1
|
Osman A. The early use of inhaled nitric oxide in premature infants requiring respiratory support. Ann Med 2023; 55:2266633. [PMID: 38079494 PMCID: PMC10880562 DOI: 10.1080/07853890.2023.2266633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/28/2023] [Indexed: 12/18/2023] Open
Abstract
Background: Earlier studies on the use of inhaled nitric oxide (iNO) for premature infants born at <34 weeks of gestation requiring respiratory support did not provide conclusive evidence of benefit. National guidelines generally discouraged the use in this population. More recent national guidelines endorsed the use of iNO in premature infants with hypoxic respiratory failure (HRF) associated with persistent pulmonary hypertension of the newborn (PPHN).Recent Studies: Two recently published observational studies evaluated the effect of administering iNO on oxygenation in the first week of life. These studies compared premature infants born at the gestational age (GA) of <34 weeks with HRF associated with PPHN to term and late preterm infants born at the GA of ≥34 weeks who received iNO. Both studies showed a similar effect of iNO on oxygenation in the two infant cohorts. The response rate in the premature infant cohort was 59% in the first study and 90% in the second. The mean response time was 9.2 h and 10.3 h, and the mean duration of therapy was 3.5 days and 8.2 days, respectively.Conclusion: The results of these studies support a trial of iNO in premature infants with persistent hypoxia despite optimum respiratory support. Obtaining a timely echocardiogram to exclude cardiac diseases and diagnose PPHN is logistically challenging for many clinicians, thus, a clinical diagnosis of PPHN might have to be made in these situations. Questions remain regarding the optimum dose of iNO and the duration of the initial iNO trial in these patients.KEY MESSAGESIn the most recently published studies, the improvement of oxygenation in iNO-treated infants born at <34 weeks of gestation with HRF and PPHN physiology was as effective as in infants born ≥34 weeks.These studies provide evidence supporting a trial of iNO in the subpopulation of premature infants with HRF associated with PPHN.
Collapse
Affiliation(s)
- Ahmed Osman
- The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
| |
Collapse
|
2
|
King BC, Hagan J, Richardson T, Berry J, Slaughter JL. Hospital variation in neonatal echocardiography among very preterm infants at US children's hospitals. J Perinatol 2023; 43:181-186. [PMID: 36163416 DOI: 10.1038/s41372-022-01522-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Estimate hospital variation in echocardiography (echo) among very preterm infants. STUDY DESIGN Retrospective cohort study of very preterm (<32 weeks) infants discharged between 2012 and 2019 from US children's hospitals. Echo exposure was identified using daily billing, and hospital variation was estimated after adjustment for illness severity. Variation in very early echo use (<3 days of life) was compared to exposure to treatment of a patent ductus arteriosus (PDA), and other practice patterns. RESULTS 27,498 subjects across 39 children's hospitals were included. Very early echo use had the greatest hospital variation (3-34%). Increasing very early echo use was not associated with PDA treatment (p = 0.93), but was associated with nitric oxide (p < 0.01) and vasoactive medications (p < 0.01). CONCLUSIONS Hospital variation in echo use among preterm infants was greatest in the first few days of life and was associated with increasing nitric oxide and vasoactive medication use. The impact of this variation on clinical outcomes is uncertain and warrants further investigation.
Collapse
Affiliation(s)
- Brian C King
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| | - Joseph Hagan
- Newborn Center, Texas Children's Hospital, Houston, TX, USA
| | | | - Jay Berry
- Complex Care, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan L Slaughter
- Center for Perinatal Research, Nationwide Children's Hospital and Department of Pediatrics, College of Medicine and Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
3
|
Kharrat A, McNamara PJ, Weisz DE, Kelly E, Masse E, Mukerji A, Louis D, Afifi J, Ye XY, Shah PS, Jain A. Clinical burden associated with therapies for cardio-pulmonary critical decompensation in preterm neonates across Canadian neonatal intensive care units. Eur J Pediatr 2022; 181:3319-3330. [PMID: 35779092 DOI: 10.1007/s00431-022-04508-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/07/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022]
Abstract
UNLABELLED The aim of this retrospective cohort study was to study the clinical burden associated with cardio-pulmonary critical decompensations (CPCDs) in preterm neonates and factors associated with mortality. Through the Canadian Neonatal Network (30 tertiary NICUs, 2010-2017), we identified infants < 32-week gestational age with CPCDs, defined by "significant exposure" to cardiotropes and/or inhaled nitric oxide (iNO): (1) either therapy for ≥ 3 consecutive days, (2) both for ≥ 2 consecutive days, or (3) any exposure within 2 days of death. Early CPCDs (≤ 3 days of age) and late CPCDs (> 3 days) were examined separately. Outcomes included CPCD-incidence, mortality, and inter-site variability using standardized ratios (observed/adjusted expected rate) and network funnel plots. Mixed-effects analysis was used to quantify unit-level variability in mortality. Overall, 10% of admissions experienced CPCDs (n = 2915). Late CPCDs decreased by ~ 5%/year, while early CPCDs were unchanged during the study period. Incidence and CPCD-associated mortality varied between sites, for both early (0.6-7.5% and 0-100%, respectively) and late CPCDs (2.5-15% and 14-83%, respectively), all p < 0.01. Units' late-CPCD incidence and mortality demonstrated an inverse relationship (slope = -2.5, p < 0.01). Mixed-effects analysis demonstrated clustering effect, with 6.4% and 8.6% of variability in mortality after early and late CPCDs respectively being site-related, unexplained by available patient-level characteristics or unit volume. Mortality was higher with combined exposure than with only-cardiotropes or only-iNO (41.3%, 24.8%, 21.5%, respectively; p < 0.01). CONCLUSIONS Clustering effects exist in CPCD-associated mortality among Canadian NICUs, with higher incidence units showing lower mortality. These data may aid network-level benchmarking, patient-level risk stratification, parental counseling, and further research and quality improvement work. WHAT IS KNOWN • Preterm neonates remain at high risk of acute and chronic complications; the most critically unwell require therapies such as cardiotropic drugs and inhaled nitric oxide. • Infants requiring these therapies are known to be at high risk for adverse neonatal outcomes and for mortality. WHAT IS NEW • This study helps illuminate the national burden of acute cardio-pulmonary critical decompensation (CPCD), defined as the need for cardiotropic drugs or inhaled nitric oxide, and highlights the high risk of morbidity and mortality associated with this disease state. • Significant nationwide variability exists in both CPCD incidence and associated mortality; a clustering effect was observed with higher incidence sites showing lower CPCD-associated mortality.
