Transcript Neonatology: The State of the Unit Melinda J Elliott, M.D. Pediatric Grand Rounds March 16, 2010

Neonatology:
The State of the
Unit
Melinda J Elliott, M.D.
Pediatric Grand Rounds
March 16, 2010
Objectives
• Sinai Demographics
• Vermont-Oxford Network Data
– Perinatal Trends
– Morbidities and PI
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Necrotizing Enterocolitis
Infections
Chronic Lung Disease
Retinopathy of Prematurity
Intraventricular Hemorrhage
Hypothermia
Breast Milk Usage in the NICU
– Mortality Data
Sinai NICU Admissions 2000-2008
Total =249
Sinai NICU Patient Days
5382 in 2008
Vermont Oxford Network
• Database tracking morbidity and mortality in
babies 22-29 6/7 weeks and/or 401-1500 g
• Many research initiatives
• 750 NICUs contribute data
• Over 55,000 VLBW infants reported in 2008
• Opportunity to compare local outcomes with
aggregate network data
• Tool for quality assurance/performance
improvement
Vermont-Oxford Network 2008
Birthweight (g)
Patients
Less that 501
2327
501-750
9963
751-1000
12341
1001-1250
13950
1251-1500
17186
All
55767
Necrotizing Enterocolitis
Necrotizing Enterocolitis in 2008
BW(g)
GA
Risk of
Mortality
Feeds
Outcome
Surgical; Alive
Surgical; Alive
920
25
High
Never Fed,
DIC after
birth
1020
27
High
Breast
Necrotizing Enterocolitis
Sinai NICU
7
6
Number of Cases
5
4
Survived
Died
3
2
1
0
2002
2003
2004
2005
Year
2006
2007
2008
NICU Infection Control
• Monthly meetings of IC subcommittee
• Systematic review of all policies having an
infection control impact
• Continuation of more stringent policies
• Continuation of handwashing audits
• Year-round educational campaign for all staff
with dedicated IC bulletin board
– IC quarterly data
– Reminder of the week derived from policy and
literature
– Handwashing audit results
Pathophysiology of ROP
• Initial hyperoxic injury
– Elevated oxygen levels (oxygen saturations >95%)
cause severe vasoconstriction and destruction of
immature retinal vessels
– The vasoconstriction severely inhibits blood flow to the
retina (retinal ischemia)
• Ischemic retina attempts to restore its blood flow by
releasing growth factors (?VEGF) to stimulate new blood
vessel growth (neovascularization)
– This “catch-up” growth is abnormal and poorly
controlled, and may result in retinal detachment and
blindness. (Beat-ROP study in progress- Trial of
intravitreal bevacizumab in severe ROP)
ROP-Prevention
• For premature babies on oxygen therapy
– Avoid hyperoxia
– Avoid wide fluctuations in oxygen saturations
– Keep oxygen saturations well controlled within
set limits depending on postmenstrual age
ROP Subcommittee
• Technology currently in use:
– Massimo pulse oximetry
– O2 blenders
• Bedside
• Transporters
• Delivery rooms
ROP Subcommittee
• Staff Education
– Multiple educational seminars completed
• Oxygen Targeting Protocol
– Developed in tandem with ROP initiative in Pediatrix
Medical Group
– Officially implemented December 2007
– Ongoing compliance audits
Hidden Oxygen Use Seen With:
• Large rather than small incremental
changes in O2 for desaturations
• Correctly identify and treat the underlying
cause for the desaturation (apnea)
• Not responding quickly enough to high
alarms
• Placing the infant back on O2 targeting
protocol when going from RA back on O2
• Pre-oxygenating for procedures or
suctioning
Flow chart for some of the clinical interventions and occurrences that contribute
to BPD
Jobe, A. H. Neoreviews 2007;7:e531-e545
Copyright ©2007 American Academy of Pediatrics
Chronic Lung Disease (CLD) Algorithm
• If the infant is hospitalized at 36 weeks, CLD is based on whether
the infant was on oxygen at 36 weeks, as answered on the
Discharge Form.
• If the infant is discharged between 34 and 36 weeks CGA, CLD is
coded YES if the infant was on oxygen at the time of discharge and
is coded NO if the infant was not on oxygen at the time of discharge.
• If the infant is discharged home or transferred before 34 weeks CGA
and the infant was not on oxygen at the time of discharge, CLD is
coded NO.
• If the infant’s gestational age is unknown, or if the infant is
discharged home or transferred before 34 weeks CGA and the infant
was on oxygen at the time of discharge, CLD is coded as unknown
and the case is not considered in calculating CLD rates.
• If the infant dies in the delivery room or prior to 36 weeks CGA, or if
the infant’s gestational age is greater than 36 weeks, CLD is coded
as not applicable and the case is not considered in calculating CLD
rates.
