Faculty Bibliography

Introduction Coronavirus disease 2019 (COVID-19) is known to cause cardiac abnormalities in adults. Cardiac abnormalities are well-described in multisystem inflammatory syndrome in children, but effects in children with acute COVID-19 are less understood. In this multicenter study, we assessed the cardiac effects of acute COVID-19 among hospitalized children (<21 years) admitted to three large healthcare systems in New York City. Methods We performed a retrospective observational study. We examined electrocardiograms, echocardiograms, troponin, or B-type natriuretic peptides. Results Of 317 admitted patients, 131 (41%) underwent cardiac testing with 56 (43%) demonstrating cardiac abnormalities. Electrocardiogram abnormalities were the most common (46/117 patients (39%)), including repolarization abnormalities and QT prolongation. Elevated troponin occurred in 14/77 (18%) patients and B-type natriuretic peptide in 8/39 (21%) patients. Ventricular dysfunction was identified in 5/27 (19%) patients with an echocardiogram, all of whom had elevated troponin. Ventricular dysfunction resolved by first outpatient follow-up. Conclusion Electrocardiogram and troponin can assist clinicians in identifying children at risk for cardiac injury in acute COVID-19.

BACKGROUND:Laser retinopexy is the current standard treatment for babies with type I retinopathy of prematurity (ROP). No guidelines exist for respiratory management during this procedure. Although neonatologists prefer to avoid intubation to prevent delays in extubation, feeding and discharge, ophthalmologists often request intubation, because sedation alone may lead to respiratory collapse. Little evidence is available regarding which treatment provides the most benefit to vulnerable infants. OBJECTIVE:This study investigated relevant associations or underlying conditions that may help guide decision-making in respiratory management during laser retinopexy. METHODS:A retrospective chart review was performed to analyze data from babies who underwent retinopexy from 2006 to 2011 at the Montefiore Medical Center. The main outcome measures included respiratory support before, during and after laser therapy; time from treatment to extubation; and time from treatment to discharge. RESULTS:The main outcomes were analyzed in four groups: never intubated (n = 27), emergently intubated (n = 7), already intubated (n = 8) and electively intubated (n = 28). No significant differences were observed in the number of pre-operative apneic/bradycardic events, postoperative time to extubation, time to discharge and delays in feeding among groups. CONCLUSIONS:No specific comorbid conditions were found to predict a need for intubation. Elective intubation did not cause delays in feedings, extubation or discharge. A selective approach to respiratory support would result in 20% of initially non-intubated patients requiring emergent intubation.

UNLABELLED:Neonatal intensive care unit (NICU) graduates require complex services after discharge. The NICU discharge process at Children's Hospital at Montefiore-Weiler, Bronx, NY (CHAM-Weiler) lacked a system for routine primary care provider (PCP) notification. Here, we describe a quality improvement project to improve communication with PCPs to ensure communication of critical information and plans. METHODS/UNASSIGNED:We assembled a multidisciplinary team and collected baseline data on discharge communication frequency and quality. We used quality improvement tools to implement a higher-quality system. The outcome measure was the successful delivery of a standardized notification and discharge summary to a PCP. We collected qualitative data through multidisciplinary meetings and direct feedback. The balancing measures comprised additional time spent during the discharge process and relaying erroneous information. We used a run chart to track progress and drive change. RESULTS/UNASSIGNED:Baseline data indicated that 67% of PCPs did not receive notifications before discharge, and when PCPs did receive notifications, the discharge plans were unclear. PCP feedback led to proactive electronic communication and a standardized notification. The key driver diagram allowed the team to design interventions that led to sustainable change. After multiple Plan-Do-Study-Act cycles, delivery of electronic PCP notifications occurred more than 90% of the time. Surveys of pediatricians who received notifications indicated that the notifications were highly valued and aided in the transition of care for these at-risk patients. CONCLUSION/UNASSIGNED:A multidisciplinary team, including community pediatricians, was key to improving the rate of PCP notification of NICU discharge to more than 90% and transmitting higher-quality information.

OBJECTIVE:To assess the incidence of intracranial hemorrhage (ICH), including intraventricular hemorrhage, in infants receiving 4.2% or 8.4% sodium bicarbonate. METHODS:This is a single-center retrospective chart review of neonates and infants with a gestational age (GA) >32 weeks and a postnatal age <2 months who received sodium bicarbonate in an intensive care unit at an academic tertiary children's hospital. The primary outcome was the incidence of ICH in patients with baseline and follow-up head imaging. The secondary outcome was the incidence of ICH on follow-up head imaging, with or without baseline head imaging. RESULTS:There were 351 patients screened, with 135 meeting inclusion criteria. Of these, 84% were born ≥37 weeks GA. Forty-two met the criteria for the primary outcome. Study participants were further subdivided into 3 groups based on the concentration of sodium bicarbonate received: only 4.2%, only 8.4%, or a mixed group that received at least 1 dose each of 4.2% and 8.4%. Intracranial hemorrhage was noted in 1 patient in each group: 8.3%, 5.6%, and 8.3%, respectively (p = 1.00). For the secondary outcome, 11 ICHs were seen on head imaging: 11.3%, 3.8%, and 10%, respectively. There was no statistically significant difference in the incidence of ICH (p = 0.325). CONCLUSIONS:The incidence of ICH in term neonates and infants was not significantly different in those receiving 4.2% vs 8.4% sodium bicarbonate. Although additional studies are needed, this study suggests it may be possible to safely expand the use of 8.4% in neonates/infants ≥37 weeks GA. These results should not be applied to preterm neonates (<37 weeks GA and/or <1500 g) or neonates with additional ICH risk factors.

