The American Academy of Pediatrics published an updated policy statement and technical report on newborn male circumcision. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.
Raising Awareness: Late Preterm Birth and Non-Medically
Indicated Inductions Prior to 39 Weeks
The National Child and Maternal Health Program offers an online educational module, Raising Awareness: Late Preterm Birth and Non-Medically Indicated Inductions Prior to 39 Weeks, that addresses the science behind medical recommendations to schedule elective deliveries on or after 39 weeks’ gestation.
This article discusses the potential benefits and challenges of minimally
invasive surgery for infants and small children, and discusses
why pediatric minimally invasive surgery is not yet the surgical default
or standard of care. Minimally invasive methods offer advantages such
as smaller incisions, decreased risk of infection, greater surgical precision,
decreased cost of care, reduced length of stay, and better clinical
information. But none of these benefits comes without cost, and
these costs, both monetary and risk-based, rise disproportionately
with the declining size of the patient.
Neurodevelopmental Outcomes in Children with Congenital Heart Disease: Evaluation and Management
A recent Scientific Statement in Circulation from the American Heart Association (and approved by the AAP) reviews the available literature on surveillance, screening, evaluation, and management strategies and puts forward a scientific statement that comprehensively reviews the literature and creates recommendations to optimize neurodevelopmental outcome in the pediatric congenital heart disease (CHD) population.
The American Academy of Pediatrics is oneof the most powerful medical and political forces advocating for children in the United States. One of the ways we do this is through policy statements concerning the care of children, statements that often directly impact our practices.
A Policy Statement, a statement of advocacy, direction, or a public health position, drives the Academy’s activities and represents our stance on particular issues, expresses a definite course of action, and should contain recommendations. A Technical Report is based on literature review and data analysis but does not include recommendations. A Clinical Report offers guidance for the pediatrician in the clinical setting, addressing best practices and state of the art medicine, and does not include recommendations.
The Committee on the Fetus and Newborn (COFN) studies issues and current advances in fetal and neonatal care and then makes recommendations regarding neonatal practice, especially those related to the medical management and care of the newborn infant.
Are you wondering how to get those Part 2 points for Maintenance of Certification? The American Board of Pediatrics has seminal articles (6 each year) listed under Part 2. All you need to do is read the articles and then answer questions from the ABP website. Better yet, read them with your group as a Journal Club and discuss the articles-then answer the questions! 10 points are awarded for each year!
From the Lead Author, Dr. Mark Hudak: The past decade has witnessed an alarming increase in the number of newborn infants who suffer through withdrawal from a variety of opioid drugs (narcotics). Prenatal exposure to these drugs may occur in the setting of maternal abuse of illicit substances (e.g., heroin) or in situations where the mother is receiving suprvised treatment for addiction with drugs such as methadone or buprenorphine. But more and more frequently, infants are being affected by exposure in the womb to prescription painkillers. In many cases, these powerful drugs are being ordered by phsyciains to treat pain associated with a chronic maternal condition, but sometimes mothers obtain these drugs surreptitiously.
The revised AAP clinical report "Neonatal Drug Withdrawal," appearing in the February 2012 Pediatrics, outlines steps that clnicians and hospitals can take to identify and monitor infants exposed to opioids and other drugs of addiction. The report also updates information from the medical literature about current treatment options for neonatal opioid withdrawal and highlights the need for further research to develop treatments that are safer and more effective and that will result in shorter treatment time and hospital stay. Reducing the number of cases of neonatal opioid withdrawal will require a partnership of the medical community with government and other health organizations to educate women and providers about this problem, to identify alternative pain management options during pregnancy, and to eliminate non-prescribed access to powerful painkillers. The AAP also expanded the report to address the management of infants and children who acquire a dependency on opioids and/or benzodiazepines in the course of hospital treatment (e.g., extended extracorporeal life support) for an acute critical illness
This multidisciplinary, electronic, interactive toolkit with a web-based interface was developed with the support of MedImmune to help improve the care and outcome of premature infants. Ronald L. Ariagno, MD, FAAP (pictured) and John J. LaBella, MD, FAAP served as co-chairs.
