Current studies are focused on improving ED triage and identifying risk factors for functional limitations in adolescents following major trauma.
Study finds that use of pediatric hospitalists results in lower costs and shorter hospital stays.
According to this review, the use of pediatric hospitalists results in lower hospital costs and shorter stays for hospitalized children. This approach does not adversely affect the experiences of the referring physician, parent, or hospital housestaff. The researchers reviewed 20 studies and found an average decrease of 10 percent in both cost and length of stay. Data on quality of care were insufficient to draw conclusions.
Landrigan, Conway, Edwards, and Srivastava, Pediatrics 117(5):1736-1744, 2006 (AHRQ grant HS13333).
Children who have surgery for hypoplastic left heart syndrome fare better at more experienced hospitals.
Treatment options for children born with hypoplastic left heart syndrome (HLHS)—a congenital anomaly in which the entire left side of the heart is underdeveloped—include palliation shortly after birth, heart transplantation, or comfort care. For this study, researchers examined in-hospital mortality rates for 754 infants with HLHS in 1997 and 880 infants in 2000. In 1997, children undergoing palliation surgery in teaching hospitals were 2.6 times as likely to die as those having surgery at nonteaching hospitals.
By 2000, however, palliation surgery was centralized at teaching hospitals. This centralization, along with medical and surgical advances, was associated with an overall decrease in mortality from 28 to 24 percent. Yet mortality rates continued to approach 50 percent at hospitals that performed only one or two of these surgeries a year, compared with 19 percent for high-volume hospitals.
Berry, Cowley, Hoff, and Srivastava, Pediatrics 117(4):1307-1313, 2006 (AHRQ grant HS11826).
Children's hospitals are much more likely that general hospitals to diagnose child abuse in severely injured infants.
Researchers examined abuse diagnosis by hospital type for children less than 1 year of age and found that children's hospitals are more than twice as likely as general hospitals to diagnose child abuse in severely injured infants (29 vs. 13 percent, respectively). General hospitals with a children's unit identified more abuse cases (19 percent) than general hospitals without a children's unit but fewer than a children's hospital. Nearly half (49 percent) of the infants studied were admitted to general hospitals, one-fourth were admitted to general hospitals with children's units, and one-fourth were admitted to a children's hospital. Infants treated at children's hospitals tended to be younger, more severely injured, and more likely to have private health insurance than those cared for at general hospitals. The researchers suggest that the variation in abuse diagnosis may result from systematic underdiagnosis of abuse in general hospitals.
Trokel, Wadimmba, Griffith, and Sege, Pediatrics 117(3):722-728, 2006 (AHRQ grant T32 HS00060).
Hospitalization rate for children with cat-scratch disease remains stable.
Despite an increase in cat ownership from 1980 to 2000, the rate of children hospitalized for cat-scratch disease in 2000 was similar to that of the 1980s. Typically, cat-scratch disease is benign and self-limited and is characterized by enlarged lymph nodes and fever. However, atypical cat-scratch disease infections can be accompanied by inflammatory responses that lead to hospitalization. During 2000, there were an estimated 437 hospitalizations for cat-scratch disease in children younger than 18. Hospital stays were as long as 19 days for typical cases and 22 days for atypical cases. The median charge was $6,140, with total annual hospital charges of about $3.5 million.
Reynolds, Holman, Curns, et al., Pediatr Infect Dis J 24(8):700-704, 2005 (Intramural).
Children who are in the ICU and have arterial catheters are at elevated risk of dying from blood infections.
Among 168 hospitalized children with positive blood cultures for Candida blood infections, 17 percent died within 1 month of the first positive culture. Children in the pediatric ICU at the time of infection were 6.3 times as likely as other children to die within 30 days, and those with an arterial line were 2.4 times as likely as other children to die within 30 days. The study involved children who were inpatients at one large hospital during the period 1998-2001.
Zaoutis, Coffin, Chu, et al., Pediatr Infect Dis J 24(8):736-739, 2005 (AHRQ grant HS10399).
Limiting use of broad-spectrum antibiotics may reduce life-threatening infections in hospitalized children.
