Pediatrics

McLaughlin, C. M., M. Bennett, N. Channabasappa, J. Journeycake and H. G. Piper (2018). “Anticoagulation results in increased line salvage for children with intestinal failure and central venous thrombosis.” J Pediatr Surg. Feb 7. [Epub ahead of print].

Full text of this article.

PURPOSE: The purpose of this study was to investigate whether anticoagulation (AC) results in thrombus resolution and increased line longevity in children with intestinal failure (IF) and catheter-associated central venous thrombosis (CVT). METHODS: A retrospective, single institution review was performed of children with IF who were dependent on parenteral nutrition with known CVT between 2006 and 2017. Frequency of catheter-related complications including infection, occlusion, and breakage were compared 18months prior to and after starting AC. Thrombus resolution during anticoagulation was also determined. Data were analyzed using Poisson regression. p-Values <0.05 were considered significant. RESULTS: Eighteen children had >/=1 CVT, with the subclavian vein most commonly thrombosed (44%). All children were treated with low molecular weight heparin, and 6 patients (33%) had clot resolution on re-imaging while receiving AC. Bloodstream infections decreased from 7.9 to 4.4 per 1000 catheter days during AC (p=0.01), and the number of infections requiring catheter replacement decreased from 3.0 to 1.0 per 1000 catheter days (p=0.01). There were no significant differences in line occlusions or breakages. CONCLUSION: Anticoagulation for children with intestinal failure and central venous thrombosis may prevent thrombus propagation, and decrease blood stream infections and line replacements. Further research is needed to determine optimal dosing and duration of therapy. LEVEL OF EVIDENCE: III; Retrospective Comparative Study.

Ahmad, K. A., M. M. Bennett, S. F. Ahmad, R. H. Clark and V. N. Tolia (2018). “Morbidity and mortality with early pulmonary haemorrhage in preterm neonates.” Arch Dis Child Fetal Neonatal Ed. Jan 27 [Epub ahead of print].

Find full text here.

OBJECTIVE: There are no large studies evaluating pulmonary haemorrhage (PH) in premature infants. We sought to quantify the clinical characteristics, morbidities and mortality associated with early PH. DESIGN: Data were abstracted from the Pediatrix Clinical Data Warehouse, a large de-identified data set. For incidence calculations, we included infants from 340 Pediatrix United States Neonatal Intensive Care Units from 2005 to 2014 without congenital anomalies. Infants <28 weeks' gestation with PH within 7 days of birth were then matched with two controls for birth weight, gestational age, gender, antenatal steroid exposure, day of life 0 or 1 intubation and multiple gestation. RESULTS: From 596 411 total infants, we identified 2799 with a diagnosis of PH. Peak incidence was 86.9 cases per 1000 admissions for neonates born at 24 weeks' gestation. We then identified 1476 infants <28 weeks' gestation with an early PH diagnosis at

Jackson, M. L., C. H. Phillips, J. Benoit, L. A. Jackson, M. Gaglani, K. Murthy, H. Q. McLean, E. A. Belongia, R. Malosh, R. Zimmerman and B. Flannery (2017). “Burden of medically attended influenza infection and cases averted by vaccination – United States, 2013/14 through 2015/16 influenza seasons.” Vaccine.

Full text of this article.

BACKGROUND: In addition to preventing hospitalizations and deaths due to influenza, influenza vaccination programs can reduce the burden of outpatient visits for influenza. We estimated the incidence of medically-attended influenza at three geographically diverse sites in the United States, and the cases averted by vaccination, for the 2013/14 through 2015/16 influenza seasons. METHODS: We defined surveillance populations at three sites from the United States Influenza Vaccine Effectiveness Network. Among these populations, we identified outpatient visits laboratory-confirmed influenza via active surveillance, and identified all outpatient visits for acute respiratory illness from healthcare databases. We extrapolated the total number of outpatient visits for influenza from the proportion of surveillance visits with a positive influenza test. We combined estimates of incidence, vaccine coverage, and vaccine effectiveness to estimate outpatient visits averted by vaccination. RESULTS: Across the three sites and seasons, incidence of medically attended influenza ranged from 14 to 54 per 1000 population. Incidence was highest in children aged 6months to 9years (33 to 70 per 1000) and lowest in adults aged 18-49years (21 to 27 per 1000). Cases averted ranged from 9 per 1000 vaccinees (Washington, 2014/15) to 28 per 1000 (Wisconsin, 2013/14). DISCUSSION: Seasonal influenza epidemics cause a considerable burden of outpatient medical visits. The United States influenza vaccination program has caused meaningful reductions in outpatient visits for influenza, even in years when the vaccine is not well-matched to the dominant circulating influenza strain.