It is intended for the pediatrician and other healthcare providers to assist in the transition of the premature infant from hospital to outpatient care, to facilitate accurate transfer of pertinent patient information and to help provide evidence-based practical measures for consideration in the care of the premature infant from birth to 12 months corrected age. There are 6 sections: Introduction, Discharge Planning, Outpatient Follow-up Care, Parent/Caregiver, Tools, and References.
Therapy for Neonatal Sepsis with IVIG
Shown Not to Be Effective
This study, published in the New England of Medicine, at 113 hospitals in 9 countries, enrolled 3,493 infants receiving antibiotics for suspected or proven serious infection. They were randomly assigned to receive 2 infusions of either polyvalent IgG immune globulin or matching placebo 48 hours apart. The primary outcome was death or major disability at the age of 2 years.
RESULTS: there was no significant between-group difference in the rates of the primary outcome and no significant differences in the rates of secondary outcomes.
Early Onset Neonatal Sepsis: The Burden of Group B
Streptococcal and E. coli Disease Continues
A recent publication from the NICHD Neonatal Research Network investigated early onset sepsis in neonatal ICU patients. The study concluded:
In the era of intrapartum chemoprophylaxis to reduce
GBS, rates of EO infection have declined but reflect a continued burden
of disease. GBS remains the most frequent pathogen in term infants,
and E coli the most significant pathogen in preterm infants. Missed
opportunities for GBS prevention continue. Prevention of E coli sepsis,
especially among preterm infants, remains a challenge.
Standard Terminology for Fetal, Infant, and Perinatal Deaths
Deaths occurring to fetuses in utero and infants shortly after birth are important events. Although we as neonatal care providers work diligently to prevent and intervene in adverse perinatal events, we often fail to diligently report them or report them well. Understanding the causes of these events, how these events may affect certain populations, and their potential risk factors begins with accurately defining cases. What we report in our delivery rooms and hospitals provide the basis of information for local quality improvement activities, city, county, regional, and state perinatal mortality reviews, and national statistics. Therefore reliable and accurate information is critical to understanding the causes and informing the solutions for fetal, infant, and perinatal deaths.
Forrest Bird, Inventor of Baby Bird
Ventilator & 2010 Pioneer Award Winner
Dr Forrest Bird turned 90 years old this year and celebrated his birthday with a large bash inviting the entire community of Sandpoint, Idaho, about 50 US and Canadian aviators, members of the military, and enough physicians to staff a medium-sized urban hospital. It was a great day to acknowledge Dr Bird's contribution to the health of children worldwide with the presentation of the Pioneer Award from the Section on Perinatal Pediatrics.
August Larry Jung – Neonatology Pioneer,
Innovator, Outdoorsman and Artist
August Larry Jung, MD, a pioneer who trained the first generation of neonatologists, died of heart disease at age 75 on January 3, 2011. In grief, Larry’s 100 year-old mother died 7 days later. Larry opened the first NICU in the Intermountain West on July 1, 1968, after completing a 6 month fellowship at the Colorado Premature Center under the tutelage of the visionary and gifted Dr. Lula O. Lubchenco. He is greatly missed by all who knew him.
The Management of Hypotension in the
Very Low Birth Weight Infant
Guideline for Practice
Developed by Lyn Vargo, PhD, RN, NNP-BC, and Istvan Seri, MD, PhD, this guideline from the National Association of Neonatal Nurses (NANN) focuses on the challenging topic of clinical management of systemic hypotension in the very-low-birth-weight infant during the first 3 days of postnatal life. Published in 2011 and endorsed by the American Academy of Pediatrics.
Oxygen Saturation Targets for Extremely Premature Infants
A brief report in the New England Journal of Medicine from the BOOST II Trial indicates the study was closed early after a joint safety analysis showed higher survival rates at 36 weeks post menstrual age in infants born less than 28 weeks who were randomly assigned to the oxygen saturation target of 91-95% rather than the 85-89% group.
Robin Sequence: From Diagnosis to Development of an Effective
Management Plan
A recent review article on Robin Sequence in Pediatrics highlights the embryology, diagnosis and management of these patients with complex airway issues. Learn the latest surgical and non-surgical management of these "at-risk" neonatal patients. Outstanding and informative pictures accompany the article.
