American journal of perinatology最新文献

This study aimed to compare the feeding outcomes of extremely premature infants (EPI, <28 weeks' gestational age) cared for by the same neonatology group at two tertiary neonatal intensive care units that employed two different oral feeding strategies (cue-based oral feeding progression [CB-OFP] and volume-based oral feeding progression [VB-OFP]).We conducted a retrospective cohort study of EPI (July 1, 2022, and April 12, 2024) patients discharged on full oral feedings. The primary outcome was postmenstrual age (PMA) when full oral feeding was achieved. Secondary outcomes included time to full oral feeds, PMA and weight at initiation and discharge, growth velocity, and length of hospital stay.Baseline characteristics were similar among 119 EPIs (CB-OFP: n = 61; VB-OFP: n = 58) except for maternal magnesium sulfate exposure and postnatal steroid use. CB-OFP infants achieved full oral feeding at an earlier PMA (median: 37.6 vs. 40.1 weeks; p < 0.001) and in fewer median days (20 vs. 27 days; p = 0.03). CB-OFP was also associated with earlier discharge (median PMA at discharge: 38.6 vs. 41.3 weeks; p < 0.001) and shorter length of stay (93 vs. 111.5 days; p < 0.001). Growth velocity and discharge weight z-scores did not differ significantly between groups.Our experience suggests that a CB-OFP strategy may be associated with earlier attainment of full oral feeds and a shorter length of stay compared with VB-OFP. Future randomized controlled trials are warranted to validate these findings and to assess potential long-term neurodevelopmental outcomes with different feeding strategies. · There is no consensus on the optimal oral feeding progression strategy for EPIs.. · A CB-OFP strategy was associated with earlier achievement of full oral feeding and a shorter length of stay.. · Oral motor interventions, including stimulation exercises, may play a role in improving oral feeding abilities in EPIs..

Despite higher morbidity and mortality risks, parents of preterm infants miss postpartum visits more often than parents of full-term infants. Whether the introduction of telemedicine improved access to postpartum care among parents of infants in the neonatal intensive care unit (NICU) is unknown. We aimed to compare postpartum visit attendance and care comprehensiveness for NICU parents before and after the option of telemedicine.We conducted a retrospective cohort study of postpartum parents without a history of hypertension who gave birth <32 weeks at two Philadelphia hospitals. We compared care receipt before and after implementation of telemedicine (2019 and 2023, respectively). Individuals with hypertension were excluded due to eligibility for a remote, text-based blood pressure monitoring program during the study period. Through manual chart review, we ascertained postpartum visit attendance and documentation of three core care elements: depression screening, contraception counseling, and blood pressure measurement.The proportion of parents without postpartum visits was similar in 2019 (13/69, 18.8%) and in 2023 (7/45, 15.6%; p = 0.65). While telemedicine was not available in 2019, 42.1% (16/38) of postpartum visits in 2023 were conducted via telemedicine. In 2019 and 2023, the proportion of visits with missed depression screenings (10.7 vs. 0%, p = 0.08) and contraception counseling (0 vs. 18.4%, p = 0.001) were low. Missed blood pressure measurements increased significantly from 3.9% in 2019 to 36.8% in 2023 (p < 0.0001); all missed measurements were during telemedicine visits.Despite the availability of telemedicine, approximately one in six NICU parents of preterm infants did not attend a postpartum visit. While telemedicine accounted for over one-third of visits in 2023, it was associated with gaps in essential care, specifically blood pressure measurements. Given the benefits of early detection and treatment for postpartum preeclampsia, supplementing telemedicine visits with in-person blood pressure measurements in NICUs may be warranted. · Telemedicine did not change postpartum visit attendance for parents of NICU infants.. · Missed postpartum blood pressures increased significantly after adoption of telemedicine.. · NICU-based blood pressure monitoring may mitigate care gaps introduced by telemedicine visits..

Objective: To describe patterns of outpatient natriuretic peptide (NP) testing and levels, including brain NP (BNP) and N-terminal pro-BNP (NT-proBNP), among pregnant patients with and without heart disease (HD) and the association between NP and severe maternal morbidity (SMM).