Tolia, V. N., K. Murthy, M. M. Bennett, E. S. Miller, D. K. Benjamin, P. B. Smith and R. H. Clark (2017). “Antenatal methadone vs buprenorphine exposure and length of hospital stay in infants admitted to the intensive care unit with neonatal abstinence syndrome.” J Perinatol: 2017 Oct [Epub ahead of print].

Full text of this article.

OBJECTIVE: Antenatal exposure to methadone or buprenorphine often causes neonatal abstinence syndrome (NAS) in newborns. However, comparative effects on affected infants’ hospital courses are inconclusive. We sought to estimate the relationship of antenatal exposure with methadone or buprenorphine and infants’ length of stay among hospitalized infants with NAS. STUDY DESIGN: This was a retrospective cohort study of hospitalized infants with NAS with either maternal exposure. Eligible infants were singleton infants born 36 weeks’ gestation and diagnosed with NAS<7 days of age between 2011 and 2014 in the Pediatrix Clinical Data Warehouse. Infant with congenital anomalies and those of multiple gestation were excluded. RESULTS: Of 3364 eligible infants, 2202 (65%) were exposed to methadone and 1162 (34%) to buprenorphine. Infants exposed to buprenorphine had a lower rate of pharmacologic treatment for NAS (88 vs 91%, P<0.001). Median length of hospital stay was shorter among infants exposed to buprenorphine (21 days (inter-quartile range; 13-31) vs methadone (24 days (15-38), P<0.0001)). On multivariable Cox proportional hazard analyses, buprenorphine was associated with a shorter length of stay (hazard ratio (HR)=1.47 (95% confidence interval (CI): 1.32-1.62, P<0.001) after controlling for maternal age, parity, race or ethnicity, prenatal care, smoking status, use of antidepressants, use of benzodiazepines, and infant gestational age, small for gestational age status, cesarean delivery, sex, out born status, type of pharmacotherapy, breast milk use, year and center. We observed similar results in model using infants matched 1:1 with propensity scores for antenatal medication exposure (HR 1.39 for buprenorphine, CI 1.32-1.62, P<0.001). CONCLUSION: Among infants born 36 weeks' gestation with NAS, antenatal buprenorphine exposure was associated with a decreased length of stay relative to antenatal methadone exposure.

Stewart, R. J., B. Flannery, J. R. Chung, M. Gaglani, M. Reis, R. K. Zimmerman, M. P. Nowalk, L. Jackson, M. Jackson, A. S. Monto, E. T. Martin, E. A. Belongia, H. McLean, A. M. Fry and F. Havers (2017). “Influenza antiviral prescribing for outpatients with an acute respiratory illness and at high risk for influenza-associated complications during five influenza seasons-united states, 2011-2016.” Clin Infect Dis: 1-20.

Full text of this article.

Background: Influenza causes millions of illnesses annually; certain groups are at higher risk for influenza-associated complications. Early antiviral treatment can reduce the risk of complications and is recommended for outpatients at increased risk. We describe antiviral prescribing among high-risk outpatients for 5 influenza seasons and explore factors that may influence prescribing. Methods: We analyzed antiviral prescription and clinical data for high-risk outpatients aged >/= 6 months with an acute respiratory illness (ARI) and enrolled in the US Influenza Vaccine Effectiveness Network during the 2011-2012 to 2015-2016 influenza seasons. We obtained clinical information from interviews and electronic medical records and tested all enrollees for influenza with rRT-PCR. We calculated the number of patients with ARI that must be treated to treat 1 patient with laboratory-confirmed influenza. Results: Among high-risk outpatients with ARI who presented to care within two days of symptom onset (early), 15% (718/4861) were prescribed an antiviral medication, including 472/1292 (37%) of those with rRT-PCR-confirmed influenza. Less than half (40%) of high-risk outpatients with influenza presented to care early. Earlier presentation to care was associated with antiviral treatment (OR: 4.1, CI: 3.5-4.8), as was fever (OR: 3.2, CI: 2.7-3.8), although 25% of high-risk outpatients with influenza were afebrile. Empiric treatment of 4 high-risk outpatients with ARI was needed to treat 1 patient with laboratory-confirmed influenza. Conclusion: Influenza antiviral medications were infrequently prescribed for high-risk outpatients with ARI who would benefit most from treatment. Efforts to increase appropriate antiviral prescribing are needed to reduce influenza-associated complications.