Collapse
Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | | | - Dany E Weisz
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Edmond Kelly
- Department of Paediatrics, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Edith Masse
- Department of Pediatrics, University of Sherbrooke, Sherbrooke, Canada
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Deepak Louis
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Jehier Afifi
- Department of Pediatrics, Dalhousie University, Halifax, Canada
| | - Xiang Y Ye
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, Canada
| | | |
Collapse
|
4
|
Hussain WA, Bondi DS, Shah P, Morgan SE, Sriram S, Schreiber MD. Implementation of an Inhaled Nitric Oxide Weaning Protocol and Stewardship in a Level 4 NICU to Decrease Inappropriate Use. J Pediatr Pharmacol Ther 2022; 27:284-291. [PMID: 35350163 DOI: 10.5863/1551-6776-27.3.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension in newborns, with limited data regarding weaning. Our institution implemented a multidisciplinary iNO weaning protocol and stewardship to reduce inappropriate use of iNO. The objective of this study was to evaluate our institutional iNO usage before and after implementation. METHODS Single-center study comparing a retrospective control group to a prospective cohort after implementation of an iNO weaning protocol. All infants in the neonatal intensive care unit (NICU) who received iNO during the study timeframe were included. The primary outcome was duration of iNO per course. RESULTS A total of 47 courses of iNO occurred during the pre-protocol timeframe compared with 37 courses in the post-protocol timeframe. Median iNO usage per course was 149 hours (IQR, 63-243) in the pre-protocol group versus 59 hours (IQR, 37-122) in the post-protocol group (p = 0.008). Length of stay was significantly longer in the pre-protocol group (p = 0.02), likely related to significantly longer ventilator days in the pre-protocol group (p = 0.02). Compliance with initiation of weaning when recommended per the protocol was 72%, and the incidence of successful weaning was 74%. CONCLUSIONS The implementation of an iNO weaning protocol in the NICU significantly decreased iNO usage by approximately 60% with no notable negative effects.
Collapse
Affiliation(s)
- Walid A Hussain
- Section of Neonatology, Department of Pediatrics (WAH), Loyola University Medical Center, Maywood, IL
| | - Deborah S Bondi
- Department of Pharmacy (DSB, PS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Pooja Shah
- Department of Pharmacy (DSB, PS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Sherwin E Morgan
- Department of Respiratory Care Services (SEM), University of Chicago Medicine, Chicago, IL
| | - Sudhir Sriram
- Section of Neonatology, Department of Pediatrics (SS, MDS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | - Michael D Schreiber
- Section of Neonatology, Department of Pediatrics (SS, MDS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| |
Collapse
|
5
|
Peluso AM, Othman HF, Karnati S, Sammour I, Aly HZ. Epidemiologic evaluation of inhaled nitric oxide use among neonates with gestational age less than 35 weeks. Pediatr Pulmonol 2022; 57:427-434. [PMID: 34842352 DOI: 10.1002/ppul.25775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/16/2021] [Accepted: 11/26/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES The use of inhaled nitric oxide (iNO) in +late preterm and term infants with pulmonary hypertension is Food and Drug Administration (FDA) approved and has improved outcomes and survival. iNO use is not FDA approved for preterm infants and previous studies show no mortality benefit. The objectives were 1) to determine the usage of iNO among preterm neonates <35 weeks before and after the 2010 National Institutes of Health consensus statement and 2) to evaluate characteristics and outcomes among preterm neonates who received iNO. METHODS This is a population-based cross-sectional study. Billing and procedure codes were used to determine iNO usage. Data were queried from the National Inpatient Sample from 2004 to 2016. Neonates were included if gestational age was <35 weeks. The epochs were spilt into 2004-2010 (Epoch 1) and 2011-2016 (Epoch 2). Prevalence of iNO use, mortality, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage, length of stay, mechanical ventilation, and cost of hospitalization. RESULTS There were 4865 preterm neonates <35 weeks who received iNO. There was a significant increase in iNO use during Epoch 2 (p < 0.001). There was significantly higher use in Epoch 2 among neonates small for gestational age (SGA) 2.3% versus 7.2%, congenital heart disease (CHD) 11.1% versus 18.6%, and BPD 35.2% versus 46.8%. Mortality was significantly lower in Epoch 2 19.8% versus 22.7%. CONCLUSION Usage of iNO was higher after the release of the consensus statement. The increased use of iNO among preterm neonates may be targeted at specific high-risk populations such as SGA and CHD neonates. There was lower mortality in Epoch 2; however, the cost was doubled.
