Faculty Bibliography

BACKGROUND: Nearly one third of US parents have limited health literacy, therefore lacking the full capability of making appropriate health decisions for themselves, and for their children. Despite the importance of addressing parent health literacy, the most commonly used health literacy instruments utilized in research were developed and validated in older adult populations, and may have reduced discriminative predictive validity in younger adults (40 years old and younger). As part of a larger controlled study of pediatric liquid medication dosing, we examined the performance of three health literacy measures, BHLS (Brief Health Literacy Screen), S-TOFHLA (Short Test of Functional Health Literacy in Adults) and NVS (Newest Vital Sign) in a diverse, younger parent population.
METHOD(S): We used data from a randomized controlled study of strategies to improve medication label and dosing tools, and reduce parental error in dosing liquid medicines. Parents and legal guardians, 18 years or older, were recruited in pediatric outpatient clinics in New York, NY, Atherton, CA and Atlanta, Georgia. Parents were eligible if they identified as caregivers for their child of 8 years or younger. Kappa statistics were used to assess the agreement between BHLS, S-TOFHLA and NVS. Multivariate logistic regressions were performed to assess the associations between these health literacy measures and making a medication dosing error (>20% deviation from correct dose). Additionally, ROC curves and contrasts were used to compare the predictive validity of these measures.
RESULT(S): Of the 1,956 parents, 92% were mothers of young children, with a mean age of 28. Over half of the parents identified as Hispanic, and nearly one-third reported low English proficiency and grade school as their highest educational attainment. According to the BHLS, 98% self-identified as having adequate health literacy, whereas, 85% of them were classified as having adequate health literacy by S-TOFHLA and only 23% by the NVS measure. Weak agreements between NVS and S-TOFHLA (kappa=0.13; 95%CI:0.11-0.14), and NVS and BHLS (kappa=0.03; 95% CI:0.0048- 0.02) were observed. Adequate health literacy, by all the measures, was associated with lower probability of making a dosing error (BHLS: aOR=0.52, p<0.001; S-TOFHLA: aOR=0.47, p<0.001; NVS: aOR=0.53, p<0.001). However, ROC contrasts estimates show significant differences between the predictive validity of BHLS and NVS (-0.01; p<0.001), and STOFHLA and BHLS (0.01; p<0.001). The ROC contrasts showed no significant differences between S-TOFHLA and NVS (-0.003; p=0.36).
CONCLUSION(S): Our analysis found the BHLS and S-TOFHLA to be poor assessments of health literacy with significant ceiling effects when administered to a younger, ethnically diverse, primarily female, adult parent population. The NVS, an objective health literacy measure, may perform better in younger adults than subjective measures such as BHLS, and measures with questionable discriminative and predictive validity, such as S-TOFHLA

In January 2020, China reported a cluster of cases of pneumonia associated with a novel pathogenic coronavirus provisionally named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2). Since then, Coronavirus Disease 2019 (COVID-19) has been reported in more than 180 countries with approximately 3 million known infections and more than 210,000 deaths attributed to this disease. The majority of confirmed COVID-19 cases have been reported in adults, especially older individuals with co-morbidities. Children have had a relatively lower rate and a less serious course of infection as reported in the literature to date. One of the most vulnerable pediatric patient populations is cared for in the neonatal intensive care unit. There is limited data on the effect of COVID-19 in fetal life, and among neonates after birth. Therefore there is an urgent need for proactive preparation, and planning to combat COVID-19, as well as to safeguard patients, their families, and healthcare personnel. This review article is based on the Centers for Disease Control and Prevention's (CDC) current recommendations for COVID-19 and its adaptation to our local resources. The aim of this article is to provide basic consolidated guidance and checklists to clinicians in the neonatal intensive care units in key aspects of preparation needed to counter exposure or infection with COVID-19. We anticipate that CDC will continue to update their guidelines regarding COVID-19 as the situation evolves, and we recommend monitoring CDC's updates for the most current information.

BACKGROUND:Healthcare spending is expected to grow faster than the economy over the next decade, and the cost of prematurity increases annually. The aim of this study was to investigate the frequency of intervention after routine laboratory testing in preterm infants. METHODS:This was a retrospective study of preterm infants (≤34 weeks) admitted to the NYU Langone Health NICU from June 2013 to December 2014. Data collected included demographics, results of laboratory tests, and resulting interventions. Intervention after a hemogram was defined as a blood transfusion. Intervention after a hepatic panel was defined as initiation or termination of ursodiol or change in dose of vitamin D. Subjects were stratified into 3 groups based on gestation (<28 weeks, 28-31 6/7 weeks, 32-34 weeks). Chi-square analysis was used to compare the frequency of intervention between the groups. RESULTS:A total of 135 subjects were included in the study. The frequency of intervention after a hemogram was 8.4% in infants <28 weeks, 4.6% in infants 28-31 6/7 weeks, and 0% in infants 32-34 weeks; this difference was found to be statistically significant (p = 0.02). The frequency of intervention after a hepatic panel was 4.2% in infants <28 weeks, 5.7% in infants 28-31 6/7 weeks, and 0% in infants 32-34 weeks, which was not found to be a statistically significant different. CONCLUSION/CONCLUSIONS:No interventions were undertaken post-routine laboratory testing in any infant 32-34 weeks and routine testing in this population may be unnecessary. Further studies are needed to elucidate if routine testing affects neonatal outcomes.

