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Paraparambil Vellamgot A, Salameh K, AlBedaywi RR, Alhoyed SM, Habboub LH, Abdellatif W, Daoud OA, Atrash M, Zakaria A. Kaiser Permanente early-onset sepsis calculator as a safe tool for reducing antibiotic use among chorioamnionitis-exposed term neonates: Qatar experience. BMJ Open Qual 2023; 12:e002459. [PMID: 37827729 PMCID: PMC10582875 DOI: 10.1136/bmjoq-2023-002459] [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: 06/14/2023] [Accepted: 09/24/2023] [Indexed: 10/14/2023] Open
Abstract
Being an important cause of early-onset neonatal sepsis, clinical chorioamnionitis in the mother results in frequent laboratory workup and antibiotic use for the neonate. Neonatal intensive care units (NICUs) in Qatar follow the categorical approach recommended by the Centers for Disease Control and Prevention, USA, and all chorioamnionitis-exposed neonates receive antibiotics.Our project aimed to reduce antibiotic use among chorioamnionitis-exposed, asymptomatic term babies by adopting the early-onset sepsis calculator (EOSCAL). Reduction of blood culture and NICU stay duration were added as secondary objectives later.The Institute of Healthcare Improvement Model of Improvement was used. Antibiotic use rate was the primary outcome measure. Blood culture rate and early transfer to the postnatal ward were added after 1 year. The process measures included the EOSCAL use rate and calculation error rate. The rate of positive culture among untreated babies within the first week was taken as a balancing measure. Monthly data were collected from February 2020 and entered as run charts. Calculation errors were dealt by multiple PDSAs. Additional outcome measures were added in January 2021. Data collection and monitoring continued till December 2022.Among 3837 inborn NICU admissions, 464 (12 %) were chorioamnionitis-exposed babies. Of them, 341 (74%) cases were eligible for inclusion. Among eligible cases, 270 (79%) did not receive antibiotics. Blood culture could be avoided among 106 (97% of low-risk babies) and NICU stay was reduced among 45 (92% of eligible low-risk babies). None of the untreated babies developed sepsis during the first week.Implementation of this project effectively and safely reduced the antibiotic use and blood culture rate among term, well-appearing babies exposed to chorioamnionitis. The project resulted in enhanced patient safety, experience and flow and reduced cost. It is recommendable to other NICU settings in Qatar.
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Affiliation(s)
| | - Khalil Salameh
- NICU, Al-Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | | | | | | | - Muna Atrash
- NICU, Al-Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
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Dsouza V, Kothari N, Mishra U, Jani P, Maheshwari R, Shah D, D'Cruz D, Baird J, Luig M. Reducing antibiotic use in asymptomatic term infants exposed to maternal chorioamnionitis: Predictive role of sepsis risk calculator. J Paediatr Child Health 2022; 58:1958-1963. [PMID: 35869737 DOI: 10.1111/jpc.16128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
AIM The sepsis risk calculator (SRC) has been shown to reduce empirical antibiotic usage in neonates at risk of early-onset sepsis without increasing adverse clinical outcomes. However, its use for categorising and improving identification of at-risk neonates exposed to chorioamnionitis in the local population has not been reported. This study compares the management guided by the SRC to our unit's clinical practice of administering empirical antibiotics to all term neonates (born ≥37 weeks gestation), symptomatic and asymptomatic, who were exposed to chorioamnionitis, and evaluates the performance of the SRC in managing asymptomatic term neonates exposed to chorioamnionitis. METHODS This single-centre retrospective study identified 178 eligible term neonates exposed to chorioamnionitis over a 17-month study period. Relevant demographic and clinical information on the mother-infant dyad was collected. The SRC was executed retrospectively in the study cohort. Descriptive statistics were used for reporting the findings. RESULTS The mean gestational age was 39 (standard deviation, SD 1) weeks, and the mean birth weight was 3472 (SD 482) g. Of the 178 neonates, 136 (76%) were asymptomatic and received empirical antibiotic therapy for 2 days (mean). Based on management recommendations from the SRC, empirical antibiotic therapy could have been avoided in 98% of asymptomatic neonates; 88% could have been managed by observation alone, avoiding mother-infant separation. No neonate died or had a positive blood culture result. CONCLUSIONS The SRC could reduce antibiotic exposure in asymptomatic neonates exposed to chorioamnionitis. It could assist clinicians to categorise risk in neonates exposed to chorioamnionitis.
