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Cornet MC, Wu YW, Forquer H, Avalos LA, Sriram A, Scheffler AW, Newman TB, Kuzniewicz MW. Maternal treatment with selective serotonin reuptake inhibitors during pregnancy and delayed neonatal adaptation: a population-based cohort study. Arch Dis Child Fetal Neonatal Ed 2024; 109:294-300. [PMID: 38071585 DOI: 10.1136/archdischild-2023-326049] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/02/2023] [Indexed: 04/20/2024]
Abstract
OBJECTIVE Selective serotonin reuptake inhibitor (SSRI) use is common in pregnancy. It is associated with delayed neonatal adaptation. Most previous studies have not adjusted for the severity of maternal mental health disorders or examined the impact of SSRI type and dosage. We examined whether treatment with SSRIs in late pregnancy (after 20 weeks) is associated with delayed neonatal adaptation independent of maternal depression and anxiety. DESIGN, SETTING AND PATIENTS Retrospective population-based birth cohort of 280 090 term infants born at 15 Kaiser Permanente Northern California hospitals, 2011-2019. Individual-level pharmacy, maternal, pregnancy and neonatal data were obtained from electronic medical records. EXPOSURE Dispensed maternal SSRI prescription after 20 weeks of pregnancy. MAIN OUTCOME MEASURES Delayed neonatal adaptation defined as a 5 min Apgar score ≤5, resuscitation at birth or admission to a neonatal intensive care unit for respiratory support. Secondary outcomes included each individual component of the primary outcome and more severe neonatal outcomes (pulmonary hypertension, hypoxic-ischaemic encephalopathy and seizures). RESULTS 7573 (2.7%) infants were exposed to SSRIs in late pregnancy. Delayed neonatal adaptation occurred in 11.2% of exposed vs 4.4% of unexposed infants (relative risk 2.52 (95% CI 2.36 to 2.70)). After multivariable adjustment, there was an association between SSRI exposure and delayed neonatal adaptation (adjusted OR 2.14 (95% CI 1.96 to 2.32)). This association was dose dependent. Escitalopram and fluoxetine were associated with the highest risk of delayed neonatal adaptation. CONCLUSIONS Infants exposed to SSRIs have increased risks of delayed adaptation in a type and dose-dependent relationship, pointing toward a causal relationship.
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Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Heather Forquer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lyndsay A Avalos
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Achyuth Sriram
- Department of Pediatrics, Kaiser Permanente Northern California, Oakland, California, USA
| | - Aaron W Scheffler
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Thomas B Newman
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Michael W Kuzniewicz
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Pediatrics, Kaiser Permanente Northern California, Oakland, California, USA
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2
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Ikeme JC, Newman TB, Kohn MA. Arginine or Hypertonic Saline-Stimulated Copeptin to Diagnose AVP Deficiency. N Engl J Med 2024; 390:289. [PMID: 38231638 DOI: 10.1056/nejmc2314326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Jesse C Ikeme
- University of California, San Francisco, San Francisco, CA
| | | | - Michael A Kohn
- University of California, San Francisco, San Francisco, CA
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3
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Wang ME, Jones VG, Kane M, Allan JM, Maleknia L, Patel R, Ip W, Newman TB, Roberts KB, Schroeder AR. Clinical Course of Children 1 to 24 Months Old With Positive Urine Cultures Without Pyuria. Acad Pediatr 2024; 24:111-118. [PMID: 37354950 DOI: 10.1016/j.acap.2023.06.023] [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: 02/22/2023] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To describe the clinical course of children with positive urine cultures without pyuria who were not given antibiotics initially, identify predictors of subsequent antibiotic treatment, and evaluate the association between subsequent treatment and urinary tract infection (UTI) within 30 days. METHODS We conducted a multicenter retrospective cohort study of children 1 to 24 months old who had positive urine cultures without pyuria and who were not started on antibiotics upon presentation to 3 health care systems from 2010 to 2021. Outcomes included clinical status at the time urine cultures resulted, escalation of care (emergency department visit or hospitalization) and subsequent antibiotic treatment within 7 days, and subsequent UTI within 30 days of presentation. RESULTS Of 202 included children, 61% were female and median age was 9 months. Of 151 patients with clinical status information when cultures resulted, 107 (70.8%, 95% confidence interval [CI] 62.9-77.9%) were improved. Two of 202 children (1.0%, 95% CI 0.2-4.0%) experienced care escalation. Antibiotics were started in 142 (82.2%) children, and treatment was associated with prior UTI (risk ratio [RR] 1.20, 95% CI 1.15-1.26) and lack of improvement (RR 1.22, 95% CI 1.13-1.33). Subsequent UTI was diagnosed in 2 of 164 (1.2%, 95% CI 0.1-4.3%) treated and 0 of 36 (0%, 95% CI 0-9.7%) untreated children. CONCLUSIONS Seventy percent of children with positive urine cultures without pyuria improved before starting antibiotics; however, >80% were ultimately treated. Future research should study the impact of diagnostic stewardship interventions and various urine testing strategies to optimize the management of children evaluated for UTI.retain-->.
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Affiliation(s)
- Marie E Wang
- Division of Pediatric Hospital Medicine (ME Wang, W Ip, and AR Schroeder), Stanford University School of Medicine, Palo Alto, Calif.
| | - Veena G Jones
- Division of Pediatric Hospital Medicine (VG Jones and JM Allan), Palo Alto Medical Foundation, Palo Alto, Calif.
| | - Miranda Kane
- Department of Pediatric Hospital Medicine (M Kane, L Maleknia, and R Patel), Kaiser Permanente Northern California, Oakland, Calif.
| | - Jessica M Allan
- Division of Pediatric Hospital Medicine (VG Jones and JM Allan), Palo Alto Medical Foundation, Palo Alto, Calif.
| | - Lydia Maleknia
- Department of Pediatric Hospital Medicine (M Kane, L Maleknia, and R Patel), Kaiser Permanente Northern California, Oakland, Calif.
| | - Ritu Patel
- Department of Pediatric Hospital Medicine (M Kane, L Maleknia, and R Patel), Kaiser Permanente Northern California, Oakland, Calif.
| | - Wui Ip
- Division of Pediatric Hospital Medicine (ME Wang, W Ip, and AR Schroeder), Stanford University School of Medicine, Palo Alto, Calif.
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics (TB Newman), University of California, San Francisco.
| | - Kenneth B Roberts
- Department of Pediatrics (KB Roberts), University of North Carolina at Chapel Hill.
| | - Alan R Schroeder
- Division of Pediatric Hospital Medicine (ME Wang, W Ip, and AR Schroeder), Stanford University School of Medicine, Palo Alto, Calif.
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4
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Cornet MC, Kuzniewicz M, Scheffler A, Forquer H, Hamilton E, Newman TB, Wu YW. Perinatal Hypoxic-Ischemic Encephalopathy: Incidence Over Time Within a Modern US Birth Cohort. Pediatr Neurol 2023; 149:145-150. [PMID: 37883841 PMCID: PMC10842130 DOI: 10.1016/j.pediatrneurol.2023.08.037] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Recent studies suggest that the incidence of perinatal hypoxic-ischemic encephalopathy (HIE) may be increasing in developed countries. However, this observed increase may be due to increased ascertainment and increased treatment with therapeutic hypothermia rather than an increase in disease burden. In a US population-based cross-sectional study, we determined the incidence of perinatal HIE over time. METHODS The study population included all 289,793 live-born infants ≥35 weeks gestational age born at 15 Kaiser Permanente Northern California hospitals between 2012 and 2019. Perinatal HIE was defined as the presence of both neonatal acidosis (i.e., cord blood pH < 7 or base deficit ≥10, or base deficit ≥10 on first infant gas) and neonatal encephalopathy confirmed by medical record review. Hospital discharge diagnoses of HIE were determined by extracting International Classification of Disease diagnostic codes for HIE assigned upon hospital discharge. RESULTS The population incidence of perinatal HIE was 1.7 per 1000. Although the incidence of perinatal HIE did not change significantly, both hospital discharge diagnoses of HIE and treatment with therapeutic hypothermia increased significantly during the study period. The sensitivity and positive predictive value of a hospital discharge diagnosis of HIE for identifying perinatal HIE confirmed by chart review were 72% and 79%, respectively. CONCLUSIONS During the study years, the incidence of perinatal HIE remained stable despite increases in hospital discharge diagnoses of HIE and in the use of therapeutic hypothermia. Our findings underscore the importance of applying stringent diagnostic criteria when diagnosing this complex condition.
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Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, California.
| | - Michael Kuzniewicz
- Department of Pediatrics, Kaiser Permanente, Northern California, Oakland, California; Division of Research, Kaiser Permanente, Northern California, Oakland, California
| | - Aaron Scheffler
- Department of Biostatistics, University of California San Francisco, San Francisco, California
| | - Heather Forquer
- Division of Research, Kaiser Permanente, Northern California, Oakland, California
| | - Emily Hamilton
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada; Obstetrical Consultant, PeriGen, Cary, North Carolina
| | - Thomas B Newman
- Department of Pediatrics, University of California San Francisco, San Francisco, California; Department of Biostatistics, University of California San Francisco, San Francisco, California
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California; Department of Neurology, University of California San Francisco, San Francisco, California
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5
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Kohn MA, Newman TB. The walking man approach to interpreting the receiver operating characteristic curve and area under the receiver operating characteristic curve. J Clin Epidemiol 2023; 162:182-186. [PMID: 37562728 DOI: 10.1016/j.jclinepi.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/22/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023]
Abstract
An accuracy study of a test that produces a wide range of results will often present a receiver operating characteristic (ROC) curve and report the area under the ROC curve (AUROC). The AUROC is a summary measure of how well the test discriminates between those with the condition or disease in question and those without it. A test that perfectly separates individuals with and without the condition has an AUROC of 1.0, and a test that doesn't separate them at all has an AUROC of 0.5. The AUROC is also the probability that a random individual with the condition will have a more abnormal test result than a random individual without the condition. In this Key Concepts article, we present our "walking man" approach to understanding ROC curves and the AUROC.
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Affiliation(s)
- Michael A Kohn
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
| | - Thomas B Newman
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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6
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Mediratta RP, Newman TB, Wang ME. Research Methods: Diagnostic Test Characteristics. Hosp Pediatr 2023; 13:e164-e169. [PMID: 37144292 DOI: 10.1542/hpeds.2023-007149] [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] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The goal of a diagnostic test is to provide information on the probability of disease. In this article, we review the principles of diagnostic test characteristics, including sensitivity, specificity, positive and negative predictive value, receiver operating characteristics curves, likelihood ratios, and interval likelihood ratios. We illustrate how interval likelihood ratios optimize the information that can be obtained from test results that can take on >2 values, how they are reflected in the slope of the receiver operating characteristics curve, and how they can be easily calculated from published data.