Collapse
Affiliation(s)
- Allison M Peluso
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Hasan F Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, Michigan, USA
| | - Sreenivas Karnati
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Ibrahim Sammour
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Hany Z Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| |
Collapse
|
6
|
Cost of clinician-driven tests and treatments in very low birth weight and/or very preterm infants. J Perinatol 2021; 41:295-304. [PMID: 33268831 DOI: 10.1038/s41372-020-00879-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/07/2020] [Accepted: 11/12/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To rank clinician-driven tests and treatments (CTTs) by their total cost during the birth hospitalization for preterm infants. STUDY DESIGN Retrospective cohort of very low birth weight (<1500 g) and/or very preterm (<32 weeks) subjects admitted to US children's hospital Neonatal Intensive Care Units (2012-2018). CTTs were defined as pharmaceutical, laboratory and imaging services and ranked by total cost. RESULTS 24,099 infants from 51 hospitals were included. Parenteral nutrition ($85M, 32% of pharmacy costs), blood gas analysis ($34M, 29% of laboratory costs), and chest radiographs ($18M, 31% of imaging costs) were the costliest CTTs overall. More than half of CTT-related costs occurred during 10% of hospital days. CONCLUSIONS The majority of CTT-related costs were from commonly used tests and treatments. Targeted efforts to improve value in neonatal care may benefit most from focusing on reducing unnecessary utilization of common tests and treatments, rather than infrequently used ones.
Collapse
|
7
|
King BC, Richardson T, Patel RM, Lee HC, Bamat NA, Hall M, Slaughter JL. Prioritization framework for improving the value of care for very low birth weight and very preterm infants. J Perinatol 2021; 41:2463-2473. [PMID: 34075201 PMCID: PMC8514333 DOI: 10.1038/s41372-021-01114-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Create a prioritization framework for value-based improvement in neonatal care. STUDY DESIGN A retrospective cohort study of very low birth weight (<1500 g) and/or very preterm (<32 weeks) infants discharged between 2012 and 2019 using the Pediatric Health Information System Database. Resource use was compared across hospitals and adjusted for patient-level differences. A prioritization score was created combining cost, patient exposure, and inter-hospital variability to rank resource categories. RESULTS Resource categories with the greatest cost, patient exposure, and inter-hospital variability were parenteral nutrition, hematology (lab testing), and anticoagulation (for central venous access and therapy), respectively. Based on our prioritization score, parenteral nutrition was identified as the highest priority overall. CONCLUSIONS We report the development of a prioritization score for potential value-based improvement in neonatal care. Our findings suggest that parenteral nutrition, central venous access, and high-volume laboratory and imaging modalities should be priorities for future comparative effectiveness and quality improvement efforts.
Collapse
Affiliation(s)
- Brian C. King
- grid.416975.80000 0001 2200 2638Department of Pediatrics, Section of Neonatology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Troy Richardson
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Ravi M. Patel
- grid.189967.80000 0001 0941 6502Division of Neonatology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Henry C. Lee
- grid.168010.e0000000419368956Division of Neonatology, Stanford University, Stanford, CA USA
| | - Nicolas A. Bamat
- grid.239552.a0000 0001 0680 8770Division of Neonatology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Matthew Hall
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Jonathan L. Slaughter
- grid.240344.50000 0004 0392 3476Division of Neonatology, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH USA
| |
Collapse
|
8
|
Subhedar NV, Jawad S, Oughham K, Gale C, Battersby C. Increase in the use of inhaled nitric oxide in neonatal intensive care units in England: a retrospective population study. BMJ Paediatr Open 2021; 5:e000897. [PMID: 33705500 PMCID: PMC7903123 DOI: 10.1136/bmjpo-2020-000897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To describe temporal changes in inhaled nitric oxide (iNO) use in English neonatal units between 2010 and 2015. DESIGN Retrospective analysis using data extracted from the National Neonatal Research Database. SETTING All National Health Service neonatal units in England. PATIENTS Infants of all gestational ages born 2010-2015 admitted to a neonatal unit and received intensive care. MAIN OUTCOME MEASURES Proportion of infants who received iNO; age at initiation and duration of iNO use. RESULTS 4.9% (6346/129 883) of infants received iNO; 31% (1959/6346) were born <29 weeks, 18% (1152/6346) 29-33 weeks and 51% (3235/6346)>34 weeks of gestation. Between epoch 1 (2010-2011) and epoch 3 (2014-2015), there was (1) an increase in the proportion of infants receiving iNO: <29 weeks (4.9% vs 15.9%); 29-33 weeks (1.1% vs 4.8%); >34 weeks (4.5% vs 5.0%), (2) increase in postnatal age at iNO initiation: <29 weeks 10 days vs 18 days; 29-33 weeks 2 days vs 10 days, (iii) reduction in iNO duration: <29 weeks (3 days vs 2 days); 29-33 weeks (2 days vs 1 day). CONCLUSIONS Between 2010 and 2015, there was an increase in the use of iNO among infants admitted to English neonatal units. This was most notable among the most premature infants with an almost fourfold increase. Given the cost of iNO therapy, limited evidence of efficacy in preterm infants and potential for harm, we suggest that exposure to iNO should be limited, ideally to infants included in research studies (either observational or randomised placebo-controlled trial) or within a protocolised pathway. Development of consensus guidelines may also help standardise practice.
Collapse
Affiliation(s)
- Nimish V Subhedar
- Neonatal Intensive care Unit, Liverpool Women's Hospital, Liverpool, UK
| | - Sena Jawad
- Neonatal Data Analysis Unit, Imperial College London, London, UK
| | - Kayleigh Oughham
- Neonatal Data Analysis Unit, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, Imperial College London Faculty of Medicine, London, UK
| | | |
Collapse
|
9
|
Greenberg JM, Poindexter BB, Shaw PA, Bellamy SL, Keller RL, Moore PE, McPherson C, Ryan RM. Respiratory medication use in extremely premature (<29 weeks) infants during initial NICU hospitalization: Results from the prematurity and respiratory outcomes program. Pediatr Pulmonol 2020; 55:360-368. [PMID: 31794157 DOI: 10.1002/ppul.24592] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/20/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The use of medications to treat respiratory conditions of extreme prematurity is often based upon studies of adults or children over 2 years of age. Little is known about the spectrum of medications used or dosing ranges. To inform the design of future studies, we conducted a prospective analysis of respiratory medication exposure among 832 extremely low gestational age neonates. METHODS The prematurity and respiratory outcomes program (PROP) enrolled neonates less than 29-week gestation from 6 centers incorporating 13 clinical sites. We collected recorded daily "respiratory" medications given along with dosing information through 40-week postmenstrual age or neonatal intensive care unit discharge if earlier. RESULTS PROP participants were exposed to a wide range of respiratory medications, often at doses beyond published recommendations. Nearly 50% received caffeine and furosemide beyond published recommendations for cumulative dose. Those who developed bronchopulmonary dysplasia were more likely to receive treatment with respiratory medications. However, more than 30% of PROP subjects that did not develop bronchopulmonary dysplasia also were treated with diuretics, systemic steroids, and other respiratory medications. CONCLUSION Extremely preterm neonates in PROP were exposed to high doses of medications at levels known to generate significant adverse effects. With limited evidence for efficacy, there is an urgent need for controlled trials in this vulnerable patient population.
