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Background: We sought to investigate the risk of pediatric surgical mortality associated with the combined effects of key preoperative comorbidities and race., Methods: We performed a retrospective study that included infants who underwent inpatient surgical procedures between 2012 and 2017 and were entered into the NSQIP-P registry. We assessed additive moderation by estimating the proportion of mortality risk attributable to the combined effects of race and the presence of a preoperative comorbidity (attributable proportion [AP])., Results: The study group was comprised of 58466 surgical cases, of whom 15711(26.9%) were neonates and 42755(73.1%) older infants. Among neonates, a history of prematurity carried a poorer prognosis in black babies than their white peers (OR:1.53, 95%CI:1.20,1.95). Additionally, there was evidence of additive moderation by race on the association between prematurity and postoperative mortality (AP: 23.9%; 95%CI: 3.8,43.9, P value = 0.020). In older infants, presence of preoperative sepsis carried almost two times higher risk of mortality for black patients than their white counterparts (OR:1.81; 95%CI:1.21,2.73). This explained 38.4% of mortality cases in black patients with preoperative sepsis (95%CI:14.0,62.7; P = 0.002). A history of prematurity also carried a greater risk of mortality in older infants of black race (OR:1.69; 95%CI: 1.27, 2.24), accounting for 24.2% of mortality cases (AP:24.2%; 95%CI:0.90, 47.5, P = 0.041)., Conclusions: We quantified the surgical burden of mortality resulting from the differential impact of key comorbidities on black neonates and infants. Our data suggest that race-specific interventions to mitigate the incidence of the identified comorbidities could narrow the racial disparities in post surgical mortality., (Copyright © 2021. Published by Elsevier Inc.)

Background: The American College of Surgeons in 2015 instituted the Children's Surgery Verification program delineating requirements for hospitals providing pediatric surgical care. Our purpose was to examine possible effects of the Children's Surgery Verification program by evaluating neonates undergoing high-risk operations., Study Design: Using the Kid's Inpatient Database 2009, we identified infants undergoing operations for 5 high-risk neonatal conditions. We considered all children's hospitals and children's units Level I centers and considered all others Level II/III. We estimated the number of neonates requiring relocation and the additional distance traveled. We used propensity score adjusted logistic regression to model mortality at Level I vs Level II/III hospitals., Results: Overall, 7,938 neonates were identified across 21 states at 91 Level I and 459 Level II/III hospitals. Based on our classifications, 2,744 (34.6%) patients would need to relocate to Level I centers. The median additional distance traveled was 6.6 miles. The maximum distance traveled varied by state, from <55 miles (New Jersey and Rhode Island) to >200 miles (Montana, Oregon, Colorado, and California). The adjusted odds of mortality at Level II/III vs Level I centers was 1.67 (95% CI 1.44 to 1.93). We estimate 1 life would be saved for every 32 neonates moved., Conclusions: Although this conservative estimate demonstrates that more than one-third of complex surgical neonates in 2009 would have needed to relocate under the Children's Surgery Verification program, the additional distance traveled is relatively short for most but not all, and this program might improve mortality. Local level ramifications of this novel national program require additional investigation., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Complications related to epicardial pacemakers in infants have been reported, though limited data are available on their incidence and associated risk factors., Objective: The hypothesis of the study is that younger, smaller patients and larger devices would be associated with complications in neonates and infants., Methods: This is a retrospective study of all patients at a single center receiving an epicardial pacemaker at ≤12 months of age (1996-2015). Patient and device characteristics were obtained. Characteristics of patients with and without complications were compared., Results: There were 86 patients with a median age of 73 days (interquartile range 13-166 days), of whom 12 (14%) had a complication. Eight (9%) needed surgical intervention, of whom 5 (6%) required explantation. Younger age (9 days vs 89 days; P = .01) and lower weight (2.91 kg vs 4.44 kg; P = .004) at implantation were associated with complications. Device characteristics were not statistically different. Patients ≤3 kg in weight and/or <5 days of age had an odds ratio of 18.1 (3.6-91.2; P < .001) for developing a complication with a negative predictive value (NPV) of 97%. Regardless of weight, patients aged >21 days were found to be at lower risk with an NPV of 96%; and regardless of age, patients weighing >4 kg had an NPV of 98%., Conclusion: Young age and low weight at the time of implantation are risk factors for complications, while device characteristics appear to play a minor role. Reserving pacemaker implantation for patients >3 kg in weight and 5 days of age may predict patients at low risk of developing complications., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Importance: Reduced death and neurodevelopmental impairment among infants is a goal of perinatal medicine., Objective: To assess the association between surgery during the initial hospitalization and death or neurodevelopmental impairment of very low-birth-weight infants., Design, Setting, and Participants: A retrospective cohort analysis was conducted of patients enrolled in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database from 1998 through 2009 and evaluated at 18 to 22 months' corrected age. Twenty-two academic neonatal intensive care units participated. Inclusion criteria were birth weight 401 to 1500 g, survival to 12 hours, and availability for follow-up. A total of 12 111 infants were included in analyses., Exposures: Surgical procedures; surgery also was classified by expected anesthesia type as major (general anesthesia) or minor (nongeneral anesthesia)., Main Outcomes and Measures: Multivariable logistic regression analyses planned a priori were performed for the primary outcome of death or neurodevelopmental impairment and for the secondary outcome of neurodevelopmental impairment among survivors. Multivariable linear regression analyses were performed as planned for the adjusted mean scores of the Mental Developmental Index and Psychomotor Developmental Index of the Bayley Scales of Infant Development, Second Edition, for patients born before 2006., Results: A total of 2186 infants underwent major surgery, 784 had minor surgery, and 9141 infants did not undergo surgery. The risk-adjusted odds ratio of death or neurodevelopmental impairment for all surgery patients compared with those who had no surgery was 1.29 (95% CI, 1.08-1.55). For patients who had major surgery compared with those who had no surgery, the risk-adjusted odds ratio of death or neurodevelopmental impairment was 1.52 (95% CI, 1.24-1.87). Patients classified as having minor surgery had no increased adjusted risk. Among survivors who had major surgery compared with those who had no surgery, the adjusted risk of neurodevelopmental impairment was greater and the adjusted mean Bayley scores were lower., Conclusions and Relevance: Major surgery in very low-birth-weight infants is independently associated with a greater than 50% increased risk of death or neurodevelopmental impairment and of neurodevelopmental impairment at 18 to 22 months' corrected age. The role of general anesthesia is implicated but remains unproven.

