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Quiñones Cardona V, Cohen SS, Cook N, Cizmeci MN, Chandel A, DiGeronimo R, Gogcu S, Jano E, Kojima K, Lee KS, McAdams RM, Menkiti O, Mietzsch U, Peeples E, Sewell E, Shenberger JS, Massaro AN, Natarajan G, Rao R, Dizon MLV. The Current State of Neonatal Neurodevelopmental Follow-up Programs in North America: A Children's Hospitals Neonatal Consortium Report. Am J Perinatol 2024. [PMID: 38458236 DOI: 10.1055/a-2283-8843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVE This study aimed to determine neonatal neurodevelopmental follow-up (NDFU) practices across academic centers. STUDY DESIGN This study was a cross-sectional survey that addressed center-specific neonatal NDFU practices within the Children's Hospitals Neonatal Consortium (CHNC). RESULTS Survey response rate was 76%, and 97% of respondents had a formal NDFU program. Programs were commonly staffed by neonatologists (80%), physical therapists (77%), and nurse practitioners (74%). Median gestational age at birth identified for follow-up was ≤32 weeks (range 26-36). Median duration was 3 years (range 2-18). Ninety-seven percent of sites used Bayley Scales of Infant and Toddler Development, but instruments used varied across ages. Scores were recorded in discrete electronic data fields at 43% of sites. Social determinants of health data were collected by 63%. Care coordination and telehealth services were not universally available. CONCLUSION NDFU clinics are almost universal within CHNC centers. Commonalities and variances in practice highlight opportunities for data sharing and development of best practices. KEY POINTS · Neonatal NDFU clinics help transition high-risk infants home.. · Interdisciplinary neonatal intensive care unit follow-up brings together previously separated outpatient service lines.. · This study reviews the current state of neonatal NDFU in North America..
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Affiliation(s)
- Vilmaris Quiñones Cardona
- Division of Neonatology, Department of Pediatrics, Drexel University, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Susan S Cohen
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Noah Cook
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mehmet N Cizmeci
- Division of Neonatology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amit Chandel
- Division of Neonatology, Department of Pediatrics, Wake Forest University, Brenner Children's Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake Forest University, Brenner Children's Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Eni Jano
- Division of Neonatology, Department of Pediatrics, University of Southern California, Children's Hospital Los Angeles, Los Angeles, California
| | - Katsuaki Kojima
- Division of Neonatology, Department of Pediatrics, University of Cincinnati, Cincinnati Children's, Cincinnati, Ohio
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ryan M McAdams
- Division of Neonatology, Department of Pediatrics, University of Wisconsin, American Family Children's Hospital, Madison, Wisconsin
| | - Ogechukwu Menkiti
- Division of Neonatology, Department of Pediatrics, Drexel University, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Eric Peeples
- Department of Pediatrics, Division of Neonatology, University of Nebraska, Children's Hospital & Medical Center, Omaha, Nebraska
| | - Elizabeth Sewell
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey S Shenberger
- Division of Neonatology, Department of Pediatrics, University of Connecticut, Connecticut Childrens, Harford, Connecticut
| | - An N Massaro
- Division of Neonatology, Department of Pediatrics, George Washington University, Children's National Medical Center, Washington, District of Columbia
| | - Girija Natarajan
- Division of Neonatology, Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Michigan
| | - Rakesh Rao
- Division of Neonatology, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri
| | - Maria L V Dizon
- Division of Neonatology, Department of Pediatrics, Northwestern University, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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McKissic D, Perez FA, Puia-Dumitrescu M, Ryan R, Hendrixson DT, Billimoria Z, DiGeronimo R, Sawyer T. Maternal COVID-19 Infection Associated with Fetal Systemic Inflammatory Complications in COVID-19-Negative Neonates: A Case-Series. Am J Perinatol 2024. [PMID: 38134940 DOI: 10.1055/a-2234-8064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
OBJECTIVE This study aimed to examine fetal and neonatal inflammatory and neurologic complications associated with maternal coronavirus disease 2019 (COVID-19) infection. STUDY DESIGN Case-series using a convenience sample of neonates cared for in a large referral-based children's hospital neonatal intensive care unit between September 2021 and May 2022. RESULTS We identified seven neonates with exposure to maternal severe acute respiratory syndrome related coronavirus 2 (SARS-CoV-2) and a presentation consistent with inflammatory complications. All had some degree of neurologic injury with neuroimaging findings including restricted diffusion indicating injury in the white matter, cortex, deep gray structures, and splenium of the corpus callosum as well as intracranial hemorrhage. In addition, many infants had cytopenia and abnormal coagulation studies. Placental pathology, when available, revealed inflammation, clot with calcifications, and hematomas with associated infarcts. CONCLUSION Neonates born to mothers with SARS-CoV-2, even when negative for the virus themselves, may have complications consistent with a systemic inflammatory syndrome. Placental pathology as well as neurologic imaging in infants with neurologic findings may help to support this diagnosis. KEY POINTS · A systemic inflammatory response may cause illness in babies born to mothers with a history of COVID-19.. · Inflammatory markers and placental pathology are helpful in supporting this diagnosis.. · Consider neuroimaging in infants of mothers with a history of COVID-19 with neurologic findings..
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Affiliation(s)
- Devin McKissic
- Division of Neonatology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Francisco A Perez
- Department of Radiology, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Ramah Ryan
- Division of Neonatology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - D Taylor Hendrixson
- Division of Neonatology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
- Division of Infectious Disease, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Zeenia Billimoria
- Division of Neonatology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
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Nayak SP, Huff KA, Zaniletti I, Ahmad I, DiGeronimo R, Hair A, Kim J, Markel TA, Piazza A, Reber K, Roberts J, Sharma J, Sullivan K, Premkumar MH, Yanowitz T. Cholestasis is associated with a higher rate of complications in both medical and surgical necrotizing enterocolitis. J Perinatol 2024; 44:100-107. [PMID: 37805591 DOI: 10.1038/s41372-023-01787-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVE To evaluate the relationship between cholestasis and outcomes in medical and surgical necrotizing enterocolitis (NEC). STUDY DESIGN A retrospective analysis of prospectively collected data from 1472 infants with NEC [455 medical (mNEC) and 1017 surgical (sNEC)] from the Children's Hospital Neonatal Database. RESULTS The prevalence of cholestasis was lower in mNEC versus sNEC (38.2% vs 70.1%, p < 0.001). In both groups, cholestasis was associated with lower birth gestational age [mNEC: OR 0.79 (95% CI 0.68-0.92); sNEC: OR 0.86 (95% CI 0.79-0.95)] and increased days of parenteral nutrition [mNEC: OR 1.08 (95% CI 1.04-1.13); sNEC: OR 1.01 (95% CI 1.01-1.02)]. For both groups, the highest direct bilirubin was associated with the composite outcome mortality or length of stay >75th percentile [mNEC: OR 1.21 (95% CI 1.06-1.38); sNEC: OR 1.06 (95% CI 1.03-1.09)]. CONCLUSION Cholestasis with both medical NEC and surgical NEC is associated with adverse patient outcomes including increased mortality or extreme length of stay.
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Affiliation(s)
| | - Katie A Huff
- Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | | | - Irfan Ahmad
- Children's Hospitals Orange County, Orange, CA, USA
| | - Robert DiGeronimo
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Amy Hair
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jae Kim
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Troy A Markel
- Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | | | - Kristina Reber
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | | | | | | | | | - Toby Yanowitz
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Kwon EG, Anderson JE, DiGeronimo R, Kirk CCJ, Billimoria ZC, Rothstein DH, Stark R, McMullan DM, Brogan TV, Riehle KJ, Rice-Townsend SE. Carotid Artery Patency and Neurodevelopmental Outcomes After Decannulation in Pediatric Extracorporeal Life Support. J Surg Res 2024; 293:475-481. [PMID: 37820396 DOI: 10.1016/j.jss.2023.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Decannulation from veno-arterial extracorporeal life support may involve ligation or repair of the carotid artery; however, differences in outcomes are not clear. This study aimed to describe short- and long-term artery patency and neurodevelopmental outcomes in neonatal and pediatric patients who underwent carotid artery repair (CAR) versus ligation at decannulation. METHODS Patients supported on veno-arterial extracorporeal life support during the first 15 mo of life from 2010 to 2020 at a large, tertiary care children's hospital were included. Decannulation strategy, postdecannulation imaging, and follow-up visits were reviewed. RESULTS 74 patients were identified with median age at cannulation 2 d (interquartile range [IQR] = 1-21 d) and median weight 3.7 kg (interquartile range= 3.2-4.4 kg). Indications included congenital cardiac conditions (27%), congenital diaphragmatic hernia (19%), pulmonary hypertension (19%), meconium aspiration (16%), and pneumonia/sepsis (14%). Forty-two patients (57%) underwent CAR. Patients on extracorporeal life support >5 d were 95% less likely to undergo CAR (P < 0.001). Of CAR patients, 18 (43%) had doppler ultrasound performed within the 2-y follow-up period. Ten of 18 patients (55.6%) had >50% stenosis (3) or complete occlusion (7). Only 36% (27/74) had formal neurodevelopmental follow-up within 6 mo and 41% (30/74) within 2 y; however, no significant differences in function were seen between groups. CONCLUSIONS Neonates and young toddler patients undergoing CAR following extracorporeal life support decannulation are at risk for partial or complete artery occlusion. In our study population, repair and ligation at decannulation appear to have similar neurodevelopmental outcomes; however, follow-up to assess function is not standardized. Longer term follow-up and risk stratification are needed to guide decannulation strategy.
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Affiliation(s)
- Eustina G Kwon
- Seattle Children's Hospital, University of Washington, Seattle, Washington.
| | - Jamie E Anderson
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Christa C J Kirk
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | | | - David H Rothstein
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Rebecca Stark
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - D Michael McMullan
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Thomas V Brogan
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Kimberly J Riehle
- Seattle Children's Hospital, University of Washington, Seattle, Washington
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Wild KT, Miquel-Verges F, Rintoul NE, DiGeronimo R, Keene S, Hamrick SE, Mahmood B, Rao R, Carr NR. Current Practices for Genetic Testing in Neonatal Extracorporeal Membrane Oxygenation: Findings from a National survey. Perfusion 2024; 39:116-123. [PMID: 36169593 DOI: 10.1177/02676591221130178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Comprehensive genetic testing with whole-exome (WES) or whole-genome (WGS) sequencing facilitates diagnosis, can optimize treatment, and may improve outcomes in critically ill neonates, including those requiring extracorporeal membrane oxygenation (ECMO) for respiratory failure. Our objective was to describe practice variation and barriers to the utilization of comprehensive genetic testing for neonates on ECMO.Methods: We performed a cross-sectional survey of Level IV neonatal intensive care units in the United States across the Children's Hospitals Neonatal Consortium (CHNC).Results: Common indications for WES and WGS included concerning phenotype, severity of disease, unexpected postnatal clinical course, and inability to wean from ECMO support. Unexpected severity of disease on ECMO was the most common indication for rapid genetic testing. Cost of utilization was the primary barrier to testing. If rapid WES or WGS were readily available, 63% of centers would consider incorporating universal screening for neonates upon ECMO cannulation.Conclusion: Despite variation in the use of WES and WGS, universal testing may offer earlier diagnosis and influence the treatment course among neonates on ECMO. Cost is the primary barrier to utilization and most centers would consider incorporating universal screening on ECMO if readily available.
