Pediatrics

Suterwala, M. S., J. Reynolds, S. Carroll, C. Sturdivant and E. S. Armstrong (2017). “Using fiberoptic endoscopic evaluation of swallowing to detect laryngeal penetration and aspiration in infants in the neonatal intensive care unit.” J Perinatol: 2017 Jan [Epub ahead of print].

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OBJECTIVE: To evaluate the safety of fiberoptic endoscopic evaluation of swallowing (FEES) and the reliability of both FEES and a videofluoroscopic swallowing study (VFSS) in identifying laryngeal penetration and tracheal aspiration in infants under 3 months old in the neonatal intensive care unit (NICU). STUDY DESIGN: Twenty-five infants at least 37 weeks postmenstrual age suspected of aspirating were assessed with FEES and VFSS. Complications, autonomic instability and vital signs before endoscope insertion and following FEES were documented. Blinded video recordings were coded by two reviewers to determine reliability. RESULTS: We found no major complications or significant differences between FEES prefeeding and postfeeding vital signs, including respiratory rate, heart rate or oxygen saturation. FEES interrater reliability was 80% for both penetration and aspiration, compared with 87 and 90%, respectively, for VFSS. CONCLUSION: FEES is safe and reliable in assessing laryngeal penetration and tracheal aspiration in NICU infants.

Ahmad, K. A., S. J. Desai, M. M. Bennett, S. F. Ahmad, Y. T. Ng, R. H. Clark and V. N. Tolia (2016). “Changing antiepileptic drug use for seizures in us neonatal intensive care units from 2005 to 2014.” J Perinatol: 2016 Nov [Epub ahead of print].

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OBJECTIVE: Neonatal seizures are a common problem in the neonatal intensive care unit and are frequently treated with antiepileptic drugs. Limited data exist on current or changing antiepileptic drug use for seizures in the neonatal intensive care unit.We sought to describe trends of antiepileptic drug exposure in a large volume of US neonatal intensive care unit from 2005 to 2014 and we hypothesized increasing levetiracetam exposure over the 10-year study period. STUDY DESIGN: Retrospective cohort study of infants from the Pediatrix Medical Group Clinical Data Warehouse, a large, multicenter, deidentified data set. Data were analyzed for trends in 2-year time periods. Our cohort included infants with a diagnosis of seizures who received an antiepileptic drug that were discharged from the neonatal intensive care unit from 1 January 2005 to 31 December 2014. RESULTS: Among 778 395 infants from 341 facilities, we identified 9134 infants with a seizure diagnosis who received an antiepileptic drug. Phenobarbital was used in 98% of the cohort. From 2005-2006 to 2013-2014 phenobarbital exposure declined from 99 to 96% (P<0.001), phenytoin exposure decreased from 15 to 11% (P<0.001) and levetiracetam exposure increased 10-fold from 1.4 to 14% (P<0.001). Overall, <1% of infants were exposed to carbamazepine, lidocaine or topiramate. CONCLUSIONS: Infants with seizures were overwhelmingly exposed to phenobarbital, despite a significant increase in levetiracetam exposure. The use of phenytoin declined and has been surpassed by levetiracetam as the second most widely used antiepileptic in the neonatal intensive care unit. These changes in antiepileptic drug usage patterns have occurred in the absence of novel efficacy data in neonates.

Tolia, V. N., S. Desai, H. Qin, P. D. Rayburn, G. Poon, K. Murthy, D. L. Ellsbury and A. Chiruvolu (2016). “Implementation of an automatic stop order and initial antibiotic exposure in very low birth weight infants.” Am J Perinatol: 2016 June [Epub ahead of print].