Workshop Definition of BPD for Infants at
Gestational Ages of <32 weeks
Physiologic Test for diagnosis of BPD
• Infants at 35-37 weeks PMA receiving
mechanical ventilation, CPAP or >30% O2 with
saturations of <96% have BPD
• Infants receiving <30% O2 or >30% with
saturations of >96% are tested for O2 need
– O2 progressively decreased gradually to room air
– No BPD if saturation is >90% in room air for 30
minutes
Prevention of Hypothermia in the
Preterm Infant
World Health Organization (WHO)
classification of hypothermia
• Core temperatures
– Mild 36 -36.4 degree C
– Moderate 32-35.9 degree C
– Severe < 32 degree C
Prevention of Hypothermia in the
Preterm Infant
• 2001 WHO report: Naked infant at 73.4oF suffers
same heat loss as naked adult at 32oF
• 2001 WHO report: Ambient temperature in delivery
room should be at least 77oF (25oC)
• Naked infants at <28 weeks gestation need an ambient
temperature of 104oF (40oC) to maintain normal temp in
20% humidity
• Increasing humidity to 60% halves these losses
Prevention of Hypothermia in the
Preterm Infant
• Percent of infants admitted to Sinai NICU with
temperature <36.5 (*polyethylene wrap instituted in late 2007)
All
2006
91
(48-76)
2007*
2008
501750g
100
751- 1001- 12511000g 1250g 1500g
94
77
92
(62-100) (50-83) (40-76) (38-69)
78
93
(46-76)
(60-95)
85
100
79
62
78
(44-82) (37-75) (39-74)
80
79
85
Establishing a Protocol to Reduce the Risk of
Hypothermia in Neonates less than or equal to 1500g
Performance Improvement Project
A Funderburk, M.D.
Aims of project:
•
Assess ability of proven interventions to reduce risk of
hypothermia in neonates less than 1500 grams by measuring
NICU admission temperatures and number of days to regain birth
weight
•
Determine if using standard checklist to implement
thermoregulatory interventions will improve their effectiveness
•
Determine if by educating hospital NICU/L&D staff to the dangers
of hypothermia and reviewing fundamentals of reducing
hypothermia will change the incidence of hypothermia
•
Evaluate effect of reducing hypothermia on secondary outcomes
such as rates of metabolic acidosis, hypoglycemia, respiratory
distress and sepsis
Establishing a Protocol to Reduce the Risk of
Hypothermia in Neonates less than or equal to 1500g
Performance Improvement Project
A Funderburk, M.D.
• Established protocol for delivery room temp, use
of polyethylene wrap, pre-warming radiant
heaters, etc, now in place
• Data collection complete and results being
analyzed now for admission and subsequent
temps, and secondary outcomes such as
metabolic acidosis, hypoglycemia, IVH, LOS, etc
• Preliminary data show significant increase in
admission temps for 2009. Final results next
year
Breast Milk in the NICU
Why is it important?
Benefits of Human Milk: Infectious
Diseases
Strong evidence exists that human milk feedings decrease
the incidence and/or severity of a wide range of
infectious diseases:
• Late-onset sepsis in preterm infants
• Necrotizing enterocolitis
• Bacterial meningitis
• Bacteremia
• Respiratory tract infection
• Urinary tract infection
• Otitis media
• Diarrhea
Pediatrics. 2005 Feb;115(2):496-506
Benefits of Human Milk: Mortality
Post-neonatal infant mortality rates in the
United States are reduced by 21% in
breastfed infants
Pediatrics. 2005 Feb;115(2):496-506
Benefits of Human Milk:
Other Health Outcomes
Studies suggest decreased rates of:
• Sudden infant death syndrome
• Insulin-dependent (type 1) diabetes mellitus
• Non–insulin-dependent (type 2) diabetes mellitus
• Asthma
• Lymphoma
• Leukemia
• Hodgkin disease
• Obesity
• Hypercholesterolemia
Pediatrics. 2005 Feb;115(2):496-506
Benefits of Human Milk:
Neurodevelopment
• Breastfeeding has been associated with slightly enhanced
performance on tests of cognitive development
• Breastfeeding during a painful procedure such as a heel-stick for
newborn screening provides analgesia to infants
Beneficial effects of breast milk in the neonatal intensive care unit on
the developmental outcome of extremely low birth weight infants at
18 months of age. NICHD, Pediatrics. 2006 Jul;118(1):e115-23
– Every 10 mL/kg per day breast milk contributed 0.53 points to
the Bayley Mental Development Index; therefore, the impact of
breast milk ingestion during the hospitalization for infants in the
highest quintile (110 mL/kg per day) on the Bayley Mental
Development Index would be 10 x 0.53, or 5.3 points.