Curtailed use of broad-spectrum cephalosporin antibiotics in children at high risk for Escherichia coli or Klebsiella species infections may reduce the incidence of such infections, according to this study. The researchers used laboratory data from the Children's Hospital of Philadelphia from May 1, 1999 to September 30, 2003 to identify children with bloodstream infections and pinpoint risk factors for such infections.
Zaoutis, Goyal, Chu, et al., Pediatrics 115(4):942-949, 2005 (AHRQ grant HS10399).
Postoperative staph infection of a child's chest cavity is a risk factor for bloodstream infection.
Up to 4 percent of children who undergo surgery that involves cutting the breastbone develop infections of the chest cavity. Children who develop postoperative chest cavity infections due to Staphylococcus aureus are much more likely to develop a bloodstream infection than children whose chest cavity infections are caused by other pathogens, according to this study. The researchers studied hospital data on 43 children who developed chest cavity infections after surgery between 1995 and 2003 at one urban children's hospital.
Shah, Lautenbach, Long, et al., Pediatr Infect Dis J 24(9):834-837, 2005 (AHRQ grant HS10399).
Children commonly suffer from bacterial infections after stem cell transplant.
Researchers studied 182 pediatric patients who underwent their first hematopoietic stem cell transplant for cancer and received gut decontamination with antibiotics at one children's hospital from 1999 to 2002. They examined the impact of several factors on infection, including stem cell source, donor, recent bacteremia, and graft versus host disease prophylaxis agents. Overall, 41 percent of patients developed bacterial infections. The majority were Gram-positive cocci, consistent with recent trends in immunocompromised patients.
Kersun, Propert, Lautenbach, et al., Pediatr Blood Cancer 45:162-169, 2005 (AHRQ grant HS10399).
Perforated appendicitis disproportionately affects Medicaid-insured and minority children.
In one-third of children who have appendicitis, the appendix ruptures before surgery, leading to more complications and longer hospital stays. Ruptured appendix usually results from delayed diagnosis and treatment and occurs more often among minority and Medicaid-insured children. Researchers used 1997 data from AHRQ's Kid's Inpatient Database of pediatric hospital discharges from 22 States to determine patient and hospital characteristics associated with perforated appendicitis.
Smink, Fishman, Kleinman, and Finkelstein, Pediatrics 115(4):920-925, 2005 (AHRQ grant T32 HS00063).
Rural hospitals appear to deliver care comparable to nonrural hospitals for many common pediatric conditions.
According to this study, the more than 20 percent of children in the United States who live in rural communities receive hospital care that is comparable to care provided in nonrural hospitals. Except for children hospitalized in large metropolitan areas, the study found no differences in length of stay or readmission rates for children with 19 medical and 9 surgical diagnoses who were treated at rural and nonrural hospitals in New York and Pennsylvania.
Lorch, Zhang, Rosenbaum, et al., Pediatrics 114(4), 2004; available online at www.pediatrics.org (AHRQ grants HS09983 and T32 HD07740).
Less than 10 percent of children with out-of-hospital cardiac arrest survive.
Despite prolonged CPR and multiple doses of epinephrine, only 9 percent of children who suffer an out-of-hospital cardiopulmonary arrest survive. According to this study, efforts to prevent conditions leading to out-of-hospital arrest—such as near-drowning and poisoning—and community outreach to improve the rate of bystander CPR may have a greater impact on survival than better therapeutic methods and changes to EMS protocols.
Young, Gausche-Hill, McClung, and Lewis, Pediatrics 114(1):157-163, 2004 (AHRQ grant HS09065).
Prolonged Candida infections in children with central venous catheters can have serious consequences.
Hospitalized children with central venous catheters in place who have a Candida infection lasting more than 3 days are three times as likely as other children to develop bloodstream infection that affects internal organs. Candida is a yeast-like fungus that is the fourth most common cause of hospital-induced bloodstream infections in the United States.
Zaoutis, Greves, Lautenbach, et al., Pediatr Infect Dis J 23(7):635-641, 2004 (AHRQ grant HS10399).
Parents will travel to distant hospitals to achieve better outcomes for children who need cardiac surgery.
