American Academy of Pediatrics. Committee on Fetus and Newborn. Hospital stay for healthy term newborns

Association between Early Basal Ganglia and Thalami Perfusion Assessed by Color Doppler Ultrasonography and Brain Injury in Infants with Hypoxic-Ischemic Encephalopathy: A Prospective Cohort Study

OBJECTIVE

To evaluate associations between neurologic outcomes and early measurements of basal ganglia (BG) and thalamic (Th) perfusion using color Doppler ultrasonography (CDUS) in infants with hypoxic-ischemic encephalopathy (HIE).

STUDY DESIGN

Prospective study of infants with mild (n = 18), moderate (n = 17), and severe HIE (n = 14) and controls (n = 17). Infants with moderate-severe HIE received therapeutic hypothermia (TH). CDUS was performed at 24-36 hours and brain magnetic resonance imaging (MRI) at a median of 10 days. Development was followed through 2.5-5 years. The primary outcome was the association between BG and Th perfusion and brain MRI injury. Secondary analyses focused on associations between perfusion measurements and admission neurologic examinations, MRI scores in infants treated with TH, and motor and sensory disability, or death. An exploratory analysis assessed the accuracy of BG and Th perfusion to predict brain MRI injury in infants treated with TH.

RESULTS

Increased BG and Th perfusion on CDUS was observed in infants with severe MRI scores and those with significant motor and neurosensory disability or death through 2.5-5 years (P < .05). Infants with severe HIE showed increased BG and Th perfusion (P < .005) compared with infants with moderate HIE. No differences were identified between the between the control and mild HIE groups. Th perfusion ≥0.237 cm/second (Area under the curve of 0.824) correctly classified 80% of infants with severe MRI scores.

CONCLUSIONS

Early dynamic CDUS of the BG and Th is a potential biomarker of severe brain injury in infants with HIE and may be a useful adjunct to currently used assessments.

Management and Outcomes of Esophageal Atresia With or Without Tracheo-Esophageal Fistula Over 15 Years in South Africa

INTRODUCTION

To determine the incidence, management and outcomes of esophageal atresia/tracheo-esophageal fistula (EA/TEF) over a 15-y period in South Africa.

METHODS

A retrospective chart review of neonates with EA/TEF presenting at the main tertiary referral hospital in the KwaZulu-Natal province between 2002 and 2017 was conducted. Data collection comprised patient and maternal demographics, clinical presentations, laboratory and radiologic investigations, surgical procedures, and outcomes. A multivariate logistic regression determined the risk factors associated with mortality.

RESULTS

Among 180 neonates, mean (SD) age of diagnosis was four (three) days postnatal with Gross Type C (n = 165, 92%) being the most common and the incidence was one per 10,000 live births. Majority were born term (n = 95, 53%) at peripheral hospitals (n = 167, 93%) with a mean birth weight of 2369 (736) grams. Overall HIV exposure rate was 27% (n = 48). Most (n = 138, 77%) patients presented with established pneumonia, 44% (n = 61) of whom required prolonged (>7 d) ventilator support. The median (IQR) hospital stay was 11 (8-20) d. Overall survival rate was 70% (n = 126). Birth weight <1500 g, life threatening anomalies, ventilation >30 d and postoperative sepsis contributed to mortality.

CONCLUSIONS

Incidence, disease types and presentations were similar to developed countries. Despite advances in technology and neonatal care in Africa, EA/TEF surgical outcomes remain suboptimal likely due to caregivers' inability to care for these infants in disadvantaged socioeconomic circumstances with poor sanitation, etc. Research is needed to identify strategies tailored for disadvantaged communities which may contribute to improved outcomes in the perioperative and postoperative period.

Anorectal Malformations: The Pivotal Role of the Good Clinical Practice

Anorectal malformations (ARM) without a fistula are a rare congenital condition. Although may seem more simple to repair compared with ARM with fistulas, surgery has proved to be challenging. We report the case of a newborn who presented a well-formed anus and normal genitalia; a blind-ending anal canal was detected after the insertion of a rectal probe, thus allowing the diagnosis of ARM. Anal probing straight after birth avoids the possible complications related to intestinal obstruction due to a missed diagnosis of ARM. Examination of the perineal region is an important step in the evaluation of the newborn and represents the tool for a prompt identification of ARM. Adding anal probing to accurate inspection perineum is a good clinical practice and should always be performed even in presence of a normal-looking perineum.

Providers' Perspectives Related to Parents' Choice of Pediatric Provider of Record and Newborn Screening: A Qualitative Study

The pediatric provider of record has a significant role in newborn screening and maintaining infant health after birth. Procedural errors and delays in communication can hinder the identification of infants with critical illnesses or follow up of unsatisfactory NBS samples. For this study, key stakeholders, including nurses, physicians, and midwives were interviewed to understand how the pediatric provider of record is selected by parents and examine factors affecting the newborn screening education and processes in the perinatal period. Provider responsibilities, timing of parent education, and social determinants of health played a role in parents' choices of the pediatric provider. Investment in future intervention programs is needed for reducing the number of infants without a designated pediatric provider of record. Research is needed to understand social complexities and healthcare systems which affect parents' choices of pediatric providers and newborn screening processes to optimize clinical outcomes for infants.

Efficacy and Safety Concerns with Sn-Mesoporphyrin as an Adjunct Therapy in Neonatal Hyperbilirubinemia: A Literature Review

Neonatal hyperbilirubinemia is a frequently observed clinical situation that, sometimes, may result in complications ranging from mild neurodevelopment impairment to serious outcome of kernicterus. The rationale logic of heme oxygenase enzyme inhibition to lower bilirubin levels is intriguing. In compliance with that rationale, metalloporphyrin was discovered. After successful results in in-vitro and animal studies, tin mesoporphyrin is now under phase II clinical trial to test for preventive and therapeutic efficacy in unconjugated hyperbilirubinemia. This review evaluates in-vitro studies, animal studies, and clinical trials for the efficacy and safety of tin analogues of metalloporphyrin. Few alternatives to metalloporphyrins are also available, synchronizing with the same rationale logic of inhibition of bilirubin production, which need further research.

