Rehospitalization in the first two weeks after discharge from the neonatal intensive care unit

Resource and Service Use after Discharge Among Infants 22-25 Weeks Estimated Gestational Age at the First High-Risk Infant Follow-Up Visit in California

OBJECTIVE

To examine resource and service use after discharge among infants born extraordinarily preterm in California who attended high-risk infant follow-up (HRIF) clinic by 12 months corrected age.

STUDY DESIGN

We included infants born 2010-2017 between 22 + 0/7 and 25 + 6/7 weeks' gestational age in the California Perinatal Quality Care Collaborative and California Perinatal Quality Care Collaborative-California Children's Services HRIF databases. We evaluated rates of hospitalization, surgeries, medications, equipment, medical service and special service use, and referrals. We examined factors associated with receiving ≥ 2 medical services, and ≥ 1 special service.

RESULTS

A total of 3941 of 5284 infants received a HRIF visit by 12 months corrected age. Infants born at earlier gestational ages used more medications, equipment, medical services, and special services and had higher rates of referral to medical and special services at the first HRIF visit. Infants with major morbidity, surgery, caregiver concerns, and mothers with more years of education had higher odds of receiving ≥ 2 medical services. Infants with Black maternal race, younger maternal age, female sex, and discharge from lower level neonatal intensive care units (NICUs) had lower odds of receiving ≥ 2 medical services. Infants with more educated mothers, multiple gestation, major morbidity, surgery, caregiver concerns, and discharge from lower level NICUs had increased odds of receiving a special service.

CONCLUSIONS

Infants born extraordinarily preterm have substantial resource use after discharge. High resource utilization was associated with maternal/sociodemographic factors and expected clinical factors. Early functional and service use information is valuable to parents and underscores the need for NICU providers to appropriately prepare and refer families.

Readmission After Neonatal Intensive Care Unit Discharge: The Importance of Social Drivers of Health

OBJECTIVE

To determine associations between sociodemographic and medical factors and odds of readmission after discharge from the neonatal intensive care unit for infants with very low birth weight (<1500g).

STUDY DESIGN

Cohort study using linked data from the California Perinatal Quality Care Collaborative, California Vital Statistics, and the Child Opportunity Index (COI) 2.0. Infants with very low birth weight born from 2009 through 2018 in California were considered. Odds ratios of readmission within 30 days of discharge adjusting for infant medical factors, maternal sociodemographic factors, and birth hospital were calculated via multivariable logistic regression and fixed-effect logistic regression models.

RESULTS

A total of 42 411 infants met inclusion criteria. Also, 8.5% of all infants were readmitted within 30 days of discharge. In addition to traditional medical risk factors, two sociodemographic factors were significantly associated with increased odds of readmission in adjusted models: payor other than private insurance for delivery [aOR = 1.25 (95% CI 1.14-1.36)] and maternal education of less than high school degree [aOR = 1.19 (95% CI 1.06-1.33)]. Neighborhood Child Opportunity Index was not associated with odds of readmission.

CONCLUSIONS

Sociodemographic factors, including lack of private insurance and lower maternal educational attainment, are significantly and independently associated with increased odds of readmission after neonatal intensive care unit discharge, in addition to traditional medical risk factors. Socioeconomic deprivation and health literacy may contribute to risk of readmission. Targeted discharge interventions focused on addressing social drivers of health warrant exploration.

Increasing Exclusive Nursery Care of Late Preterm and Low Birth Weight Infants

BACKGROUND AND OBJECTIVE

Late preterm (LPT) and low birth weight (LBW) infants are populations at increased risk for NICU admission, partly due to feeding-related conditions. This study was aimed to increase the percentage of LPT and LBW infants receiving exclusive nursery care using quality improvement methodologies.

METHODS

A multidisciplinary team implemented interventions at a single academic center. Included infants were 35 to 36 weeks gestational age and term infants with birth weights <2500 g admitted from the delivery room to the nursery. Drivers of change included feeding protocol, knowledge, and care standardization. We used statistical process control charts to track data over time. The primary outcome was the percentage of infants receiving exclusive nursery care. Secondary outcomes included rates of hypoglycemia, phototherapy, and average weight loss. Balancing measures were exclusive breast milk feeding rates and length of stay.

RESULTS

Included infants totaled 1336. The percentage of LPT and LBW infants receiving exclusive nursery care increased from 83.9% to 88.8% with special cause variation starting 1 month into the postintervention period. Reduction in neonatal hypoglycemia, 51.7% to 45.1%, coincided. Among infants receiving exclusive nursery care, phototherapy, weight loss, exclusive breast milk feeding, and length of stay had no special cause variation.

CONCLUSIONS

Interventions involving a nursery feeding protocol, knowledge, and standardization of care for LPT and LBW infants were associated with increased exclusive nursery care (4.9%) and reduced rates of neonatal hypoglycemia (6.6%) without adverse effects. This quality initiative allowed for the preservation of the mother-infant dyad using high-value care.

Early Readmission following NICU Discharges among a National Sample: Associated Factors and Spending

OBJECTIVE

Infants admitted to the neonatal intensive care unit (NICU) are at increased likelihood of hospital readmission when compared with non-NICU admitted infants, resulting in appreciable financial and emotional burdens. Early readmission, days to weeks, following NICU discharge, may be preventable. Population-based data identifying potentially modifiable factors and spending associated with early readmission are lacking.

STUDY DESIGN

We conducted a secondary data analysis of privately insured infants in the IBM MarketScan Research Database born from 2011 to 2017 in all 50 states and admitted to the NICU. We examined demographic and clinical characteristics of early readmission within 7 days and between 8 and 30 days following NICU discharge and the payments of NICU and readmission care. Data were analyzed using univariate and multivariable logistic regression.

RESULTS

Of the 86,741 NICU survivors analyzed, 3,131 infants (3.6%) were readmitted by 7 days and 2,128 infants (2.5%) between 8 and 30 days. Preterm infants had reduced odds of readmission by 7 days compared with term infants. Infants transferred to a step-down facility (vs. discharge home) and those with congenital anomalies had higher independent odds of readmission by 7 and 8 to 30 days. A higher percentage of NICU infants within the lowest quartile of initial NICU length of stay (LOS) were readmitted by 7 days compared with NICU infants in the middle and highest LOS quartiles (64 vs. 36%, p < 0.01). Median payments of readmissions at 7 and 8 to 30 days was $12,785 and 14,380, respectively.

CONCLUSION

Being term, being transferred to a step-down facility, and having a congenital anomaly were risk factors for early readmission. Shorter initial NICU LOS may be a contributing factor to readmission by 7 days, especially among term infants. These findings identify factors associated with readmission with the hope of preventing early readmission, minimizing spending, and optimizing ideal timing of NICU discharge.

KEY POINTS

· Preterm infants were less likely than term infants to be readmitted within 7 days after discharge.. · Transferred infants had higher odds of readmission versus those who were discharged home.. · Payments for an average single NICU day were $1,000 less than for an average day of readmission..

Comparison of short-term outcomes of 35-weeks' gestation infants cared for in a level II NICU vs mother-baby, a retrospective study

BACKGROUND

Late preterm infants are at high risk for medical complications and represent a growing NICU population. While 34-weeks' gestation infants are generally admitted to the NICU and 36-weeks'gestation infants stay in mother-baby, there is wide practice variation for 35-weeks'gestation infants. The objective of this study was to compare short-term outcomes of 35-weeks' gestation infants born at two hospitals within the same health system (DUHS), where one (DRH) admits all 35-weeks' gestation infants to their level II NICU and the other (DUH) admits all 35-weeks' gestation infants to mother-baby, unless clinical concern.

METHODS

We conducted a retrospective cohort analysis of 35-weeks' gestation infants born at DUHS from 2014-2019. Infant specific data were collected for birth, demographics, medications, medical therapies, LOS, ED visits and readmissions. 35-weeks' gestation infants at each hospital (DRH vs DUH) that met inclusion criteria were compared, regardless of unit(s) of care.

