Laura P. Ward

Universal maternal drug testing in a high-prevalence region of prescription opiate abuse.

OBJECTIVE To evaluate the efficacy of a universal maternal drug testing protocol for all mothers in a community hospital setting that experienced a 3-fold increase in neonatal abstinence syndrome (NAS) over the previous 5 years. STUDY DESIGN We conducted a retrospective cohort study between May 2012 and November 2013 after the implementation of universal maternal urine drug testing. All subjects with positive urine tests were reviewed to identify a history or suspicion of drug use, insufficient prenatal care, placental abruption, sexually transmitted disease, or admission from a justice center, which would have prompted urine testing using our previous risk-based screening guidelines. We also reviewed the records of infants born to mothers with a positive toxicology for opioids to determine whether admission to the special care nursery was required. RESULTS Out of the 2956 maternal specimens, 159 (5.4%) positive results were recorded. Of these, 96 were positive for opioids, representing 3.2% of all maternity admissions. Nineteen of the 96 (20%) opioid-positive urine tests were recorded in mothers without screening risk factors. Seven of these 19 infants (37%) required admission to the special care nursery for worsening signs of NAS, and 1 of these 7 required pharmacologic treatment. CONCLUSION Universal maternal drug testing improves the identification of infants at risk for the development of NAS. Traditional screening methods underestimate in utero opioid exposure.

Pharmacokinetics of Oral Methadone in the Treatment of Neonatal Abstinence Syndrome: A Pilot Study.

OBJECTIVE To characterize the population pharmacokinetics of oral methadone in neonates requiring pharmacologic treatment of neonatal abstinence syndrome and to develop a pharmacokinetic (PK) model toward an evidence-based treatment protocol. STUDY DESIGN Based on a methadone dosing protocol, serum concentrations of methadone and its metabolites were assessed by high performance liquid chromatography-tandem mass spectrometry from dried blood spots. Population PK analysis was performed to determine the volume of distribution and clearance of oral methadone. Methadone plasma concentration-time profiles were simulated from the deduced PK model to optimize the dosing regimen. RESULTS There was substantial interindividual variability in methadone concentrations. Blood concentrations of methadone were best described by a 1-compartment model with first-order absorption. The population mean estimates (coefficient of variation percentage) for oral clearance and volume of distribution were 8.94 (103%) L/h/70 kg and 177 (133%) L/70 kg, respectively. Optimized dosing strategies were developed based on the simulated PK profiles. We suggest a starting dose of 0.1 mg/kg per dose every 6 hours for most patients requiring pharmacologic treatment of neonatal abstinence syndrome followed by an expedited weaning phase. CONCLUSIONS The proposed dosing regimen may reduce the cumulative dose of opioid and shorten the length of hospitalization. Future studies should aim to validate the simulated dosing schemes with clinical data and expand our understanding of the between-patient PK variability. TRIAL REGISTRATION ClinicalTrials.gov: NCT01754324.

Improving Exclusive Breastfeeding in an Urban Academic Hospital

BACKGROUND AND OBJECTIVE: Breastfeeding has many well-established health benefits for infants and mothers. There is greater risk reduction in health outcomes with exclusive breastfeeding (EBF). Our urban academic facility has had long-standing low EBF rates, serving a population with breastfeeding disparities. We sought to improve EBF rates through a Learning Collaborative model by participating in the Best Fed Beginnings project. METHODS: Formal improvement science methods were used, including the development of a key driver diagram and plan–do–study–act cycles. Improvement activities followed the Ten Steps to Successful Breastfeeding. RESULTS: We demonstrated significant improvement in the median adherence to 2 process measures, rooming in and skin-to-skin after delivery. Subsequently, the proportion of infants exclusively breastfed at hospital discharge in our facility increased from 37% to 59%. We demonstrated an increase in sustained breastfeeding in a subset of patients at a postpartum follow-up visit. These improvements led to Baby-Friendly designation at our facility. CONCLUSIONS: This quality improvement initiative resulted in a higher number of infants exclusively breastfed in our patient population at “high risk not to breastfeed.” Other hospitals can use these described methods and techniques to improve their EBF rates.

Challenges in Caring for the Neonate Who Acquires Methicillin-Resistant Staphylococcus aureus via Vertical Transmission

Neonates most often present with methicillin-resistant Staphylococcus aureus (MRSA) infections beyond 3 days of age. Infection is usually acquired horizontally from direct contact with a family member or health care personnel who has MRSA colonizing the nares or skin. If the genital tract of a pregnant woman is colonized with MRSA, the infant may acquire the bacterium during labor and delivery. We describe the case of a term infant who likely acquired MRSA colonization via vertical transmission. This report calls attention to the challenges associated with the interpretation of a single blood culture positive for MRSA in such an infant, the treatment of MRSA infections in neonates, and the prevention of future MRSA infections in the mother–infant pair.

A quality improvement initiative to reduce necrotizing enterocolitis across hospital systems

ObjectiveNecrotizing enterocolitis (NEC) is a devastating intestinal disease in premature infants. Local rates of NEC were unacceptably high. We hypothesized that utilizing quality improvement methodology to standardize care and apply evidence-based practices would reduce our rate of NEC.Study designA multidisciplinary team used the model for improvement to prioritize interventions. Three neonatal intensive care units (NICUs) developed a standardized feeding protocol for very low birth weight (VLBW) infants, and employed strategies to increase the use of human milk, maximize intestinal perfusion, and promote a healthy microbiome.ResultsThe primary outcome measure, NEC in VLBW infants, decreased from 0.17 cases/100 VLBW patient days to 0.029, an 83% reduction, while the compliance with a standardized feeding protocol improved.ConclusionThrough reliable implementation of evidence-based practices, this project reduced the regional rate of NEC by 83%. A key outcome and primary driver of success was standardization across multiple NICUs, resulting in consistent application of best practices and reduction in variation.

Widespread Hospital Variation in Supplementation of Breastfed Newborns

Multiple health organizations, including the American Academy of Pediatrics,1 endorse the recommendation for exclusive breastfeeding for the first 6 months of life. In the United States, most women initiate breastfeeding, but a majority do not meet their intended goals of duration.2 There is a complex interplay of factors that impact breastfeeding outcomes, which include sociodemographic variables, psychosocial issues, maternal health, and infant conditions. However, hospital practices also play a significant role in a mother’s experience during the birth hospitalization and can be critical in setting the stage for breastfeeding success after discharge.2 In this issue of Pediatrics , Nguyen et al3 noted that in 2014, New York had the highest national rate of formula supplementation in breastfed newborns in the first 2 days of life. These authors sought to determine the factors that influence this finding. By using birth certificate data, they included 176 764 … Address correspondence to Laura P. Ward, MD, IBCLC, Division of Neonatology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 7009, Cincinnati, OH 45229-3039. E-mail: laura.ward{at}cchmc.org