Incidence, Risk Factors, and Reasons for 30-Day Hospital Readmission Among Healthy Late Preterm Infants

OBJECTIVE

Late preterm infants have an increased risk of morbidity relative to term infants. We sought to determine the rate, temporal trend, risk factors, and reasons for 30-day readmission.

METHODS

This is a retrospective cohort study of infants born at 34 to 42 weeks' gestation in California between January 1, 2011, and December 31, 2017. Birth certificates maintained by California Vital Statistics were linked to discharge records maintained by the California Office of Statewide Health Planning and Development. Multivariable logistic regression was used to identify risk factors and derive a predictive model.

RESULTS

Late preterm infants represented 4.3% (n = 122 014) of the study cohort (n = 2 824 963), of which 5.9% (n = 7243) were readmitted within 30 days. Compared to term infants, late preterm infants had greater odds of readmission (odds ratio [OR]: 2.34 [95% confidence interval (CI): 2.28-2.40]). The temporal trend indicated increases in all-cause and jaundice-specific readmission infants (P < .001). The common diagnoses at readmission were jaundice (58.9%), infections (10.8%), and respiratory complications (3.5%). In the adjusted model, factors that were associated with greater odds of readmission included assisted vaginal birth, maternal age ≥34 years, diabetes, chorioamnionitis, and primiparity. The model had predictive ability of 60% (c-statistic 0.603 [95% CI: 0.596-0.610]) in late preterm infants who had <5 days length of stay at birth.

CONCLUSION

The findings contribute important information on what factors increase or decrease the risk of readmission. Longitudinal studies are needed to examine promising hospital predischarge and follow-up care practices.

Clinical Differentiation between a Normal Anus, Anterior Anus, Congenital Anal Stenosis, and Perineal Fistula: Definitions and Consequences—The ARM-Net Consortium Consensus

In the past, an anteriorly located anus was often misdiagnosed and treated as an anorectal malformation (ARM) with a perineal fistula (PF). The paper aims to define the criteria for a normal anus, an anterior anus (AA) as an anatomic variant, and milder types of ARM such as congenital anal stenosis (CAS) and PF. An extensive literature search was performed by a working group of the ARM-Net Consortium concerning the subject “Normal Anus, AA, and mild ARM”. A consensus on definitions, clinical characteristics, diagnostic management, and treatment modalities was established, and a diagnostic algorithm was proposed. The algorithm enables pediatricians, midwives, gynecologists, and surgeons to make a timely correct diagnosis of any abnormally looking anus and initiate further management if needed. Thus, the routine physical inspection of a newborn should include the inspection of the anus and define its position, relation to the external sphincter, and caliber. A correct diagnosis and use of the presented terminology will avoid misclassifications and allow the initiation of correct management. This will provide a reliable comparison of different therapeutic management and outcomes of these patient cohorts in the future.

Readmission of late preterm and term neonates in the neonatal period

OBJECTIVE

To determine the incidence of hospital readmissions in late preterm and term neonates, the most common reasons for readmission, and analyze the risk factors for readmission in the neonatal period.

METHODS

Newborn infants admitted to a well-baby nursery ≥ 36 weeks gestation were included in this retrospective cohort study. Data for all infants born in a 3-year period and readmitted in the first 28 days of life were analyzed. Indication for readmission was one diagnosed during initial workup in the pediatric emergency room visit before readmission.

RESULTS

The final cohort consisted of 5408 infants. The readmission rate was 4.0% (219/5408). Leading readmission causes were respiratory tract infection (29.58%), jaundice (13.70%), and urinary tract infection (9.59%). The mean ± SD age of readmitted infants was 13.3 ± 7.1 days. The mean ± SD treatment duration of treatment was 5.5 ± 3.0 days. In the multivariate regression analysis, infants that were during the initial hospitalization transferred to special care/NICU had a lower chance of readmission during the neonatal period (p = 0.04, OR = 0.23, 95% CI 0.06-0.93). Infants with mothers aged from 19-24 years had a higher risk of readmission (p = 0.005, OR = 1.62, 95% CI 1.16-2.26).

CONCLUSIONS

Finding that infants that were during the initial hospitalization transferred to special care or a NICU setting were less likely to require hospitalization in the neonatal period is an interesting one. Further research into how different approach in these settings reduce the risk of readmission is necessary.

Ratio of cord blood bilirubin and albumin as predictors of neonatal hyperbilirubinaemia

Aim of the study

To compare cord blood albumin (CBA) and cord blood bilirubin (CBB) at birth as predictors for development of neonatal hyperbilirubinaemia.

Material and methods

CBA and CBB of 388 healthy term neonates born by lower segment caesarean section (LSCS) were determined at birth and transcutaneous bilirubin (TCB) was measured every 12 hours from birth until 7 days of life or development of hyperbilirubinaemia requiring phototherapy.

Results

The cut-off value of CBB and CBA as obtained by the receiver operating characteristic (ROC) curve was 1.90 mg/dl and 3.17 g/dl respectively. The sensitivity, specificity and positive predictive value (PPV) for CBB were 97.4%, 40.6% and 71.09% while for CBA they were 40.8%, 34.8% and 48.41%. The cut-off value for CBB/CBA ratio was 0.719 as obtained by the ROC curve and was determined to have 97.4% sensitivity, 62.6% specificity and a PPV of 79.61%.

Conclusions

CBB/CBA is a better indicator compared to CBA and CBB alone for prediction of neonatal hyperbilirubinaemia.

The Impact of COVID-19 Infection on Labor and Delivery, Newborn Nursery, and Neonatal Intensive Care Unit: Prospective Observational Data from a Single Hospital System

OBJECTIVE

Since its emergence in late 2019, severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the novel coronavirus that causes novel coronavirus disease 2019 (COVID-19), has spread globally. Within the United States, some of the most affected regions have been New York, and Northern New Jersey. Our objective is to describe the impact of COVID-19 in a large delivery service in Northern New Jersey, including its effects on labor and delivery (L&D), the newborn nursery, and the neonatal intensive care unit (NICU).

