Search

Objective Test web-based implementation for the science of enhancing resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) burnout. Design RCT using two cohorts of HCWs of four NICUs each, to improve HCW well-being (primary outcome: burnout). Cohort 1 received WISER while Cohort 2 acted as a waitlist control. Results Cohorts were similar, mostly female (83%) and nurses (62%). In Cohorts 1 and 2 respectively, 182 and 299 initiated WISER, 100 and 176 completed 1-month follow-up, and 78 and 146 completed 6-month follow-up. Relative to control, WISER decreased burnout (−5.27 (95% CI: −10.44, −0.10), p = 0.046). Combined adjusted cohort results at 1-month showed that the percentage of HCWs reporting concerning outcomes was significantly decreased for burnout (−6.3% (95%CI: −11.6%, −1.0%); p = 0.008), and secondary outcomes depression (−5.2% (95%CI: −10.8, −0.4); p = 0.022) and work-life integration (−11.8% (95%CI: −17.9, −6.1); p Conclusion WISER appears to durably improve HCW well-being. Clinical Trials Number NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133

Objectives For infants born extremely low birth weight (ELBW), we examined the 1) correlation between results on the Ages and Stages Questionnaire (ASQ), and the Bayley Scales of Infant Development II (BSID-II) at 18-22 months corrected age; 2) degree to which earlier ASQ assessments predict later BSID-II results; 3) impact of ASQ use on follow-up study return rates. Study Design ASQ data were collected at 4, 8, 12, and 18-22 months corrected age. The BSID-II was completed at 18-22 months corrected age. ASQ and BSID-II 18 – 22 month sensitivity and specificity were examined. Ability of earlier ASQs to predict later BSID-II scores was examined through linear regression analyses. Results ASQ sensitivity and specificity at 18-22 months were 73% and 65%, respectively. Moderate correlation existed between earlier ASQ and later BSID-II results. Conclusions For ELBW infant assessment, the ASQ cannot substitute for the BSID-II, but appears to improve tracking success.

Beginning in October 1995, and for several years thereafter, our institution used indomethacin as a first-line tocolytic drug. Our purpose is to compare the outcomes of very low birth weight infants who were exposed to antenatal indomethacin with those who were not exposed to this therapy. We used our center's component of the NICHD Neonatal Research Network's Generic Data Base which recorded the outcomes of all live born infants weighing less than 1500 g over a 5-year period. We abstracted data concerning neonatal morbidity (death, Grades III to IV intraventricular hemorrhage (IVH), necrotizing enterocolitis and patent ductus arteriosus), as well as other factors including gestational age, birth weight, antenatal corticosteroid treatment and maternal hypertension or pre-eclampsia. Univariate analysis was performed using Fisher's exact test. Multivariate analysis using logistic regression was performed to control for confounding factors. A total of 85 infants who were exposed to antenatal indomethacin were compared to 464 infants who were not exposed to the drug. In the univariate analysis, antenatal indomethacin exposure was not associated with a significant increase in the incidence of necrotizing enterocolitis or patent ductus arteriosus. The incidence of Grades III to IV IVH was 17.9% in those infants exposed to antenatal indomethacin compared to 7.1% in the nonexposed infants (p=0.008). The incidence of neonatal death in the exposed infants was 27.7 versus 16.4 in the nonexposed infants (p=0.02). After controlling for antenatal corticosteroids, maternal pre-eclampsia, gestational age and birth weight, antenatal indomethacin was significantly associated with an increased incidence of IVH, but not neonatal death. Antenatal indomethacin was associated with significantly higher rates of IVH. Additional studies assessing the potential risks of indomethacin tocolysis are needed before it is used as a first-line tocolytic therapy.