Methods: A nationwide sample of pregnant patients delivering at ≥20 weeks in the Epic Cosmos dataset from 2017-2023 was extracted. Outpatient NP levels drawn between 24-34 weeks' gestation were identified, categorized as normal or elevated (BNP ≥ 100 or NT-proBNP ≥ 300 pg/mL), and described according to the presence or absence of congenital or acquired HD based on ICD-10 codes. The primary outcomes were CDC-defined SMM and non-transfusion SMM. Among those with NP testing, the association between elevated levels and SMM was assessed using logistic regression after applying stabilized inverse probability treatment weights (SIPTW) that included demographic characteristics, HD, obesity, and other medical comorbidities.

Results: Of 3,935,745 unique pregnancies, 3,920,088 (99.6%) had no NP testing, 14,180 (0.4%) had normal NP, and 1,477 (0.04%) had elevated NP. Of those with any HD, 1.6% underwent NP testing. A greater proportion of those with normal NP (N=1,287 [9.1%]) and elevated NP (N=406 [27.5%]) experienced SMM compared to those without NP testing (N=99,176 [2.5%]; p<0.001), with similar results for non-transfusion SMM. The odds of SMM and non-transfusion SMM were higher in patients with elevated NP levels; this association persisted, but was attenuated, in SIPTW-adjusted models (SMM crude OR 14.6, 95% CI 13.0, 16.4 and aOR 1.2, 95% CI 1.1, 1.2; non-transfusion SMM crude OR 25.4, 95% CI 22.6, 28.6 and aOR 1.2, 95% CI 1.2, 1.2).

Conclusion: NP testing remains underutilized during pregnancy, even among patients with heart disease. Elevated levels are associated with higher SMM risk, although the attenuation in association after covariate adjustment suggests its additive value in predicting SMM may be limited.

Structured clinical guidelines improve outcomes in neonatal care. At Oklahoma Children's Hospital, the need for a standardized approach to extremely low birth weight (ELBW) infants became urgent due to rising acuity and care variability. Despite existing nursing protocols, the unit lacked comprehensive interdisciplinary guidelines for ELBW infants. Key goals included reducing intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP).Multidisciplinary teams developed eight clinical pathways using evidence-based models. The Appreciative Inquiry framework was used to engage staff and build consensus. The interdisciplinary workgroups conducted literature reviews, developed system-based protocols, and facilitated iterative revisions. Pathways were implemented and were supported by education, exposure, and saturation strategies. Key metrics were benchmarked using Vermont Oxford Network (VON) data, with IVH, BPD, and ROP as outcome measures and mortality as a balancing measure. Real-time data collection was used to drive further improvement. PDSA (plan, do, study, act) cycles targeted thermoregulation, line placement, early surfactant administration, and glucose and oxygen management.Post implementation data (n = 130) showed a reduction in severe IVH (from 25 to ∼20%), a 7% reduction in grade 2 and grade 3 BPD, consistently low ROP rates (<3%), and a downward mortality trend in 2023.ELBW pathways improved care standardization and outcomes without increasing mortality. Continued efforts beyond the first week of life are needed to sustain and expand improvements. · Multidisciplinary pathways improved standardization and care for ELBW infants.. · Pathways led to modest gains in BPD and IVH, guiding future quality improvement priorities.. · Education and teamwork drove adoption and sustainability without major resource needs..

Objective: To examine genetic testing strategies and their impact on redirection of care and on reducing prognostic uncertainty in the NICU Study design: Retrospective cohort study from 2020-2021 Results: 133 out of 774 (17%) NICU infants received genetic testing, most commonly whole exome sequencing. A genetic diagnosis was achieved in 33% of cases. 70% of infants who received genetic testing were not critically ill. Decisions about redirection of care were associated with presence of critical illness and not by presence of genetic diagnosis. Many rare diagnoses were made through genetic testing in the NICU, but except for certain chromosomal anomalies, these diagnoses had wide variability in reported phenotypic presentations. Conclusions Genetic testing achieves a unifying diagnosis for many NICU patients, yet many of these diagnoses have variable clinical presentations. Redirection of care in the NICU is reliant on clinical illness severity more often than achievement of a genetic diagnosis. Clinicians must provide meaningful interpretation of genetic test results to families and be prepared to confront uncertainty even after pathogenic variants are found.

