Mitchell Goldstein

Prevention of postpartum smoking relapse in mothers of infants in the neonatal intensive care unit

Objective:Approximately 40% of women who smoke tobacco quit smoking during pregnancy, yet up to 85% relapse after delivery. Those who resume smoking often do so by 2 to 8 weeks postpartum. Smoking mothers are more than twice as likely to quit breastfeeding by 10 weeks postpartum. The hospitalization of a newborn, while stressful, is an opportunity to emphasize the importance of a smoke-free environment for babies. Supporting maternal-infant bonding may reduce maternal stress and motivate mothers to remain smoke free and continue breastfeeding. The objective of this study was to reduce postpartum smoking relapse and prolong breastfeeding duration during the first 8 weeks postpartum in mothers who quit smoking just before or during pregnancy and have newborns admitted to the Neonatal Intensive Care Unit (NICU).Study Design:This study was an Institutional Review Board-approved prospective randomized clinical trial. After informed consent, mothers of newborns admitted to the NICU were randomized to a control or intervention group. Both groups received weekly encouragement to remain smoke free and routine breastfeeding support. Mothers in the intervention group were also given enhanced support for maternal-infant bonding including information about newborn behaviors, and were encouraged to frequently hold their babies skin-to-skin.Result:More mothers were smoke free (81 vs 46%, P<0.001) and breastfeeding (86 vs 21%, P<0.001) in the intervention than in the control group at 8 weeks postpartum.Conclusion:Interventions to support mother–infant bonding during a newborns hospitalization in the NICU are associated with reduced rates of smoking relapse and prolonged duration of breastfeeding during the first 8 weeks postpartum.

Impact of ART on pregnancies in California: an analysis of maternity outcomes and insights into the added burden of neonatal intensive care

Objective:We reviewed the occurrence of prematurity, low birth weight, multiple gestations, frequency of stillbirths and maternity care-associated variables including hospital stay and hospital charges of women conceiving using assisted reproductive technology (ART) or artificial insemination (AI) compared with women with a history of infertility who conceived naturally, and all other naturally conceived pregnancies in California at non-federal hospitals between 2009 and 2011. At a single center, infants born after ART/AI were compared with infants provided care in the normal nursery.Study design:Publically available inpatient data sets from the California Office of Statewide Health Planning and Development for years 2009–2011 using data from all California non-federal hospitals were used to determine the impact of ART on a variety of pregnancy-related outcomes and infant characteristics. Infant data from a single center was used to determine hospital charges for infants delivered over an 18-month period to compare the hospital and physician charges indexed to similar charges for infants admitted to the ‘normal’ newborn nursery.Result:Among ART/AI pregnancies, there was a 4–5-fold increase in stillbirths, compared with a 2–3-fold increase among women with infertility compared with other naturally conceiving women. ART/AI pregnancies underwent more cesarean sections (fourfold), and a near fourfold increase in the rate of preterm deliveries. Multiple gestations were increased 24–27-fold compared with naturally conceived pregnancies. Maternal hospital stay and hospital charges were increased among those undergoing ART/AI. Infant charges were increased multi-fold for singletons, twins and triplets delivered after ART/AI compared with naturally conceived infants.Conclusion:Multiple births, preterm births and a higher overall rate of fetal anomalies were found in California after ART/AI for 2009–2011. Cesarean section rates, longer length of maternal stay and hospital charges among women receiving ART/AI could be lowered if emphasis on elective single embryo transfers was a higher priority among providers. Charges for the care of infants delivered after ART/AI are substantially higher than among naturally conceived infants born late preterm or at term. Families seeking ART/AI need to be informed of the impact of these adverse pregnancy outcomes, including neonatal outcomes and charges for medical care for their infant(s), when considering ART/AI.

Using Patient-Centered Care After a Prenatal Diagnosis of Trisomy 18 or Trisomy 13: A Review

Importance Patient-centered care (PCC) has been advocated by the Institute of Medicine to improve health care in the United States. Four concepts of PCC align with clinical ethics principles and are associated with enhanced patient/parent satisfaction. These concepts are dignity and respect, information sharing, participation, and collaboration. The objective of this article is to use the PCC approach as a framework for an extensive literature review evaluating the current status of counseling regarding prenatal diagnosis of trisomy 18 (T18) or trisomy 13 (T13) and to advocate PCC in the care of these infants. Observations Extensive availability of prenatal screening and diagnostic testing has led to increased detection of chromosomal anomalies early in pregnancy. After diagnosis of T18 or T13, counseling and care have traditionally been based on assumptions that these aneuploidies are lethal or associated with poor quality of life, a view that is now being challenged. Recent evidence suggests that there is variability in outcomes that may be improved by postnatal interventions, and that quality-of-life assumptions are subjective. Parental advocacy for their infant’s best interest mimics this variability as requests for resuscitation, neonatal intensive care, and surgical intervention are becoming more frequent. Conclusions and Relevance With new knowledge and increased parental advocacy, physicians face ethical decisions in formulating recommendations including interruption vs continuation of pregnancy, interventions to prolong life, and choices to offer medical or surgical procedures. We advocate a PCC approach, which has the potential to reduce harm when inadequate care and counseling strategies create conflicting values and uncertain outcomes between parents and caregivers in the treatment of infants with T18 and T13.

