JAMA Pediatrics: Neonatology Topic Collection

Prognostic Significance of Low-Grade Intraventricular Hemorrhage in the Current Era of Neonatology Prognostic Significance of Low-Grade IVH

Sola-Visner M. — Wed, 01 May 2013 00:00:00 GMT

Cranial ultrasonography (CUS) is performed routinely in extremely preterm infants admitted to the neonatal intensive care unit (NICU), and periventricular-intraventricular hemorrhages (PIVHs) are found in approximately 30% of infants born at less than 29 weeks' gestation. Compared with infants with no hemorrhages, infants with intraventricular hemorrhages leading to ventricular dilatation (grade 3 in the Papile classification) or infants with intraparenchymal hemorrhages (grade 4) clearly have higher incidences of cerebral palsy and worse cognitive outcomes. However, the significance of isolated small hemorrhages confined to the germinal matrix (grade 1) or of intraventricular hemorrhages without ventricular dilatation (grade 2) has been less clearly established. Studies evaluating the outcome of infants with these findings have been sparse and have yielded controversial results, and thus there is variability in how the significance of these low-grade hemorrhages is interpreted by neonatologists and conveyed to the parents.

Neurodevelopmental Outcomes of Extremely Low-Gestational-Age Neonates With Low-Grade Periventricular-Intraventricular Hemorrhage Outcomes of Neonates With Ventricular Hemorrhage

Payne AH, Hintz SR, Hibbs A, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Low-grade periventricular-intraventricular hemorrhage is a common neurologic morbidity among extremely low-gestational-age neonates, yet the outcomes associated with this morbidity are not fully understood. In a contemporary multicenter cohort, we evaluated the impact of such hemorrhages on early (18-22 month) neurodevelopmental outcomes of extremely premature infants.

Objective

To compare neurodevelopmental outcomes at 18 to 22 months' corrected age for extremely low-gestational-age infants with low-grade (grade 1 or 2) periventricular-intraventricular hemorrhage with those of infants with either no hemorrhage or severe (grade 3 or 4) hemorrhage demonstrated on cranial ultrasonography.

Design

Longitudinal observational study.

Setting

Sixteen centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network.

Participants

A total of 1472 infants born at less than 27 weeks' gestational age between January 1, 2006, and December 31, 2008, with ultrasonography results within the first 28 days of life and surviving to 18 to 22 months with complete follow-up assessments were eligible.

Main Exposure

Low-grade periventricular-intraventricular hemorrhage.

Main Outcome Measures

Outcomes included cerebral palsy; gross motor functional limitation; cognitive and language scores according to the Bayley Scales of Infant Development, 3rd Edition; and composite measures of neurodevelopmental impairment. Regression modeling evaluated the association of hemorrhage severity with adverse outcomes while controlling for potentially confounding variables and center differences.

Results

Low-grade hemorrhage was not associated with significant differences in unadjusted or adjusted risk of any adverse neurodevelopmental outcome compared with infants without hemorrhage. Compared with low-grade hemorrhage, severe hemorrhage was associated with decreased adjusted continuous cognitive (β, −3.91 [95% CI, −6.41 to −1.42]) and language (β, −3.19 [−6.19 to −0.19]) scores as well as increased odds of each adjusted categorical outcome except severe cognitive impairment (odds ratio [OR], 1.46 [0.74 to 2.88]) and mild language impairment (OR, 1.35 [0.88 to 2.06]).

Conclusions and Relevance

At 18 to 22 months, the neurodevelopmental outcomes of extremely low-gestational-age infants with low-grade periventricular-intraventricular hemorrhage are not significantly different from those without hemorrhage. Additional study at school age and beyond would be informative.

Nurse Staffing and NICU Infection Rates Nurse Staffing and NICU Infection Rates

Rogowski JA, Staiger D, Patrick T, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights.

Objective

To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes.

Design

Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010).

Setting

Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs.

Participants

All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments.

Exposures

We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010.

Main Outcomes and Measures

An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection.

Results

Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation–higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009.

Conclusions and Relevance

Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.