RESULTS

726 infants of 35-weeks' gestation were identified, 591 met our inclusion criteria (DUH -462, DRH -129). Infants discharged from DRH were more likely to receive medical therapies (caffeine, antibiotics, blood culture, phototherapy, NGT), had a 4 day longer LOS, but were more likely to feed exclusively MBM at discharge. There were no differences in ED visits; however, more infants from DUH were readmitted within 30 days of discharge.

CONCLUSIONS

Our findings suggest admitting 35-weeks' gestation infants directly to the NICU increases medical interventions and LOS, but might reduce hospital readmissions.

Risk factors for hospital readmission among infants with prolonged neonatal intensive care stays

OBJECTIVE

To assess risk factors associated with 30-day hospital readmission after a prolonged neonatal intensive care stay.

STUDY DESIGN

Retrospective analysis of 57,035 infants discharged >14 days from the NICU between 2013 and 2016. Primary outcome was 30-day, all-cause hospital readmission. Adjusted likelihood of readmission accounting for demographic and clinical characteristics, including chronic conditions was also estimated.

RESULTS

The 30-day readmission rate was 10.7%. Respiratory problems accounted for most (31.0%) readmissions. In multivariable analysis, shunted hydrocephalus [OR 2.2 (95%CI 1.8-2.7)], gastrostomy tube [OR 2.0 (95%CI 1.8-2.3)], tracheostomy [OR 1.5 (95%CI 1.2-1.8)], and use of public insurance [OR 1.3 (95%CI 1.2-1.4)] had the highest likelihood of readmission. Adjusted hospital readmission rates varied significantly (p < 0.001) across hospitals.

CONCLUSIONS

The likelihood of hospital readmission was highest for infants with indwelling medical devices and public insurance. These findings will inform future initiatives to reduce readmission for high risk infants with medical and social complexity.

Health Equity and Disparities in ROP Care: A Need for Systematic Evaluation

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disorder that can have devastating visual sequelae if not managed appropriately. From an ophthalmology standpoint, ROP care is complex, since it spans multiple care settings and providers, including those in the neonatal intensive care unit (NICU), step down nurseries, and the outpatient clinic setting. This requires coordination and communication between providers, ancillary staff, and most importantly, effective communication with the patient's family members and caregivers. Often, factors related to the social determinants of health play a significant role in effective communication and care coordination with the family, and it is important for ophthalmologists to recognize these risk factors. The aim of this article is to (1) review the literature related to disparities in preterm birth outcomes and infants at risk for ROP; (2) identify barriers to ROP care and appropriate follow up, and (3) describe patient-oriented solutions and future directions for improving ROP care through a health equity lens.

The healthcare needs of preterm and extremely premature babies in Australia-assessing the long-term health service use and costs with a data linkage cohort study

The health conditions associated with extreme prematurity will likely require life-long treatment and management. As such, planning for the provision of healthcare services is essential in order to maximise their long-term well-being. We sought to quantify the use of healthcare services and the associated costs for extremely premature babies compared to preterm and term babies in Australia using a whole-of-population linked administrative dataset. In the first year of life, extremely premature babies had an average of 3.4 hospital admissions, and 2 emergency department presentations. They also had an average of 16 specialist attendances, 33 pathology tests and 6 diagnostic imaging tests performed. This was more than that utilised by preterm and full-term babies. The mean annual cost of hospitalisations was $182,312 for extremely premature babies in the first year and $9958 in the second year. The mean annual out-of-pocket fees for these services were $2212 and $121 in the first and second years respectively.Conclusion: Understanding the long-term healthcare needs of extremely premature babies in order to provide both an adequate number of services and also connection between services should be a central part of health system planning as the survival rates of extremely premature babies improve over time. What is Known: • The health service use of extremely premature babies is higher at the time of birth. • Health conditions and disabilities associated with extreme prematurity require life-long care. What is New: • Extremely premature babies have more diverse and frequent access to services than premature and term babies until at least age 2. • This comes at higher cost to families through out-of-pocket payments.

Follow-Up of Low Birth Weight Preterm Infants After Hospital Discharge: Incidence and Reasons for Rehospitalization

OBJECTIVES

The rehospitalization frequency/indications of low birth weight (LBW) preterms and the effect of rehospitalization on growth and neurodevelopment were investigated.

METHODS

LBW preterms discharged from NICU were prospectively followed until the corrected age of 1 year. Infants rehospitalized after discharge were defined as the study group and those not rehospitalized as the control group. The frequency, duration and etiology of rehospitalization were investigated and the effects of neonatal complications, surgery and socio-demographic status on rehospitalization were assessed.

RESULTS

The study and the control group included 113 and 217 infants, respectively. Infants in the study group were rehospitalized 247 times in total. Rehospitalization was significantly higher in the male gender (39.7% vs. 28.9%, p < 0.05). Hyperbilirubinemia-anemia, anemia-surgery and pulmonary-other infections were the most common indications for rehospitalization in the 0-14 days, 15 days to 2 months and 2-12 months, respectively. Intrauterine growth had no impact on rehospitalization. Somatic growth and neurodevelopment were significantly delayed in the study group (p < 0.05).

CONCLUSION

Birth weight and gestational week are the most important determinants of rehospitalization. Rehospitalized preterm infants have significant deficits in both somatic growth and neurodevelopment despite high-quality follow-up care.

Readmissions among NICU graduates: Who, when and why?

Readmission amongst previous neonatal intensive care unit (NICU) graduates, especially for preterm infants, is common and remains a significant risk for these infants beyond the neonatal period. This review explores risk factors for readmissions, common reasons for requiring rehospitalization and explores opportunities for improving the transition from discharge to home with the ultimate goal of reducing readmissions for these high risk infants.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status

OBJECTIVE

To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge.

STUDY DESIGN

This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37 weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5 days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors.

RESULTS

Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5 years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits.

CONCLUSIONS

Among immigrant mothers, non-English primary language, >5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Late preterm infants - Changing trends and continuing challenges

Late preterm infants, defined as newborns born between 340/7-366/7 weeks of gestational age, constitute a unique group among all premature neonates. Often overlooked because of their size when compared to very premature infants, this population is still vulnerable because of physiological and structural immaturity. Comprising nearly 75% of babies born less than 37 weeks of gestation, late preterm infants are at increased risk for morbidities involving nearly every organ system as well as higher risk of mortality when compared to term neonates. Neurodevelopmental impairment has especially been a concern for these infants. Due to various reasons, the rate of late preterm births continue to rise worldwide. Caring for this high risk population contributes a significant financial burden to health systems. This article reviews recent trends in regarding rate of late preterm births, common morbidities and long term outcomes with special attention to neurodevelopmental outcomes.

Late preterm: a new high risk group in neonatology

Late preterm infants are those infants born between 34 0/7 weeks through 36 6/7 week of gestation. These are physiologically less mature and have limited compensatory responses to the extrauterine environment compared with term infants. Despite their increased risk for morbidity and mortality, late preterm newborns are often cared in the well-baby nurseries of hospital after birth and are discharged from the hospital by 2-3 days of postnatal age. They are usually treated like developmentally mature term infants because many of them are of same birth weight and same size as term infants. There is a steady increase in the late preterm birth rate in last decade because of either maternal, fetal, or placental/uterine causes. There has been shift in the distribution of births from term and post-term toward earlier gestations. Although late preterm infants are the largest subgroup of preterm infants, there has been little research on this group until recently. This is mainly because of labeling them as "near-term". Such infants were being looked upon as "almost mature", and were thought as neonate requiring either no or minimal concern. In the obstetric and pediatric practice, late preterm infants are often considered functionally and developmentally mature and often managed by protocols developed for full-term infants. Thus, limited efforts are taken to prolong pregnancy in cases of preterm labor beyond 34 weeks, moreover after 34 weeks most centers do not administer antenatal prophylactic steroids. These practices are based on previous studies reporting neonatal mortality and morbidity in the late preterm period to be only slightly higher in comparison with term infants and whereas in the current scenario the difference is significant. Late preterm infants have 2-3-fold increased risk of morbidities such as hypothermia, hypoglycemia, delayed lung fluid clearance, respiratory distress, poor feeding, jaundice, sepsis, and readmission rates after initial hospital discharge. This leads to huge impact on the overall health care resources. In this review, we cover various aspects of these late preterm infants like etiology, immediate and long-term outcome.

