Dan L. Stewart

Prevention and management of procedural pain in the neonate: An update

The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor, yet painful procedures. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures.

Effect of Fluconazole Prophylaxis on Candidiasis and Mortality in Premature Infants: A Randomized Clinical Trial

IMPORTANCE Invasive candidiasis in premature infants causes death and neurodevelopmental impairment. Fluconazole prophylaxis reduces candidiasis, but its effect on mortality and the safety of fluconazole are unknown. OBJECTIVE To evaluate the efficacy and safety of fluconazole in preventing death or invasive candidiasis in extremely low-birth-weight infants. DESIGN, SETTING, AND PATIENTS This study was a randomized, blinded, placebo-controlled trial of fluconazole in premature infants. Infants weighing less than 750 g at birth (N = 361) from 32 neonatal intensive care units (NICUs) in the United States were randomly assigned to receive either fluconazole or placebo twice weekly for 42 days. Surviving infants were evaluated at 18 to 22 months corrected age for neurodevelopmental outcomes. The study was conducted between November 2008 and February 2013. INTERVENTIONS Fluconazole (6 mg/kg of body weight) or placebo. MAIN OUTCOMES AND MEASURES The primary end point was a composite of death or definite or probable invasive candidiasis prior to study day 49 (1 week after completion of study drug). Secondary and safety outcomes included invasive candidiasis, liver function, bacterial infection, length of stay, intracranial hemorrhage, periventricular leukomalacia, chronic lung disease, patent ductus arteriosus requiring surgery, retinopathy of prematurity requiring surgery, necrotizing enterocolitis, spontaneous intestinal perforation, and neurodevelopmental outcomes-defined as a Bayley-III cognition composite score of less than 70, blindness, deafness, or cerebral palsy at 18 to 22 months corrected age. RESULTS Among infants receiving fluconazole, the composite primary end point of death or invasive candidiasis was 16% (95% CI, 11%-22%) vs 21% in the placebo group (95% CI, 15%-28%; odds ratio, 0.73 [95% CI, 0.43-1.23]; P = .24; treatment difference, -5% [95% CI, -13% to 3%]). Invasive candidiasis occurred less frequently in the fluconazole group (3% [95% CI, 1%-6%]) vs the placebo group (9% [95% CI, 5%-14%]; P = .02; treatment difference, -6% [95% CI, -11% to -1%]). The cumulative incidences of other secondary outcomes were not statistically different between groups. Neurodevelopmental impairment did not differ between the groups (fluconazole, 31% [95% CI, 21%-41%] vs placebo, 27% [95% CI, 18%-37%]; P = .60; treatment difference, 4% [95% CI, -10% to 17%]). CONCLUSIONS AND RELEVANCE Among infants with a birth weight of less than 750 g, 42 days of fluconazole prophylaxis compared with placebo did not result in a lower incidence of the composite of death or invasive candidiasis. These findings do not support the universal use of prophylactic fluconazole in extremely low-birth-weight infants. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00734539.

Patent Ductus Arteriosus in Preterm Infants.

Despite a large body of basic science and clinical research and clinical experience with thousands of infants over nearly 6 decades,1 there is still uncertainty and controversy about the significance, evaluation, and management of patent ductus arteriosus in preterm infants, resulting in substantial heterogeneity in clinical practice. The purpose of this clinical report is to summarize the evidence available to guide evaluation and treatment of preterm infants with prolonged ductal patency in the first few weeks after birth.

The apgar score

The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia; does not predict individual neonatal mortality or neurologic outcome; and should not be used for that purpose. An Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting form that accounts for concurrent resuscitative interventions.

Total healthcare costs in the US for preterm infants with respiratory syncytial virus lower respiratory infection in the first year of life requiring medical attention

Abstract Background: Respiratory syncytial virus (RSV) lower respiratory infection (LRI) is the most common cause of hospitalization among infants <1 year of age. The healthcare costs of preterm infants with RSV LRI were compared with those without RSV LRI in the first year of life. Methods: This retrospective cohort study propensity-matched premature infants ≤36 weeks’ gestational age (wGA) and/or ≤2499 g birth weight, born May 1, 2001 through April 30, 2006 (five RSV seasons) with RSV LRI to those without RSV LRI in a national United States health plan. The primary outcome was first-year healthcare costs and utilization excluding the birth hospitalization compared between the study cohorts. Subgroup analysis evaluated costs and healthcare resource utilization by GA (≤32 wGA and 33–36 wGA) and hospitalization status (hospitalized and outpatient). Results: A total of 2995 infants with RSV LRI were matched to 2995 controls. Infants with RSV LRI had

Open lung biopsy in pediatric patients on extracorporeal membrane oxygenation

9115 higher healthcare costs (RSV LRI group:

Timing of intracranial hemorrhage during extracorporeal life support

19 559; control group:

Fulminant Neonatal Liver Failure in Siblings: Probable Congenital Hemophagocytic Lymphohistiocytosis

10 444; p < 0.001) in the first year of life. Late preterm infants (33–36 wGA) with an RSV hospitalization incurred

Hospital Stay for Healthy Term Newborn Infants

21 977 higher costs (p < 0.001) and those with an outpatient RSV LRI incurred

The use of extracorporeal membrane oxygenation in patients with gram-negative or viral sepsis.

3898 higher costs (p < 0.001) compared to corresponding controls. Similar results were found among infants ≤32 wGA with higher costs in the RSV LRI group. Rates of all-cause hospitalizations, emergency department visits, and ambulatory visits were significantly higher among infants with RSV LRI compared to controls. Conclusion: Development of RSV LRI among preterm and late preterm infants is associated with significantly higher healthcare costs in the first year of life. These findings must be considered in the context of potential study limitations that may have over- or underestimated costs, such as unconfirmed RSV infection, unintentional omission of fatal cases, and unobserved imbalances between groups.