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Affiliation(s)
- Rishi P Mediratta
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, California
| | - Marie E Wang
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Palo Alto, California
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7
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Wickremasinghe AC, Kuzniewicz MW, Walsh EM, Li S, Newman TB. NICU Versus Mother/Baby Unit Admission for Low-Acuity Infants Born at 35 Weeks' Gestation. Pediatrics 2023; 151:190930. [PMID: 36994638 DOI: 10.1542/peds.2022-056861] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVES To estimate the effect of NICU admission of low-acuity infants born at 35 weeks' gestation versus care in a mother/baby unit, on inpatient and outpatient medical outcomes. METHODS This retrospective cohort study included 5929 low-acuity infants born at 350/7 to 356/7 weeks' gestation at 13 Kaiser Permanente Northern California hospitals with level II or level III NICUs between January 1, 2011, and December 31, 2021. Exclusion criteria included congenital anomalies and early respiratory support or antibiotics. We used multivariable regression and regression discontinuity analyses to control for confounding variables. RESULTS Infants admitted to the NICU within 2 hours of birth (n = 862, 14.5%) had a 58 hour adjusted (98-hour unadjusted) longer length of stay. NICU admission was associated with an increased probability of a length of stay ≥96 hours (67% vs 21%; adjusted odds ratio [aOR], 4.94; 95% confidence interval [CI], 3.96-6.16). Regression discontinuity results suggested a similar (57 hour) increase in length of stay. Readmission risk, primarily for jaundice, was lower for those admitted to the NICU (3% vs 6%; aOR, 0.43; 95% CI, 0.27-0.69). Infants admitted to the NICU were slightly less likely to be receiving exclusive breast milk at 6-month follow-up (15% vs 25%; aOR, 0.73; 95% CI, 0.55-0.97; adjusted marginal risk difference -5%). CONCLUSIONS Admitting low-acuity infants born at 35 weeks' gestation to the NICU was associated with decreased readmission, but with longer length of stay and decreased exclusive breast milk feeding at 6 months. Routine NICU admission may be unnecessary for low-acuity infants born at 35 weeks' gestation.
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Affiliation(s)
| | - Michael W Kuzniewicz
- Department of Pediatrics, Kaiser Permanente, Santa Clara, California
- Division of Research, Kaiser Permanente, Oakland, California
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente, Oakland, California
| | - Sherian Li
- Division of Research, Kaiser Permanente, Oakland, California
| | - Thomas B Newman
- Division of Research, Kaiser Permanente, Oakland, California
- Departments of Pediatrics
- Epidemiology and Biostatistics, University of California, San Francisco, California
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8
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Kemper AR, Newman TB, Wright JL. Race and the 2022 American Academy of Pediatrics Hyperbilirubinemia Guideline. JAMA Pediatr 2023; 177:435-436. [PMID: 36780184 DOI: 10.1001/jamapediatrics.2022.5913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco.,Department of Pediatrics, School of Medicine, University of California, San Francisco
| | - Joseph L Wright
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore.,Department of Health Policy and Management, University of Maryland School of Public Health, College Park
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9
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Cornet MC, Kemper AR, Maisels MJ, Watchko J, Newman TB. Neonatal hyperbilirubinemia and bilirubin neurotoxicity: what can be learned from the database analysis? Pediatr Res 2022; 92:1204. [PMID: 35136201 DOI: 10.1038/s41390-022-01973-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 09/03/2021] [Revised: 11/30/2021] [Accepted: 01/23/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
| | - Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Beaumont Children's Hospital, Royal Oak, MI, USA
| | - Jon Watchko
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Thomas B Newman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
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10
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Guterman EL, Sporer KA, Newman TB, Crowe RP, Lowenstein DH, Josephson SA, Betjemann JP, Burke JF. Real-World Midazolam Use and Outcomes With Out-of-Hospital Treatment of Status Epilepticus in the United States. Ann Emerg Med 2022; 80:319-328. [PMID: 35931608 PMCID: PMC9930617 DOI: 10.1016/j.annemergmed.2022.05.024] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/13/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Guidelines recommend 10-mg intramuscular midazolam as the first-line treatment option for status epilepticus. However, in real-world practice, it is frequently administered intranasally or intravenously and is dosed lower. Therefore, we used conventional and instrumental variable approaches to examine the effectiveness of midazolam in a national out-of-hospital cohort. METHODS This retrospective cohort study of adults with status epilepticus used the ESO Data Collaborative research dataset (January 1, 2019, to December 31, 2019). The exposures were the route and dose of midazolam. We performed hierarchical logistic regression and 2-stage least squares regression using agency treatment patterns as an instrument to examine our outcomes, rescue therapy, and ventilatory support. RESULTS There were 7,634 out-of-hospital encounters from 657 EMS agencies. Midazolam was administered intranasally in 20%, intravenously in 46%, and intramuscularly in 35% of the encounters. Compared with intramuscular administration, intranasal midazolam increased (risk difference [RD], 6.5%; 95% confidence interval [CI], 2.4% to 10.5%) and intravenous midazolam decreased (RD, -11.1%; 95% CI, -14.7% to -7.5%) the risk of rescue therapy. The differences in ventilatory support were not statistically significant (intranasal RD, -1.5%; 95% CI, -3.2% to 0.3%; intravenous RD, -0.3%; 95% CI, -1.9% to 1.2%). Higher doses were associated with a lower risk of rescue therapy (RD, -2.6%; 95% CI, -3.3% to -1.9%) and increased ventilatory support (RD, 0.4%; 95% CI, 0.1% to 0.7%). The instrumental variable analysis yielded similar results, except that dose was not associated with ventilatory support. CONCLUSION The route and dose of midazolam affect clinical outcomes. Compared with intramuscular administration, intranasal administration may be less effective and intravenous administration more effective in terminating status epilepticus, although the differences between these and previous results may reflect the nature of real-world data as opposed to randomized data.
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Affiliation(s)
- Elan L Guterman
- Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA.
| | - Karl A Sporer
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Thomas B Newman
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA
| | - Remle P Crowe
- ESO, Inc. Kaiser Permanente, Northern California, San Francisco, CA
| | - Daniel H Lowenstein
- Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA
| | - S Andrew Josephson
- Department of Neurology, University of California, San Francisco, CA; Weill Institute for Neurosciences, University of California, San Francisco, CA
| | - John P Betjemann
- Department of Neurology, Kaiser Permanente, Northern California, San Francisco, CA
| | - James F Burke
- Department of Neurology, Ohio State Wexner Medical Center, Columbus, OH; Department of Neurology, University of Michigan, Ann Arbor, MI
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11
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Kuzniewicz MW, Li SX, McCulloch CE, Newman TB. Predicting the Need for Phototherapy After Discharge: Update for 2022 Phototherapy Guidelines. Pediatrics 2022; 150:188723. [PMID: 35927471 DOI: 10.1542/peds.2022-058020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Michael W Kuzniewicz
- Pediatrics, University of California, San Francisco, San Francisco, California.,Department of Pediatrics.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sherian Xu Li
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Thomas B Newman
- Departments of Epidemiology and Biostatistics.,Pediatrics, University of California, San Francisco, San Francisco, California.,Division of Research, Kaiser Permanente Northern California, Oakland, California
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12
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Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, Downs SM, Grout RW, Bundy DG, Stark AR, Bogen DL, Holmes AV, Feldman-Winter LB, Bhutani VK, Brown SR, Maradiaga Panayotti GM, Okechukwu K, Rappo PD, Russell TL. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2022; 150:188726. [PMID: 35927462 DOI: 10.1542/peds.2022-058859] [Citation(s) in RCA: 100] [Impact Index Per Article: 50.0] [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] [Accepted: 06/29/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | | | - M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Jon F Watchko
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen M Downs
- Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina
| | - Randall W Grout
- Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana
| | - David G Bundy
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Debra L Bogen
- Allegheny County Health Department, Pittsburgh, Pennsylvania
| | - Alison Volpe Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
| | - Lori B Feldman-Winter
- Department of Pediatrics, Division of Adolescent Medicine, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Vinod K Bhutani
- Department of Pediatrics, Neonatal and Developmental Medicine Stanford University School of Medicine, Stanford, California
| | | | - Gabriela M Maradiaga Panayotti
- Division of Primary Care, Duke Children's Hospital and Health Center, Duke University Medical Center, Durham, North Carolina
| | - Kymika Okechukwu
- Department of Quality, American Academy of Pediatrics, Itasca, Illinois
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13
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Slaughter JL, Kemper AR, Newman TB. Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2022; 150:188725. [PMID: 35927519 DOI: 10.1542/peds.2022-058865] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 11/24/2022] Open
Abstract
CONTEXT Severe hyperbilirubinemia is associated with kernicterus. Informed guidance on hyperbilirubinemia management, including preventive treatment thresholds, is essential to safely minimize neurodevelopmental risk. OBJECTIVE To update the evidence base necessary to develop the 2022 American Academy of Pediatrics clinical practice guideline for management of hyperbilirubinemia in the newborn infant ≥35 weeks' gestation. DATA SOURCE PubMed. STUDY SELECTION English language randomized controlled trials and observational studies. Excluded: case reports or series, nonsystematic reviews, and investigations focused on <35-weeks' gestation infants. DATA EXTRACTION Topics addressed in the previous clinical practice guideline (2004) and follow-up commentary (2009) were updated with new evidence published through March 2022. Evidence reviews were conducted for previously unaddressed topics (phototherapy-associated adverse effects and effectiveness of intravenous immune globulin [IVIG] to prevent exchange transfusion). RESULTS New evidence indicates that neurotoxicity does not occur until bilirubin concentrations are well above the 2004 exchange transfusion thresholds. Systematic review of phototherapy-associated adverse effects found limited and/or inconsistent evidence of late adverse effects, including cancer and epilepsy. IVIG has unclear benefit for preventing exchange transfusion in infants with isoimmune hemolytic disease, with a possible risk of harm due to necrotizing enterocolitis. LIMITATIONS The search was limited to 1 database and English language studies. CONCLUSIONS Accumulated evidence justified narrowly raising phototherapy treatment thresholds in the updated clinical practice guideline. Limited evidence for effectiveness with some evidence of risk of harm support the revised recommendations to limit IVIG use.
