Margaret Parker

Cohort Profile: Project Viva

We established Project Viva to examine prenatal diet and other factors in relation to maternal and child health. We recruited pregnant women at their initial prenatal visit in eastern Massachusetts between 1999 and 2002. Exclusion criteria included multiple gestation, inability to answer questions in English, gestational age ≥22 weeks at recruitment and plans to move away before delivery. We completed in-person visits with mothers during pregnancy in the late first (median 9.9 weeks of gestation) and second (median 27.9 weeks) trimesters. We saw mothers and children in the hospital during the delivery admission and during infancy (median age 6.3 months), early childhood (median 3.2 years) and mid-childhood (median 7.7 years). We collected information from mothers via interviews and questionnaires, performed anthropometric and neurodevelopmental assessments and collected biosamples. We have collected additional information from medical records and from mailed questionnaires sent annually to mothers between in-person visits and to children beginning at age 9 years. From 2341 eligible women, there were 2128 live births; 1279 mother-child pairs provided data at the mid-childhood visit. Primary study outcomes include pregnancy outcomes, maternal mental and cardiometabolic health and child neurodevelopment, asthma/atopy and obesity/cardiometabolic health. Investigators interested in learning more about how to obtain Project Viva data can contact Project_Viva@hphc.org.

Pasteurized Human Donor Milk Use among US Level 3 Neonatal Intensive Care Units

Background: Pasteurized human donor milk (DM) is recommended by the World Health Organization and American Academy of Pediatrics for preterm infants when mother’s own milk is unavailable, yet the extent and predictors of use and criteria for use in US neonatal intensive care units (NICUs) are unknown. Objective: This study aimed to evaluate current DM use in US level 3 NICUs and predictors and criteria of use. Methods: We sent mail surveys to 302 US level 3 NICU directors. We used multivariable logistic regression to analyze predictors of DM use. Results: Survey response rate was 60%, and 76 of 182 (42%) directors reported DM use. Among DM users, 30% have used DM < 2 years and 55% for 2 to 5 years. Among nonusers, 63% were uncertain of turnaround time when ordering DM, 36% were unclear what guidelines milk banks followed, and 31% were unsure of parent receptiveness. In multivariate analyses, > 800 annual admissions (odds ratio [OR], 4.11; 95% confidence interval [CI], 1.43-11.82; reference ≤ 400 admissions) and location in the Midwest (OR, 3.02; 95% CI, 1.17-7.76) and West (OR, 6.33; 95% CI, 2.28-15.57; reference Northeast) were positively associated with DM use; safety-net hospitals (> 75% Medicaid insurance) were negatively associated (OR, 0.35; 95% CI, 0.14-0.89). Conclusion: Pasteurized human donor milk use is rapidly emerging among US level 3 NICUs. Larger NICUs and those in the West and Midwest were more likely to use DM, while safety-net hospitals were less likely to use DM. Lack of knowledge by medical directors of accessibility, safety, and parental receptiveness may be barriers to DM use.

Gestational Glucose Tolerance and Cord Blood Leptin Levels Predict Slower Weight Gain in Early Infancy

OBJECTIVE To determine the extent to which known prenatal and perinatal predictors of childhood obesity also predict weight gain in early infancy. STUDY DESIGN We studied 690 infants participating in the prospective cohort Project Viva. We measured length and weight at birth and at 6 months. Using multivariable linear regression, we examined relationships of selected maternal and infant factors with change in weight-for-length z-score (WFL-z) from 0 to 6 months. RESULTS Mean (standard deviation) change in WFL-z from 0 to 6 months was 0.23 (1.11), which translates to 4500 grams gained from birth to 6 months of life in an infant with average birth weight and length. After adjustment for confounding variables and birth weight-for-gestational age z-score (-0.28 [95% confidence interval, -0.37, -0.19] per unit), cord blood leptin (-0.40 [95%confidence interval, -0.61, -0.19] per 10 ng/mL), and gestational diabetes -0.50 [95%confidence interval, -0.88, -0.11] versus normal glucose tolerance)were each associated with slower gain in WFL-z from 0 to 6 months. CONCLUSIONS Higher neonatal leptin and gestational diabetes predicted slower weight gain in the first 6 months of life. The hormonal milieu of the intrauterine environment may determine growth patterns in early infancy and thus later obesity.

10 Years after Baby-Friendly Designation Breastfeeding Rates Continue to Increase in a US Neonatal Intensive Care Unit

Background: Mothers of preterm and sick infants admitted to the neonatal intensive care unit (NICU) often encounter more difficulties with breastfeeding than mothers of healthy term newborns. The extent to which Baby-Friendly designation is associated with breastfeeding rates for NICU infants over time is unknown. Objective: This study aimed to determine the rate of breastfeeding initiation and continuation in a US, inner-city, level 3 NICU 10 years after Baby-Friendly designation. Methods: We compared the rate of breastfeeding initiation and continuation among breastfeeding-eligible mothers with infants admitted to the Boston Medical Center NICU in 1999 and 2009, using chi-square tests. Results: Breastfeeding initiation increased from 74% in 1999 to 85% in 2009 (P = .04). Any breast milk at 2 weeks of age increased from 66% to 80% (P = .05), and exclusive breastfeeding at 2 weeks remained stable between 1999 and 2009. Breastfeeding initiation increased from 68% to 86% among black mothers from 1999 to 2009 (P = .01). Conclusion: Improvement in breastfeeding initiation and any breastfeeding at 2 weeks of age continued 10 years after Baby-Friendly designation among mothers with NICU infants in a US, inner-city, level 3 NICU.

