Pediatrics

Tolia, V. N., T. M. Bahr, M. M. Bennett, G. Martin, R. G. Greenberg, M. M. Laughon and R. H. Clark (2019). “The Association of Hydrocortisone Dosage on Mortality in Infants Born Extremely Premature.” J Pediatr 207: 143-147.

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OBJECTIVE: To characterize common dosing strategies and to investigate the association between hydrocortisone dosage and in-hospital mortality in infants born extremely premature. STUDY DESIGN: We performed a retrospective review of a cohort of infants born less-than-or-equal-to 30 weeks’ gestational age from 2010 to 2016 from the Pediatrix Clinical Data Warehouse who received hydrocortisone in the first 14 postnatal days. Infants were divided by initial hydrocortisone dosage (high: >2 mg/kg/d vs low: less-than-or-equal-to 2 mg/kg/d). Baseline characteristics and medication coexposures were compared and mortality was evaluated in a multivariable analysis. RESULTS: A total of 1427 infants were included, 733 with high dosage (51%) and 694 with low dosage (49%). The groups were similar with regard to baseline characteristics. Infants in the high-dosage group had significantly more exposure to any vasopressors (89% vs 84%, P < .001) and greater mortality (50% vs 23%, P < .001) vs the low-dosage group. High dosage of hydrocortisone was associated independently with death (aOR 3.27, 95% CI 2.47-4.34, P < .001) in a multivariable regression analysis including propensity scoring for dosage and other covariates. When the cohort was split into quartiles by dosage, mortality was lower in the lower-dosage quartiles compared with the higher quartiles (mortality range 13%-50%). CONCLUSIONS: In this retrospective analysis of a large sample of infants born premature, increased initial hydrocortisone dosage was associated independently with increased mortality. Trials to assess the impact of hydrocortisone dosage in this population are needed.

Misra, S. M., C. Garcia, P. Swamy, S. Kumar, J. Chavez, Jr. and A. Gupta (2019). “Reaching Uninsured Overweight and Obese Children Through the FitKids Mobile Lifestyle Modification Program: Lessons Learned.” J Community Health 44(2): 208-214.

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The US prevalence of childhood obesity remains high with ~ 1 in five children diagnosed with obesity, and rates of obesity are likely higher in uninsured and Medicaid populations than in those with private insurance. To understand the impact of an obesity intervention, an established mobile clinic program conducted a study to determine whether a FitKids Mobile Lifestyle Modification Program could reach overweight and obese uninsured children. Eighty-six children (ages 8-18 years) participated in the FitKids study over two trial periods. The first trial consisted of four total visits, but subsequent visits after the initial visit had poor turnout. Through telephonic interviews, parents described positive aspects of the program: (1) providers’ individual attention to their child, (2) increased knowledge about obesity, nutrition, and diet, (3) and parent and child were motivated to be more active. The most common barriers noted for return visits were (1) personal/family factors, (2) scheduling issues, and (3) distance to the clinic. As quality improvement, for the second trial, total number of visits was reduced from 4 to 3 visits and reminder calls were instituted. Percentage of children who returned for the third visit (67.5% for Trial 1 and 62.5% for Trial 2) was not improved despite quality improvement interventions. Mobile clinics provide a unique solution to reach underserved overweight and obese children to help them create a more active and healthy lifestyle, but more research is needed to understand how best to optimize programs.

Chiruvolu, A. (2019). “Author’s Response: Meconium-stained newborns and respiratory support.” Pediatrics 143(3): e2-e3.

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Our practice has a resuscitation team, including a neonatal provider proficient in intubation, to attend deliveries associated with MSAF. The determination of a newborn being vigorous or nonvigorous was made soon after birth by the resuscitation team during both retrospective and prospective time periods. During the prospective time period, when the newborn appeared nonvigorous, the newborn was handed over by the obstetric provider to the neonatal provider, and routine initial steps of resuscitation were performed on the warmer. The label of nonvigorous was given before initial stimulation was performed. We do not believe that the prospective nonvigorous cohort in our study was sicker than the retrospective cohort given the fact that only 55% needed positive pressure ventilation. The rest of them responded to routine initial steps of resuscitation, such as drying and stimulation. The 1- and 5-minute Apgar scores and the proportion of newborns with a 1-minute Apgar score of <3 and/or a 5-minute Apgar score of <7 were similar between both retrospective and prospective groups. We agree that other practices may be different from ours; hence, the incidence of MAS needs to be monitored with different denominators, such as all the term newborns or all the term newborns born through MSAF. However, because the major revision was in the management of newborns who were nonvigorous, it was important to report the change with the denominator being all the newborns who were nonvigorous and meconium stained. There was a risk of diluting the effect of the change with the denominator being all newborns born through MSAF because we know the majority of newborns who are meconium stained are vigorous (∼90%); however, newborns who are nonvigorous are at a higher risk for respiratory issues, including MAS. As for now, we respectfully follow NRP suggestions while we await more published evidence. In addition, we will continue to monitor our practice over a longer period of time, and we plan to present the respiratory data after adjustment of risk factors on all term newborns born through MSAF. (Full text of this correspondence.)