OBJECTIVE: The present study assessed the ability of a rapid chemiluminescent DNA probe assay to detect bacterial growth in blood culture specimens before their detection by continuous-monitoring blood culture (CMBC) systems. STUDY DESIGN: Three newborn intensive care units, which are members of the National Institute of Child Health and Human Development Neonatal Research Network, participated in this study. Each center employs an automated CMBC system against which the DNA probe was compared. A total of 1700 blood cultures were analyzed. A 3-ml aliquot of culture medium was removed from each culture during early incubation, processed, and analyzed by the DNA probe. RESULTS: Of 1700 blood cultures, 130 (7.6%) were detected positive by a CMBC system. Coagulase-negative staphylococci (CNS) were present in 90 (69%) of the positive cultures, and 26 (29%) were detected by the DNA probe. Other organisms accounted for the remaining 40 positive cultures, and 31 (78%) of these were detected by the probe assay. Seventy-six percent of all positive cultures were detected by a CMBC system within 24 hours. Ninety-eight percent of all positive cultures were detected by a CMBC system within 48 hours. Of the two organisms that grew in a CMBC system beyond 48 hours, both were CNS and one of these was considered a contaminant. Therefore, 99% of clinically significant organisms were detected by a CMBC system within 48 hours. CONCLUSION: This DNA probe is not sufficiently sensitive to be clinically useful; however, automated CMBC systems are sufficiently sensitive to aid in clinical decision-making regarding the continuance or discontinuance of antibiotic therapy following 48 hours of culture incubation.

When intensive care for newborns was introduced thirty years ago its primary goal was to improve the rates of survival of sick and premature infants. Medicine has been successful in attaining this goal; however, as more infants survive, the cost of intensive care and the additional cost of services and care for handicapped survivors continue to escalate. In order to curb the increasing cost of newborn intensive care, heightened initiatives directed at the prevention of premature births will be necessary.

234 Surgical Closure of A Patient Ductus Arteriosus (PDA) is Associated with Increased Neuro-Sensory Impairment in Extremely Low Birth Weight (ELBW) Infants: Results from The Trial of Indomethacin Prophylaxis in Preterms

Background: A multicenter randomized trial comparing the effects of dex therapy initiated at 14 or 28 days of life in VLBW (501-1500g) infants at risk for chronic lung disease (CLD) was conducted by the NICHD Neonatal Research Network. Group 1 received dex on study days 1-14 and placebo on study days 14-28. Group 2 received placebo on study days 1-14 and steroids, if needed, on study days 14-28. Group 2 infants with minimal or no ventilator dependence on study day 14 continued to receive placebo to study day 28.Purpose: To assess the relation of dex and other factors to definite or possible/clinical infection. Methods: Data on suspicion of infection, cultures performed, and antibiotic therapy were collected daily for 42 days after randomization. Infectious complications were evaluated for study days 1-14 and 1-42. Findings: 371 patients were enrolled. Group 1 (n=182) and Group 2 (n=189) had similar baseline risk factors for infection. During the first 14 days, Group 1 infants were significantly more likely than Group 2 infants to have a positive blood culture (36% vs 24%, p=0.012) and a definite infection (22% vs 14%, p=0.038). Over the 6-week study period, 42% of all infants had at least one positive blood culture (Group 1, 46% vs. Group 2, 38%, p=0.12) and 25% of infants were judged to have one or more definite infections (Group 1, 29% vs. Group 2, 21%, p=0.08). Among patients who were cultured, infants in Group 1 were significantly more likely to have a positive blood culture than were those in Group 2 (53% vs. 41%, p=0.02). Factors present at the time of randomization (including BW, GA, race, sex, prenatal steroids, C/S, sepsis hx, severity of RDS, medications given and treatment assignment) were evaluated for their association with subsequent infection. Using logistic regression models, randomization to Group 1 and antacid/H2 blocker therapy were both associated with an increased risk of definite infection for days 1-14 and antacid/H2 blocker treatment increased risk for the entire study period. Increasing birthweight and C/S delivery were both associated with a decreased risk of definite infection.Conclusion: Contrary to the findings of smaller trials, infection was more common in patients randomized to dex than placebo during the first 2 study weeks. In addition, the risk of infection over the entire 42-day study period was higher when dex was started at 2 weeks of age than when dex was started at 4 weeks of age, if needed. The decision to treat VLBW infants with or at risk for CLD with dex must be based on a balance of potential benefits and risks.