Current practice in the introduction of solid foods for preterm infants

OBJECTIVE

The present study compared the age of first solid foods in a cohort of preterm infants with term infants and identified factors influencing timing of solid food introduction.

DESIGN

Structured interviews on infant feeding practices, growth and medical status at term equivalence and at 3, 6, 9 and 12 months corrected postnatal age. The age of solid food introduction was compared between term and preterm infants, and the influence of maternal, infant and milk feeding factors was assessed.

SETTING

This prospective longitudinal study recruited primary carers of preterm and term infants from a regional metropolitan referral hospital in eastern Australia.

PARTICIPANTS

One hundred and fifty infants (preterm, n 85; term, n 65).

RESULTS

When corrected for prematurity, preterm infants received solid foods before the recommended age for the introduction of solid foods for term infants. Median introduction of solid foods for preterm infants was 14 weeks corrected age (range 12-17 weeks). This was significantly less than 19 weeks (range 17-21 weeks) for term infants (P < 0·001). Lower maternal education and male gender were associated with earlier introduction of solid foods among preterm infants.

CONCLUSIONS

Preterm infants are introduced to solid foods earlier than recommended for term infants, taking account of their corrected age. Further research is needed to assess any risk or benefit associated with this pattern and thus to develop clear evidence-based feeding guidelines for preterm infants.

Characterizing Early State Regulation in Preterm Infants

OBJECTIVES

To characterize state regulation and behavior of preterm infants after discharge from the neonatal intensive care unit (NICU).

METHODS

We recruited singleton infants born at ≤35 weeks of gestational age (GA) before NICU discharge. Parents completed surveys at discharge and 1, 3, and 6 months after discharge. Infant medical history was gleaned from the medical record. Surveys captured sociodemographic information and measures of infant state regulation (Baby Pediatric Symptom Checklist [BPSC]) and feeding behaviors. We calculated the median BPSC subscale scores at each time point and the proportion of infants with scores in the problem range (≥3/5). We explored longitudinal and cross-sectional correlates of BPSC scores.

RESULTS

Fifty families completed the discharge questionnaire, and 42 (84%) completed the 6-month questionnaire. The median GA at birth was 34 weeks (IQR 30.1, 34.4 weeks); the median birth weight was 1930 g (IQR 1460, 2255 g). The median scores were above population norms for irritability and difficulty with routines. Twenty-one infants (40%) had irritability subscale scores in the problem range at 1 month, and 20 (38%) had problem scores on difficulties with routines. Only 9 infants (17%) had problem scores on the inflexibility subscale. Scores in all 3 domains showed different patterns from population norms from 1 to 6 months. BPSC scores were correlated with infant feeding behaviors at 1, 3, and 6 months.

CONCLUSION

Scores for irritability and difficulty with routines among preterm infants were high compared with population norms and differed from normative values through 6 months after discharge. Preterm infants demonstrate problems with state regulation after NICU discharge that may require directed intervention.

Late Preterm Infants: Morbidities, Mortality, and Management Recommendations

Infants born between 34 weeks 0 days and 36 weeks 6 days of gestation are termed late preterm. This group accounts for the majority of premature births in the United States, with rates increasing in each of the last 3 years. This increase is significant given their large number: nearly 280,000 in 2016 alone. Late preterm infants place a significant burden on the health care and education systems because of their increased risk of morbidities and mortality compared with more mature infants. This increased risk persists past the newborn period, leading to the need for continued health monitoring throughout life.

Antenatal and Intrapartum Risk Factors for Hypoxic-Ischemic Encephalopathy in a US Birth Cohort

OBJECTIVE

To identify risk factors for hypoxic-ischemic encephalopathy (HIE) within a recent US birth cohort.

STUDY DESIGN

In a retrospective cohort study of 44 572 singleton infants ≥36 weeks of gestation born at Kaiser Permanente Northern California in 2008-2015, we identified all infants with HIE based on the presence of 3 inclusion criteria: clinical signs of neonatal encephalopathy, NICU admission, and either a 10-minute Apgar of ≤5 or a base excess of ≤-15 mmol/L. Neonatal acidemia was defined as a base excess of ≤-12 mmol/L. We ascertained antenatal and intrapartum complications from electronic records. Multivariable analysis was performed using logistic regression.

RESULTS

There were 45 infants (1.0 per 1000) with HIE and 197 (4.4 per 1000) with neonatal acidemia. Of the infants with HIE, 64% had an intrapartum complication consisting of a sentinel event (36%), clinical chorioamnionitis (40%), or both (11%). Risk factors for HIE on multivariable analysis were sentinel event (relative risk [RR], 16.1; 95% CI, 8.4-33) and clinical chorioamnionitis (RR, 5.2; 95% CI, 2.7-9.9). After removing the 16 infants with HIE who were exposed to a sentinel event from multivariate analysis, maternal age of ≥35 years (RR, 2.5; 95% CI, 1.1-5.6) and a urinary tract infection during pregnancy (RR, 2.6; 95% CI, 1.0-6.5) emerged as potential antenatal risk factors for HIE.

CONCLUSIONS

A significant proportion of HIE is preceded by a sentinel event, emphasizing the importance of developing improved methodologies to predict and prevent this perinatal complication. Strategies focused on reducing other complications such as clinical chorioamnionitis and/or maternal pyrexia may also improve our ability to prevent HIE.

Immunization Completion in Infants Born at Low Birth Weight

BACKGROUND

Low birth weight (LBW) has been associated with underimmunization. We sought to understand the effect of LBW on immunization completion after controlling for previously hypothesized mediators, including prematurity, neonatal illness, well-child care, non-well-child visits, and provider consistency.

METHODS

We formed a retrospective cohort of infants born between 2008 and 2011 with ≥2 years of military healthcare follow-up. International Classification of Diseases, Ninth Revision codes were used to identify LBW, preterm birth, neonatal illnesses, well-child visits, non-well-child visits, provider consistency, and parental rank in the inpatient and outpatient records. Immunization records were extracted from both records. Logistic regression determined the odds of immunization completion and well-child care completion (ie, having had ≥6 WCC visits by 15 months of age).

RESULTS

Of 135964 included infants, 116521 (85.7%) were completely immunized at the age of 2 years. In adjusted analysis, the odds of immunization completion were significantly decreased in infants born at LBW (odds ratio [OR], 0.88 [95% confidence interval (CI), 0.79-0.97]), very LBW (OR, 0.61 [95% CI, 0.48-0.77]), or extremely LBW (OR, 0.45 [95% CI, 0.33-0.63]) or at ≤32 weeks' gestation (OR, 0.76 [95% CI, 0.63-0.92]), infants with chronic lung disease (OR, 0.63 [95% CI, 0.45-0.88]), male infants (OR, 0.96 [95% CI, 0.93-0.99]), and infants who experienced decreased provider consistency (OR, 0.92 [95% CI, 0.91-0.92]). The rate of immunization completion increased with the overall number of healthcare visits (OR, 1.02 [95% CI, 1.02-1.02]) and complete well-child care (OR, 1.80 [95% CI, 1.75-1.86]). However, children born LBW or preterm were significantly less likely to have complete well-child care.

