Neonatal Intensive Care Unit Graduates Research Articles

Emphasis on follow-ups of discharged neonates from neonatal intensive care units

During the first few months of life, preterm infants and critically ill term infants may be admitted to neonatal intensive care unit (NICU) and require various treatments and support. The rapid development of Neonatology in the last decade allowed more of these infants to survive and could be discharged. Therefore, this group of babies are also name as graduates. Considering that NICU graduates may encounter a variety of ongoing medical problems including growth, nutrition, feeding problems, bronchopulmonary dysplasia, and neurologic injury which might take days, months or even years to recover. The follow-up doctors must equip with relevant knowledge of possible complications and rehabilitations in order to provide comprehensive post-discharge management, because prompt and proactive management and interventions can improve the long-term outcome of these babies. Key words: Intensive care units, neonatal; Patient discharge; Continuity of patient care; Follow-up studies

Prevalence and Longevity of PTSD Symptoms Among Parents of NICU Infants Analyzed Across Gestational Age Categories.

Objective. This study aims to investigate whether posttraumatic stress disorder (PTSD) symptoms exist >1 year after neonatal intensive care unit (NICU) experience and whether PTSD symptomatology differs across parents of infants of different gestational age categories. Methods. A survey was given to parents at routine NICU follow-up visits. Parents completed the PTSD CheckList-Civilian (PCL-C), a standardized scale comprising 17 key symptoms of PTSD. Parents also rated how traumatic their birth experience, first day in the NICU, and first week in the NICU were from "Not Traumatic at All" to "Most Traumatic." Fisher's exact test was used to compare PCL-C responses across gestational age categories (Extremely Preterm, Very Preterm, Moderate to Late preterm, and Full Term). Results. Eighty parents participated. In total, 15% of parents had "Moderate to High Severity" PTSD symptoms. There were no statistical differences in PTSD prevalence between parents of children <1 year old and parents of children >1 year old (P = .51). There was also no statistical difference in prevalence of "Moderate to High Severity" level of PTSD symptoms across gestational age (P = .16). Overall, 38% of parents rated at least one experience as "Most traumatic." Conclusion. A high percentage of parents who had a recent NICU experience and parents who had a NICU experience more than a year ago demonstrated PTSD symptoms. In light of these results, many parents of NICU graduates-both mothers and fathers-would benefit from access to long-term counseling services.

Development of a Multidisciplinary Medical Home Program for NICU Graduates.

Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population. This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs. The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down. Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

Hearing screening outcome in neonatal intensive care unit graduates from a tertiary care centre in Singapore.

We aimed to analyse the outcome of universal newborn hearing screening (UNHS) and high-risk hearing screening in neonatal intensive care unit (NICU) graduates in a tertiary care unit. The hearing screen programme comprises a 2-stage automated auditory brainstem response protocol followed by a high-risk hearing screen at 3-6 months. This study is a retrospective study of NICU graduates born between April 2002 and December 2009. Data on hearing screening, audiological assessment, and management were extracted from a computerized data management system (HITRACK). Of 100,225 newborn infants, 2.9% were admitted to the NICU during the study period. The overall incidence of hearing loss (HL) of any type/severity was 35/1,000 infants. Of infants with HL, 92.4% had their first automated auditory brainstem response at/before 1 month of corrected age. The incidence of congenital permanent HL identified by the UNHS was 15.4/1,000. The corrected median age of diagnosis was 4.5 months (1-23.5 months). Of 2,552 NICU graduates who passed the UNHS, 75.5% were retested at 3-6 months of life. Twelve infants with permanent late-onset HL were identified, raising the overall incidence of permanent HL to 19.9/1,000; 1.1/1,000 had auditory neuropathy. Of the 92 infants with HL, 89 (96.7%) had multiple risk factors. There is a high incidence of HL in NICU graduates; 22.6% were late in onset. An early rescreen in those who pass the UNHS is a beneficial step for this high risk population.