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Affiliation(s)
- K Taylor Wild
- Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | | | - Natalie E Rintoul
- Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle WA, USA
| | - Sarah Keene
- Children's Healthcare of Atlanta, School of Medicine, Emory University, Atlanta, GA, USA
| | - Shannon E Hamrick
- Children's Healthcare of Atlanta, School of Medicine, Emory University, Atlanta, GA, USA
| | - Burhan Mahmood
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rakesh Rao
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Nicholas R Carr
- Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, UT, USA
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6
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Linden AF, Howk AA, Billimoria Z, Devine M, DiGeronimo R, Gray B, Hamrick SE, Keene SD, Rintoul N, Mahmood B. Neonatal Carotid Artery and Internal Jugular Vein Management Practices at Extracorporeal Membrane Oxygenation Decannulation: No Standard Approach. J Pediatr Surg 2023; 58:2196-2200. [PMID: 37573253 DOI: 10.1016/j.jpedsurg.2023.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND There are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging. METHODS A survey was distributed to the 37 institutions in the Children's Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols. RESULTS The response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging. CONCLUSIONS Significant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Allison F Linden
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA.
| | - Amy A Howk
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Zeenia Billimoria
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Matthew Devine
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Brian Gray
- Department of Surgery, Indiana University, 705 Riley Hospital Dr, Bloomington, IN, 46202, USA
| | - Shannon E Hamrick
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Sarah D Keene
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Natalie Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Burhan Mahmood
- UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, Division of Newborn Medicine, University of Pittsburgh School of Medicine, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
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Hanna M, Ahmad I, Yanowitz T, Kim J, Hunter C, DiGeronimo R, Ahmad KA, Sullivan K, Markel TA, Hair AB, Chaaban H, Pammi M, Huff KA, Jasani B, Fuchs L, Cuna A, Garg PM, Reber K, Premkumar MH. Current Patterns of Probiotic Use in U.S. Neonatal Intensive Care Units: A Multi-Institution Survey. Am J Perinatol 2023. [PMID: 37494969 DOI: 10.1055/a-2140-8727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE Probiotic supplementation is associated with health benefits in preterm infants. The 2021 American Academy of Pediatrics (AAP) statement on probiotic use advised caution, citing heterogeneity and absence of federal regulation. We assessed the impact of the AAP statement and current institution-wide patterns of probiotic use across neonatal intensive care units (NICU) across the United States. STUDY DESIGN A cross-sectional web-based institutional survey using REDCap was emailed to 430 Children's Hospital Neonatal Consortium (CHNC) and Pediatrix Medical Group institutions. The survey captured data on probiotic formulations, supplementation, initiation and cessation criteria, reasons for discontinuation, interest in initiating, and AAP statement's impact. RESULTS Ninety-five (22.1%) hospitals, including 42/46 (91%) CHNC and 53/384 (14%) Pediatrix institutions, completed the survey. Thirty-seven (39%) currently use probiotics. Fourteen different probiotic formulations were reported. The common criteria for initiation were birth weight <1,500 g and gestational age <32 weeks. Parental consent or assent was obtained at only 30% of institutions. Five hospitals (11%) with prior probiotic use discontinued solely due to the AAP statement. Overall, 23 (24%) of hospitals indicated that the AAP statement significantly influenced their decision regarding probiotic use. Nineteen of 51 nonusers (37%) are considering initiation. CONCLUSION Probiotic use in preterm infants is likely increasing in NICUs across the United States, but significant variability exists. The 2021 AAP statement had variable impact on NICUs' decision regarding probiotic use. The growing interest in adopting probiotics and the significant interhospital variability highlight the need for better regulation and consensus guidelines to ensure standardized use. KEY POINTS · Probiotic use in preterm infants is likely increasing in U.S. NICUs, but clinical variability exists.. · The AAP statement on probiotic use in preterm infants had a modest impact on current practices.. · There's a need for better product regulation and consensus guidelines to ensure standardized use..
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Affiliation(s)
- Morcos Hanna
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas
| | - Irfan Ahmad
- Division of Neonatology, Children's Hospitals Orange County, Orange, California
| | - Toby Yanowitz
- Division of Neonatology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jae Kim
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Catherine Hunter
- Department of Surgery, Division of Pediatric Surgery, Oklahoma Children's Hospital, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Robert DiGeronimo
- Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Kaashif A Ahmad
- Department of Pediatrics, Pediatrix and Obstetrix Specialists of Houston, Houston, Texas
| | - Kevin Sullivan
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Neonatology, Nemours/AI duPont Hospital for Children, Wilmington, Delaware
| | - Troy A Markel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Amy B Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas
| | - Hala Chaaban
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Mohan Pammi
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas
| | - Katie A Huff
- Division of Neonatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Bonny Jasani
- Division of Neonatology, Hospital for Sick Children, Toronto, Canada
| | - Lynn Fuchs
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Neonatology, Nemours/AI duPont Hospital for Children, Wilmington, Delaware
| | - Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Parvesh M Garg
- Division of Neonatology, Wake Forest University, Winston Salem, North Carolina
| | - Kristina Reber
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas
| | - Muralidhar H Premkumar
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas
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Yung D, Jackson EO, Blumenfeld A, Redding G, DiGeronimo R, McGuire JK, Riker M, Tressel W, Berkelhamer S, Eldredge LC. A multidisciplinary approach to severe bronchopulmonary dysplasia is associated with resolution of pulmonary hypertension. Front Pediatr 2023; 11:1077422. [PMID: 37063675 PMCID: PMC10098720 DOI: 10.3389/fped.2023.1077422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/08/2023] [Indexed: 04/18/2023] Open
Abstract
Objective To describe our multidisciplinary bronchopulmonary dysplasia (BPD) consult team's systematic approach to BPD associated pulmonary hypertension (PH), to report our center outcomes, and to evaluate clinical associations with outcomes. Study design Retrospective cohort of 60 patients with BPD-PH who were referred to the Seattle Children's Hospital BPD team from 2018 to 2020. Patients with critical congenital heart disease were excluded. Demographics, comorbidities, treatments, closure of hemodynamically relevant intracardiac shunts, and clinical outcomes including time to BPD-PH resolution were reviewed. Results Median gestational age of the 60 patients was 25 weeks (IQR: 24-26). 20% were small for gestational age (SGA), 65% were male, and 25% received a tracheostomy. With aggressive cardiopulmonary management including respiratory support optimization, patent ductus arteriosus (PDA) and atrial septal defect (ASD) closure (40% PDA, 5% ASD, 3% both), and limited use of pulmonary vasodilators (8%), all infants demonstrated resolution of PH during the follow-up period, including three (5%) who later died from non-BPD-PH morbidities. Neither SGA status nor the timing of PH diagnosis (<36 vs. ≥36 weeks PMA) impacted the time to BPD-PH resolution in our cohort [median 72 days (IQR 30.5-166.5)]. Conclusion Our multidisciplinary, systematic approach to BPD-PH management was associated with complete resolution of PH with lower mortality despite less sildenafil use than reported in comparable cohorts. Unique features of our approach included aggressive PDA and ASD device closure and rare initiation of sildenafil only after lack of BPD-PH improvement with respiratory support optimization and diagnostic confirmation by cardiac catheterization.
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Affiliation(s)
- Delphine Yung
- Division of Cardiology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Emma O. Jackson
- Heart Center, Seattle Children’s Hospital, Seattle, WA, United States
| | - Alyssa Blumenfeld
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Gregory Redding
- Division of Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, and Seattle Children’s Hospital, Seattle, WA, United States
| | - John K. McGuire
- Division of Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Meredith Riker
- Heart Center, Seattle Children’s Hospital, Seattle, WA, United States
| | - William Tressel
- Collaborative Health Studies Coordinating Center, Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Sara Berkelhamer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, and Seattle Children’s Hospital, Seattle, WA, United States
| | - Laurie C. Eldredge
- Division of Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
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Quinones Cardona V, Rao R, Zaniletti I, Joe P, Johnson YR, DiGeronimo R, Hamrick SE, Lee KS, Mietzsch U, Natarajan G, Peeples ES, Wu TW, Hossain T, Flibotte J, Chandel A, Distler A, Shenberger JS, Oghifobibi O, Massaro AN, Dizon MLV. Association of Hospital Resource Utilization With Neurodevelopmental Outcomes in Neonates With Hypoxic-Ischemic Encephalopathy. JAMA Netw Open 2023; 6:e233770. [PMID: 36943267 PMCID: PMC10031395 DOI: 10.1001/jamanetworkopen.2023.3770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
IMPORTANCE Intercenter variation exists in the management of hypoxic-ischemic encephalopathy (HIE). It is unclear whether increased resource utilization translates into improved neurodevelopmental outcomes. OBJECTIVE To determine if higher resource utilization during the first 4 days of age, quantified by hospital costs, is associated with survival without neurodevelopmental impairment (NDI) among infants with HIE. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of neonates with HIE who underwent therapeutic hypothermia (TH) at US children's hospitals participating in the Children's Hospitals Neonatal Database between 2010 and 2016. Data were analyzed from December 2021 to December 2022. EXPOSURES Infants who survived to 4 days of age and had neurodevelopmental outcomes assessed at greater than 11 months of age were divided into 2 groups: (1) death or NDI and (2) survived without NDI. Resource utilization was defined as costs of hospitalization including neonatal neurocritical care (NNCC). Data were linked with Pediatric Health Information Systems to quantify standardized costs by terciles. MAIN OUTCOMES AND MEASURES The main outcome was death or NDI. Characteristics, outcomes, hospitalization, and NNCC costs were compared. RESULTS Among the 381 patients who were included, median (IQR) gestational age was 39 (38-40) weeks; maternal race included 79 (20.7%) Black mothers, 237 (62.2%) White mothers, and 58 (15.2%) mothers with other race; 80 (21%) died, 64 (17%) survived with NDI (combined death or NDI group: 144 patients [38%]), and 237 (62%) survived without NDI. The combined death or NDI group had a higher rate of infants with Apgar score at 10 minutes less than or equal to 5 (65.3% [94 of 144] vs 39.7% [94 of 237]; P < .001) and a lower rate of infants with mild or moderate HIE (36.1% [52 of 144] vs 82.3% [195 of 237]; P < .001) compared with the survived without NDI group. Compared with low-cost centers, there was no association between high- or medium-hospitalization cost centers and death or NDI. High- and medium-EEG cost centers had lower odds of death or NDI compared with low-cost centers (high vs low: OR, 0.30 [95% CI, 0.16-0.57]; medium vs low: OR, 0.29 [95% CI, 0.13-0.62]). High- and medium-laboratory cost centers had higher odds of death or NDI compared with low-cost centers (high vs low: OR, 2.35 [95% CI, 1.19-4.66]; medium vs low: OR, 1.93 [95% CI, 1.07-3.47]). High-antiseizure medication cost centers had higher odds of death or NDI compared with low-cost centers (high vs. low: OR, 3.72 [95% CI, 1.51-9.18]; medium vs low: OR, 1.56 [95% CI, 0.71-3.42]). CONCLUSIONS AND RELEVANCE Hospitalization costs during the first 4 days of age in neonates with HIE treated with TH were not associated with neurodevelopmental outcomes. Higher EEG costs were associated with lower odds of death or NDI yet higher laboratory and antiseizure medication costs were not. These findings serve as first steps toward identifying aspects of NNCC that are associated with outcomes.
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Affiliation(s)
- Vilmaris Quinones Cardona
- St Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Rakesh Rao
- St Louis Children's Hospital, St Louis, Missouri
| | | | - Priscilla Joe
- UCSF Benioff Children's Hospital, Oakland, California
| | - Yvette R Johnson
- Cook's Children's Medical Center, Department of Pediatrics, Texas Christian University Medical School, Fort Worth
| | | | - Shannon E Hamrick
- Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Kyong-Soon Lee
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ulrike Mietzsch
- Seattle Children's Hospital, University of Washington, Seattle
| | - Girija Natarajan
- Children's Hospital of Michigan, Central Michigan University, Detroit
| | | | - Tai-Wei Wu
- Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | | | - John Flibotte
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amit Chandel
- Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amy Distler
- St Louis Children's Hospital, St Louis, Missouri
| | - Jeffrey S Shenberger
- Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - An N Massaro
- Childrens National Health Systems, Washington, DC
| | - Maria L V Dizon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Weems MF, Grover TR, Seabrook R, DiGeronimo R, Gien J, Keene S, Rintoul N, Daniel JM, Johnson Y, Guner Y, Zaniletti I, Murthy K. Analgesia, Sedation, and Neuromuscular Blockade in Infants with Congenital Diaphragmatic Hernia. Am J Perinatol 2023; 40:415-423. [PMID: 34044457 DOI: 10.1055/s-0041-1729877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to describe the use, duration, and intercenter variation of analgesia and sedation in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN This is a retrospective analysis of analgesia, sedation, and neuromuscular blockade use in neonates with CDH. Patient data from 2010 to 2016 were abstracted from the Children's Hospitals Neonatal Database and linked to the Pediatric Health Information System. Patients were excluded if they also had non-CDH conditions likely to affect the use of the study medications. RESULTS A total of 1,063 patients were identified, 81% survived, and 30% were treated with extracorporeal membrane oxygenation (ECMO). Opioid (99.8%), sedative (93.4%), and neuromuscular blockade (87.9%) use was common. Frequency of use was higher and duration was longer among CDH patients treated with ECMO. Unadjusted duration of use varied 5.6-fold for benzodiazepines (median: 14 days) and 7.4-fold for opioids (median: 16 days). Risk-adjusted duration of use varied among centers, and prolonged use of both opioids and benzodiazepines ≥5 days was associated with increased mortality (p < 0.001) and longer length of stay (p < 0.001). Use of sedation or neuromuscular blockade prior to or after surgery was each associated with increased mortality (p ≤ 0.01). CONCLUSION Opioids, sedatives, and neuromuscular blockade were used commonly in infants with CDH with variable duration across centers. Prolonged combined use ≥5 days is associated with mortality. KEY POINTS · Use of analgesia and sedation varies across children's hospital NICUs.. · Prolonged opioid and benzodiazepine use is associated with increased mortality.. · Postsurgery sedation and neuromuscular blockade are associated with mortality..