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Affiliation(s)
| | - Alex R Kemper
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, California
| | - Thomas B Newman
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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14
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Schroeder AR, Newman TB, Girod S, Hashemi S, Häberle AD. Estimated Cumulative Incidence of Wisdom Tooth Extractions in Privately Insured US Patients. Front Dent Med 2022. [DOI: 10.3389/fdmed.2022.937165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo determine the cumulative incidence and predictors of third molar (3M, “wisdom teeth”) extractions in the US.MethodsWe retrospectively analyzed a US private dental insurance claims database to create a Kaplan-Meier curve for cumulative incidence of 3M extractions, and used Cox proportional hazards to assess associations between sex, geographic region, and extractions.ResultsBetween 2007 and 2016, by age 25, ~80% of patients underwent ≥1 tooth extraction and an estimated 50% of patients underwent ≥1 3M extraction. Factors associated with 3M extractions included female sex (adjusted hazard ratio [aHR] 1.08, 95% CI 1.07 – 1.08) and residence in the West (aHR 1.82, 95% CI 1.81-1.85) or South (aHR 1.5, 95% CI 1.49 – 1.51) geographic regions as compared to the Northeast.Conclusion3M extractions are likely the most common surgery performed in US adolescents and young adults. Significant geographic variation suggests that elucidation of the indications for this common procedure is a public health priority.
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Abstract
OBJECTIVES To estimate the effect of readmission for inpatient phototherapy on parent-reported exclusive and any breast milk feeding at 2-month well-child visits. METHODS We performed a retrospective cohort study using electronic health record data. From births at 16 Kaiser Permanente Northern California hospitals (2013-2017), we identified a cohort of infants ≥35 weeks' gestation with outpatient total serum bilirubin levels ranging from 1 mg/dL below to 2.9 mg/dL above the American Academy of Pediatrics phototherapy threshold at <15 days of age. We compared breast milk feeding at 2-month well-child visits among those readmitted and not readmitted to the hospital for phototherapy, adjusting for bilirubin and other confounding variables. RESULTS Approximately one-quarter (26.5%) of the cohort (n = 7729) were readmitted for phototherapy. Almost half (48.5%) of the infants who were not readmitted for phototherapy received exclusively breast milk at the 2-month visit compared with slightly fewer infants who were readmitted (42.9%). In both groups of infants, most (82.2% not readmitted and 81.2% readmitted) received any breast milk. Readmission for phototherapy was associated with a lower adjusted risk of exclusive breast milk feeding (adjusted risk ratio 0.90; 95% confidence interval [CI], 0.84 to 0.96), corresponding to a marginal absolute reduction in exclusive breast milk feeding of 5.0% (95% CI, -7.9% to -2.1%). It was not associated with a reduction in any breast milk feeding (adjusted risk ratio, 1.00; 95% CI, 0.97 to 1.02). CONCLUSIONS Infants readmitted for phototherapy were more likely to receive any formula, but no less likely to receive any breast milk at 2-month well-child visits.
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Affiliation(s)
| | - Pearl W Chang
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Sherian X Li
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michael W Kuzniewicz
- Pediatrics, University of California, San Francisco, California.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics.,Pediatrics, University of California, San Francisco, California
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16
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Kuzniewicz MW, Newman TB. Updated Bhutani bilirubin curves include 12-hour-age levels and demonstrate gestational age and racial differences. J Pediatr 2022; 240:310-313. [PMID: 34952667 DOI: 10.1016/j.jpeds.2021.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Thomas B Newman
- University of California, San Francisco, San Francisco, California
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17
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Digitale JC, Chang PW, Li SX, Kuzniewicz MW, Newman TB. The effect of hospital phototherapy on early breastmilk feeding. Paediatr Perinat Epidemiol 2021; 35:717-725. [PMID: 34184759 DOI: 10.1111/ppe.12794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 01/05/2021] [Revised: 04/20/2021] [Accepted: 05/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect of phototherapy on breastmilk feeding is unclear. OBJECTIVE To estimate the effect of inpatient phototherapy on breastmilk feeding at 2-month well-child visits. METHODS We performed a retrospective cohort study using electronic health record data. From births at 16 Kaiser Permanente Northern California hospitals (2013-2017), we identified a cohort of infants ≥ 35 weeks' gestation with total serum bilirubin levels close to the American Academy of Pediatrics 2004 phototherapy threshold during their birth hospitalisation. We compared self-reported breastmilk feeding at 2-month well-child visits among those who had and had not received birth hospitalisation phototherapy, adjusting for bilirubin levels and other confounding variables. We used multiple imputation (K = 200) to address missing data. RESULTS Approximately a quarter of infants in the cohort (24.5%) received phototherapy during their birth hospitalisation. At the 2-month visit, exclusive breastmilk feeding was less common (RR 0.91, 95% interval [CI] 0.88, 0.95) among those who received phototherapy (41.3%) than those who did not (45.2%). However, no association remained after adjusting for potential confounders (RR 0.99, 95% CI 0.95, 1.04; average treatment effect on the treated [ATET] -0.2%, 95% CI -2.0%, 1.5%). In contrast, any breastmilk feeding was similar between infants who did (76.8%) and did not get phototherapy (77.9%). After adjusting for confounders, phototherapy had a slightly positive association with any breastmilk feeding at 2 months (RR 1.02, 95% CI 1.00, 1.04). Among infants who received phototherapy, the proportion being fed any breastmilk at the 2-month visit was an estimated 1.6 percentage points higher than it would have been if they had not received phototherapy (ATET 1.6%, 95% CI 0.1%, 3.1%). Multiple imputation results were similar. CONCLUSIONS Birth hospitalisation phototherapy can be delivered in a way that does not adversely affect breastmilk feeding at 2 months.
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Affiliation(s)
- Jean C Digitale
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Pearl W Chang
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Sherian X Li
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Michael W Kuzniewicz
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Thomas B Newman
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA.,Department of Pediatrics, University of California, San Francisco, CA, USA
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18
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Digitale JC, Kim MO, Kuzniewicz MW, Newman TB. Update on Phototherapy and Childhood Cancer in a Northern California Cohort. Pediatrics 2021; 148:peds.2021-051033. [PMID: 34716218 DOI: 10.1542/peds.2021-051033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Accepted: 08/10/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We aimed to reassess the relationship between phototherapy and cancer in an extended version of a previous cohort and to replicate a report from Quebec of increased cancer risk after phototherapy beginning at age 4 years. METHODS This cohort study included 139 100 children born at ≥35 weeks' gestation from 1995 to 2017, followed through March 16, 2019, in Kaiser Permanente Northern California hospitals who had a qualifying bilirubin level from -3 mg/dL to +4.9 mg/dL from the American Academy of Pediatrics phototherapy threshold; an additional 40 780 children and 5 years of follow-up from our previous report. The exposure was inpatient phototherapy (yes or no), and the outcomes were various types of childhood cancer. We used Cox proportional hazard models, controlling for propensity-score quintiles, and allowed for time-dependent exposure effects to assess for the risk of cancer after a latent period. RESULTS Over a mean (SD) follow-up of 8.2 (5.7) years, the crude incidence of cancer per 100 000 person-years was 25.1 among those exposed to phototherapy and 19.2 among those not exposed (233 cases of cancer). After propensity adjustment, phototherapy was not associated with any cancer (hazard ratio [HR]: 1.13, 95% confidence interval [CI]: 0.83-1.54), hematopoietic cancer (HR: 1.17, 95% CI: 0.74-1.83), or solid tumors (HR: 1.01, 95% CI: 0.65-1.58). We also found no association with cancer diagnoses at age ≥4 years. CONCLUSIONS We did not confirm previous, concerning associations between phototherapy and adjusted risk of any cancer, nonlymphocytic leukemia, or brain and/or central nervous systems tumors in later childhood.
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Affiliation(s)
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics.,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Michael W Kuzniewicz
- Pediatrics.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics.,Pediatrics.,Division of Research, Kaiser Permanente Northern California, Oakland, California
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19
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de Ferranti SD, Kazi DS, Bibbins-Domingo K, Daniels S, Howaniec B, Khera AV, Newman TB, Vernacchio L. Perspectives on Identifying and Treating Familial Hypercholesterolemia in Childhood. Clin Chem 2021; 67:1312-1317. [PMID: 34491300 DOI: 10.1093/clinchem/hvab157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/05/2021] [Indexed: 11/14/2022]
Affiliation(s)
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Dept. of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Dhruv S Kazi
- Dept. of Pediatrics, Harvard Medical School, Boston, MA USA.,Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Cardiovascular Institute, Boston, MA USA
| | | | - Kirsten Bibbins-Domingo
- Vice Dean for Population Health at University of California San Francisco, General Internist at Zuckerberg San Francisco General Hospital, San Francisco, CA USA and Former Member and Chair of the U.S. Preventive Services Task Force
| | - Stephen Daniels
- Pediatric Preventive Cardiologist, Chair of the Department of Pediatrics at the University of Colorado School of Medicine, Denver, CO USA and Pediatric Lipid Guideline Author
| | - Barbara Howaniec
- APRN Private Practice Psychiatric Nurse Practitioner, Lewiston, ME USA and Parent of a Child with FH
| | - Amit V Khera
- Internist/Cardiologist and Associate Director of the Precision Medicine Unit at Mass General Hospital, Boston, MA USA
| | - Thomas B Newman
- Professor Emeritus of Epidemiology & Biostatistics and Pediatric at University of California San Francisco, San Francisco, CA
| | - Louis Vernacchio
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Primary Care Pediatrician and Chief Medical Officer for Boston Children's Hospital Primary Care Network, Boston, MA USA
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20
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Maisels MJ, Newman TB, Kaplan M. A new hour-specific serum bilirubin nomogram for neonates ≥35 weeks of gestation. J Pediatr 2021; 237:317. [PMID: 34265340 DOI: 10.1016/j.jpeds.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
Affiliation(s)
- M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Beaumont Children's Hospital, Rochester, Michigan
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics, Department of Pediatrics, University of California, San Francisco, California
| | - Michael Kaplan
- Emeritus, Department of Neonatology, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University, Jerusalem, Israel
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21
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Weiss NM, Kuzniewicz MW, Shimano KA, Walsh EM, Newman TB. Use of Complete Blood Cell Count Components to Screen for Hereditary Spherocytosis in Neonates. Pediatrics 2021; 148:peds.2020-021642. [PMID: 34376530 DOI: 10.1542/peds.2020-021642] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The neonatal hereditary spherocytosis (HS) index, defined as the mean corpuscular hemoglobin concentration divided by the mean corpuscular volume, has been proposed as a screening tool for HS in neonates. In a population of mostly white infants, an HS Index >0.36 was 97% sensitive and >99% specific. We evaluated the utility of the HS Index among a more racially and ethnically diverse population and determined if its discrimination varies with total serum bilirubin (TSB) levels. METHODS Infants born at ≥35 weeks' gestation at 15 Kaiser Permanente Northern California hospitals from 1995 to 2015 were eligible (N = 670 272). Erythrocyte indices from the first complete blood count drawn at ≤7 days and TSB levels drawn at ≤30 days were obtained. Diagnoses of HS were confirmed via chart review. RESULTS HS was confirmed in 79 infants, 1.2 per 10 000. HS was more common among infants of white and "other" race or ethnicity and among those with higher peak TSB levels. The area under the receiver operating characteristic curve for the HS Index was 0.84 (95% confidence interval 0.78-0.90). Likelihood ratios ranged from 10.1 for an HS Index ≥0.380 to 0.1 for an HS Index <0.310. Dichotomized at 0.36, the HS Index was 56% sensitive and 93% specific. Discrimination of the HS Index appeared best among infants with TSB levels <10 mg/dL. CONCLUSIONS The HS Index, when obtained from a CBC drawn within the first week after birth, had only modest ability to alter the probability of HS.