– The potential long-term benefit of receiving breast milk in the
NICU for extremely low birth weight infants may be to optimize
cognitive potential and reduce the need for early intervention and
Pediatrics. 2005 Feb;115(2):496-506
special education services
Benefits of Human Milk:
Maternal Health Benefits
Important health benefits of breastfeeding and lactation are
also described for mothers:
• Decreased postpartum bleeding and more rapid uterine
involution attributable to increased concentrations of
oxytocin
• Decreased menstrual blood loss and increased child
spacing attributable to lactational amenorrhea
• Earlier return to prepregnancy weight
• Decreased risk of breast cancer
• Decreased risk of ovarian cancer
• Possibly decreased risk of hip fractures and
osteoporosis in the postmenopausal period
Pediatrics. 2005 Feb;115(2):496-506
Benefits of Human Milk: Community
Benefits
• Potential for decreased annual health care costs of $3.6
billion in the United States
• Decreased costs for public health programs such as the
Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC)
• Decreased parental employee absenteeism and
associated loss of family income
• More time for attention to siblings and other family
matters as a result of decreased infant illness
• Decreased environmental burden for disposal of formula
cans and bottles
• Decreased energy demands for production and transport
of artificial feeding products
Pediatrics. 2005 Feb;115(2):496-506
Benefits of Human Milk: Summary
• Human milk is the recommended source of nutrition for
preterm and term newborns
• Human milk has a large number of health benefits for
babies, mothers, and society
Human milk is an extremely
important MEDICATION that
should be used in every
newborn!!!
Human Milk: Underutilized
• Human milk, despite its great health benefits for
both mom and baby, remains underutilized
Percent of US children who were breastfed (1999-2006)
Source: http://www.cdc.gov/BREASTFEEDING/DATA/NIS_data/index.htm
Human Milk: Underutilized in NICU
Babies
• Human milk utilization is even worse in the NICU population
• Breast milk use at discharge is only ~40% for babies born
501-1500 grams
• Utilization for larger NICU babies is slightly higher, but still
lower than term babies
Despite NICU babies being at higher risk for NEC, infection,
ROP, neurodevelopmental impairment, etc – they have the
lowest rates of human milk utilization.
The babies that need human milk the most are the group least
likely to receive it!!
Source: Pediatrix Clinical Data Warehouse
WHY????
Highly suggested
reading for the
entire NICU staff
J Obstet Gynecol Neonatal Nurs. 2005;34:109
Two questions, two barriers
Maternity and neonatal nurses have raised several
questions about talking with women about lactation for
their infants, but two are the most common:
1. “Does it really matter?” — or — “Is there a clinically
significant difference between formula and mothers’ milk
for infants?”
2. “Won’t I make these women feel guilty or pressured if I
promote lactation, because infant feeding method should
be a personal choice?”
J Obstet Gynecol Neonatal Nurs. 2005;34:109
Does it really matter?
YES, IT REALLY DOES!!
• Review the first half of the presentation
again – there are multiple very real
advantages to providing human milk
(for both mom and baby)
• Hundreds of scientific papers have
been published on this topic
• Human milk is superior to formula
• Formula is inferior to human milk
What if I make mom feel guilty?
• Contrary to common assumptions, several studies show that women
want evidence-based knowledge about formula and mothers’ milk
feedings to make an informed choice for themselves and their
infants.
• In one study, moms were asked about their initial feeding intent, they
indicated that they initially planned to formula feed primarily because
they “did not know anyone who had ever breastfed” or because they
felt that lactation would involve discomfort and lifestyle changes.
• All mothers reported that the major reason they changed the initial
decision was hearing from a health care provider that their milk was
best for their infant.
Moms want what is best for their babies – it is our responsibility to
make sure that they clearly understand that human milk is the best
choice.
J Obstet Gynecol Neonatal Nurs. 2005;34:109
What if I make mom feel guilty?
• Consider this: What if a mom decides to not provide
human milk, and no staff member discusses this with her
further, out of fear of making her feel guilty.
• What if her baby gets NEC, and she reads somewhere
that breast milk use is associated with a lower incidence
of NEC? Do you think she will feel guilty then?
This is not about “making someone feel guilty” – this is
about providing important information to families so they
can make the best decisions possible for their baby.
J Obstet Gynecol Neonatal Nurs. 2005;34:109
Please counsel all your patients
about the benefits of breast
feeding, particularly those with
premature infants. Continue this
discussion with every interaction
you have with them!
NICU Mortality 2008
Birthweight (g)
Gest. Age
Cause of Death
650
241
Acute air embolus, pneumopericardium
570
234
Twin B, Respiratory failure
0
Hypoplastic lungs, Hydrops,
Died at < 12 Hours of life
2100
28
580
231
Twin A, Grade IV ICH, Removed from life
support
500
231
Twin B, Grade IV ICH, Removed from life
support
600
241
Respiratory failure, severe pulmonary
hemorrhage, grade III ICH
Delivery Room Deaths 2008
Birthweight (g)
Gest. Age (weeks)
545
216
526
215
478
223
Sinai NICU Survival 2004-2008
120
100
Percent
80
60
40
20
0
<24
24
25
26
27
28
29
30
31
Completed Weeks Gestation
32
33
3436
Survival to Discharge Without Known Morbidity***
Infants 501-1500 grams Sinai NICU 2008
***None of the following morbidities at discharge: Severe IVH, CLD,
NEC, pneumothorax, any nosocomial infection, PVL, Extreme LOS
120
100
Percent
80
60
40
20
0
<24
24-26
27-29
30-32
Completed Weeks Gestation
>32