To assess for differences in congenital diaphragmatic hernia patient characteristics between those requiring single or multiple intubation attempts, and to determine the relationship between number of intubation attempts and time to intubation with outcomes. This was a retrospective cohort study of 205 infants with congenital diaphragmatic hernia born at Texas Children's Hospital. Patient demographics and severity numbers were compared to number of laryngoscopies as a surrogate for intubation attempts. Number of laryngoscopies and time to intubation were compared to clinical outcomes. Binary logistic regression and receiver operating characteristic curve analysis were used. There was no significant difference in baseline characteristics or CDH severity in those requiring single or multiple attempts. Greater number of intubation attempts was not associated with adverse outcomes but there was a significant association between longer time to successful intubation and mortality and higher risk of tracheostomy or death before discharge. Each additional minute before successful intubation was associated with 28% higher odds of mortality (p = 0.031) and 42% higher odds of tracheostomy or death before discharge (p = 0.006) CONCLUSION: Delayed time to intubation but not number of intubation attempts was associated with higher mortality and risk of tracheostomy or death in babies with CDH. Prenatal information including receipt of the FETO procedure, CDH severity markers, gestational age and birth weight cannot reliably be used to predict the likelihood of challenging intubations in infants with CDH.
To compare the effect of skin-to-skin contact (SSC) initiation at three different time points on exclusive breastfeeding (EBF) rates at 6 weeks among healthy term infants delivered via cesarean section. In this open-label randomized controlled trial, neonates were assigned to three groups: Group 1 (immediate SSC in the delivery room), Group 2 (SSC after transfer to the recovery room), and Group 3 (breastfeeding initiation followed by SSC in the recovery room). The primary outcome was the percentage of mothers exclusively breastfeeding (EBF) at 6 weeks. Secondary outcomes included duration of SSC, early initiation of breastfeeding (EIBF) rates, exclusive breastfeeding rates at 6 months, and challenges during implementation of SSC. Baseline characteristics were similar across 750 enrolled infants (250 per group). In Group 1, 46 babies (18.4%) faced challenges in SSC initiation and were reallocated. No significant difference in 6-week EBF rates (RR 0.98, 95% CI: 0.77-1.25, p = 0.90). Group 3 was associated with the highest EIBF rates (RR 0.5, 95% CI 0.3-0.8, p = 0.013) and the longest duration of SSC. Given the challenges of immediate intraoperative SSC after a C-section, our study found that initiating SSC in the recovery room is a practical and effective alternative, having a similar impact on breastfeeding rates. While the timing of SSC does not significantly impact EBF rates at 6 weeks or 6 months, it remains a critical factor for EIBF. Our findings show that immediate SSC significantly optimizes EIBF. Furthermore, the high EBF rates sustained across all cohorts suggest that robust institutional support is a primary driver of long-term breastfeeding success.
Determine the association of infant mortality (IM) and gentrification, a composite measure of rising neighborhood income, education, and housing costs. Retrospective cohort analysis of 672,432 infants born 2010-2019 across metropolitan Michigan. Multilevel multivariable regression models examined the association of gentrification and IM. Gentrification components were evaluated in separate models. Gentrification was not associated with IM, but some of its components were. Living in a census tract with an above median rise in income or education attainment was associated with lower odds of IM, compared to below median change (Income: aOR=0.88; 95% CI: 0.82-0.95; Education: aOR=0.93; 95% CI: 0.86-0.997). Rent increases above the median were linked to higher IM among term infants and lower IM among infants <32 weeks' gestation. The association of IM with rising home values varied by maternal insurance status. Indicators of increasing community affluence, often combined to define gentrification, have opposing relationships with IM.
