Neera K. Goyal

Association of late-preterm birth with asthma in young children: practice-based study

OBJECTIVE: To evaluate the association of late-preterm birth with asthma severity among young children. METHODS: A retrospective cohort study was performed with electronic health record data from 31 practices affiliated with an academic medical center. Participants included children born in 2007 at 34 to 42 weeks of gestation and monitored from birth to 18 months. We used multivariate logistic or Poisson models to assess the impact of late-preterm (34–36 weeks) and low-normal (37–38 weeks) compared with term (39–42 weeks) gestation on diagnoses of asthma and persistent asthma, inhaled corticosteroid use, and numbers of acute respiratory visits. RESULTS: Our population included 7925 infants (7% late-preterm and 21% low-normal gestation). Overall, 8.3% had been diagnosed with asthma by 18 months. Compared with term gestation, late-preterm gestation was associated with significant increases in persistent asthma diagnoses (adjusted odds ratio [aOR]: 1.68), inhaled corticosteroid use (aOR: 1.66), and numbers of acute respiratory visits (incidence rate ratio: 1.44). Low-normal gestation was associated with increases in asthma diagnoses (aOR: 1.34) and inhaled corticosteroid use (aOR: 1.39). CONCLUSION: Birth at late-preterm and low-normal gestational ages might be an important risk factor for the development of asthma and for increased health service use in early childhood.

Home Visiting and Outcomes of Preterm Infants: A Systematic Review

BACKGROUND AND OBJECTIVES: Home visiting is 1 strategy to improve child health and parenting. Since implementation of home visiting trials 2 decades ago, US preterm births (<37 weeks) have risen by 20%. The objective of this study was to review evidence regarding home visiting and outcomes of preterm infants METHODS: Searches of Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Cochrane Controlled Trial Register, PsycINFO, and Embase were conducted. Criteria for inclusion were (1) cohort or controlled trial designs; (2) home-based, preventive services for infants at medical or social risk; and (3) outcomes reported for infants born preterm or low birth weight (<2500 g). Data from eligible reports were abstracted by 2 reviewers. Random effects meta-analysis was used to synthesize data for developmental and parent interaction measures. RESULTS: Seventeen studies (15 controlled trials, 2 cohort studies) were reviewed. Five outcome domains were identified: infant development, parent-infant interaction, morbidity, abuse/neglect, and growth/nutrition. Six studies (n = 336) demonstrated a pooled standardized mean difference of 0.79 (95% confidence interval 0.57 to 1.02) in Home Observation for Measurement of the Environment Inventory scores at 1 year in the home-visited groups versus control. Evidence for other outcomes was limited. Methodological limitations were common. CONCLUSIONS: Reviewed studies suggest that home visiting for preterm infants promotes improved parent-infant interaction. Further study of interventions targeting preterm infants within existing programs may strengthen the impact and cost benefits of home visiting in at-risk populations.

Discrepancies Between Transcutaneous and Serum Bilirubin Measurements

OBJECTIVE: To characterize discrepancies between transcutaneous bilirubin (TcB) measurements and total serum bilirubin (TSB) levels among newborns receiving care at multiple nursery sites across the United States. METHODS: Medical records were reviewed to obtain data on all TcB measurements collected during two 2-week periods on neonates admitted to participating newborn nurseries. Data on TSB levels obtained within 2 hours of a TcB measurement were also abstracted. TcB – TSB differences and correlations between the values were determined. Data on demographic information for individual newborns and TcB screening practices for each nursery were also collected. Multivariate regression analysis was used to identify characteristics independently associated with the TcB – TSB difference. RESULTS: Data on 8319 TcB measurements were collected at 27 nursery sites; 925 TSB levels were matched to a TcB value. The mean TcB – TSB difference was 0.84 ± 1.78 mg/dL, and the correlation between paired measurements was 0.78. In the multivariate analysis, TcB – TSB differences were 0.67 mg/dL higher in African-American newborns than in neonates of other races (P < .001). The TcB – TSB difference also varied significantly based on brand of TcB meter used and hour of age of the infant. For 2.2% of paired measurements, the TcB measurement underestimated the TSB level by ≥3 mg/dL. CONCLUSIONS: During routine clinical care, TcB measurement provided a reasonable estimate of TSB levels in healthy newborns. Discrepancies between TcB and TSB levels were increased in African-American newborns and varied based on brand of meter used.

Hospital care and early breastfeeding outcomes among late preterm, early-term, and term infants.