Placental weight mediates the effects of prenatal factors on fetal growth: the extent differs by preterm status.

Elevated pre‐pregnancy BMI, excessive gestational weight gain (GWG), and gestational diabetes mellitus (GDM) are known determinants of fetal growth. The role of placental weight is unclear. We aimed to examine the extent to which placental weight mediates the associations of pre‐pregnancy BMI, GWG, and GDM with birth weight‐for‐gestational age, and whether the relationships differ by preterm status.

Implementation of a Donor Milk Program Is Associated with Greater Consumption of Mothers' Own Milk among VLBW Infants in a US, Level 3 NICU.

Background: It is unclear whether use of donor milk (DM) changes the provision of mothers’ own milk (MOM) to very low birth weight (VLBW) infants in the neonatal intensive care unit (NICU). Objectives: To determine whether (1) the rates of any MOM and human milk consumption at feeding initiation and discharge and (2) the proportion of VLBW infants who stopped consuming any MOM and human milk during hospitalization changed in the 2 years after versus before implementation of a DM program in a US, inner-city, level 3 NICU. Methods: We studied VLBW infants admitted to Boston Medical Center in the 2 years before (n = 74) and after (n = 80) implementation of a DM program (June 2011). We used multivariable logistic regression to compare milk consumption at feeding initiation and discharge and Cox proportional hazards to compare the proportion of infants that stopped consuming milk during the hospitalization pre and post our DM program. Results: After adjustment for maternal race, age, insurance, delivery type, gestational age, and birth weight, we found a 6.0-fold increased odds (95% CI, 2.0-17.7) of consuming MOM at discharge and a 49% reduction in the cessation of MOM consumption during hospitalization (hazard ratio [HR], 0.51; 95% CI, 0.28-0.93) in the 2 years after versus before our DM program. Conclusion: Implementation of a DM program was associated with greater consumption of MOM throughout hospitalization and at discharge among VLBW infants. Implementation of DM programs may augment support of mothers to provide breast milk in level 3 NICUs.

The Effect of an Electronic SBAR Communication Tool on Documentation of Acute Events in the Pediatric Intensive Care Unit

The Situation, Background, Assessment, Recommendation (SBAR) handoff tool is designed to improve communication. The effects of integrating an electronic medical record (EMR) with a SBAR template are unclear. The research team hypothesizes that an electronic SBAR template improves documentation and communication between nurses and physicians. In all, 84 patient events were recorded from 542 admissions to the pediatric intensive care unit. Three time periods were studied: (a) paper documentation only, (b) electronic documentation, and (c) electronic documentation with an SBAR template. Documentation quality was assessed using a 4-point scoring system. The frequency of event notes increased progressively during the 3 study periods. Mean quality scores improved significantly from paper documentation to EMR free-text notes and to electronic SBAR-template notes, as did nurse and attending physician notification. The implementation of an electronic SBAR note is associated with more complete documentation and increased frequency of documentation of communication among nurses and physicians.

Maternal BMI, gestational diabetes, and weight gain in relation to childhood obesity: The mediation effect of placental weight

High prepregnancy body mass index (BMI), excessive gestational weight gain (GWG), and gestational diabetes mellitus (GDM) are associated with the risk of childhood obesity. This study aims to examine the extent to which these effects may be mediated through the placenta.

Variability of Criteria for Pasteurized Donor Human Milk Use A Survey of U.S. Neonatal Intensive Care Unit Medical Directors

BACKGROUND Use of donor human milk (DHM) is increasing, but criteria for its use are not well defined. MATERIALS AND METHODS We conducted a 34-question Internet-based survey of medical directors of U.S. level 3 and level 4 neonatal intensive care units (NICUs), with the goal of describing specifics of policies developed to guide DHM use in U.S. NICUs. Respondents reported NICU characteristics and details of policies concerning DHM use. Policy-specified criteria for DHM use, if any, were described. Bivariate and multivariate analyses were used to identify NICU characteristics associated with DHM use. RESULTS Respondents returned 153 (33%) surveys, with use of DHM reported by 91 (59%). Donor human milk use was more likely with more than 100 annual admissions <1500 g at birth (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.7) and with Vermont-Oxford Network participants (OR, 4.6; 95% CI, 1.8-11.6). Among 72 NICUs reporting a written policy, criteria for providing DHM required birth weights varying from <1000 to <1800 g and/or gestational ages from <28 to <34 completed weeks, but criteria were reportedly waived in many circumstances. Policies regarding duration of DHM therapy were similarly varied. CONCLUSIONS Criteria for initiating and continuing DHM vary widely among U.S. level 3 and level 4 NICUs. Donor human milk use is more frequent in NICUs with many very low-birth-weight admissions and among Vermont-Oxford Network participants. Further research is needed to define short- and long-term outcomes and cost benefits of DHM use in subgroups of NICU patients, particularly for uses other than necrotizing enterocolitis prevention.

Implementing Change Steps to Initiate a Human Donor Milk Program in a US Level III NICU

Initiating a pasteurized human donor milk (PDM) program in a level III neonatal intensive care unit (NICU) can be a difficult process that requires commitment by a multidisciplinary team, education, sufficient funding, and “buy-in” from NICU staff, families, and hospital administration. We began planning for our program in February 2011 and started using PDM in June 2011. This paper describes the steps taken and the obstacles overcome to initiate a PDM program for our hospital’s tiniest, sickest, and most vulnerable patients.