According to this study, nearly two-thirds of parents are willing to travel for an extra 2 hours to a referral hospital to reduce the mortality risk from 4 to 3 percent for pediatric heart surgery. This finding is based on interviews with 103 parents or adult primary caregivers of children referred to a pediatric cardiology clinic.
Chang, Joyce, Castillo, et al., Can J Cardiol 20(9):877-882, 2004 (AHRQ grant HS13217).
GI disorders are a leading cause of hospitalization in children.
Excluding normal newborn infants and conditions related to pregnancy, gastrointestinal (GI) disorders were the third leading cause of hospitalization of children in 1997. In that year, there were about 330,000 pediatric discharges associated with a principal GI diagnosis in the United States. These discharges accounted for more than 1.1 million hospital days and $2.6 billion in hospital charges.
Guthery, Hutchings, Dean, and Hoff, J Pediatr 144:589-594, 2004 (AHRQ grant HS11826).
Few pediatric ER workers have received the smallpox vaccine.
Although most pediatric ER workers say they are willing to receive the smallpox vaccine, few had done so after the first year of the national vaccination program. A 2002 survey in the weeks before the start of the program found that 72 percent of those surveyed were willing to receive the vaccine. However, fewer than 20 percent of targeted health care workers had been immunized as of October 31, probably because of concerns about vaccine-related adverse events.
Everett, Zaoutis, Halpern, et al., Pediatr Infect Dis J 23(4):331-337, 2004 (AHRQ grant HS10399).
Appendicitis is the most common surgical emergency in children.
Appendicitis requires prompt treatment because of the risk of perforation, but its diagnosis continues to be a challenge for clinicians. Between 5 and 25 percent of children with suspected appendicitis are found to have a normal appendix during surgery. These unnecessary surgeries were cut nearly in half at one hospital with use of a clinical guideline and selective use of CT scans and ultrasound as recommended by the guideline.
Smink, Finkelstein, Pena, et al., J Pediatr Surg 39(3):458-463, 2004 (AHRQ grant T32 HS00063).
Better education for children and parents could reduce pediatric hospitalizations.
Many pediatric hospitalizations might be avoided if parents and children were better educated about the child's condition, medications, need for followup care, and the importance of avoiding known disease triggers. For this study, the researchers surveyed inpatient attending physicians and the parents of 554 children who were admitted to an urban hospital over a 14-month period with avoidable hospitalization conditions (AHCs), such as urinary tract conditions and asthma. The researchers found that 13 percent of the hospitalizations could have been avoided.
Flores, Abreu, Chaisson, and Sun, Pediatrics 112(5):1021-1030, 2003.
Also: Lee, Baraff, Wall, et al., Clin Pediatr 42:613-619, 2003 (AHRQ
grant HS10604).
Also: Winickoff, Buckley, Palfrey, et al., Pediatrics 112(5):1127-1133,
2003 (AHRQ grant T32 HS00063).
Conflicts are common between clinicians and parents of critically ill children.
Nearly half of the children treated in a pediatric intensive care unit (PICU) for more than 8 days had some conflict associated with their care, according to this study. Most conflicts involved disagreement between clinicians and family members, but they also occurred among clinicians (e.g., between intensive care doctors and surgical specialists). Conflicts most often involved minority patients (45 vs. 25 percent) and patients who had Medicaid coverage (43 vs. 14 percent). Ethics consultations and family meetings can resolve most conflicts and improve PICU quality of care.
Studdert, Burns, Mello, et al., Pediatrics 112(3):553-558, 2003 (AHRQ grant K02 HS11285).
Hospital type and experience determine tracheotomy outcomes.
Researchers examined tracheotomy rates and patient outcomes in 1997 using hospital discharge records from 22 States. Children cared for in children's hospitals or in teaching hospitals were significantly less likely to be discharged to a long-term care facility. Hospitals performing more pediatric tracheotomies had significantly lower mortality rates than hospitals performing fewer of these surgeries.
Lewis, Carron, Perkins, et al., Arch Otolaryngol Head Neck Surg 129:523-529, 2003 (AHRQ grant HS00002).
Pastoral care providers explain spiritual care needs.
