,843/1,798 LBW, and 3,480/3,238 PTB's recorded for 2007/2008, respectively. To describe the effect of quitting smoking during pregnancy, we calculated the exposure impact number for smoking during pregnancy. Major findings are: (1) relative to smoking during pregnancy, significantly lower risk of LBW among never smoking mothers [OR, year: 0.56, 2007; 0.54, 2008] and for smoking cessation during pregnancy [0.57, 2007; 0.72, 2008]; (2) relative to smoking during pregnancy, significantly lower risk of PTB was found for never smoking mothers [0.68, 2007; 0.68, 2008] and for smoking cessation during pregnancy [0.69, 2007; 0.69, 2008]; (3) an exposure impact assessment indicating each LBW or PTB outcome in the county could have been prevented either by at least 35 mothers quitting smoking during pregnancy or by 25 mothers being never smokers during pre-pregnancy. Our findings identify an important burden of adverse infant outcomes due to maternal smoking in San Bernardino County that can be effectively decreased by maternal smoking cessation.

Teaching ethics in neonatal and perinatal medicine: What is happening in Canada?

Ethically challenging clinical situations are frequently encountered in neonatal and perinatal medicine (NPM), resulting in a complex environment for trainees and a need for ethics training during NPM residency. In the present study, the authors conducted a brief environmental scan to investigate the ethics teaching strategies in Canadian NPM programs. Ten of 13 (77%) accredited Canadian NPM residency programs participated in a survey investigating teaching strategies, content and assessment mechanisms. Although informal ethics teaching was more frequently reported, there was significant variability among programs in terms of content and logistics, with the most common topics being 'The medical decision making process: Ethical considerations' and 'Review of bioethics principles' (88.9% each); lectures by staff or visiting staff was the most commonly reported formal strategy (100%); and evaluation was primarily considered to be part of their overall trainee rotation (89%). This variability indicates the need for agreement and standardization among program directors regarding these aspects, and warrants further investigation.

Abnormal heart rate characteristics before clinical diagnosis of necrotizing enterocolitis

OBJECTIVE

Earlier diagnosis and treatment of necrotizing enterocolitis (NEC) in preterm infants, before clinical deterioration, might improve outcomes. A monitor that measures abnormal heart rate characteristics (HRC) of decreased variability and transient decelerations was developed as an early warning system for sepsis. As NEC shares pathophysiologic features with sepsis, we tested the hypothesis that abnormal HRC occur before clinical diagnosis of NEC.

STUDY DESIGN

Retrospective review of Bells stage II to III NEC cases among infants <34 weeks gestation enrolled in a prospective randomized clinical trial of HRC monitoring at three neonatal intensive care units.

RESULT

Of 97 infants with NEC and HRC data, 33 underwent surgical intervention within 1 week of diagnosis. The baseline HRC index from 1 to 3 days before diagnosis was higher in patients who developed surgical vs medical NEC (2.06±1.98 vs 1.22±1.10, P=0.009). The HRC index increased significantly 16 h before the clinical diagnosis of surgical NEC and 6 h before medical NEC. At the time of clinical diagnosis, the HRC index was higher in patients with surgical vs medical NEC (3.3±2.2 vs 1.9±1.7, P<0.001).

CONCLUSION

Abnormal HRC occur before clinical diagnosis of NEC, suggesting that continuous HRC monitoring may facilitate earlier detection and treatment.

Nurse Activism in the newborn intensive care unit

Nurses working in a newborn intensive care unit report that treatment decision disagreements for infants in their care may lead to ethical dilemmas involving all health-care providers. Applying Rest’s Four-Component Model of Moral Action as the theoretical framework, this study examined the responses of 224 newborn intensive care unit nurses to the Nurses Ethical Involvement Survey. The three most frequent actions selected were as follows: talking with other nurses, talking with doctors, and requesting a team meeting. The multiple regression analysis indicates that newborn intensive care unit nurses with greater concern for the ethical aspects of clinical practice (p = .001) and an increased perception of their ability to influence ethical decision making (p = .018) were more likely to display Nurse Activism. Future research is necessary to identify other factors leading to and inhibiting Nurse Activism as these findings explained just 8.5% of the variance.

Very late onset infections in the neonatal intensive care unit

OBJECTIVE

We sought to determine the risk factors, incidence, and mortality of very late onset bacterial infection (blood, urine, or cerebrospinal fluid culture positive occurring after day of life 120) in preterm infants.

STUDY DESIGN

A retrospective observational cohort study of all very low birth weight infants cared for between day of life 120 and 365 in 292 neonatal intensive care units in the United States from 1997 to 2008.

RESULTS

We identified 3918 infants who were hospitalized beyond 120 days of life. Of these, 1027 (26%) were evaluated with at least 1 culture (blood, urine, or cerebrospinal fluid), and 276 (27%) of the evaluated infants had 414 episodes of culture-positive infection. Gram-positive organisms caused most of the infections (48%). The risk of death was higher in infants with positive cultures (odds ratio; 10.5, 95% confidence interval [7.2-15.5]) or negative cultures (4.8, [3.5-6.7]) compared to infants that were never evaluated with a culture (p<0.001). Mortality was highest with fungal infections (8/24, 33%) followed by Gram-positive cocci (40/142, 28%).

CONCLUSIONS

Important predictive risk factors for early and late onset sepsis (birth weight and gestational age) did not contribute to risk of developing very late onset infection. Evaluation for infection (whether positive or negative) was a significant risk factor for death. GPC and fungal infections were associated with high mortality.