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Affiliation(s)
- Nicole M Weiss
- Departments of Pediatrics .,Department of Pediatrics, Kaiser Permanente Santa Clara, Santa Clara, California
| | - Michael W Kuzniewicz
- Departments of Pediatrics.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Eileen M Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Thomas B Newman
- Departments of Pediatrics.,Division of Research, Kaiser Permanente Northern California, Oakland, California.,Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
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22
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Kolodzie K, Cakmakkaya OS, Boparai ES, Tavakol M, Feiner JR, Kim MO, Newman TB, Niemann CU. Perioperative Normal Saline Administration and Delayed Graft Function in Patients Undergoing Kidney Transplantation: A Retrospective Cohort Study. Anesthesiology 2021; 135:621-632. [PMID: 34265037 DOI: 10.1097/aln.0000000000003887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Perioperative normal saline administration remains common practice during kidney transplantation. The authors hypothesized that the proportion of balanced crystalloids versus normal saline administered during the perioperative period would be associated with the likelihood of delayed graft function. METHODS The authors linked outcome data from a national transplant registry with institutional anesthesia records from 2005 to 2015. The cohort included adult living and deceased donor transplants, and recipients with or without need for dialysis before transplant. The primary exposure was the percent normal saline of the total amount of crystalloids administered perioperatively, categorized into a low (less than or equal to 30%), intermediate (greater than 30% but less than 80%), and high normal saline group (greater than or equal to 80%). The primary outcome was the incidence of delayed graft function, defined as the need for dialysis within 1 week of transplant. The authors adjusted for the following potential confounders and covariates: transplant year, total crystalloid volume, surgical duration, vasopressor infusions, and erythrocyte transfusions; recipient sex, age, body mass index, race, number of human leukocyte antigen mismatches, and dialysis vintage; and donor type, age, and sex. RESULTS The authors analyzed 2,515 records. The incidence of delayed graft function in the low, intermediate, and high normal saline group was 15.8% (61/385), 17.5% (113/646), and 21% (311/1,484), respectively. The adjusted odds ratio (95% CI) for delayed graft function was 1.24 (0.85 to 1.81) for the intermediate and 1.55 (1.09 to 2.19) for the high normal saline group compared with the low normal saline group. For deceased donor transplants, delayed graft function in the low, intermediate, and high normal saline group was 24% (54/225 [reference]), 28.6% (99/346; adjusted odds ratio, 1.28 [0.85 to 1.93]), and 30.8% (277/901; adjusted odds ratio, 1.52 [1.05 to 2.21]); and for living donor transplants, 4.4% (7/160 [reference]), 4.7% (14/300; adjusted odds ratio, 1.15 [0.42 to 3.10]), and 5.8% (34/583; adjusted odds ratio, 1.66 [0.65 to 4.25]), respectively. CONCLUSIONS High percent normal saline administration is associated with delayed graft function in kidney transplant recipients. EDITOR’S PERSPECTIVE
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23
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Abstract
BACKGROUND AND OBJECTIVES Bilirubin screening before discharge is performed to identify neonates at risk for future hyperbilirubinemia. The American Academy of Pediatrics recommends using a graph of bilirubin levels by age (the Bhutani Nomogram) to guide follow-up and a different graph to determine phototherapy recommendations. Our objective was to evaluate predictive models that incorporate the difference between the last total serum bilirubin (TSB) before discharge and the American Academy of Pediatrics phototherapy threshold (Δ-TSB) to predict a postdischarge TSB above the phototherapy threshold by using a single graph. METHODS We studied 148 162 infants born at ≥35 weeks' gestation at 11 Kaiser Permanente Northern California facilities from 2012 to 2017 whose TSB did not exceed phototherapy levels and who did not receive phototherapy during the birth hospitalization. We compared 3 logistic models (Δ-TSB; Δ-TSB-Plus, which included additional variables; and the Bhutani Nomogram) by using the area under the receiver operating characteristic curve (AUC) in a 20% validation subset. RESULTS A total of 2623 infants (1.8%) exceeded the phototherapy threshold postdischarge. The predicted probability of exceeding the phototherapy threshold after discharge ranged from 56% for a predischarge Δ-TSB 0 to 1 mg/dL below the threshold to 0.008% for Δ-TSB >7 mg/dL below the threshold. Discrimination was better for the Δ-TSB model (AUC 0.93) and the Δ-TSB-Plus model (AUC 0.95) than for the Bhutani Nomogram (AUC 0.88). CONCLUSIONS The use of Δ-TSB models had excellent ability to predict postdischarge TSB above phototherapy thresholds and may be simpler to use than the Bhutani Nomogram.
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Affiliation(s)
- Michael W Kuzniewicz
- Division of Research and .,Departments of Pediatric and.,Department of Pediatrics, Kaiser Permanente, Northern California, Oakland, California; and
| | - Jina Park
- Department of Pediatrics, Kaiser Permanente, Northern California, Oakland, California; and
| | | | | | - Charles E McCulloch
- Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Thomas B Newman
- Division of Research and.,Departments of Pediatric and.,Epidemiology and Biostatistics, University of California, San Francisco, California
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24
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Newman TB. Antibiotic Treatment for Inpatient Asthma Exacerbations: What Have We Learned? JAMA Intern Med 2021; 181:427-428. [PMID: 33464279 DOI: 10.1001/jamainternmed.2020.7229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco
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25
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Newman TB. Possible Immortal Time Bias in Study of Antibiotic Treatment and Outcomes in Patients Hospitalized for Asthma. JAMA Intern Med 2021; 181:568-569. [PMID: 33464282 DOI: 10.1001/jamainternmed.2020.7602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco
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Abstract
OBJECTIVE The aim was to analyze the impact of decreased head computed tomography (CT) imaging on detection of abnormalities and outcomes for children with isolated head trauma. METHODS The study involves a multicenter retrospective cohort of patients younger than 19 years presenting for isolated head trauma to emergency departments in the Pediatric Health Information System database from 2003 to 2015. Patients directly admitted or transferred to another facility and those with a discharge diagnosis code for child maltreatment were excluded. Outcomes were ascertained from administrative and billing data. Trends were tested using mixed effects logistic regression, accounting for clustering within hospitals and adjusted for age, sex, insurance type, race, presence of a complex chronic condition, and hospital-level case mix index. RESULTS Between 2003 and 2015, 306,041 children presented for isolated head trauma. The proportion of children receiving head CT imaging was increasing until 2008, peaking at just under 40%, before declining to 25% by 2015. During the recent period of decreased head CT imaging, the detection of skull fractures (odds ratio [OR]/year, 0.96; 95% confidence interval [CI], 0.95-0.97) and intracranial bleeds (OR/year, 0.96; 95% CI, 0.94-0.97), hospitalization (OR/year, 0.96; 95% CI, 0.95-0.96), neurosurgery (OR/year, 0.91; 95% CI, 0.87-0.95), and revisit (OR/year, 0.98; 95% CI, 0.96-1.00) also decreased, without significant changes in mortality (OR/year, 0.93; 95% CI, 0.84-1.04) or persistent neurologic impairment (OR/year, 1.03; 95% CI, 0.92-1.15). CONCLUSIONS The recent decline in CT scanning in children with isolated head trauma was associated with a reduction in detection of intracranial abnormalities, and a concomitant decrease in interventions, without measurable patient harm.