Describe rates of intraventricular hemorrhage (IVH) in the VentFirst cohort, model risks for severe IVH and compare IVH rates to a contemporaneous population. Sub-analysis of the VentFirst multi-center randomized trial. Head ultrasound findings from 548 infants <29 weeks' gestation who survived to first head ultrasound study in the VentFirst trial were analyzed. Any grade of IVH was found in 31% and severe (grade III/ IV) IVH in 8%. Logistic regression indicated gestational age (GA), twin gestation and 1-minute Apgar as risks for severe IVH. Odds of any IVH and severe IVH were lower in the VentFirst population than in a comparable population in the Vermont Oxford Network. Severe IVH in the VentFirst trial was associated with low GA, twin gestation and low 1-minute Apgar score. The lower odds of IVH for the study cohort compared to a similar population may reflect optimized delivery conditions. ClinicalTrials.gov Identifier: NCT02742454.
The American Board of Pediatrics (ABP) has proposed a competency-based fellowship model offering a 2-year clinical pathway with 18 training blocks and no scholarly requirement. This position statement, representing neonatal-perinatal medicine (NPM) training program directors, division leaders, and key stakeholders, contends that the model is not viable for NPM training. Compressing 18 clinical blocks into 24 months would require approximately 3500 annual training hours, nearly double a sustainable NICU workload, approaching Accreditation Council for Graduate Medical Education duty-hour limits, while reducing didactic education by one-third. Survey data from 110 of 111 NPM programs show 76% opposition. Concerns include trainee wellness, reduction in program complement, workforce and funding implications, and the erosion of scholarly training essential to advancing neonatal care. We propose alternatives, including a 2-year residency + 3-year fellowship (2 + 3) pathway and restructured residency tracks, addressing competency gaps while preserving training quality, duration, and collaborative governance.
As the prevalence of cannabis use continues to increase among women of reproductive age, studies exploring the impact of in utero cannabis exposure on birth outcomes are warranted. Using data from the National Birth Defects Prevention Study, logistic regression was used to assess the relationship between maternal self-report of cannabis use during early pregnancy and 1) preterm birth, and 2) being born SGA. Patterns of cannabis use during the first six months of pregnancy were also assessed. Three percent of the sample (n = 324) reported cannabis use in early pregnancy. A slight majority (56%) of users ceased the use of cannabis after the second month of pregnancy. No significant association was observed between cannabis use and preterm birth (aOR = 1.27, 95% CI: 0.88-1.83) or SGA (aOR = 1.00, 95% CI: 0.68-1.47). Cannabis use in early pregnancy was not significantly associated with preterm birth or SGA in this sample.
Understanding the research experiences of bereaved parents is necessary to advance palliative care. To evaluate levels of and factors associated with bereaved parent comfort, benefit, and distress from research participation and to qualitatively explore research experiences. Exploratory analysis of survey data from parents of infants who died in a level IV NICU (2010-2020). Fisher's exact and Chi-square tests were used to identify factors associated with parental comfort, distress, and benefit. Qualitative analyzed was performed using the constant comparative method. 40/146 parents (27%) responded. 83% reported being "very comfortable" or "comfortable", 83% reported "some" to "a lot" of benefit, 26% reported "a great deal" to "a lot" of distress from participation. Goal-discordant care was significantly associated with distress. Research participation themes included "helping others", "processing experiences" and "re-living negative experiences". Bereaved NICU parents simultaneously experience distress, comfort, and benefit from research participation.
To examine associations between parental holding during therapeutic hypothermia (TH) and neonatal intensive care unit (NICU) outcomes among infants with hypoxic-ischemic encephalopathy (HIE). Retrospective cohort of 379 infants with HIE at two level IV NICUs (2017-2024). Unadjusted and adjusted regression models evaluated associations between holding during TH and NICU outcomes. Overall, 28% of infants were held during TH. Holding was less common among infants with greater clinical severity, public insurance, or those identified as Hispanic, Asian, or Black. After adjustment for clinical and sociodemographic factors, holding was associated with faster time to full oral feeding (HR = 1.4, p < 0.01), earlier age at full oral feeding (HR = 1.6, p < 0.01), shorter hospitalization (β = -7.5, p = 0.02), and higher odds of breastmilk feeding at discharge (OR = 3.2, p = 0.03). Parental holding during TH is associated with favorable short-term NICU outcomes, supporting its potential role as a family-centered care practice during neonatal neurocritical care.