Pastoral care providers from 115 hospitals in 42 States responded to a survey about their perceptions of the spiritual care needs of hospitalized children and their parents, barriers to better care, and the quality of spiritual care in children's hospitals. Most agreed that empathetic listening, praying with children and families, touch and silent communication, and religious rituals or rites were very effective.
Feudtner, Haney, and Dimmers, Pediatrics 111(1):e67, 2003, online at www.pediatrics.org (AHRQ grant K08 HS0002).
Despite the debilitating nature and prevalence of mental health problems in children, many disorders continue to be underdiagnosed and inadequately treated. AHRQ-funded research focuses on improving delivery of mental health care in primary care practice.
Use of antidepressants among children increased significantly from 1997 to 2002.
Overall use of antidepressants among children increased from 0.9 million children (1.3 percent) in 1997 to 1.4 million children (1.8 percent) in 2002. This increase was driven by a doubling in antidepressant use by adolescents, from 2.1 percent in 1997 to 3.9 percent in 2002, with no change in use among children younger than age 13. This finding is consistent with the higher prevalence of depression in adolescents (about 6 percent) than in younger children (about 2 percent). The increase in antidepressant use was most evident in groups that previously had lower levels of use, such as girls, blacks, and low-income children. By 2002, there were no significant differences in antidepressant use related to a child's race, sex, or family income.
Vitiello, Zuvekas, and Norquest, J Am Acad Child Adolesc Psychiatry 45(3):271-279, 2006 (AHRQ Publication No. 06-R037)* (Intramural).
Cognitive behavioral therapy used with antidepressants offers additional benefits to adolescents with depression.
This study involved 152 adolescents aged 12 to 18 with major depressive disorder who were in treatment at an HMO pediatric primary care practice. They were randomly assigned to receive antidepressants alone or antidepressants plus brief cognitive behavioral therapy. Adolescents who received the combination treatment used approximately 20 percent less medication than those who received medication only. The researchers note that these results are consistent with recent studies indicating that depressed youths only reluctantly take antidepressant medication and look for opportunities to discontinue it.
Clarke, Debar, Lynch, et al., J Am Acad Child Adolesc Psychiatry 44(9):888-898, 2005 (AHRQ grants HS10535 and HS13854).
Mental health problems among children who have special health care needs and their caregivers are barriers to care.
The mental health problems of children with special health care needs and their caregivers appear to be barriers to obtaining needed care, according to this study. In a survey of a random sample of 1,088 caregivers in Washington, DC, in 2002, the researchers asked about children's unmet needs, mental health status, and the caregivers' mental health status. Caregivers with symptoms of depression were much more likely than those without depression to report children's unmet needs for hospital and physician care, mental health services, and other types of health care. Most of the children were black and urban, so these findings may differ for children of other races and those living in rural areas.
Gaskin and Mitchell, J Ment Health Policy Econ 8:29-35, 2005 (AHRQ grant HS10912).
Despite questions about efficacy and safety, use of atypical antipsychotic drugs in children continues.
Atypical antipsychotic drugs, such as risperidone and clozapine, are approved to treat schizophrenia in adults but not children. Some studies suggest more prevalent and serious side effects in children and adolescents, such as weight gain and sedation. Nevertheless, this study found that nearly one-fourth of children and adolescents with prescription claims for these drugs were aged 9 or younger. Since schizophrenia is seldom diagnosed before adolescence, it is likely that these drugs are being prescribed to treat behavior disorders such as ADHD, conclude the researchers.
Curtis, Masselink, Ostbye, et al., Arch Pediatr Adolesc Med 159:362-366, 2005 (AHRQ grant HS10385).
Improving primary care access to effective treatment for adolescent depression improves outcomes.
This randomized controlled trial involved 418 primary care patients aged 13-21 with depression who were enrolled in managed care and treated between 1999 and 2003. Subjects were randomized to either quality improvement (intervention) or usual care (control). After 6 months, intervention patients reported significantly fewer depressive symptoms than usual care patients, higher quality of life scores, and greater satisfaction with mental health care.
Asarnow, Jaycox, Duan, et al., JAMA 293(3):311-319, 2005 (AHRQ grant HS09908).
Many children who have special needs for physical health care also have mental health problems.