Tolia, V. N., T. M. Bahr, M. M. Bennett, G. Martin, R. G. Greenberg, M. M. Laughon and R. H. Clark (2018). “The Association of Hydrocortisone Dosage on Mortality in Infants Born Extremely Premature.” J Pediatr Dec 21. [Epub ahead of print].

Full text of this article.

OBJECTIVE: To characterize common dosing strategies and to investigate the association between hydrocortisone dosage and in-hospital mortality in infants born extremely premature. STUDY DESIGN: We performed a retrospective review of a cohort of infants born less-than-or-equal-to 30 weeks’ gestational age from 2010 to 2016 from the Pediatrix Clinical Data Warehouse who received hydrocortisone in the first 14 postnatal days. Infants were divided by initial hydrocortisone dosage (high: >2 mg/kg/d vs low: less-than-or-equal-to 2 mg/kg/d). Baseline characteristics and medication coexposures were compared and mortality was evaluated in a multivariable analysis. RESULTS: A total of 1427 infants were included, 733 with high dosage (51%) and 694 with low dosage (49%). The groups were similar with regard to baseline characteristics. Infants in the high-dosage group had significantly more exposure to any vasopressors (89% vs 84%, P < .001) and greater mortality (50% vs 23%, P < .001) vs the low-dosage group. High dosage of hydrocortisone was associated independently with death (aOR 3.27, 95% CI 2.47-4.34, P < .001) in a multivariable regression analysis including propensity scoring for dosage and other covariates. When the cohort was split into quartiles by dosage, mortality was lower in the lower-dosage quartiles compared with the higher quartiles (mortality range 13%-50%). CONCLUSIONS: In this retrospective analysis of a large sample of infants born premature, increased initial hydrocortisone dosage was associated independently with increased mortality. Trials to assess the impact of hydrocortisone dosage in this population are needed.

Tolia, V. N., K. Murthy, M. M. Bennett, R. G. Greenberg, D. K. Benjamin, P. B. Smith and R. H. Clark (2018). “Morphine vs Methadone Treatment for Infants with Neonatal Abstinence Syndrome.” J Pediatr 203: 185-189.

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OBJECTIVE: To estimate the relationship of initial pharmacotherapy with methadone or morphine and length of stay (LOS) in infants with neonatal abstinence syndrome (NAS) admitted to the neonatal intensive care unit (NICU). STUDY DESIGN: From the Pediatrix Clinical Data Warehouse database, we identified all infants born at >/=36 weeks of gestation between 2011 and 2015 who were diagnosed with NAS (International Classification of Diseases, Ninth Revision code 779.5) and treated with methadone or morphine in the first 7 days of life. We used multivariable Cox proportional hazards regression analysis to quantify the association between initial treatment and LOS after adjusting for maternal age, maternal race/ethnicity, maternal drug use, maternal smoking, gestational age, small for gestational age status, inborn status, and discharge year. RESULTS: We identified a total of 7667 eligible infants, including 1187 treated with methadone (15%) and 6480 treated with morphine (85%). Birth weight, gestational age, and sex were similar in the 2 groups. Methadone treatment was associated with a 22% shorter median LOS (18 days [IQR, 11-30 days] vs 23 days [IQR, 16-33]; P < .001) and a 19% shorter median NICU stay (17 days [IQR, 10-29 days] vs 21 days [IQR, 14-36 days]; P < .001). After adjustment, methadone was associated with a shorter LOS (hazard ratio for discharge, 1.24; 95% CI, 1.11-1.37; P < .001) CONCLUSION: Among infants born at >/=36 weeks of gestation with NAS, initial methadone treatment was associated with a shorter LOS compared with morphine treatment. Future prospective comparative effectiveness trials to treat infants with NAS are needed to verify this observation.