To evaluate intubation success and safety among extremely low birthweight (ELBW) infants before, during, and after the introduction of a new video laryngoscope (VL) in a Level 3 neonatal intensive care unit. Single-center retrospective cohort study. Three phases (pre-introduction, introduction, and post-introduction), each with 40 intubations, were analyzed. Primary success and safety outcomes included first-attempt success and any tracheal intubation-associated events (TIAEs), respectively. Univariable analyses were used to compare patient, provider, and practice characteristics and outcomes by phase. No significant differences were observed between the pre-introduction and introduction phases. The post-introduction phase had significantly fewer TIAEs compared to both the pre-introduction (2 [5%] vs 8 [20%]; p = 0.04) and introduction phases (2 [5%] vs 8 [20%]; p = 0.04). Safety outcomes improved with continued use of the new VL among ELBW intubations. Further research is needed to explore the role of training and experience with new airway technologies.
To evaluate the ability of a tiered, risk-stratified postnatal management pathway to safely provide monitoring and postnatal care recommendations based on the prenatal Coarctation of Aorta (CoA) risk category. Retrospective cohort study of fetuses with CoA concern on fetal echocardiogram. Postnatal recommendations were based on prenatal risk categories as follows: mild-concern (nursery, echo before discharge); moderate-concern (NICU, echo before 24 h); high-concern (PGE infusion, CICU, admission echo). For mild (40/87), moderate (13/87), and high (34/87) concern categories, 3%, 38%, and 82% had CoA repair before initial discharge. Eighty percent of mild-concern initially remained with parents. For moderate-concern, 6/13 transferred to CICU and 5 required surgery pre-discharge. Umbilical catheters placed if CICU transfer. A standardized risk-stratified postnatal CoA pathway can be effectively implemented in a delivery hospital and minimize medicalization of low-to-moderate-concern newborns. With appropriate safety nets, select patients can concurrently receive CoA evaluation and newborn care.
Describe the golden hour and hospital outcomes of conjoined twins METHODS: Retrospective single center study of conjoined twins. Main outcome measures included delivery room characteristics. Secondary outcomes included survival and length of stay. From 2013-2025, there were 19 sets of conjoined twins (active resuscitation in 13; palliative in 6). Respiratory interventions in the delivery room were frequently needed including continuous positive airway pressure (75%), positive pressure ventilation (67%), and endotracheal intubation (25%). There were two sets with emergency separation, each with one surviving twin. For the 10 sets who underwent separation, survival at NICU discharge was 80% (twin A) and 100% (twin B). The delivery room resuscitation of conjoined twins is complex with high rates of advanced respiratory intervention. These deliveries necessitate an experienced multidisciplinary team and an individualized delivery plan based on specific anatomy and reinforced with simulation. Survival is high among twins who undergo separation.
To quantify systemic exposure to budesonide following intratracheal administration; evaluate the impact of intratracheal budesonide on blood glucocorticoid activity (cortisol plus betamethasone as cortisol equivalents); and relate the latter to outcomes. Sub-study of the PLUSS randomized trial(ACTRN12617000322336) of intratracheal budesonide with surfactant versus surfactant alone. Among 63 infants enrolled at Kidz First Neonatal Care, Auckland, systemic exposure to intratracheal budesonide was low, and cortisol equivalents were similar between intervention groups at 36-48 h (adjusted-ratio-geometric-means = 1.16, 95% CI 0.52-2.57). Antenatal betamethasone <24 h before birth contributed to neonatal blood glucocorticoid activity for up to 24-48 h. Infants above the upper tertile for cortisol equivalents at <60 h, compared with those below the lower tertile, had increased likelihood of severe intraventricular hemorrhage and possibly death. Systemic exposure to intratracheal budesonide has little to no effect on cortisol equivalents at 36-48 h. High glucocorticoid activity after birth may be associated with poorer neonatal outcomes.