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Affiliation(s)
- Eric R. Coon
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Thomas B. Newman
- Departments of Epidemiology and Biostatistics and Pediatrics, University of California, San Francisco
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS
| | - Jacob Wilkes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Susan L. Bratton
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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Digitale JC, Newman TB. New Statin Use and Mortality in Older Veterans. JAMA 2020; 324:1907-1908. [PMID: 33170235 DOI: 10.1001/jama.2020.19012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jean C Digitale
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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28
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Newman TB, Kemper AR. Avoiding Harm From Hyperbilirubinemia Screening. JAMA Pediatr 2019; 173:1208-1209. [PMID: 31589273 DOI: 10.1001/jamapediatrics.2019.3759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco
| | - Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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Schroeder AR, Newman TB, Park KT. Dangers of Opioid Prescribing for Young Adults After Dental Procedures-Reply. JAMA Intern Med 2019; 179:998. [PMID: 31107504 DOI: 10.1001/jamainternmed.2019.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alan R Schroeder
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics, University of California, San Francisco.,Department of Pediatrics, University of California, San Francisco
| | - K T Park
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Genentech, South San Francisco, California
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Abstract
OBJECTIVES We previously reported a clinical prediction rule to estimate the probability of rebound hyperbilirubinemia using gestational age (GA), age at phototherapy initiation, and total serum bilirubin (TSB) relative to the treatment threshold at phototherapy termination. We investigated (1) how a simpler 2-variable model would perform and (2) the absolute rebound risk if phototherapy were stopped at 2 mg/dL below the threshold for treatment initiation. METHODS Subjects for this retrospective cohort study were infants born 2012-2014 at ≥35 weeks' gestation at 1 of 17 Kaiser Permanente hospitals who underwent inpatient phototherapy before age 14 days. TSB reaching the phototherapy threshold within 72 hours of phototherapy termination was considered rebound. We simplified by using the difference between the TSB level at the time of phototherapy termination and the treatment threshold at the time of phototherapy initiation as 1 predictor, and kept GA as the other predictor. RESULTS Of the 7048 infants treated with phototherapy, 4.6% had rebound hyperbilirubinemia. The area under the receiver operating characteristic curve was 0.876 (95% confidence interval, 0.854 to 0.899) for the 2-variable model versus 0.881 (95% confidence interval, 0.859 to 0.903) for the 3-variable model. The rebound probability after stopping phototherapy at 2 mg/dL below the starting threshold was 2.5% for infants ≥38 weeks' GA and 10.2% for infants <38 weeks' GA. CONCLUSIONS Rebound hyperbilirubinemia can be predicted by a simpler 2-variable model consisting of GA and the starting threshold-ending TSB difference. Infants <38 weeks' gestation may need longer phototherapy because of their higher rebound risk.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington; Departments of
| | - Thomas B Newman
- Epidemiology and Biostatistics and.,Pediatrics, University of California, San Francisco, San Francisco, California; and.,Division of Research, Kaiser Permanente Northern California, Oakland, California
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31
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Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med 2019; 179:145-152. [PMID: 30508022 PMCID: PMC6439650 DOI: 10.1001/jamainternmed.2018.5419] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [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] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults. OBJECTIVE To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse in this population. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined outpatient opioid prescriptions for patients aged 16 to 25 years in the Optum Research Database in 2015. Prescriptions were linked by National Provider Identifier number to a clinician category. EXPOSURES Individuals were included in the index dental opioid (opioid-exposed) cohort if they filled an opioid prescription from a dental clinician in 2015, had continuous health plan coverage and no record of opioid prescriptions for 12 months before receiving the prescription, and had 12 months of health plan coverage after receiving the prescription. Two age- and sex-matched opioid-nonexposed control individuals were selected for each opioid-exposed individual and were assigned a corresponding phantom prescription date. MAIN OUTCOMES AND MEASURES Receipt of an opioid prescription within 90 to 365 days, a health care encounter diagnosis associated with opioid abuse within 365 days, and all-cause mortality within 365 days of the index opioid or phantom prescription date. RESULTS Among 754 002 individuals with continuous enrollment in 2015, 97 462 patients (12.9%) received 1 or more opioid prescriptions, of whom 29 791 (30.6%) received prescriptions supplied by a dental clinician. The opioid-exposed cohort included 14 888 participants (7882 women [52.9%], 11 273 white [75.7%], with mean [SD] age, 21.8 [2.4] years), and the randomly selected opioid-nonexposed cohort included 29 776 participants (15 764 women [52.9%], 20 078 [67.4%] white, with mean [SD] age, 21.8 [2.4] years). Among the 14 888 individuals in the index dental opioid cohort, 1021 (6.9%) received another opioid prescription 90 to 365 days later compared with 30 of 29 776 (0.1%) opioid-nonexposed controls (adjusted absolute risk difference, 6.8%; 95% CI, 6.3%-7.2%), and 866 opioid-exposed individuals (5.8%) experienced 1 or more subsequent health care encounters with an opioid abuse-related diagnosis compared with 115 opioid-nonexposed controls (0.4%) (adjusted absolute risk difference, 5.3%; 95% CI, 5.0%-5.7%). There was only 1 death in each cohort. CONCLUSIONS AND RELEVANCE The findings suggest that a substantial proportion of adolescents and young adults are exposed to opioids through dental clinicians. Use of these prescriptions may be associated with an increased risk of subsequent opioid use and abuse.
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Affiliation(s)
- Alan R Schroeder
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Melody Dehghan
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Thomas B Newman
- Department of Epidemiology and Biostatistics, University of California, San Francisco.,Department of Pediatrics, University of California, San Francisco
| | - Jason P Bentley
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - K T Park
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Kemper AR, Slaughter JL, Newman TB. Shining a Light on Concerns about Phototherapy to Prevent Allergic Skin Disease. Neonatology 2019; 116:27. [PMID: 30889591 DOI: 10.1159/000495529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 10/16/2018] [Accepted: 11/18/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Alex R Kemper
- Nationwide Children's Hospital, Columbus, Ohio, USA,
| | | | - Thomas B Newman
- University of California, San Francisco, San Francisco, California, USA
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Abstract
UNLABELLED : media-1vid110.1542/5804915133001PEDS-VA_2018-0648Video Abstract BACKGROUND AND OBJECTIVES: In a recent Danish study, researchers found an increased risk of childhood epilepsy after phototherapy but only in boys. We investigated this association in a Kaiser Permanente Northern California cohort. METHODS From 499 642 infants born at ≥35 weeks' gestation in 1995-2011 followed for ≥60 days, we excluded 1773 that exceeded exchange transfusion thresholds and 1237 with seizure diagnoses at <60 days. We ascertained phototherapy, covariates, and outcomes from electronic records and existing databases. Our primary outcome was ≥1 encounter with a seizure diagnosis plus ≥1 prescription for an antiepileptic drug. We used Cox and Poisson models to adjust for bilirubin levels and other confounding variables. RESULTS A total of 37 683 (7.6%) infants received any phototherapy. The mean (SD) follow-up time was 8.1 (5.2) years. The crude incidence rate per 1000 person-years of the primary outcome was 1.24 among phototherapy-exposed children and 0.76 among those unexposed (rate ratio: 1.63; 95% confidence interval [CI]: 1.44 to 1.85). The adjusted hazard ratio (aHR) was 1.22 (95% CI: 1.05 to 1.42; P = .009). Boys were at higher risk of seizures overall (aHR = 1.18; 95% CI: 1.10 to 1.27) and had a higher aHR for phototherapy (1.33; 95% CI: 1.10 to 1.61) than girls (1.07; 95% CI: 0.84 to 1.37), although effect modification by sex was not statistically significant (P = .17). The adjusted 10-year excess risks per 1000 were 2.4 (95% CI: 0.6 to 4.1) overall, 3.7 (95% CI: 1.2 to 6.1) in boys, and 0.8 (95% CI: -1.7 to 3.2) in girls. CONCLUSIONS Phototherapy in newborns is associated with a small increased risk of childhood seizures, even after adjusting for bilirubin values, and the risk is more significant in boys.
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Affiliation(s)
- Thomas B Newman
- Departments of Epidemiology and Biostatistics, .,Pediatrics, and.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Yvonne W Wu
- Pediatrics, and.,Neurology, University of California, San Francisco, San Francisco, California; and
| | - Michael W Kuzniewicz
- Pediatrics, and.,Division of Research, Kaiser Permanente Northern California, Oakland, California
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Abstract
OBJECTIVES Our aim was to quantify the associations of both hyperbilirubinemia and phototherapy with childhood asthma using a population-based cohort with total serum bilirubin (TSB) levels. METHODS Retrospective cohort study of infants born at ≥35 weeks' gestation in the Kaiser Permanente Northern California health system (n = 109 212) from 2010 to 2014. Cox models were used to estimate hazard ratios (HRs) for a diagnosis of asthma. RESULTS In the study, 16.7% of infants had a maximum TSB level of ≥15 mg/dL, 4.5% of infants had a maximum TSB level of ≥18 mg/dL, and 11.5% of infants received phototherapy. Compared with children with a maximum TSB level of 3 to 5.9 mg/L, children with a TSB level of 9 to 11.9 mg/dL, 12 to 14.9 mg/dL, and 15 to 17.9 mg/dL were at an increased risk for asthma (HR: 1.22 [95% confidence interval (CI): 1.11-1.3], HR: 1.18 [95% CI: 1.08-1.29], and HR: 1.30 [95% CI: 1.18-1.43], respectively). Children with a TSB level of ≥18 mg/dL were not at an increased risk for asthma (HR: 1.04; 95% CI: 0.90-1.20). In propensity-adjusted analyses, phototherapy was not associated with asthma (HR: 1.07; 95% CI: 0.96-1.20). CONCLUSIONS Modest levels of hyperbilirubinemia were associated with an increased risk of asthma, but an association was not seen at higher levels. No dose-response relationship was seen. Using phototherapy to prevent infants from reaching these modest TSB levels is unlikely to be protective against asthma.
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Affiliation(s)
- Michael W Kuzniewicz
- Division of Research, Kaiser Permanente, Oakland, California; and .,Departments of Pediatrics and
| | - Hamid Niki
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Charles E McCulloch
- Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Thomas B Newman
- Departments of Pediatrics and.,Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
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Wickremasinghe AC, Kuzniewicz MW, McCulloch CE, Newman TB. Efficacy of Subthreshold Newborn Phototherapy During the Birth Hospitalization in Preventing Readmission for Phototherapy. JAMA Pediatr 2018; 172:378-385. [PMID: 29482208 PMCID: PMC5875379 DOI: 10.1001/jamapediatrics.2017.5630] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 11/14/2022]
Abstract
IMPORTANCE Treatment of jaundiced newborns with subthreshold phototherapy (phototherapy given to newborns with bilirubin levels below those recommended in American Academy of Pediatrics [AAP] guidelines) is common. However, the use of subthreshold phototherapy may have risks and increase costs, and, to date, it has not been systematically studied in newborns. OBJECTIVES To estimate the efficacy of subthreshold phototherapy for newborns with total serum bilirubin (TSB) levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold during the birth hospitalization in preventing readmissions for phototherapy, and to identify predictors of readmission for phototherapy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 25 895 newborns born at 35 or more weeks' gestation, born in 1 of 16 Kaiser Permanente Northern California hospitals from January 1, 2010, through December 31, 2014, with at least 1 TSB level from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold and not exceeding the threshold during the birth hospitalization. Data were analyzed from November 1, 2015, to November 28, 2017. EXPOSURE Subthreshold phototherapy during the birth hospitalization. MAIN OUTCOMES AND MEASURES Readmission for phototherapy. RESULTS Among 25 895 newborns with qualifying TSB levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold, 4956 (19.1%) received subthreshold phototherapy and 241 of these (4.9%) were readmitted for phototherapy compared with 2690 of 20 939 untreated newborns (12.8%) (unadjusted odds ratio [OR], 0.35; 95% CI, 0.30-0.40). In a logistic regression model, adjustment for confounding variables, including gestational age, race/ethnicity, formula feedings per day, and the difference between the TSB level and the phototherapy threshold, strengthened the association (OR, 0.28; 95% CI, 0.19-0.40). Estimated numbers needed to treat ranged from 60.8 in the lowest quintile of predicted risk to 6.3 in the highest quintile. Newborns who received formula feedings had lower adjusted odds of readmission for phototherapy compared with exclusively breastfed newborns (OR, 0.58; 95% CI, 0.47-0.72 for >0 to <2 formula feedings per day; OR, 0.24; 95% CI, 0.21-0.27 for ≥6 formula feedings per day). Subthreshold phototherapy was associated with a 22-hour longer length of stay (95% CI, 16-28 hours). CONCLUSIONS AND RELEVANCE Subthreshold phototherapy during the birth hospitalization is effective in preventing readmissions for phototherapy; however, for each readmission prevented, many newborns require phototherapy who would otherwise not need it.