CONCLUSIONS

After adjustment for preterm birth, comorbid neonatal conditions, and early childhood patterns of healthcare use, LBW was significantly associated with immunization noncompletion in a universal healthcare system. Provider consistency and well-child care seem important for increasing immunization completion in LBW infants.

Impact of NICU admission on Colorado-born late preterm infants: breastfeeding initiation, continuation and in-hospital breastfeeding practices

OBJECTIVE

Compare breastfeeding initiation and continuation rates, and in-hospital breastfeeding practices, of late preterm infants (LPIs) cared for in a NICU versus those cared for exclusively in the nursery (non-NICU).

STUDY DESIGN

Using data from the 2009-2014 Colorado Pregnancy Risk Assessment Monitoring System (PRAMS), breastfeeding initiation, continuation, and in-hospital breastfeeding practices of NICU versus non-NICU LPIs (34 0/7 to 36 6/7 weeks gestation, n = 20,767) were analyzed, and multivariate models were created controlling for maternal and infant characteristics.

RESULTS

Mothers of NICU LPIs were equally likely to initiate breastfeeding (APR 1.0; 95% CI 0.95-1.06) but less likely to continue breastfeeding at 10 weeks (APR 0.86; 95% CI 0.76-0.99) compared to mothers of non-NICU LPIs. Mothers of NICU LPIs were less likely to breastfeed in the hospital, less likely to be told to feed infants on demand, and more likely to be given a breast pump during hospitalization.

CONCLUSIONS

There are significant differences in both breastfeeding continuation and several in-hospital breastfeeding practices for NICU versus non-NICU LPIs. Further research is needed so that targeted policies and programs can be developed to improve breastfeeding rates in this vulnerable population.

Health Services Use by Late Preterm and Term Infants From Infancy to Adulthood: A Meta-analysis

CONTEXT

Late-preterm infants born at 34 to 36 weeks' gestation have increased risks of various health problems. Health service utilization (HSU) of late-preterm infants has not been systematically summarized before.

OBJECTIVES

To summarize the published literature on short- and long-term HSU by late-preterm infants versus term infants from infancy to adulthood after initial discharge from the hospital.

DATA SOURCES

We searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO.

STUDY SELECTION

Cohort and case-control studies that compared HSU (admissions, emergency department visits, etc) between late-preterm infants and term infants were included.

DATA EXTRACTION

Data extracted included study design, setting, population, HSU, covariates, and effect estimates.

RESULTS

Fifty-two articles were included (50 cohort and 2 case-control studies). Meta-analyses with random effect models that used the inverse-variance method found that late-preterm infants had higher chances of all-cause admissions than term infants during all the time periods. The magnitude of the differences decreased with age from the neonatal period through adolescence, with adjusted odds ratios from 2.34 (95% confidence intervals 1.19-4.61) to 1.09 (1.05-1.13) and adjusted incidence rate ratios from 2.62 (2.52-2.72) to 1.14 (1.11-1.18). Late-preterm infants had higher rates of various cause-specific HSU than term infants for jaundice, infection, respiratory problems, asthma, and neurologic and/or mental health problems during certain periods, including adulthood.

LIMITATIONS

Considerable heterogeneity existed and was partially explained by the variations in the adjustment for multiple births and gestational age ranges of the term infants.

CONCLUSIONS

Late-preterm infants had higher risks for all-cause admissions as well as for various cause-specific HSU during the neonatal period through adolescence.

Physical Growth, Morbidity Profile and Mortality Among Healthy Late Preterm Neonates

OBJECTIVE

To compare the physical growth outcomes, morbidity profile and mortality at an age of 12 months among late preterm (34 0/7to 36 6/7) neonates to term (37 0/7to 41 6/7) neonates.

STUDY DESIGN

Prospective cohort study.

SETTING

A tertiary care center of Northern India during 2014-2015.

PARTICIPANTS

200 apparently healthy late preterms and term infants, followed up to 12 months of age.

MAIN OUTCOME MEASURES

Physical growth parameters, morbidity profile and mortality.

RESULTS

At mean age of 12 months, mean (SD) weight, length and head circumference of late preterms were 7.4 (0.8) kg, 69.2 (2.5) cm and 43.0 (1.1) cm, respectively; which were significantly lower than that of the full term infants [8.7 (1.6) kg, 72.2 (3.1) cm and 44.2 (1.1) cm] (P< 0.001). On univariate analysis, late preterm group was associated with higher odds (95% CI) of being underweight [5.6 (3.4, 5.5)], stunted [3.5 (2.1, 5.8)] and wasted [3.6 (1.9, 6.9)]. On multivariate analysis, only adjusted odds of late preterms becoming underweight by one year was significant [OR 4.1; 95% CI (1.6, 10.4)]. Feeding difficulties, jaundice and re-hospitalization rates were significantly higher in the late preterm group. The median (IQR) episodes per baby for late preterms as compared to terms for diarrhea [1.84 (0,3) vs 1.14 (0,2) (P <0.001)], and fever [1.33 (0,2) vs. 0.95 (0,2) (P = 0.01)] were higher.

CONCLUSION

Healthy late preterms are at significantly higher risk of being underweight in the first year of life, in addition to having significantly higher morbidity.

The impact of preterm birth <37 weeks on parents and families: a cross-sectional study in the 2 years after discharge from the neonatal intensive care unit

BACKGROUND

Little is known about the quality of life of parents and families of preterm infants after discharge from the neonatal intensive care unit (NICU). Our aims were (1) to describe the impact of preterm birth on parents and families and (2) and to identify potentially modifiable determinants of parent and family impact.

METHODS

We surveyed 196 parents of preterm infants <24 months corrected age in 3 specialty clinics (82% response rate). Primary outcomes were: (1) the Impact on Family Scale total score; and (2) the Infant Toddler Quality of Life parent emotion and (3) time limitations scores. Potentially modifiable factors were use of community-based services, financial burdens, and health-related social problems. We estimated associations of potentially modifiable factors with outcomes, adjusting for socio-demographic and infant characteristics using linear regression.

RESULTS

Median (inter-quartile range) infant gestational age was 28 (26-31) weeks. Higher Impact on Family scores (indicating worse effects on family functioning) were associated with taking ≥3 unpaid hours/week off from work, increased debt, financial worry, unsafe home environment and social isolation. Lower parent emotion scores (indicating greater impact on the parent) were also associated with social isolation and unpaid time off from work. Lower parent time limitations scores were associated with social isolation, unpaid time off from work, financial worry, and an unsafe home environment. In contrast, higher parent time limitations scores (indicating less impact) were associated with enrollment in early intervention and Medicaid.

CONCLUSIONS

Interventions to reduce social isolation, lessen financial burden, improve home safety, and increase enrollment in early intervention and Medicaid all have the potential to lessen the impact of preterm birth on parents and families.

Impact of a Transition Home Program on Rehospitalization Rates of Preterm Infants

OBJECTIVES

To evaluate the effects of a transition home program on 90-day rehospitalization rates of preterm (PT) infants born at <37 weeks gestational age implemented over 3 years for infants with Medicaid and private insurance, and to identify the impact of social/environmental and medical risk factors on rehospitalization.

STUDY DESIGN

In this prospective cohort study of 954 early, moderate, and late PT infants, all families received comprehensive transition home services provided by social workers and family resource specialists (trained peers) working with the medical team. Rehospitalization data were obtained from a statewide database and parent reports. Group comparisons were made by insurance type. Regression models were run to identify factors associated with rehospitalization and duration of rehospitalization.

RESULTS

In bivariable analyses, Medicaid was associated with more infants hospitalized, more than 1 hospitalization, and more days of hospitalization. Early PT infants had more rehospitalizations by 90 days than moderate (P = .05) or late PT infants (P = .01). In regression modeling, year 3 of the transition home program vs year 1 was associated with a lower risk for rehospitalization by 90 days (OR, 0.57; 95% CI, 0.36-0.93; P = .03). Medicaid (P = .04), non-English-speaking (P = .02), multiple pregnancies (P = .05), and bronchopulmonary dysplasia (P = .001) were associated with increased risk. Both bronchopulmonary dysplasia and Medicaid were associated with increased days of rehospitalization in adjusted analyses. The major cause of rehospitalization was respiratory illness (61%).