Collapse
Affiliation(s)
- James M Greenberg
- Departments of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brenda B Poindexter
- Departments of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Pamela A Shaw
- Department of Biostatistics, Epidemiology and Informatics, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scarlett L Bellamy
- Department of Biostatistics, Epidemiology and Informatics, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roberta L Keller
- Department of Pediatrics, University of California-San Francisco, San Francisco, California
| | - Paul E Moore
- Departments of Pediatrics and Pharmacology, Vanderbilt University, Nashville, Tennessee
| | | | - Rita M Ryan
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
10
|
Riley CM, Mastropietro CW, Sassalos P, Buckley JR, Costello JM, Iliopoulos I, Jennings A, Cashen K, Suguna Narasimhulu S, Gowda KMN, Smerling AJ, Wilhelm M, Badheka A, Bakar A, Moser EAS, Amula V. Utilization of inhaled nitric oxide after surgical repair of truncus arteriosus: A multicenter analysis. CONGENIT HEART DIS 2019; 14:1078-1086. [PMID: 31713327 DOI: 10.1111/chd.12849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/14/2019] [Accepted: 09/11/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) is common following repair of truncus arteriosus. Inhaled nitric oxide (iNO) is an effective yet costly therapy that is frequently implemented postoperatively to manage elevated PVR. OBJECTIVES We aimed to describe practice patterns of iNO use in a multicenter cohort of patients who underwent repair of truncus arteriosus, a lesion in which recovery is often complicated by elevated PVR. We also sought to identify patient and center factors that were more commonly associated with the use of iNO in the postoperative period. DESIGN Retrospective cohort study. SETTING 15 tertiary care pediatric referral centers. PATIENTS All infants who underwent definitive repair of truncus arteriosus without aortic arch obstruction between 2009 and 2016. INTERVENTIONS Descriptive statistics were used to demonstrate practice patterns of iNO use. Bivariate comparisons of characteristics of patients who did and did not receive iNO were performed, followed by multivariable mixed logistic regression analysis using backward elimination to identify independent predictors of iNO use. MAIN RESULTS We reviewed 216 patients who met inclusion criteria, of which 102 (46%) received iNO in the postoperative period: 69 (68%) had iNO started in the operating room and 33 (32%) had iNO initiated in the ICU. Median duration of iNO use was 4 days (range: 1-21 days). In multivariable mixed logistic regression analysis, use of deep hypothermic circulatory arrest (odds ratio: 3.2; 95% confidence interval: 1.2, 8.4) and center (analyzed as a random effect, p = .02) were independently associated with iNO use. CONCLUSIONS In this contemporary multicenter study, nearly half of patients who underwent repair of truncus arteriosus received iNO postoperatively. Use of iNO was more dependent on individual center practice rather than patient characteristics. The study suggests a need for collaborative quality initiatives to determine optimal criteria for utilization of this important but expensive therapy.
Collapse
Affiliation(s)
- Christine M Riley
- Department of Pediatrics, Division of Cardiac Critical Care, Children's National Health System, Washington, District of Columbia
| | - Christopher W Mastropietro
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Peter Sassalos
- Department of Cardiac Surgery, Section of Pediatric Cardiovascular Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jason R Buckley
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - John M Costello
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Ilias Iliopoulos
- Department of Pediatrics, Division of Cardiac Critical Care, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aimee Jennings
- Department of Pediatrics, Division of Critical Care, Seattle Children's Hospital, Seattle, Washington
| | - Katherine Cashen
- Department of Pediatrics, Division of Critical Care, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Sukumar Suguna Narasimhulu
- Department of Pediatrics, Division of Cardiac Intensive Care, University of Central Florida College of Medicine, The Heart Center at Arnold Palmer Hospital for Children, Orlando, Florida
| | - Keshava M N Gowda
- Department of Pediatrics, Division of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Arthur J Smerling
- Department of Pediatrics, Division of Critical Care, Columbia University College of Physicians & Surgeons, Morgan Stanley Children's Hospital of New York, New York, New York
| | - Michael Wilhelm
- Department of Pediatrics, Division of Cardiac Intensive Care, University of Wisconsin, Madison, Wisconsin
| | - Aditya Badheka
- Department of Pediatrics, Division of Critical Care Medicine, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Adnan Bakar
- Department of Pediatrics, Division of Cardiac Critical Care, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Cohen Children's Medical Center, New Hyde Park, New York
| | - Elizabeth A S Moser
- Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Venu Amula
- Department of Pediatrics, Division of Critical Care Medicine, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| |
Collapse
|
11
|
Hospital Variation in Child Protection Reports of Substance Exposed Infants. J Pediatr 2019; 208:141-147.e2. [PMID: 30770194 PMCID: PMC6486842 DOI: 10.1016/j.jpeds.2018.12.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/19/2018] [Accepted: 12/31/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine whether hospital-level factors contribute to discrepancies in reporting to Child Protective Services (CPS) of infants diagnosed with prenatal substance exposure. STUDY DESIGN We used a linked dataset of birth, hospital, and CPS records using diagnostic codes (International Classification of Diseases, Ninth Revision) to identify infants diagnosed with prenatal substance exposure. Using multilevel models, we examined hospital-level and individual birth-level factors in relation to a report to CPS among those infants prenatally exposed to substances. RESULTS Of the 760 863 infants born in Washington State between 2006 and 2013, 12 308 (1.6%) were diagnosed with prenatal substance exposure. Infants born at hospitals that served larger populations of patients with Medicaid (OR, 1.25; 95% CI, 1.07-1.45) and hospitals with higher occupancy rates (OR, 1.43; 95% CI, 1.15-1.77) were more likely to be reported to CPS. Infants exposed to amphetamines (OR, 2.58; 95% CI, 2.31-2.90) and cocaine (OR, 2.33; 95% CI-1.92, 2.83) were more likely to be reported and infants exposed to cannabis (OR, 0.62; 95% CI-0.55, 0.70) were less likely to be reported to CPS than infants exposed to opioids. Infants with Native American mothers were more likely to be reported to CPS than infants with white mothers (OR, 1.47; 95% CI, 1.27-1.70). CONCLUSIONS Hospital-level and individual birth-level factors impact the likelihood of infants prenatally exposed to substances being reported to CPS, providing additional knowledge about which infants are reported to CPS. Targeted education and improved policies are necessary to ensure more standardized approaches to CPS reporting of prenatal substance exposure.
