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Intrauterine exposure to methylphenidate tied to increased cardiac risk
The use of methylphenidate by pregnant women is associated with a small increased risk of congenital cardiac malformations in newborns. However, a comparable increased risk is not found with intrauterine exposure to stimulants, according to a population-based cohort study published Dec. 13.
Krista F. Huybrechts, PhD, and her associates analyzed data from more than 1 million pregnancies in the United States. They found that the overall incidence of congenital malformations among the 1,813,894 pregnancies was 35 per 1,000 control infants, compared with 45.9 per 1,000 infants whose mothers used methylphenidate and 45.4 per 1,000 infants whose mothers used amphetamines. 
For the subset of infants with cardiac malformations, the risk per 1,000 infants was 12.7 for controls, 18.8 for methylphenidate exposure, and 15.4 for amphetamine exposure. The researchers identified an adjusted relative risk of 1.11 for overall congenital abnormalities and 1.28 for cardiac abnormalities with methylphenidate exposure, compared with a relative risk of 1.05 for overall congenital abnormalities and 0.96 for cardiac abnormalities with stimulant exposure.
An analysis among 2,560,069 pregnancies in Denmark, Finland, Iceland, Norway, and Sweden yielded a similarly significant relative risk of 1.28 for cardiac malformations associated with methylphenidate exposure (JAMA Psychiatry 2017. doi: 10.1001/jamapsychiatry.2017.3644).
“We found a 28% increased prevalence of cardiac malformations after first-trimester exposure to methylphenidate,” wrote Dr. Huybrechts of Brigham and Women’s Hospital, Boston, and her associates. “Although the absolute risk is small, it is nevertheless important evidence to consider when weighing the potential risks and benefits of different treatment strategies for [attention-deficit/hyperactivity disorder] in young women of reproductive age and in pregnant women.”
The researchers had no financial conflicts to disclose. The study was supported in part by grants from the National Institutes of Mental Health, the Eunice Kennedy Shriver National Institute for Child Health & Human Development, and the Söderström König Foundation.
The use of methylphenidate by pregnant women is associated with a small increased risk of congenital cardiac malformations in newborns. However, a comparable increased risk is not found with intrauterine exposure to stimulants, according to a population-based cohort study published Dec. 13.
Krista F. Huybrechts, PhD, and her associates analyzed data from more than 1 million pregnancies in the United States. They found that the overall incidence of congenital malformations among the 1,813,894 pregnancies was 35 per 1,000 control infants, compared with 45.9 per 1,000 infants whose mothers used methylphenidate and 45.4 per 1,000 infants whose mothers used amphetamines.
For the subset of infants with cardiac malformations, the risk per 1,000 infants was 12.7 for controls, 18.8 for methylphenidate exposure, and 15.4 for amphetamine exposure. The researchers identified an adjusted relative risk of 1.11 for overall congenital abnormalities and 1.28 for cardiac abnormalities with methylphenidate exposure, compared with a relative risk of 1.05 for overall congenital abnormalities and 0.96 for cardiac abnormalities with stimulant exposure.
An analysis among 2,560,069 pregnancies in Denmark, Finland, Iceland, Norway, and Sweden yielded a similarly significant relative risk of 1.28 for cardiac malformations associated with methylphenidate exposure (JAMA Psychiatry 2017. doi: 10.1001/jamapsychiatry.2017.3644).
“We found a 28% increased prevalence of cardiac malformations after first-trimester exposure to methylphenidate,” wrote Dr. Huybrechts of Brigham and Women’s Hospital, Boston, and her associates. “Although the absolute risk is small, it is nevertheless important evidence to consider when weighing the potential risks and benefits of different treatment strategies for [attention-deficit/hyperactivity disorder] in young women of reproductive age and in pregnant women.”
The researchers had no financial conflicts to disclose. The study was supported in part by grants from the National Institutes of Mental Health, the Eunice Kennedy Shriver National Institute for Child Health & Human Development, and the Söderström König Foundation.
The use of methylphenidate by pregnant women is associated with a small increased risk of congenital cardiac malformations in newborns. However, a comparable increased risk is not found with intrauterine exposure to stimulants, according to a population-based cohort study published Dec. 13.
Krista F. Huybrechts, PhD, and her associates analyzed data from more than 1 million pregnancies in the United States. They found that the overall incidence of congenital malformations among the 1,813,894 pregnancies was 35 per 1,000 control infants, compared with 45.9 per 1,000 infants whose mothers used methylphenidate and 45.4 per 1,000 infants whose mothers used amphetamines.
For the subset of infants with cardiac malformations, the risk per 1,000 infants was 12.7 for controls, 18.8 for methylphenidate exposure, and 15.4 for amphetamine exposure. The researchers identified an adjusted relative risk of 1.11 for overall congenital abnormalities and 1.28 for cardiac abnormalities with methylphenidate exposure, compared with a relative risk of 1.05 for overall congenital abnormalities and 0.96 for cardiac abnormalities with stimulant exposure.
An analysis among 2,560,069 pregnancies in Denmark, Finland, Iceland, Norway, and Sweden yielded a similarly significant relative risk of 1.28 for cardiac malformations associated with methylphenidate exposure (JAMA Psychiatry 2017. doi: 10.1001/jamapsychiatry.2017.3644).
“We found a 28% increased prevalence of cardiac malformations after first-trimester exposure to methylphenidate,” wrote Dr. Huybrechts of Brigham and Women’s Hospital, Boston, and her associates. “Although the absolute risk is small, it is nevertheless important evidence to consider when weighing the potential risks and benefits of different treatment strategies for [attention-deficit/hyperactivity disorder] in young women of reproductive age and in pregnant women.”
The researchers had no financial conflicts to disclose. The study was supported in part by grants from the National Institutes of Mental Health, the Eunice Kennedy Shriver National Institute for Child Health & Human Development, and the Söderström König Foundation.
FROM JAMA PSYCHIATRY
Prenatal vitamin D supplementation plagued by lack of evidence
Prenatal vitamin D supplementation may reduce the risk of small for gestational age and early wheeze in infants, but most of the evidence comes from small, low-quality trials, according to a systematic review and meta-analysis.
Researchers reported on a meta-analysis of 43 randomized controlled trials, involving 8,406 participants, which examined the effects of vitamin D supplementation during pregnancy (BMJ. 2017;359:j5237. doi: 10.1136/bmj.j5237).
The most commonly reported outcomes involved fetal growth and preterm birth. A pooling of 37 comparisons suggested that vitamin D supplementation increased mean birth weight by an average of 58 g, compared with low-dose vitamin D, no vitamin D, or placebo.
Two high-quality trials using a regular dose of vitamin D, which were conducted in high-income countries, found a 19% reduction in the risk of persistent/recurrent wheeze by age 3, which the authors said was consistent with other data suggesting a beneficial effect of vitamin D in adults with asthma. However, there were no other respiratory effects, such as on the risk of upper or lower respiratory tract infections.
There were few studies that reported on maternal clinical outcomes, and those that did showed no evidence of benefit.
“Though some observational studies have shown associations between maternal vitamin D deficiency and gestational diabetes and preeclampsia, we did not find robust corroborating evidence from randomised controlled trials,” wrote Daniel E. Roth, MD, and his colleagues at the Hospital for Sick Children, Toronto, and the University of Toronto.
They did report significantly higher maternal and cord blood concentrations of 25-hydroxyvitamin D in the intervention groups, compared with controls.
The median sample size of the studies was 133, and the researchers found that only 8 of the 43 trials had an overall low risk of bias. They also noted that there were wide variations in baseline maternal vitamin D levels.
“Though trials of prenatal vitamin D supplementation are being published at an accelerating pace, randomised controlled trials published up to 2017 were generally small, low quality, and rarely designed to examine clinical outcomes,” the researchers wrote.