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Affiliation(s)
- Mark F Weems
- Division of Neonatology, Department of Pediatrics, Le Bonheur Children's Hospital and the University of Tennessee Health Science Center, Memphis, Tennessee
| | - Theresa R Grover
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | | | - Robert DiGeronimo
- Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Jason Gien
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah Keene
- Department of Pediatrics, Children's Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie Rintoul
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - John M Daniel
- Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri Kansas, Kansas City, Missouri
| | - Yvette Johnson
- Department of Neonatology, Cook Children's Hospital, Fort Worth, Texas
| | - Yigit Guner
- Children's Hospital of Orange County and University of California Irvine, Orange, California
| | | | - Karna Murthy
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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11
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Porta NFM, Naing K, Keene S, Grover TR, Hedrick H, Mahmood B, Seabrook R, Daniel Iv J, Harrison A, Weems MF, Yoder BA, DiGeronimo R, Haberman B, Dariya V, Guner Y, Rintoul NE, Murthy K. Variability for Age at Successful Extubation in Infants with Congenital Diaphragmatic Hernia. J Pediatr 2023; 253:129-134.e1. [PMID: 36202240 DOI: 10.1016/j.jpeds.2022.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/30/2022] [Accepted: 09/18/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to characterize clinical factors associated with successful extubation in infants with congenital diaphragmatic hernia. STUDY DESIGN Using the Children's Hospitals Neonatal Database, we identified infants with congenital diaphragmatic hernia from 2017 to 2020 at 32 centers. The main outcome was age in days at the time of successful extubation, defined as the patient remaining extubated for 7 consecutive days. Unadjusted Kaplan-Meier and multivariable Cox proportional hazards ratio equations were used to estimate associations between clinical factors and the main outcome. Observations occurred through 180 days after birth. RESULTS There were 840 eligible neonates with a median gestational age of 38 weeks and birth weight of 3.0 kg. Among survivors (n = 693), the median age at successful extubation was 15 days (interquartile range [IQR]: 8-29 days, 95th percentile: 71 days). For nonsurvivors (n = 147), the median age at death was 21 days (IQR: 11-39 days, 95th percentile: 110 days). Center (adjusted hazards ratio: 0.22-15, P < .01), low birth weight, intrathoracic liver position, congenital heart disease, lower 5-minute Apgar score, lower pH upon admission to Children's Hospitals Neonatal Database center, and use of extracorporeal support were independently associated with older age at successful extubation. Tracheostomy was associated with multiple failed extubations. CONCLUSION Our findings suggest that infants who have not successfully extubated by about 3 months of age may be candidates for tracheostomy with chronic mechanical ventilation or palliation. The variability of timing of successful extubation among our centers supports the development of practice guidelines after validating clinical criteria.
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Affiliation(s)
- Nicolas F M Porta
- Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie Children's Hospitals of Chicago, Chicago, IL.
| | - Khatija Naing
- School of Public Health, University of Illinois at Chicago, Chicago, IL; Children's Hospitals Neonatal Consortium, Dover, DE
| | - Sarah Keene
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Theresa R Grover
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Holly Hedrick
- Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Burhan Mahmood
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ruth Seabrook
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - John Daniel Iv
- Children's Mercy Hospitals and Clinics and University of Missouri -Kansas City, Kansas City, MO
| | - Allen Harrison
- Neonatal Intensive Care Unit, Arkansas Children's Hospital, Little Rock, AR
| | - Mark F Weems
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Bradley A Yoder
- University of Utah School of Medicine and Primary Children's Hospital, Salt Lake City, UT
| | - Robert DiGeronimo
- University of Washington and Seattle Children's Hospital, Seattle, WA
| | - Beth Haberman
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati School of Medicine
| | - Vedanta Dariya
- University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX
| | - Yigit Guner
- Division of Pediatric Surgery Children's Hospital of Orange County and Department of Surgery University of California Irvine, Orange, CA
| | - Natalie E Rintoul
- Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Karna Murthy
- Children's Hospitals Neonatal Consortium, Dover, DE; Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie Children's Hospitals of Chicago, Chicago, IL
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12
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Huff KA, Nayak SP, Ahmad I, DiGeronimo R, Hair A, Kim JH, Markel T, Piazza A, Reber K, Roberts J, Sharma J, Sullivan K, Ahmad KA, Yanowitz T, Premkumar MH. Patterns of lipid-injectable emulsion use in neonatal intensive care units across the United States: A multi-institution survey. JPEN J Parenter Enteral Nutr 2023; 47:51-58. [PMID: 35689505 DOI: 10.1002/jpen.2422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/28/2022] [Accepted: 06/07/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Lipid-injectable emulsions (ILEs) are a necessity for neonates dependent on parenteral nutrition (PN). In this manuscript, we describe the patterns of ILE use in neonatal intensive care units (NICUs) in the United States (US). METHODS An electronic survey was sent to 488 NICUs across the US between December 2020 and March 2021. Survey fields included availability and utilization of various ILE in neonates. RESULTS The response rate was 22% (107 out of 488). Soybean oil ILE (SO-ILE) and soybean oil, medium-chain triglycerides, olive oil, fish oil ILE (SO, MCT, OO, FO-ILE) had similar availability (87% vs 86%, respectively), and SO, MCT, OO, FO-ILE was more commonly used (SO-ILE, 71% vs SO, MCT, OO, FO-ILE, 86%). Fish oil-ILE (FO-ILE) was used by 55% of centers. SO-ILE was most frequently used with PN and needs <4 weeks without cholestasis (79%). The most common reason for SO, MCT, OO, FO-ILE use was cholestasis (71%). ILE minimization was used by 28% of SO-ILE and 22% of SO, MCT, OO, FO-ILE users; 95% of these centers restrict SO, MCT, OO, FO-ILE to doses ≤2 g/kg/day. Twenty-two percent of centers started FO-ILE at direct bilirubin of >5 mg/dl. CONCLUSION The results of this survey reveal significant variability in ILE usage across the US. Lipid minimization with SO, MCT, OO, FO-ILE and initiation of FO-ILE for cholestasis at higher bilirubin thresholds are prevalent. Such reports are crucial for a better understanding of ILE use in the NICU and in future ILE development.
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Affiliation(s)
- Katie A Huff
- Department of Pediatrics, Division of Neonatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sujir Pritha Nayak
- Department of Pediatrics, Division of Neonatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Irfan Ahmad
- Division of Neonatology, Children's Hospitals Orange County, Orange, California, USA
| | - Robert DiGeronimo
- Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Amy Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Troy Markel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Anthony Piazza
- Division of Neonatal-Perinatal Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kristina Reber
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jessica Roberts
- Division of Neonatal-Perinatal Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jotishna Sharma
- Department of Pediatrics, Division of Neonatology, University of Missouri - Kansas School of Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kevin Sullivan
- Division of Neonatal and Perinatal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kaashif A Ahmad
- Division of Neonatology, Pediatrix and Obstetrix Specialists of Houston, Houston, Texas, USA
| | - Toby Yanowitz
- Department of Pediatrics, Division of Newborn Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
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13
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Ahmad I, Premkumar MH, Hair AB, Sullivan KM, Zaniletti I, Sharma J, Nayak SP, Reber KM, Padula M, Brozanski B, DiGeronimo R, Yanowitz TD. Variability in antibiotic duration for necrotizing enterocolitis and outcomes in a large multicenter cohort. J Perinatol 2022; 42:1458-1464. [PMID: 35760891 DOI: 10.1038/s41372-022-01433-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 05/01/2022] [Accepted: 06/09/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To evaluate variability in antibiotic duration for necrotizing enterocolitis (NEC) and associated clinical outcomes. STUDY DESIGN Five-hundred ninety-one infants with NEC (315 medical; 276 surgical) were included from 22 centers participating in Children's Hospitals Neonatal Consortium (CHNC). Multivariable analyses were used to determine predictors of variability in time to full feeds (TFF) and length of stay (LOS). RESULTS Median (IQR) antibiotic duration was 12 (9, 17) days for medical and 17 (14, 21) days for surgical NEC. Wide variability in antibiotic use existed both within and among centers. Duration of antibiotic therapy was associated with longer TFF in both medical (OR 1.04, 95% CI [1.01, 1.05], p < 0.001) and surgical NEC (OR 1.02 [1, 1.03] p = 0.046); and with longer LOS in medical (OR 1.03 [1.02, 1.04], p < 0.001) and surgical NEC (OR 1.01 [1.01, 1.02], p = 0.002). CONCLUSION Antibiotic duration for both medical and surgical NEC remains variable within and among high level NICUs.
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Affiliation(s)
| | | | - Amy B Hair
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Kevin M Sullivan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Jotishna Sharma
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Kristina M Reber
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Michael Padula
- University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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14
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Mikhael M, Cleary JP, Zaniletti I, Truog WE, Ibrahim J, DiGeronimo R, Cuna A, Kielt MJ, Coghill CH, Vyas-Read S, Yallapragada S, Engle WA, Savani RC, Murthy K, Lagatta JM. Chronic lung disease in full-term infants: Characteristics and neonatal intensive care outcomes in infants referred to children's hospitals. Pediatr Pulmonol 2022; 57:2082-2091. [PMID: 35578392 DOI: 10.1002/ppul.25983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/03/2022] [Accepted: 05/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe characteristics, outcomes, and risk factors for death or tracheostomy with home mechanical ventilation in full-term infants with chronic lung disease (CLD) admitted to regional neonatal intensive care units. STUDY DESIGN This was a multicenter, retrospective cohort study of infants born ≥37 weeks of gestation in the Children's Hospitals Neonatal Consortium. RESULTS Out of 67,367 full-term infants admitted in 2010-2016, 4886 (7%) had CLD based on receiving respiratory support at either 28 days of life or discharge. 3286 (67%) were still hospitalized at 28 days receiving respiratory support, with higher mortality risk than those without CLD (10% vs. 2%, p < 0.001). A higher proportion received tracheostomy (13% vs. 0.3% vs. 0.4%, p < 0.001) and gastrostomy (30% vs. 1.7% vs. 3.7%, p < 0.001) compared to infants with CLD discharged home before 28 days and infants without CLD, respectively. The diagnoses and surgical procedures differed significantly between the two CLD subgroups. Small for gestational age, congenital pulmonary, airway, and cardiac anomalies and bloodstream infections were more common among infants with CLD who died or required tracheostomy with home ventilation (p < 0.001). Invasive ventilation at 28 days was independently associated with death or tracheostomy and home mechanical ventilation (odds ratio 7.6, 95% confidence interval 5.9-9.6, p < 0.0001). CONCLUSION Full-term infants with CLD are at increased risk for morbidity and mortality. We propose a severity-based classification for CLD in full-term infants. Future work to validate this classification and its association with early childhood outcomes is necessary.
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Affiliation(s)
- Michel Mikhael
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, California, USA
| | - John P Cleary
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, California, USA
| | | | - William E Truog
- Children's Mercy Kansas City, University of Missouri, Kansas City, Missouri, USA
| | - John Ibrahim
- Division of Newborn Medicine, Magee-Women's Hospital of UPMC/Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Alain Cuna
- Children's Mercy Kansas City, University of Missouri, Kansas City, Missouri, USA
| | - Matthew J Kielt
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carl H Coghill
- Division of Neonatology, Department of Pediatrics, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shilpa Vyas-Read
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - William A Engle
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rashmin C Savani
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Karna Murthy
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joanne M Lagatta
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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15
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Natarajan G, Hamrick SE, Zaniletti I, Lee KS, Mietzsch U, DiGeronimo R, Dizon MLV, Peeples ES, Yanowitz TD, Wu TW, Flibotte J, Joe P, Massaro AN, Rao R. Opioid exposure during therapeutic hypothermia and short-term outcomes in neonatal encephalopathy. J Perinatol 2022; 42:1017-1025. [PMID: 35474129 DOI: 10.1038/s41372-022-01400-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the association between opioid exposure during therapeutic hypothermia (TH) for perinatal hypoxic-ischemic encephalopathy (HIE) and in-hospital outcomes. STUDY DESIGN In this retrospective cohort study, linked data were accessed on infants ≥36 weeks gestation, who underwent TH for HIE, born from 2010-2016 in 23 Neonatal Intensive Care Units participating in Children's Hospitals Neonatal Consortium and Pediatric Health Information Systems. We excluded infants who received opioids for >5 days. RESULTS The cohort (n = 1484) was categorized as No opioid [240(16.2%)], Low opioid (1-2 days) [574 (38.7%)] and High opioid group (HOG, 3-5 days) [670 (45.2%)]. After adjusting for HIE severity, opioids were not associated with abnormal MRI, but were associated with decreased likelihood of complete oral feeds at discharge. HOG had increased likelihood of prolonged hospital stay and ventilation. CONCLUSION Opioid exposure during TH was not associated with abnormal MRI; its association with adverse short-term outcomes suggests need for cautious empiric use.