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Affiliation(s)
- Vanessa Dsouza
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nakul Kothari
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Umesh Mishra
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Pranav Jani
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rajesh Maheshwari
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Dharmesh Shah
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Daphne D'Cruz
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jane Baird
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Melissa Luig
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
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Ackermann K, Baker J, Festa M, McMullan B, Westbrook J, Li L. Computerized Clinical Decision Support Systems for the Early Detection of Sepsis Among Pediatric, Neonatal, and Maternal Inpatients: Scoping Review. JMIR Med Inform 2022; 10:e35061. [PMID: 35522467 PMCID: PMC9123549 DOI: 10.2196/35061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/27/2022] [Accepted: 03/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sepsis is a severe condition associated with extensive morbidity and mortality worldwide. Pediatric, neonatal, and maternal patients represent a considerable proportion of the sepsis burden. Identifying sepsis cases as early as possible is a key pillar of sepsis management and has prompted the development of sepsis identification rules and algorithms that are embedded in computerized clinical decision support (CCDS) systems. OBJECTIVE This scoping review aimed to systematically describe studies reporting on the use and evaluation of CCDS systems for the early detection of pediatric, neonatal, and maternal inpatients at risk of sepsis. METHODS MEDLINE, Embase, CINAHL, Cochrane, Latin American and Caribbean Health Sciences Literature (LILACS), Scopus, Web of Science, OpenGrey, ClinicalTrials.gov, and ProQuest Dissertations and Theses Global (PQDT) were searched by using a search strategy that incorporated terms for sepsis, clinical decision support, and early detection. Title, abstract, and full-text screening was performed by 2 independent reviewers, who consulted a third reviewer as needed. One reviewer performed data charting with a sample of data. This was checked by a second reviewer and via discussions with the review team, as necessary. RESULTS A total of 33 studies were included in this review-13 (39%) pediatric studies, 18 (55%) neonatal studies, and 2 (6%) maternal studies. All studies were published after 2011, and 27 (82%) were published from 2017 onward. The most common outcome investigated in pediatric studies was the accuracy of sepsis identification (9/13, 69%). Pediatric CCDS systems used different combinations of 18 diverse clinical criteria to detect sepsis across the 13 identified studies. In neonatal studies, 78% (14/18) of the studies investigated the Kaiser Permanente early-onset sepsis risk calculator. All studies investigated sepsis treatment and management outcomes, with 83% (15/18) reporting on antibiotics-related outcomes. Usability and cost-related outcomes were each reported in only 2 (6%) of the 31 pediatric or neonatal studies. Both studies on maternal populations were short abstracts. CONCLUSIONS This review found limited research investigating CCDS systems to support the early detection of sepsis among pediatric, neonatal, and maternal patients, despite the high burden of sepsis in these vulnerable populations. We have highlighted the need for a consensus definition for pediatric and neonatal sepsis and the study of usability and cost-related outcomes as critical areas for future research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/24899.
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Affiliation(s)
- Khalia Ackermann
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Jannah Baker
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Marino Festa
- Kids Critical Care Research, Department of Paediatric Intensive Care, Children's Hospital at Westmead, Sydney, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
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Goel N, Cannell S, Davies G, Natti MS, Kirupaalar V, Abelian A, Saeed S, Smith R, Manikonda R, Pitchaikani PK, Davies D, Morris RM, Edwards L, Govindaraju R, Creese K, Jones J, Choudhary J, Rowley S, Sethuraman C, Muxworthy H, Curtis F, Donnelly P, Joishy M, Barnard I, Kenny C, Pal R, Jones K, Banerjee S. Implementation of an adapted Sepsis Risk Calculator algorithm to reduce antibiotic usage in the management of early onset neonatal sepsis: a multicentre initiative in Wales, UK. Arch Dis Child Fetal Neonatal Ed 2022; 107:303-310. [PMID: 34551917 DOI: 10.1136/archdischild-2020-321489] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/06/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Assess the impact of introducing a consensus guideline incorporating an adapted Sepsis Risk Calculator (SRC) algorithm, in the management of early onset neonatal sepsis (EONS), on antibiotic usage and patient safety. DESIGN Multicentre prospective study SETTING: Ten perinatal hospitals in Wales, UK. PATIENTS All live births ≥34 weeks' gestation over a 12-month period (April 2019-March 2020) compared with infants in the preceding 15-month period (January 2018-March 2019) as a baseline. METHODS The consensus guideline was introduced in clinical practice on 1 April 2019. It incorporated a modified SRC algorithm, enhanced in-hospital surveillance, ongoing quality assurance, standardised staff training and parent education. The main outcome measure was antibiotic usage/1000 live births, balancing this with analysis of harm from delayed diagnosis and treatment, disease severity and readmissions from true sepsis. Outcome measures were analysed using statistical process control charts. MAIN OUTCOME MEASURES Proportion of antibiotic use in infants ≥34 weeks' gestation. RESULTS 4304 (14.3%) of the 30 105 live-born infants received antibiotics in the baseline period compared with 1917 (7.7%) of 24 749 infants in the intervention period (45.5% mean reduction). All 19 infants with culture-positive sepsis in the postimplementation phase were identified and treated appropriately. There were no increases in sepsis-related neonatal unit admissions, disease morbidity and late readmissions. CONCLUSIONS This multicentre study provides evidence that a judicious adaptation of the SRC incorporating enhanced surveillance can be safely introduced in the National Health Service and is effective in reducing antibiotic use for EONS without increasing morbidity and mortality.