Objective: To evaluate the impact of a modified surgical site infection (SSI) prevention bundle, focused on closing-phase equipment changes, on post-cesarean SSI rates.

Study design: We conducted a retrospective cohort study of cesarean deliveries performed by a single large obstetrical and maternal-fetal medicine practice from April 1, 2018 to February 28, 2025. The amended bundle, implemented in September 2021, introduced universal glove changes, light handle replacement, suction catheter tip removal, Bovie replacement, sterile re-draping, and a new surgical tray and instruments for fascial closure. Standardized prophylactic antibiotics, abdominal and vaginal preparation, and dressing protocols remained unchanged. Deliveries were categorized as pre-implementation (April 2018-August 2021) and post-implementation (October 2021-February 2025). SSI was defined as wound separation requiring packing or wound infection necessitating antibiotics within 30 days. Logistic regression models adjusted for maternal age and gestational age. Subgroup analyses stratified by labor status, primary versus repeat cesarean, and body mass index (BMI).

Results: A total of 2,467 cesarean deliveries were included, with 1,271 in the pre-implementation and 1,196 in the post-implementation group. SSI occurred in 2.6% of pre-implementation versus 3.3% of post-implementation deliveries (adjusted OR 1.27, 95% CI 0.80-2.04; p=0.313). No significant temporal trends were observed before (p=0.151) or after (p=0.221) bundle implementation. Subgroup analyses by labor status, prior cesarean, and BMI similarly showed no significant associations between the bundle and SSI risk.

Conclusion: Introducing closing-phase equipment changes on top of standardized SSI prevention practices did not reduce post-cesarean SSI rates. These findings suggest that once core measures such as antibiotics, prep, and dressings are standardized, additional equipment changes alone may not provide incremental benefit. These findings highlight the importance of rigorously evaluating process changes before widespread implementation.

Objective: Evaluate if the 2022 formula shortage had an impact on current feeding plans.

Study design: Survey was created and offered to birthing people at a single center July 2023 through January 2024. Analysis included descriptive statistics and Chi-square for categorical variables to determine if there was any statistical difference between groups.

Result: In the study sample, n=163, 55% (n=90) planned on exclusively breastfeeding, 7% (n=11) on formula feeding only, and 37% (n=61) on a combination of breastmilk and formula. While 85% (n=137) were aware of the shortage, 17% (n=27) agreed or strongly agreed that the formula shortage impacted their feeding plan. There were no differences in responses by race. Participants with older age and higher education level indicated that there were more important factors other than the formula shortage when choosing what they were planning to feed the baby.

Conclusion: In our study, while most respondents were aware of the formula shortage, 17% indicated that the 2022 formula shortage continues to impact feeding plans.

Perinatal and maternal morbidity in the setting of preterm birth may differ by delivery indication. We compared perinatal and maternal outcomes of second trimester (24 0/7 - 27 6/7 weeks' gestation) deliveries indicated for preeclampsia with severe features (PE-SF) with those following preterm premature rupture of membranes (PPROM). Secondary analysis of an observational cohort study of singleton and twin preterm deliveries before 35 weeks' gestation at 33 hospitals across the United States. Singletons without congenital anomalies who were delivered due to PE-SF or PPROM from 24 0/7 - 27 6/7 weeks gestation were included. The primary outcome was a composite of perinatal morbidity or death, defined as fetal or neonatal death, severe bronchopulmonary dysplasia grade III, intraventricular hemorrhage grade III-IV, necrotizing enterocolitis stage IIA or greater, periventricular leukomalacia, retinopathy of prematurity stage III-IV, or culture-proven sepsis. Secondary outcomes included components of the primary outcome, small-for-gestational-age (SGA) birth, and a composite of maternal morbidity. Among 7515 in the original cohort, 164 deliveries for PE-SF and 119 deliveries following PPROM were included. Individuals with PE-SF were more likely to have BMI ≥ 30 kg/m2, hypertensive disorder of pregnancy in a prior pregnancy, chronic hypertension, and cesarean birth (p <0.05) compared with those who delivered following PPROM. Composite perinatal morbidity or death did not differ between groups (aOR 1.60, 95% CI 0.89, 2.85, p=0.11), but fetal death was significantly higher in the PE-SF group (aOR 6.04, 95% CI 1.42, 25.71). Neonates delivered for PE-SF were more likely to be SGA (aOR 13.45, 95% CI 2.92, 61.94). Composite maternal morbidity did not differ between groups (aOR 1.18, 95% CI 0.62, 2.26). Second-trimester preterm birth indicated for PE-SF was associated with a higher rate of fetal death than birth for PPROM. Composite neonatal and maternal morbidity did not differ by indication.