Home Visiting Program for NICU Graduates: Feasibility and Potential for Impact

Neonatal intensive care unit (NICU) admissions have been increasing. Home visiting services are an integral part of caring for high-risk children with limited resources. The effectiveness of physician-led home visiting programs on post-NICU health outcomes is not well studied. The Pediatric Visiting Doctors (PVD) program provides home-based primary care for high-risk children including NICU graduates, for 6 months after discharge. The team consisted of a pediatrician, and care coordinator or social worker. The study compares the characteristics and care utilization of PVD program participants with a hospital-based pediatric clinic population. A retrospective cohort study of PVD infants born from 2013–2016, who were enrolled after referral during their NICU admission, was conducted. Data were also obtained on infants who were hospital clinic patients born during the same time frame, with parents residing in the PVD catchment area, and had a minimum 72-hour NICU stay. Between group differences were assessed; and logistic regression and generalized linear models were used to adjust for uneven group characteristics. Forty-six PVD participants completed the program, and 91 comparison infants had at least 6 months of post-NICU clinic visits. PVD program completers received a median of 5 home visits. There were no differences in emergency care use or hospitalization. PVD program participants were more likely to attend development clinic compared to the non-PVD group (59% vs 12%, p = 0.002). Physician-led home visiting services is a feasible way of providing clinical care to this population. Additional research is needed to assess patient-centered outcomes of these programs.

NICU Graduate Reunion: "A Celebration of Life".

Few understand the experience of having an infant in the neonatal intensive care unit (NICU). This article provides a discussion about the importance of an annual reunion for former NICU infants, their families, and neonatal staff. The purpose of this article is to explain the impact of the NICU reunion on families and neonatal healthcare providers and describe the experience of organizing this reunion over the past 20 years. This is a description of how a NICU reunion was organized at a regional neonatal center. Graphic-designed invitations were e-mailed to NICU graduates, who previously agreed to being contacted, 2 months prior to the reunion date. Social media were utilized to publicize the event on the hospital's Web site. At the reunion, parents and families introduced their NICU graduate to the neonatal staff who cared for them while hospitalized. Sometimes staff found it difficult to recognize the NICU graduates, who were toddlers or older. Parents were relaxed, expressing their appreciation for care received. The impact of seeing an infant, born at 24 weeks, now walking, talking, and running cultivates pride in the NICU healthcare team. The reunion adds a positive dimension to the work of NICU caregivers. Parents look forward to attending the reunion to reconnect with NICU staff and other NICU parents. Directions for future study include a comparison of staff and families who attend the NICU reunion and those who do not, by using a survey or online evaluation tool, to improve future reunions.

Respiratory Medications in Infants

To determine patterns of respiratory medications used in neonatal intensive care unit graduates. The Prematurity Respiratory Outcomes Program enrolled 835 babies <29weeks of gestation in the first week. Of 751 survivors, 738 (98%) completed at least 1, and 85% completed all 4, postdischarge medication usage in-person/telephone parental questionnaires requested at 3, 6, 9, and 12months of corrected age. Respiratory drug usage over the first year of life after in neonatal intensive care unit discharge was analyzed. During any given quarter, 66%-75% of the babies received no respiratory medication and 45% of the infants received no respiratory drug over the first year. The most common postdischarge medication was the inhaled bronchodilator albuterol; its use increased significantly from 13% to 31%. Diuretic usage decreased significantly from 11% to 2% over the first year. Systemic steroids (prednisone, most commonly) were used in approximately 5% of subjects in any one quarter. Inhaled steroids significantly increased over the first year from 9% to 14% at 12months. Drug exposure changed significantly based on gestational age with 72% of babies born at 23-24weeks receiving at least 1 respiratory medication but only 40% of babies born at 28weeks. Overall, at some time in the first year, 55% of infants received at least 1 drug including an inhaled bronchodilator (45%), an inhaled steroid (22%), a systemic steroid (15%), or diuretic (12%). Many babies born at <29weeks have no respiratory medication exposure postdischarge during the first year of life. Inhaled medications, including bronchodilators and steroids, increase over the first year.

Factors Influencing Acceptance Into Part C Early Intervention Among Low-Risk Graduates of Neonatal Intensive Care Units

Low-risk infants discharged from a neonatal intensive care unit (NICU) can include infants whose stay was due to late-term prematurity, suspicion of sepsis, breathing issues, and/or feeding challenges. This study aimed to identify the degree to which sociodemographic and medical factors contribute to low-risk NICU graduates being accepted into Part C early intervention services. Family sociodemographic and child medical factors were examined for 3,826 low-risk graduates of NICUs in 1 Midwestern state. These NICU graduates were compared with the general population of children birth to age 3 years in the state for rates of enrollment in Part C programs. Low-risk NICU graduates had significantly higher early intervention acceptance rates than children in the general population. Neonatal intensive care unit graduates residing in an urban area were more likely to be accepted into early intervention services than those residing in a rural area. The length of NICU stay also predicted acceptance into services; the likelihood of acceptance into early intervention programs increased for each additional day a child stayed in the NICU. Low-risk NICU graduates should be monitored routinely after discharge for developmental delays and the need for referral to Part C early intervention programs any time in the children's first 3 years of life.