BACKGROUND Compared with term infants (39-41 weeks), early-term (37-38 weeks) and late preterm (34-36 weeks) infants have increased breastfeeding difficulties. We evaluated how hospital practices affect breastfeeding by gestational age. METHODS This Listening to Mothers III survey cohort included 1,860 mothers who delivered a 34-41-week singleton from July 2011 to June 2012. High hospital support was defined as at least seven practices consistent with the Baby-Friendly Hospital Initiatives Ten Steps for United States hospitals. Logistic regression tested mediating effects of hospital support on the relationship between gestational age and breastfeeding at 1 week postpartum. RESULTS High hospital support was associated with increased exclusive breastfeeding (AOR 2.21 [95% CI 1.58-3.09]). Just 16.4 percent of late preterm infants experienced such support, compared with early-term (37.9%) and term (30.7%) infants (p = 0.004). Although overall breastfeeding rates among late preterm, early-term, and term infants were 87, 88, and 92 percent, respectively, (p = 0.21), late preterm versus term infants were less likely to exclusively breastfeed (39.8 vs. 62.3%, p = 0.002). Inclusion of hospital support in multivariable modeling did not attenuate the effect of late preterm gestation. DISCUSSION Differences in practices do not account for decreased exclusive breastfeeding among late preterm infants. Hospital supportive practices increase the likelihood of any breastfeeding.

Adherence to Discharge Guidelines for Late-Preterm Newborns

OBJECTIVE: To evaluate trends in adherence to American Academy of Pediatrics recommendations for early discharge of late-preterm newborns and to test the association between hospital characteristics and early discharge. PATIENTS AND METHODS: This study was a population-based cohort study using statewide birth-certificate and hospital-discharge data for newborns in California, Missouri, and Pennsylvania from 1993 to 2005. A total of 282 601 late-preterm newborns at 611 hospitals were included. Using logistic regression, we studied the association of early discharge with regional and hospital factors, including teaching affiliation, volume, and urban versus rural location, adjusting for patient factors. RESULTS: From 1995 to 2000, early discharge decreased from 71% of the sample to 40%. However, by 2005, 39% were still discharged early. Compared with Pennsylvania, California (adjusted odds ratio [aOR]: 5.95 [95% confidence interval (CI): 5.03–7.04]), and Missouri (aOR: 1.56 [95% CI: 1.26–1.93]) were associated with increased early discharge. Nonteaching hospitals were more likely than teaching hospitals to discharge patients early if they were uninsured (aOR: 1.91 [95% CI: 1.35–2.69]) or in a health maintenance organization plan (aOR: 1.40 [95% CI: 1.06–1.84]) but not patients with fee-for-service insurance (aOR: 1.04 [95% CI: 0.80–1.34]). A similar trend for newborns on Medicaid was not statistically significant (aOR: 1.77 [95% CI: 0.95–3.30]). CONCLUSIONS: Despite a decline in the late 1990s, early discharge of late-preterm newborns remains common. We observe differences according to state, hospital teaching affiliation, and patient insurance. Additional research on the safety and appropriateness of early discharge for this population is necessary.

Stronger instruments via integer programming in an observational study of late preterm birth outcomes

In an optimal nonbipartite match, a single population is divided into matched pairs to minimize a total distance within matched pairs. Nonbipartite matching has been used to strengthen instrumental variables in observational studies of treatment effects, essentially by forming pairs that are similar in terms of covariates but very different in the strength of encouragement to accept the treatment. Optimal nonbipartite matching is typically done using network optimization techniques that can be quick, running in polynomial time, but these techniques limit the tools available for matching. Instead, we use integer programming techniques, thereby obtaining a wealth of new tools not previously available for nonbipartite matching, including fine and near-fine balance for several nominal variables, forced near balance on means and optimal subsetting. We illustrate the methods in our on-going study of outcomes of late-preterm births in California, that is, births of 34 to 36 weeks of gestation. Would lengthening the time in the hospital for such births reduce the frequency of rapid readmissions? A straightforward comparison of babies who stay for a shorter or longer time would be severely biased, because the principal reason for a long stay is some serious health problem. We need an instrument, something inconsequential and haphazard that encourages a shorter or a longer stay in the hospital. It turns out that babies born at certain times of day tend to stay overnight once with a shorter length of stay, whereas babies born at other times of day tend to stay overnight twice with a longer length of stay, and there is nothing particularly special about a baby who is born at 11:00 pm.