The study was supported by the Hospital for Sick Children. No conflicts of interest were declared.
Prenatal vitamin D supplementation may reduce the risk of small for gestational age and early wheeze in infants, but most of the evidence comes from small, low-quality trials, according to a systematic review and meta-analysis.
Researchers reported on a meta-analysis of 43 randomized controlled trials, involving 8,406 participants, which examined the effects of vitamin D supplementation during pregnancy (BMJ. 2017;359:j5237. doi: 10.1136/bmj.j5237).
The most commonly reported outcomes involved fetal growth and preterm birth. A pooling of 37 comparisons suggested that vitamin D supplementation increased mean birth weight by an average of 58 g, compared with low-dose vitamin D, no vitamin D, or placebo.
Two high-quality trials using a regular dose of vitamin D, which were conducted in high-income countries, found a 19% reduction in the risk of persistent/recurrent wheeze by age 3, which the authors said was consistent with other data suggesting a beneficial effect of vitamin D in adults with asthma. However, there were no other respiratory effects, such as on the risk of upper or lower respiratory tract infections.
There were few studies that reported on maternal clinical outcomes, and those that did showed no evidence of benefit.
“Though some observational studies have shown associations between maternal vitamin D deficiency and gestational diabetes and preeclampsia, we did not find robust corroborating evidence from randomised controlled trials,” wrote Daniel E. Roth, MD, and his colleagues at the Hospital for Sick Children, Toronto, and the University of Toronto.
They did report significantly higher maternal and cord blood concentrations of 25-hydroxyvitamin D in the intervention groups, compared with controls.
The median sample size of the studies was 133, and the researchers found that only 8 of the 43 trials had an overall low risk of bias. They also noted that there were wide variations in baseline maternal vitamin D levels.
“Though trials of prenatal vitamin D supplementation are being published at an accelerating pace, randomised controlled trials published up to 2017 were generally small, low quality, and rarely designed to examine clinical outcomes,” the researchers wrote.
The study was supported by the Hospital for Sick Children. No conflicts of interest were declared.
Prenatal vitamin D supplementation may reduce the risk of small for gestational age and early wheeze in infants, but most of the evidence comes from small, low-quality trials, according to a systematic review and meta-analysis.
Researchers reported on a meta-analysis of 43 randomized controlled trials, involving 8,406 participants, which examined the effects of vitamin D supplementation during pregnancy (BMJ. 2017;359:j5237. doi: 10.1136/bmj.j5237).
The most commonly reported outcomes involved fetal growth and preterm birth. A pooling of 37 comparisons suggested that vitamin D supplementation increased mean birth weight by an average of 58 g, compared with low-dose vitamin D, no vitamin D, or placebo.
Two high-quality trials using a regular dose of vitamin D, which were conducted in high-income countries, found a 19% reduction in the risk of persistent/recurrent wheeze by age 3, which the authors said was consistent with other data suggesting a beneficial effect of vitamin D in adults with asthma. However, there were no other respiratory effects, such as on the risk of upper or lower respiratory tract infections.
There were few studies that reported on maternal clinical outcomes, and those that did showed no evidence of benefit.
“Though some observational studies have shown associations between maternal vitamin D deficiency and gestational diabetes and preeclampsia, we did not find robust corroborating evidence from randomised controlled trials,” wrote Daniel E. Roth, MD, and his colleagues at the Hospital for Sick Children, Toronto, and the University of Toronto.
They did report significantly higher maternal and cord blood concentrations of 25-hydroxyvitamin D in the intervention groups, compared with controls.
The median sample size of the studies was 133, and the researchers found that only 8 of the 43 trials had an overall low risk of bias. They also noted that there were wide variations in baseline maternal vitamin D levels.
“Though trials of prenatal vitamin D supplementation are being published at an accelerating pace, randomised controlled trials published up to 2017 were generally small, low quality, and rarely designed to examine clinical outcomes,” the researchers wrote.
The study was supported by the Hospital for Sick Children. No conflicts of interest were declared.
FROM BMJ
Key clinical point:
Major finding: Prenatal vitamin D supplementation is associated with a 40% reduction in the risk of having an SGA infant.
Data source: A systematic review and meta-analysis of 43 randomized controlled trials.
Disclosures: The study was supported by the Hospital for Sick Children, Toronto. No conflicts of interest were declared.
Biologics during pregnancy did not affect infant vaccine response
The use of biologic therapy during pregnancy did not lower antibody titers among infants vaccinated against Haemophilus influenzae B (HiB) or tetanus toxin, according to the results of a study of 179 mothers reported in the January issue of Clinical Gastroenterology and Hepatology (2017. doi: 10.1016/j.cgh.2017.08.041).
Additionally, there was no link between median infliximab concentration in uterine cord blood and antibody titers among infants aged 7 months and older, wrote Dawn B. Beaulieu, MD, with her associates. “In a limited cohort of exposed infants given the rotavirus vaccine, there was no association with significant adverse reactions,” they also reported.
Experts now recommend against live vaccinations for infants who may have detectable concentrations of biologics, but it remained unclear whether these infants can mount adequate responses to inactive vaccines. Therefore, the researchers analyzed data from the Pregnancy in IBD and Neonatal Outcomes (PIANO) registry collected between 2007 and 2016 and surveyed women about their infants’ vaccination history. They also quantified antibodies in serum samples from infants aged 7 months and older and analyzed measured concentrations of biologics in cord blood.
Among 179 mothers with IBD, most had inactive (77%) or mild disease activity (18%) during pregnancy, the researchers said. Eleven (6%) mothers were not on immunosuppressives while pregnant, 15 (8%) were on an immunomodulator, and the rest were on biologic monotherapy (65%) or a biologic plus an immunomodulator (21%). A total of 46 infants had available HiB titer data, of whom 38 were potentially exposed to biologics; among 49 infants with available tetanus titers, 41 were potentially exposed. In all, 71% of exposed infants had protective levels of antibodies against HiB, and 80% had protective titers to tetanus toxoid. Proportions among unexposed infants were 50% and 75%, respectively. Proportions of protective antibody titers did not significantly differ between groups even after excluding infants whose mothers received certolizumab pegol, which has negligible rates of placental transfer.
A total of 39 infants received live rotavirus vaccine despite having detectable levels of biologics in cord blood at birth. Seven developed mild vaccine reactions consisting of fever (six infants) or diarrhea (one infant). This proportion (18%) resembles that from a large study (N Engl J Med. 2006;354:23-33) of healthy infants who were vaccinated against rotavirus, the researchers noted. “Despite our data suggesting a lack of severe side effects with the rotavirus vaccine in these infants, in the absence of robust evidence, one should continue to avoid live vaccines in infants born to mothers on biologic therapy (excluding certolizumab) during the first year of life or until drug clearance is confirmed,” they suggested. “With the growing availability of tests, one conceivably could test serum drug concentration in infants, and, if undetectable, consider live vaccination at that time, if appropriate for the vaccine, particularly in infants most likely to benefit from such vaccines.”
The Crohn’s and Colitis Foundation provided funding. Dr. Beaulieu disclosed a consulting relationship with AbbVie, and four coinvestigators also reported ties to pharmaceutical companies.
The use of biologic therapy during pregnancy did not lower antibody titers among infants vaccinated against Haemophilus influenzae B (HiB) or tetanus toxin, according to the results of a study of 179 mothers reported in the January issue of Clinical Gastroenterology and Hepatology (2017. doi: 10.1016/j.cgh.2017.08.041).
Additionally, there was no link between median infliximab concentration in uterine cord blood and antibody titers among infants aged 7 months and older, wrote Dawn B. Beaulieu, MD, with her associates. “In a limited cohort of exposed infants given the rotavirus vaccine, there was no association with significant adverse reactions,” they also reported.