Parent Perspectives on Readiness for Discharge Home after Neonatal Intensive Care Unit Admission

To explore the parent perspective on discharge home from the neonatal intensive care unit (NICU). We interviewed parents of NICU graduates with a range of demographic characteristics and medical complexities to explore parent perspectives on readiness for discharge. Interviews were transcribed and coded by a 6-member team. We performed content analysis to identify themes and develop a family-centered conceptual framework around readiness for NICU discharge. We interviewed a total of 15 parents who experienced NICU stays with 18 infants. Parents who have experienced NICU discharge have a spectrum of needs that evolve from the time the child is in the NICU, at time of discharge, and at home afterward. These needs consistently centered around 5 themes-communication, parent role clarity, emotional support, knowledge sources, and financial resources. Parents described many ways the system could have better prepared them and connected them with essential resources. Summarizing the voices of the parents who participated in this study, we have compiled a series of practical recommendations for clinicians to use in daily practice to help parents feel prepared and confident for the transition home from the NICU.

Parental Perspectives on Diagnosis and Prognosis of Neonatal Intensive Care Unit Graduates with Cerebral Palsy

To describe how parents of neonatal intensive care unit (NICU) graduates with cerebral palsy (CP) perceive both the accuracy of prognoses provided in the NICU and the timing of their child's diagnosis of CP, and to assess the influence of functional outcome on these perceptions. We surveyed parents of NICU graduates with CP about timing and benefit of diagnosis, accuracy of prognosis, and functional abilities of their children. After piloting and validation, CP parent support groups circulated the survey on social media, websites, and email lists. Bivariate relationships between categorical responses to survey questions were assessed with the χ2 test, and multivariable logistic regression was performed to identify independent factors associated with perceptions about the timing of diagnosis. Parents of 463 children were included. Two-thirds (67%) of the children were diagnosed with CP before age 2 years, yet 40% of the respondents felt that diagnosis was made late, and only 11% categorized diagnosis as early. More than one-half (59%) perceived a benefit to diagnosis. There was a significant association between earlier age at diagnosis and greater functional limitations; 24% of parents who recalled being given a prognosis reported that their child functioned as predicted, and 46% reported that their child exceeded expectations. Parents were more likely to believe that children with fewer functional limitations had exceeded expectations. Parents remember prognostic discussions about children who develop CP as underestimating functional outcome. Diagnosis is rarely seen as early and is associated with benefits. These observations suggest that clinicians should aim to diagnose CP early and to maintain guarded optimism about future outcomes. Tools for improved communication are urgently needed.

Neonatal Neuroprotection: Bringing Best Practice to the Bedside in the NICU.

Preterm birth interrupts the precise process of fetal maturation, forcing critical neurologic growth to continue within the Neonatal Intensive Care Unit (NICU). Concern for the impact of the NICU experience on the developing brain led to a unit-based Quality Improvement (QI) project to promote best outcomes for our graduates. The objective was to implement a standard of care for neonatal neuroprotection in a large urban tertiary center. A multidisciplinary committee researched and developed the Neonatal Neuroprotective Best Practice Guidelines to identify optimal interventions, as well as provide physiologic rationales to reinforce importance of these practices. An educational initiative accompanied release of this document to support consistency in clinical practice and to stress the critical role that every caregiver played in a child's outcome. As the Best Practice Guidelines encompassed virtually all aspects of caregiving in the NICU, it was impractical to measure the impact of such a broad range of interventions in a methodical manner. The full effect of these interventions will not likely be evident until NICU graduates have grown into childhood and adolescence. These constraints limited the scope of this QI project to the practicalities of identifying neuroprotective best practice and bringing it to the bedside. When combined with evidence-based medical and nursing care, neuroprotective care represents the best means of facilitating normal development and minimizing disability for our NICU graduates.

A study to assess the knowledge and practice of initiation of immunisation in mothers of low birth weight Neonatal Intensive Care Unit (NICU) graduates in a tertiary care centre