Neonatal opioid withdrawal syndrome (NOWS) is a significant public health concern with associated prolonged neonatal hospitalizations. While the Finnegan Neonatal Abstinence Scoring Tool (FNAST) is validated for use in full-term in-utero opioid exposed infants, there is no validated tool for preterm opioid-exposed or critically ill infants with iatrogenic opioid withdrawal. We aimed to evaluate the concordance of a novel NICU Withdrawal Assessment Scale (NWAS) designed for this critically ill infant cohort with the traditional FNAST. Fifteen critically ill infants in the NICU with iatrogenic opioid withdrawal were dual assessed with the NWAS and FNAST. Correlation between the scores was determined using Spearman's correlation and linear regression. The mean gestational age of the cohort was 31.9 weeks (SD 6.0) with a range of neonatal diagnoses, and average length of opioid treatment of 35.4 days (SD 17.9). A total of 93 occurrences of simultaneous NWAS and FNAST scores were obtained. The Spearman correlation coefficient was Rho=0.77 (95% Cl: 0.67 - 0.84, p-value <.0001) indicating a strong, positive linear correlation. Linear regression indicated as positive correlation with magnitude of the scores [R = 0.77, y (FNAST score) = 0.85 + 1.49 x (NWAS score), p-value <0.0001]. Further examination of the association with management with the NWAS tool and clinical outcomes can inform future creation of evidence-based guidelines for the treatment of NOWS in premature and critically ill infants.

Neonatal late-onset sepsis is associated with increased mortality and morbidity, adversely impacting long-term outcome. The objective of this study was to examine neurodevelopmental (ND) outcomes at 18 to 24 months' corrected age (CA) in infants with late-onset bacterial sepsis (LOS) and to categorize outcomes based on type of bacterial pathogen in a cohort of preterm infants born less than 29 weeks gestation in Canada.We conducted a retrospective cohort study of all non-anomalous infants born at <29 weeks gestational age (GA) who were admitted to Canadian NICUs, from January 1, 2010, to December 31, 2017, who had an ND assessment at 18 to 24 months' CA at Canadian Neonatal Follow-Up Network clinics. The primary outcome was the composite outcome of death or ND impairment (NDI). Secondary outcomes included significant NDI, and each component of primary outcome. We compared ND outcomes among infants with Gram-positive (GP) sepsis, Gram-negative (GN) sepsis, mixed sepsis, and no sepsis using bivariate and multivariate analyses after adjusting for potential confounders.Of the 3,640 infants included, 823 (22.6%) developed LOS. Of the 823 infants, 569 (69.1%) had GP sepsis, 172 (20.9%) had GN sepsis, and 82 (10%) had mixed sepsis. Infants with LOS had significantly lower birth weight, GA, younger mothers, and significantly higher rates of major neonatal morbidities compared with the no-sepsis group. In multivariable logistic regression, infants with GN sepsis and mixed sepsis had significantly higher odds of death/NDI (GN sepsis, adjusted odds ratio [aOR] = 1.80; 95% CI: 1.27, 2.54; mixed LOS, aOR = 2.38, 95% CI: 1.41, 4.01) as compared with no sepsis.Late-onset bacterial sepsis, particularly Gram-negative and mixed sepsis, was associated with an increased risk of adverse outcomes including death or NDI at 18 to 24 months CA in infants born <29 weeks' GA in Canada. · Late-onset sepsis is an important risk factor for morbidity and mortality in preterm infants.. · The clinical presentations vary depending on the causative bacteria.. · There is limited data on neurodevelopmental outcomes based on type of bacterial pathogen..