CONCLUSIONS

Transition home prevention strategies must be directed at both social/environmental and medical risk factors to decrease the risk of rehospitalization.

Gestational age and 1-year hospital admission or mortality: a nation-wide population-based study

Background

Describe the 1-year hospitalization and in-hospital mortality rates, in infants born after 31 weeks of gestational age (GA).

Methods

This nation-wide population-based study used the French medico-administrative database to assess the following outcomes in singleton live-born infants (32–43 weeks) without congenital anomalies (year 2011): neonatal hospitalization (day of life 1 – 28), post-neonatal hospitalization (day of life 29 – 365), and 1-year in-hospital mortality rates. Marginal models and negative binomial regressions were used.

Results

The study included 696,698 live-born babies. The neonatal hospitalization rate was 9.8%. Up to 40 weeks, the lower the GA, the higher the hospitalization rate and the greater the likelihood of requiring the highest level of neonatal care (both p < 0.001). The relative risk adjusted for sex and pregnancy-related diseases (aRR) reached 21.1 (95% confidence interval [CI]: 19.2-23.3) at 32 weeks. The post-neonatal hospitalization rate was 12.1%. The raw rates for post-neonatal hospitalization fell significantly from 32 – 40 and increased at 43 weeks and this persisted after adjustment (aRR = 3.6 [95% CI: 3.3–3.9] at 32 and 1.5 [95% CI: 1.1–1.9] at 43 compared to 40 weeks). The main causes of post-neonatal hospitalization were bronchiolitis (17.2%), gastroenteritis (10.4%) ENT diseases (5.4%) and accidents (6.2%). The in-hospital mortality rate was 0.85‰, with a significant decrease (p < 0.001) according to GA at birth (aRR = 3.8 [95% CI: 2.4–5.8] at 32 and 6.6 [95% CI: 2.1–20.9] at 43, compared to 40 weeks.

Conclusion

There’s a continuous change in outcome in hospitalized infants born above 31 weeks. Birth at 40 weeks gestation is associated with the lowest 1-year morbidity and mortality.

Hospital-assisted home care after early discharge from a Swedish neonatal intensive care unit was safe and readmissions were rare

AIM

It is common in Sweden to discharge infants early from a neonatal intensive care unit (NICU) and provide hospital-assisted neonatal home care (HANHC), as an alternative to hospital care, for infants with a persisting need for specialised care. This study assessed the safety of HANHC by reviewing hospital readmissions.

METHODS

We retrospectively reviewed the files of all 1410 infants enrolled in HANHC at the NICU at Sachs' Children's Hospital, Stockholm, from 2002 to 2011 up until hospital readmission or their discharge from HANHC. Each readmitted infant was matched to the next HANHC infant who was not readmitted. Predictors and reasons for readmission were investigated in a retrospective nested case-control study.

RESULTS

We readmitted 74 (5.2%) of the 1410 infants in HANHC. Extremely preterm infants, born at less than 28 weeks, were readmitted more frequently than other infants, with an odds ratio of 6.07 (range 2.06-17.8). The most common symptoms were respiratory symptoms (55%), and viral respiratory tract infections were the most common reason (28%) for readmission.

CONCLUSION

HANHC was safe for the vast majority of infants (94.8%). Extremely preterm birth was identified as a predictor for hospital readmission. Further studies investigating the safety of HANHC in other settings would be valuable.

Supporting Parents of Premature Infants Transitioning from the NICU to Home: A Pilot Randomized Control Trial of a Smartphone Application

OBJECTIVE

To determine whether parents of Very Low Birth Weight (VLBW) infants in the Neonatal Intensive Care Unit (NICU) transitioning home with the NICU-2-Home smartphone application have greater parenting self-efficacy, are better prepared for discharge and have shorter length of stay (LOS) than control parents.

METHODS

A four-week pilot randomized controlled trial during the transition home with 90 VLBW parents randomized to usual care (n=44) or usual care plus NICU-2-Home (n=46), a smartphone application designed for VLBW parents. Parenting Sense of Competence Scale (PSOC) was assessed at baseline, day after discharge, and two weeks post-discharge. Preparedness for discharge and length of stay (LOS) were secondary outcomes. Analyses by usage were also included.

RESULTS

While parents of VLBW infants in the intervention group did not show an improvement in PSOC during the transition when compared directly to controls, after accounting for actual mean app usage, PSOC improved 7% (2.71 points/time greater; 95%CI = 1.45, 6.27) for intervention versus controls. Compared to controls, above-average users increased their PSOC score by 14% (6.84 points/time; 95%CL = 5.02, 8.67), average users by 11% (4.58 points/time; 95%CL = 2.89, 6.27) and below-average users by 6% (2.41 points/time; 95%CL = 0.04, 4.79). Moderate evidence showed LOS was shorter for above-average users compared to the control group (β = 12.2. SE = 6.9, p = 0.085).

CONCLUSION

A smartphone application used by parents of VLBW infants during the transition home from the NICU can improve parenting self-efficacy, discharge preparedness, and LOS with improved benefits based on usage.

Maturational, comorbid, maternal and discharge domain impact on preterm rehospitalizations: a comparison of planned and unplanned rehospitalizations

OBJECTIVE

To determine the predictive value of (1) maternal, (2) maturational, (3) comorbid and (4) discharge domains associated with preterm infant rehospitalization.

STUDY DESIGN

Retrospective, cohort study of preterm infants discharged home from a level IV neonatal intensive care unit. Rates of unplanned and planned 6-month readmissions were assessed. The four domains were modeled incrementally and separately to predict relative and combined contributions to the readmission risk.

RESULT

Out of 504 infants, 5% had 30-day readmissions (22 unplanned, three planned). By 6 months, 13% were rehospitalized (52 unplanned, 15 planned). Sixty-seven infants had 96 readmission events with 30% of readmission events elective. The four domains together predicted 78% of total 1-month, all 6-month and unplanned 6-month readmissions. Discharge complexity was as predictive as comorbidity in all models.

CONCLUSION

These four-domain models were more predictive than single domains. Many total readmission events were planned, suggesting parsing planned and unplanned rehospitalizations may benefit quality-improvement efforts.

Challenges, successes and opportunities for reducing readmissions in a referral-based children's hospital NICU

AIM

To evaluate readmission data in a level IV neonatal intensive care unit (NICU) to identify patient characteristics and process failures which serve as drivers for readmission.

METHODS

Our center is a primary referral center in Central and Southeast Ohio, providing us a unique opportunity to evaluate readmissions. We studied our current discharge process, caregiver perception of discharge readiness, parental comfort and the pre-discharge and post-discharge characteristics of infants.

RESULTS

Our readmission rate during the 4 year period has remained stable at 9.8%. 74% of the caregivers rated that their perception of their baby's medical readiness for discharge was good to excellent. Duration of hospitalization and public insurance coverage (Medicaid) were significant risk factors for readmission (p = 0.00). In our setting, the majority of the patients are readmitted through the emergency department and nearly half of all readmissions were for 3 or fewer days. Patients discharged from our Comprehensive Center for BPD had similar readmission rate despite characteristics which should increase their readmission rate.

CONCLUSIONS

Readmission rate is a poor indicator of the quality of care provided in the NICU. In addition to patient factors such as longer length of stay and Medicaid, our data suggests that preventing readmission depends on having systems in place to help families cope with transition of care after discharge.