Background: Premature and low birth weight (LBW) infants are susceptible to infections including those which are preventable. The coverage of immunization in this subset of babies is poor. The present pilot study was an attempt to identify factors which lead to delay in initiation of immunization in this vulnerable group. The objective of this study was to assess knowledge and practice of initiation of immunization in mothers of low birth weight (&lt;2 Kg) NICU graduates and effect of specific counselling on the practice of immunization. Methods: A prospective pilot study was done between 1st April to 30th June 2016. In the first phase, mothers of LBW and preterm babies were assessed using 2 validated questionnaires on discharge and in High-Risk OPD. In the second phase, a different set of mothers were assessed similarly but counseled specifically by the principal investigator to initiate immunization irrespective of the weight and chronological age. Results were interpreted using the Fischer Exact test, Independent T-test and McNemar.Results: Among 30 babies in the study, 16 (53.33%) were immunized, of which 6 (37.5%) babies had a timely initiation. Birth weight and duration of NICU stay significantly affected the time of initiation of immunization. There was a significant lack of knowledge in mothers of non-immunized babies. When counseled by the primary investigator, 85.8% and 50% of mothers agreed that immunization can be initiated at birth and even if birth weight is less than 2 kg respectively.Conclusions: Immunization initiation was delayed in most of the preterm and low birth weight babies. Post counseling a favorable change was observed in mothers’ knowledge but not practice.

Health-care spending and utilization for children discharged from a neonatal intensive care unit

To describe health-care spending and utilization for infants discharged from the neonatal intensive care unit (NICU). Retrospective cohort analysis of 4973 NICU graduates in the Truven MarketScan Medicaid database, with follow-up to the third birthday. Health-care spending and utilization after NICU discharge were assessed. Using logistic regression, we assessed clinical characteristics associated with hospitalization and emergency department (ED) visits. Most (69.5%) post-NICU spending occurred within the first year [$33,276 per member per year]. Inpatient care accounted for most (71.6%) of the 3-year spending. The percentages of infants with a 1-year readmission or ED visit were 36.8% and 63.7%, respectively. Medical technology was associated with the highest likelihoods of hospital [aOR 17.8 (95%CI 12.2-26.0)] and ED use [aOR 2.3 (95%CI 1.8-3.0)]. Hospital care accounts for the majority of spending for NICU graduates. Infants with medical technology have the highest risk of hospital and ED use.

Efectividad de la atención domiciliaria de enfermería en el seguimiento de prematuros después del alta hospitalaria

Los prematuros con alta hospitalaria de la Unidad de Cuidado Intensivo Neonatal (UCIN), deben admitirse a un programa de seguimiento para prevenir que tengan complicaciones durante la transición al hogar y se produzcan reingresos hospitalarios. Además, los padres de infantes prematuros experimentan diversos sentimientos y desafíos cuando estos llegan al hogar. El objetivo de este protocolo de práctica clínica basada en la evidencia es analizar la mejor evidencia científica disponible respecto de la efectividad de los programas de atención domiciliaria de enfermería (ADE) para el seguimiento de prematuros egresados de la UCIN. Se utilizó como metodología la práctica clínica basada en la evidencia: inicialmente se planteó una pregunta clínica de tipo pronóstico y se planteó objetivos acordes a esta, a partir de los que se identificó un conjunto de descriptores con los que se realizó la búsqueda de evidencia científica en diferentes bases de datos científicas.

Complex Surgical Infants Benefit From Postdischarge Telemedicine Visits.

Transition from the neonatal intensive care unit (NICU) to home is challenging for caregivers of complex surgical infants. A prospective, observational cohort pilot study using telemedicine to improve transition was implemented in a quaternary level IV NICU. (1) To assess, identify, and resolve patient care concerns in the immediate postdischarge period. (2) To improve caregiver knowledge and care practices. Caregivers of medically complex infants participated in telemedicine visits with neonatal providers within 1 week of discharge. Providers reviewed infant health, equipment use, and outpatient follow-up. Video was used to visualize the infant, home environment, and care practices. Caregivers completed a postvisit satisfaction survey. Ninety-three visits were performed from May 2015 to March 2017. Seventy-six percent of visits were postsurgery patients. Seventy-eight postdischarge issues were identified: medication administration (13%), respiratory (19%), feeding (33%), and surgical site (35%). Fifty percent of caregivers reported that telemedicine visits prevented an additional call or visit to a clinician; 12% prompted an earlier visit (n = 93). Caregiver satisfaction rating was high. Median estimation of total mileage saved by respondents was 1755 miles. Postdischarge telemedicine visits with complex surgical NICU graduates identify clinical issues, provide caregivers with support, and save travel time. Advanced practice nurses are instrumental in patient recruitment, with patient visits, and in providing postdischarge continuity of care. Barriers to implementation were identified. A randomized controlled study is warranted to measure the value of telemedicine visits for specific patient cohorts.

Severe acquired subglottic stenosis in neonatal intensive care graduates: a case–control study

ObjectiveTo analyse current incidence and risk factors associated with severe acquired subglottic stenosis (SASGS) requiring surgical intervention in neonates.DesignRetrospective case–control study.SettingSole tertiary children’s hospital.ParticipantsPatients who underwent surgical intervention for SASGS...