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Affiliation(s)
- Nitin Goel
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Gemma Davies
- Department of Neonatal Medicine, Singleton Hospital, Swansea, UK
| | | | | | - Artur Abelian
- Department of Paediatrics, Wrexham Maelor Hospital, Wrexham, UK
| | - Shakir Saeed
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Rhian Smith
- Department of Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Ravi Manikonda
- Department of Paediatrics, Nevill Hall Hospital, Abergavenny, UK
| | | | - Dawn Davies
- Department of Paediatrics, Bronglais General Hospital, Aberystwyth, Ceredigion, UK
| | - Rachel May Morris
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | - Lynsey Edwards
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Kate Creese
- Department of Paediatrics, Princess of Wales Hospital, Bridgend, UK
| | - Jane Jones
- Department of Paediatrics, Wrexham Maelor Hospital, Wrexham, UK
| | - Jalil Choudhary
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Sarah Rowley
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Helen Muxworthy
- Department of Women's Health, Singleton Hospital, Swansea, UK
| | - Felicity Curtis
- Department of Women's Health, Singleton Hospital, Swansea, UK
| | | | - Manohar Joishy
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Ian Barnard
- Department of Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Celyn Kenny
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | - Rajarshi Pal
- Department of Paediatrics, Glangwili General Hospital, Carmarthen, Carmarthenshire, UK
| | - Karen Jones
- Department of Paediatrics, Glangwili General Hospital, Carmarthen, Carmarthenshire, UK
| | - Sujoy Banerjee
- Department of Neonatal Medicine, Singleton Hospital, Swansea, UK
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Oshima Y, Tanaka S, Tsumura K, Tsuda S, So K, Shinagawa T, Yamasaki F, Kawaguchi A, Nomiyama M, Yokoyama M. Amniotic fluid Gram stain and interleukin-6 can predict early-onset neonatal sepsis. J Obstet Gynaecol Res 2020; 47:726-733. [PMID: 33314429 DOI: 10.1111/jog.14595] [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: 05/15/2020] [Revised: 10/12/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022]
Abstract
AIM To clarify whether amniotic fluid findings (Gram stain and interleukin [IL]-6 level) can predict early-onset neonatal sepsis (EONS) before delivery. METHODS We compared the sensitivity and specificity and the values of the area under the receiver-operating characteristic (AUROC) curve of maternal inflammatory responses and amniotic fluid findings using IL-6 and Gram stain to predict EONS. Patients who underwent amniocentesis for suspected intra-amniotic infection (IAI) after 22 weeks and 0 days of gestation and delivered on the same day at our hospital between January 2013 and December 2018 were included. RESULTS Out of 200 patients, EONS developed in 9 patients. The AUROC curves of maternal white blood cells count, C-reactive protein and body temperature were low (range, 0.6-0.7), whereas that of amniotic fluid IL-6 was high (0.90). Sensitivity and specificity for amniotic fluid findings were, respectively, 100% and 67% for IL-6 (cut-off value: 17.4 ng/mL) and 100% and 88% for the Gram stain; these values were superior to those of maternal inflammatory responses. When examining the accuracy of the amniotic fluid Gram stain separately before and after 34 gestation weeks, similar results were obtained. Amniotic fluid IL-6 before 34 gestation weeks showed specificity similar to that of the Gram stain; however, there were large differences in cut-off values based on gestational age. CONCLUSION Gram stain results of amniotic fluid can predict EONS with high sensitivity and specificity when IAI is suspected. False-negative amniotic fluid Gram stain results can be prevented by measuring amniotic fluid IL-6 simultaneously.
