Pediatrics

Bixler, G. M., G. C. Powers, R. H. Clark, M. W. Walker and V. N. Tolia (2017). “Changes in the diagnosis and management of patent ductus arteriosus from 2006 to 2015 in united states neonatal intensive care units.” J Pediatr 189: 105-112.

Full text of this article.

OBJECTIVE: To identify changes in the diagnosis, pharmacotherapy, and surgical ligation of patent ductus arteriosus (PDAs) in infants born premature and report on temporal changes in mortality and morbidity from a large volume of neonatal intensive care units (NICUs) in the US. STUDY DESIGN: We queried the Pediatrix Clinical Data Warehouse for all inborn infants without major anomalies born between 23 and 30 weeks’ gestation from 2006 to 2015 for a diagnosis of PDA, use of indomethacin or ibuprofen, history of ductal ligation, mortality, and major morbidities. RESULTS: There were 829 091 infants entered in the Clinical Data Warehouse; 61 520 infants from 280 NICUs met our inclusion criteria. The diagnosis of PDA declined from 51% to 38% (P < .001), use of indomethacin or ibuprofen decreased from 32% to 18%, and PDA ligation decreased from 8.4% to 2.9% (both P < .001). During the study period, mortality decreased with no increase in any measured morbidity. Of the 163 sites with data for both periods, 128 (79%) showed a decrease in the diagnosis of PDA, and 132 (81%) showed a decrease in the use indomethacin and/or ibuprofen when 2011-2015 was compared with 2006-2010. Of 103 sites with at least 1 PDA ligation, 85 (83%) showed a decrease in PDA ligation in a similar comparison. CONCLUSIONS: In this large population of infants <30 weeks' gestation from 280 NICUs across the US, there were significant decreases in the diagnosis and treatment of the PDA. Although there was no evidence of increased morbidities, it remains uncertain how these changes may directly affect infant outcomes.

Chiruvolu, A., H. Qin, E. T. Nguyen and R. W. Inzer (2017). “The effect of delayed cord clamping on moderate and early late-preterm infants.” Am J Perinatol: 2017 Sep [Epub ahead of print].

Full text of this article.

Objective: This study aims to evaluate the clinical consequences of protocol-driven delayed umbilical cord clamping (DCC) implementation in moderate and early latepreterm (MELP) infants born between 320/7 and 346/7 weeks gestation. Study Design: We conducted a prospective cohort study with a historic control cohort comparison. The prospective study period was 1 year when DCC was performed for 60 seconds duration (DCC cohort, n ¼ 106). The study period for historic control cohort with no DCC was also 1 year before DCC implementation (historic cohort, n ¼ 137). Results: The mean hematocrit at birth was significantly higher in the DCC cohortcompared with the historic cohort (49.1 14.9 vs. 45.7 15.7; p ¼ 0.01). Fewer infants in the DCC cohort were admitted to neonatal intensive care unit (NICU) on respiratory support compared with the historic cohort (17.9 vs. 29.9%; p ¼ 0.04). The incidence of respiratory distress syndrome was significantly lower in the DCC cohort compared with the historic cohort (2.8 vs. 14.6%; p ¼ 0.002). There were no differences in the incidence of phototherapy or NICU length of stay (LOS) between groups. Conclusion: In MELP infants, DCC was associated with increased hematocrit and better respiratory transition at birth. DCC was not associated with increased phototherapy or NICU LOS.

Chiruvolu A, Qin H, Nguyen ET, Inzer RW. The Effect of Delayed Cord Clamping
on Moderate and Early Late-Preterm Infants. Am J Perinatol. 2017 Sep 28.

Full text of this article.

Objective This study aims to evaluate the clinical consequences of protocol-driven delayed umbilical cord clamping (DCC) implementation in moderate and early latepreterm (MELP) infants born between 320/7 and 346/7 weeks gestation. Study Design We conducted a prospective cohort study with a historic control cohort
comparison. The prospective study period was 1 year when DCC was performed for 60 seconds duration (DCC cohort, n ¼ 106). The study period for historic control cohort with no DCC was also 1 year before DCC implementation (historic cohort, n ¼ 137). Results The mean hematocrit at birth was significantly higher in the DCC cohort compared with the historic cohort (49.1 ” 14.9 vs. 45.7 ” 15.7; p ¼ 0.01). Fewer infants in the DCC cohort were admitted to neonatal intensive care unit (NICU) on respiratory support compared with the historic cohort (17.9 vs. 29.9%; p ¼ 0.04). The incidence of respiratory distress syndrome was significantly lower in the DCC cohort compared with the historic cohort (2.8 vs. 14.6%; p ¼ 0.002). There were no differences in the incidence of phototherapy or NICU length of stay (LOS) between groups. Conclusion In MELP infants, DCC was associated with increased hematocrit and better respiratory transition at birth. DCC was not associated with increased phototherapy or NICU LOS.