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Objective: To evaluate if an antibiotic automatic stop order (ASO) changed early antibiotic exposure (use in the first 7 days of life) or clinical outcomes in very low birth weight (VLBW) infants. Study Design We compared birth characteristics, early antibiotic exposure, morbidity, and mortality data in VLBW infants (with birth weight <= 1500 g) born 2 years before (pre-ASO group, n = 313) to infants born in the 2 years after (post-ASO, n = 361) implementation of an ASO guideline. Early antibiotic exposure was quantified by days of therapy (DOT) and antibiotic use > 48 hours. Secondary outcomes included mortality, early mortality, early onset sepsis (EOS), and necrotizing enterocolitis. Results Birth characteristics were similar between the two groups. We observed reduced median antibiotic exposure (pre-ASO: 6.5 DOT vs. Post-ASO: 4 DOT; p < 0.001), and a lower percentage of infants with antibiotic use > 48 hours (63.4 vs. 41.3%; p < 0.001). There were no differences in mortality (12.1 vs 10.2%; p = 0.44), early mortality, or other reported morbidities. EOS accounted for less than 10% of early antibiotic use. Conclusions Early antibiotic exposure was reduced after the implementation of an ASO without changes in observed outcomes.

Langer, J. C., J. S. Gordon and L. E. Chen (2016). “Subspecialization within pediatric surgical groups in North America.” J Pediatr Surg 51(1): 143-148.

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PURPOSE: The purpose of this study was to assess the current status of subspecialization in North American pediatric surgical practices and to evaluate factors associated with subspecialization. METHODS: A survey was sent to each pediatric surgical practice in the United States and Canada. For each of 44 operation types, ranging in complexity and volume, the respondents chose one of the following responses: 1. everyone does the operation; 2. group policy – only some surgeons do the operation; 3. group policy – anyone can do it but mentorship required; 4. only some do it due to referral patterns; 5. no one in the group does it. Association of various factors with degree of subspecialization was analyzed using nonparametric statistics with p<0.05 considered significant. RESULTS: Response rate was 70%. There was significant variability in subspecialization among groups. Factors found to be significantly associated with increased subspecialization included free-standing children's hospitals, pediatric surgery training programs, higher number of surgeons, higher case volume, and greater volume of tertiary/quaternary cases. CONCLUSIONS: There is wide variation in the degree of subspecialization among North American pediatric surgery practices. These data will help to inform ongoing debate around strategies that may be useful in optimizing pediatric surgical care and patient outcomes in the future.

Chiruvolu, A., V. N. Tolia, H. Qin, G. L. Stone, D. Rich, R. J. Conant and R. W. Inzer (2015). “Effect of delayed cord clamping on very preterm infants.” American Journal of Obstetrics and Gynecology 213(5).

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OBJECTIVE: Despite significant proposed benefits, delayed umbilical cord clamping (DCC) is not practiced widely in preterm infants largely because of the question of feasibility of the procedure and uncertainty regarding the magnitude of the reported benefits, especially intraventricular hemorrhage (IVH) vs the adverse consequences of delaying the neonatal resuscitation. The objective of this study was to determine whether implementation of the protocol-driven DCC process in our institution would reduce the incidence of IVH in very preterm infants without adverse consequences. STUDY DESIGN: We implemented a quality improvement process for DCC the started in August 2013 in infants born at <= 32 weeks’ gestational age. Eligible infants were left attached to the placenta for 45 seconds after birth. Neonatal process and outcome data were collected until discharge. We compared infants who received DCC who were born between August 2013 and August 2014 with a historic cohort of infants who were born between August 2012 and August 2013, who were eligible to receive DCC, but whose cord was clamped immediately after birth, because they were born before the protocol implementation. RESULTS: DCC was performed on all the 60 eligible infants; 88 infants were identified as historic control subjects. Gestational age, birthweight, and other demographic variables were similar between both groups. There were no differences in Apgar scores or admission temperature, but significantly fewer infants in the DCC cohort were intubated in delivery room, had respiratory distress syndrome, or received red blood cell transfusions in the first week of life compared with the historic cohort. A significant reduction was noted in the incidence of IVH in the DCC cohort compared with the historic control group (18.3% vs 35.2%). After adjustment for gestational age, an association was found between the incidence of IVH and DCC with IVH was significantly lower in the DCC cohort compared with the historic cohort; an odds ratio of 0.36 (95% confidence interval, 0.15-0.84; P < .05). There were no significant differences in deaths and other major morbidities. CONCLUSION: DCC, as performed in our institution, was associated with significant reduction in IVH and early red blood cell transfusions. DCC in very preterm infants appears to be safe, feasible, and effective with no adverse consequences.