Over one-third of children with special health care needs for a physical problem also have a mental health problem, but only one-quarter of caregivers recognize the children's need for mental health services. The researchers recommend that mental health screenings and assessments be incorporated as a routine part of primary health care for these children.
Canty-Mitchell, Austin, Jaffee, et al., Arch Psychiatr Nurs 18(3):79-87, 2004 (AHRQ grant HS10453).
Use of antipsychotic medications has nearly doubled among children enrolled in Tennessee Medicaid.
Nearly 1 of every 100 adolescents enrolled in TennCare, Tennessee's program for the uninsured and Medicaid, became a new user of an antipsychotic drug in 2001. Study findings show that much of this increase was due to prescribing of antipsychotics for nonpsychotic conditions, such as attention-deficit/hyperactivity disorder, conduct disorder, and affective disorders.
Cooper, Hickson, Fuchs, et al., Arch Pediatr Adolesc Med 158:753-759, 2004 (HS10384).
Psychosocial adjustment problems may affect some disabled school children.
Disabled children with learning impairments and family burdens such as poverty or maternal depression are more likely than other disabled children to have poor psychosocial adjustment, according to this study. When mothers reported that the child's disability caused a work, sleep, or financial burden and when families were poor, children were about twice as likely to have poor psychosocial adjustment as other children without these problems.
Witt, Riley, and Coiro, Arch Pediatr Adolesc Med 157(7):687-695, 2003 (AHRQ grants HS11254 and T32 HS00063).
Four million babies are born each year in the United States. AHRQ's current research focuses on improving the babies' health outcomes, promoting breastfeeding, and reducing racial and ethnic disparities in access to care.
Each year, more than 1 million U.S. infants are delivered by c-section.
One-fourth of all children born in the United States each year are delivered by cesarean section. This reflects a 38 percent increase in the use of c-section since 1997, when about one-fifth of all babies were delivered this way. This rise in the use of c-sections was accompanied by a 60 percent decline in the rate of women giving birth vaginally after having a previous child born via c-section and a 33 percent rise in the rate of repeat c-sections. The national bill for childbirth as a whole in 2003 was $34 billion, with hospital stays involving c-section delivery accounting for nearly half this amount ($15 billion). Medicaid was billed for 43 percent of childbirths overall and 41 percent of those involving c-section.
These data were drawn from AHRQ's Healthcare Cost and Utilization Project (HCUP).
Hospitalizations Related to Childbirth, 2003, Statistical Brief 11, is available at www.hcup-us.ahrq.gov/reports/statbriefs.jsp (Intramural).
Teamwork in the delivery room is closely related to the quality of neonatal resuscitation.
Independent observers viewed recordings of the resuscitation of infants born by cesarean section and assessed compliance with Neonatal Resuscitation Program guidelines. All 132 clinical teams involved in the study exhibited certain teamwork behaviors—communication, management, and leadership—that are correlated with the quality of neonatal resuscitation in the delivery room. Although these correlations do not confirm a causal relationship, they may be used in training providers on how to prevent and manage neonatal resuscitation errors.
Thomas, Sexton, Lasky, et al., J Perinatol 26:163-169, 2006 (AHRQ grant HS11164).
Infants born prematurely at 30-34 weeks gestation may have substantial health problems.
Compared with full-term infants (at least 37 weeks gestation), infants born at 30-34 weeks gestation are more than four times as likely to require assisted ventilation; they also are at greater risk for pneumothorax and meningitis. Within 3 months of hospital discharge, 11 percent of premature infants born at 30-34 weeks gestation were readmitted to the hospital. Hospital readmission was more likely among male infants and those with chronic lung disease.
Escobar, McCormick, Zupanic, et al., Arch Dis Child Fetal Neonatal Ed 91(4):F238-F244, 2006 (AHRQ grant HS10131).
Babies being cared for in the NICU are at risk for misidentification.
According to this study conducted in one neonatal intensive care unit (NICU), nearly half of infants cared for in the NICU on any given day were at risk for misidentification. Indeed, during one calendar year, there was not a single day without at least one pair of patients at risk for misidentification. Misidentification could result in an infant being given a medication, procedure, or mother's expressed breast milk intended for another infant, perhaps with serious adverse consequences. The most common reasons for misidentification risk were similar appearing medical record numbers, identical surnames, and similar sounding surnames.
