Neonatal intensive care unit discharge of infants with cardiorespiratory events: Tri-country comparison of academic centers

This article includes multiple AASPP members as authors. It was published in the Journal of Neonatal-Perinatal Medicine in January of 2016:

Neonatal intensive care unit (NICU) and special nursery admissions occur in 7–14% of all births. The gestational age of infants admitted spans from 23 weeks to post term gestation of greater than 42 weeks. The average length of stay for an infant in the NICU ranges from a few days to several months.

The discharge of infants from the NICU is a complex process that requires forethought and planning. This can be the direct result of the patients themselves, coordination of care after a prolonged hospital stay, and resolution and/or improvement of complex multifactorial medical diagnoses. The risk assessment for hospital readmission and death within the first year following discharge remains a concern.

Taking this into account, additional factors to be considered are a family’s readiness for discharge and completion of necessary education and training. Families often need additional supports such as home equipment and technological support. Appropriate multidisciplinary follow-up should also be arranged prior to discharge.

The true cornerstone of the discharge decision is the readiness of the infant. The neonatal period is characterized by physiologic changes greatly influenced by gestational age and confounding illnesses and complications. Respiratory difficulties remain one of the greatest challenges, apnea being a common problem. The widely accepted definition of apnea in infants is a cessation of breathing for greater than or equal to 20 seconds, or a shorter respiratory pause associated with oxygen desaturation and or bradycardia. While the broad general consensus of NICU discharge is based on medical stability and physiologic readiness of infants, the parameters by which these are measured is more
The purpose of this survey is to characterize and compare the NICU discharge practice of infants with cardiorespiratory events in the United States, Canada and France.

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Assigning cause for sudden unexpected infant death

This article includes multiple AASPP members as authors. It was published online in Forensic Science, Medicine, and Pathology in January of 2015:

Sudden infant death syndrome (SIDS) was originally defined in 1969, focusing attention on sudden death in infants without an identified cause. These infants had a similar age at death and a strong association with sleep in common. Naming the sudden death SIDS instead of calling it ‘‘cause unknown’’ facilitated an enhanced focus on parental support and on research. Later studies identified prone sleep as a significant risk factor for SIDS-classified deaths. The definition of SIDS was expanded in 1991, with an  emphasis on scene investigation. Although further modifications have been recommended, no  consensus has been achieved. Indeed, a review of recent publications reported that the 1969 definition continues to be used 7% of the time, the 1991 definition 35% of the time, other modifications 26% of the time and in 20% no definition was mentioned. Initially there were no candidate etiologies to explain these deaths. In the intervening years, however, much has been learned about environmental, biological, and genetic risk factors for deaths classified as SIDS. Once prone sleep was identified as a significant risk factor, most developed countries implemented back-to-sleep campaigns. SIDS-classified death rates started to decline after 1990, as did non-SIDS-classified postneonatal mortality rates, and continued to decline until 2001. Much of this decline was initially attributed to an overall decrease in SIDS-classified deaths. Since 2001, however, SIDS-classified death rates have not continued to decrease whereas there has been a diagnostic shift to other assigned causes of sudden unexpected infant death or to unknown cause. Illustrating the impact of how these deaths are classified, SIDS-classified deaths declined by 20% from 2005 to 2011, whereas for the same period the rate of accidental infant deaths increased by 5% and rates for undetermined/unclassified deaths also increased.

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Trends in Infant Bedding Use: National Infant Sleep Position Study, 1993–2010

This article includes multiple AASPP members as authors. It was published in Pediatrics in January 2015:

Rates of sudden infant death syndrome (SIDS), the leading cause of postneonatal mortality, have declined slowly in the United States since 2000, from 66.3 to 52.7 per 100 000 live births in 2010. Concurrently, infant mortality related to unintentional sleep-related suffocation, the leading cause of infant mortality from injury, has increased more than twofold, from 7.0 per 100 000 live births in 2000 to 15.9 per 100 000 live births in 2010. Blankets, quilts, and pillows are examples of bedding that can be potentially hazardous to infants if under or around them during sleep. Soft objects and loose bedding such as these items can obstruct the infant airway and pose a suffocation risk. In addition, this type of bedding is a recognized risk factor for SIDS. Because of these risks, the American Academy of Pediatrics (AAP) recommends that soft objects and loose bedding be removed from the infant sleep area. A US study showed that certain types of bedding increased the odds for SIDS approximately fivefold. This finding is consistent with studies from the United States, Europe, New Zealand, and Australia in which adjusted odds ratios (aORs) for SIDS and the use of these types of bedding ranged from 3.1 to 6.7. Recommendations about the avoidance of bedding in the sleep environment were first issued in 1996 when the AAP advised that infants be placed to sleep in environments free of soft surfaces and gas-trapping objects. In April 1999, the Consumer Product Safety Commission, the National Institute of Child Health and Human Development, and the AAP Task Force issued a safety alert recommending that infants “be placed to sleep on their backs on a firm, tight-fitting mattress in a crib that meets current safety standards and that pillows, quilts, comforters, sheepskins and other pillow-like soft products be removed from the crib.” In 2000, the AAP more strongly recommended against the use of bedding. The proportion of US infants who are placed to sleep with bedding such as pillows, blankets, and quilts is unknown. Understanding caregiver behavior related to infant sleep practices and how it has changed can inform the
refinement and promotion of interventions aimed at reducing unsafe practices. In the present study, we used data from the NISP (National Infant Sleep Position) Study to estimate the prevalence of reported use of certain types of bedding and examine trends from 1993 to 2010 (overall and according to race/ethnicity). We also investigated characteristics associated with bedding use from 2007 to 2010.

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