Objective This study was aimed to compare health care costs and utilization at birth through 1 year, between preterm and term infants, by week of gestation. Methods A cross-sectional study of infants born at ≥ 23 weeks of gestational age (GA) at Kaiser Permanente Northern California facilities between 2000 and 2011, using outcomes data from an internal neonatal registry and cost estimates from an internal cost management database. Adjusted models yielded estimates for cost differences for each GA group. Results Infants born at 25 to 37 weeks incur significantly higher birth hospitalization costs and experience significantly more health care utilization during the initial year of life, increasing progressively for each decreasing week of gestation, when compared with term infants. Among all very preterm infants (≤ 32 weeks), each 1-week decrease in GA is associated with incrementally higher rates of mortality and major morbidities. Conclusion We provide estimates of potential cost savings that could be attributable to interventions that delay or prevent preterm delivery. Cost differences were most extreme at the lower range of gestation (≤ 30 weeks); however, infants born moderately preterm (31–36 weeks) also contribute substantially to the burden, as they represent a higher proportion of total births.
Background: Weight loss is universal for exclusively breastfed newborns in the first few days after birth. Many newborns exclusively breastfed during birth hospitalization receive formula in the first month after discharge and thus cease exclusive breastfeeding. However, the relationship between early weight loss and subsequent cessation of breastfeeding and exclusive breastfeeding is unknown. Research aim: This study aimed to determine the relationship between newborn weight loss and duration and exclusivity of breastfeeding among newborns breastfed exclusively during the birth hospitalization. Methods: Retrospective cohort study at Kaiser Permanente Northern California hospitals between 2009 and 2013. The main predictor variable was weight loss during birth hospitalization. The main outcomes were cessation of breastfeeding and cessation of exclusive breastfeeding in the first 25 days after discharge. Results: Among our sample, 83,344 were exclusively breastfed during birth hospitalization. At 25 days after discharge, 15.6%, 95% confidence interval (CI) [14.6%, 16.6%], of those delivered vaginally and 17.6%, 95% CI [14.5%, 20.6%], of those delivered by cesarean section were estimated to have completely ceased breastfeeding; 57.0%, 95% CI [55.5%, 58.4%], and 57.9%, 95% CI [53.6%, 61.8%], respectively, had ceased exclusive breastfeeding. Survival curves depicting rates of breastfeeding cessation through 1 month did not differ by degree of weight loss or by weight loss trajectory. However, curves depicting rates of exclusive breastfeeding demonstrated significantly more formula use among those with more weight loss at discharge. Conclusion: Among those exclusively breastfed during birth hospitalization, weight loss nomograms may help identify newborns at higher risk of cessation of exclusive breastfeeding. Lactation support targeted to those with exacerbated weight loss trajectories may improve duration of exclusive breastfeeding.
Compared with the Finnegan Neonatal Abstinence Scoring System (FNASS), the Eat, Sleep, Console (ESC) approach reduces pharmacotherapy and length of stay (LOS) for neonatal opioid withdrawal syndrome (NOWS) infants. The independent outcome contribution of ESC is unknown as the approach combines ESC assessment with additional management changes. Our objective was to evaluate ESC assessment’s independent impact on outcomes compared with FNASS. We conducted a retrospective cohort study of in utero opioid-exposed infants ≥35 weeks gestation managed with FNASS versus ESC. Outcomes included pharmacotherapy initiation, LOS, length of pharmacotherapy, and emergency department visit/readmissions. Among 151 FNASS and 100 ESC managed infants, pharmacotherapy initiation ( P = .47), LOS for all infants ( P = .49), and LOS for pharmacologically treated infants ( P = .68) were similar. Length of pharmacotherapy did not differ ( P = .84). Emergency department evaluation/NOWS readmission was equally rare ( P = .65). Using equivalent models of care, comparison of ESC and FNASS assessment tools showed no difference in NOWS outcomes.
Current algorithms for management of neonatal early-onset sepsis (EOS) result in medical intervention for large numbers of uninfected infants. We developed multivariable prediction models for estimating the risk of EOS among late preterm and term infants based on objective data available at birth and the newborn's clinical status.To examine the effect of neonatal EOS risk prediction models on sepsis evaluations and antibiotic use and assess their safety in a large integrated health care system.The study cohort includes 204 485 infants born at 35 weeks' gestation or later at a Kaiser Permanente Northern California hospital from January 1, 2010, through December 31, 2015. The study compared 3 periods when EOS management was based on (1) national recommended guidelines (baseline period [January 1, 2010, through November 31, 2012]), (2) multivariable estimates of sepsis risk at birth (learning period [December 1, 2012, through June 30, 2014]), and (3) the multivariable risk estimate combined with the infant's clinical condition in the first 24 hours after birth (EOS calculator period [July 1, 2014, through December 31, 2015]).The primary outcome was antibiotic administration in the first 24 hours. Secondary outcomes included blood culture use, antibiotic administration between 24 and 72 hours, clinical outcomes, and readmissions for EOS.The study cohort included 204 485 infants born at 35 weeks' gestation or later: 95 343 in the baseline period (mean [SD] age, 39.4 [1.3] weeks; 46 651 male [51.0%]; 37 007 white, non-Hispanic [38.8%]), 52 881 in the learning period (mean [SD] age, 39.3 [1.3] weeks; 27 067 male [51.2%]; 20 175 white, non-Hispanic [38.2%]), and 56 261 in the EOS calculator period (mean [SD] age, 39.4 [1.3] weeks; 28 575 male [50.8%]; 20 484 white, non-Hispanic [36.4%]). In a comparison of the baseline period with the EOS calculator period, blood culture use decreased from 14.5% to 4.9% (adjusted difference, -7.7%; 95% CI, -13.1% to -2.4%). Empirical antibiotic administration in the first 24 hours decreased from 5.0% to 2.6% (adjusted difference, -1.8; 95% CI, -2.4% to -1.3%). No increase in antibiotic use occurred between 24 and 72 hours after birth; use decreased from 0.5% to 0.4% (adjusted difference, 0.0%; 95% CI, -0.1% to 0.2%). The incidence of culture-confirmed EOS was similar during the 3 periods (0.03% in the baseline period, 0.03% in the learning period, and 0.02% in the EOS calculator period). Readmissions for EOS (within 7 days of birth) were rare in all periods (5.2 per 100 000 births in the baseline period, 1.9 per 100 000 births in the learning period, and 5.3 per 100 000 births in the EOS calculator period) and did not differ statistically (P = .70). Incidence of adverse clinical outcomes, including need for inotropes, mechanical ventilation, meningitis, and death, was unchanged after introduction of the EOS calculator.Clinical care algorithms based on individual infant estimates of EOS risk derived from a multivariable risk prediction model reduced the proportion of newborns undergoing laboratory testing and receiving empirical antibiotic treatment without apparent adverse effects.