Gray, Suresh, Ursprung, et al., Pediatrics 117(1):43-47, 2006 (AHRQ grant HS11583).
Catheterization may not be the best way to diagnose urinary tract infections in feverish infants.
Urinary tract infections (UTIs) are the most common cause of serious bacterial infections in feverish infants younger than 3 months. Most doctors use urethral catheterization to diagnose UTIs in young infants, but its accuracy is only marginally better than bag collection. Also, it is technically difficult, invasive, and painful. In a study of 3,066 infants aged 3 months or younger, catheterization and bag collection demonstrated similar sensitivity, but bag collection had somewhat lower specificity as indicated by more false positives. False positives are of particular concern for doctors who manage UTIs aggressively with routine hospitalization and imaging.
Schroeder, Newman, Wasserman, et al., Arch Pediatr Adolesc Med 159:915-922, 2005 (AHRQ grant HS06485).
Use of broad-spectrum antibiotics during labor is linked to late-onset serious bacterial infections in infants.
Over one-third of women in labor are given antibiotics to prevent the transmission of group B streptococcus (GBS) to their infants. Although use of intrapartum antibiotics (IPA) has been very successful in preventing neonatal GBS infection in the first week of life, this study found a relationship between IPA and the occurrence of late-onset (7 to 90 days after birth) serious bacterial infections. Also, pathogens that caused these late-onset infections were more likely to be resistant to ampicillin if the mother received ampicillin during labor. Thus, penicillin—an antibiotic that treats a narrow range of bacteria—is recommended instead of ampicillin for IPA to prevent GBS.
Glasgow, Young, Wallin, et al., Pediatrics 116(3):696-702, 2005 (AHRQ grant HS11826).
Delayed sternal closure increases the risk of infection in young infants who undergo heart surgery.
Most median sternostomies (cracking open of the rib cage to permit open heart surgery) in infants are performed within the first few weeks of life to correct life-threatening, complex congenital heart disease. Infection of the mid-sternum strikes 1.4 percent of children who undergo this procedure and 3 percent of those who have heart and lung transplant. Delayed sternal closure appears to substantially elevate the risk of infection with Gram-negative bacteria, according to this study.
Long, Shah, Lautenbach, et al., Pediatr Infect Dis J 24(4):315-319, 2005 (AHRQ grant HS10399).
Racial disparities found in survival of very low-birthweight babies.
Researchers analyzed the medical records of more than 74,000 black and white very low-birthweight (VLBW) infants treated at 332 hospitals. Hospitals were defined as minority-serving if more than 35 percent of the VLBW infants they treated were black. They found that far more black infants were treated by minority-serving hospitals than were treated at hospitals where less than 15 percent of infants were black. Both black and white VLBW babies were 28 percent more likely to die at minority-serving hospitals than at other hospitals, even though the hospitals treated similarly ill infants.
Morales, Staiger, Horbar, et al., Am J Public Health 95(12):2206-2212, 2005 (AHRQ grants HS13280 and HS10858).
Study focuses on the cost-effectiveness and utility of routine circumcision.
Eighty-six percent of male infants in the United States without a complicating diagnosis are circumcised shortly after birth. This author examines the costs and cost-effectiveness of this procedure and the importance of various sociocultural and religious precedents that support the continued use of routine circumcision.
Gray, Med Decis Making 24:688-692, 2004 (AHRQ Publication No. 05-R029)* (Intramural).
QI program improves use of recommended therapy to prevent respiratory distress in preterm infants.
Prophylactic surfactant therapy immediately after birth is recommended for preterm infants to prevent respiratory distress syndrome (RDS), but few infants routinely receive it, and many who do receive it get delayed treatment. This study showed that a collaborative quality improvement program, which included audit and feedback, reviews of the evidence on surfactant treatment, training, and ongoing faculty collaboration significantly increases the use of surfactant in the delivery room within minutes of a preterm infant's birth.