MATERIALS AND METHODS

Between April 21, 2020 and May 5, 2020, a total of 78 mothers (3.6% of deliveries) were identified by screening history or examination to either be COVID-19 positive or possible positives (persons under investigation). Of the mothers who were tested after admission to L&D, 28% tested positive for SARS-CoV-2.

DISCUSSION

Isolation between mother and infant was recommended in 62 cases, either because the mother was positive for SARS-CoV-2 or because the test was still pending. Fifty-four families (87%) agreed to isolation and separation. The majority of infants, 51 (94%), were initially isolated on the newborn nursery. Six needed NICU admission. No infants had clinical evidence of symptomatic COVID-19 infection. Fourteen infants whose mothers were positive for SARS-CoV-2, and who had been separated from the mother at birth were tested for SARS-CoV-2 postnatally. All were negative.

RESULTS

COVID-19 posed a significant burden to mothers, infants, and staff over the 5-week study period. The yield from screening mothers for COVID-19 on L&D was high. Most families accepted the need for postnatal isolation and separation of mother and newborn.

CONCLUSION

Our study suggests that the transmission of SARS-CoV-2 from mother to her fetus/newborn seems to be uncommon if appropriate separation measures are performed at birth.

KEY POINTS

· The yield of targeted testing for SARS-CoV-2, on mothers on Labor and Delivery is high.. · Agreement to separation of mothers and infants to reduce transmission of SARS-CoV-2 was high.. · The incidence of symptomatic COVID-19 in newborns is low, if appropriate separation occurs at birth..

Pre-discharge Cardiorespiratory Monitoring in Preterm Infants. the CORE Study

Objective: Ensuring cardiorespiratory (CR) stability is essential for a safe discharge. The aim of this study was to assess the impact of a new pre-discharge protocol named CORE on the risk of hospital readmission (RHR). Methods: Preterm infants admitted in our NICU between 2015 and 2018 were randomly assigned to CORE (exposed) or to standard (not-exposed) discharge protocol. CORE included 24 h-clinical observation, followed by 24 h-instrumental CR monitoring only for high-risk infants. RHR 12 months after discharge and length of stay represent the primary and secondary outcomes, respectively. Results: Three hundred and twenty three preterm infants were enrolled. Exposed infants had a lower RHR (log-rank p < 0.05). The difference was especially marked 3 months after discharge (9.09 vs. 21.6%; p = 0.004). The hospital length of stay in exposed and not-exposed infants was 39(26-58) and 43(26-68) days, respectively (p = 0.16). Conclusions: The CORE protocol could help neonatologists to define the best timing for discharge reducing RHR without lengthening hospital stay.

Adherence to AAP Healthy Newborn Discharge Criteria in a Tertiary Care Children's Hospital

OBJECTIVES

In 2015, the American Academy of Pediatrics (AAP) published an updated consensus statement containing 17 discharge recommendations for healthy term newborn infants. In this study, we identify whether the AAP criteria were met before discharge at a tertiary care academic children's hospital.

METHODS

A stratified random sample of charts from newborns who were discharged between June 1, 2015, and May 31, 2016, was reviewed. Of the 531 charts reviewed, 433 were included in the study. A review of each chart was performed, and data were collected.

RESULTS

Descriptive statistics for our study population (N = 433) revealed that all 17 criteria were followed <5% of the time. The following criteria were met 100% of the time: clinical course and physical examination, postcircumcision bleeding, availability of family members or health care providers to address follow-up concerns, anticipatory guidance, first appointment with the physician scheduled or parents knowing how to do so, pulse oximetry screening, and hearing screening. These criteria were met at least 95% to 99% of the time: appropriate vital signs, regular void and stool frequency, appropriate jaundice and sepsis management, and metabolic screening. The following criteria were met 50% to 95% of the time: maternal serologies, hepatitis B vaccination, and social risk factor assessment. Four of the criteria were met <50% of the time: feeding assessment, maternal vaccination, follow-up timing for newborns discharged at <48 hours of life, and car safety-seat assessment.

CONCLUSIONS

Our data reveal that the AAP healthy term newborn discharge recommendations are not consistently followed in our institution.

Parental Management of Discharge Instructions: A Systematic Review

CONTEXT

Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review.

OBJECTIVE

To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.

DATA SOURCES

We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).

STUDY SELECTION

We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.

DATA EXTRACTION

Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.

RESULTS

Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0).

LIMITATIONS

The studies were primarily observational in nature.

CONCLUSIONS

Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

Effect of Temperature on Heart Rate Variability in Neonatal ICU Patients With Hypoxic-Ischemic Encephalopathy

OBJECTIVE

To determine whether measures of heart rate variability are related to changes in temperature during rewarming after therapeutic hypothermia for hypoxic-ischemic encephalopathy.

DESIGN

Prospective observational study.

SETTING

Level 4 neonatal ICU in a free-standing academic children's hospital.

PATIENTS

Forty-four infants with moderate to severe hypoxic-ischemic encephalopathy treated with therapeutic hypothermia.

INTERVENTIONS

Continuous electrocardiogram data from 2 hours prior to rewarming through 2 hours after completion of rewarming (up to 10 hr) were analyzed.

MEASUREMENTS AND MAIN RESULTS

Median beat-to-beat interval and measures of heart rate variability were quantified including beat-to-beat interval SD, low and high frequency relative spectral power, detrended fluctuation analysis short and long α exponents (αS and αL), and root mean square short and long time scales. The relationships between heart rate variability measures and esophageal/axillary temperatures were evaluated. Heart rate variability measures low frequency, αS, and root mean square short and long time scales were negatively associated, whereas αL was positively associated, with temperature (p < 0.01). These findings signify an overall decrease in heart rate variability as temperature increased toward normothermia.

CONCLUSIONS

Measures of heart rate variability are temperature dependent in the range of therapeutic hypothermia to normothermia. Core body temperature needs to be considered when evaluating heart rate variability metrics as potential physiologic biomarkers of illness severity in hypoxic-ischemic encephalopathy infants undergoing therapeutic hypothermia.