Collapse
|
12
|
Wang H, Dong Y, Sun B. Admission volume is associated with mortality of neonatal respiratory failure in emerging neonatal intensive care units. J Matern Fetal Neonatal Med 2018; 32:2233-2240. [PMID: 29385861 DOI: 10.1080/14767058.2018.1430133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The aim of this survey was to explore the relationship between admission volume and mortality of neonates with hypoxemic respiratory failure (NRF) in emerging neonatal intensive care units (NICUs). METHODS NRF from 55 NICUs were retrospectively included with death risk as the major outcome. Perinatal comorbidities, underlying disease severity, respiratory support, facility utilization, and economic burden in the early postnatal period were compared among five NICU admission volume categories defined by NRF incidence, with score for neonatal acute physiology perinatal extension II (SNAPPE-II) also assessed as initial severity. RESULTS Compared to NICUs with NRF < 50 cases/year, NRF incidence, NRF/NICU, NRF/NICU admissions, and magnitude of ventilator use were several times higher, and mortality rates 20-50% lower, in NICUs of 150-199 and ≥200 cases/year (p < .01), even after adjustment with SNAPPE-II in stratified ranges. Median SNAPPE-II values, which correlated with the death rate of NRF (r = .282, p < .001), were lower in NICUs of 150-199 and ≥200 than in <50, 50-99, and 100-149 categories (13 versus 18, p < .01). NRF mortalities were not correlated with the proportion of very low birth weight patients in each category. CONCLUSIONS Neonates in NICUs with smaller NRF admission volume and decreased magnitude of ventilator use had a higher risk of death as assessed by SNAPPE-II, which should be targeted in the quality improvement of newly established, resource-limited NICUs.
Collapse
Affiliation(s)
- Huanhuan Wang
- a Department of Neonatology , Children's Hospital of Fudan University , Shanghai , China
| | - Ying Dong
- a Department of Neonatology , Children's Hospital of Fudan University , Shanghai , China
| | - Bo Sun
- a Department of Neonatology , Children's Hospital of Fudan University , Shanghai , China
| | -
- a Department of Neonatology , Children's Hospital of Fudan University , Shanghai , China
| |
Collapse
|
13
|
Dani C, Corsini I, Cangemi J, Vangi V, Pratesi S. Nitric oxide for the treatment of preterm infants with severe RDS and pulmonary hypertension. Pediatr Pulmonol 2017; 52:1461-1468. [PMID: 29058384 DOI: 10.1002/ppul.23843] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) cannot be recommended for the routine treatment of respiratory failure in premature neonates, but it has been suggested that the effectiveness of iNO therapy should be further studied in more select preterm infants, such as those with persistent pulmonary hypertension of the newborn (PPHN). OBJECTIVE To evaluate the frequency of PPHN in very preterm infants with severe respiratory distress syndrome (RDS), to assess the effectiveness of iNO in these patients, and to individuate possible predictive factors for the response to iNO in preterm infants with RDS. STUDY DESIGN We retrospectively studied infants <30 weeks of gestational age or birth weight <1250 g, who were affected by severe RDS and treated with iNO during the first week of life. Clinical characteristics of infants with or without echocardiographic diagnosis of PPHN were compared, as well as those of responder or no responder to iNO therapy. Effectiveness of iNO was evaluated by recording changes of MAP, FiO2 , SpO2 /FiO2 ratio, and oxygenation index (OI) before, and 3 ± 1, 6 ± 1, 12 ± 3, 24 ± 6, 48 ± 6, and 72 ± 12 h after beginning therapy. RESULTS We studied 42 (4.6%) infants, of whom 28 (67%) had PPHN and 14 (33%) did not. iNO therapy was associated with improved oxygenation in both the groups but it was quicker in the PPHN than in the no PPHN group. Multivariate analysis showed that FiO2 >0.65, diagnosis of PPHN, and birth weight >750 g independently predicts effectiveness of iNO in very preterm infants with RDS. CONCLUSION We found that PPHN is a frequent complication of severe RDS in very preterm infants and iNO therapy can improve their oxygenation earlier than in infants without PPHN. iNO therapy is not recommended for the routinely treatment of RDS in premature neonates but in cases of concurrent diagnosis of PPHN it should be considered carefully.