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Affiliation(s)
- Girija Natarajan
- Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, USA.
| | | | | | - Kyong-Soon Lee
- Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Ulrike Mietzsch
- Pediatrics/Neonatology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Robert DiGeronimo
- Pediatrics/Neonatology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Maria L V Dizon
- Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric S Peeples
- Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Toby D Yanowitz
- Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tai-Wei Wu
- Neonatology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Flibotte
- Pediatrics/ Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - An N Massaro
- Neonatology, Children's National Health Systems, Washington, DC, USA
| | - Rakesh Rao
- Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
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16
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Rao R, Mietzsch U, DiGeronimo R, Hamrick SE, Dizon MLV, Lee KS, Natarajan G, Yanowitz TD, Peeples ES, Flibotte J, Wu TW, Zaniletti I, Mathur AM, Massaro A. Utilization of Therapeutic Hypothermia and Neurological Injury in Neonates with Mild Hypoxic-Ischemic Encephalopathy: A Report from Children's Hospital Neonatal Consortium. Am J Perinatol 2022; 39:319-328. [PMID: 32892328 DOI: 10.1055/s-0040-1716341] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study was aimed to describe utilization of therapeutic hypothermia (TH) in neonates presenting with mild hypoxic-ischemic encephalopathy (HIE) and associated neurological injury on magnetic resonance imaging (MRI) scans in these infants. STUDY DESIGN Neonates ≥ 36 weeks' gestation with mild HIE and available MRI scans were identified. Mild HIE status was assigned to hyper alert infants with an exaggerated response to arousal and mild HIE as the highest grade of encephalopathy recorded. MRI scans were dichotomized as "injury" versus "no injury." RESULTS A total of 94.5% (257/272) neonates with mild HIE, referred for evaluation, received TH. MRI injury occurred in 38.2% (104/272) neonates and affected predominantly the white matter (49.0%, n = 51). Injury to the deep nuclear gray matter was identified in (10.1%) 20 infants, and to the cortex in 13.4% (n = 14 infants). In regression analyses (odds ratio [OR]; 95% confidence interval [CI]), history of fetal distress (OR = 0.52; 95% CI: 0.28-0.99) and delivery by caesarian section (OR = 0.54; 95% CI: 0.31-0.92) were associated with lower odds, whereas medical comorbidities during and after cooling were associated with higher odds of brain injury (OR = 2.31; 95% CI: 1.37-3.89). CONCLUSION Majority of neonates with mild HIE referred for evaluation are being treated with TH. Odds of neurological injury are over two-fold higher in those with comorbidities during and after cooling. Brain injury predominantly involved the white matter. KEY POINTS · Increasingly, neonates with mild HIE are being referred for consideration for hypothermia therapy.. · Drift in clinical practice shows growing number of neonates treated with hypothermia as having mild HIE.. · MRI data show that 38% of neonates with mild HIE have brain injury, predominantly in the white matter..
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Affiliation(s)
- Rakesh Rao
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Ulrike Mietzsch
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Robert DiGeronimo
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, Washington
| | | | - Maria L V Dizon
- Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - Kyong-Soon Lee
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Toby D Yanowitz
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tai-Wei Wu
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Isabella Zaniletti
- Department of Pediatrics, Children's Hospitals Association, Kansas City, Kansas
| | - Amit M Mathur
- Department of Pediatrics, St. Louis University School of Medicine, St. Louis, Missouri
| | - An Massaro
- Department of Pediatrics, Children's National Health Systems, Washington, Dist. of Columbia
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17
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Cuna A, Lagatta JM, Savani RC, Vyas-Read S, Engle WA, Rose RS, DiGeronimo R, Logan JW, Mikhael M, Natarajan G, Truog WE, Kielt M, Murthy K, Zaniletti I, Lewis TR. Association of time of first corticosteroid treatment with bronchopulmonary dysplasia in preterm infants. Pediatr Pulmonol 2021; 56:3283-3292. [PMID: 34379886 PMCID: PMC8453128 DOI: 10.1002/ppul.25610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/13/2021] [Accepted: 07/31/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the association between the time of first systemic corticosteroid initiation and bronchopulmonary dysplasia (BPD) in preterm infants. STUDY DESIGN A multi-center retrospective cohort study from January 2010 to December 2016 using the Children's Hospitals Neonatal Database and Pediatric Health Information System database was conducted. The study population included preterm infants <32 weeks' gestation treated with systemic corticosteroids after 7 days of age and before 34 weeks' postmenstrual age. Stepwise multivariable logistic regression was used to assess the association between timing of corticosteroid initiation and the development of Grade 2 or 3 BPD as defined by the 2019 Neonatal Research Network criteria. RESULTS We identified 598 corticosteroid-treated infants (median gestational age 25 weeks, median birth weight 760 g). Of these, 47% (280 of 598) were first treated at 8-21 days, 25% (148 of 598) were first treated at 22-35 days, 14% (86 of 598) were first treated at 36-49 days, and 14% (84 of 598) were first treated at >50 days. Infants first treated at 36-49 days (aOR 2.0, 95% CI 1.1-3.7) and >50 days (aOR 1.9, 95% CI 1.04-3.3) had higher independent odds of developing Grade 2 or 3 BPD when compared to infants treated at 8-21 days after adjusting for birth characteristics, admission characteristics, center, and co-morbidities. CONCLUSIONS Among preterm infants treated with systemic corticosteroids in routine clinical practice, later initiation of treatment was associated with a higher likelihood to develop Grade 2 or 3 BPD when compared to earlier treatment.
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Affiliation(s)
- Alain Cuna
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
| | - Joanne M Lagatta
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rashmin C Savani
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shilpa Vyas-Read
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - William A Engle
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rebecca S Rose
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - J Wells Logan
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michel Mikhael
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, California, USA
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, Missouri, USA
| | - William E Truog
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
| | - Matthew Kielt
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karna Murthy
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Tamorah R Lewis
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
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18
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Saoud R, Locke D, Fry JT, Matoba N, Datta A, DiGeronimo R, Leuthner SR, Coghill CH, Natarajan G, Niehaus JZ, Schlegel AB, Weiner J, Dereddy N, Shah A, Sullivan KM. Withdrawal of artificial nutrition and hydration: a survey of level IV neonatal intensive care units. J Perinatol 2021; 41:2372-2374. [PMID: 33758396 DOI: 10.1038/s41372-021-01011-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Robin Saoud
- Department of Pediatrics and Division of Neonatology, Harbor-UCLA Medical Center, Torrance, CA, USA.,Division of Neonatology, Children's Hospital of Orange County, Orange, CA, USA
| | - Devika Locke
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.,Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Jessica T Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nana Matoba
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Ankur Datta
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Robert DiGeronimo
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Division of Neonatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Neonatology, Children's Wisconsin, Milwaukee, WI, USA
| | - Carl H Coghill
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Neonatology, Children's of Alabama, Birmingham, AL, UK
| | - Girija Natarajan
- Department of Pediatrics, Central Michigan University, Detroit, MI, USA.,Division of Neonatology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Jason Z Niehaus
- Department of Pediatrics, Indiana University, Indianapolis, IN, USA.,Division of Neonatology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Amy Brown Schlegel
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, OH, USA.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Julie Weiner
- Department of Pediatrics at University of Missouri - Kansas City, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Narendra Dereddy
- Department of Pediatrics, University of Central Florida, Orlando, FL, USA.,Division of Neonatology, AdventHealth for Children, Orlando, FL, USA
| | - Anita Shah
- Division of Neonatology, Children's Hospital of Orange County, Orange, CA, USA
| | - Kevin M Sullivan
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA. .,Division of Neonatology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
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19
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Agarwal P, Natarajan G, Sullivan K, Rao R, Rintoul N, Zaniletti I, Keene S, Mietzsch U, Massaro AN, Billimoria Z, Dirnberger D, Hamrick S, Seabrook RB, Weems MF, Cleary JP, Gray BW, DiGeronimo R. Venovenous versus venoarterial extracorporeal membrane oxygenation among infants with hypoxic-ischemic encephalopathy: is there a difference in outcome? J Perinatol 2021; 41:1916-1923. [PMID: 34012056 DOI: 10.1038/s41372-021-01089-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/01/2021] [Accepted: 04/29/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Our hypothesis was that among infants with hypoxic-ischemic encephalopathy (HIE), venoarterial (VA), compared to venovenous (VV), extracorporeal membrane oxygenation (ECMO) is associated with an increased risk of mortality or intracranial hemorrhage (ICH). DESIGN/METHODS Retrospective cohort analysis of infants in the Children's Hospitals Neonatal Database from 2010 to 2016 with moderate or severe HIE, gestational age ≥36 weeks, and ECMO initiation <7 days of age. The primary outcome was mortality or ICH. RESULTS Severe HIE was more common in the VA ECMO group (n = 57), compared to the VV ECMO group (n = 53) (47.4% vs. 26.4%, P = 0.02). VA ECMO was associated with a significantly higher risk of death or ICH [57.9% vs. 34.0%, aOR 2.39 (1.08-5.28)] and mortality [31.6% vs. 11.3%, aOR 3.06 (1.08-8.68)], after adjusting for HIE severity. CONCLUSIONS In HIE, VA ECMO was associated with a higher incidence of mortality or ICH. VV ECMO may be beneficial in this population.
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Affiliation(s)
- Prashant Agarwal
- Department of Pediatrics, Children's Hospital of Michigan/Central Michigan University, Detroit, MI, USA.
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan/Central Michigan University, Detroit, MI, USA
| | - Kevin Sullivan
- Department of Pediatrics, AI duPont Hospital for Children/Thomas Jefferson University, Wilmington, DE, USA
| | - Rakesh Rao
- Department of Pediatrics, Washington University in St. Louis, St Louis, MO, USA
| | - Natalie Rintoul
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Sarah Keene
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - Ulrike Mietzsch
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - An N Massaro
- Department of Pediatrics, The George Washington University School of Medicine and Children's National Hospital, Washington DC, DC, USA
| | - Zeenia Billimoria
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Daniel Dirnberger
- Department of Pediatrics, AI duPont Hospital for Children, Wilmington, DE, USA
| | - Shannon Hamrick
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - Ruth B Seabrook
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mark F Weems
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - John P Cleary
- Department of Pediatrics, Children's Hospital of Orange County, Orange, CA, USA
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert DiGeronimo
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
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20
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Ramaraj A, Jensen G, Rice-Townsend S, DiGeronimo R, Yalon L, Stark R. Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population. Perfusion 2021; 37:752-756. [PMID: 34264146 DOI: 10.1177/02676591211030767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Complications associated with use of dual-lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas are of concern in pediatric patients. While the risk of atrial perforation is believed to be higher with bicaval cannulas, direct comparison of complication rate between atrial and bicaval cannulas has not been conducted in this population. METHODS A retrospective review was conducted at a free-standing children's hospital of all patients 0-18 years old, placed on VV-ECMO with a dual-lumen cannula from January 2009 to December 2018. Patients were grouped based on cannula type. Complications were assessed over the entire duration of the ECMO run. Logistic regression analyses were used to evaluate for an association between cannula type and risk of pericardial effusion or cannula-related complication requiring median sternotomy or pericardial drain placement. RESULTS During the study period 119 patients were placed on VVECMO using a dual-lumen cannula. Eighty-two patients (69%) were <2 years old, 19 (16%) were 2-10 years old, and 18 (15%) were 11-18 years old. Seventy-three were cannulated with an atrial cannula and 46 patients received a bicaval cannula. Pericardial effusions were seen in 30% and 24% of these patients respectively while severe complications were seen in 9.6% and 8.7% of patients respectively. Compared to patients treated with a bicaval cannula, those who received an atrial cannula had similar odds of effusions (OR: 1.41, 95% CI: 0.62-3.36) and severe complications (OR 0.89, 95% CI: 0.27-3.18). After adjusting for age, weight, cannula and circuit manipulations, and use of echocardiography, the OR of effusion was 1.91 (95% CI: 0.65-6.42), and the adjusted OR of severe complication was 0.69 (95% CI: 0.16-3.33). CONCLUSIONS There were no significant differences in frequency of pericardial effusions or severe cannula-related complications between the treatment groups across all pediatric patients and within the subgroup of patients under 2 years of age.