Delayed diagnosis: An important prognostic factor for oesophageal atresia in developing countries

AIM

The aim of this study is to analyse the effect of delayed diagnosis on mortality rates, and evaluate the role of delayed diagnosis as a new prognostic factor in patients with oesophageal atresia (OA), especially in developing countries.

METHODS

The records of 80 consecutive patients with OA (2008-2013) were reviewed. Patients were divided into two groups according to the time of diagnosis. As we demonstrated the effect of delayed diagnosis on mortality, we decided to develop a new classification that will be utilised to predict the prognosis of OA. The discrimination ability of the new prognostic classification was compared with those of the Waterston, Montreal and Spitz classifications using the area under the curve.

RESULTS

The parameters of the new prognostic classification were birth weight less than 2000 g, the presence of major cardiac/life-threatening anomalies and delay in diagnosis. Class I consisted of patients with none or one of these parameters. Class II consisted of patients with two or three of these parameters. The area under the curve of the new classification was better than those of the other classifications in determining the prognosis of patients with OA.

CONCLUSIONS

Delayed diagnosis of OA significantly led to morbidity and mortality. Although delayed diagnosis is not a characteristic of newborn or a marker of severity for OA and is a health care system issue in developing countries, we here point out that it is a prognostic factor in its own right. Our new classification has a superior discriminatory ability compared to the above-mentioned classifications.

Early discharge following birth - What characterises mothers and newborns?

BACKGROUND

Early postnatal discharge has increased over the past 50 years and today we lack the knowledge on who is discharged early that would allow us to improve quality of postnatal care. The aim of this study was to describe maternal and infant predictors for early postnatal discharge in a country with equal access to health care.

METHODS

An observational study of 2786 mothers, recruited in pregnancy was conducted from April 2013 to August 2014 in four of the five regions in Denmark. Data were analysed using Kaplan-Meier method and multinomial regression models. Outcome variable was time of discharge after birth.

RESULTS

In total 34% mothers were discharged within 12 hours (very early) and 25% between 13 and 50 hours (early), respectively. Vaginal birth and multiparity were the most influential predictors, as Caesarean section compared to vaginal birth had an OR of 0.35 (CI 0.26-0.48) and primiparous compared to multiparous had an OR of 0.22 (CI 0.17-0.29) for early discharge. Other predictors for early discharge were: no induction of labour, no epidural painkiller, bleeding less than 500 ml during delivery, higher gestational age, early expected discharge and positive breastfeeding experience. Smoking, favourable social support and breastfeeding knowledge were significantly associated with discharge within 12 hours. Finally time of discharge varied significantly according to region and time of day of birth.

CONCLUSIONS

Parity and birth related factors were the strongest predictors of early discharge. Psycho-social predictors indicate that the parents are involved in the decision of when to be discharge.

Is pre-discharge echocardiography indicated for asymptomatic neonates with a heart murmur? A retrospective analysis

OBJECTIVE

The purpose of this study was to determine whether a murmur detected on routine pre-discharge examination of asymptomatic newborn children in the first 48 hours of life warrants further investigation with echocardiography.

METHODS

We conducted a retrospective review of all echocardiography studies of neonates born at Jordan University Hospital between August, 2007 and June, 2014. Findings on physical examination as well as the indication of the echocardiographic studies were reviewed. We included asymptomatic neonates for whom echocardiographic studies were carried out due to the sole indication of a heart murmur on routine pre-discharge neonatal physical examination.

RESULTS

Of 309 asymptomatic newborns with murmurs on pre-discharge examination, echocardiography revealed 68 (22%) cases of CHD, with 18 (6%) designated as significant heart disease with anticipated intervention during infancy or childhood. The most common abnormality was ventricular septal defect occurring in 36 cases. Critical heart diseases detected included hypoplastic left heart syndrome in two and aortic valve stenosis in four newborns.

CONCLUSIONS

Although most asymptomatic neonates with heart murmurs have normal hearts, a small percentage may have significant heart disease. The decision to refer an asymptomatic newborn with a murmur for echocardiography before discharge from the hospital remains controversial and must be supported by other evidence such as murmur characteristics and local trends in parental compliance with follow-up well-baby visits.

Unconditional Prenatal Income Supplement and Birth Outcomes

BACKGROUND AND OBJECTIVES

Perinatal outcomes have improved in developed countries but remain poor for disadvantaged populations. We examined whether an unconditional income supplement to low-income pregnant women was associated with improved birth outcomes.

METHODS

This study included all mother-newborn pairs (2003-2010) in Manitoba, Canada, where the mother received prenatal social assistance, the infant was born in the hospital, and the pair had a risk screen (N = 14 591). Low-income women who received the income supplement (Healthy Baby Prenatal Benefit [HBPB], n = 10 738) were compared with low-income women who did not receive HBPB (n = 3853) on the following factors: low birth weight, preterm, small and large for gestational age, Apgar score, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from risk screens were used to develop propensity scores and to balance differences between groups in regression models; γ sensitivity analyses were conducted to assess sensitivity to unmeasured confounding. Population-attributable and preventable fractions were calculated.

RESULTS

HBPB was associated with reductions in low birth weight (aRR, 0.71 [95% CI, 0.63-0.81]), preterm births (aRR, 0.76 [95% CI, 0.69-0.84]) and small for gestational age births (aRR, 0.90 [95% CI, 0.81-0.99]) and increases in breastfeeding (aRR, 1.06 [95% CI, 1.03-1.09]) and large for gestational age births (aRR, 1.13 [95% CI, 1.05-1.23]). For vaginal births, HBPB was associated with shortened LOS (weighted mean, 2.86; P < .0001). Results for breastfeeding, low birth weight, preterm birth, and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI, 13.6-28.3) for low birth weight births and 17.5% (95% CI, 11.2-23.8) for preterm births were associated with HBPB.

CONCLUSIONS

Receipt of an unconditional prenatal income supplement was associated with positive outcomes. Placing conditions on income supplements may not be necessary to promote prenatal and perinatal health.

"You should go so that others can come"; the role of facilities in determining an early departure after childbirth in Morogoro Region, Tanzania

BACKGROUND

Tanzania is among ten countries that account for a majority of the world's newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women's experiences in the time preceding discharge from a facility after childbirth are limited.