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Affiliation(s)
| | - Michael W. Kuzniewicz
- Department of Pediatrics, University of California, San Francisco,Division of Research, Kaiser Permanente Northern California, Oakland
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas B. Newman
- Department of Pediatrics, University of California, San Francisco,Division of Research, Kaiser Permanente Northern California, Oakland,Department of Epidemiology and Biostatistics, University of California, San Francisco
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Affiliation(s)
- Alan R Schroeder
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
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Kuzniewicz MW, Puopolo KM, Fischer A, Walsh EM, Li S, Newman TB, Kipnis P, Escobar GJ. A Quantitative, Risk-Based Approach to the Management of Neonatal Early-Onset Sepsis. JAMA Pediatr 2017; 171:365-371. [PMID: 28241253 DOI: 10.1001/jamapediatrics.2016.4678] [Citation(s) in RCA: 279] [Impact Index Per Article: 39.9] [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 Current algorithms for management of neonatal early-onset sepsis (EOS) result in medical intervention for large numbers of uninfected infants. We developed multivariable prediction models for estimating the risk of EOS among late preterm and term infants based on objective data available at birth and the newborn's clinical status. OBJECTIVES To examine the effect of neonatal EOS risk prediction models on sepsis evaluations and antibiotic use and assess their safety in a large integrated health care system. DESIGN, SETTING, AND PARTICIPANTS The study cohort includes 204 485 infants born at 35 weeks' gestation or later at a Kaiser Permanente Northern California hospital from January 1, 2010, through December 31, 2015. The study compared 3 periods when EOS management was based on (1) national recommended guidelines (baseline period [January 1, 2010, through November 31, 2012]), (2) multivariable estimates of sepsis risk at birth (learning period [December 1, 2012, through June 30, 2014]), and (3) the multivariable risk estimate combined with the infant's clinical condition in the first 24 hours after birth (EOS calculator period [July 1, 2014, through December 31, 2015]). MAIN OUTCOMES AND MEASURES The primary outcome was antibiotic administration in the first 24 hours. Secondary outcomes included blood culture use, antibiotic administration between 24 and 72 hours, clinical outcomes, and readmissions for EOS. RESULTS The study cohort included 204 485 infants born at 35 weeks' gestation or later: 95 343 in the baseline period (mean [SD] age, 39.4 [1.3] weeks; 46 651 male [51.0%]; 37 007 white, non-Hispanic [38.8%]), 52 881 in the learning period (mean [SD] age, 39.3 [1.3] weeks; 27 067 male [51.2%]; 20 175 white, non-Hispanic [38.2%]), and 56 261 in the EOS calculator period (mean [SD] age, 39.4 [1.3] weeks; 28 575 male [50.8%]; 20 484 white, non-Hispanic [36.4%]). In a comparison of the baseline period with the EOS calculator period, blood culture use decreased from 14.5% to 4.9% (adjusted difference, -7.7%; 95% CI, -13.1% to -2.4%). Empirical antibiotic administration in the first 24 hours decreased from 5.0% to 2.6% (adjusted difference, -1.8; 95% CI, -2.4% to -1.3%). No increase in antibiotic use occurred between 24 and 72 hours after birth; use decreased from 0.5% to 0.4% (adjusted difference, 0.0%; 95% CI, -0.1% to 0.2%). The incidence of culture-confirmed EOS was similar during the 3 periods (0.03% in the baseline period, 0.03% in the learning period, and 0.02% in the EOS calculator period). Readmissions for EOS (within 7 days of birth) were rare in all periods (5.2 per 100 000 births in the baseline period, 1.9 per 100 000 births in the learning period, and 5.3 per 100 000 births in the EOS calculator period) and did not differ statistically (P = .70). Incidence of adverse clinical outcomes, including need for inotropes, mechanical ventilation, meningitis, and death, was unchanged after introduction of the EOS calculator. CONCLUSIONS AND RELEVANCE Clinical care algorithms based on individual infant estimates of EOS risk derived from a multivariable risk prediction model reduced the proportion of newborns undergoing laboratory testing and receiving empirical antibiotic treatment without apparent adverse effects.
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Affiliation(s)
- Michael W Kuzniewicz
- Perinatal Research Unit, Division of Research, Kaiser Permanente Northern California, Oakland2Department of Pediatrics, University of California, San Francisco3The Permanente Medical Group, Oakland, California
| | - Karen M Puopolo
- Newborn Care at Pennsylvania Hospital, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania5Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Eileen M Walsh
- Perinatal Research Unit, Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sherian Li
- Perinatal Research Unit, Division of Research, Kaiser Permanente Northern California, Oakland
| | - Thomas B Newman
- Department of Pediatrics, University of California, San Francisco
| | - Patricia Kipnis
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland
| | - Gabriel J Escobar
- Perinatal Research Unit, Division of Research, Kaiser Permanente Northern California, Oakland3The Permanente Medical Group, Oakland, California6Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland
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Slaughter JL, Reagan PB, Newman TB, Klebanoff MA. Comparative Effectiveness of Nonsteroidal Anti-inflammatory Drug Treatment vs No Treatment for Patent Ductus Arteriosus in Preterm Infants. JAMA Pediatr 2017; 171:e164354. [PMID: 28046188 PMCID: PMC5575787 DOI: 10.1001/jamapediatrics.2016.4354] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [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: 01/22/2023]
Abstract
IMPORTANCE Patent ductus arteriosus (PDA) is associated with increased mortality and worsened respiratory outcomes, including bronchopulmonary dysplasia (BPD), in preterm infants. Nonsteroidal anti-inflammatory drugs (NSAIDs) are efficacious in closing PDA, but the effectiveness of NSAID-mediated PDA closure in improving mortality and preventing BPD is unclear. OBJECTIVE To determine the effectiveness of NSAID treatment for PDA in reducing mortality and moderate/severe BPD at 36 weeks postmenstrual age. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 12 018 infants born at 28 gestational weeks or younger discharged between January 2006 and December 2013 from neonatal intensive care units in 25 US children's hospitals included in the Pediatric Health Information System. We performed an instrumental variable analysis that incorporated clinician preference-based, institutional variation in NSAID treatment frequency to determine the effect of NSAID treatment for PDA on mortality and BPD. EXPOSURES Proportion of NSAID-treated infants born at each infant's institution within ±6 months of that infant's birth. MAIN OUTCOMES AND MEASURES The primary composite outcome was death, moderate, or severe BPD at 36 weeks postmenstrual age. RESULTS Of the 6370 male and 5648 female infants in this study, 4995 (42%) were white, 3176 (26%) were African American, 1823 (15%) were Hispanic, and 1555 (13%) were other races/ethnicities. The proportion of NSAID-treated infants at each infant's hospital within ±6 months of that infant's birth was associated with NSAID treatment and not associated with gestation, race/ethnicity, or sex. An infant's chances of receiving NSAID treatment increased by 0.84% (95% CI, 0.8-0.9; P < .001) for every 1% increase in the annual NSAID treatment percentage at a given hospital. An instrumental variable analysis demonstrated no association between NSAID treatment and the odds of mortality or BPD (odds ratio, 0.94; 95% CI, 0.70-1.25; P = .69), mortality (odds ratio, 0.73; 95% CI, 0.43-1.13; P = .18), or BPD (odds ratio, 1.01; 95% CI, 0.73-1.45; P = .94) in survivors. CONCLUSIONS AND RELEVANCE When we incorporated clinician preference-based practice variation as an instrument to minimize the effect of unmeasured confounding, we detected no changes in the odds of mortality or moderate/severe BPD among similar preterm infants born at 28 weeks or younger following NSAID treatment for PDA initiated 2 to 28 days postnatally. Our findings agree with available randomized clinical trial evidence and support a conservative approach to PDA management.
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Affiliation(s)
- Jonathan L Slaughter
- The Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH 43205,Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205
| | - Patricia B Reagan
- The Department of Economics, The Ohio State University, Columbus, OH 43210,Center for Human Resource Research, The Ohio State University, Columbus, OH 43210
| | - Thomas B Newman
- Department of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Mark A Klebanoff
- The Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH 43205,Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205
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Chang PW, Kuzniewicz MW, McCulloch CE, Newman TB. A Clinical Prediction Rule for Rebound Hyperbilirubinemia Following Inpatient Phototherapy. Pediatrics 2017; 139:peds.2016-2896. [PMID: 28196932 DOI: 10.1542/peds.2016-2896] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 12/19/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The American Academy of Pediatrics provides little guidance on when to discontinue phototherapy in newborns treated for hyperbilirubinemia. We sought to develop a prediction rule to estimate the probability of rebound hyperbilirubinemia after inpatient phototherapy. METHODS Subjects for this retrospective cohort study were infants born in 2012 to 2014 at ≥35 weeks' gestation at 16 Kaiser Permanente Northern California hospitals who received inpatient phototherapy before age 14 days. We defined rebound as the return of total serum bilirubin (TSB) to phototherapy threshold within 72 hours of phototherapy termination. We used stepwise logistic regression to select predictors of rebound hyperbilirubinemia and devised and validated a prediction score by using split sample validation. RESULTS Of the 7048 infants treated with inpatient phototherapy, 4.6% had rebound hyperbilirubinemia. Our prediction score consisted of 3 variables: gestational age <38 weeks (adjusted odds ratio [aOR] 4.7; 95% confidence interval [CI], 3.0-7.3), younger age at phototherapy initiation (aOR 0.51 per day; 95% CI, 0.38-0.68), and TSB relative to the treatment threshold at phototherapy termination (aOR 1.5 per mg/dL; 95% CI, 1.4-1.7). The model performed well with an area under the receiver operating characteristic curve of 0.89 (95% CI, 0.86-0.91) in the derivation data set and 0.88 (95% CI, 0.86-0.90) in the validation data set. Approximately 70% of infants had scores <20, which correspond to a <4% probability of rebound hyperbilirubinemia. CONCLUSIONS The risk of rebound hyperbilirubinemia can be quantified according to an infant's gestational age, age at phototherapy initiation, and TSB relative to the treatment threshold at phototherapy termination.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington;
| | - Michael W Kuzniewicz
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and.,Departments of Pediatrics, and
| | - Charles E McCulloch
- Epidemiology & Biostatistics, University of California, San Francisco, California
| | - Thomas B Newman
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and.,Departments of Pediatrics, and.,Epidemiology & Biostatistics, University of California, San Francisco, California
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Schroeder AR, Newman TB. US Preventive Task Force cites insufficient evidence for pediatric lipid screening. J Pediatr 2017; 180:291-294. [PMID: 28010798 DOI: 10.1016/j.jpeds.2016.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Thomas B Newman
- University of California, San Francisco San Francisco, California
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Chang PW, Newman TB, Maisels MJ. Update on Predicting Severe Hyperbilirubinemia and Bilirubin Neurotoxicity Risks in Neonates. Curr Pediatr Rev 2017; 13:181-187. [PMID: 28117009 DOI: 10.2174/1573396313666170123151408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 11/04/2016] [Revised: 01/14/2017] [Accepted: 01/17/2017] [Indexed: 11/22/2022]
Abstract
Extreme hyperbilirubinemia and kernicterus, though rare, continue to occur despite the adoption of universal screening. Unless they are known to have glucose-6-phosphate dehydrogenase deficiency, infants who currently develop kernicterus in high resource countries are often otherwise healthy newborns discharged from the well-baby nursery. In this review, we highlight risk factors that increase the risk of a newborn ≥35 weeks gestational age developing severe hyperbilirubinemia, as well as the risk factors that increase the hyperbilirubinemic infant's risk of kernicterus.