Palivizumab Prophylaxis for Respiratory Syncytial Virus: Examining the Evidence Around Value

Abstract Respiratory syncytial virus (RSV) infection is the most common cause of lower respiratory tract infection and the leading cause of hospitalization among young children, incurring high annual costs among US children under the age of 5 years. Palivizumab has been found to be effective in reducing hospitalization and preventing serious lower respiratory tract infections in high-risk infants. This paper presents a systematic review of the cost-effectiveness studies of palivizumab and describes the main highlights of a round table discussion with clinical, payer, economic, research method, and other experts. The objectives of the discussion were to (1) review the current state of clinical, epidemiology, and economic data related to severe RSV disease; (2) review new cost-effectiveness estimates of RSV immunoprophylaxis in US preterm infants, including a review of the field’s areas of agreement and disagreement; and (3) identify needs for further research.

Respiratory Syncytial Virus Hospitalizations among U.S. Preterm Infants Compared with Term Infants Before and After the 2014 American Academy of Pediatrics Guidance on Immunoprophylaxis: 2012–2016

Objective The objective of this study was to compare risk for respiratory syncytial virus (RSV) hospitalizations (RSVH) for preterm infants 29 to 34 weeks gestational age (wGA) versus term infants before and after 2014 guidance changes for immunoprophylaxis (IP), using data from the 2012 to 2016 RSV seasons. Study Design Using commercial and Medicaid claims databases, infants born between July 1, 2011 and June 30, 2016 were categorized as preterm or term. RSVH during the RSV season (November‐March) were identified for infants aged <6 months and rate ratios (RRs) for hospitalization comparing preterm and term infants were calculated. Difference‐in‐difference models were fit to evaluate the changes in hospitalization risks in preterm versus term infants from 2012 to 2014 seasons to 2014 to 2016 seasons. Results In all seasons, preterm infants had higher RSVH rates than term infants. Seasonal RRs prior to the guidance change for preterm wGA categories versus term infants ranged from 1.6 to 3.4. After the guidance change, the seasonal RRs ranged from 2.6 to 5.6. In 2014 to 2016, the risk associated with prematurity of 29 to 34 wGA versus term was significantly higher than in 2012 to 2014 (P<0.0001 for commercial and Medicaid samples). Conclusion In infants aged <6 months, the risk for RSVH for infants 29 to 34 wGA compared with term infants increased significantly after the RSV IP recommendations became more restrictive.

National Bronchiolitis Hospitalization Rates Among Preterm and Full Term Infants: 2010–2015

Abstract Background The 2014 American Academy of Pediatrics (AAP) policy statement on respiratory syncytial virus immunoprophylaxis (RSV IP) recommended against its use in infants 29–34 weeks gestational age (wGA) without chronic lung disease or bronchopulmonary dysplasia (CLD/BPD) or congenital heart disease (CHD). This study examined the impact of these changes by evaluating RSV IP use and bronchiolitis hospitalization rates among full-term (FT) and preterm (PT) infants 29–34 wGA in the 2014–15 RSV season relative to previous seasons. Methods Infants born 7/1/2009 to 6/30/2015 were identified in the MarketScan Multistate Medicaid (MED) and Commercial (COM) databases; DRG and ICD-9-CM codes were used to select FT and PT infants without CLD/BPD or CHD. Outpatient RSV IP use was identified by drug and administration codes. Bronchiolitis hospitalizations were identified by diagnosis codes (466.11 and 466.19) during the RSV season (Nov–Mar) and summarized by chronologic age (CA). Hospitalization rates were calculated per 100 infant-seasons, and statistical significance was tested using generalized linear regression models with Poisson error, log link, and log offset for exposure time. Results 1.1 mil MED and 1.0 mil COM births were identified; 5.2% MED and 4.8% COM infants were born at 29–34 wGA. RSV IP use decreased among MED and COM infants 29–34 wGA (P < .01) in 2014–15 compared with 2013–14. Bronchiolitis hospitalization rates increased for MED and COM infants 29–34 wGA in 2014–15 compared with 2013–14 (rate ratios <3 months CA: MED 1.45, P = .009 and COM 2.1, P = .004; 3–6 months CA: MED 1.35, P = .023 and COM 1.7, P = .053), whereas the rates for FT infants remained the same (rate ratios 0.94–1.08, P > .05). Absolute increases were greatest for infants 29–30 wGA and <3 months CA (MED +10.0 and COM +8.3 per 100 infant-seasons). Similar trends were observed when 2014–15 was compared with the combined 2010–14 RSV seasons. Conclusion In the 2014–15 RSV season, there was an increase in bronchiolitis hospitalization rates among PT infants born at 29–34 wGA when <3 months and 3–6 months CA, but no increase among FT infants. Trends were consistent in the MED and COM populations and are associated with the change to AAP policy. Funding AstraZeneca Disclosures L. R. Krilov, AstraZeneca/MedImmune: Consultant, Research grant and Research support; J. Fergie, MedImmune: Speaker’s Bureau, Research grant and Research support; M. Goldstein, AstraZeneca/MedImmune: Consultant, Research grant and Research support; K. K. McLaurin, AstraZeneca: Employee, Salary; S. Wade, Truven Health Analytics: Consultant, Consulting fee; D. Diakun, Truven Health Analytics: Employee, Salary; A. Kong, Truven Health Analytics: Employee, Salary