NIH Consensus Statement on Inhaled
Nitric Oxide for Premature Infants
A recent NIH Consensus Development Conference Statement published in Pediatrics addresses the use of iNO in premature infants to improve outcomes, including chronic lung disease. Although experimental models have shown encouraging results on the effect of iNO on enhanced lung growth and decreased lung inflammation, the conference found the combined results from 14 randomized controlled trials in infants 34 weeks or less showed equivocal effects on pulmonary outcomes, survival, and neurodevelopmental outcomes.
New Guidelines for Screening and Management of Neonatal Hypoglycemia
This month, Pediatrics has published revised guidelines for neonatal hypoglycemia. Written by the Committee on the Fetus and Newborn, the committee notes: "it is a pragmatic approach to a controversial issue for which evidence is lacking but guidance is needed." This clinical report provides a practical guide for the screening and subsequent management of neonatal hypoglycemia (NH) in at-risk preterm (34-36 6/7 weeks' gestational age) and term infants.
Bevacizumab: Effective Therapy for Zone 1, Stage 3+ Retinopathy of Prematurity (ROP)
In a landmark study of 150 infants with stage 3+ ROP published in the February 17th New England Journal of Medicine, intravitreal treatment with bevacizumab (Avastin) was shown to be superior to laser treatment among infants with zone 1, but not zone 2, disease. An additional benefit of this therapy is, unlike laser treatment, it was associated with preservation of growth of retinal vessels after treatment.
2011 Perinatal Pediatrics Spring Workshop
Networking Opportunities
The 2011 Spring Workshop promises to be a refreshing opportunity to learn more about the practice of neonatology in a relaxing and informative setting. Topics covered include global neonatology, health care reform and what it means for neonatologists, racial disparity and birth outcome, and new information about MOC.
Friday Night Reception - 6:30-7:30pm
Everyone is invited to mingle with colleagues and faculty. Sponsored by Abbott Nutrition
Work/Life Balance Discussion for Junior Faculty and Fellows
12:45pm on Saturday
Several junior faculty and fellows requested an opportunity to talk to each other about Work/Life Balance issues as they embark on their careers. As a follow-up to the workshop on Work/Life Balance, we have set aside space (and lunch!*) for people to discuss with each other some of their concerns, frustrations and solutions. Please join us for what promises to be an insightful discussion! There is no cost to attend this group. Please let us know if you are interested through FaceBook or LinkedIn. Sponsored by Mead Johnson Nutrition
The American Heart Association and the International Consensus on Cardiopulmonary Resuscitation recently published new neonatal resuscitation guidelines. Included in the new guidelines are recommendations are updated algorithms with emphasis on CPAP and positive pressure ventilation.
Highlights include:
Deletion of meconium from initial assessment
Changes in recommendation for 100% oxygen
Stronger indications of when to intubate
Stronger recommendations of two-thumb chest compressions
Use of pulse oximetry when using exygen in resuscitation
The section's educational meeting in San Francisco was informative, successful, and fun, starting with the Merenstein lecture given by Michael Harrison, MD of UCSF, on fetal intervention surgery. The Friday night poster session had over 70 posters and was well attended.
Saturday, we held a joint session with the Section on Cardiology and Sunday, focused on the ELBW infant. Jacqueline Noonan, MD, gave an entertaining presentation on the history of pediatric and neonatal cardiology. Another highlight was an outstanding talk by Alan Jobe, MD, on ventilation strategies for the ELBW infant.
Tom Nasca, MD, recently published the new resident and fellow ACGME Duty Hours Recommendations in the New England Journal of Medicine. "The aim of these standards was to promote high quality learning and safe care in teaching institutions." These new recommendations may have significant implications for your institution, your newborn intensive care unit, or your practice with new hires.
Did you know that you can access all of the NICHD Cochrane Reviews in one place? You can click on the link to the right under Useful Links or below to access their website.
The Neonatal Cochrane Reviews are systematic reviews of randomized controlled trials of interest to neonatologists. There are several new and updated reviews including studies of banked human milk, oral lactoferrin for the treatment of sepsis, and the timing of surgery for CDH. These reviews make it easier to use evidence-based medicine to guide our clinical practices.