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Affiliation(s)
- Pearl W Chang
- Seattle Children's Hospital, M/S FA.2.115, PO Box 5371, Seattle, WA 98145. United States
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, CA. United States
| | - M Jeffrey Maisels
- Department of Pediatrics, Beaumont Children's Hospital and Oakland University William Beaumont School of Medicine, Royal Oak, MI. United States
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Newman TB, Wickremasinghe AC, Walsh EM, Grimes BA, McCulloch CE, Kuzniewicz MW. Phototherapy and Risk of Type 1 Diabetes. Pediatrics 2016; 138:peds.2016-0687. [PMID: 27940766 PMCID: PMC5079076 DOI: 10.1542/peds.2016-0687] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 08/22/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Increases in both phototherapy use and the incidence of type 1 diabetes mellitus (DM-1) have been reported. One large study has suggested a strong association between them. Our objective was to quantify any association between neonatal phototherapy and DM-1 in a northern California integrated health care system. METHODS This retrospective cohort study included 499 642 children born at ≥35 weeks' gestation in 15 Kaiser Permanente Northern California hospitals from 1995 to 2011 and followed until March 31, 2014. We ascertained phototherapy, bilirubin levels, and other covariates from electronic records. We identified DM-1 cases using a diabetes registry and inpatient and outpatient diagnoses. We used traditional and propensity-adjusted Cox models to quantify associations. RESULTS Phototherapy use increased from 2.7% in 1995 to 16.0% in 2011. DM-1 was diagnosed in 37 of 39 406 children who had received phototherapy (15.1 per 100 000 person-years; mean follow-up 6.2 years) and 712 of 460 236 who had not (18.8 per 100 000 person-years; mean follow-up 8.2 years). There was no evidence of increasing diabetes incidence. We found no association between phototherapy and DM-1 in either unadjusted analyses (incidence rate ratio 0.81; 95% confidence interval, 0.56 to 1.12) or analyses adjusted for hyperbilirubinemia and other covariates (hazard ratio 1.06; 95% confidence interval, 0.78 to 1.45). DM-1 incidence was most strongly associated with race and ethnicity, with whites at highest risk (25.6 per 100 000) and Asians at lowest risk (8.9 per 100 000). CONCLUSIONS We found no evidence of increased DM-1 risk in children who had received phototherapy.
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Affiliation(s)
- Thomas B. Newman
- Departments of Epidemiology and Biostatistics, and,Pediatrics, University of California, San Francisco, California;,Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Andrea C. Wickremasinghe
- Departments of Epidemiology and Biostatistics, and,Department of Pediatrics, Kaiser Permanente, Santa Clara, California
| | - Eileen M. Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | | | | | - Michael W. Kuzniewicz
- Pediatrics, University of California, San Francisco, California;,Division of Research, Kaiser Permanente Northern California, Oakland, California; and
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Wu YW, Kuzniewicz MW, Croen L, Walsh EM, McCulloch CE, Newman TB. Risk of Autism Associated With Hyperbilirubinemia and Phototherapy. Pediatrics 2016; 138:peds.2016-1813. [PMID: 27669736 DOI: 10.1542/peds.2016-1813] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 07/11/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Whether neonatal hyperbilirubinemia and/or phototherapy increase the risk of autism spectrum disorder (ASD) is unclear. We sought to quantify the risk of ASD associated with elevated total serum bilirubin (TSB) levels and with phototherapy. METHODS In a retrospective cohort study of 525 409 infants born at ≥35 weeks' gestation in 15 Kaiser Permanente Northern California (KPNC) hospitals, 1995-2011, we obtained all TSB levels and determined which infants received phototherapy. From the KPNC Autism Registry, we identified patients with ASD diagnosed at a KPNC Autism Center, by a clinical specialist, or by a pediatrician. We calculated Cox proportional hazard ratios (HRs) for time to diagnosis of ASD, adjusting for confounding factors. RESULTS Among infants in the birth cohort, 2% had at least 1 TSB level ≥20 mg/dL, and 8% received phototherapy. The rate of ASD was 13 per 1000 births. Crude analyses revealed an association between TSB ≥20 and ASD (relative risk: 1.4; 95% confidence interval [CI]: 1.1-1.6), and between phototherapy and ASD (relative risk: 1.7; 95% CI: 1.5-1.8). After adjusting for confounders, TSB ≥20 (HR: 1.09; 95% CI: 0.89-1.35) and phototherapy (HR: 1.10; 95% CI: 0.98-1.24) were no longer significantly associated with ASD. Independent risk factors for ASD included maternal and paternal age; maternal and paternal higher education; male sex; birth weight <2500 g or ≥4200 g; and later year of birth. CONCLUSIONS After adjustment for the effects of sociodemographic factors and birth weight, neither hyperbilirubinemia nor phototherapy was an independent risk factor for ASD.
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Affiliation(s)
- Yvonne W Wu
- Departments of Neurology, .,Pediatrics, and.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michael W Kuzniewicz
- Pediatrics, and.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Lisa Croen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Charles E McCulloch
- Epidemiology and Biostatistics, University of California, San Francisco, California; and
| | - Thomas B Newman
- Pediatrics, and.,Division of Research, Kaiser Permanente Northern California, Oakland, California.,Epidemiology and Biostatistics, University of California, San Francisco, California; and
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Affiliation(s)
- Thomas B Newman
- Department of Pediatrics, University of California, San Francisco2Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University, Stanford, California
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco4Department of Medicine, University of California, San Francisco
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Kuzniewicz MW, Greene DN, Walsh EM, McCulloch CE, Newman TB. Association Between Laboratory Calibration of a Serum Bilirubin Assay, Neonatal Bilirubin Levels, and Phototherapy Use. JAMA Pediatr 2016; 170:557-61. [PMID: 27064480 DOI: 10.1001/jamapediatrics.2015.4944] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The American Academy of Pediatrics treatment recommendations for neonatal jaundice are based on age-specific total serum bilirubin (TSB) levels. In May 2012, Ortho Clinical Diagnostics adjusted the calibrator values for Vitros Chemistry Products BuBc Slides (Ortho Clinical Diagnostics), a widely used method to quantify TSB, after concerns of positively biased results. OBJECTIVE To investigate the association between recalibration of a reflectance spectrophotometry serum bilirubin assay and TSB levels and phototherapy use among newborns. DESIGN, SETTING, AND PARTICIPANTS Descriptive study comparing TSB levels and phototherapy use before and after recalibration at Kaiser Permanente Northern California, a large, integrated health care delivery system. The study evaluated live births at or after 35 weeks' gestation at 12 facilities that used universal serum bilirubin screening before (January 1, 2010, through April 30, 2012; n = 61 677) and after (July 1, 2012, through December 31, 2013; n = 42 571) recalibration. The analysis took place in December 2015. INTERVENTION Recalibration of bilirubin testing instruments. MAIN OUTCOMES AND MEASURES Proportions of newborns with (1) at least 1 TSB value at or above 15 mg/dL; (2) at least 1 TSB level exceeding the American Academy of Pediatrics phototherapy threshold; (3) phototherapy during the birth hospitalization; and (4) at least 1 readmission for phototherapy. RESULTS In 104 420 infants (61 677 in the prerecalibration period and 42 511 in the postrecalibration period), a TSB was obtained in 99.2% of infants during birth and in 99.5% of infants within the first 30 days after birth. The postrecalibration period was associated with a 1.25 mg/dL (95% CI, 1.19-1.31; P < .001) decrease in mean maximum TSB, which led to a 39% relative reduction (from 20.4% to 12.4%) in infants with a TSB level of 15 mg/dL or more and a 51% relative reduction (from 9.3% to 4.5%) in infants with a TSB level that was at or above the American Academy of Pediatrics phototherapy threshold. Phototherapy during birth hospitalizations was reduced by 59% (absolute risk reduction, 5.5%; 95% CI, 4.7%-6.1%) and readmissions for phototherapy by 53% (absolute risk reduction, 1.8%; 95% CI, 1.4%-2.3%). CONCLUSIONS AND RELEVANCE Modest recalibration-induced reductions in mean TSB concentrations was associated with a significant reduction in the percentage of infants with clinically significant hyperbilirubinemia. Current laboratory accuracy standards are insufficient to detect biases that can have significant clinical effect. These data underline the need for increased integration of laboratory expertise into clinical guidelines and to support international initiatives to standardize laboratory measurements.