Use of a Nebulizer to Deliver High Frequency High Flow with a Nasal Cannula

The Vortan Percussive NEBTM (P-NEB) is a compact single patient, multiple use and disposable high frequency percussive nebulizer intended for the clearance of endobronchial secretions in adult patients. According to the manufacturer’s specification, “During exhalation the pneumatic capacitor and pulmonary modulator cycle to deliver high frequency (typically 11-30Hz) pressure bursts to provide an effective intrapulmonary percussion treatment.” According to the product user guide, “the high frequency pressure bursts are identical to those delivered by a high frequency ventilator.” There no studies to support whether this device could be used to provide high frequency ventilation for infants. We demonstrated the potential for HFV using this device previously [1], but noted that the PEEP levels produced may be insufficient to support its use in situations greater PEEP greater than 6cm H2O. We hypothesized that P-NEB produced adequate flow to use as a high frequency nasal cannula ((HF)2NC) for infants. Methods

The Implementation of an Economic Teleradiology Solution and Its Application to Neonatal and Pediatric Critical Care Medicine

The Implementation of an Economic Teleradiology Solution and Its Application to Neonatal and Pediatric Critical Care Medicine

Conventional Pulse Oximetry Can Give Spurious Data in a Neonatal Population at Risk for Retinopathy of Prematurity (ROP) |[dagger]| 1260

Tighter control of oxygen titration in “at risk” premature neonates might reduce the incidence of complications associated with retinopathy of prematurity (STOP-ROP). Pulse oximetry (SpO2) has been used as a reference in determining oxygenation. SpO2 is determined by comparing absorbance of light (red and infrared) at two wavelengths during pulsatile blood flow. Motion, perfusion, and ambient light overwhelm the ability of a conventional oximeter to continuously transduce accurate readings in “at risk” premature infants. The Masimo Signal Extraction Technology (SET) calculates a noise reference and uses adaptive filters to attenuate artifact and amplify relevant signals. This study compares the Masimo SET to a conventional pulse oximeter (Nellcor) on ten sick newborns at risk for ROP. The Masimo sensor (LNOP Neo Pt) was attached to a Masimo prototype oximeter and the Nellcor sensor (N-25) to a Nellcor N-200 oximeter. Neonates were monitored for 3-4 hours with a sensor on each foot, then sensors were switched to the opposite foot and similarly monitored. ECG was interfaced from a SpaceLabs monitor to distinguish false oximeter events. Intrinsic motion, caregiver, and parental influenced desaturation were noted. The Masimo SET waveform was examined via a frequency analysis plot of SpO2. “True” desaturation occurred when a peak corresponding to the ECG frequency domain was identified and multiples of the waveform corroborated the finding (Comp. Biol. Med. 26:143-159, 1996). The total duration of Nellcor false alarms was nearly 14 times greater than Masimo SET. On average, the Nellcor alarmed falsely every 13.9min for 36.6s; Masimo SET, every 87.8min for 16.9s. False titration of oxygen may produce significant morbidity in the premature infant. A survey of >100 NICUs reported that the majority set high SpO2 alarms which “could predispose an infant on supplemental oxygen to hyperoxemia”(J. Perinatol. 17:341-5, 1997). The caregiver is numbed to a true alarm condition. Because of the high alarm rate, studies based upon a caregivers response to conventional oximetry are suspect at best. Table

Neonatal Intensive Care Design: A Practical Approach 1066

The design or redesign of a Neonatal Intensive Care Unit requires a unified approach which necessitates dedication to understanding newborn physiology and maturation, as well as an effort to provide a physical environment conductive to the patient, the family and the neonatal health care team. This must be accomplished with both space and cost a major consideration. We have just completed the planning, design, and implementation of a new forty bed NICU. Unless there is a well defined approach to the project, hospital politics and unresolved departmental issues are a prelude to failure. The following scheme outlines our approach to designing a modern NICU which will be ”user friendly: and satisfy the needs of all involved groups.