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Affiliation(s)
- Akila Ramaraj
- Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Guy Jensen
- General Surgery, Naval Hospital Bremerton, Bremerton, WA, USA
| | - Samuel Rice-Townsend
- Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Robert DiGeronimo
- Department of Neonatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Larissa Yalon
- Extracorporeal Life Support Services, Seattle Children's Hospital, Seattle, WA, USA
| | - Rebecca Stark
- Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
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21
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Seabrook RB, Grover TR, Rintoul N, Weems M, Keene S, Brozanski B, DiGeronimo R, Haberman B, Hedrick H, Gien J, Ali N, Chapman R, Daniel J, Harrison HA, Johnson Y, Porta NFM, Uhing M, Zaniletti I, Murthy K. Treatment of pulmonary hypertension during initial hospitalization in a multicenter cohort of infants with congenital diaphragmatic hernia (CDH). J Perinatol 2021; 41:803-813. [PMID: 33649432 DOI: 10.1038/s41372-021-00923-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 11/02/2020] [Accepted: 01/14/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Describe inpatient pulmonary hypertension (PH) treatment and factors associated with therapy at discharge in a multicenter cohort of infants with CDH. METHODS Six years linked records from Children's Hospitals Neonatal Database and Pediatric Health Information System were used to describe associations between prenatal/perinatal factors, clinical outcomes, echocardiographic findings and PH medications (PHM), during hospitalization and at discharge. RESULTS Of 1106 CDH infants from 23 centers, 62.8% of infants received PHM, and 11.6% of survivors were discharged on PHM. Survivors discharged on PHM more frequently had intrathoracic liver, small for gestational age, and low 5 min APGARs compared with those discharged without PHM (p < 0.0001). Nearly one-third of infants discharged without PHM had PH on last inpatient echo. CONCLUSIONS PH medication use is common in CDH. Identification of infants at risk for persistent PH may impact ongoing management. Post-discharge follow-up of all CDH infants with echocardiographic evidence of PH is warranted.
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Affiliation(s)
- Ruth B Seabrook
- Nationwide Children's Hospital and the Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Theresa R Grover
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Natalie Rintoul
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Weems
- LeBonheur Children's Hospital and the University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sarah Keene
- Children's Healthcare of Atlanta at Egleston, Emory Children's Pediatric Institute, and Emory University School of Medicine, Atlanta, GA, USA
| | - Beverly Brozanski
- St Louis Children's Hospital and the Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Beth Haberman
- Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Holly Hedrick
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Gien
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Rachel Chapman
- Children's Hospital Los Angeles and the Fetal & Neonatal Institute, Department of Pediatrics. USC Keck School of Medicine, Los Angeles, CA, USA
| | - John Daniel
- Children's Mercy Hospitals & Clinics, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | | | | | - Nicolas F M Porta
- Ann & Robert H Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael Uhing
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Karna Murthy
- Ann & Robert H Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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22
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Peeples ES, Rao R, Dizon MLV, Johnson YR, Joe P, Flibotte J, Hossain T, Smith D, Hamrick S, DiGeronimo R, Natarajan G, Lee KS, Yanowitz TD, Mietzsch U, Wu TW, Maitre NL, Pallotto EK, Speziale M, Mathur AM, Zaniletti I, Massaro A. Predictive Models of Neurodevelopmental Outcomes After Neonatal Hypoxic-Ischemic Encephalopathy. Pediatrics 2021; 147:peds.2020-022962. [PMID: 33452064 DOI: 10.1542/peds.2020-022962] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To develop predictive models for death or neurodevelopmental impairment (NDI) after neonatal hypoxic-ischemic encephalopathy (HIE) from data readily available at the time of NICU admission ("early") or discharge ("cumulative"). METHODS In this retrospective cohort analysis, we used data from the Children's Hospitals Neonatal Consortium Database (2010-2016). Infants born at ≥35 weeks' gestation and treated with therapeutic hypothermia for HIE at 11 participating sites were included; infants without Bayley Scales of Infant Development scores documented after 11 months of age were excluded. The primary outcome was death or NDI. Multivariable models were generated with 80% of the cohort; validation was performed in the remaining 20%. RESULTS The primary outcome occurred in 242 of 486 infants; 180 died and 62 infants surviving to follow-up had NDI. HIE severity, epinephrine administration in the delivery room, and respiratory support and fraction of inspired oxygen of 0.21 at admission were significant in the early model. Severity of EEG findings was combined with HIE severity for the cumulative model, and additional significant variables included the use of steroids for blood pressure management and significant brain injury on MRI. Discovery models revealed areas under the curve of 0.852 for the early model and of 0.861 for the cumulative model, and both models performed well in the validation cohort (goodness-of-fit χ2: P = .24 and .06, respectively). CONCLUSIONS Establishing reliable predictive models will enable clinicians to more accurately evaluate HIE severity and may allow for more targeted early therapies for those at highest risk of death or NDI.
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Affiliation(s)
- Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska;
| | - Rakesh Rao
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Maria L V Dizon
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois
| | - Yvette R Johnson
- Department of Pediatrics, Cook Children's Medical Center, Fort Worth, Texas.,Department of Pediatrics, Texas Christian University and University of North Texas Health Science Center, Fort Worth, Texas
| | - Priscilla Joe
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, Oakland, California
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tanzeema Hossain
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Danielle Smith
- Department of Pediatrics, University of Colorado Denver, Denver, Colorado
| | - Shannon Hamrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Robert DiGeronimo
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Kyong-Soon Lee
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Toby D Yanowitz
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ulrike Mietzsch
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Tai-Wei Wu
- Department of Pediatrics, Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California
| | - Nathalie L Maitre
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Eugenia K Pallotto
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Mark Speziale
- Department of Pediatrics, Rady Children's Hospital-San Diego and University of California, San Diego, San Diego, California
| | - Amit M Mathur
- Department of Pediatrics, Saint Louis University, St Louis, Missouri
| | - Isabella Zaniletti
- Department of Pediatrics, Children's Hospital Association, Lenexa, Kansas; and
| | - An Massaro
- Department of Pediatrics, Children's National Health System, Washington, District of Columbia
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23
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Brei BK, Gray MM, Umoren R, Handley S, DiGeronimo R, Sawyer T, Smith K, Billimoria Z. Interprofessional ECMO telerounding: a novel approach to neonatal ECMO clinical participation and education. J Perinatol 2021; 41:824-829. [PMID: 32963301 PMCID: PMC7505939 DOI: 10.1038/s41372-020-00827-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/21/2020] [Accepted: 09/14/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Determine the feasibility, strengths, and barriers of offering extracorporeal membrane oxygenation (ECMO) telerounding to neonatal intensive care unit (NICU) care providers. STUDY DESIGN NICU providers were invited to join ECMO rounds by teleconference. Data were collected on telerounding participation and ECMO concepts discussed. A survey was sent to all providers. RESULTS From March 2018 to February 2020, telerounding on 24 neonatal ECMO patients (168 ECMO days) was performed in a Level IV NICU. A mean of four providers joined telerounds per ECMO day with an increase from 3 to 6 providers over the study period. Nearly all respondents felt telerounding lowered barriers to attending ECMO rounds (94%), promoted engagement (89%), and improved continuity of care (78%). Barriers to ECMO telerounding were suboptimal audio connections and limited ability to participate in the clinical discussion. CONCLUSION ECMO telerounding is well-received by NICU providers. It can improve provider participation, complement existing in-person ECMO rounds, and ECMO education.
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Affiliation(s)
- Brianna K. Brei
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA USA
| | - Megan M. Gray
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA USA
| | - Rachel Umoren
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA USA
| | - Sarah Handley
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA USA
| | - Robert DiGeronimo
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA USA
| | - Taylor Sawyer
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA USA
| | - Kendra Smith
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA USA
| | - Zeenia Billimoria
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA.
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24
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Yallapragada S, Savani RC, Mūnoz-Blanco S, Lagatta JM, Truog WE, Porta NFM, Nelin LD, Zhang H, Vyas-Read S, DiGeronimo R, Natarajan G, Wymore E, Haberman B, Machry J, Potoka K, Murthy K. Qualitative indications for tracheostomy and chronic mechanical ventilation in patients with severe bronchopulmonary dysplasia. J Perinatol 2021; 41:2651-2657. [PMID: 34349231 PMCID: PMC8331995 DOI: 10.1038/s41372-021-01165-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/13/2021] [Accepted: 07/13/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND The decision to pursue chronic mechanical ventilation involves a complex mix of clinical and social considerations. Understanding the medical indications to pursue tracheostomy would reduce the ambiguity for both providers and families and facilitate focus on appropriate clinical goals. OBJECTIVE To describe potential indications to pursue tracheostomy and chronic mechanical ventilation in infants with severe BPD (sBPD). STUDY DESIGN We surveyed centers participating in the Children's Hospitals Neonatal Consortium to describe their approach to proceed with tracheostomy in infants with sBPD. We requested a single representative response per institution. Question types were fixed form and free text responses. RESULTS The response rate was high (31/34, 91%). Tracheostomy was strongly considered when: airway malacia was present, PCO2 ≥ 76-85 mmHg, FiO2 ≥ 0.60, PEEP ≥ 9-11 cm H2O, respiratory rate ≥ 61-70 breaths/min, PMA ≥ 44 weeks, and weight <10th %ile at 44 weeks PMA. CONCLUSIONS Understanding the range of indications utilized by high level NICUs around the country to pursue a tracheostomy in an infant with sBPD is one step toward standardizing consensus indications for tracheostomy in the future.
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Affiliation(s)
| | - Rashmin C. Savani
- grid.267313.20000 0000 9482 7121UT Southwestern Medical Center, Dallas, TX USA
| | - Sara Mūnoz-Blanco
- grid.267313.20000 0000 9482 7121UT Southwestern Medical Center, Dallas, TX USA
| | - Joanne M. Lagatta
- grid.30760.320000 0001 2111 8460Medical College of Wisconsin, Milwaukee, WI USA
| | - William E. Truog
- grid.239559.10000 0004 0415 5050Children’s Mercy-Kansas City and the University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Nicolas F. M. Porta
- grid.413808.60000 0004 0388 2248Northwestern University & Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
| | - Leif D. Nelin
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA
| | - Huayan Zhang
- grid.239552.a0000 0001 0680 8770Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Shilpa Vyas-Read
- grid.189967.80000 0001 0941 6502Emory University, Atlanta, GA USA
| | - Robert DiGeronimo
- grid.240741.40000 0000 9026 4165Seattle Children’s Hospital/University of Washington, Seattle, WA USA
| | - Girija Natarajan
- grid.414154.10000 0000 9144 1055Children’s Hospital of Michigan, Detroit, MI USA
| | - Erica Wymore
- grid.430503.10000 0001 0703 675XUniversity of Colorado, Aurora, CO USA
| | - Beth Haberman
- grid.239573.90000 0000 9025 8099Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Joana Machry
- grid.413611.00000 0004 0467 2330Johns Hopkins All Children’s Hospital, St. Petersburg, FL USA
| | - Karin Potoka
- grid.413473.60000 0000 9013 1194Akron Children’s Hospital, Akron, OH USA
| | | | - Karna Murthy
- grid.413808.60000 0004 0388 2248Northwestern University & Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
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Freed AS, Candadai SVC, Sikes MC, Thies J, Byers HM, Dines JN, Ndugga-Kabuye MK, Smith MB, Fogus K, Mefford HC, Lam C, Adam MP, Sun A, McGuire JK, DiGeronimo R, Dipple KM, Deutsch GH, Billimoria ZC, Bennett JT. The Impact of Rapid Exome Sequencing on Medical Management of Critically Ill Children. J Pediatr 2020; 226:202-212.e1. [PMID: 32553838 PMCID: PMC7736066 DOI: 10.1016/j.jpeds.2020.06.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/23/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To evaluate the clinical usefulness of rapid exome sequencing (rES) in critically ill children with likely genetic disease using a standardized process at a single institution. To provide evidence that rES with should become standard of care for this patient population. STUDY DESIGN We implemented a process to provide clinical-grade rES to eligible children at a single institution. Eligibility included (a) recommendation of rES by a consulting geneticist, (b) monogenic disorder suspected, (c) rapid diagnosis predicted to affect inpatient management, (d) pretest counseling provided by an appropriate provider, and (e) unanimous approval by a committee of 4 geneticists. Trio exome sequencing was sent to a reference laboratory that provided verbal report within 7-10 days. Clinical outcomes related to rES were prospectively collected. Input from geneticists, genetic counselors, pathologists, neonatologists, and critical care pediatricians was collected to identify changes in management related to rES. RESULTS There were 54 patients who were eligible for rES over a 34-month study period. Of these patients, 46 underwent rES, 24 of whom (52%) had at least 1 change in management related to rES. In 20 patients (43%), a molecular diagnosis was achieved, demonstrating that nondiagnostic exomes could change medical management in some cases. Overall, 84% of patients were under 1 month old at rES request and the mean turnaround time was 9 days. CONCLUSIONS rES testing has a significant impact on the management of critically ill children with suspected monogenic disease and should be considered standard of care for tertiary institutions who can provide coordinated genetics expertise.