The aim of the study was elaboration of optimal perioperative antibiotic therapy in neonates according to CDC criteria (Center for Disease Control and Prevention). Classification in 4 groups of infections was carried out in relation to contamination of the surgical wound: clean, clean-contamination, contaminated and dirty. Based on the authors' own experience, CDC criteria were adapted to the contamination of surgical wounds in neonatal surgery. Antibiotic therapy for each of the four groups was also proposed except for the newborns with birth weight below 1500 g. For the neonates with extreme low birth weight (<1500 g) individual treatment based on other risk factors of infection, abnormal bacterial colonization and antibiotics received up to now have to be taken into consideration. Criteria for local and general infection were also defined. We consider that our report concerning rules of antibiotic therapy in neonates requiring surgical treatment will contribute to rational antibiotic administration in this group of patients. Verification of this report should be performed, based on a multicentre study.

Groups of neonates who are usually treated at hospitals that provide specialized pediatric care are not adequately classified by the use of diagnosis-related groups (DRGs). Therefore, a set of revised DRGs, pediatric modified DRGs (PM-DRGs), have been developed. Use of PM-DRGs substantially improves the classification of neonates in the following ways: a single pediatric modified major diagnostic category has been defined to include only and all neonates (patients younger than 29 days of age when admitted to the hospital); deaths and transfers of newborns are no longer combined into a single group; birth weight (rather than diagnosis) is used as the primary variable to differentiate categories of neonates; and duration of mechanical ventilation, presence of major problems, and surgery are used to define specific PM-DRGs. A total of 46 PM-DRGs have been developed to replace the 7 DRGs for neonates. Based on a sample of discharged patients from 13 children's hospitals, the overall variance reduction in duration of stay for neonates using PM-DRGs was 38.7% compared with 20.4% for DRGs. Variance reduction for PM-DRGs was 45.9% compared with 16.3% for DRGs when operating cost per case was used instead of duration of stay. After removing outliers at 150 days, the duration of stay variance reduction was 53.3% vs 23.6%, respectively, and the operating cost variance reduction was 58.8% vs 17.8%, respectively.