Maternal role attainment with medically fragile infants: Part 2. relationship to the quality of parenting

We examined which components of maternal role attainment (identity, presence, competence) influenced quality of parenting for 72 medically fragile infants, controlling for maternal education and infant illness severity. Maternal competence was related to responsiveness. Maternal presence and technology dependence were inversely related to participation. Greater competence and maternal education were associated with better normal caregiving. Presence was negatively related although competence was positively related to illness-related caregiving. Mothers with lower competence and more technology dependent children perceived their children as more vulnerable and child cues as more difficult to read. Maternal role attainment influenced parenting quality for these infants more than did child illness severity; thus interventions are needed to help mothers develop their maternal role during hospitalization and after discharge. © 2010 Wiley Periodicals, Inc. Res Nurs Health 34:35-48, 2011.

Updated meta-analysis of probiotics for preventing necrotizing enterocolitis in preterm neonates

OBJECTIVE

Systematic reviews of randomized, controlled trials (RCTs) indicate lower mortality and necrotizing enterocolitis (NEC) and shorter time to full feeds after probiotic supplementation in preterm (<34 weeks' gestation) very low birth weight (VLBW; birth weight <1500 g) neonates. The objective of this study was to update our 2007 systematic review of RCTs of probiotic supplementation for preventing NEC in preterm VLBW neonates.

METHODS

We searched in March 2009 the Cochrane Central register; Medline, Embase, and Cinahl databases; and proceedings of the Pediatric Academic Society meetings and gastroenterology conferences. Cochrane Neonatal Review Group search strategy was followed. Selection criteria were RCTs of any enteral probiotic supplementation that started within first 10 days and continued for > or =7 days in preterm VLBW neonates and reported on stage 2 NEC or higher (Modified Bell Staging).

RESULTS

A total of 11 (N = 2176), including 4 new (n = 783), trials were eligible for inclusion in the meta-analysis by using a fixed-effects model. The risk for NEC and death was significantly lower. Risk for sepsis did not differ significantly. No significant adverse effects were reported. Trial sequential analysis) showed 30% reduction in the incidence of NEC (alpha = .05 and .01; power: 80%).

CONCLUSIONS

The results confirm the significant benefits of probiotic supplements in reducing death and disease in preterm neonates. The dramatic effect sizes, tight confidence intervals, extremely low P values, and overall evidence indicate that additional placebo-controlled trials are unnecessary if a suitable probiotic product is available.

Benevolent injustice: a neonatal dilemma

There is a little-recognized cohort of NICU patients whose outcomes are the result of a "benevolent injustice" in their healthcare course. Many of these infants are saved by technology; however, they are left both medically fragile and medically dependent, and many of them are required to live in a medical facility. Many of these babies never get to go home with their parents. This emerging cohort of patients may evolve from the difficult ability to prognosticate outcomes for neonates, overtreatment, and acquiescing to parental demands for continued aggressive care. Neonatology is an unpredictable process and one that is never intended to harm, but carries with it the potential of devastating consequences, thus creating a benevolent injustice.

The offer they can't refuse: parents and perinatal treatment decisions

Despite a widespread myth of parental autonomy in decision-making for extremely preterm neonates, families in the United States are often not given access to accurate information about the consequences of preterm birth, resuscitation and treatment, or about their ethical options. Professional, philosophical, and financial incentives for hospitals and neonatologists to provide intensive treatment may trump parental wishes in delivery rooms and neonatal units. Parents may also be intimidated by the atmosphere of intensive care and by the behavior of committed staff. Prenatal advance directives allow parents to receive information on outcomes, treatments, and options, including palliative care, 'on their own turf' and as a part of routine prenatal counseling. The use of directives and other techniques for transparency in obstetric and neonatal care could improve the process of informed parental choice.

Conscientious objection: a potential neonatal nursing response to care orders that cause suffering at the end of life? Study of a concept

This article is an exploratory effort meant to solicit and provoke dialog. Conscientious objection is proposed as a potential response to the moral distress experienced by neonatal nurses. The most commonly reported cause of distress for all nurses is following orders to support patients at the end of their lives with advanced technology when palliative or comfort care would be more humane. Nurses report that they feel they are harming patients or causing suffering when they could be comforting instead. We examined the literature on moral distress, futility, and the concept of conscientious objection from the perspective of the nurse's potential response to performing advanced technologic interventions for the dying patient. We created a small pilot study to engage in clinical verification of the use of our concept of conscientious objection. Data from 66 neonatal intensive care and pediatric intensive care unit nurses who responded in a one-month period are reported here. Interest in conscientious objection to care that causes harm or suffering was very high. This article reports the analysis of conscientious objection use in neonatal care.

Prevention and treatment of necrotising enterocolitis in preterm neonates

Prevention and treatment of NEC has become an area of priority for research due to the increasing number of preterm survivors at risk, and the significant mortality and morbidity related to the illness. Probiotic supplementation appears to be a promising option for primary prevention of NEC but further large trials are necessary for documenting their safety in terms of sepsis as well as long-term neurodevelopmental outcomes and immune function. As new frontiers including immunomodulating agents like pentoxifylline continue to be explored, the impact of well-established simple strategies like antenatal glucocorticoid therapy, and early and preferential use of breast milk must not be forgotten. Clinical research on manifestations of ileus of prematurity, and feeding in the presence of common risk factors such as IUGR is needed. Safety of minimal enteral feeds in terms of NEC and benefits of standardised feeding regimens need to be confirmed. Association of common clinical practices such as red cell transfusions, H2 receptor blockade, and thickening of feeds with NEC warrants attention. An approach utilising a package of potentially better practices seems to be the most appropriate strategy for the prevention and treatment of NEC.