Collapse
Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy.,Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Jessica Cangemi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Venturella Vangi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Simone Pratesi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| |
Collapse
|
14
|
Seth SA, Soraisham AS, Harabor A. Risk factors and outcomes of early pulmonary hypertension in preterm infants. J Matern Fetal Neonatal Med 2017; 31:3147-3152. [PMID: 28783986 DOI: 10.1080/14767058.2017.1365129] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Data on early pulmonary arterial hypertension (PAH) in preterm infants is limited and outcomes are conflicting. Our objectives are to examine the risk factors and neonatal outcomes of early onset PAH (EOPAH) diagnosed in the first 2 weeks of age in preterm infants in a large perinatal center. METHODS We performed a case-control study to assess the risk factors and clinical outcomes of preterm infants with EOPAH. Preterm infants (<34 weeks) admitted to NICU between 2009 and 2013 with a diagnosis of PAH in the first 2 weeks of age were matched to two consecutive controls for gestational age, birth weight, and year of birth. We performed univariate and multivariate analyses. RESULTS Of 1798 eligible infants, 60 (3.3%) had EOPAH with 57/60 (95%) diagnosed in the first 7 d of age. Infants with early PAH had higher incidence of prolonged rupture of membrane (47% versus 29%), oligohydramnios (37% versus 16%) and received less antenatal steroids (78% versus 91%). Fifty-one infants received inhaled nitric oxide (iNO) and all responded well. The overall mortality rate was not significantly different between two groups (13.3% versus 8%). After adjusting for potential confounding variables, early PAH is associated with bronchopulmonary dysplasia (BPD) (aOR 3.06, 95% CI 1.43, 6.54) and BPD/death (aOR 2.65, 95% CI 1.25, 5.64) and severe intraventricular hemorrhage (aOR 3.08, 95% CI 1.28, 7.39). CONCLUSION Early onset pulmonary arterial hypertension in preterm is not uncommon and is associated with bronchopulmonary dysplasia and severe intraventricular hemorrhage. Inhaled nitric oxide was used to treat in majority of cases with good response and survival is high.
Collapse
Affiliation(s)
- Saad Ahmed Seth
- a Department of Pediatrics, Section of Neonatology, Cumming School of Medicine , Alberta Children's Hospital Research Institute, University of Calgary , Calgary , Alberta , Canada
| | - Amuchou Singh Soraisham
- a Department of Pediatrics, Section of Neonatology, Cumming School of Medicine , Alberta Children's Hospital Research Institute, University of Calgary , Calgary , Alberta , Canada
| | - Andrei Harabor
- a Department of Pediatrics, Section of Neonatology, Cumming School of Medicine , Alberta Children's Hospital Research Institute, University of Calgary , Calgary , Alberta , Canada
| |
Collapse
|
15
|
Children with Complex Medical Conditions: an Under-Recognized Driver of the Pediatric Cost Crisis. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s40746-016-0071-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
16
|
Early inhaled nitric oxide in preterm infants <34 weeks with evolving bronchopulmonary dysplasia. J Perinatol 2016; 36:883-9. [PMID: 27442155 DOI: 10.1038/jp.2016.112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 04/08/2016] [Accepted: 04/18/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate whether early treatment with inhaled nitric oxide (iNO) could prevent bronchopulmonary dysplasia (BPD) in very preterm infants. STUDY DESIGN A non-randomized, controlled trial was conducted prospectively in 27 neonatal intensive care units over 12 months. Preterm infants with gestational age <34 weeks and after 7 days of life, who received invasive mechanical ventilation (MV) or nasal continuous positive airway pressure for >2 days, were treated either with low-dose iNO (from 5 as initial dose to 2 parts per million as maintenance dose for ⩾7 days, n=162) or as non-placebo control (n=240). Primary outcome was the incidence of moderate-to-severe BPD at 36 weeks postmenstrual age and/or death before discharge. Secondary outcomes were major complications. RESULTS iNO was started on average on day 19 of life (median duration 18 days, range 7 to 55 days). Rate of survival without BPD was significantly lower in the iNO than in the control group, whereas overall rates of BPD, death and major complications were similar between the two groups. Infants who started MV and iNO on postnatal days 15 to 21 had significantly increased survival without BPD (47.6% vs 17.1%, P=0.03, relative risk 2.7, 95% confidence interval 1.1 to 6.5). Additionally, pooled data from both groups showed that rates of perinatal co-morbidities and postnatal complications were higher in BPD infants than in non-BPD infants. The overall incidence of BPD was 55.6% and 75.9% for birth weight <1500 and <1000 g, respectively, or 1.6% for the total population <34 weeks of gestation admitted through the network. CONCLUSION Treatment with low-dose iNO did not decrease the overall risk of BPD and death nor showed adverse effects in short-term morbidities among very preterm infants. The benefit of delayed iNO treatment on BPD warrants further studies.
Collapse
|
17
|
Handley SC, Steinhorn RH, Hopper AO, Govindaswami B, Bhatt DR, Van Meurs KP, Ariagno RL, Gould JB, Lee HC. Inhaled nitric oxide use in preterm infants in California neonatal intensive care units. J Perinatol 2016; 36:635-9. [PMID: 27031320 PMCID: PMC4963282 DOI: 10.1038/jp.2016.49] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/25/2015] [Accepted: 01/25/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe inhaled nitric oxide (iNO) exposure in preterm infants and variation in neonatal intensive care unit (NICU) use. STUDY DESIGN This was a retrospective cohort study of infants, 22 to 33+6/7 weeks of gestational age (GA), during 2005 to 2013. Analyses were stratified by GA and included population characteristics, iNO use over time and hospital variation. RESULTS Of the 65 824 infants, 1718 (2.61%) received iNO. Infants, 22 to 24+6/7 weeks of GA, had the highest incidence of iNO exposure (6.54%). Community NICUs (n=77, median hospital use rate 0.7%) used less iNO than regional NICUs (n=23, median hospital use rate 5.8%). In 22 to 24+6/7 weeks of GA infants, the median rate in regional centers was 10.6% (hospital interquartile range 3.8% to 22.6%). CONCLUSION iNO exposure varied with GA and hospital level, with the most use in extremely premature infants and regional centers. Variation reflects a lack of consensus regarding the appropriate use of iNO for preterm infants.