Dental Surgery Under General Anesthesia Among Neonatal Intensive Care Unit Graduates

Dental Surgery Under General Anesthesia Among Neonatal Intensive Care Unit Graduates

Changes in tonal audiometry in children with progressive sensorineural hearing loss and history of Neonatal Intensive Care Unit discharge. A 20 year long-term follow-up

ObjectiveNewborns from Neonatal intensive care units (NICU) are at high-risk for sensorineural hearing loss (SNHL) a follow-up is needed for early diagnosis and intervention. Our objective here was to describe the features and changes of SNHL at different periods during a follow-up of almost 20 years. MethodsRisk factors for SNHL during development were analyzed. The audiological examination included: Brainstem auditory evoked potentials (BAEP), and Transient evoked otoacoustic emissions (TEOAE). At birth; tonal audiometry (between 125 and 8000 Hz), and tympanometry were performed at 5, 10, 15, and 20 years of age. ResultsSixty-five percent of cases presented bilateral absence of BAEP. At 5 years of age, the most frequent SNHL level was severe (42.5%), followed by moderate (22.5%), and profound level (20%), in all cases, the SNHL was symmetrical with a predominance of lesion for the high frequencies. Exchange transfusion was associated with a higher degree of SNHL (OR = 6.00, CI = 1.11–32.28, p < 0.02). In 55%, SNHL remained stable, but in 40% of the cases it was progressive. At the end of the study six cases with moderate loss progressed to the severe level and seven cases with severe level progressed to profound. ConclusionsForty percent of infants with SNHL discharged from NICU may present a progression in the hearing loss. Exchange transfusion was associated with a higher degree of SNHL. NICU graduates with SNHL merit a long-term audiological follow-up throughout their lifespan.

Early Intervention Services Improve School-age Functional Outcome Among Neonatal Intensive Care Unit Graduates

ObjectiveTo evaluate the effect of community-based early intervention (EI) services the on functional outcomes of high-risk infants at school age. MethodsThis was a retrospective cohort study using data from the US Department of Education's National Early Intervention Longitudinal Study. Participants were enrolled in 1997 to 1998 with follow-up through 5 years and had a neonatal intensive care unit (NICU) admission, birth weight >400 g, and gestational age >23 weeks. Kindergarten outcomes were teacher assessments of academic and physical skills compared with classmates. Because treatment assignment is determined according to level of clinical need, we used repeated measures, marginal structural models with inverse probability of treatment weighting to account for confounding by indication. ResultsOf 405 participants, 47% had academic ratings average/above average and 71% had physical skills ratings average/above average. Odds of average/above average academic skills were lower for those with delayed EI enrollment (adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI], 0.43–0.99) and trending, although not significantly, higher for those with greater service duration (aOR, 1.47; 95% CI, 0.98–2.22) and breadth (odds ratio, 1.74; 95% CI, 0.95–3.20). Odds of average/above average physical skills were lower for those with delayed EI enrollment (aOR, 0.61; 95% CI, 0.40–0.93) and higher for those with greater intensity (aOR, 1.06; 95% CI, 1.00–1.13) and breadth (aOR, 1.86; 95% CI, 1.03–3.35), approaching significance for those with greater service duration (aOR, 1.41; 95% CI, 0.96–2.09). ConclusionsLonger, more intense services were associated with higher kindergarten skills ratings in children at risk for disabilities. Our novel findings support the effectiveness of large-scale EI programs and reinforce the importance of referral after NICU discharge.

Short-term outcome of brainstem auditory function in term infants after discharge from the neonatal intensive care unit

Objectives: To examine short-term outcome of brainstem auditory function in term infants after discharge from the neonatal intensive care unit (NICU).Methods: Brainstem auditory evoked response (BAER) was recorded and analysed at various click rates at 2–4 months of age in 43 term NICU graduates. The data were compared with those in age-matched normal controls.Results: The threshold of BAER in the NICU graduates was marginally elevated. The graduates also showed an increase in wave III latency at 91/s and wave V latency at all 21–91/s. The I–V interval was increased at 51 and 91/s, whereas the I–III and III–V intervals were slightly increased, with no significant differences from normal controls at any click rates. The amplitudes of waves I and V in the NICU graduates were moderately reduced at all click rates. Wave III amplitudes were reduced at 51 and 91/s. None of the slopes of BAER variables-rate functions in the NICU graduates differed significantly from normal controls.Conclusions: The BAER was moderately abnormal in the NICU graduates, suggesting that brainstem auditory function is moderately impaired at 2–4 months of age after discharge. There is a need to monitor postnatal auditory and neural development for NICU graduates.