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Affiliation(s)
- Amanda S. Freed
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA
| | - Sarah V. Clowes Candadai
- Department of Laboratories, Seattle Children’s Hospital, Seattle WA,Patient-centered Laboratory Utilization Guidance Services (PLUGS), Seattle Children’s Hospital, Seattle WA
| | - Megan C. Sikes
- Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA
| | - Jenny Thies
- Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA
| | - Heather M. Byers
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA
| | - Jennifer N. Dines
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA
| | | | - Mallory B. Smith
- Department of Pediatrics, Division of Pediatric Critical Care, University of Washington, Seattle WA
| | - Katie Fogus
- Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA
| | - Heather C. Mefford
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA,Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA,Brotman Baty Institute for Precision Medicine, Seattle WA
| | - Christina Lam
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA,Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA,Brotman Baty Institute for Precision Medicine, Seattle WA,Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle WA
| | - Margaret P. Adam
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA,Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA
| | - Angela Sun
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA,Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA
| | - John K. McGuire
- Department of Pediatrics, Division of Pediatric Critical Care, University of Washington, Seattle WA
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle WA
| | - Katrina M. Dipple
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA,Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle WA
| | - Gail H. Deutsch
- Department of Pathology, University of Washington and Seattle Children’s Hospital, Seattle WA
| | - Zeenia C. Billimoria
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle WA
| | - James T. Bennett
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle WA,Division of Genetic Medicine, Seattle Children’s Hospital, Seattle WA,Brotman Baty Institute for Precision Medicine, Seattle WA,Center for Developmental Biology and Regenerative Medicine, Seattle Children’s Research Institute, Seattle WA
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26
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Sawyer T, Billimoria Z, Handley S, Smith K, Yalon L, Brogan TV, DiGeronimo R. Therapeutic Plasma Exchange in Neonatal Septic Shock: A Retrospective Cohort Study. Am J Perinatol 2020; 37:962-969. [PMID: 31176309 DOI: 10.1055/s-0039-1692184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to examine the use of therapeutic plasma exchange (TPE) as adjunctive therapy in neonatal septic shock. STUDY DESIGN This retrospective cohort study was performed on a convenience sample of neonates in a quaternary children's hospital between January 2018 and February 2019. RESULTS We identified three neonates with septic shock who received TPE. Two neonates had adenovirus sepsis, and one had group B streptococcal sepsis. All neonates were on extracorporeal life support (ECLS) when TPE was started. The median duration of TPE was 6 days (interquartile range [IQR]: 3-15), with a median of four cycles (IQR: 3-5). Lactate levels decreased significantly after TPE (median before TPE: 5.4 mmol/L [IQR: 2.4-6.1] vs. median after TPE: 1.2 mmol/L [IQR: 1.0-5.8]; p < 0.001). Platelet levels did not change (median before TPE: 73,000/mm3 [IQR: 49,000-100,000] vs. median after TPE: 80,000/mm3 (IQR: 62,000-108,000); p = 0.2). Organ failure indices improved after TPE in two of the three neonates. Hypocalcemia was seen in all cases despite prophylactic calcium infusions. One neonate died, and two survived to ICU discharge. CONCLUSION TPE can be safely performed in neonates with septic shock. TPE may have a role as an adjunctive therapy in neonates with septic shock requiring ECLS.
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Affiliation(s)
- Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Zeenia Billimoria
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Sarah Handley
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Kendra Smith
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Larissa Yalon
- Extracorporeal Life Support Services, Seattle Children's Hospital, Seattle, Washington
| | - Thomas V Brogan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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27
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Fry JT, Matoba N, Datta A, DiGeronimo R, Coghill CH, Natarajan G, Brozanski B, Leuthner SR, Niehaus JZ, Schlegel AB, Shah A, Zaniletti I, Bartman T, Murthy K, Sullivan KM. Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units. J Pediatr 2020; 217:86-91.e1. [PMID: 31831163 DOI: 10.1016/j.jpeds.2019.10.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/12/2019] [Accepted: 10/14/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs). STUDY DESIGN We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation. RESULTS Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death. CONCLUSIONS From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.
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Affiliation(s)
- Jessica T Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Nana Matoba
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ankur Datta
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Robert DiGeronimo
- Department of Pediatrics, University of Washington, Seattle, WA; Division of Neonatology, Seattle Children's Hospital, Seattle, WA
| | - Carl H Coghill
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL; Division of Neonatology, Children's of Alabama, Birmingham, AL
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, MI; Division of Neonatology, Children's Hospital of Michigan, Detroit, MI
| | - Beverly Brozanski
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA; Division of Newborn Medicine, UPMC Children's Hospital, Pittsburgh, PA
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; Division of Neonatology, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Jason Z Niehaus
- Department of Pediatrics, Indiana University, Indianapolis, IN; Division of Neonatology, Riley Hospital for Children, Indianapolis, IN
| | - Amy Brown Schlegel
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Anita Shah
- Division of Neonatology, Children's Hospital of Orange County, Orange, CA
| | | | - Thomas Bartman
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Karna Murthy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Kevin M Sullivan
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Division of Neonatology, Nemours/AI duPont Hospital for Children, Wilmington, DE
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- Children's Hospitals Neonatal Consortium, Kansas City, MO
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28
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Vyas-Read S, Wymore EM, Zaniletti I, Murthy K, Padula MA, Truog WE, Engle WA, Savani RC, Yallapragada S, Logan JW, Zhang H, Hysinger EB, Grover TR, Natarajan G, Nelin LD, Porta NFM, Potoka KP, DiGeronimo R, Lagatta JM. Utility of echocardiography in predicting mortality in infants with severe bronchopulmonary dysplasia. J Perinatol 2020; 40:149-156. [PMID: 31570799 PMCID: PMC7222140 DOI: 10.1038/s41372-019-0508-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the relationship between interventricular septal position (SP) and right ventricular systolic pressure (RVSP) and mortality in infants with severe BPD (sBPD). STUDY DESIGN Infants with sBPD in the Children's Hospitals Neonatal Database who had echocardiograms 34-44 weeks' postmenstrual age (PMA) were included. SP and RVSP were categorized normal, abnormal (flattened/bowed SP or RVSP > 40 mmHg) or missing. RESULTS Of 1157 infants, 115 infants (10%) died. Abnormal SP or RVSP increased mortality (SP 19% vs. 8% normal/missing, RVSP 20% vs. 9% normal/missing, both p < 0.01) in unadjusted and multivariable models, adjusted for significant covariates (SP OR 1.9, 95% CI 1.2-3.0; RVSP OR 2.2, 95% CI 1.1-4.7). Abnormal parameters had high specificity (SP 82%; RVSP 94%), and negative predictive value (SP 94%, NPV 91%) for mortality. CONCLUSIONS Abnormal SP or RVSP is independently associated with mortality in sBPD infants. Negative predictive values distinguish infants most likely to survive.
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Affiliation(s)
- Shilpa Vyas-Read
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
| | - Erica M Wymore
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Karna Murthy
- Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael A Padula
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - William E Truog
- Children's Mercy Hospital, University of Missouri, Kansas City, MO, USA
| | - William A Engle
- Riley Hospital for Children, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rashmin C Savani
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - J Wells Logan
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Huayan Zhang
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Erik B Hysinger
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Cincinnati, OH, USA
| | - Theresa R Grover
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Girija Natarajan
- Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Leif D Nelin
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Nicolas F M Porta
- Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karin P Potoka
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Joanne M Lagatta
- Children's Hospital of Wisconsin, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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29
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Motz P, Do J, Lam T, DiBlasi RM, Fang T, Kelly K, DiGeronimo R, Billimoria ZC. Decreasing radiographs in neonates through targeted quality improvement interventions. J Perinatol 2020; 40:330-336. [PMID: 31844185 PMCID: PMC7223959 DOI: 10.1038/s41372-019-0565-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Our aim was to decrease radiograph use for monitoring placement of peripherally inserted central catheters (PICC) and endotracheal tubes (ETT) in neonates admitted to the neonatal intensive care unit (NICU) by 20% from November 2017 to November 2018. STUDY DESIGN We carried out three Plan-Do-Study-Act (PDSA) cycles: (1) implementation of a radiograph protocol emphasizing ideal patient positioning, standard radiograph views and frequency, (2) standardizing ETT depth using the NRP guidelines, and (3) implementation of an institution specific ETT depth guideline. RESULTS The pre-intervention radiographs per PICC day was 0.86 versus a post-intervention value of 0.46 (P = 0.004). The pre-intervention radiographs per ETT day was 1.45 versus a post-intervention value of 1.07 (P = 0.002). CONCLUSIONS Our multidisciplinary NICU team performed a QI project, which resulted in more than a 20% decrease in the number of radiographs used for monitoring placement of PICCs and ETTs.
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Affiliation(s)
- Patrick Motz
- 0000000122986657grid.34477.33University of Washington School of Medicine, Seattle, WA USA
| | - Julie Do
- 0000000122986657grid.34477.33University of Washington School of Medicine, Seattle, WA USA
| | - Teresa Lam
- 0000000122986657grid.34477.33University of Washington School of Medicine, Seattle, WA USA
| | - Robert M. DiBlasi
- 0000 0000 9026 4165grid.240741.4Seattle Children’s Hospital and Research Institute, Seattle, WA USA
| | - Tim Fang
- 0000 0000 9026 4165grid.240741.4Seattle Children’s Hospital and Research Institute, Seattle, WA USA
| | - Karen Kelly
- 0000 0000 9026 4165grid.240741.4Seattle Children’s Hospital and Research Institute, Seattle, WA USA
| | - Robert DiGeronimo
- 0000000122986657grid.34477.33University of Washington School of Medicine, Seattle, WA USA
| | - Zeenia C. Billimoria
- 0000000122986657grid.34477.33University of Washington School of Medicine, Seattle, WA USA
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30
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Yanowitz TD, Sullivan KM, Piazza AJ, Brozanski B, Zaniletti I, Sharma J, DiGeronimo R, Nayak SP, Wadhawan R, Reber KM, Murthy K. Does the initial surgery for necrotizing enterocolitis matter? Comparative outcomes for laparotomy vs. peritoneal drain as initial surgery for necrotizing enterocolitis in infants <1000 g birth weight. J Pediatr Surg 2019; 54:712-717. [PMID: 30765157 DOI: 10.1016/j.jpedsurg.2018.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 11/25/2018] [Accepted: 12/12/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Quantify short-term outcomes associated with initial surgery [laparotomy (LAP) vs. peritoneal drain (PD)] for necrotizing enterocolitis (NEC) in extremely-low-birth-weight (ELBW) infants. METHODS Using the Children's Hospitals Neonatal Database, we identified ELBW infants <32 weeks' gestation with surgical NEC (sNEC). Unadjusted and multivariable regression analyses were used to estimate the associations between LAP (or PD) and death/short bowel syndrome (SBS) and length of stay (LOS). RESULTS LAP was the more common initial procedure for sNEC (n = 359/528, 68%). Infants receiving LAP were older and heavier. Initial procedure was unrelated to death/SBS in both bivariate (LAP: 43% vs PD: 46%, p = 0.573) and multivariable analyses (OR = 0.89, 95% CI = 0.57, 1.38, p = 0.6). LAP was inversely related to mortality (29% vs. 41%, p < 0.007) in bivariate analysis, but not significant in multivariable analysis accounting for markers of preoperative illness severity. However, the association between LAP and SBS (14% vs. 5%, p = 0.012) remained significant in multivariable analyses (adjusted OR = 2.25, p = 0.039). LOS among survivors was unrelated to the first surgical procedure in multivariable analysis. CONCLUSION ELBW infants who undergo LAP as the initial operative procedure for sNEC may be at higher risk for SBS without a clear in-hospital survival advantage or shorter hospitalization. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - Kevin M Sullivan
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | | | | | | | - Jotishna Sharma
- University of Missouri Kansas City School of Medicine, Kansas City, MO
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31
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White BR, Zhang C, Presson AP, Friddle K, DiGeronimo R. Prevalence and outcomes for assisted home feeding in medically complex neonates. J Pediatr Surg 2019; 54:465-470. [PMID: 29937107 DOI: 10.1016/j.jpedsurg.2018.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/30/2018] [Accepted: 05/27/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To describe the prevalence and outcome of assisted home feeding (AHF) in medically complex neonatal intensive care unit (NICU) patients, and to identify variables associated with AHF in this population. STUDY DESIGN 1223 infants who survived to discharge from 2013 to 2015 were identified in our single-center, retrospective cohort study at a large tertiary referral NICU. Demographic and selected disease-specific variables were compared between infants discharged on full oral feeding (PO) versus AHF. RESULT 404 (33%) infants were discharged on AHF (NG = 201, GT = 186, NJ = 17). AHF neonates were born at an earlier gestational age, lower birth weight, had longer hospital admission, greater post-menstrual age at discharge, and had more associated co-morbidities compared to the PO group. CONCLUSION AHF was a frequently used and safe intervention in our large cohort of infants. LEVEL OF EVIDENCE Treatment Study Level III.