Experts now recommend against live vaccinations for infants who may have detectable concentrations of biologics, but it remained unclear whether these infants can mount adequate responses to inactive vaccines. Therefore, the researchers analyzed data from the Pregnancy in IBD and Neonatal Outcomes (PIANO) registry collected between 2007 and 2016 and surveyed women about their infants’ vaccination history. They also quantified antibodies in serum samples from infants aged 7 months and older and analyzed measured concentrations of biologics in cord blood.
Among 179 mothers with IBD, most had inactive (77%) or mild disease activity (18%) during pregnancy, the researchers said. Eleven (6%) mothers were not on immunosuppressives while pregnant, 15 (8%) were on an immunomodulator, and the rest were on biologic monotherapy (65%) or a biologic plus an immunomodulator (21%). A total of 46 infants had available HiB titer data, of whom 38 were potentially exposed to biologics; among 49 infants with available tetanus titers, 41 were potentially exposed. In all, 71% of exposed infants had protective levels of antibodies against HiB, and 80% had protective titers to tetanus toxoid. Proportions among unexposed infants were 50% and 75%, respectively. Proportions of protective antibody titers did not significantly differ between groups even after excluding infants whose mothers received certolizumab pegol, which has negligible rates of placental transfer.
A total of 39 infants received live rotavirus vaccine despite having detectable levels of biologics in cord blood at birth. Seven developed mild vaccine reactions consisting of fever (six infants) or diarrhea (one infant). This proportion (18%) resembles that from a large study (N Engl J Med. 2006;354:23-33) of healthy infants who were vaccinated against rotavirus, the researchers noted. “Despite our data suggesting a lack of severe side effects with the rotavirus vaccine in these infants, in the absence of robust evidence, one should continue to avoid live vaccines in infants born to mothers on biologic therapy (excluding certolizumab) during the first year of life or until drug clearance is confirmed,” they suggested. “With the growing availability of tests, one conceivably could test serum drug concentration in infants, and, if undetectable, consider live vaccination at that time, if appropriate for the vaccine, particularly in infants most likely to benefit from such vaccines.”
The Crohn’s and Colitis Foundation provided funding. Dr. Beaulieu disclosed a consulting relationship with AbbVie, and four coinvestigators also reported ties to pharmaceutical companies.
The use of biologic therapy during pregnancy did not lower antibody titers among infants vaccinated against Haemophilus influenzae B (HiB) or tetanus toxin, according to the results of a study of 179 mothers reported in the January issue of Clinical Gastroenterology and Hepatology (2017. doi: 10.1016/j.cgh.2017.08.041).
Additionally, there was no link between median infliximab concentration in uterine cord blood and antibody titers among infants aged 7 months and older, wrote Dawn B. Beaulieu, MD, with her associates. “In a limited cohort of exposed infants given the rotavirus vaccine, there was no association with significant adverse reactions,” they also reported.
Experts now recommend against live vaccinations for infants who may have detectable concentrations of biologics, but it remained unclear whether these infants can mount adequate responses to inactive vaccines. Therefore, the researchers analyzed data from the Pregnancy in IBD and Neonatal Outcomes (PIANO) registry collected between 2007 and 2016 and surveyed women about their infants’ vaccination history. They also quantified antibodies in serum samples from infants aged 7 months and older and analyzed measured concentrations of biologics in cord blood.
Among 179 mothers with IBD, most had inactive (77%) or mild disease activity (18%) during pregnancy, the researchers said. Eleven (6%) mothers were not on immunosuppressives while pregnant, 15 (8%) were on an immunomodulator, and the rest were on biologic monotherapy (65%) or a biologic plus an immunomodulator (21%). A total of 46 infants had available HiB titer data, of whom 38 were potentially exposed to biologics; among 49 infants with available tetanus titers, 41 were potentially exposed. In all, 71% of exposed infants had protective levels of antibodies against HiB, and 80% had protective titers to tetanus toxoid. Proportions among unexposed infants were 50% and 75%, respectively. Proportions of protective antibody titers did not significantly differ between groups even after excluding infants whose mothers received certolizumab pegol, which has negligible rates of placental transfer.
A total of 39 infants received live rotavirus vaccine despite having detectable levels of biologics in cord blood at birth. Seven developed mild vaccine reactions consisting of fever (six infants) or diarrhea (one infant). This proportion (18%) resembles that from a large study (N Engl J Med. 2006;354:23-33) of healthy infants who were vaccinated against rotavirus, the researchers noted. “Despite our data suggesting a lack of severe side effects with the rotavirus vaccine in these infants, in the absence of robust evidence, one should continue to avoid live vaccines in infants born to mothers on biologic therapy (excluding certolizumab) during the first year of life or until drug clearance is confirmed,” they suggested. “With the growing availability of tests, one conceivably could test serum drug concentration in infants, and, if undetectable, consider live vaccination at that time, if appropriate for the vaccine, particularly in infants most likely to benefit from such vaccines.”
The Crohn’s and Colitis Foundation provided funding. Dr. Beaulieu disclosed a consulting relationship with AbbVie, and four coinvestigators also reported ties to pharmaceutical companies.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: In utero biologic exposure did not prevent immune response to Haemophilus influenzae B and tetanus vaccines during infancy.
Major finding: Proportions of protective antibody titers did not significantly differ among groups.
Data source: A prospective study of 179 mothers with IBD and their infants.
Disclosures: The Crohn’s and Colitis Foundation provided funding. Dr. Beaulieu disclosed a consulting relationship with AbbVie, and four coinvestigators also reported ties to pharmaceutical companies.
Screening for postpartum depression is essential
CHICAGO – according to Nerissa S. Bauer, MD, MPH.
Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).
Postpartum mood disorders
Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).
PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.
Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.
Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.
Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).
Your role in screening mothers
It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).
The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).
“Early treatment shows best results,” Dr. Bauer said. Yet less than half of mothers experiencing PPD seek treatment for it.
“Mothers may feel they ‘are strong enough’ and do not need help,” Dr. Bauer said. Or they feel they have to use what limited energy they have on their baby, or they worry about being “labeled as crazy or unable to care for their baby,” she said. Cultural factors also can play a role in this reticence to seek help (Qual Health Res. 2008 Sep;18[9]:1161-73).
“However, mothers are receptive to communication with their child’s pediatrician,” Dr. Bauer said, creating an opportunity for screening that mothers may not otherwise get.
Screening tools and procedures
Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).
Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).
The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).
The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.
You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”
The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?
If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.
“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”
After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.
Dr. Bauer offerred the following recommendations for clinical practice:
- Choose a validated screener for postpartum depression.
- Share the tool with everyone in your practice.
- Identify ways to integrate the screening tool into daily work flow.
- Collect data.
- Implement and assess how it went after a short time, using plan-do-study-act cycles.
Dr. Bauer advised consulting the following websites for information regarding postpartum depression:
- AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
- Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
- PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
- PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().
Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.
CHICAGO – according to Nerissa S. Bauer, MD, MPH.
Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).
Postpartum mood disorders
Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).
PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.
Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.
Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.
Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).
Your role in screening mothers
It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).
The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).
“Early treatment shows best results,” Dr. Bauer said. Yet less than half of mothers experiencing PPD seek treatment for it.
“Mothers may feel they ‘are strong enough’ and do not need help,” Dr. Bauer said. Or they feel they have to use what limited energy they have on their baby, or they worry about being “labeled as crazy or unable to care for their baby,” she said. Cultural factors also can play a role in this reticence to seek help (Qual Health Res. 2008 Sep;18[9]:1161-73).