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Affiliation(s)
- Michael W Kuzniewicz
- Division of Research, Kaiser Permanente Northern California, Oakland2Division of Neonatology, Kaiser Permanente Northern California, Oakland, California3Department of Pediatrics, University of California, San Francisco
| | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas B Newman
- Division of Research, Kaiser Permanente Northern California, Oakland3Department of Pediatrics, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
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Abstract
OBJECTIVE To determine whether neonatal phototherapy is associated with cancer in the first year after birth. METHODS We analyzed a data set from the California Office of Statewide Health Planning and Development that was created by linking birth certificates, death certificates, and hospital discharge abstracts up to age 1 year. Subjects were 5 144 849 infants born in California hospitals at ≥35 weeks' gestation from 1998 to 2007. We used International Classification of Diseases, Ninth Revision codes to identify phototherapy at <15 days and discharge diagnoses of cancer at 61 to 365 days. We adjusted for potential confounding variables by using traditional and propensity-adjusted logistic regression models. RESULTS Cancer was diagnosed in 58/178 017 infants with diagnosis codes for phototherapy and 1042/4 966 832 infants without such codes (32.6/100 000 vs 21.0/100 000; relative risk 1.6; 95% confidence interval [CI], 1.2-2.0, P = .002). In propensity-adjusted analyses, associations were seen between phototherapy and overall cancer (adjusted odds ratio [aOR] 1.4; 95% CI, 1.1-1.9), myeloid leukemia (aOR 2.6; 95% CI, 1.3-5.0), and kidney cancer (aOR 2.5; 95% CI, 1.2-5.1). The marginal propensity-adjusted absolute risk increase for cancer after phototherapy in the total population was 9.4/100 000 (number needed to harm of 10 638). Because of the higher baseline risk of cancer in infants with Down syndrome, the number needed to harm was 1285. CONCLUSIONS Phototherapy may slightly increase the risk of cancer in infancy, although the absolute risk increase is small. This risk should be considered when making phototherapy treatment decisions, especially for infants with bilirubin levels below current treatment guidelines.
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Affiliation(s)
- Andrea C. Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Northern California, Santa Clara, California;,Department of Epidemiology & Biostatistics, and,Address correspondence to Andrea C. Wickremasinghe, MD, Department 302–Neonatology, Kaiser Permanente Santa Clara Medical Center, 700 Lawrence Expy, Santa Clara, CA 95051. E-mail:
| | - Michael W. Kuzniewicz
- Department of Pediatrics, University of California, San Francisco, California; and,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | | | - Thomas B. Newman
- Department of Epidemiology & Biostatistics, and,Department of Pediatrics, University of California, San Francisco, California; and,Division of Research, Kaiser Permanente Northern California, Oakland, California
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Slaughter JL, Reagan PB, Bapat RV, Newman TB, Klebanoff MA. Nonsteroidal anti-inflammatory administration and patent ductus arteriosus ligation, a survey of practice preferences at US children's hospitals. Eur J Pediatr 2016; 175:775-83. [PMID: 26879388 PMCID: PMC5056586 DOI: 10.1007/s00431-016-2705-y] [Citation(s) in RCA: 32] [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: 07/27/2015] [Revised: 11/23/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
UNLABELLED We surveyed neonatal leadership at 46 US children's hospitals via web-based survey to identify local preferences and concerns regarding indomethacin prophylaxis, nonsteroidal anti-inflammatory drug (NSAID) treatment, and patent ductus arteriosus (PDA) ligation. We received a 100 % survey response (N = 46). Practice guidelines for prophylactic indomethacin were reported at 28 % of NICUs, for NSAID treatment of PDA at 39 % and for surgical ligation at 27 %. Respondents noted intra-institutional practice variation for indomethacin prophylaxis (33 %), NSAID treatment (70 %), and PDA ligation (73 %). The majority of institutions did not prescribe indomethacin prophylaxis (72 %). For PDA treatment, indomethacin was preferred over ibuprofen (80 %). We validated our survey results via comparison with billing data as documented in the Pediatric Health Information System (PHIS) database, finding that survey responses directly correlated with local billing data (p < 0.0001). At institutions that did not typically administer NSAIDs for PDA closure or surgical PDA ligation, a lack of evidence for their effectiveness in improving long-term outcomes and the risk of treatment-associated adverse effects were the most often cited reasons. CONCLUSION No consensus exists among providers at US children's hospitals regarding prophylactic indomethacin, NSAID treatment, or PDA ligation. Lack of evidence and safety concerns play a prominent role. WHAT IS KNOWN • NSAIDs and surgical PDA ligation are efficacious in preventing intraventricular hemorrhage (IVH) and closing PDA in preterm infants, but have not been shown to improve long-term respiratory, neurodevelopmental, or mortality outcomes. What is New: • Practice preferences for indomethacin prophylaxis, NSAID, and surgical PDA treatment vary both among and within institutions. Lack of treatment effectiveness and the risk of adverse effects are major concerns.
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Affiliation(s)
- Jonathan L Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, USA.
| | - Patricia B Reagan
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Department of Economics and Center for Human Resource Research, Ohio State University Columbus, OH, USA
| | - Roopali V Bapat
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Mark A Klebanoff
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
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Newman TB, Wickremasinghe AC, Walsh EM, Grimes BA, McCulloch CE, Kuzniewicz MW. Retrospective Cohort Study of Phototherapy and Childhood Cancer in Northern California. Pediatrics 2016; 137:peds.2015-1354. [PMID: 27217477 DOI: 10.1542/peds.2015-1354] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [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: 03/25/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate the association between neonatal phototherapy use and childhood cancer. METHODS This retrospective cohort study included 499 621 children born at ≥35 weeks' gestation from 1995 to 2011 in Kaiser Permanente Northern California hospitals, who survived to hospital discharge and were followed ≥60 days. We obtained data on home and inpatient phototherapy, covariates, and cancer incidence from electronic records. We used propensity-adjusted Cox and Poisson models to control for confounding and unequal follow-up times. RESULTS There were 60 children with a diagnosis of cancer among 39 403 exposed to phototherapy (25 per 100 000 person-years), compared with 651 of 460 218 unexposed children (18 per 100 000 person-years; incidence rate ratio [IRR] 1.4; P = .01). Phototherapy was associated with increased rates of any leukemia (IRR 2.1; P = .0007), nonlymphocytic leukemia (IRR 4.0; P = .0004), and liver cancer (IRR 5.2; P = .04). With adjustment for a propensity score that incorporated bilirubin levels, chromosomal disorders, congenital anomalies, and other covariates, associations were no longer statistically significant: Adjusted hazard ratios (95% confidence intervals) were 1.0 (0.7-1.6) for any cancer, 1.6 (0.8-3.5) for any leukemia, 1.9 (0.6-6.9) for nonlymphocytic leukemia, and 1.4 (0.2-12) for liver cancer. Upper limits of 95% confidence intervals for adjusted 10-year excess risk were generally <0.1% but reached 4.4% for children with Down syndrome. CONCLUSIONS Although phototherapy use was associated with increased cancer rates (particularly nonlymphocytic leukemia), control for confounding variables eliminated or attenuated the associations. Nonetheless, the possibility of even partial causality suggests that avoiding unnecessary phototherapy may be prudent.
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Affiliation(s)
- Thomas B Newman
- Departments of Epidemiology and Biostatistics, and Pediatrics, University of California, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Andrea C Wickremasinghe
- Departments of Epidemiology and Biostatistics, and Department of Pediatrics, Kaiser Permanente Santa Clara, Santa Clara, California
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | | | | | - Michael W Kuzniewicz
- Pediatrics, University of California, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; and
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Affiliation(s)
- Michael J Martin
- Michael J. Martin is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sapna E Thottathil is with Supply Chain Programming, School Food FOCUS, a program of the Tides Center, San Francisco. Thomas B. Newman is with the Department of Epidemiology and Biostatistics and the Department of Pediatrics, University of California, San Francisco
| | - Sapna E Thottathil
- Michael J. Martin is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sapna E Thottathil is with Supply Chain Programming, School Food FOCUS, a program of the Tides Center, San Francisco. Thomas B. Newman is with the Department of Epidemiology and Biostatistics and the Department of Pediatrics, University of California, San Francisco
| | - Thomas B Newman
- Michael J. Martin is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sapna E Thottathil is with Supply Chain Programming, School Food FOCUS, a program of the Tides Center, San Francisco. Thomas B. Newman is with the Department of Epidemiology and Biostatistics and the Department of Pediatrics, University of California, San Francisco
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Wickremasinghe AC, Risley RJ, Kuzniewicz MW, Wu YW, Walsh EM, Wi S, McCulloch CE, Newman TB. Risk of Sensorineural Hearing Loss and Bilirubin Exchange Transfusion Thresholds. Pediatrics 2015; 136:505-12. [PMID: 26283777 DOI: 10.1542/peds.2014-3357] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [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: 06/22/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES High bilirubin levels are associated with sensorineural hearing loss (SNHL). However, few large studies of relative and excess risk exist. We sought to quantify the risk of SNHL in newborns who had bilirubin levels at or above American Academy of Pediatrics exchange transfusion thresholds (ETT). METHODS Infants born at ≥35 weeks gestation in 15 Kaiser Permanente Northern California hospitals from 1995-2011 were eligible (N = 525 409). We used a nested double cohort design. The exposed cohort included subjects with ≥1 bilirubin level at or above ETT. The unexposed cohort was a 3.6% random sample of subjects with all bilirubin levels below ETT (10 unexposed per exposed). An audiologist, blinded to bilirubin levels, reviewed the charts of children in whom SNHL had been diagnosed before age 8 years to confirm the diagnosis. We calculated Cox proportional hazard ratios for time to diagnosis of SNHL. RESULTS SNHL was confirmed in 11 (0.60%) of the 1834 exposed subjects and in 43 (0.23%) of the 19 004 unexposed. Only bilirubin levels ≥10 mg/dL above ETT were associated with a statistically significant increased risk of SNHL (hazard ratio: 36 [95% confidence interval (CI): 13 to 101]). Likewise, only bilirubin levels ≥35 mg/dL were associated with a statistically significant increased risk of SNHL (hazard ratio: 91 [95% CI: 32 to 255]). For subjects with total serum bilirubin levels 0 to 4.9 mg/dL above ETT, the upper limit of the 95% CI for excess risk was 0.5%. CONCLUSIONS Only bilirubin levels well above ETT were associated with SNHL. At lower bilirubin levels, the excess risk of SNHL was low.
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Affiliation(s)
- Andrea C Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Northern California, Santa Clara, California; Departments of Epidemiology & Biostatistics,
| | | | - Michael W Kuzniewicz
- Division of Research, Kaiser Permanente Northern California, Oakland, California Pediatrics, and
| | - Yvonne W Wu
- Pediatrics, and Neurology, University of California, San Francisco, California
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Soora Wi
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Thomas B Newman
- Departments of Epidemiology & Biostatistics, Division of Research, Kaiser Permanente Northern California, Oakland, California Pediatrics, and
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