METHODS

Household survey of 1267 women who delivered in the preceding 2-14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders.

RESULTS

Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001). Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred.

CONCLUSION

Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women's perceptions that it is safe and beneficial to leave hospitals soon after birth.

Information gaps in newborn care and their potential for harm

BACKGROUND

Access to complete and correct patient information is vital for physicians to make appropriate patient care decisions and to avoid medical errors. However, the perinatal period represents a unique situation in which care of the fetus is initiated by an obstetrician and then assumed by either a pediatrician or a family practice physician after birth. This often abrupt handoff of care has the potential to result in an inadequate transfer of information and significant gaps in care. A study was conducted to determine the presence and extent of information gaps in newborn care.

METHODS

Maternal demographics and history, and results of all prenatal laboratory tests, were obtained from maternal interviews and medical records. The collected data were compared with information in infant medical records. A positive maternal history not documented in the infant medical record was counted as an information gap.

RESULTS

Of 72 enrolled mother-infant dyads, nearly all (71 [99%]) of mothers had at least one positive history in the areas reviewed, and 59 (82%) newborn charts had one or more information gaps. Thirty-eight (53%) newborn charts had one of two or fewer information gaps, and 17 (24%) had four or more information gaps. None of the infants with a maternal history of depression, positive family history of an infectious disease, potentially inheritable genetic disorder, or family history of phototherapy or exchange transfusion had these documented in their medical records.

CONCLUSIONS

The results of this study suggest that significant information gaps are common in newborn care at birth and may have the potential for an adverse impact on the care and outcomes of the newborn. Obtaining a history directly from the parents rather than relying on maternal medical records may minimize or eliminate these information gaps and thus improve newborn care.

Initial assessment and management of the newborn

This article summarizes the initial assessment of normal newborns and describes a few of the common variations that may occur. These variations require a pediatric provider to reassure anxious new parents and provide follow-up communication with the subsequent primary care provider.

Perinatal outcomes of maternal overweight and obesity in term infants: a population-based cohort study in Canada

The objective of this study was to assess the impact of increased pre-pregnancy maternal body mass index (BMI) on perinatal outcomes in term, singleton pregnancies who received prenatal care in community-based practices. The sample of 1996 infants included in the study was drawn from the All Our Babies Study, a prospective pregnancy cohort from Calgary. Multivariable logistic regression explored the relationship between the main outcomes, infant birth weight, Apgar score, admission to neonatal intensive care (NICU) and newborn duration of hospitalization, and BMI prior to pregnancy. Approximately 10% of the infants were macrosoms, 1.5% had a low Apgar score (<7 at 5 min), 6% were admitted to intensive care and 96% were discharged within 48 h after delivery. Although the infants of overweight and obese women were more likely to have increased birth weight as compared to infants of normal weight women, there were no differences in Apgar score, admission to NICU, or length of postnatal hospital stay among groups. This study suggests that in otherwise healthy term, singleton pregnancies, obesity does not seem to increase the risk of severe fetal impairment, neonatal admission to intensive care or duration of postnatal hospitalization.

Timing of initial well-child visit and readmissions of newborns

BACKGROUND AND OBJECTIVES

Recommendations for the timing of the first well-child visit (WCV) after discharge from a well-baby nursery (WBN) suggest that the visit occur within 48 hours of discharge for those with a WBN length of stay of ≤48 hours and within 3 to 5 days for those with a WBN length of stay of >48 hours. The purpose of these early visits is to detect conditions that may cause readmission in the first weeks after birth, but the effectiveness of early visits to accomplish this has not been shown. The objectives of this study were to determine (1) the frequency of early visits and (2) to compare readmission rates for those who had an early visit compared with those who did not.

METHODS

Using data from a large health care system in Utah, we determined the readmission rates newborns with an estimated gestational age ≥34 weeks and compared the rates for those who had an early WCV with those who did not.

RESULTS

Of 79 720 newborns, 50 606 (63%) were discharged within 48 hours of birth. Of these, 7638 (15%) had a visit within 72 hours of discharge. The readmission rate for newborns who had a visit within the recommended time frame was 15.7 per 1000 compared with 18.4 for those with a later visit (odds ratio 0.85; 95% confidence interval 0.73-0.99) CONCLUSIONS: The frequency of first WCVs that occurred within the recommended time frames was low. Early visits were associated with a 15% reduction in the rate of readmissions.

Important considerations for the newborn: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision

PURPOSE OF REVIEW

This article addresses three areas in which new policies and research demonstrate the opportunity to impact the health of neonates: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision.

RECENT FINDINGS

Recent research has identified that child healthcare providers are not typically adhering to the recommended first newborn visit within 48 h of hospital discharge. Despite its benefits, cost-effectiveness, and the recommendation that routine screening for cyanotic congenital heart disease be added to the panel of universal newborn screening, adoption of this practice is variable. Evidence suggests a significant reduction in the transmission of HIV linked to circumcision, leading professional organizations to generate new policy statements on neonatal male circumcision.

SUMMARY

Pediatric healthcare providers should pay careful attention to the timing of the first newborn outpatient follow-up visit. Pulse oximetry screening for cyanotic congenital heart disease is specific, sensitive and meets criteria for universal screening, and providers should utilize well designed screening protocols. In addition, healthcare providers for newborns, especially those who perform circumcisions, should provide nonbiased, up-to-date information on the medical, financial, and ethical aspects of the procedure.

Individualized follow up programme and early discharge in term neonates

BACKGROUND

Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration.

METHODS

During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge.

RESULTS

During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%).

CONCLUSIONS

Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.

Impact of breastfeeding self-efficacy and sociocultural factors on early breastfeeding in an urban, predominantly Dominican community

BACKGROUND

Latinas have high breastfeeding initiation rates that decrease significantly in the first postpartum months. Little is known about the effects of self-efficacy and sociocultural factors on early breastfeeding among low-income Latinas. This study quantifies early breastfeeding rates and identifies factors associated with breastfeeding at 4-6 weeks postpartum in our community.