“However, mothers are receptive to communication with their child’s pediatrician,” Dr. Bauer said, creating an opportunity for screening that mothers may not otherwise get.
Screening tools and procedures
Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).
Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).
The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).
The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.
You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”
The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?
If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.
“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”
After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.
Dr. Bauer offerred the following recommendations for clinical practice:
- Choose a validated screener for postpartum depression.
- Share the tool with everyone in your practice.
- Identify ways to integrate the screening tool into daily work flow.
- Collect data.
- Implement and assess how it went after a short time, using plan-do-study-act cycles.
Dr. Bauer advised consulting the following websites for information regarding postpartum depression:
- AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
- Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
- PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
- PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().
Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.
CHICAGO – according to Nerissa S. Bauer, MD, MPH.
Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).
Postpartum mood disorders
Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).
PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.
Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.
Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.
Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).
Your role in screening mothers
It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).
The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).
“Early treatment shows best results,” Dr. Bauer said. Yet less than half of mothers experiencing PPD seek treatment for it.
“Mothers may feel they ‘are strong enough’ and do not need help,” Dr. Bauer said. Or they feel they have to use what limited energy they have on their baby, or they worry about being “labeled as crazy or unable to care for their baby,” she said. Cultural factors also can play a role in this reticence to seek help (Qual Health Res. 2008 Sep;18[9]:1161-73).
“However, mothers are receptive to communication with their child’s pediatrician,” Dr. Bauer said, creating an opportunity for screening that mothers may not otherwise get.
Screening tools and procedures
Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).
Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).
The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).
The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.
You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”
The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?
If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.
“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”
After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.
Dr. Bauer offerred the following recommendations for clinical practice:
- Choose a validated screener for postpartum depression.
- Share the tool with everyone in your practice.
- Identify ways to integrate the screening tool into daily work flow.
- Collect data.
- Implement and assess how it went after a short time, using plan-do-study-act cycles.
Dr. Bauer advised consulting the following websites for information regarding postpartum depression:
- AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
- Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
- PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
- PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().
Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 2017
Two changes are made to resuscitation practice in delivery room
CHICAGO – , according to Gary M. Weiner, MD, of the department of pediatrics and neonatal-perinatal medicine at the University of Michigan and C.S. Mott Children’s Hospital in Ann Arbor.
One is recommending an electronic cardiac (EC) monitor to assess heart rate during resuscitation instead of relying on pulse oximetry, and the other is no longer recommending routine tracheal suction in nonvigorous babies with meconium-stained fluid, he told attendees at the American Academy of Pediatrics annual meeting.
About two-thirds of all births have a risk factor for needing resuscitation, and about 10%-20% of babies with a risk factor will need positive pressure ventilation (PPV). But risk factors do not identify all newborns who will need it. The risk is greatest for newborns less than 36 weeks’ or greater than 40 weeks’ gestational age, but 7% of term newborns will need PPV despite having no risk factors.
Situations in which there is the highest risk for advanced resuscitation include the following:
- Fetal bradycardia: 24-fold greater odds.
- Intrauterine growth restriction (IUGR): 20-fold greater odds.
- Clinical chorioamnionitis: 17-fold greater odds.
- Forceps or vacuum: 17-fold greater odds.
- Meconium-stained amniotic fluid (MSAF): 17-fold greater odds.
- Gestational diabetes: 16-fold greater odds.
- Abruption: 12-fold greater odds.
- General anesthesia: 11-fold greater odds.
These risks were determined in a prospective multicenter, case-control study of 61,593 births (Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102[1]:F44-F50).
Assembling a team and using checklists
Teamwork and communication are key in delivery room emergencies, and teams should debrief afterward, ideally having videotaped the resuscitation, if possible, Dr. Weiner said.
He discussed preparation for a very-low-birth-weight birth, a “routine emergency” requiring many tasks in a short period of time: 130 tasks in the first hour and 40 in the first 3 minutes.
“Decisions made during the first hour have long-term implications, so you need multiple caregivers and a high-performance team,” Dr. Weiner said. In addition to a thorough understanding of the clinical situation, a high-performance team should have both effective leadership, and clearly defined roles and responsibilities for each member. Clinicians on the team need highly developed technical skills that they reliably and consistently execute with precision. “Practice, refine, practice, refine,” he emphasized.
It’s also important to make use of preset protocols, scripts, and checklists, Dr. Weiner said. These tools assure consistency, facilitate communication among team members, and improve outcomes. Research has shown that use of protocols, scripts, and checklists leads to improved stroke and trauma care, decreased complications during intubation, fewer central-line complications, and decreased perioperative mortality and complications.
He also recommended implementing a standardized equipment check and team briefing “time-out,” similar to a surgical time-out. This time-out gives teams an opportunity to identify a team leader, define member roles and responsibilities, check all equipment and supplies, discuss risk factors and possible scenarios, talk with the obstetrician and, if possible, introduce the leader or another team member to the parents.
In a study from University of California, San Diego, Medical Center, using checklists as part of resuscitation of potentially high-risk infants reduced the occurrence of communication problems from 24% to 4% of resuscitations (P less than 0.001) over a 3-year period (Resuscitation. 2013 Nov;84[11]:1552-7).
Delayed cord clamping
Dr. Weiner also discussed the benefits of placental transfusion. The fetal-placental unit includes approximately 110 mL/kg of blood, and about one-third of its volume remains in the placenta immediately after birth. Immediate cord clamping means a loss of 10-20 mL/kg of “potential” newborn blood volume, and could contribute to unstable pulmonary blood flow or a carotid artery pressure spike (Matern Health Neonatol Perinatol. 2016. doi: 10.1186/s40748-016-0032-y).
“Umbilical blood flow is complex,” he said. Blood flows toward the baby via the umbilical vein during inhalation, but stops or reverses during crying. The umbilical artery primarily carries blood to the placenta, and flow stops after about 4 minutes in more than half of infants. Gravity’s role in blood flow is controversial (Lancet. 2014 Jul 19;384[9939]:235-40).
The two options for placental transfusion are delayed cord clamping and milking the umbilical cord (also called “stripping”). In vaginal births, delayed clamping allows 20 mL/kg blood to transfer to the baby by 3 minutes after birth, with 90% of that reaching the baby in the first minute (Lancet. 1969 Oct 25;294[7626]:871-3).
Blood transfer is less efficient in cesarean births, so milking may be more efficient than simply delaying clamping, according to a small randomized controlled trial of preterm infants around 28 weeks’ gestational age. No difference between the methods was seen in vaginal births. To milk the cord, pinch it near the placenta and squeeze it toward the newborn for 2 seconds; then release, refill and repeat.
The biggest benefits in delayed cord clamping or milking occur among preterm infants: decreased mortality, higher mean arterial pressure on day 1, and a lower risk of blood transfusion, necrotizing enterocolitis, and a Bayley Motor score below 85 at 18-22 months. Term babies also get benefits, though: increased hemoglobin at birth (approximately 2 g/dL), a 0.5- to 5-point average increase in boys’ Ages & Stages fine motor and social domain scores at age 4 years, and among high-risk infants, a lower risk of iron deficiency anemia at age 1 year (JAMA Pediatr. 2017;171[3]:264-70).
According to current guidelines from the American Academy of Pediatrics, “delayed cord clamping longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth,” but “there is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation.” They also recommend against routine milking for newborns less than 29 weeks’ gestation (Pediatrics. 2015 Nov;136 Suppl 2:S196-218).
Meconium-related complications
Meconium-stained amniotic fluid (MSAF) is common, occurring in about 8% of deliveries and increasing with gestational age, but meconium aspiration syndrome (MAS) is less common, occurring in about 2% of all MSAF cases (Int J Pediatr. 2012. doi: 10.1155/2012/321545).