Collapse
Affiliation(s)
- S C Handley
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - R H Steinhorn
- Department of Pediatrics, University of California, Davis, Davis, CA, USA
| | - A O Hopper
- Department of Pediatrics, Loma Linda University, Loma Linda, CA, USA
| | - B Govindaswami
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - D R Bhatt
- Department of Pediatrics, Kaiser Permanente, Fontana, CA, USA
| | - K P Van Meurs
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - R L Ariagno
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Oak Ridge Institute for Research and Education (ORISE), Oak Ridge, TN, USA
- US Food and Drug Administration, Silver Spring, MD, USA
| | - J B Gould
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| | - H C Lee
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| |
Collapse
|
18
|
Truog WE, Nelin LD, Das A, Kendrick DE, Bell EF, Carlo WA, Higgins RD, Laptook AR, Sanchez PJ, Shankaran S, Stoll BJ, Van Meurs KP, Walsh MC. Inhaled nitric oxide usage in preterm infants in the NICHD Neonatal Research Network: inter-site variation and propensity evaluation. J Perinatol 2014; 34:842-6. [PMID: 24901452 PMCID: PMC4323079 DOI: 10.1038/jp.2014.105] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/10/2014] [Accepted: 04/14/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The use of inhaled nitric oxide (iNO) in preterm infants remains controversial. In October 2010, a National Institutes of Health consensus development conference cautioned against use of iNO in preterm infants. This study aims (1) to determine the prevalence and variability in use of iNO in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN) before and after the consensus conference and (2) separately, to examine associations between iNO use and severe bronchopulmonary dysplasia (BPD) or death. STUDY DESIGN The NICHD NRN Generic Database collects data including iNO use on very preterm infants. A total of 13 centers contributed data across the time period 2008 to 2011. Infants exposed or not to iNO were compared using logistic regression, which included factors related to risk as well as their likelihood of being exposed to iNO. RESULT A total of 4885 infants were assessed between 2008 and 2011; 128 (2.6%) received iNO before day 7, 140 (2.9%) between day 7 and 28, and 47 (1.0%) at >28 days. Center-specific iNO use during 2008 to 2010 ranged from 21.9 to 0.4%; 12 of 13 sites reduced usage and overall NRN iNO usage decreased from 4.6 to 1.6% (P<0.001) in 2011. The use of iNO started between day 7 and day 14 was more prevalent among younger infants with more severe courses in week 1 and associated with increased risk of severe BPD or death (odds ratio 2.24; 95% confidence interval 1.23 to 4.07). CONCLUSION The variability and total use of iNO decreased in 2011 compared with 2008 to 2010. iNO administration started at ⩾ day 7 was associated with more severe outcomes compared with infants without iNO exposure.
Collapse
Affiliation(s)
- W E Truog
- Center for Infant Pulmonary Disorders, Children's Mercy Hospitals and Clinics and the University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - L D Nelin
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University School of Medicine, Columbus, OH, USA
| | - A Das
- Statistics & Epidemiology Unit, RTI International, Rockville, MD, USA
| | - D E Kendrick
- Statistics & Epidemiology Unit, RTI International, Rockville, MD, USA
| | - E F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - W A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - R D Higgins
- Eunice Kennedy Shriver National Institute of Health & Human Development, National Institutes of Health, Bethesda, MD, USA
| | - A R Laptook
- Department of Pediatrics, Women & Infants' Hospital, Brown University School of Medicine, Providence, RI, USA
| | - P J Sanchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - S Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - B J Stoll
- Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - K P Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo, Alto, CA, USA
| | - M C Walsh
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
19
|
Variation in treatment of neonatal abstinence syndrome in US children's hospitals, 2004-2011. J Perinatol 2014; 34:867-72. [PMID: 24921412 DOI: 10.1038/jp.2014.114] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/11/2014] [Accepted: 05/05/2014] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by opioid-exposed infants. There is no standard treatment for NAS and surveys suggest wide variation in pharmacotherapy for NAS. Our objective was to determine whether different pharmacotherapies for NAS are associated with differences in outcomes and to determine whether pharmacotherapy and outcome vary by hospital. STUDY DESIGN We used the Pediatric Health Information System Database from 2004 to 2011 to identify a cohort of infants with NAS requiring pharmacotherapy. Mixed effects hierarchical negative binomial models evaluated the association between pharmacotherapy and hospital with length of stay (LOS), length of treatment (LOT) and hospital charges, after adjusting for socioeconomic variables and comorbid clinical conditions. RESULT Our cohort included 1424 infants with NAS from 14 children's hospitals. Among hospitals in our sample, six used morphine, six used methadone and two used phenobarbital as primary initial treatment for NAS. In multivariate analysis, when compared with NAS patients initially treated with morphine, infants treated with methadone had shorter LOT (incidence rate ratio (IRR) = 0.55; P < 0.0001) and LOS (IRR = 0.60; P < 0.0001). Phenobarbital as a second-line agent was associated with increased LOT (IRR = 2.09; P<0.0001), LOS (IRR = 1.78; P < 0.0001) and higher hospital charges (IRR = 1.84; P < 0.0001). After controlling for case-mix, hospitals varied in LOT, LOS and hospital charges. CONCLUSION We found variation in hospital in treatment for NAS among major US children's hospitals. In analyses controlling for possible confounders, methadone as initial treatment was associated with reduced LOT and hospital stay.