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Affiliation(s)
- Yuko Oshima
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Satoko Tanaka
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saga University, Saga, Japan
| | - Keisuke Tsumura
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Satoko Tsuda
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Kunio So
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Takaaki Shinagawa
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Fumio Yamasaki
- Department of Pathology, Japan Community Health Care Organization, Saga Central Hospital, Saga, Japan
| | - Atsushi Kawaguchi
- Center for Comprehensive Community Medicine Faculty of Medicine, Saga University, Saga, Japan
| | - Makoto Nomiyama
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Masatoshi Yokoyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saga University, Saga, Japan
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Pettinger KJ, Mayers K, McKechnie L, Phillips B. Sensitivity of the Kaiser Permanente early-onset sepsis calculator: A systematic review and meta-analysis. EClinicalMedicine 2020; 19:100227. [PMID: 32140666 PMCID: PMC7046522 DOI: 10.1016/j.eclinm.2019.11.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Determining which babies should receive antibiotics for potential early onset sepsis (EOS) is challenging. We performed a meta-analysis quantifying how many EOS cases might be 'missed' using the Kaiser Permanente electronic calculator, compared with National Institute for Health and Care Excellence (NICE) guidelines. METHODS A systematic literature search was carried out for studies citing the article in which the calculator was publicised. Studies were eligible if they presented data evaluating the calculator, either by retrospective case review or prospective cohort study. The primary outcome measure was numbers of culture positive EOS cases where the calculator did not recommend empirical antibiotics, but NICE guidelines would have. Data were pooled using a random effect meta-analysis. A subgroup analysis was performed using data from studies of babies exposed to chorioamnionitis. FINDINGS Eleven studies were included. There were a total of 75 EOS cases across the studies and a minimum of 14 (best case scenario), and a maximum of 22 (worst case scenario) cases where use of the calculator would have resulted in delayed or missed treatment, compared to if NICE guidelines had been followed. The probability of missed/delayed treatment for an EOS case were best case 0.19 [95% confidence intervals 0.11 - 0.29], worst case 0.31 [95% CI 0.17 - 0.49]. The probability of missing cases was significantly more in babies exposed to chorioamnionitis. INTERPRETATION A large proportion of EOS cases were 'missed' by the calculator. Further evaluation of the calculator is recommended before it is introduced into UK clinical practice. FUNDING None.
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Affiliation(s)
| | - Katie Mayers
- Leeds Centre for Newborn Care, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK
| | - Liz McKechnie
- Leeds Centre for Newborn Care, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington YO10 5DD, UK
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Deshmukh M, Mehta S, Patole S. Sepsis calculator for neonatal early onset sepsis - a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2019; 34:1832-1840. [PMID: 31352846 DOI: 10.1080/14767058.2019.1649650] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Over investigation and overuse of empirical antibiotics is a concern in management of neonatal early onset sepsis (EOS) using the Centers for Disease Control and Prevention guidelines. "Sepsis calculator" is a risk-based prediction model for managing neonates at risk of EOS. OBJECTIVE To compare outcomes of neonatal EOS using of sepsis calculator versus conventional approach. METHODS A systematic review of randomized controlled trials (RCT) and non-RCTs reporting on outcomes after implementation of sepsis calculator for EOS for neonates >34-week gestation was conducted using the Cochrane methodology. Databases PubMed, CINAHL, Embase, Cochrane Central library and Google Scholar were searched in May 2019. Primary outcomes were antibiotics usage and laboratory tests for managing EOS. Secondary outcomes included hospital admissions and readmissions, blood culture positive EOS and mortality. The level of evidence (LOE) was summarized using the GRADE guidelines. RESULTS A total of 387 articles were retrieved after initial search. Six high quality non-RCTs fulfilled inclusion criteria. Meta-analysis (random effects model) showed that implementation of sepsis calculator was associated with reduced antibiotic usage [N = 172,385; OR = 0.22 (0.14-0.36); p < .00001; heterogeneity (I2) = 97%, Number needed to treat (NNT): 22], laboratory tests [N = 168,432; OR = 0.14 (0.08-0.27); p < .00001; I2 = 99%, NNT = 8], and admissions to neonatal unit [N = 16,628; OR = 0.24 (0.11-0.51); p = .0002; I2 = 98%, NNT = 7]; LOE: moderate. There was no difference in mortality, culture positive EOS, and readmissions. CONCLUSION Moderate quality evidence indicates that the implementation of a sepsis calculator was associated with reduced usage of antibiotics, laboratory tests and admission to neonatal unit with no increase in mortality and readmissions.
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Affiliation(s)
- Mangesh Deshmukh
- Department of Neonatology, Fiona Stanley Hospital, Murdoch, Australia
| | - Shailender Mehta
- Department of Neonatology, Fiona Stanley Hospital, Murdoch, Australia
| | - Sanjay Patole
- Department of Neonatal Paediatrics, King Edward Memorial Hospital, Perth, Australia
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