SUBJECTS AND METHODS

Mothers were recruited from a newborn clinic (NBC) in the first postpartum week. Questionnaires in the NBC and 4-6 weeks later assessed feeding practices, breastfeeding self-efficacy, and sociocultural factors. Feeding practices in the well baby nursery (WBN) were obtained by chart review. A scale from "1" (exclusive formula feeding) to "5" (exclusive breastfeeding) characterized feeding practices. Paired-sample t tests assessed change in feeding practices, and regression analysis assessed the impact of factors on breastfeeding at 4-6 weeks.

RESULTS

We interviewed 209 women: 86.1% Latina, 47.3% foreign-born, and 94.2% Medicaid-recipients. Breastfeeding increased from WBN to NBC (2.6±1.2 to 2.9±1.4; p<0.05) and then decreased by 4-6 weeks (2.9±1.4 to 2.5±1.44; p<0.05), without significant change between WBN and 4-6 weeks. Higher levels of education [β=0.21 (0.08, 0.56)], breastfeeding a previous child for ≥6 months [β=0.35 (0.57, 1.8)], foreign birth [β=0.2 (0.06, 1.07)], and higher breastfeeding self-efficacy scores [β=0.38 (0.02, 0.05)] were associated with more breastfeeding. Higher breastfeeding self-efficacy scores were associated with exclusive breastfeeding [adjusted odds ratio=1.18 (1.05, 1.32)].

CONCLUSIONS

Breastfeeding self-efficacy was the sole, modifiable factor associated with exclusive breastfeeding. Efforts to improve breastfeeding self-efficacy may serve to support breastfeeding in this population.

The passage of meconium alone is not a sign of correctly positioned anus

OBJECTIVE

The aim of this study is to determine the consequences of delayed presentation of anorectal malformations and emphasize the causes of delayed diagnosis of these malformations.

METHODS

We retrospectively reviewed 54 neonatal patients with a diagnosis of anorectal malformations. Group 1 consisted of 35 patients diagnosed within the first 48 h of life and Group 2 included 19 patients diagnosed after 48 h of life.

RESULTS

Obstructive symptoms at the time of diagnosis, overall complications and the mean postoperative hospitalization period in Group 2 were markedly higher than that of Group 1. A comprehensive neonatal examination within the first 48 h of life was performed in 32 (91.4%) patients in Group 1 and 5 (26.3%) of the patients in Group 2 (p < 0.001).

CONCLUSIONS

The passage of meconium is not the only sign of correctly positioned anus. A careful physical examination and awareness of this anomaly are of great importance in making a timely diagnosis of anorectal malformations.

Clinical guidelines for postpartum women and infants in primary care-a systematic review

Background

While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care.

Methods

PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument.

Results

Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.

Conclusions

Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.

Impact of newborn follow-up visit timing on subsequent ED visits and hospital readmissions: an instrumental variable analysis

OBJECTIVE

To determine whether newborn first outpatient visit (FOV) within 3 days of discharge is associated with reduced rates of emergency department (ED) visits and hospital readmissions.

METHODS

Retrospective cohort analysis was performed of all newborns who were born and had outpatient follow-up within a large academic medical center to determine whether they had ED visits or hospital readmission within 2 weeks after hospital discharge. Multivariable regression using an instrumental variable for timing of FOV was conducted to estimate the relationship between FOV within 3 days of discharge and ED visits and hospital readmissions within 2 weeks of discharge, adjusting for potential confounders. Stratified analyses assessed this relationship in subpopulations with medical or social risk factors.

RESULTS

Of 3282 newborns, 178 (5%) had 1 or more ED visits or hospital readmissions within 2 weeks of hospital discharge. FOV within 3 days was not significantly associated with ED visits and readmissions in the instrumental variable analysis (IVA) (-0.035, P = .11) or the ordinary least squares analysis (OLS) (0.006, P = .52). The difference in coefficients between these analyses, however, suggests that IVA successfully adjusted for some unmeasured bias. In stratified analyses, only newborns born to African American mothers or discharged by family medicine providers demonstrated a significant relationship between FOV within 3 days and reduced odds of ED visits and readmissions.

CONCLUSIONS

No significant relationship between outpatient visit timing and ED visits and hospital readmissions was found. Further study is needed to assess the impact of early outpatient visits on other newborn outcomes.

Factors associated with timing of first outpatient visit after newborn hospital discharge

OBJECTIVE

To determine factors associated with newborns having their first outpatient visit (FOV) beyond 3 days after postpartum hospital discharge.

METHODS

Retrospective cohort analysis of all newborns born at a large urban university hospital during a 1-year period, discharged home within 96 hours of birth, and with an outpatient visit with an affiliated provider within 60 days after discharge.

RESULTS

Of 3282 newborns, 1440 (44%) had their FOV beyond 3 days after discharge. Newborns born to first-time mothers, breast-feeding, at high risk for hyperbilirubinemia, or with a pathological diagnosis were significantly (P < .05) less likely to have FOV beyond 3 days in adjusted multivariable analysis, while newborns born via Caesarian section, of older gestational age, with Medicaid insurance, or discharged on a Thursday or Friday were more likely to have FOV beyond 3 days. Discharging provider characteristics independently associated with FOV beyond 3 days included family medicine providers, providers out of residency longer, and providers practicing at the institution longer. In addition, practice of outpatient follow-up had an independent impact on timing of FOV. Having an appointment date and time recorded on the nursery record or first appointment with a home nurse decreased the odds that time to FOV was beyond 3 days of discharge.

CONCLUSIONS

Physician decisions regarding timing of outpatient visit after newborn discharge may take into account newborn medical and social characteristics, but certain patient, provider, and practice features associated with this timing may represent unrecognized barriers to care.

ABM Clinical Protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term, revision 2013

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Axillary temperatures in full-term newborn infants: using evidence to guide safe and effective practice

PURPOSE

Although the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend obtaining temperature in newborn infants via the axilla, controversy still exists whether to obtain rectal or axillary temperatures. Of concern is the risk of perforating the rectum or colon during rectal temperature-taking. The purpose of this study was to explore the accuracy of electronic thermometer measuring temperature in the axilla compared with the rectum in full-term newborn infants.