Collapse
|
20
|
Sasi A, Sehgal A. Use of inhaled nitric oxide in preterm infants: a regional survey of practices. Heart Lung 2014; 43:347-50. [PMID: 24856233 DOI: 10.1016/j.hrtlng.2014.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To conduct a regional survey of neonatal intensive care unit (NICU) Directors in Australia and New Zealand (ANZ) to ascertain current practice. BACKGROUND Use of inhaled nitric oxide (iNO) therapy in infants < 34 weeks gestational age is not supported by current evidence. METHODS A cross-sectional electronic survey based on structured questionnaire was conducted amongst the Directors of all the tertiary neonatal intensive care units in Australia and New Zealand Neonatal Network (ANZNN). Information was collected on indications, dosage, monitoring response and weaning for iNO therapy. RESULTS The survey was sent to 28 units, of which 2 were quaternary units' not routinely admitting preterm infants, hence were excluded from analysis. The response rate was 77% (20/26). Majority of units (16; 80%) did not have preterm specific protocol. In almost all units nitric was used as early rescue for hypoxemic respiratory failure (95%; 19/20). Neonatologist performed functional echocardiography (fECHO) was frequently used for prior assessment (90%) and monitoring (65%). Variations were noted regarding initiating criteria, dosage and weaning strategies. CONCLUSIONS Wide variation in practice was noted highlighting the need for the formulation of consensus guidelines.
Collapse
Affiliation(s)
- Arun Sasi
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
| | - Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| |
Collapse
|
21
|
Bardach NS, Coker TR, Zima BT, Murphy JM, Knapp P, Richardson LP, Edwall G, Mangione-Smith R. Common and costly hospitalizations for pediatric mental health disorders. Pediatrics 2014; 133:602-9. [PMID: 24639270 PMCID: PMC3966505 DOI: 10.1542/peds.2013-3165] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Inpatient pediatric mental health is a priority topic for national quality measurement and improvement, but nationally representative data on the patients admitted or their diagnoses are lacking. Our objectives were: to describe pediatric mental health hospitalizations at general medical facilities admitting children nationally; to assess which pediatric mental health diagnoses are frequent and costly at these hospitals; and to examine whether the most frequent diagnoses are similar to those at free-standing children's hospitals. METHODS We examined all discharges in 2009 for patients aged 3 to 20 years in the nationally representative Kids' Inpatient Database (KID) and in the Pediatric Health Information System (free-standing children's hospitals). Main outcomes were frequency of International Classification of Diseases, Ninth Revision, Clinical Modification-defined mental health diagnostic groupings (primary and nonprimary diagnosis) and, using KID, resource utilization (defined by diagnostic grouping aggregate annual charges). RESULTS Nearly 10% of pediatric hospitalizations nationally were for a primary mental health diagnosis, compared with 3% of hospitalizations at free-standing children's hospitals. Predictors of hospitalizations for a primary mental health problem were older age, male gender, white race, and insurance type. Nationally, the most frequent and costly primary mental health diagnoses were depression (44.1% of all mental health admissions; $1.33 billion), bipolar disorder (18.1%; $702 million), and psychosis (12.1%; $540 million). CONCLUSIONS We identified the child mental health inpatient diagnoses with the highest frequency and highest costs as depression, bipolar disorder, and psychosis, with substance abuse an important comorbid diagnosis. These diagnoses can be used as priority conditions for pediatric mental health inpatient quality measurement.
Collapse
Affiliation(s)
- Naomi S. Bardach
- Department of Pediatrics, University of California at San Francisco, San Francisco, California
| | - Tumaini R. Coker
- Children’s Discovery and Innovation Institute and Mattel Children’s Hospital University of California at Los Angeles, Los Angeles, California;,RAND Corporation, Santa Monica, California
| | - Bonnie T. Zima
- Department of Psychiatry and Biobehavioral Science, University of California at Los Angeles, Los Angeles, California
| | - J. Michael Murphy
- Child Psychiatry Service, Massachusetts General Hospital, Boston, Massachusetts;,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Penelope Knapp
- Department of Psychiatry, University of California at Davis, Davis, California
| | - Laura P. Richardson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington;,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Glenace Edwall
- Minnesota State Health Access Data Assistance Center, Minneapolis, Minnesota
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington;,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| |
Collapse
|
22
|
Dani C, Pratesi S. Nitric oxide for the treatment of preterm infants with respiratory distress syndrome. Expert Opin Pharmacother 2012. [PMID: 23194109 DOI: 10.1517/14656566.2013.746662] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Inhaled Nitric oxide (iNO) has been proposed as effective treatment for improving oxygenation in preterm infants with respiratory distress syndrome (RDS), and for preventing the development of bronchopulmonary dysplasia (BPD). AREAS COVERED This drug evaluation mainly reviews the results of clinical studies on the effects of iNO in preterm infants with RDS which have provided contradictory results probably due to their different designs. Three recent meta-analyses of these studies have concluded that iNO therapy is not effective in decreasing the risk of death and BPD and cannot be recommended as routine treatment. The same meta-analyses suggest that some strategy of iNO treatment and some subgroups of patients, such as infants with persistent pulmonary hypertension of the newborn (PPHN), should be further studied. EXPERT OPINION At present, the available evidence does not support the use of iNO in preterm infants with RDS, and iNO therapy cannot be recommended for the routine treatment of respiratory failure in premature neonates. In the future, further studies in selected populations using adequate doses and investigating the effectiveness of other drugs, such as sildenafil, might affect the use and diffusion of iNO.
Collapse
Affiliation(s)
- Carlo Dani
- Careggi University Hospital of Florence, Department of Surgical and Medical Critical Care, Section of Neonatology, Viale Morgagni, 85, 50134 Florence, Italy.
| | | |
Collapse
|