PREDICTING NOSOCOMIAL BACTEREMIA IN VERY LOW BIRTH WEIGHT (VLBW) INFANTS: UTILITY OF THE CRIB SCORE. † 998

Indomethacin in the Extremely Low Birthweight (ELBW) Infant-Reduction in Intraventricular Hemorrhage. † 949

The rapid detection of microorganisms from blood culture is important because of its impact on appropriate selection and duration of antimicrobial therapy. The present study compared the ability of a rapid DNA probe assay to detect bacterial growth in blood culture specimens to their detection by continuous-monitoring blood culture systems (CMBCS). A total of 1700 blood cultures collected from 3 intensive care nurseries were analyzed. A 3cc aliquot of blood was removed from each culture during early incubation (mean 14 hrs), processed and analyzed by the DNA probe.

Neurodevelopmental outcome following antenatal phenobarbital (PB) exposure in a multicenter randomized trial. • 1049

Increased antenatal glucocorticoid use decreases mortality and morbidity in the NICHD Neonatal Research Network's very low birth weight (VLBW) infants.• 1269

Objective: Infants of different racial groups were compared to determine if there is an effect of race on the short-term outcome of VLBW neonates. Methods: The NICHD Neonatal Research Network maintains a registry of all VLBW neonates (501-1500g) born +/or cared for at participating centers. Maternal and infant data are collected by chart review.Results: Between Jan 1 and Dec 31, 1995, 2023 infants were entered into the registry. Of these, 965 were black, 707 white, and 351 of other races. There were significant differences in the prenatal and perinatal histories of infants analyzed by race (Table). Black mothers were significantly more likely to be 24h, and less likely to have received antenatal steroids and to have been delivered by C/S. By contrast, there were relatively few differences in early diagnoses, therapies, short-term outcome or mortality(15% B, 17% W, 15% O). Among survivors and nonsurvivors, there were no differences in length of stay. Black infants were significantly less likely to receive surfactants (47% B, 58% W, 54% O) and more likely to have surgery for a PDA (23% B, 11% W, 14% O). There were no significant differences by race in other complications, including RDS, CLD, NEC, or sepsis.Conclusion: Although there were differences by race in the prenatal histories of this VLBW cohort, these did not correspond to significant differences in initial morbidity or short-term complications.

Important differences among centers in survival without CLD at 28 days in VLBW infants have been reported (Avery et al, Pediatrics 79:26-30, 1987). That study was conducted before the use of surfactant, did not include infants

We have previously reported that less than 20% of eligible VLBW infants receive antenatal steroid (ANS) treatment. The purpose of this analysis was to compare the rates of ANS therapy and characteristics of women treated with ANS in the Network before and after the Consensus Development Conference (CDC), 2/28/94. ANS treatment of mothers of VLBW infants in the 34 mos before (n = 7610) and the 16 mos after the CDC (n = 3151) were compared. Overall, ANS use increased from 20.6% (center range 1-39%) to 45.9% (27-66%); during the latest available 4-mo period, 55% of VLBW mothers were treated. During both periods patients with prenatal care, multiple gestation, hypertension/preeclampsia, diabetes, c-section, tocolytics or antibiotics were more likely (OR 1.09- 4.58) and those with antepartum hemorrhage or labor were less likely (OR 0.62- 0.76) to receive ANS. Patients with PROM and prolonged ROM were less likely before the CDC (OR 0.74 and 0.76, respectively) and more likely after the CDC(OR 1.66 and 1.87, respectively) to receive ANS. The OR for ANS plus antibiotics increased from 1.86 to 3.78 post CDC. ANS increased approximately 2-fold in all GA groups after the CDC: Table

The CRIB score (CS) is a risk-adjustment statistical model derived from minimum and maximum FiO2, maximum base deficit and congenital malformation data, as well as gestational age (GA) and birthweight (BW). In the UK CS at≤ 12 hrs of age has been proposed as a better predictor of neonatal mortality (Mort) and morbidity than BW alone.