Goniometer Measurements of Oral Labial Angle and Evaluation of Oral Motor Reflexes in Preterm Infants: Comparison to Findings in Term Infants

To date, no study has evaluated changes in oral labial angle as preterm infants mature. The main purpose of this study was to document goniometer measurements of the labial angle of the mouth in preterm infants, to assess changes with development, to compare to findings in healthy term infants, and also evaluate oral motor reflexes in these groups. Seventy-eight preterm infants and 45 healthy term infants were recruited for the prospective study. Labial angle was assessed via goniometer, and oral motor reflexes and the volume of milk ingested were evaluated. There was significant difference between term and preterm infants' labial angles (P < .01). The distribution of preterm infants' angles were similar to term infants' by 36 to 40 weeks' postmenstrual age. Goniometer measurements of the oral labial angle may reveal oral motor performance in preterm infants and may be relevant for feeding skills assessment in this group of infants.

Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome

OBJECTIVE

Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that may last for months. Our objective was to determine if infants with NAS are at increased risk for hospital readmission compared with uncomplicated term and late preterm newborns.

METHODS

In this longitudinal retrospective cohort study, administrative data were used for all births from 2006 to 2009 in the New York State Inpatient Database. We identified infants with NAS, born late preterm or uncomplicated term, as independent groups using diagnostic codes and determined readmission rates. We fit a multivariable logistic regression model with 30-day readmission after discharge as the outcome and infant characteristics, clinical morbidities, insurance type, and length of birth hospitalization as predictors.

RESULTS

From 2006 to 2009 in New York State, 700 613 infants were classified as uncomplicated term, 51 748 were born late preterm, and 1643 infants were diagnosed with NAS. After adjusting for confounders, infants with NAS (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.75-3.55) were more likely than uncomplicated term infants to be readmitted within 30 days of birth hospitalizations. The risk of readmission was similar to late preterm infants (OR 2.26, 95% CI 2.09-2.45). Length of birth hospitalization in days was inversely related to odds of being readmitted within 30 days of birth hospitalization (OR 0.94 95% CI 0.92-0.96).

CONCLUSIONS

When compared with uncomplicated term infants, infants diagnosed with NAS were more than twice as likely to be readmitted to the hospital. Future research and state-level policies should investigate means to mitigate risk of hospital readmission for infants with NAS.

Association of Gestational Age at Birth with Reasons for Subsequent Hospitalisation: 18 Years of Follow-Up in a Western Australian Population Study

Background

Preterm infants are at a higher risk of hospitalisation following discharge from the hospital after birth. The reasons for rehospitalisation and the association with gestational age are not well understood.

Methods

This was a retrospective birth cohort study of all live, singleton infants born in Western Australia between 1^st January 1980 and 31^st December 2010, followed to 18 years of age. Risks of rehospitalisation following birth discharge by principal diagnoses were compared for gestational age categories (<32, 32–33, 34–36, 37–38 weeks) and term births (39–41weeks). Causes of hospitalisations at various gestational age categories were identified using ICD-based discharge diagnostic codes.

Results

Risk of rehospitalisation was inversely correlated with gestational age. Growth-related concerns were the main causes for rehospitalisation in the neonatal period (<1 month of age) for all gestational ages. Infection was the most common reason for hospitalisation from 29 days to 1 year of age, and up to 5 years of age. Injury-related hospitalisations increased in prevalence from 5 years to 18 years of age. Risk of rehospitalisation was higher for all preterm infants for most causes.

Conclusions

The highest risks of rehospitalisation were for infection related causes for most GA categories. Compared with full term born infants, those born at shorter GA remain vulnerable to subsequent hospitalisation for a variety of causes up until 18 years of age.

Is preterm birth a human-specific syndrome?

Human preterm birth (PTB), a multifactorial syndrome affecting offspring born before 37 completed weeks of gestation, is the leading cause of newborn death worldwide. Remarkably, the degree to which early parturition contributes to mortality in other placental mammals remains unclear. To gain insights on whether PTB is a human-specific syndrome, we examined within- and between-species variation in gestation length across placental mammals and the impact of early parturition on offspring fitness. Within species, gestation length is normally distributed, and all species appear to occasionally give birth before the 'optimal' time. Furthermore, human gestation length, like that of many mammalian species, scales proportionally to body mass, suggesting that this trait, like many others, is constrained by body size. Premature humans suffer from numerous cognitive impairments, but little is known of cognitive impairments in other placental mammals. Human gestation differs in the timing of the 'brain growth spurt', where unlike many mammals, including closely related primates, the trajectory of human brain growth directly overlaps with the parturition time window. Thus, although all mammals experience early parturition, the fitness costs imposed by the cognitive impairments may be unique to our species. Describing PTB broadly in mammals opens avenues for comparative studies on the physiological and genetic regulators of birth timing as well as the development of new mammalian models of the disease.

Neonatal intensive care unit discharge of infants with cardiorespiratory events: Tri-country comparison of academic centers

OBJECTIVE

Compare how NICUs within academic centers in Canada, France, and the United States make discharge decisions regarding cardiorespiratory recordings and home use of apnea monitors, oximeters and caffeine.

STUDY DESIGN

An anonymous survey was sent to neonatologists through the member listserv of the American Academy of Pediatrics Section on Perinatal Pediatrics, the Canadian Fellowship Program Directory, and to Level 3 NICUs in France.

RESULTS

The response rates were 89% , 83% , and 79% for US, Canada and France respectively. In Canada, 45% perform pre-discharge recordings vs. 38% in France and 24% in the US. Apnea free days prior to discharge were required in 100% of centers in Canada, 96% in France, and 92% in the US. In Canada and France, 65% and 68% of units discharge patients on monitors vs. 99% in the US. 64% of the US centers sometimes use home caffeine compared to 40% in Canada and 34% in France. Over 60% of the centers in Canada and France wait until at least 40 weeks post menstrual age to discharge patients, whereas only about 33% of the US wait that late to discharge patients.

CONCLUSIONS

Discharge practices from NICUs are not well standardized across institutions or countries. Canada and France keep infants in the hospital longer and are less likely than the US to use home monitoring and home caffeine.

Hospital admissions and gestational age at birth: 18 years of follow up in Western Australia

BACKGROUND

Infants born moderate to late preterm are twice as likely to be rehospitalised within the first few weeks following discharge from the birth admission. It is not understood how rehospitalisation risk changes with age or how risks have changed over time.

METHODS

A retrospective birth cohort study of all live, singleton births in Western Australia 1 January 1980-31 December 2010, without congenital anomalies, followed to 18 years of age. Rehospitalisation rates for gestational age categories (<28, 28-31, 32-33, 34-36, 37-38 and ≥42 weeks) were compared with term births (39-41 weeks) using negative binomial regression. To assess whether rehospitalisation risk changed with age or over time, analyses were conducted for different age intervals and for 5-year birth cohorts.

RESULTS

Rehospitalisation rates were higher up to 18 years for all preterm and early term categories including early term (37-38 weeks) [130.2/1000 person-years at risk (pyr); 95% confidence interval 129.1, 131.4]; late preterm (34-36 weeks) (164.2/1000 pyr; 161.1, 167.4), and post-term (≥42 weeks) (115.3/1000 pyr; 111.7, 119.0) compared with term births (109.1/1000 pyr; 108.5, 109.7). The effect of gestational age on rehospitalisation was highest during the first year of life and declined by adolescence [e.g. 34-36 weeks: rate ratio = 2.10 (2.04, 2.15) for 29 days-1 year; 1.14 (1.11, 1.18) for 12-18 years]. The risk of rehospitalisation up to 1 year of age has declined since 1980, except for those born <32 weeks.

CONCLUSIONS

Rehospitalisation risk is greater for singleton children born at all gestational ages compared with those born full term. This effect of gestational age on rehospitalisation is highest in the first year post-discharge, but has almost disappeared by adolescence.

Intimate partner violence increases adverse outcomes at birth and in early infancy

OBJECTIVE

To determine the effect of intimate partner violence (IPV) on birth outcomes and infant hospitalization.