OBJECTIVE:To compare the electrical activity of the diaphragm (Edi) of premature infants placed on continuous positive airway pressure (CPAP) with the Edi of premature infants placed on noninvasive neurally adjusted ventilatory assist (NIV NAVA). The secondary aim was to evaluate the feasibility of the use of NIV NAVA mode in the busy tertiary neonatal unit. STUDY DESIGN/METHODS:This was a prospective crossover pilot study of premature infants requiring noninvasive respiratory support. Infants were randomized to initially receive either CPAP/biphasic (group 1) or NIV NAVA (group 2) and were then crossed over to the alternate group. Continuous Edi signals were recorded for 24 h, with 12 h each on CPAP/biphasic, and NIV NAVA along with other clinical and respiratory parameters.  Results: Ten infants with a mean gestation age of 29 weeks (range 25-34 weeks) were enrolled, with a total cumulative Edi monitoring of 240 h. The average Edi peak on the biphasic/CPAP group (15.6 ± 7 mcV) was significantly higher (P < 0.005), compared to the Edi Peak on the NIV NAVA group (10.8 ± 3.3 mcV). The Edi min values were 3.23 ± 1.1 mcV, and 3.07 ± 0.5 mcV on CPAP/biphasic and NIV NAVA (P = 0.69) respectively. There were no significant differences in other clinical parameters between the two groups. No major adverse events were recorded during Edi catheter monitoring. CONCLUSION/CONCLUSIONS:The Edi peak values were significantly lower in NIV NAVA mode compared to CPAP/biphasic mode. The Edi catheter and NIV NAVA may also be used safely in premature infants.

OBJECTIVE: To determine longitudinal measurements of resting energy expenditure (REE) by indirect calorimetry (IC) in healthy term infants during the first 2 months of life. STUDY DESIGN/METHODS:) with IC in a respiratory and metabolic steady state. RESULTS:production measurements were 9.3 ± 2.0 and 7.7 ± 1.2 mL/kg/min and 8.1 ± 2.2 and 6.4 ± 1.1 mL/kg/min at 1 and 2 months of age, respectively. CONCLUSION/CONCLUSIONS: This pilot study demonstrates longitudinal measurements of REE by IC in healthy term infants during the first 2 months of life. We also demonstrate that, overall, there is consistency in REE values in this population, with a likely decrease in individual longitudinal measurements over the first 2 months of life.

PURPOSE/OBJECTIVE:We conducted a consented pilot newborn screening (NBS) for Pompe, Gaucher, Niemann-Pick A/B, Fabry, and MPS 1 to assess the suitability of these lysosomal storage disorders (LSDs) for public health mandated screening. METHODS:At five participating high-birth rate, ethnically diverse New York City hospitals, recruiters discussed the study with postpartum parents and documented verbal consent. Screening on consented samples was performed using multiplexed tandem mass spectrometry. Screen-positive infants underwent confirmatory enzymology, DNA testing, and biomarker quantitation when available. Affected infants are being followed for clinical management and long-term outcome. RESULTS:Over 4 years, 65,605 infants participated, representing an overall consent rate of 73%. Sixty-nine infants were screen-positive. Twenty-three were confirmed true positives, all of whom were predicted to have late-onset phenotypes. Six of the 69 currently have undetermined disease status. CONCLUSION/CONCLUSIONS:Our results suggest that NBS for LSDs is much more likely to detect individuals at risk for late-onset disease, similar to results from other NBS programs. This work has demonstrated the feasibility of using a novel consented pilot NBS study design that can be modified to include other disorders under consideration for public health implementation as a means to gather critical evidence for evidence-based NBS practices.

Background Maternal chorioamnionitis is a risk factor for sepsis but, often, these infants are asymptomatic at birth. Different markers for infections, such as the immature to total (I/T) white blood cell (WBC) ratio, are used to help determine which infants require lumbar punctures (LPs), in addition to blood cultures and antibiotics. The timing of when the complete blood count (CBC) is obtained may have some effect on the length of antibiotic treatment. Aims The purpose of this proof-of-concept study was to assess if obtaining a CBC at greater than four hours of life as compared to less than four hours of life has an impact on the incidence of LPs performed in asymptomatic, full-term infants undergoing evaluation for sepsis secondary to maternal chorioamnionitis. Methods We performed a retrospective study of full-term, asymptomatic infants admitted for sepsis evaluation secondary to maternal chorioamnionitis. Subjects were grouped based upon the timing of their initial CBC (early = < four hours of life or late = > four hours of life). The incidence of LPs, duration of antibiotic treatment, and length of hospitalization were compared between the groups. Results A total of 230 subjects were included in the study (early group = 124, late group = 106). Subjects in the late group underwent significantly fewer LPs than subjects in the early group, 5.7% vs. 22.6% (p<0.001). There was no difference in length of treatment or hospitalization. Conclusions Asymptomatic full-term infants undergoing evaluation for sepsis secondary to maternal chorioamnionitis are less likely to undergo an LP if their initial CBC is obtained at greater than four hours of life.