OBJECTIVES To estimate the effect of NICU admission of low-acuity infants born at 35 weeks’ gestation versus care in a mother/baby unit, on inpatient and outpatient medical outcomes. METHODS This retrospective cohort study included 5929 low-acuity infants born at 350/7 to 356/7 weeks’ gestation at 13 Kaiser Permanente Northern California hospitals with level II or level III NICUs between January 1, 2011, and December 31, 2021. Exclusion criteria included congenital anomalies and early respiratory support or antibiotics. We used multivariable regression and regression discontinuity analyses to control for confounding variables. RESULTS Infants admitted to the NICU within 2 hours of birth (n = 862, 14.5%) had a 58 hour adjusted (98-hour unadjusted) longer length of stay. NICU admission was associated with an increased probability of a length of stay ≥96 hours (67% vs 21%; adjusted odds ratio [aOR], 4.94; 95% confidence interval [CI], 3.96–6.16). Regression discontinuity results suggested a similar (57 hour) increase in length of stay. Readmission risk, primarily for jaundice, was lower for those admitted to the NICU (3% vs 6%; aOR, 0.43; 95% CI, 0.27–0.69). Infants admitted to the NICU were slightly less likely to be receiving exclusive breast milk at 6-month follow-up (15% vs 25%; aOR, 0.73; 95% CI, 0.55–0.97; adjusted marginal risk difference −5%). CONCLUSIONS Admitting low-acuity infants born at 35 weeks’ gestation to the NICU was associated with decreased readmission, but with longer length of stay and decreased exclusive breast milk feeding at 6 months. Routine NICU admission may be unnecessary for low-acuity infants born at 35 weeks’ gestation.
To examine the relationship between high (≥5%) weight loss during the first 24 h after birth and eventual excess weight loss (EWL) of ≥10% of birth weight.
Design
Retrospective cohort study.
Setting
Kaiser Permanente Northern California hospitals.
Patients
63 096 infants born at ≥36 weeks in 2009–2010, of whom 59 761 (94.5%) had a weight subsequent to birth weight measured at <24 h.
Main predictor measure
Per cent of birth weight lost by 24 h of age.
Main outcome measure
Weight nadir, defined as the lowest recorded inpatient or outpatient weight in the first 30 days after birth, expressed as a percentage of birth weight.
Results
Among infants who breastfed at least once, mean (±SD) weight nadir was 6.3±3.5% below birth weight, and 9.6% of the newborns lost ≥10% of birth weight. Among 2670 infants who lost ≥5% of their birth weight in the first 24 h, 782 (29%) eventually developed EWL, compared with 4840 (8%) of 57 109 infants who lost <5% (p<0.0005). In multivariate analysis, ≥5% first-day weight loss predicted eventual EWL (≥10%) with an OR of 4.06 (95% CI 3.69 to 4.46) after adjusting for gestational age, method of delivery, maternal race/ethnicity and hospital of birth.
Conclusions
High first-day weight loss predicts eventual weight nadir and can be used to identify infants who might benefit from targeted interventions to support breastfeeding and prevent EWL.
In newborns at risk for early-onset sepsis, empiric antibiotics are often initiated while awaiting the results of blood cultures. The duration of empiric therapy can be guided by the time to positivity (TTP) of blood cultures. The objective of the study was to determine the TTP of neonatal blood cultures for early-onset sepsis and the factors which may impact TTP.Observational study of blood cultures growing pathogenic species obtained within 72 hours of birth from infants born at 23-42 weeks gestation, at 19 hospitals in Northern California, Boston, and Philadelphia. TTP was defined as the time from blood culture collection to the time organism growth was reported by the microbiology laboratory.A total of 594 blood cultures growing pathogenic bacteria were identified. Group B Streptococcus and Escherichia coli accounted for 74% of blood culture isolates. Median TTP was 21.0 hours (interquartile range, 17.1-25.3 hours). Blood cultures were identified as positive by 24 hours after they were obtained in 68% of cases; by 36 hours in 94% of cases; and by 48 hours in 97% of cases. Neither the administration of maternal intrapartum antibiotic prophylaxis, gestational age <35 weeks, nor blood culture system impacted median TTP.Pathogens are isolated by 36 hours after blood culture collection in 94% of neonatal early blood cultures, regardless of maternal antibiotic administration. TTP information can inform decisions regarding the duration of empiric neonatal antibiotic therapies.