Horbar, Carpenter, Buzas, et al., Br Med J 329:1004-1010, 2004.
Also: Horbar, Carpenter, Buzas, et al., Pediatrics 113(6):1593-1602, 2004 (AHRQ
grant HS10528).
First-week followup of newborns helps to prevent severe jaundice and other problems.
These researchers identified barriers to early newborn followup to prevent jaundice, including communication difficulties, problems with systems and processes of care, and lack of parental knowledge. They recommend using E-mail to notify community-based providers about the baby's birth and to provide them with lab results. They also suggest that a pediatrician be chosen before discharge, parents be given a list of early warning signs and a call-in number to report problems, and the nursery initiate a followup call to the mother.
Salem-Schatz, Peterson, Palmer, et al., Jt Comm J Qual Safety
30(11):593-601, 2004.
Also: Chou, Palmer, Ezhuthachan, et al., Pediatrics 112(6):1264-1273, 2003.
Also: Palmer, Clanton, Ezhuthachan, et al., Pediatrics 112(6):1388-1393, 2004
(AHRQ grant HS09782).
Also: Madden, Soumerai, Lieu, et al., Pediatrics 113(1):42-49, 2004 (HS10060).
Experts offer recommendations for prevention of kernicterus.
In newborns with jaundice, blood levels of bilirubin can become high enough to result in neurotoxicity, a condition of severe jaundice called kernicterus. Left untreated, kernicterus can result in cerebral palsy, mental retardation, hearing loss, and difficulty in moving the eyes. These authors present recommendations for early identification, prevention, and treatment of kernicterus.
Bhutani, Johnson, Maisels, et al., J Perinatol 24(10):650-662, 2004 (AHRQ grant HD/HS369145).
Basing NICU referrals on outcomes data may lower U.S. infant mortality rates.
The researchers used 1994-2000 data from a collaborative network of neonatal intensive care units (NICUs) in 49 States and 22 countries to assess the potential of several approaches to improve the quality of neonatal care. NICU mortality rates ranged from 9 percent for low-mortality hospitals to 15 percent for high-mortality hospitals. The researchers conclude that more lives could be saved if referrals were based on infant outcomes data instead of high NICU volume.
Rogowski, Staiger, and Horbar, Health Affairs 23(5):88-97, 2004 (AHRQ grants HS13371, HS10528).
Rehospitalization is common for premature infants with bronchopulmonary dysplasia.
Bronchopulmonary dysplasia (BPD) affects many low birthweight and premature babies. It is marked by abnormal lung x-rays, respiratory compromise, and prolonged oxygen requirement. Infants with BPD may have pulmonary problems long past the neonatal period and thus are more susceptible to respiratory infections and other serious conditions that can lead to hospitalization. The researchers found no clinical or demographic factors that reliably predicted rehospitalization of infants with BPD.
Smith, Zupancic, McCormick, et al., J Pediatr 144:799-803, 2004 (AHRQ grant T32 HS00063).
Studies focus on reducing mortality rates and improving long-term outcomes of very low birthweight babies.
Babies who are extremely low birthweight (ELBW, 1.1 to 2.2 pounds) and very low birthweight (VLBW, less than 3.3 pounds) are at greater risk of dying or having neurodevelopmental problems than babies who weigh more at birth. These two studies examined hospital mortality and school difficulties among ELBW children. The first study found that more ELBW babies could be saved if they were referred to hospitals based on the hospitals' past neonatal intensive care unit mortality rates rather than the volume of ELBW babies they treat. The second study found that school-aged ELBW children are burdened by childhood disability, school-related difficulties, and increased use of special educational resources.
Rogowski, Horbar, Staiger, et al., JAMA 291(2):202-209, 2004 (AHRQ
grants HS10328 and HS13371).
Also: Saigal, den Ouden, Wolke, et al., Pediatrics 112(4):943-950,
2003 (AHRQ grant HS08385).
Wage inequality is associated with infant mortality rates in wealthy industrialized countries.