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Affiliation(s)
- Benjamin R White
- Department of Pediatrics, University of Utah, School of Medicine; Division of Neonatology, University of Utah, School of Medicine.
| | - Chong Zhang
- Department of Internal Medicine, Division of Epidemiology, University of Utah, School of Medicine
| | - Angela P Presson
- Department of Pediatrics, University of Utah, School of Medicine; Department of Internal Medicine, Division of Epidemiology, University of Utah, School of Medicine
| | - Kim Friddle
- University of Utah, College of Nursing, Salt Lake City, UT
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, WA
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32
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Dizon MLV, Rao R, Hamrick SE, Zaniletti I, DiGeronimo R, Natarajan G, Kaiser JR, Flibotte J, Lee KS, Smith D, Yanowitz T, Mathur AM, Massaro AN. Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs. BMC Pediatr 2019; 19:67. [PMID: 30813933 PMCID: PMC6391819 DOI: 10.1186/s12887-019-1441-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/20/2019] [Indexed: 12/20/2022] Open
Abstract
Background While intercenter variation (ICV) in anti-epileptic drug (AED) use in neonates with seizures has been previously reported, variation in AED practices across regional NICUs has not been specifically and systematically evaluated. This is important as these centers typically have multidisciplinary neonatal neurocritical care teams and protocolized approaches to treating conditions such as hypoxic ischemic encephalopathy (HIE), a population at high risk for neonatal seizures. To identify opportunities for quality improvement (QI), we evaluated ICV in AED utilization for neonates with HIE treated with therapeutic hypothermia (TH) across regional NICUs in the US. Methods Children’s Hospital Neonatal Database and Pediatric Health Information Systems data were linked for 1658 neonates ≥36 weeks’ gestation, > 1800 g birthweight, with HIE treated with TH, from 20 NICUs, between 2010 and 2016. ICV in AED use was evaluated using a mixed-effect regression model. Rates of AED exposure, duration, prescription at discharge and standardized AED costs per patient were calculated as different measures of utilization. Results Ninety-five percent (range: 83–100%) of patients with electrographic seizures, and 26% (0–81%) without electrographic seizures, received AEDs. Phenobarbital was most frequently used (97.6%), followed by levetiracetam (16.9%), phenytoin/fosphenytoin (15.6%) and others (2.4%; oxcarbazepine, topiramate and valproate). There was significant ICV in all measures of AED utilization. Median cost of AEDs per patient was $89.90 (IQR $24.52,$258.58). Conclusions Amongst Children’s Hospitals, there is marked ICV in AED utilization for neonatal HIE. Variation was particularly notable for HIE patients without electrographic seizures, indicating that this population may be an appropriate target for QI processes to harmonize neuromonitoring and AED practices across centers.
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Affiliation(s)
- Maria L V Dizon
- Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, 225 East Chicago Ave, Box 45, Chicago, IL, 60611, USA.
| | - Rakesh Rao
- Washington University, St. Louis, MO, USA
| | | | | | - Robert DiGeronimo
- Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | | | | | - John Flibotte
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Toby Yanowitz
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - An N Massaro
- Children's National Health Systems, Washington, DC, USA
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Natarajan G, Mathur A, Zaniletti I, DiGeronimo R, Lee KS, Rao R, Dizon M, Hamrick S, Rudine A, Cook N, Smith D, Flibotte J, Murthy K, Massaro A. Withdrawal of Life-Support in Neonatal Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2019; 91:20-26. [PMID: 30559002 DOI: 10.1016/j.pediatrneurol.2018.08.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/13/2018] [Accepted: 08/30/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE We describe the frequency and timing of withdrawal of life-support (WLS) in moderate or severe hypoxic-ischemic encephalopathy (HIE) and examine its associations with medical and sociodemographic factors. PROCEDURES We undertook a secondary data analysis of a prospective multicenter data registry of regional level IV Neonatal Intensive Care Units participating in the Children's Hospitals Neonatal Database. Infants ≥36 weeks gestational age with HIE admitted to a Children's Hospitals Neonatal Database Neonatal Intensive Care Unit between 2010 and 2016, who underwent therapeutic hypothermia were categorized as (1) infants who died following WLST and (2) survivors with severe HIE (requiring tube feedings at discharge). RESULTS Death occurred in 267/1,925 (14%) infants with HIE, 87.6% following WLS. Compared to infants with WLS (n = 234), the survived severe group (n = 74) had more public insurance (73% vs 39.3%, P = 0.00001), lower household income ($37,020 vs $41,733, P = 0.006) and fewer [20.3% vs 35.0%, P = 0.0212] were from the South. Among infants with WLS, electroencephalogram was performed within 24 hours in 75% and was severely abnormal in 64% cases; corresponding rates for MRI were 43% and 17%, respectively. Private insurance was independently associated with WLS, after adjustment for HIE severity and center. CONCLUSIONS In a multicenter cohort of infants with HIE, WLS occurred frequently and was associated with sociodemographic factors. The rationale for decision-making for WLS in HIE require further exploration.
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Affiliation(s)
- Girija Natarajan
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Michigan.
| | - Amit Mathur
- Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital
| | | | - Robert DiGeronimo
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Kyong-Soon Lee
- Division of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rakesh Rao
- Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital
| | - Maria Dizon
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University Chicago, Illinois
| | - Shannon Hamrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta at Egleston, Atlanta
| | - Anthony Rudine
- Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Noah Cook
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Danielle Smith
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karna Murthy
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University Chicago, Illinois
| | - An Massaro
- Department of Pediatrics, Children's National Medical Center, and George Washington University School of Medicine, Washington DC
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- Children's Hospitals Neonatal Consortium, Kansas City, MO
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Massaro AN, Murthy K, Zaniletti I, Cook N, DiGeronimo R, Dizon MLV, Hamrick SEG, McKay VJ, Natarajan G, Rao R, Richardson T, Smith D, Mathur AM. Intercenter Cost Variation for Perinatal Hypoxic-Ischemic Encephalopathy in the Era of Therapeutic Hypothermia. J Pediatr 2016; 173:76-83.e1. [PMID: 26995699 DOI: 10.1016/j.jpeds.2016.02.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/14/2016] [Accepted: 02/09/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To quantify intercenter cost variation for perinatal hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia across children's hospitals. STUDY DESIGN Prospectively collected data from the Children's Hospitals Neonatal Database and Pediatric Health Information Systems were linked to evaluate intercenter cost variation in total hospitalization costs after adjusting for HIE severity, mortality, length of stay, use of extracorporeal support or nitric oxide, and ventilator days. Secondarily, costs for intensive care unit bed, electroencephalography (EEG), and laboratory and neuroimaging testing were also evaluated. Costs were contextualized by frequency of favorable (survival with normal magnetic resonance imaging) and adverse (death or need for gastric tube feedings at discharge) outcomes to identify centers with relative low costs and favorable outcomes. RESULTS Of the 822 infants with HIE treated with therapeutic hypothermia at 19 regional neonatal intensive care units, 704 (86%) survived to discharge. The median cost/case for survivors was $58 552 (IQR $32 476-$130 203) and nonsurvivors $29 760 (IQR $16 897-$61 399). Adjusting for illness severity and select interventions, intercenter differences explained 29% of the variation in total hospitalization costs. The widest cost variability across centers was EEG use, although low cost and favorable outcome centers ranked higher with regards to EEG costs. CONCLUSIONS There is marked intercenter cost variation associated with treating HIE across regional children's hospitals. Our investigation may help establish references for cost and enhance quality improvement and resource utilization projects related to HIE.
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Affiliation(s)
- An N Massaro
- Children's National Health System and the Department of Pediatrics, George Washington University School of Medicine, Washington, DC.
| | - Karna Murthy
- Ann and Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; Children's Hospitals Neonatal Consortium, Inc
| | | | - Noah Cook
- Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert DiGeronimo
- Department of Pediatrics, University of Utah and the Primary Children's Medical Center, Salt Lake City, UT
| | - Maria L V Dizon
- Ann and Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Shannon E G Hamrick
- Department of Pediatrics and Children's Healthcare of Atlanta at Egleston, Emory University, Atlanta, GA
| | | | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI
| | - Rakesh Rao
- Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO
| | | | - Danielle Smith
- Children's Hospital of Colorado and Department of Pediatrics, University of Colorado, Aurora, CO
| | - Amit M Mathur
- Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO
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Kaeppler C, Switchenko N, DiGeronimo R, Yoder BA. Do normal head ultrasounds need repeating in infants less than 30 weeks gestation? J Matern Fetal Neonatal Med 2015; 29:2428-33. [PMID: 26414689 DOI: 10.3109/14767058.2015.1086741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Current head ultrasound (HUS) screening recommendations in preterm infants often include a repeat HUS, regardless of initial findings. The objective of this study is to determine the rate of subsequent severe intraventricular hemorrhage (IVH), ventriculomegaly (VM), or periventricular leukomalacia (PVL) among infants < 30 weeks gestation (EGA) with a normal HUS at day of life (DOL) 4-10. METHODS Retrospectively collected data were analyzed for all infants < 30 weeks EGA cared for in one NICU from 1 January 2010 to 31 August 2014. Infants with severe congenital anomalies were excluded. We reviewed the first three HUSs and last documented HUS. Severe IVH was defined as > Papile grade 2 and significant interval HUS change was defined as development of severe IVH, PVL, or VM. RESULTS Of the 383 infants who had an initial screening HUS between DOL 4 and 10, 258 (67%) were initially normal and repeat screening was performed in 228 of these. None developed severe IVH on follow-up HUS. One infant developed VM secondary to GBS meningitis, and one developed echogenicity concerning for PVL that later resolved. CONCLUSIONS Among very preterm infants with a normal HUS between DOL 4 and 10, routine follow-up HUS is unlikely to identify a significant change.
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Affiliation(s)
| | | | - Robert DiGeronimo
- a Department of Pediatrics and.,b Division of Neonatology , University of Utah School of Medicine , Salt Lake City , UT , USA
| | - Bradley A Yoder
- a Department of Pediatrics and.,b Division of Neonatology , University of Utah School of Medicine , Salt Lake City , UT , USA
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Stiers J, Aguayo C, Siatta A, Presson AP, Perez R, DiGeronimo R. Potential and Actual Neonatal Organ and Tissue Donation After Circulatory Determination of Death. JAMA Pediatr 2015; 169:639-45. [PMID: 25961731 DOI: 10.1001/jamapediatrics.2015.0317] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The need for transplants continues to exceed organ and tissue donor availability. Although recent surgical advances have resulted in successful transplants using very small pediatric donors, including neonates, the actual practice of neonatal organ donation after circulatory determination of death (DCDD) remains uncommon. OBJECTIVE To describe the percentage of neonates potentially eligible for DCDD, including those who underwent successful donation, and reasons for ineligibility in those who did not in a single neonatal intensive care unit (NICU). DESIGN, SETTING, AND PARTICIPANTS We obtained data from the Children's Hospital Neonatal Database and Intermountain Donor Services (IDS) organ procurement records. The 136 deaths that occurred in the NICU of the Primary Children's Hospital, Salt Lake City, Utah, from January 1, 2010, through May 7, 2013, were reviewed retrospectively from January 12 through July 1, 2014, to determine potential eligibility for DCDD as determined by IDS minimum eligibility criteria (requirement of life-sustaining interventions and weight >2 kg). For patients who did not undergo DCDD, we reviewed records to determine the reasons for ineligibility. MAIN OUTCOMES AND MEASURES Potential eligibility for DCDD among neonates who died in the study NICU. RESULTS Of 136 deaths in the NICU, 60 (44.1%) met criteria for DCDD; however, fewer than 10% were referred appropriately to the regional organ procurement organization for evaluation. Forty-five neonates (33.1%) ultimately died within 90 minutes of withdrawal of life-sustaining interventions and thus would have been eligible for organ donation based on warm ischemic time. The most common causes of death among the 60 potentially eligible neonatal donors were neonatal encephalopathy (n = 17) and multiple congenital anomalies (n = 14). Nonreferral or late referral by the medical team was the most frequent reason for donor ineligibility, including 49 neonates (36.0%). Overall, only 4 neonates (2.9%) underwent successful DCDD. CONCLUSIONS AND RELEVANCE Although almost half of all neonatal deaths identified met minimum IDS criteria, most of these patients were not referred or were referred too late for evaluation. Although small size remains the primary reason for exclusion from DCDD, improved education with regard to criteria and the importance of timely referral by neonatologists and other members of the NICU team would likely result in a significant increase of future donations.