Risk factors for severe MAS include thick meconium and an abnormal fetal heart rate. But about two-thirds of MAS cases are mild, not requiring ventilation or continuous positive airway pressure (CPAP), Dr. Weiner said. Practice should be driven by evidence from randomized controlled trials (RCTs).
“Nonrandomized observational studies can be misleading, and rational conjecture has led to many mistakes in medicine,” he said. “Be willing to challenge conventional wisdom.”
For example, the standard of care in the 1970s, based on two nonrandomized retrospective reviews of 175 babies, included orapharyngeal and nasopharyngeal suction by the obstetrician and endotracheal tube (ETT) suction by the pediatrician. In the 2000s, however, an RCT of 2,500 infants found no benefit from orapharyngeal and nasopharyngeal suction, even with thick MSAF, (Lancet. 2004 Aug 14-20;364[9434]:597-602) and another RCT with 2,100 infants found no benefit from ETT suction (Pediatrics. 2000 Jan;105[1 Pt 1]:1-7).
More recent, smaller studies have confirmed those conclusions and found similar lack of benefit from ETT in non-vigorous infants, contributing to the new recommendation (Resuscitation. 2016 Aug;105:79-84; Indian J Pediatr. 2016 Oct;83[10]:1125-30).
“Routine tracheal suction is no longer recommended for nonvigorous babies with meconium stained fluid,” Dr. Weiner said. Since MSAF is risk factor for resuscitation, though, at least two clinicians with Neonatal Resuscitation Program (NRP) training should be present, as well as a full team if resuscitation is expected.
Heart rate assessment and tracking
“The baby’s heart rate needs to be monitored during PPV [positive pressure ventilation] because a prompt increase in the baby’s heart rate is the most important indicator of effective PPV,” Dr. Weiner said in an interview. “Half of errors made during NRP [Neonatal Resuscitation Program] simulations are the result of incorrect heart rate assessment.”
Recent evidence comparing pulse oximetry to an EC monitor favored the latter for tracking heart rate, leading to the other new recommendation.
“The baby’s heart rate can be monitored using the pulse oximeter,” Dr. Weiner said. “However, health providers should consider using an electronic cardiac monitor in addition to pulse oximetry because studies show that it achieves a reliable signal faster.” He cited a study of 20 newborns that showed an EC monitor determined the heart rate in a median 34 seconds, compared with 122 seconds with the pulse oximeter (Pediatr Int. 2012 Apr;54[2]:205-7).
Pulse oximetry takes 90-120 seconds to attain a reliable signal and may not work if there’s poor perfusion, but an EC monitor provides continuous heart rate monitoring even with poor perfusion. So an initial heart rate assessment by auscultation is fine, but if PPV begins, EC monitoring may be better and is the preferred method with anticipated resuscitation or chest compressions.
However, pulse oximetry is still recommended “whenever positive pressure ventilation is started or oxygen is administered in order to guide the appropriate amount of oxygen supplementation,” Dr. Weiner noted.
He added that “preliminary studies suggest that handheld Doppler fetal heart monitors correlate well with ECG, provide a rapid audible heart rate and may be a promising alternative in the future” (Pediatr Int. 2017 Oct;59[10]:1069-73).
Correct ventilation techniques
“Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn,” Dr. Weiner said. “If the heart rate is not rapidly increasing, ask if the chest is moving.”
He emphasized that no compressions should occur until after at least 30 seconds of PPV that moves the chest. He provided a “MR. SOPA” acronym: Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternative airway.
You also should be aware of possible leaking or obstruction around the mask, which is common, he said, so monitor pressure instead of volume.
“We are not good at identifying leak, obstruction, or adequate tidal volume,” Dr. Weiner said. “A colorimetric CO2 detector attached to the mask is a simple indicator of gas exchange” (Resuscitation. 2014 Nov;85[11]:1568-72).
He also strongly recommended inserting an alternative airway before starting chest compressions with either intubation or a laryngeal mask.
Dr. Weiner concluded with the following list of clinical practice changes you may consider:
- Use a standardized equipment checklist.
- Develop and practice standardized scripts.
- Debrief after all resuscitations; use videotape if you can.
- Delay cord clamping for most term and preterm babies.
- Do not routinely intubate/suction nonvigorous newborns with MSAF. Initiate resuscitation.
- Use an electronic cardiac monitor if resuscitation is required.
- Use a colorimetric CO2 detector with PPV.
- Intubate or place a laryngeal mask before starting compressions.
Dr. Weiner reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – , according to Gary M. Weiner, MD, of the department of pediatrics and neonatal-perinatal medicine at the University of Michigan and C.S. Mott Children’s Hospital in Ann Arbor.
One is recommending an electronic cardiac (EC) monitor to assess heart rate during resuscitation instead of relying on pulse oximetry, and the other is no longer recommending routine tracheal suction in nonvigorous babies with meconium-stained fluid, he told attendees at the American Academy of Pediatrics annual meeting.
About two-thirds of all births have a risk factor for needing resuscitation, and about 10%-20% of babies with a risk factor will need positive pressure ventilation (PPV). But risk factors do not identify all newborns who will need it. The risk is greatest for newborns less than 36 weeks’ or greater than 40 weeks’ gestational age, but 7% of term newborns will need PPV despite having no risk factors.
Situations in which there is the highest risk for advanced resuscitation include the following:
- Fetal bradycardia: 24-fold greater odds.
- Intrauterine growth restriction (IUGR): 20-fold greater odds.
- Clinical chorioamnionitis: 17-fold greater odds.
- Forceps or vacuum: 17-fold greater odds.
- Meconium-stained amniotic fluid (MSAF): 17-fold greater odds.
- Gestational diabetes: 16-fold greater odds.
- Abruption: 12-fold greater odds.
- General anesthesia: 11-fold greater odds.
These risks were determined in a prospective multicenter, case-control study of 61,593 births (Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102[1]:F44-F50).
Assembling a team and using checklists
Teamwork and communication are key in delivery room emergencies, and teams should debrief afterward, ideally having videotaped the resuscitation, if possible, Dr. Weiner said.
He discussed preparation for a very-low-birth-weight birth, a “routine emergency” requiring many tasks in a short period of time: 130 tasks in the first hour and 40 in the first 3 minutes.
“Decisions made during the first hour have long-term implications, so you need multiple caregivers and a high-performance team,” Dr. Weiner said. In addition to a thorough understanding of the clinical situation, a high-performance team should have both effective leadership, and clearly defined roles and responsibilities for each member. Clinicians on the team need highly developed technical skills that they reliably and consistently execute with precision. “Practice, refine, practice, refine,” he emphasized.
It’s also important to make use of preset protocols, scripts, and checklists, Dr. Weiner said. These tools assure consistency, facilitate communication among team members, and improve outcomes. Research has shown that use of protocols, scripts, and checklists leads to improved stroke and trauma care, decreased complications during intubation, fewer central-line complications, and decreased perioperative mortality and complications.
He also recommended implementing a standardized equipment check and team briefing “time-out,” similar to a surgical time-out. This time-out gives teams an opportunity to identify a team leader, define member roles and responsibilities, check all equipment and supplies, discuss risk factors and possible scenarios, talk with the obstetrician and, if possible, introduce the leader or another team member to the parents.
In a study from University of California, San Diego, Medical Center, using checklists as part of resuscitation of potentially high-risk infants reduced the occurrence of communication problems from 24% to 4% of resuscitations (P less than 0.001) over a 3-year period (Resuscitation. 2013 Nov;84[11]:1552-7).