According to this study, one measure of social inequality—wage inequality—is associated with the infant mortality rate in 19 wealthy countries belonging to the Organization for Economic Cooperation and Development. After controlling for a country's gross domestic product per capita and wage inequality, variables associated with better health included higher income per capita, the method of health care financing, and more physicians per 1,000 population. Higher alcohol consumption, a larger proportion of the population in unions, and more government expenditures on health were associated with poorer health outcomes.
Macinko, Shi, and Starfield, Soc Sci Med 58:279-292, 2004.
Also: Macinko, Shi, Starfield, and Wulu, Med Care Res Rev 6(4):407-452,
2003 (AHRQ grant T32 HS00029).
Relying on clinical guidelines to treat young infants with fevers may not improve outcomes.
In this study of more than 3,000 infants aged 3 months or younger with fevers, experienced pediatricians who relied on their clinical judgment more than existing guidelines were able to minimize hospitalizations and avoid unnecessary lab testing without a negative impact on outcomes. Rather than hospitalization, physicians saw many infants in repeat office visits and had frequent telephone followup.
Pantell, Newman, Bernzweig, et al., JAMA 291(10):1203-1212, 2004 (AHRQ grant HS06485).
Newborns from low-income families are more than twice as likely as other newborns to be discharged early.
These researchers studied nearly 3,000 medically low-risk infants using a 1999 California postpartum survey and found that newborns from low-income families were more than twice as likely as other newborns to be discharged after only a 1-night stay following vaginal delivery or a 3-night stay or less after cesarean delivery. Among newborns discharged early, 68 percent did not receive followup care within the recommended timeframe.
Galbraith, Egerter, Marchi, et al., Pediatrics 111(2):364-371, 2003 (AHRQ grant T32 HS00086).
Study hints at a link between breastfeeding and intelligence.
Researchers examined the relationship between breastfeeding history and 15 indicators of physical health, emotional health, and cognitive ability among 16,903 adolescents, including 2,734 sibling pairs. They found a persistent positive correlation between breastfeeding and cognitive ability; that is, siblings who were breastfed had higher cognitive ability than those who were not. The effect was large enough to matter, and it persisted into adolescence.
Evenhouse and Reilly, Health Serv Res 40(6):1781-1802, 2005 (AHRQ grant HS00086).
Short maternal length of stay does not affect breastfeeding if combined with outpatient support.
Retrospective examinations of medical records on 20,366 mother-infant pairs was conducted to determine the impact on breastfeeding of an HMO's early discharge protocol. Results showed that hospital stays of 24 hours or less after normal vaginal deliveries did not adversely affect breastfeeding when combined with outpatient breastfeeding support and a home visitor program.
Madden, Soumerai, Lieu, et al., Pediatrics 111(3):519-524, 2003 (AHRQ grant HS10060).
Strategies for identifying neonatal jaundice are examined.
Based on a review of almost 5,000 abstracts and articles, researchers determined whether measurements by noninvasive instruments are reliable in identifying babies who need blood tests to confirm high bilirubin levels. They also suggest that future research is needed to validate newer noninvasive devices and address cost-effectiveness issues.
A summary of this evidence report (AHRQ Publication No. 03-E005) and the full report, Management of Neonatal Hyperbilirubinemia (AHRQ Publication No. 03-E011), are available from AHRQ* (AHRQ contract 290-97-0019).
Clinical records can be used to identify children with disabling cerebral palsy.
These researchers found that clinical and research study records can be used to distinguish children with disabling cerebral palsy (CP) from those with no CP or nondisabling CP. They examined records of neurological examination findings and functional motor assessments of low birthweight children who were born in the Netherlands, Canada, and Germany and were 2 to 8 years of age at the time of the study.
Panet, Qiu, Rosenbaum, et al., Dev Med Child Neurol 45(9):628-633, 2003 (AHRQ grant HS08385).
Lengthened postpartum stays may be cost effective.
Investigators estimated life-years saved from reduced infant mortality due to lengthening postpartum stays to mandated times for 113,147 infants born in Washington State in 1989 or 1990. The infants had postpartum stays short enough to be affected by length-of-stay legislation. Results show that lengthening postpartum stays to federally mandated levels is cost effective.
Malkin, Keeler, Broder, et al., Pediatrics 3(4):e316, 2003 online at www.pediatrics.org (AHRQ grant HS09342).