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Affiliation(s)
- Justin Stiers
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City
| | | | | | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City4Division of Epidemiology, Department of Pediatrics, University of Utah, Salt Lake City
| | - Richard Perez
- Division of Transplant Surgery, Department of Surgery, University of California, Davis, Sacramento
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City
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Massaro AN, Murthy K, Zaniletti I, Cook N, DiGeronimo R, Dizon M, Hamrick SEG, McKay VJ, Natarajan G, Rao R, Smith D, Telesco R, Wadhawan R, Asselin JM, Durand DJ, Evans JR, Dykes F, Reber KM, Padula MA, Pallotto EK, Short BL, Mathur AM. Short-term outcomes after perinatal hypoxic ischemic encephalopathy: a report from the Children's Hospitals Neonatal Consortium HIE focus group. J Perinatol 2015; 35:290-6. [PMID: 25393081 DOI: 10.1038/jp.2014.190] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/18/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To characterize infants affected with perinatal hypoxic ischemic encephalopathy (HIE) who were referred to regional neonatal intensive care units (NICUs) and their related short-term outcomes. STUDY DESIGN This is a descriptive study evaluating the data collected prospectively in the Children's Hospital Neonatal Database, comprised of 27 regional NICUs within their associated children's hospitals. A consecutive sample of 945 referred infants born ⩾36 weeks' gestation with perinatal HIE in the first 3 days of life over approximately 3 years (2010-July 2013) were included. Maternal and infant characteristics are described. Short-term outcomes were evaluated including medical comorbidities, mortality and status of survivors at discharge. RESULT High relative frequencies of maternal predisposing conditions, cesarean and operative vaginal deliveries were observed. Low Apgar scores, profound metabolic acidosis, extensive resuscitation in the delivery room, clinical and electroencephalographic (EEG) seizures, abnormal EEG background and brain imaging directly correlated with the severity of HIE. Therapeutic hypothermia was provided to 85% of infants, 15% of whom were classified as having mild HIE. Electrographic seizures were observed in 26% of the infants. Rates of complications and morbidities were similar to those reported in prior clinical trials and overall mortality was 15%. CONCLUSION Within this large contemporary cohort of newborns with perinatal HIE, the application of therapeutic hypothermia and associated neurodiagnostic studies appear to have expanded relative to reported clinical trials. Although seizure incidence and mortality were lower compared with those reported in the trials, it is unclear whether this represented improved outcomes or therapeutic drift with the treatment of milder disease.
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Affiliation(s)
- A N Massaro
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - K Murthy
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University Chicago, IL, USA
| | - I Zaniletti
- Children's Hospitals Association, Overland Park, KS, USA
| | - N Cook
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - R DiGeronimo
- Department of Pediatrics, University of Utah and the Primary Children's Medical Center, Salt Lake City, UT, USA
| | - M Dizon
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University Chicago, IL, USA
| | - S E G Hamrick
- Emory University Department of Pediatrics and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - V J McKay
- All Children's Hospital, St Petersburg, FL, USA
| | - G Natarajan
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - R Rao
- Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Loius, MO, USA
| | - D Smith
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - R Telesco
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - R Wadhawan
- Florida Hospital for Children, Orlando, FL, USA
| | - J M Asselin
- Children's Hospital Oakland & Research Center, Neonatal/Pediatric Research, Oakland, CA, USA
| | - D J Durand
- Children's Hospital Oakland & Research Center, Neonatal/Pediatric Research, Oakland, CA, USA
| | - J R Evans
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - F Dykes
- Emory University Department of Pediatrics and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - K M Reber
- Nationwide Children's Hospital and the Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH, USA
| | - M A Padula
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - E K Pallotto
- Children's Hospitals Mercy and Clinics and the Department of Pediatrics, University of Missouri School of Medicine, Kansas City, MO, USA
| | - B L Short
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - A M Mathur
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Arrington CB, Bleyl SB, Matsunami N, Bowles NE, Leppert TI, Demarest BL, Osborne K, Yoder BA, Byrne JL, Schiffman JD, Null DM, DiGeronimo R, Rollins M, Faix R, Comstock J, Camp NJ, Leppert MF, Yost HJ, Brunelli L. A family-based paradigm to identify candidate chromosomal regions for isolated congenital diaphragmatic hernia. Am J Med Genet A 2012; 158A:3137-47. [PMID: 23165927 DOI: 10.1002/ajmg.a.35664] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 08/21/2012] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm that causes high newborn mortality. Isolated or non-syndromic CDH is considered a multifactorial disease, with strong evidence implicating genetic factors. As low heritability has been reported in isolated CDH, family-based genetic methods have yet to identify the genetic factors associated with the defect. Using the Utah Population Database, we identified distantly related patients from several extended families with a high incidence of isolated CDH. Using high-density genotyping, seven patients were analyzed by homozygosity exclusion rare allele mapping (HERAM) and phased haplotype sharing (HapShare), two methods we developed to map shared chromosome regions. Our patient cohort shared three regions not previously associated with CDH, that is, 2q11.2-q12.1, 4p13 and 7q11.2, and two regions previously involved in CDH, that is, 8p23.1 and 15q26.2. The latter regions contain GATA4 and NR2F2, two genes implicated in diaphragm formation in mice. Interestingly, three patients shared the 8p23.1 locus and one of them also harbored the 15q26.2 segment. No coding variants were identified in GATA4 or NR2F2, but a rare shared variant was found in intron 1 of GATA4. This work shows the role of heritability in isolated CDH. Our family-based strategy uncovers new chromosomal regions possibly associated with disease, and suggests that non-coding variants of GATA4 and NR2F2 may contribute to the development of isolated CDH. This approach could speed up the discovery of the genes and regulatory elements causing multifactorial diseases, such as isolated CDH.
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Affiliation(s)
- Cammon B Arrington
- Department of Pediatrics (Cardiology), University of Utah School of Medicine, Salt Lake City, Utah 84112, USA
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Allibhai T, DiGeronimo R, Whitin J, Salazar J, Yu TTS, Ling XB, Cohen H, Dixon P, Madan A. Effects of moderate versus deep hypothermic circulatory arrest and selective cerebral perfusion on cerebrospinal fluid proteomic profiles in a piglet model of cardiopulmonary bypass. J Thorac Cardiovasc Surg 2009; 138:1290-6. [DOI: 10.1016/j.jtcvs.2009.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 04/08/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
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Tyree K, Tyree M, DiGeronimo R. Correlation of brain tissue oxygen tension with cerebral near-infrared spectroscopy and mixed venous oxygen saturation during extracorporeal membrane oxygenation. Perfusion 2009; 24:325-31. [PMID: 19948748 DOI: 10.1177/0267659109353966] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this prospective, animal study was to compare brain tissue oxygen tension (PbtO(2)) with cerebral near infrared spectroscopy (NIRS) and mixed venous oxygen saturation (SVO(2)) during venoarterial extracorporeal membrane oxygenation (VA ECMO) in a porcine model. This was accomplished using twelve immature piglets with surgically implanted catheters placed in the superficial cerebral cortex to measure brain PbtO(2) and microdialysis metabolites. The NIRS sensor was placed overlying the forehead to measure cerebral regional saturation index (rSO(2)i) while SVO(2) was measured directly from the ECMO circuit. Animals were placed on VA ECMO followed by an initial period of stabilization, after which they were subjected to graded hypoxia and recovery. Our results revealed that rSO(2)i and SVO(2) correlated only marginally with PbtO(2) (R(2)=0.32 and R(2)=0.26, respectively) while the correlation between rSO(2)i and SVO( 2) was significantly stronger (R(2)=0.59). Cerebral metabolites and rSO(2)i were significantly altered during attenuation of PbtO( 2), p<0.05). A subset of animals, following exposure to hypoxia, experienced markedly delayed recovery of both rSO(2)i and PbtO( 2) despite rapid normalization of SVO(2). Upon further analysis, these animals had significantly lower blood pressure (p=0.001), lower serum pH (p=0.01), and higher serum lactate (p=0.02). Additionally, in this subgroup, rSO(2)i correlated better with PbtO(2) (R(2)=0.76). These findings suggest that, in our ECMO model, rSO(2)i and SVO( 2) correlate reasonably well with each other, but not necessarily with brain PbtO(2) and that NIRS-derived rSO(2)i may more accurately reflect cerebral tissue hypoxia in sicker animals.
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Affiliation(s)
- Kreangkai Tyree
- Division of Neonatology, Department of Pediatrics, Wilford Hall USAF Medical Center, Lackland AFB, TX 78236-5300 , USA.
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Salazar J, Coleman R, Griffith S, McNeil J, Young H, Calhoon J, Serrano F, DiGeronimo R. Brain preservation with selective cerebral perfusion for operations requiring circulatory arrest: protection at 25°C is similar to 18°C with shorter operating times☆☆☆. Eur J Cardiothorac Surg 2009; 36:524-31. [DOI: 10.1016/j.ejcts.2009.04.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 04/07/2009] [Accepted: 04/08/2009] [Indexed: 11/16/2022] Open
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Coppola CP, Tyree M, Larry K, DiGeronimo R. A 22-year experience in global transport extracorporeal membrane oxygenation. J Pediatr Surg 2008; 43:46-52; discussion 52. [PMID: 18206454 DOI: 10.1016/j.jpedsurg.2007.09.021] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 09/02/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE Transport extracorporeal membrane oxygenation (ECMO) is currently available at 12 centers. We report a 22-year experience from the only facility providing global transport ECMO. Indications for transport ECMO include lack of ECMO services, inability to transport conventionally, inability to wean from cardiopulmonary bypass, extracorporeal cardiopulmonary resuscitation, and need to move a patient on ECMO for specialized services such as organ transplantation. METHODS Retrospective database review of children undergoing inhouse and transport ECMO from 1985 to 2007. RESULTS Sixty-eight children underwent transport ECMO. Fifty-six were transported on ECMO into our facility. The remaining 12 were moved between 2 outside locations. Ground vehicles and fixed-wing aircraft were used. Distance transported was 8 to 7500 miles (13-12070 km), mean 1380 miles (2220 km). There were 116 inhouse ECMO runs. No child died during transport. Survival to discharge after transport ECMO was 65% (44/68) and, for inhouse ECMO, was 70% (81/116). CONCLUSIONS Transport ECMO is feasible and effective, with survival rates comparable to inhouse ECMO. We have used transport ECMO to help children at non-ECMO centers with pulmonary failure who have not improved with inhaled nitric oxide and high-frequency ventilation. We have also transported a child after extracorporeal cardiopulmonary resuscitation, which may represent an emerging indication for transport ECMO. Transport ECMO often is the only option for children too unstable for conventional transport or those already on ECMO and requiring a specialized service at another facility, such as organ transplantation.
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Affiliation(s)
- Christopher P Coppola
- Department of Surgery, Wilford Hall Medical Center, San Antonio, Lackland AFB, TX 78236, USA.
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Croley M, DiGeronimo R, McCurnin D. 294 LITHIUM DILUTION CARDIAC OUTPUT MONITORING IN A PREMATURE NEONATE MODEL. J Investig Med 2006. [DOI: 10.2310/6650.2005.x0008.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE To characterize the population and survival of neonatal and pediatric patients transported by Wilford Hall Medical Center (WHMC) on extracorporeal membrane oxygenation (ECMO) since 1985. STUDY DESIGN A retrospective chart, literature, and database review of pediatric and neonatal patients transported on ECMO by the WHMC ECMO transport team. In addition, a subpopulation analysis was performed comparing neonates with meconium aspiration syndrome (MAS) placed on ECMO at WHMC with those infants with MAS transported on ECMO. Characteristics of interest for this comparison included disease severity before ECMO, age at initiation of ECMO, survival, ECMO-related complications, and duration of ECMO support. RESULTS Forty-two patients transported on ECMO were identified: 23 neonatal respiratory cases (survival 57%), 7 pediatric respiratory cases (survival 71%), 4 cardiac cases (survival 50%), and 8 extra-institutional ECMO transports (survival 63%). In the MAS subpopulation, there was significantly greater survival in the in-house group--97% (31/32)--than in the ECMO transport group--75% (9/12); there were no other significant differences between these groups. Overall, no ECMO-related complications leading to patient demise could be identified in the ECMO transport group. CONCLUSIONS ECMO transport, although demonstrating acceptable survival, is a risk-laden modality that should not replace early referral to an ECMO center.
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Affiliation(s)
- Bernard J Wilson
- Department of Pediatrics, Section of Newborn Medicine, San Antonio Military Pediatric Center, San Antonio, Texas, USA
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