Showing posts with label newborn. Show all posts
Showing posts with label newborn. Show all posts

Wednesday, July 29, 2015

Think Prenatal Ultrasound and Newborn Pulse Oximetry Screening Will Find All Neonatal Coarctations? Think Again!


By: Lewis First, MD, MS; Editor-in-Chief      

Bridget Coila
     We have been taught to carefully check newborns for distal pulses and listen for murmurs in the first few days after birth to make sure we are not missing a coarctation of the aorta.  Add in prenatal ultrasound screening and newborn pulse oximetry screening and you might think no coarctation will escape early detection.   
      Well, Lannering et al. (doi: 10.1542/peds.2015-1155) prove that assumption wrong in a review of infants seen with this cardiac disorder between 2003 to 2012 in their referral area.  The authors find that almost 50% of the 90 cases diagnosed were not identified prenatally or screened positive in the nursery leaving a large number to be picked up on follow-up visits or because the infant became sick upon discharge as the ductus closed.   
      If there was ever a reason to make sure we are doing good bread and butter physicals on our newborns, not just in the nursery but in their early postnatal visits to the office, this article will make you a believer.  Take heart and read more about what the authors recommend to avoid missing this important neonatal cardiac disorder.

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Tuesday, July 21, 2015

Choosing Wisely: New Suggestions for Adding Value and Decreasing Costs in Caring for Newborns

By: Lewis First, MD, MS; Editor-in-Chief  
German Tenorio

   The Choosing Wisely campaign, started by the ABIM Foundation, has spread to include all medical fields—offering suggestions for ways to reduce unnecessary tests based on evidence to date. The American Academy of Pediatrics has endorsed ten recommendations for “Choosing Wisely” that can be found at the following link http://www.choosingwisely.org/societies/american-academy-of-pediatrics. While these recommendations deal with infant, toddler and childhood pediatric conditions, up until now we have not had recommendations for ways to add value and reduce costs in newborns. Fortunately this week, Ho et al. (doi: 10.1542/peds.2015-0737) offer five tests and treatments that should not be automatically considered for newborns based on an expert consensus panel. 
      The five areas include (1) avoidance of anti-reflux medications for symptomatic gastroesophageal reflux disease or for apnea and desaturations in preterm infants; (2) avoidance of antibiotics beyond 48 hours when initial cultures are negative and infants remain asymptomatic (30 avoidance of pneumograms for apnea of prematurity; (4) avoidance of routine daily chest x-rays without an indication in intubated infants; and (5) avoidance of routine term or discharge MRIs in previously preterm infants.   
     This special article reviews the rationale leading to these decisions and is a welcome contribution to maintaining high quality in newborns while reducing cost—which can only enhance the value of the care we provide to this population.  Choose wisely and read this article and hopefully implement these five suggestions if you haven’t already.

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Thursday, February 5, 2015

Are You Seeing Infants for Their First Well-child Visit Early Enough to Prevent Readmission?




 German Tenirio @Flickr
          It is recommended that the first well-child visit following discharge from the well-baby nursery occur within 48 hours for infants discharged in less than 48 hours and within 3-5 days for those who do stay more than 48 hours.  How effective are these guidelines in preventing unintended readmissions to the hospital? 
Shakib et al. (doi:10.1542/peds.2014-2329) opted to study this question using a large data-set in Utah that tracked both well child visits and readmission rates for a population of over 79,000 newborns. While 63% of these babies went home in less than 48 hours post-birth, only 15% had a well-child visit in 72 hours (and less in the recommended 48 hours).  To no surprise, those infants who were seen shortly after discharge had a 15% lower readmission rate than those with a later visit. 
          How strictly do you adhere to seeing early discharged babies for a visit within 48-72 hours?  Do you agree seeing babies shortly after birth has helped you prevent a readmission and if so, what type of readmission are you finding your can prevent? We would love to hear your take on this study, and whether or not you feel a 48 hour office visit does help reduce readmissions by sharing your comments via a response to this blog, an e-letter or our Facebook or Twitter sites.

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Wednesday, January 14, 2015

Treating Jaundice in the NICU and Lowering Cases of Readmission

By: Beth Tarini, Editorial Board Member

 Courtesy of Jim Champion
Jaundice continues to vex those who care for newborns.  The majority of babies are jaundiced to some degree.but must don't need treatment. The challenge is to identify those that need treatment without over treating the healthy or overlooking those that need treatment.

In years past, conversations about jaundiced newborns focused on our vigintiphobia – our fear that a bilirubin level of 20 mg/dL would lead to kernicterus unless treated with exchange transfusion.  Now our conversations focus on the effect of early discharge after birth.  According to the AAP, early discharge is defined as less than 48 hours for vaginal birth and more than 96 hours for Caesarean section. (1)  The conundrum is that the greatest risk for severe jaundice occurs at a time after “early discharge” babies have left the hospital.  This can create a challenge for monitoring babies – especially if they don’t have timely follow-up with a healthcare provider after discharge.

The debate over whether early discharge increases the readmission rate for jaundice among newborns is ongoing.  To this debate, Dr. Lain et al. (doi:10.1542/peds.2014-2388) add data based on the first population-based study of the issue.  The study, conducted in Australia from 2001-2010, examined the readmission rate for over 780,000 newborns, looking specifically at how factors such as gestational age might influence the readmission rate.  The authors found that 0.8% of all the infants studied were readmitted for jaundice.   However, those at highest risk for readmission were infants born early term (37 & 38 weeks gestation) and discharged less than 48 hours [aOR 9.43 (95% CI: 8.34-10.67) and 4.05 (95% CI: 3.62-4.54) respectively]. 

What is the reason for these findings?  One theory is that early discharge causes jaundice among this subset of newborns.  However, since this is a cohort study, these findings are associative and should not be viewed as causal.  It is also possible that early term infants are followed more closely after early discharge, which increases their chance of being identified as having an elevated bilirubin, which leads to a readmission.  In this study, we don’t know the bilirubin level that prompted the readmission.  We are left to assume that the level required treatment.

What can we do with these data?  Well, the authors themselves admit that prolonging the hospital stay is unlikely to be an economical viable solution.  It would mean that we would have to keep over 80 infants in the hospital longer just to prevent one admission.  Also noted is that unlike the U.S., Australia does not have universal bilirubin screening guidelines prior to discharge.  It would be interesting to see if these findings persist in those countries that have universal bilirubin screening.  Of course, as we already know, universal screening has been associated with increased use of phototherapy and increased readmission rates, likely due, in part, to over treatment (2).

So, in some ways, the more the conversation about jaundice has changed, the more it has stayed the same.  While we are not talking about vigintiphobia, we are still talking about fear - fear of kernicterus in the shadow of early hospital discharge.



1:American Academy of Pediatrics.Committee on Fetus and Newborn.Hospital stay for
healthy term newborns. Pediatrics.2010 Feb;125(2):405-9. doi:10.1542/peds.2009-3119.

2:Kuzniewicz MW, Escobar GJ, Newman TB. Impact of universal bilirubin screening on severe hyperbilirubinemia. Pediatrics. 2009 Oct;124(4):1031-9. Oct;124(4):1031-9. 
doi:10.1542/peds.2008-2980.
 

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