DESIGN

This was an agreement study involving a purposive sample of newborn infants who were greater than 37 weeks' gestation. The general care nursery was located in a large, urban Midwestern academic medical center, and data collection occurred between May 2010 and August 2010.

METHODS

On admission to the general care nursery, both axillary and rectal temperatures were taken using the FasTemp device by Filac Electronic. Axillary temperatures were taken first, followed immediately by rectal temperature. Descriptive statistics, Pearson correlations, and scatter plots were computed.

RESULTS

In 69 newborns, the mean difference between rectal and left axilla temperatures was 0.23°C. There was a significant correlation between rectal temperature and the body temperature for the left axilla (r = 0.786; P = .01).

CONCLUSIONS

These preliminary data support the use of left axillary temperature measurement in the full-term newborn infant in the first few days of life to provide a safe and accurate alternative to rectal temperatures.

CLINICAL RELEVANCE

Nurses caring for newborn infants now have evidence showing that temperature-taking in the left axilla is an alternative to using rectal temperatures, possibly minimizing discomfort and potential risk of perforation.

The views of mothers and GPs about postpartum care in Australian general practice

BACKGROUND

The postpartum period is a time of increased morbidity for mothers and infants under 12 months, yet is an under-researched area of primary care. Despite a relatively clear framework for involving general practitioners (GPs) in antenatal care, the structure of maternity service provision in some Australian jurisdictions has resulted in highly variable roles of general practice in routine postpartum care. This study aimed to investigate the views and experiences of mothers and GPs about postpartum care in general practice.

METHODS

This was a qualitative study of mothers and GPs in rural, regional and metropolitan areas of Queensland, Australia. Semi-structured interviews were conducted with 88 mothers and six general practitioners between September 2010 and February 2012. Interviews were recorded and transcribed verbatim. Data were analysed thematically and compared across groups.

RESULTS

Three main themes emerged: The relationship between the mother and GP; practice management; and GP visits. This paper focuses on the theme GP visits and its subthemes: recommendations for GP visits; scope of practice; and content of a routine visit. Recommendations about GP visits given to mothers varied by birthing sector, obstetric provider and model of maternity care resulting in confusion amongst mothers about the timing and role of GPs in routine postpartum care. Similarly, GPs voiced concerns about a lack of consistent guidelines for their involvement in routine postpartum care. Although ideally placed to provide primary care to mothers and their infants in the postpartum period, the lack of consistent guidelines for the role of GPs is of concern to both the GPs and early parenting women.

CONCLUSION

General practice is an important source of postpartum care for mothers and provides a basis for ongoing support for the family. More consistent guidelines and better coordination with other care providers would benefit both mothers and GPs.

Neonatal colon perforation due to anorectal malformations: Can it be avoided?

Anorectal malformations (ARM) are common anomalies in neonates. Diagnostic and therapeutic delays in the management of ARM may lead to colonic perforation, and even death. Physical examination of the perineum is often sufficient to diagnose ARM in neonates. Notwithstanding, delayed diagnosis of ARM has become increasingly familiar to surgeons, as evidenced by the number of recent publications on this topic in the literature. In this commentary, we discuss spontaneous colonic perforation due to delayed diagnosis of ARM in neonates, and highlight the importance of early diagnosis in assuring good outcomes with surgical management. At this point, a thorough examination of the perineum during the initial newborn assessment is mandatory, particularly in those patients presenting with abdominal signs or symptoms.

Neonatal withdrawal syndrome, Michigan, 2000-2009

BACKGROUND

Neonatal withdrawal syndrome, which is associated most frequently with opioid use in pregnancy, is an emerging public health concern, with recent studies documenting an increase in the rate of U.S. infants diagnosed.

PURPOSE

This study examined neonatal withdrawal syndrome diagnosis among Michigan infants from 2000 to 2009 and hospital length of stay (LOS) between infants with and without the syndrome for a subset of years (2006-2009).

METHODS

Michigan live birth records from 2000 to 2009 were linked with hospital discharge data to identify infants with neonatal withdrawal syndrome. Linked data were restricted to infants born between 2006 and 2009 to examine the difference in hospital LOS between infants with and without the syndrome. Multivariable regression models were constructed to examine the adjusted impact of syndrome diagnosis on infant LOS and fit using negative binomial distribution. Data were analyzed from July 2011 to February 2012.

RESULTS

From 2000 to 2009, the overall birth rate of infants with neonatal withdrawal syndrome increased from 41.2 to 289.0 per 100,000 live births (p<0.0001). Among infants born from 2006 to 2009, the average hospital LOS for those with the syndrome was between 1.36 (95% CI=1.24, 1.49) and 5.75 (95% CI=5.41, 6.10) times longer than for infants without it.

CONCLUSIONS

Diagnosis of neonatal withdrawal syndrome increased significantly in Michigan with infants who had the syndrome requiring a significantly longer LOS compared to those without it.

Discharge timing, outpatient follow-up, and home care of late-preterm and early-term infants

OBJECTIVE

To compare the timing of hospital discharge, time to outpatient follow-up, and home care practices (breastfeeding initiation and continuation, tobacco smoke exposure, supine sleep position) for late-preterm (LPT; 34 0/7-36 6/7 weeks) and early-term (ET; 37 0/7-38/6/7 weeks) infants with term infants.

METHODS

We analyzed 2000-2008 data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System. χ(2) Analyses were used to measure differences in maternal and infant characteristics, hospital discharge, outpatient care, and home care among LPT, ET, and term infants. We calculated adjusted risk ratios for the risk of adverse care outcomes among LPT and ET infants compared with term infants.

RESULTS

In the adjusted analysis, LPT infants were less likely to be discharged early compared with term infants, whereas there was no difference for ET infants (risk ratio [RR; 95% confidence interval (CI)]: 0.65 [0.54-0.79]; 0.95 [0.88-1.02]). [corrected]. LPT and ET infants were more likely to have timely outpatient follow-up (1.07 [1.06-1.08]; 1.02 [1.02-1.03]), more likely to experience maternal tobacco smoke exposure (1.09 [1.05-1.14]; 1.08 [1.06-1.11]), less likely to be initially breastfed (0.95 [0.94-0.97]; 0.98 [0.97-0.98]), less likely to be breastfed for ≥10 weeks (0.88 [0.86-0.90]; 0.94 [0.93-0.96]), and less likely to be placed in a supine sleep position (0.95 [0.93-0.97]; 0.97 [0.96-0.98]).