A recent report presents data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network on care of and morbidity and mortality rates for very low birth weight infants, according to gestational age (GA). The infants were extremely low GA (22–28 weeks) and very low birth weight (401–1500 g) who were born at network centers between January 1, 2003, and December 31, 2007. The authors concluded that “Although the majority of infants with GAs of >24 weeks survive, high rates of morbidity among survivors continue to be observed."
Intrauterine growth curves for preterm infants are limited by small, older, homogeneous samples; non-US data; combined genders; a lack of length and head circumference curves; and/or are based on different samples for weight, length and head circumference curves. The new intrauterine growth curves created and validated in a new study (Olsen, et al Pediatrics 2010;125:e214-e244) using a contemporary, large, racially diverse US sample provide clinicians and researchers with an updated tool for growth assessment in US NICUs.
Tom Nasca, MD, recently published the new resident and fellow ACGME Duty Hours Recommendations in the New England Journal of Medicine. "The aim of these standards was to promote high quality learning and safe care in teaching institutions." These new recommendations may have significant implications for your institution, your newborn intensive care unit, or your practice with new hires.
Two recent articles published in the New England Journal of Medicine (NEJM) and presented at the PAS meeting report on the results from the NICHD Neonatal Research Network SUPPORT Trial (Surfactant, Positive Pressure, and Oxygenation Randomization Trial). These studies compared
intubation and surfactant treatment vs. CPAP initiated in the delivery room and
targeted oxygen saturation of 85 to 89% vs. 91 to 95%
in 1,316 babies born at 24-27 6/7 weeks.
The primary outcomes were death or bronchopulmonary dysplasia, or death or ROP.
The newly developed Section on Perinatal Pediatrics strategic plan emphasizes the Section's commitment to advocacy and value to members. The plan identifies four new areas of focus for the Section in the next five years and proposes some initial steps. The strategic domains and first steps include:
Education:
Creation of the new Web site
Reconfiguration of Section educational venues to incorporate cutting-edge technologies and integrate adult learning theory
Global Health:
Broaden global outreach of the Section to partner with other organizations to improve perinatal health worldwide
Provide mechanisms to link members interested in global health with opportunities
Educational Modules for Residents and Fellows on Global and Community Health
Leadership:
Identify new leaders in Neonatal-Perinatal Medicine and foster leadership development among trainees and young neonatologists
Offer programs aimed at strengthening the skills of existing leaders
Quality:
Collaborate with quality-oriented organizations to explore the possibility of creating a Council on Perinatal Quality
Develop and make widely available tools and teaching modules on quality
An error in CPT 2009 regarding 99465, a code for attendance at delivery, is causing denial of your codes for attendance at delivery with resuscitation.
March of Dimes' Symposium on Quality Improvement
to Prevent Prematurity
In October, 2009, this Symposium brought together a multidisciplinary group to discuss quality improvement as an essential component in the strategy to prevent prematurity, promote health, and save costs.The Symposium explored the state of quality initiatives to prevent preterm birth and developed an action agenda to decrease the rate of preterm births that are not inevitable or medically necessary.
Exploring & Evaluating Practices in Neonatal-Perinatal Medicine
New from the Committee on Practice
Making the transition from residency and fellowship training into practice is difficult and challenging, whether the move is to the familiar realm of academia or to a world of private practice, professional corporate, or hospital-employed neonatology. The Perinatal Section's Committee on Practice has developed these materials to assist fellows in their career planning, and interviewing with, and evaluation of, practices.
Pediatricians considering the role of neonatology in their community setting may also find these discussions enlightening as they negotiate a mutually-supportive relationship. Neonatal divisions and practice groups evaluating the scope of their practices and the duties assumed by practice associates will likewise find these materials helpful, especially if expanding their scope of practice responsibilities, enlarging their patient base, or adding/replacing an associate.
Neonatal Scale Predicts Developmental Problems Later in Childhood
A neonatal scale was better at predicting developmental problems in children up to preschool age than gestational age and socioeconomic status, according to a study in Pediatrics. The Neonatal Intensive Care Unit Network Neurobehavioral Scale includes measures of ability to follow animate and inanimate auditory and visual stimuli, hypertonic responses, lethargy, and arousal and stress levels.