Delayed cord clamping
Dr. Weiner also discussed the benefits of placental transfusion. The fetal-placental unit includes approximately 110 mL/kg of blood, and about one-third of its volume remains in the placenta immediately after birth. Immediate cord clamping means a loss of 10-20 mL/kg of “potential” newborn blood volume, and could contribute to unstable pulmonary blood flow or a carotid artery pressure spike (Matern Health Neonatol Perinatol. 2016. doi: 10.1186/s40748-016-0032-y).
“Umbilical blood flow is complex,” he said. Blood flows toward the baby via the umbilical vein during inhalation, but stops or reverses during crying. The umbilical artery primarily carries blood to the placenta, and flow stops after about 4 minutes in more than half of infants. Gravity’s role in blood flow is controversial (Lancet. 2014 Jul 19;384[9939]:235-40).
The two options for placental transfusion are delayed cord clamping and milking the umbilical cord (also called “stripping”). In vaginal births, delayed clamping allows 20 mL/kg blood to transfer to the baby by 3 minutes after birth, with 90% of that reaching the baby in the first minute (Lancet. 1969 Oct 25;294[7626]:871-3).
Blood transfer is less efficient in cesarean births, so milking may be more efficient than simply delaying clamping, according to a small randomized controlled trial of preterm infants around 28 weeks’ gestational age. No difference between the methods was seen in vaginal births. To milk the cord, pinch it near the placenta and squeeze it toward the newborn for 2 seconds; then release, refill and repeat.
The biggest benefits in delayed cord clamping or milking occur among preterm infants: decreased mortality, higher mean arterial pressure on day 1, and a lower risk of blood transfusion, necrotizing enterocolitis, and a Bayley Motor score below 85 at 18-22 months. Term babies also get benefits, though: increased hemoglobin at birth (approximately 2 g/dL), a 0.5- to 5-point average increase in boys’ Ages & Stages fine motor and social domain scores at age 4 years, and among high-risk infants, a lower risk of iron deficiency anemia at age 1 year (JAMA Pediatr. 2017;171[3]:264-70).
According to current guidelines from the American Academy of Pediatrics, “delayed cord clamping longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth,” but “there is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation.” They also recommend against routine milking for newborns less than 29 weeks’ gestation (Pediatrics. 2015 Nov;136 Suppl 2:S196-218).
Meconium-related complications
Meconium-stained amniotic fluid (MSAF) is common, occurring in about 8% of deliveries and increasing with gestational age, but meconium aspiration syndrome (MAS) is less common, occurring in about 2% of all MSAF cases (Int J Pediatr. 2012. doi: 10.1155/2012/321545).
Risk factors for severe MAS include thick meconium and an abnormal fetal heart rate. But about two-thirds of MAS cases are mild, not requiring ventilation or continuous positive airway pressure (CPAP), Dr. Weiner said. Practice should be driven by evidence from randomized controlled trials (RCTs).
“Nonrandomized observational studies can be misleading, and rational conjecture has led to many mistakes in medicine,” he said. “Be willing to challenge conventional wisdom.”
For example, the standard of care in the 1970s, based on two nonrandomized retrospective reviews of 175 babies, included orapharyngeal and nasopharyngeal suction by the obstetrician and endotracheal tube (ETT) suction by the pediatrician. In the 2000s, however, an RCT of 2,500 infants found no benefit from orapharyngeal and nasopharyngeal suction, even with thick MSAF, (Lancet. 2004 Aug 14-20;364[9434]:597-602) and another RCT with 2,100 infants found no benefit from ETT suction (Pediatrics. 2000 Jan;105[1 Pt 1]:1-7).
More recent, smaller studies have confirmed those conclusions and found similar lack of benefit from ETT in non-vigorous infants, contributing to the new recommendation (Resuscitation. 2016 Aug;105:79-84; Indian J Pediatr. 2016 Oct;83[10]:1125-30).
“Routine tracheal suction is no longer recommended for nonvigorous babies with meconium stained fluid,” Dr. Weiner said. Since MSAF is risk factor for resuscitation, though, at least two clinicians with Neonatal Resuscitation Program (NRP) training should be present, as well as a full team if resuscitation is expected.
Heart rate assessment and tracking
“The baby’s heart rate needs to be monitored during PPV [positive pressure ventilation] because a prompt increase in the baby’s heart rate is the most important indicator of effective PPV,” Dr. Weiner said in an interview. “Half of errors made during NRP [Neonatal Resuscitation Program] simulations are the result of incorrect heart rate assessment.”
Recent evidence comparing pulse oximetry to an EC monitor favored the latter for tracking heart rate, leading to the other new recommendation.
“The baby’s heart rate can be monitored using the pulse oximeter,” Dr. Weiner said. “However, health providers should consider using an electronic cardiac monitor in addition to pulse oximetry because studies show that it achieves a reliable signal faster.” He cited a study of 20 newborns that showed an EC monitor determined the heart rate in a median 34 seconds, compared with 122 seconds with the pulse oximeter (Pediatr Int. 2012 Apr;54[2]:205-7).
Pulse oximetry takes 90-120 seconds to attain a reliable signal and may not work if there’s poor perfusion, but an EC monitor provides continuous heart rate monitoring even with poor perfusion. So an initial heart rate assessment by auscultation is fine, but if PPV begins, EC monitoring may be better and is the preferred method with anticipated resuscitation or chest compressions.
However, pulse oximetry is still recommended “whenever positive pressure ventilation is started or oxygen is administered in order to guide the appropriate amount of oxygen supplementation,” Dr. Weiner noted.
He added that “preliminary studies suggest that handheld Doppler fetal heart monitors correlate well with ECG, provide a rapid audible heart rate and may be a promising alternative in the future” (Pediatr Int. 2017 Oct;59[10]:1069-73).
Correct ventilation techniques
“Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn,” Dr. Weiner said. “If the heart rate is not rapidly increasing, ask if the chest is moving.”
He emphasized that no compressions should occur until after at least 30 seconds of PPV that moves the chest. He provided a “MR. SOPA” acronym: Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternative airway.
You also should be aware of possible leaking or obstruction around the mask, which is common, he said, so monitor pressure instead of volume.
“We are not good at identifying leak, obstruction, or adequate tidal volume,” Dr. Weiner said. “A colorimetric CO2 detector attached to the mask is a simple indicator of gas exchange” (Resuscitation. 2014 Nov;85[11]:1568-72).
He also strongly recommended inserting an alternative airway before starting chest compressions with either intubation or a laryngeal mask.
Dr. Weiner concluded with the following list of clinical practice changes you may consider:
- Use a standardized equipment checklist.
- Develop and practice standardized scripts.
- Debrief after all resuscitations; use videotape if you can.
- Delay cord clamping for most term and preterm babies.
- Do not routinely intubate/suction nonvigorous newborns with MSAF. Initiate resuscitation.
- Use an electronic cardiac monitor if resuscitation is required.
- Use a colorimetric CO2 detector with PPV.
- Intubate or place a laryngeal mask before starting compressions.
Dr. Weiner reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – , according to Gary M. Weiner, MD, of the department of pediatrics and neonatal-perinatal medicine at the University of Michigan and C.S. Mott Children’s Hospital in Ann Arbor.
One is recommending an electronic cardiac (EC) monitor to assess heart rate during resuscitation instead of relying on pulse oximetry, and the other is no longer recommending routine tracheal suction in nonvigorous babies with meconium-stained fluid, he told attendees at the American Academy of Pediatrics annual meeting.
About two-thirds of all births have a risk factor for needing resuscitation, and about 10%-20% of babies with a risk factor will need positive pressure ventilation (PPV). But risk factors do not identify all newborns who will need it. The risk is greatest for newborns less than 36 weeks’ or greater than 40 weeks’ gestational age, but 7% of term newborns will need PPV despite having no risk factors.
Situations in which there is the highest risk for advanced resuscitation include the following:
- Fetal bradycardia: 24-fold greater odds.