DEXAMETHASONE THERAPY IN INFANTS AT RISK FOR CHRONIC LUNG DISEASE(CLD): A MULTI-CENTER, RANDOMIZED, DOUBLE-MASKED TRIAL • 1399

Cranial sonography (CS) is the most commonly used tool for imaging the neonatal brain. Yet, little is known about inter-rater reliability and the effect of image quality on final interpretation. As part of a multi-center study, 1524 CS on 590 infants were interpreted for presence and severity(Papile grade) of intracranial hemorrhage (ICH) by 3 pediatric radiologists experienced in cranial sonography. Discrepancies among the 3 central readers were adjudicated and final interpretation reached by consensus. The quality of a subset of sonograms (1004) was assessed as good, poor but readable, and unreadable. Final interpretation by central readers was compared to that of local readers and congruence assessed by the Kappa statistic.

IN UTERO MAGNESIUM EXPOSURE: RISK OF DEATH AND OF INTRAVENTRICULAR HEMORRHAGE (IVH) IN VERY LOW BIRTH WEIGHT (VLBW) INFANTS. • 1336

DECISION ANALYSIS OF CORTICOSTEROID TREATMENT IN PREGNANCIES 24-32 WEEKS' GESTATION WITH PRETERM PREMATURE RUPTURE OF MEMBRANES. † 1575

ITT (analysis by protocol-assigned rather than actual therapy) is the gold standard for clinical trials. Yet, ITT has been criticized as overly conservative and a potential cause of false-negative conclusions for major trials like the NNST involving highly controversial therapies and virtually unavoidable treatment protocol violations. In analyzing NNST, we compared standard ITT to an analysis designed to adjust for treatment noncompliance. NNST, a 12-center, 34-month, double-masked trial, compared early (14-28d) with late (28-42d, if needed) steroids (S) for infants ≤1500 g BW and ventilator dependent at 14d. Survivors were given an extubation score (ES) equal to the days from randomization to successful extubation. (Deaths received a score higher than that of any survivor.) By ITT, ES did not differ significantly between the early and late groups (medians 36.0 vs. 36.5; Wilcoxon p=0.18). Yet, 13% of the late group received open-label S between 14 and 28 d, a protocol violation that might bias ITT toward the null hypothesis. In the adjusted analysis, the ES of the 13% were replaced by their expected values had they remained under protocol. These values were estimated from a model based on late group infants who did not receive open-label S, using pre-randomization variables selected by bootstrap. This yielded a median ES for early and late groups of 36.0 and 36.0 d, respectively (Wilcoxon p=0.22). Using a similar approach for death or ventilator therapy at 120 d, the p was 0.87 by the adjusted analysis and 0.25 for ITT. For NNST, a trial involving great effort to maximize compliance as well as an increase in sample size in anticipation of 10% noncompliance, ITT is supported by the adjusted analyses. The value of such analyses deserves exploration in other trials.

NEONATAL MORTALITY AND MORBIDITIES IN VERY LOW BIRTH WEIGHT (VLBW) INFANTS: A SEVEN-YEAR TREND ANALYSIS OF THE NEONATAL RESEARCH NETWORK DATA. † 1392