Purpose: Extended bed rest after catheter ablation plays a major role in postprocedure recovery and ambulation time, length of stay, patient experience, and complication risks. The VASCADE MVP (Cardiva Medical, Santa Clara, CA) venous vascular closure system (VVCS), is an investigational device that delivers an extravascular, resorbable collagen plug and aims to provide ambulatory hemostasis in 2-3 hours compared to the current standard of care of 4-8 hours for manual compression (MC).
Method(s): AMBULATE was an FDA IDE, multicenter, openlabel, randomized controlled trial of VVCS vs. MC for multi-access ablation procedures. Inclusion criteria were 3-4 femoral vein sheaths (6-12F inner diameter; no more than 2 access sites per limb). Primary efficacy outcome was Time to Ambulation (TTA); secondary efficacy outcomes included Total Post Procedure Time (TPPT), Time to Discharge Eligibility (TTDe) and Time to Hemostasis (TTH). Safety endpoints were 30-day major and minor complications, measured by limb, and powered for non-inferiority to MC. A prespecified 30-day ultrasound sub-study (25 subjects per arm) was conducted in addition to collection of pain medication usage during bedrest and a patient reported satisfaction survey at discharge. Database was locked April 2018.
Result(s): 204 eligible patients across 28 operators and 13 sites were randomized to receive VVCS (100 patients; 369 access sites) or MC (104 patients; 382 access sites). Demographic, baseline, and procedural characteristics were similar between groups (Table 1). Anticoagulant or antiplatelet therapy was reported in 84% of patients in the VVCS group and 85% of patients in the MC group. Mean TTA, TPPT, TTDe, and TTH were all substantially lower in the VVCS arm (Table 1). Post-procedural pain medication and opioid use were also substantially lower in the VVCS arm (Table 1). There were no major access-site complications in either group including those within the ultrasound sub-study. Minor complications were non-inferior with 1.0% in the VVCS arm and 2.4% in the MC arm. In the ultrasound sub-study, minor complications were 0.0% in the VVCS arm and 4.0% in the MC arm. Patient satisfaction for length of bed rest and comfort during bed rest were 63% and 36% higher with VVCS vs. MC (P<.0001 for both). Patient reported pain scores during bedrest were 25% lower (P=.001) with VVCS vs. MC and 40% lower (P=.002) for subjects with a previous ablation.
Conclusion(s): Use of the VVCS for multi-access ablation procedures resulted in significant reductions in TTA, TPPT, TTH, TTDe and opioid use, with increased patient satisfaction and no increase in complications

BACKGROUND:Following neonatal resuscitation program (NRP) training, decay in clinical skills can occur. Simulation-based deliberate practice (SBDP) has been shown to maintain NRP skills to a variable extent. Our study objectives were (a) to determine whether a single 30 min simulation-based intervention that incorporates SBDP and mastery learning (ML) can effectively restore skills and prevent skill decay and (b) to compare different timing options. METHODS:Following NRP certification, pediatric residents were randomly assigned to receive a video-recorded baseline assessment plus SBDP-ML refresher education at between 6 and 9 months (early) or between 9 and 12 months (late). One year following initial certification, participants had repeat skill retention videotaped evaluations. Participants were scored by blinded NRP instructors using validated criteria scoring tools and assigned a global performance rating score (GRS). RESULTS:Twenty-seven participants were included. Residents in both early and late groups showed significant skill decay 7 and 10 months after initial NRP. SBDP-ML booster sessions significantly improved participants' immediate NRP performance scores (p<0.001), which persisted for 2 months, but were again lower 4 months later. CONCLUSIONS:NRP skills may be boosted to mastery levels after a short SBDP-ML intervention and do not appear to significantly decline after 2 months. Brief booster training could potentially serve as a useful supplement to traditional NRP training for pediatric residents.

Therapeutic hypothermia (TH) is provided to newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE) to improve survival and long-term neurodevelopmental outcomes. Although the benefits certainly outweigh the risks associated with therapeutic hypothermia, it is important to be mindful of potential rare side effects in the background of asphyxia-related injury to various body organs. One of those side effects includes subcutaneous fat necrosis (SCFN) that can occur in term newborns after perinatal hypoxia-ischemia or other stressing factors such as systemic hypothermia. It is usually a self-limited condition, however, in some cases, it can lead to severe hypercalcemia. We report three such cases of SCFN in newborns with HIE treated with TH. Due to potential long-term complications, such as metastatic calcifications, caregivers should be informed about this potential complication prior to discharge from hospital so that they can help diagnose or continue to monitor cases of severe hypercalcemia.