Jackson, M. L., J. R. Chung, L. A. Jackson, C. H. Phillips, J. Benoit, A. S. Monto, E. T. Martin, E. A. Belongia, H. Q. McLean, M. Gaglani, K. Murthy, R. Zimmerman, M. P. Nowalk, A. M. Fry and B. Flannery (2017). “Influenza vaccine effectiveness in the united states during the 2015-2016 season.” N Engl J Med 377(6): 534-543.

Full text of this article.

BACKGROUND: The A(H1N1)pdm09 virus strain used in the live attenuated influenza vaccine was changed for the 2015-2016 influenza season because of its lack of effectiveness in young children in 2013-2014. The Influenza Vaccine Effectiveness Network evaluated the effect of this change as part of its estimates of influenza vaccine effectiveness in 2015-2016. METHODS: We enrolled patients 6 months of age or older who presented with acute respiratory illness at ambulatory care clinics in geographically diverse U.S. sites. Using a test-negative design, we estimated vaccine effectiveness as (1-OR)x100, in which OR is the odds ratio for testing positive for influenza virus among vaccinated versus unvaccinated participants. Separate estimates were calculated for the inactivated vaccines and the live attenuated vaccine. RESULTS: Among 6879 eligible participants, 1309 (19%) tested positive for influenza virus, predominantly for A(H1N1)pdm09 (11%) and influenza B (7%). The effectiveness of the influenza vaccine against any influenza illness was 48% (95% confidence interval [CI], 41 to 55; P<0.001). Among children 2 to 17 years of age, the inactivated influenza vaccine was 60% effective (95% CI, 47 to 70; P<0.001), and the live attenuated vaccine was not observed to be effective (vaccine effectiveness, 5%; 95% CI, -47 to 39; P=0.80). Vaccine effectiveness against A(H1N1)pdm09 among children was 63% (95% CI, 45 to 75; P<0.001) for the inactivated vaccine, as compared with -19% (95% CI, -113 to 33; P=0.55) for the live attenuated vaccine. CONCLUSIONS: Influenza vaccines reduced the risk of influenza illness in 2015-2016. However, the live attenuated vaccine was found to be ineffective among children in a year with substantial inactivated vaccine effectiveness. Because the 2016-2017 A(H1N1)pdm09 strain used in the live attenuated vaccine was unchanged from 2015-2016, the Advisory Committee on Immunization Practices made an interim recommendation not to use the live attenuated influenza vaccine for the 2016-2017 influenza season.

Wolk, C. B., S. Jager-Hyman, S. C. Marcus, B. K. Ahmedani, J. E. Zeber, J. A. Fein, G. K. Brown, A. Lieberman and R. S. Beidas (2017). “Developing implementation strategies for firearm safety promotion in paediatric primary care for suicide prevention in two large us health systems: A study protocol for a mixed-methods implementation study.” BMJ Open 7(6): 1-10.

Full text of this article.

INTRODUCTION: The promotion of safe firearm practices, or firearms means restriction, is a promising but infrequently used suicide prevention strategy in the USA. Safety Check is an evidence-based practice for improving parental firearm safety behaviour in paediatric primary care. However, providers rarely discuss firearm safety during visits, suggesting the need to better understand barriers and facilitators to promoting this approach. This study, Adolescent Suicide Prevention In Routine clinical Encounters, aims to engender a better understanding of how to implement the three firearm components of Safety Check as a suicide prevention strategy in paediatric primary care. METHODS AND ANALYSIS: The National Institute of Mental Health-funded Mental Health Research Network (MHRN), a consortium of 13 healthcare systems across the USA, affords a unique opportunity to better understand how to implement a firearm safety intervention in paediatric primary care from a system-level perspective. We will collaboratively develop implementation strategies in partnership with MHRN stakeholders. First, we will survey leadership of 82 primary care practices (ie, practices serving children, adolescents and young adults) within two MHRN systems to understand acceptability and use of the three firearm components of Safety Check (ie, screening, brief counselling around firearm safety and provision of firearm locks). Then, in collaboration with MHRN stakeholders, we will use intervention mapping and the Consolidated Framework for Implementation Research to systematically develop and evaluate a multilevel menu of implementation strategies for promoting firearm safety as a suicide prevention strategy in paediatric primary care. ETHICS AND DISSEMINATION: Study procedures have been approved by the University of Pennsylvania. Henry Ford Health System and Baylor Scott & White institutional review boards (IRBs) have ceded IRB review to the University of Pennsylvania IRB. Results will be submitted for publication in peer-reviewed journals.