- Intrauterine growth restriction (IUGR): 20-fold greater odds.
- Clinical chorioamnionitis: 17-fold greater odds.
- Forceps or vacuum: 17-fold greater odds.
- Meconium-stained amniotic fluid (MSAF): 17-fold greater odds.
- Gestational diabetes: 16-fold greater odds.
- Abruption: 12-fold greater odds.
- General anesthesia: 11-fold greater odds.
These risks were determined in a prospective multicenter, case-control study of 61,593 births (Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102[1]:F44-F50).
Assembling a team and using checklists
Teamwork and communication are key in delivery room emergencies, and teams should debrief afterward, ideally having videotaped the resuscitation, if possible, Dr. Weiner said.
He discussed preparation for a very-low-birth-weight birth, a “routine emergency” requiring many tasks in a short period of time: 130 tasks in the first hour and 40 in the first 3 minutes.
“Decisions made during the first hour have long-term implications, so you need multiple caregivers and a high-performance team,” Dr. Weiner said. In addition to a thorough understanding of the clinical situation, a high-performance team should have both effective leadership, and clearly defined roles and responsibilities for each member. Clinicians on the team need highly developed technical skills that they reliably and consistently execute with precision. “Practice, refine, practice, refine,” he emphasized.
It’s also important to make use of preset protocols, scripts, and checklists, Dr. Weiner said. These tools assure consistency, facilitate communication among team members, and improve outcomes. Research has shown that use of protocols, scripts, and checklists leads to improved stroke and trauma care, decreased complications during intubation, fewer central-line complications, and decreased perioperative mortality and complications.
He also recommended implementing a standardized equipment check and team briefing “time-out,” similar to a surgical time-out. This time-out gives teams an opportunity to identify a team leader, define member roles and responsibilities, check all equipment and supplies, discuss risk factors and possible scenarios, talk with the obstetrician and, if possible, introduce the leader or another team member to the parents.
In a study from University of California, San Diego, Medical Center, using checklists as part of resuscitation of potentially high-risk infants reduced the occurrence of communication problems from 24% to 4% of resuscitations (P less than 0.001) over a 3-year period (Resuscitation. 2013 Nov;84[11]:1552-7).
Delayed cord clamping
Dr. Weiner also discussed the benefits of placental transfusion. The fetal-placental unit includes approximately 110 mL/kg of blood, and about one-third of its volume remains in the placenta immediately after birth. Immediate cord clamping means a loss of 10-20 mL/kg of “potential” newborn blood volume, and could contribute to unstable pulmonary blood flow or a carotid artery pressure spike (Matern Health Neonatol Perinatol. 2016. doi: 10.1186/s40748-016-0032-y).
“Umbilical blood flow is complex,” he said. Blood flows toward the baby via the umbilical vein during inhalation, but stops or reverses during crying. The umbilical artery primarily carries blood to the placenta, and flow stops after about 4 minutes in more than half of infants. Gravity’s role in blood flow is controversial (Lancet. 2014 Jul 19;384[9939]:235-40).
The two options for placental transfusion are delayed cord clamping and milking the umbilical cord (also called “stripping”). In vaginal births, delayed clamping allows 20 mL/kg blood to transfer to the baby by 3 minutes after birth, with 90% of that reaching the baby in the first minute (Lancet. 1969 Oct 25;294[7626]:871-3).
Blood transfer is less efficient in cesarean births, so milking may be more efficient than simply delaying clamping, according to a small randomized controlled trial of preterm infants around 28 weeks’ gestational age. No difference between the methods was seen in vaginal births. To milk the cord, pinch it near the placenta and squeeze it toward the newborn for 2 seconds; then release, refill and repeat.
The biggest benefits in delayed cord clamping or milking occur among preterm infants: decreased mortality, higher mean arterial pressure on day 1, and a lower risk of blood transfusion, necrotizing enterocolitis, and a Bayley Motor score below 85 at 18-22 months. Term babies also get benefits, though: increased hemoglobin at birth (approximately 2 g/dL), a 0.5- to 5-point average increase in boys’ Ages & Stages fine motor and social domain scores at age 4 years, and among high-risk infants, a lower risk of iron deficiency anemia at age 1 year (JAMA Pediatr. 2017;171[3]:264-70).
According to current guidelines from the American Academy of Pediatrics, “delayed cord clamping longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth,” but “there is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation.” They also recommend against routine milking for newborns less than 29 weeks’ gestation (Pediatrics. 2015 Nov;136 Suppl 2:S196-218).
Meconium-related complications
Meconium-stained amniotic fluid (MSAF) is common, occurring in about 8% of deliveries and increasing with gestational age, but meconium aspiration syndrome (MAS) is less common, occurring in about 2% of all MSAF cases (Int J Pediatr. 2012. doi: 10.1155/2012/321545).
Risk factors for severe MAS include thick meconium and an abnormal fetal heart rate. But about two-thirds of MAS cases are mild, not requiring ventilation or continuous positive airway pressure (CPAP), Dr. Weiner said. Practice should be driven by evidence from randomized controlled trials (RCTs).
“Nonrandomized observational studies can be misleading, and rational conjecture has led to many mistakes in medicine,” he said. “Be willing to challenge conventional wisdom.”
For example, the standard of care in the 1970s, based on two nonrandomized retrospective reviews of 175 babies, included orapharyngeal and nasopharyngeal suction by the obstetrician and endotracheal tube (ETT) suction by the pediatrician. In the 2000s, however, an RCT of 2,500 infants found no benefit from orapharyngeal and nasopharyngeal suction, even with thick MSAF, (Lancet. 2004 Aug 14-20;364[9434]:597-602) and another RCT with 2,100 infants found no benefit from ETT suction (Pediatrics. 2000 Jan;105[1 Pt 1]:1-7).
More recent, smaller studies have confirmed those conclusions and found similar lack of benefit from ETT in non-vigorous infants, contributing to the new recommendation (Resuscitation. 2016 Aug;105:79-84; Indian J Pediatr. 2016 Oct;83[10]:1125-30).
“Routine tracheal suction is no longer recommended for nonvigorous babies with meconium stained fluid,” Dr. Weiner said. Since MSAF is risk factor for resuscitation, though, at least two clinicians with Neonatal Resuscitation Program (NRP) training should be present, as well as a full team if resuscitation is expected.
Heart rate assessment and tracking
“The baby’s heart rate needs to be monitored during PPV [positive pressure ventilation] because a prompt increase in the baby’s heart rate is the most important indicator of effective PPV,” Dr. Weiner said in an interview. “Half of errors made during NRP [Neonatal Resuscitation Program] simulations are the result of incorrect heart rate assessment.”
Recent evidence comparing pulse oximetry to an EC monitor favored the latter for tracking heart rate, leading to the other new recommendation.
“The baby’s heart rate can be monitored using the pulse oximeter,” Dr. Weiner said. “However, health providers should consider using an electronic cardiac monitor in addition to pulse oximetry because studies show that it achieves a reliable signal faster.” He cited a study of 20 newborns that showed an EC monitor determined the heart rate in a median 34 seconds, compared with 122 seconds with the pulse oximeter (Pediatr Int. 2012 Apr;54[2]:205-7).
Pulse oximetry takes 90-120 seconds to attain a reliable signal and may not work if there’s poor perfusion, but an EC monitor provides continuous heart rate monitoring even with poor perfusion. So an initial heart rate assessment by auscultation is fine, but if PPV begins, EC monitoring may be better and is the preferred method with anticipated resuscitation or chest compressions.
However, pulse oximetry is still recommended “whenever positive pressure ventilation is started or oxygen is administered in order to guide the appropriate amount of oxygen supplementation,” Dr. Weiner noted.