Immediate Kangaroo Mother Care (iKMC) after delivery and delayed cord clamping (DCC), both improve cardiorespiratory stability in newborns. This prospective observational study included 96 moderate to late preterm (MLPT) neonates. Preductal pulse oximetry (SpO₂) and heart rate (HR) were recorded during the first 10 min after birth. Neonates who received iKMC and DCC were compared to those who did not receive iKMC. iKMC was performed in 64.6% of the infants. The iKMC group showed a non-significant trend toward higher SpO₂ levels. Mean SpO₂ was 76.06% in the iKMC group versus 70.98% in the non-iKMC group; at 420 s, it was 95.13% versus 93.77%. HR was significantly higher in the iKMC group at all time points, averaging 102.2 bpm at 120 s compared to 87.1 bpm in the non-iKMC group. Combining iKMC with DCC improves hemodynamic stability and oxygenation in MLPT infants, with higher HR and earlier stabilization of SpO₂ levels.
To evaluate whether paracetamol serum concentration monitoring is associated with ductal closure, hepatic or renal toxicity, and to assess the cost-effectiveness of routine serum monitoring in preterm infants treated for haemodynamically significant patent ductus arteriosus (hsPDA). A multi-centre retrospective cohort study of 172 preterm infants treated with paracetamol for hsPDA (2018-2024). Associations between paracetamol serum concentrations, clinical outcomes, and monitoring costs were examined using multivariable mixed-effects modelling and micro-costing analysis. PDA closure after the first course occurred in 40.7%. On multivariate analysis, paracetamol concentration monitoring was not associated with PDA closure (OR 0.98, 95% CI:0.92-1.03, p = 0.68), ALT elevation (p = 0.443) or creatinine rise (p = 0.88). Across 222 assays, routine monitoring cost £6036 (£120.72 per actionable result) and remained non-cost effective across all sensitivity analyses. Routine monitoring of paracetamol serum concentrations offers minimal clinical value and is not cost-effective. Selective, indication-based monitoring should replace universal testing.
To evaluate the feasibility and diagnostic yield of universal genome sequencing (GS) in infants receiving extracorporeal membrane oxygenation (ECMO). Prospective multicenter study across eight Children's Hospital Neonatal Consortium sites (October 2021-August 2023). Infants initiated on ECMO were enrolled for GS regardless of suspected genetic disease. Demographics, ECMO indications, and results from standard-care testing and study-based GS were analyzed. Twenty-five infants were enrolled. Primary ECMO indications included congenital diaphragmatic hernia (28%), meconium aspiration syndrome (24%), and primary respiratory failure (20%). GS identified pathogenic or likely pathogenic variants in 6/25 infants (24%), including three cytogenetic-confirmed diagnoses and three molecular diagnoses identified only by GS. Variants of uncertain significance were identified in 44% of infants, while 32% had negative results. Universal GS during ECMO is feasible and yields a relatively high rate of clinically relevant diagnoses, supporting further assessment of the integration of genomic testing into ECMO care pathways.
This study aimed to determine the influence of nosocomial bacterial and viral infections of preterm very low birth weight (VLBW) infants on neurodevelopmental outcome and on rehospitalization rates during the first two years of life. Retrospective single-center cohort study including preterm infant born between 2010 and 2018 and followed until two years of age corrected for prematurity (Bayley scales). Of 620 study infants 418 without neurodevelopmental impairment (NDI). were compared to 202 infants with NDI. Single or multiple nosocomial infections were not risk factors for NDI in a multivariate logistic regression model checked for multicollinearity. Infants with NDI were of younger gestational age, had lower birth weights and higher rates of neonatal complications (ileus, periventricular leukomalacia, and bronchopulmonary dysplasia). Nosocomial infection were also not risk factors for rehospitalizations by infectious diseases. Nosocomial infections did not significantly influence NDI and rehospitalization rates in preterm VLBW infants. The study was registered at "Deutsches Register Klinischer Studien" DRKS00019000.
