OBJECTIVE: To measure within-subject changes in ventilation/perfusion (V'/Q') mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.
DESIGN: Single-arm, non-randomised, feasibility trial.
SETTING: Three centres in the Children's Hospital of Philadelphia neonatal care network.
PATIENTS: Twelve preterm infants of postmenstrual age 27-35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO) >0.25 on CPAP of 4-7 cm HO.
INTERVENTIONS: We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V'/Q' mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V'/Q' improved by more than 5%.
MAIN OUTCOME MEASURES: Within-subject change in V'/Q' mismatch between baseline and best CPAP levels.
RESULTS: There was a median (IQR) within-subject reduction in V'/Q' mismatch of 1.2 (0-3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5-8) cm HO.
CONCLUSIONS: Non-invasive measures of V'/Q' mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.
TRIAL REGISTRATION NUMBER: NCT02983825.
OBJECTIVE: Describe 1-month outcomes among newborns of persons with perinatal COVID-19.
STUDY DESIGN: Prospective observational study of pregnant persons who tested positive for SARS-CoV-2 between 14 days before and 3 days after delivery and their newborns, from 3/2020 to 3/2021 at two urban high-risk academic hospitals. Phone interviews were conducted to determine 1-month newborn outcomes.
RESULTS: Among 9748 pregnant persons, 209 (2.1%) tested positive for perinatal SARS-CoV-2. Symptomatically infected persons were more likely to have a preterm delivery due to worsening maternal condition and their newborns were more likely to test positive for SARS-CoV-2 compared with asymptomatic persons. Six of 191 (3.1%) infants tested were positive for SARS-CoV-2; none had attributable illness before discharge. Of 169 eligible families, 132 (78.1%) participated in post-discharge interviews; none reported their newborn tested positive for SARS-CoV-2 by 1 month of age.
CONCLUSION: Symptomatic perinatal COVID-19 had a substantial effect on maternal health but no apparent short-term effect on newborns.
BACKGROUND: Although delivery room (DR) intervention decreases with increasing gestational age (GA), little is known about DR management of moderate and late preterm (MLP) infants.
METHODS: Using the Vermont Oxford Network database of all NICU admissions, we examined the receipt of DR interventions including supplemental oxygen, positive pressure ventilation, continuous positive airway pressure, endotracheal tube ventilation, chest compressions, epinephrine, and surfactant among MLP infants (30 to 36 weeks') without congenital anomalies born from 2011 to 2020. Pneumothorax was examined as a potential resuscitation-associated complication. Intervention frequency was assessed at the infant- and hospital-level, stratified by GA and over time.
RESULTS: Overall, 55.3% of 616 110 infants (median GA: 34 weeks) from 483 Vermont Oxford Network centers received any DR intervention. Any DR intervention frequency decreased from 89.7% at 30 weeks to 44.2% at 36 weeks. From 2011 to 2020, there was an increase in the provision of continuous positive airway pressure (17.9% to 47.8%, P ≤.001) and positive pressure ventilation (22.9% to 24.9%, P ≤.001) and a decrease in endotracheal tube ventilation (6.9% to 4.0% P ≤.001), surfactant administration (3.5% to 1.3%, P ≤.001), and pneumothorax (1.9% to 1.6%, P ≤.001). Hospital rates of any DR intervention varied (median 54%, interquartile range 47% to 62%), though the frequency was similar across hospitals with different NICU capabilities after adjustment.
CONCLUSIONS: The DR management of MLP infants varies at the individual- and hospital-level and is changing over time. These findings illustrate the differing interpretation of resuscitation guidelines and emphasize the need to study MLP infants to improve evidence-based DR care.
OBJECTIVE: To measure within-subject changes in ventilation/perfusion (V'/Q') mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.
DESIGN: Single-arm, non-randomised, feasibility trial.
SETTING: Three centres in the Children's Hospital of Philadelphia neonatal care network.
PATIENTS: Twelve preterm infants of postmenstrual age 27-35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO) >0.25 on CPAP of 4-7 cm HO.
INTERVENTIONS: We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V'/Q' mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V'/Q' improved by more than 5%.
MAIN OUTCOME MEASURES: Within-subject change in V'/Q' mismatch between baseline and best CPAP levels.
RESULTS: There was a median (IQR) within-subject reduction in V'/Q' mismatch of 1.2 (0-3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5-8) cm HO.
CONCLUSIONS: Non-invasive measures of V'/Q' mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.
TRIAL REGISTRATION NUMBER: NCT02983825.
<p><strong>Importance: </strong>Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.</p>
<p><strong>Objective: </strong>To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.</p>
<p><strong>Design, Setting, and Participants: </strong>This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021.</p>
<p><strong>Exposure: </strong>Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births.</p>
<p><strong>Main Outcomes and Measures: </strong>Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area.</p>
<p><strong>Results: </strong>The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas.</p>
<p><strong>Conclusions and Relevance: </strong>In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.</p>
<p><strong>AIM: </strong>Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).</p>
<p><strong>METHODS: </strong>Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.</p>
<p><strong>RESULTS: </strong>Among 3,521 infants who received CPR, 2,080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 hours. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).</p>
<p><strong>CONCLUSION: </strong>Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.</p>
<p>Smartphone-integrated consumer baby monitors that measure vital signs are popular among parents but are not regulated by the US Food and Drug Administration (FDA). This study measured the accuracy of pulse oximetry-based consumer baby monitors using an FDA-cleared oximeter as a reference.</p>