Coronavirus disease 2019 (COVID-19) pandemic caused significant mortality and morbidity in people of all age groups worldwide. Given the uncertainty regarding the mode of transmission and potential effects of COVID-19 on pregnant mothers and their newborns, guidelines for taking care of maternal-newborn dyads have evolved tremendously since the pandemic began. There has been an enormous influx of published materials regarding the outcomes of mothers and newborns. Still, multiple knowledge gaps regarding comprehensive information about risk to the mothers and newborns exist, which need to be addressed. Current evidence suggests that mothers with symptomatic COVID-19 infection are at increased risk of severe illness during pregnancy, with a higher need for respiratory support and premature deliveries. Neonates born to mothers with COVID-19 are at increased risk of needing intensive care; however, most newborns do well after birth. As new mutant variants arise, we need to be cautious while proactively understanding any new evolving patterns. All leading health authorities strongly recommend COVID-19 vaccination before or during pregnancy to reduce the risk of maternal morbidities and benefit from passing antibodies to newborns prenatally and via breastmilk. Additionally, there are racial, ethnic, and socioeconomic disparities in outcomes and vaccination coverage for pregnant women. This article summarizes the rapidly evolving evidence for the last 1.5 years and aims to help health care professionals care for mothers with COVID-19 and their newborns. KEY POINTS: · COVID-19 in pregnancy can cause perinatal morbidities.. · Breastfeeding and breast milk are safe for newborns.. · COVID-19 vaccination reduces the risk for morbidities..

Near-infrared spectroscopy (NIRS) is a technology that is easy to use and can provide helpful information about organ oxygenation and perfusion by measuring regional tissue oxygen saturation (rSO2) with near-infrared light. The sensors can be placed in different anatomical locations to monitor rSO2 levels in several organs. While NIRS is not without limitations, this equipment is now becoming increasingly integrated into modern healthcare practice with the goal of achieving better outcomes for patients. It can be particularly applicable in the monitoring of pediatric patients because of their size, and especially so in infant patients. Infants are ideal for NIRS monitoring as nearly all of their vital organs lie near the skin surface which near-infrared light penetrates through. In addition, infants are a difficult population to evaluate with traditional invasive monitoring techniques that normally rely on the use of larger catheters and maintaining vascular access. Pediatric clinicians can observe rSO2 values in order to gain insight about tissue perfusion, oxygenation, and the metabolic status of their patients. In this way, NIRS can be used in a non-invasive manner to either continuously or periodically check rSO2. Because of these attributes and capabilities, NIRS can be used in various pediatric inpatient settings and on a variety of patients who require monitoring. The primary objective of this review is to provide pediatric clinicians with a general understanding of how NIRS works, to discuss how it currently is being studied and employed, and how NIRS could be increasingly used in the near future, all with a focus on infant management.

OBJECTIVE: The study aimed to evaluate the effects of inhaled iloprost on oxygenation indices in neonates with persistent pulmonary hypertension of the newborn (PPHN). STUDY DESIGN/METHODS:) were recorded. RESULTS: < 0.05), with no significant change in required mean airway pressure over that same period. There was no change in vasopressor use or clinically significant worsening of platelets count, liver, and kidney functions after initiating iloprost. CONCLUSION/CONCLUSIONS: Inhaled iloprost is well tolerated and seems to have beneficial effects in improving oxygenation indices in neonates with PPHN who do not respond to iNO. There is a need of well-designed prospective trials to further ascertain the benefits of using inhaled iloprost as an adjunct treatment in neonates with PPHN who do not respond to iNO alone. KEY POINTS/CONCLUSIONS:· Inhaled iloprost seems to have beneficial effects in improving oxygenation indices in PPHN.. · Inhaled iloprost is generally well tolerated in newborns with PPHN.. · There is a need for prospective RCTs to further ascertain the benefits of using inhaled iloprost..

OBJECTIVE:The use of oral dextrose gel (DG) reduces IV dextrose use. Prior studies used weight-based dosing (WD), though barriers exist, and are mitigated using standard dosing (SD). Our outcomes include IV dextrose use, NICU admissions, breastfeeding, adverse events, and assessment of WD vs SD. STUDY DESIGN/METHODS:Retrospective chart review comparing pre-DG, WD, and SD in 16490 newborns (1329 hypoglycemic) ≥ 35 weeks admitted to the nursery over 3 years. RESULTS:There was reduction in IV dextrose use 10.9% vs 6.5% (p = 0.004) and NICU admissions 27.9% vs 16.1% (p < 0.001) associated with DG use, and increased rate of breastfed infants 33.8% vs 43.5% (p = 0.001), with no difference between WD and SD. No difference noted in adverse events across the study period. CONCLUSIONS:DG utilization is associated with reduced IV dextrose use, NICU admissions, and improved breastfeeding rates without changes in adverse events. We offer SD as a safe alternative to WD.