STUDY DESIGN

Hospitalization records for the first 4 months of life for infants born in the Military Health System in 2006-2007 were linked to Family Advocacy Program-substantiated cases of IPV among military parents. Adverse outcomes were identified using International Classification of Diseases, Ninth Revision codes. Logistic regression modeling calculated the OR of children exposed to IPV experiencing adverse outcomes.

RESULTS

A total of 204,546 infants were born during the study period. Among these, 173,026 infants (85%) were linked to active duty military parents. 31,603 infants (18%) experienced adverse outcomes, and 3059 infants (1.8%) were born into families with IPV. The infants exposed to IPV had a 31% increased odds of experiencing adverse outcomes compared with infants without known IPV exposure. IPV exposure increased the odds of the following outcomes: prematurity (OR, 1.45; 95% CI, 1.29-1.62), low birth weight (OR, 1.57; 95% CI, 1.25-1.97), respiratory problems (OR, 1.17; 95% CI, 1.04-1.32), neonatal hospitalization (OR, 1.39; 95% CI, 1.20-1.61), and postneonatal hospitalization (OR, 1.52; 95% CI, 1.29-1.81). After controlling for prematurity and demographic variables, IPV exposure was associated with low birth weight (OR, 1.52; 95% CI, 1.16-1.99), neonatal hospitalization (OR, 1.24; 95% CI, 1.02-1.49), and postneonatal hospitalization (OR, 1.27; 95% CI, 1.03-1.56).

CONCLUSION

Infants exposed to IPV are more likely to experience adverse birth outcomes and infant hospitalization. Routinely addressing IPV during prenatal and early pediatric visits may potentially prevent these adverse outcomes.

Neonatal intensive care unit to home: the transition from parent and pediatrician perspectives, a prospective cohort study

OBJECTIVES

To describe the experience of a low-income population during the transition from the neonatal intensive care unit (NICU) to home and to compare these experiences with pediatrician perspectives.

STUDY DESIGN

A prospective cohort study in a Level III, 40-bed NICU at a county hospital in Northern California affiliated with seven outpatient pediatric clinics. We surveyed parents in English or Spanish at discharge (n=79) and two weeks after discharge (n=49), along with outpatient pediatricians (n=17). Parents assessed experiences with discharge and the frequency with which barriers were encountered after discharge. We compared parent experiences with pediatrician estimates on four of these barriers.

RESULT

Spanish survey participants had more difficulty finding a NICU doctor (P=0.05) or nurse (P=0.001) to answer their questions. After discharge, 16% of families experienced significant challenges with two or more barriers. In contrast, the majority of pediatricians estimated that 50% or more families had significant challenges with all four barriers.

CONCLUSION

Communication difficulties were the most commonly reported barriers during the NICU stay and physicians overestimated the frequency that families experienced challenges after discharge. Parent input is important to create effective interventions aimed at improving care and limiting disparities.

Paternal and maternal concerns for their very low-birth-weight infants transitioning from the NICU to home

This study examines qualitatively the concerns and coping mechanisms of fathers and mothers of very low-birth-weight (VLBW; <1500 g) neonatal intensive care unit (NICU) infants as they transition to home from the NICU. In-depth, semistructured phone interviews were conducted with a sample of fathers and mothers of VLBW NICU infants in the Chicago area who had transitioned home, and parental concerns were examined during the transition to home. Phone interviews lasting 30 to 60 minutes were transcribed verbatim, and all interviews were coded using content and narrative analysis. Twenty-five parents (10 fathers, 15 mothers) of 16 VLBW infants who had an average gestational age of 29.5 weeks and an average NICU stay of 58.38 days completed the interview. Overriding concerns included pervasive uncertainty, lingering medical concerns, and partner-related adjustment concerns that differed by gender. A variety of resilient coping methods during this stressful transition are also described. Fathers and mothers of VLBW NICU graduates have evolving but often differing concerns as they transition from the NICU to home. Many of these concerns can be addressed with improved discharge information exchanges and anticipatory guidance. Supporting parents during this stressful and often difficult transition may lead to decreased family stress, improved care, and better infant outcomes.

Challenges to measuring variation in readmission rates of neonatal intensive care patients

OBJECTIVE

To examine the viability of a hospital readmission quality metric for infants requiring neonatal intensive care.

METHODS

Two cohorts were constructed. First, a cohort was constructed from infants born in California from 1995 to 2009 at 23 to 34 weeks' gestation, using birth certificates linked to maternal and infant inpatient records (N = 343,625). Second, the Medicaid Analytic eXtract (MAX) identified Medicaid-enrolled infants admitted to the neonatal intensive care unit (NICU) during their birth hospitalization in 18 states during 2006 to 2008 (N = 254,722). Hospital and state-level unadjusted readmission rates and rates adjusted for gestational age, birth weight, insurance status, gender, and common complications of preterm birth were calculated.

RESULTS

Within California, there were wide variations in hospital-level readmission rates that were not completely explained through risk adjustment. Similar unadjusted variation was seen between states using MAX data, but risk adjustment and calculation of hospital-level rates were not possible because of missing gestational age, birth weight, and birth hospital data.

CONCLUSIONS

The California cohort shows significant variation in hospital-level readmission rates after risk adjustment, supporting the premise that readmission rates of prematurely born infants may reflect care quality. However, state data do not include term and early term infants requiring neonatal intensive care. MAX allows for multistate comparisons of all infants requiring NICU care. However, there were extensive missing data in the few states with sufficient information on managed care patients to calculate state-level measures. Constructing a valid readmission measure for NICU care across diverse states and regions requires improved data collection, including potential linkage between MAX data and vital statistics records.

Rehospitalization during the first year of life by insurance status

OBJECTIVE

To assess the association of insurance status on infant rehospitalization in a population-based setting.

METHODS

In this longitudinal retrospective study, hospitalizations were tracked for 1 year after birth discharge for 203 031 infants born in hospitals during 2008 using data from the New York State Inpatient Database. Relative risk was estimated using multivariable negative binomial regression models.

RESULTS

Rehospitalization occurred in 9010 infants (4.4%). Medicaid coverage and being uninsured were strong predictors of rehospitalizations after adjustment for birth weight and other factors. Medicaid also bears a disproportionate share of the economic burden. Normal birth weight infants have the lowest risk, but comprise the majority of costs. Jaundice and acute bronchiolitis were the leading causes of rehospitalization within 30 days and 1 year, respectively.

DISCUSSION

Future research can explore the preventability of rehospitalizations, and evaluate novel strategies for discharge and postnatal care coordination especially for uninsured and Medicaid-enrolled infants.

N-gram support vector machines for scalable procedure and diagnosis classification, with applications to clinical free text data from the intensive care unit

BACKGROUND

Existing risk adjustment models for intensive care unit (ICU) outcomes rely on manual abstraction of patient-level predictors from medical charts. Developing an automated method for abstracting these data from free text might reduce cost and data collection times.

OBJECTIVE

To develop a support vector machine (SVM) classifier capable of identifying a range of procedures and diagnoses in ICU clinical notes for use in risk adjustment.

MATERIALS AND METHODS

We selected notes from 2001-2008 for 4191 neonatal ICU (NICU) and 2198 adult ICU patients from the MIMIC-II database from the Beth Israel Deaconess Medical Center. Using these notes, we developed an implementation of the SVM classifier to identify procedures (mechanical ventilation and phototherapy in NICU notes) and diagnoses (jaundice in NICU and intracranial hemorrhage (ICH) in adult ICU). On the jaundice classification task, we also compared classifier performance using n-gram features to unigrams with application of a negation algorithm (NegEx).

RESULTS

Our classifier accurately identified mechanical ventilation (accuracy=0.982, F1=0.954) and phototherapy use (accuracy=0.940, F1=0.912), as well as jaundice (accuracy=0.898, F1=0.884) and ICH diagnoses (accuracy=0.938, F1=0.943). Including bigram features improved performance on the jaundice (accuracy=0.898 vs 0.865) and ICH (0.938 vs 0.927) tasks, and outperformed NegEx-derived unigram features (accuracy=0.898 vs 0.863) on the jaundice task.