CONCLUSIONS

Given that LPT and ET infants bear an increased risk of morbidity and mortality, greater efforts are needed to ensure safe and healthy posthospitalization and home care practices for these vulnerable infants.

Passive cooling during transport of asphyxiated term newborns

OBJECTIVE

To evaluate the efficacy and safety of passive cooling during transport of asphyxiated newborns.

STUDY DESIGN

Retrospective medical record review of newborns with perinatal asphyxia transported for hypothermia between July 2007 and June 2010.

RESULT

Of 43 newborns transported, 27 were passively cooled without significant adverse events. Twenty (74%) passively cooled newborns arrived with temperature between 32.5 and 34.5 °C. One newborn arrived with a temperature <32.5, and 6 (22%) had temperatures >34.5 °C. Time from birth to hypothermia was significantly shorter among passively cooled newborns compared with newborns not cooled (215 vs 327 min, P<0.01), even though time from birth to admission to Boston Children's Hospital was similar (252 vs 259 min, P=0.77). Time from birth to admission was the only significant predictor of increased time to reach target temperature (P=0.001).

CONCLUSION

Exclusive passive cooling achieves significantly earlier initiation of effective hypothermia for asphyxiated newborns but should not delay transport for active cooling.

Early readmission of newborns in a large health care system

BACKGROUND

Early readmissions of apparently healthy newborns after discharge from well baby nurseries (WBN) may reflect an inadequate assessment of the newborn's readiness for discharge.

OBJECTIVE

To determine the frequency, causes, costs, and variations in rates of early rehospitalization of newborns discharged from 21 WBNs in 1 health care system.

METHODS

We queried the Enterprise Data Warehouse of Intermountain Healthcare (IH), a large Utah health care system, to identify newborns with gestational ages of 34 to 42 weeks discharged from an IH WBN between 2000 and 2010. We identified all newborns admitted to an IH hospital within 28 days of discharge and recorded their birth hospital, age, reason(s) for admission, length of stay, and inpatient costs.

RESULTS

During the study period, 296 114 infants were discharged from IH hospital WBNs. Of these, 5308 (17.9/1000) were readmitted within 28 days of discharge. Of the 5308 infants who were readmitted, 41% had feeding problems, 35% had jaundice, and 33% had respiratory distress. The majority of newborns with feeding problems and jaundice were admitted in their first 2 weeks of life. Late preterm and early term newborns had higher rates of readmission than term infants. There were significant variations in readmission rates of newborns born at the 21 hospitals in the IH system.

CONCLUSIONS

Potentially preventable conditions, including feeding problems and jaundice, account for most early readmissions of newborns. Late preterm and early term newborns have higher rates of readmission and should be assessed for other factors associated with early readmission.

Nutritional requirements and feeding recommendations for small for gestational age infants

We define the small for gestational age (SGA) infant as an infant born ≥ 35 weeks' gestation and <10th percentile on the Fenton Growth Chart. Policy statements from many organizations recommend mother's own milk for SGA infants because it meets most of their nutritional requirements and provides short- and long-term benefits. Several distinct patterns of intrauterine growth restriction are identified among the heterogeneous grouping of SGA infants; each varies with regard to neonatal morbidities, requirements for neonatal management, postnatal growth velocities, neurodevelopmental progress, and adult health outcomes. There is much we do not know about nutritional management of the SGA infant. We need to identify and define: infants who have "true" growth restriction and are at high risk for adverse metabolic outcomes in later life; optimal growth velocity and "catch-up" growth rates that are conducive with life-long health and well being; global approaches to management of hypoglycemia; and an optimal model for postdischarge care. Large, rigorously conducted trials are required to determine whether aggressive feeding of SGA infants results in improved nutritional rehabilitation, growth, and neurodevelopmental outcomes. Before birth, maternal supplementation with specific nutrients reduces the rate and severity of growth restriction and may prevent nutrient deficiency states if infants are born SGA. After birth, the generally accepted goal is to provide enough nutrients to achieve postnatal growth similar to that of a normal fetus. In addition, we recommend SGA infants be allowed to "room in" with their mothers to promote breastfeeding, mother-infant attachment, and skin-to-skin contact to assist with thermoregulation.

Establishing successful breastfeeding in the newborn period

The first days after delivery of a newborn infant are critical for breastfeeding establishment. Successful initiation and continuation-especially of exclusive breastfeeding-have become public health priorities, but it is fraught with many individual- and systems-level barriers. In this article, we review how hospital newborn services can be constructed or restructured to support the breastfeeding mother-infant dyad so that they can achieve high levels of breastfeeding success. Important positive and negative factors from the prenatal period, and the preparation for hospital discharge are also discussed.

Guideline-based educational intervention to decrease the risk for readmission of newborns with severe hyperbilirubinemia

INTRODUCTION

The purpose of this study was to determine if educational intervention with medical providers in combination with a management tool to facilitate clinical guideline usage would (a) increase quality of care, (b) increase compliance with published guidelines, and (c) decrease hospital readmissions as a result of hyperbilirubinemia in the first week of life.

METHOD

A quality improvement initiative was undertaken with a preintervention/postintervention design.

INTERVENTION

An educational intervention was offered to persons who provide medical care to newborns. The charts of newborns were reviewed before and after the intervention in three samples: a care quality sample (N = 244), a compliance sample (N = 240), and a readmission sample.

RESULTS

In the quality care sample, documentation of three quality care indicators improved significantly and one worsened significantly. In the compliance sample, the percentage of infants who were given appropriate follow-up appointments in primary care based on their hyperbilirubinemia risk at discharge improved (p = .03), and the readmission rate of newborns within the first week of life as a result of hyperbilirubinemia decreased by 50%.

DISCUSSION

An educational intervention with a clinical tool may help change provider practice. Longer follow-up is needed to determine if the impact is sustainable.