Evaluate Neonatal Intensive Care Unit (NICU) interpreter access and utilization, unit-based interpreter policies and initiatives, staff awareness and confidence in understanding language-access laws, and perceptions of language-based inequities. An exploratory national survey of NICU staff was distributed via the National Association of Neonatal Nurses and the American Academy of Pediatrics (AAP) (10/2024-4/2025). Descriptive statistics and qualitative analysis were used for survey results. The 189 respondents represented all ten AAP districts. Most were aware of NICU-based interpreter policies (76%). 81% were not aware of additional state laws/provisions and many lacked confidence understanding federal (43%) or state (63%) language-access laws. Many respondents disagreed that language-discordance resulted in worse quality of care (40%) and outcomes (59%) in their NICU. Results highlight the need for additional education on federal and state laws and provisions as well as the broad and systemic nature of language-based healthcare inequities across institutions.
Early-onset neonatal sepsis (EOS) carries significant mortality, prompting the initiation of empiric antibiotics pending blood culture results, which increases neonatal antibiotic exposure. In 2022, our institution shortened antibiotic coverage of EOS rule-outs from 36 to 24 h. We evaluated the safety of this change and its impact on antibiotic use. This single hospital retrospective cohort study (2018-2023) compared infants <72 h of life who underwent EOS evaluation under 36- vs. 24-h protocols. Demographics, causative organisms, time to positivity (TTP), and antibiotic utilization for EOS were compared. Among 1491 blood cultures, 17 had positive cultures and all had a TTP < 24 h. Cohorts were clinically similar. Mean antibiotic days initiated in the first 72 h of life decreased from 1.8 to 1.5 following the protocol change (Standard Deviations 0.29 and 0.25). Reducing antibiotic coverage from 36 to 24 h lowered antibiotic exposure without inappropriate discontinuation of antibiotics.
To conduct a detailed epidemiological exploration of the relative contributions of cannabis and ethnicity to US atrial septal defect (ASD) rates (ASDR). State-based ASDR data from the US National Births Defects Prevention Network, substance use, income and ethnicity data analyzed in RStudio. Ethnic effects were significant with relative risks amongst African Americans and American Indians and Alaskan Natives of 2·40 (95%C.I. 2·27, 2·54) and 2·31 (2·19, 21·43), Cohen's D of 1·44 and 1·46 and P values of 2·94 × 10-168 and 3·01 × 10-172 compared to others, respectively. In general, additive models inclusion of ethnicity:cannabinoid and ethnicity:tobacco interactions were significant down to P=zero for cannabis, Δ9THC and cannabidiol. Sequentially doubly robust targeted multiple likelihood estimations confirmed epidemiologically causal relationships under standard assumptions. ASDR amongst Asians and Pacific Islanders in Nevada showed an exponential doubling time of 2.83 years. Cannabinoid and cannabinoid:ethnicity interactions drive ASDR and meet epidemiological causal criteria.
The shortages in pediatric subspecialist workforce are threatening care of children in the US. A prolonged residency plus fellowship of 6 years and relatively low salaries may discourage medical students from choosing pediatric fellowship training. To address this "subspecialty shortage," the American Board of Pediatrics (ABP) recently announced a fundamental shift toward competency-based medical education (CBME). This proposal reduces fellowship training duration to a two-year clinical track option. This change is likely to start as early as 2028. We propose an alternate approach that is similar in length (5-years) but with a shorter residency (2-years) and a three-year fellowship for procedural-based subspecialties in pediatrics, cardiology and intensive care fields, such as neonatal-perinatal medicine (NPM), and pediatric critical care medicine (PCCM).