This study was undertaken to assess the Idiopathic Respiratory Distress Syndrome (IRDS) in premature infants whose birth weights exceeded 1820 gms (4 lbs). During the past 3 years 66 (41%) of 160 infants admitted to our Newborn ICU with IRDS weighed more than 1820 gms. Thirty of the 66 were transferred from outlying hospitals. Estimated gestational ages ranged from 34-38 wks with a mean of 35.7. Birth weights ranged from 1820-3856 gms with a mean of 2358 gms. There was a predominance of males. Of the various prenatal conditions assessed, 80% of the 66 mothers were > 20 yrs of age and 67% were multigravid. Twenty percent of the mothers had complications of pregnancy including 4 diabetics, 2 narcotic addicts, and 1 toxemic. Thirty-three percent were delivered by c-section. The severity of IRDS in this group of infants was variable. Half of the infants required oxygen in concentrations > 60%. Assisted ventilation was needed in 87% of those transferred and 47% of those delivered at our hospital. Apgar scores and initial blood gases were not useful in predicting the subsequent need for ventilation assistance. Seven of the 66 infants expired. Pneumothorax and cerebral hemorrhage were encountered in 4 of the 7. It is concluded that IRDS may be severe in a surprising number of large birthweight prematures. It is unclear whether IRDS occurs more frequently at higher altitudes (5000 ft) and is more severe. It is recommended that these infants be evaluated and followed as closely as their smaller-weight counterparts.

A prospective study using Computed Tomography (CT) was initiated to determine the incidence of sub-ependymal (SEH) and intraventricular hemorrhage (IVH) in infants ≤ 1500 grams. All 38 infants ≤ 1500 grams who were admitted to the Newborn Intensive Care Unit during a five month period have been evaluated. The initial CT waa performed between the third and seventh postnatal day. If a CVH was noted, follow-up CT was done at one and three weeks after the initial CT. Nine of the 23 infants who survived had SEH and/or IVII present on the initial CT. Only one of these nine infants was suspected of having a CVU on clinical findings. Of these nine, five who had a small SEH and/or IVH with nornal ventricular size, had complete resolution of the hemorrhage at three weeks. The other four infants who demonstrated some degree of ventricular dilatation with the hemorrhage on the initial CT, required medical intervention to prevent the development of clinical hydrocephalus. This study documents, for the first time, the relatively high incidence of CVH in infants ≤ 1500 grams and indicates that there are at least two types of CVH: 1) CVH with no ventricular dilatation which resolves spontaneously and 2) CVH with ventricular dilatation which requires medical intervention to prevent the development of clinical hydrocephalus.

Serial lumbar puncture (LP) as a method of treating hydrocephalus was evaluated in ten infants of birthweights ≤ 1500 grams, who had a cerebral intraventricular hemorrhage(CVH) and ventricular dilatation identified by computed tomography (CT).Each of the infants had an initial CT scan within the first ten days of life. Follow-up CT scans were done at weekly intervals. If progressive ventricular dilatation was observed, daily LP was attempted. Ventricular size remained stable or decreased throughout the tapping period and remained so after the cessation of tapping in eight of the ten infants. Follow-up CT scans at six months of age on eight of the ten infants showed no increase in ventricular size and an increase in the thickness of the cerebral mantle. The two infants from whom cerebrospinal fluid could not be obtained had progressive ventricular dilatation and required the placement of a ventriculo-peritoneal shunt. This approach to early intervention of progressive ventricular dilatation secondary to CVH by means of serial LP may arrest the development of hydrocephalus and eliminate the need for a shunt.

To assess the impact of supraventricular tachycardia (SVT) on cardiac output in the neoante, we measured noninvasively ascending aortic blood flow (QAo) pre and post cardioversion (cv) in 4 neonates with paroxysmal atrial tachycardia (PAT) or atrial flutter (AF). Ascending aortic blood flow velocity (VAo) was determined using a portable, 5MHz, pulsed Doppler velocimeter and suprasternal transducer. Aortic cross sectional area (AAo) was calculated from echographic measurements of the internal diameter of the ascending aorta. Left ventricular output was computed as QAo(ml/min)=VAo (cm/sec)×AAo (cm2)×60sec/min. The infants ranged in age from 1 to 14 days, mean 5 days, and ranged in weight from 2.9 to 3.7kg, mean 3.5kg. 2 patients had PAT and 2 had AF with 2:1 block. Conversion required DC countershock in 2 patients, digoxin in 1, and facial ice application in 1. This study demonstrates that SVT impairs significantly cardiac output and stroke volume in the neonate and emphasizes the impact of successful cardioversion in returning systemic blood flow to normal levels.