DISCUSSION

Overall, a classifier using n-gram support vectors displayed excellent performance characteristics. The classifier generalizes to diverse patient populations, diagnoses, and procedures.

CONCLUSIONS

SVM-based classifiers can accurately identify procedure status and diagnoses among ICU patients, and including n-gram features improves performance, compared to existing methods.

Readmission of Preterm Infants Less Than 32 Weeks Gestation Into Early Childhood: Does Gender Difference Still Play a Role?

The aim of the study was to investigate the frequency of and the predictors for rehospitalization in preterm infants into early childhood, focusing on gender differences. All preterm infants born at <32 weeks of gestation in North Tyrol between January 2003 and December 2005 were enrolled in this survey. About one fifth of all children were readmitted, showing an inverse downward trend with increasing age. The most common reason for readmission in the third (36.5%) and fourth (42.9%) years of life was respiratory infection, but changed to miscellaneous surgeries in the fifth (52.1%). Male sex showed significantly higher readmission rates and more miscellaneous surgeries. Additionally, male sex and chronic lung disease were risk conditions for rehospitalization in the multivariate analysis. Readmission rates and respiratory infections in preterm-born children showed an inverse downward trend with increasing age. In early childhood, gender difference still plays a role with regard to rehospitalization.

Epidemiology of moderate preterm, late preterm and early term delivery

Moderate preterm, late preterm, and early term deliveries represent a major and growing public health concern. These deliveries are associated with significant financial burden and pose serious risks to mothers and newborns. Women who deliver at moderate and late gestational ages in one pregnancy are at increased risk of delivering at these gestational ages, or earlier, in a subsequent pregnancy. Births in moderate preterm and late preterm gestational ages are associated with significant infant morbidity and mortality. Efforts to reduce deliveries in moderate preterm and late preterm gestations and interventions designed to ameliorate the problems in infants delivered at the gestational ages may be targets worthy of future investigation.

Hospital readmissions and emergency department visits in moderate preterm, late preterm, and early term infants

The increased vulnerability of late preterm infants is no longer a novel concept in neonatology, with many studies documenting excess morbidity and mortality in these infants during the birth hospitalization. Because outcomes related to gestational age constitute a continuum, it is important to analyze data from the gestational age groups that bookend late preterm infants infants-moderate preterm infants (31-32 weeks) and early term infants (37-38 weeks). This article evaluates hospital readmissions and emergency department visits in the first 30 days after discharge from birth hospitalization in a large cohort of infants greater than or equal to 31 weeks' gestation.

Hospitalization of early preterm, late preterm, and term infants during the first year of life by gestational age

OBJECTIVES

The goal of this study was to describe hospitalizations of infants during the first year of life according to week of gestational age (GA). We hypothesized that odds of any hospitalization would generally decrease with increasing GA, with late preterm infants experiencing additional increased risk of specific hospitalizations, such as hyperbilirubinemia.

METHODS

Birth certificates for > 6.6 million infants born in California hospitals between 1993 and 2005 and surviving to discharge were linked to hospital discharge records during the first year of life. Odds of any hospitalization and any hospitalization for specific diagnoses during the first year of life were determined for infants 23 to 44 weeks' GA. Further analysis determined odds of any hospitalization within 14, 30, and 90 days of birth discharge, and observed odds were compared with expected odds obtained through quadratic modeling.

RESULTS

Odds of any hospitalization within the first year of life decreased with advancing GA, but observed odds of any hospitalization exceeded expected odds for 35-, 36-, and 37-week GA infants for all time periods after discharge. Odds of any hospitalization for hyperbilirubinemia were greatest for infants 33 to 38 weeks' GA (peak odds ratio at 36 weeks' GA: 2.86 [95% confidence interval: 2.73-3.00]), and a relative peak in odds of any hospitalization for specific infections was observed among infants 33 to 36 weeks' GA.

CONCLUSIONS

Odds of any hospitalization during the first year of life exceeded expected odds of hospitalization for 35-, 36-, and 37-week GA infants. GAs at risk overlapped with, but were not identical to, GAs identified as late preterm infants.

Feeding Problems of NICU and PICU Graduates: Perceptions of Parents and Providers

There is little known about family experiences with pediatric feeding problems after NICU or PICU discharge. The study purposes were to better understand the family experiences with and consequences of feeding problems among NICU and PICU graduates after they transitioned home. Using a qualitative, descriptive design, 15 parents and 10 health professionals completed in-depth interviews. Data were analyzed using qualitative content analysis. Analysis revealed that feeding problems greatly impacted families. Education and resources were considered important, but generally insufficient. Though some parent-provider partnerships were strong, many others were not, and at-times, partnerships were fraught with conflict, communication problems, and lack of collaboration. System barriers and financial concerns escalated parents' distress, affecting their emotional responses. Parents' perceptions of discrepancies between their family situation and those of "normal" families violated their expectations. Understanding the perspectives of parents and providers regarding feeding problems common among NICU and PICU graduates is essential to developing effective interventions.

Changes in Oral Feeding in Preterm Infants Two Weeks After Hospital Discharge

The purpose of this analysis was to measure changes in preterm infant feeding skill between discharge and two weeks post-discharge. Data were from two samples - 22 preterm infants who participated in a non-experimental study of feeding readiness and 63 preterm infants who participated in a study of four oral feeding approaches. Both studies were approved by the institutional review board; parents gave informed consent. The Early Feeding Skills Assessment (EFSA) was used to measure feeding skills. Data were analyzed descriptively and by ANOVA and regression. Analysis revealed that feeding skills changed selectively from discharge to post-discharge and that discharge skills were predictive of post-discharge skill. Changes that occur in feeding skills during the immediate post-discharge period have received little attention from researchers. The findings suggest that enhanced pre-discharge assessment and parent teaching maybe necessary to reduce reported parental stress associated with feeding the newly discharged infant and to promote a positive feeding experience.

'The influence of gestational age and socioeconomic status on neonatal outcomes in late preterm and early term gestation: a population based study'

Background

Infants born late preterm (34 + 0 to 36 + 6 weeks GA (gestational age)) are known to have higher neonatal morbidity than term (37 + 0 to 41 + 6 weeks GA) infants. There is emerging evidence that these risks may not be homogenous within the term cohort and may be higher in early term (37 + 0 to 38 + 6 weeks GA). These risks may also be affected by socioeconomic status, a risk factor for preterm birth.

Methods

A retrospective population based cohort of infants born at 34 to 41 weeks of GA was assembled; individual and area-level income was used to develop three socioeconomic (SES) groups. Neonatal morbidity was grouped into respiratory distress syndrome (RDS), other respiratory disorders, other complications of prematurity, admission to a Level II/III nursery and receipt of phototherapy. Regression models were constructed to examine the relationship of GA and SES to neonatal morbidity while controlling for other perinatal variables.

Results

The cohort contained 25 312 infants of whom 6.1% (n = 1524) were born preterm and 32.4% (n = 8203) were of low SES. Using 39/40 weeks GA as the reference group there was a decrease in neonatal morbidity at each week of gestation. The odds ratios remained significantly higher at 37 weeks for RDS or other respiratory disorders, and at 38 weeks for all other outcomes. SES had an independent effect, increasing morbidity with odds ratios ranging from 1.2–1.5 for all outcomes except for the RDS group, where it was not significant.

Conclusions

The risks of morbidity fell throughout late preterm and early term gestation for both respiratory and non-respiratory morbidity. Low SES was associated with an independent increased risk. Recognition that the morbidities associated with prematurity continue into early term gestation and are further compounded by SES is important to develop strategies for improving care of early term infants, avoiding iatrogenic complications and prioritizing public health interventions.