State of the Art in Conventional Mechanical Ventilation
Despite a shift to noninvasive respiratory support, mechanical ventilation remains an essential tool in the care of critically ill neonates. This review examines the special challenges of ventilating the extremely low birth weight infants that now constitute an increasing proportion of ventilated infants, attempts to provide a simple functional classification of ventilator modes and addresses the key aspects of synchronized ventilation modes.
Premedication for Nonemergency Endotracheal Intubation in the Neonate
Several studies have shown that use of premedications for elective neonatal intubation is effective and safe, provides adequate pain control, and also reduces the time and number of attempts taken to intubate. Use of premedications also minimizes cardiorespiratory and hormonal changes associated with awake intubation. Despite this evidence in support of pain control in neonates, several studies continue to report that awareness, assessment, and management of procedural pain in newborns is still inadequate, and considerable variations occur from nursery to nursery and provider to provider in the management of pain associated with intubation in the newborn.
National Association of Neonatal Nurses Issues Statement on Human Milk and Breastfeeding
Mother's milk and breastfeeding are important aspects of optimal care of newborns, especially those who are born preterm or with other serious conditions. The unique nutritional and immunological benefits of human milk make it an integral component of care of infants in the newborn intensive care unit. NANN has issued a statement strongly supporting human milk and breastfeeding.
The AAP is pleased to announce the creation of a new, comprehensive online resource for pediatricians and families that addresses the topic of immunizations. This new site replaces the Childhood Immunization Support Program Web site and contains information about vaccine-preventable diseases, vaccine safety information, and tools and resources to help pediatricians effectively and efficiently administer immunizations in their offices.
Breastfeeding Residency Curriculum Online Resource Available
A free online resource, developed by the American Academy of Pediatrics, helps residents develop confidence and skills in breastfeeding care and includes: presentations on breastfeeding management, clinical cases and evaluation
and tracking tools.
In preterm neonates with a patient ductus arteriosus (PDA), the standard of care has been to attempt to close the defect. Yet some experts have asked whether we need to treat PDA in most preemies. If we are to resolve the condition, there are various methods and protocols for treatment and even prevention; how do outcomes for PDA closure vary by treament strategy? Dr. Darshak Sanghavi, chief of pediatric cardiology and assistant professor of pediatrics at the University of Massachusetts Medical School, lays out the important points of discussion on PDA closure with host, Dr. Jennifer Shu.
Surgeon General's Conference Outlines Agenda
to Prevent Preterm Birth
Experts convened by the National Institutes of Health for the Office of the Surgeon General met in June and released an agenda for activities in the public and private sectors to reduce the nation's rate of preterm birth. The agenda calls for a national system to better understand the occurence of preterm birth and a national education program to help women reduce their chances of giving birth prematurely. The agenda also calls for improved methods for estimating the age of the fetus, and studies to identify biomarkers which would signal the beginning of preterm labor.
AAP Section on Breastfeeding Develops Hospital Template to Enhance Breastfeeding Success
Maternity hospital practices such as free formula, pacifiers, and poor breastfeeding counseling may undermine successful breastfeeding. The AAP Section on Breastfeeding has developed a template to help hospitals develop and implement practices designed to optimize breastfeeding success.
NICHD Workshops Address Two Important Neonatal Issues: Hypoglycemia & Hospital-Acquired Infection
NICHD Neonatal Hypoglycemia Workshop
Recognizing the common occurrence of neonatal hypoglycemia and the potential for insufficient glucose supply to injure the developing brain, as well as a need to support research to fill the missing gaps in knowledge about neonatal hypoglycemia and its clinical implications, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) convened a workshop, held September 8-9, 2008. A diverse group of experts participated.
Hospital-acquired or nosocomial infection occurs at high rates in the Newborn Intensive Care Unit (NICU) and often leads to significant morbidity and mortality. Up to 50% of extremely low birth weight infants develop infection in the NICU. This conference, held August 7-8, 2008, reviewed the existing information with respect to antenatal, perinatal and neonatal management including short term and long term morbidity and mortality for infants with hospital acquired infections. Approximately 20 invited investigators, including international experts, assisted in exploring this important agenda.
Neurodevelopmental Outcomes in Children with Congenital Heart Disease: Evaluation and Management 