Association of Maternal and Community Factors With Enrollment in Home Visiting Among At-Risk, First-Time Mothers

OBJECTIVES We identified individual and contextual factors associated with referral and enrollment in home visiting among at-risk, first-time mothers. METHODS We retrospectively studied referral and enrollment in a regional home visiting program from 2007 to 2009 in Hamilton County, Ohio. Using linked vital statistics and census tract data, we obtained individual and community measures on first-time mothers meeting eligibility criteria for home visiting (low income, unmarried, or age < 18 years). Generalized linear modeling was performed to determine factors associated with relative risk (RR) of (1) referral to home visiting among eligible mothers and (2) enrollment after referral. RESULTS Of 8187 first-time mothers eligible for home visiting, 2775 were referred and 1543 were enrolled. Among referred women, high school completion (RR = 1.10) and any college (RR = 1.17) compared with no high school completion were associated with increased enrollment, and enrollment was less likely for those living in communities with higher socioeconomic deprivation (RR = 0.71; P < .05). CONCLUSIONS Barriers to enrollment in home visiting persisted at multiple ecological levels. Ongoing evaluation of enrollment in at-risk populations is critical as home visiting programs are implemented and expanded.

Prioritizing a research agenda: a Delphi study of the better outcomes through research for newborns (BORN) network.

BACKGROUND There is a paucity of evidence to guide clinical management for term and late preterm newborns. The Better Outcomes through Research for Newborns (BORN) network is a national collaborative of clinicians formed to increase the evidence-base for well newborn care. OBJECTIVE To develop a consensus-based, prioritized research agenda for well newborn care. DESIGN A two-round modified Delphi survey of BORN members was conducted. Round 1 was an open-ended survey soliciting 5 clinical questions identified as important and under-researched. Using qualitative methods, 20 most common themes were extracted and transformed into research questions. Round 2 survey respondents ranked the top 20 questions using a 5- point Likert scale and a quantitative analysis was conducted. RESULTS Round 1 survey generated 439 unique research questions that fell into 57 themes. In the Round 2 survey, the highest rated questions were: 1) At what weight-loss percentage is it medically necessary to formula supplement a breastfeeding infant? 2) What is the optimal management of infants with neonatal abstinence syndrome? 3) How and when should we initiate a workup for sepsis, and how should these newborns be managed? CONCLUSIONS Research priorities of clinicians include criteria for medically indicated formula supplementation of the breastfed newborn, management of neonatal abstinence syndrome and management of newborns at-risk for sepsis.

Effects of home visiting and maternal mental health on use of the emergency department among late preterm infants.

OBJECTIVE To describe use of the emergency department (ED) among late preterm versus term infants enrolled in a home visiting program and to determine whether home visiting frequency was associated with outcome differences. DESIGN Retrospective, cohort study. SETTING Regional home visiting program in southwest Ohio from 2007–2010. PARTICIPANTS Late preterm and term infants born to mothers enrolled in home visiting. Program eligibility requires ≥ one of four characteristics: unmarried, low income, < 18 years, or suboptimal prenatal care. METHODS Data were derived from vital statistics, hospital discharges, and home visiting records. Negative binomial regression was used to determine association of ED visits in the first year with late preterm birth and home visit frequency, adjusting for maternal and infant characteristics. RESULTS Of 1,804 infants, 9.2% were born during the late preterm period. Thirty-eight percent of all infants had at least one ED visit, 15.6% had three or more. No significant difference was found between the number of ED visits for late preterm and term infants (39.4% vs. 37.8% with at least one ED visit, p = .69). In multivariable analysis, late preterm birth combined with a maternal mental health diagnosis was associated with an ED incident rate ratio (IRR) of 1.26, p = .03; high frequency of home visits was not significant (IRR = .92, p = .42). CONCLUSIONS Frequency of home visiting service over the first year of life is not significantly associated with reduced ED visits for infants with at-risk attributes and born during the late preterm period. Research on how home visiting can address ED use, particularly for those with prematurity and maternal mental health conditions, may strengthen program impact and cost benefits.

Using quality improvement to promote implementation and increase well child visits in home visiting

A key goal of home visiting is to connect children with medical homes through anticipatory guidance regarding recommended well child care (WCC). Substantial barriers to WCC among low socioeconomic families can limit achievement of this outcome. Quality improvement strategies have been widely adopted in healthcare but only recently implemented in home visiting to achieve program outcomes. The objective of this initiative was to increase the percentage of infants enrolled in home visiting who completed at least 3 recommended WCC visits in the first 6 months of life within a large, multi-model program comprised of 11 sites. A series of 33 quality improvement cycles were conducted at 3 sites involving 18 home visitors and 139 families with infants in the target age range. These were deployed sequentially, and changes within and across sites were monitored using trend charts over time. Adopted strategies were then implemented program-wide. Initiatives focused on staff training in WCC recommendations, data collection processes, monthly family tracking reports, and enhanced communication with primary care offices. Data were shared in iterative sessions to identify methods for improving adherence. Wide baseline variability across sites was observed, with the percentage of infants with recommended care ranging from 35% to 83%. Over the project timeline, the percentage of infants receiving at least 3 WCC visits in the first 6 months increased from 58% to 86%. Quality improvement within home visiting can be used to improve WCC adherence and provides an example of maximizing implementation of home visiting interventions.