He added that “preliminary studies suggest that handheld Doppler fetal heart monitors correlate well with ECG, provide a rapid audible heart rate and may be a promising alternative in the future” (Pediatr Int. 2017 Oct;59[10]:1069-73).
Correct ventilation techniques
“Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn,” Dr. Weiner said. “If the heart rate is not rapidly increasing, ask if the chest is moving.”
He emphasized that no compressions should occur until after at least 30 seconds of PPV that moves the chest. He provided a “MR. SOPA” acronym: Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternative airway.
You also should be aware of possible leaking or obstruction around the mask, which is common, he said, so monitor pressure instead of volume.
“We are not good at identifying leak, obstruction, or adequate tidal volume,” Dr. Weiner said. “A colorimetric CO2 detector attached to the mask is a simple indicator of gas exchange” (Resuscitation. 2014 Nov;85[11]:1568-72).
He also strongly recommended inserting an alternative airway before starting chest compressions with either intubation or a laryngeal mask.
Dr. Weiner concluded with the following list of clinical practice changes you may consider:
- Use a standardized equipment checklist.
- Develop and practice standardized scripts.
- Debrief after all resuscitations; use videotape if you can.
- Delay cord clamping for most term and preterm babies.
- Do not routinely intubate/suction nonvigorous newborns with MSAF. Initiate resuscitation.
- Use an electronic cardiac monitor if resuscitation is required.
- Use a colorimetric CO2 detector with PPV.
- Intubate or place a laryngeal mask before starting compressions.
Dr. Weiner reported having no disclosures, and no external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 2017
ACOG advises against vaginal seeding
The practice of vaginal seeding should not be performed outside of an approved research protocol until adequate data on safety and potential benefits are available, according to a new policy statement from the American College of Obstetricians and Gynecologists.
Vaginal seeding is “the practice of inoculating a cotton gauze or a cotton swab with vaginal fluids to transfer the vaginal flora to the mouth, nose, or skin of a newborn infant,” according to ACOG.
Data from several studies have suggested babies delivered by cesarean may lack the immunologic and metabolic benefits of vaginally delivered babies because of the unique properties of vaginal fluid, and a proof-of-concept study showed changes in newborns’ microbiome profiles when they received transfers of vaginal fluid soon after a cesarean delivery. However, the impact of the fluid transfer (vaginal seeding) remains unknown, according to the ACOG committee opinion (Obstet Gynecol. 2017;130:e274-8).
Additional safety concerns include the potential transfer of pathogens from mother to neonate from undiagnosed maternal conditions such as gonorrhea, human papillomavirus, group A streptococci, and others, the committee noted.
Women who wish to perform neonatal seeding themselves should be educated about the risks and tested for infectious diseases and pathogenic bacteria, the committee emphasized. Additionally, ACOG urged ob.gyns. to document the discussion in the medical record. The infant’s physician should also be made aware of the procedure because of the potential for neonatal infection.
The research on vaginal seeding currently consists of one pilot study, with an outcome measure of neonatal microbiota. No studies of other clinical outcomes have been completed.
“The paucity of data on this subject supports the need for additional research on the safety and benefit of vaginal seeding,” the ACOG Committee on Obstetric Practice wrote.
In the meantime, ACOG recommends exclusive breastfeeding in the first 6 months, noting that there are mixed data on associations between breastfeeding and the development of asthma and atopic disease in childhood.
The practice of vaginal seeding should not be performed outside of an approved research protocol until adequate data on safety and potential benefits are available, according to a new policy statement from the American College of Obstetricians and Gynecologists.
Vaginal seeding is “the practice of inoculating a cotton gauze or a cotton swab with vaginal fluids to transfer the vaginal flora to the mouth, nose, or skin of a newborn infant,” according to ACOG.
Data from several studies have suggested babies delivered by cesarean may lack the immunologic and metabolic benefits of vaginally delivered babies because of the unique properties of vaginal fluid, and a proof-of-concept study showed changes in newborns’ microbiome profiles when they received transfers of vaginal fluid soon after a cesarean delivery. However, the impact of the fluid transfer (vaginal seeding) remains unknown, according to the ACOG committee opinion (Obstet Gynecol. 2017;130:e274-8).
Additional safety concerns include the potential transfer of pathogens from mother to neonate from undiagnosed maternal conditions such as gonorrhea, human papillomavirus, group A streptococci, and others, the committee noted.
Women who wish to perform neonatal seeding themselves should be educated about the risks and tested for infectious diseases and pathogenic bacteria, the committee emphasized. Additionally, ACOG urged ob.gyns. to document the discussion in the medical record. The infant’s physician should also be made aware of the procedure because of the potential for neonatal infection.
The research on vaginal seeding currently consists of one pilot study, with an outcome measure of neonatal microbiota. No studies of other clinical outcomes have been completed.
“The paucity of data on this subject supports the need for additional research on the safety and benefit of vaginal seeding,” the ACOG Committee on Obstetric Practice wrote.
In the meantime, ACOG recommends exclusive breastfeeding in the first 6 months, noting that there are mixed data on associations between breastfeeding and the development of asthma and atopic disease in childhood.
The practice of vaginal seeding should not be performed outside of an approved research protocol until adequate data on safety and potential benefits are available, according to a new policy statement from the American College of Obstetricians and Gynecologists.
Vaginal seeding is “the practice of inoculating a cotton gauze or a cotton swab with vaginal fluids to transfer the vaginal flora to the mouth, nose, or skin of a newborn infant,” according to ACOG.
Data from several studies have suggested babies delivered by cesarean may lack the immunologic and metabolic benefits of vaginally delivered babies because of the unique properties of vaginal fluid, and a proof-of-concept study showed changes in newborns’ microbiome profiles when they received transfers of vaginal fluid soon after a cesarean delivery. However, the impact of the fluid transfer (vaginal seeding) remains unknown, according to the ACOG committee opinion (Obstet Gynecol. 2017;130:e274-8).
Additional safety concerns include the potential transfer of pathogens from mother to neonate from undiagnosed maternal conditions such as gonorrhea, human papillomavirus, group A streptococci, and others, the committee noted.
Women who wish to perform neonatal seeding themselves should be educated about the risks and tested for infectious diseases and pathogenic bacteria, the committee emphasized. Additionally, ACOG urged ob.gyns. to document the discussion in the medical record. The infant’s physician should also be made aware of the procedure because of the potential for neonatal infection.
The research on vaginal seeding currently consists of one pilot study, with an outcome measure of neonatal microbiota. No studies of other clinical outcomes have been completed.
“The paucity of data on this subject supports the need for additional research on the safety and benefit of vaginal seeding,” the ACOG Committee on Obstetric Practice wrote.
In the meantime, ACOG recommends exclusive breastfeeding in the first 6 months, noting that there are mixed data on associations between breastfeeding and the development of asthma and atopic disease in childhood.
FROM OBSTETRICS & GYNECOLOGY
Listen carefully
The widespread use of fetal ultrasound has dramatically decreased the number of delivery room surprises. In this country, most infants with a cardiac anomaly detected in utero probably are delivered at tertiary medical centers, leapfrogging over the maternity units at their local community hospitals. But infants with critical cardiac conditions continue to arrive unheralded at every hospital, both large and small. And many of these babies are asymptomatic without tachypnea or cyanosis. A study reported in the October 2017 Pediatrics by Hu et al. suggests a strategy for detecting these little masters of disguise before their lesions get them into serious trouble (doi: 10.1542/peds.2017-1154).
Pulse oximetry has been widely debated as a method for detecting congenital heart disease, because of course it misses the cases that are acyanotic. In a series of more than 150,000 asymptomatic neonates, and 92% for major congenital heart disease. Their false-positive rate for both categories was just a bit over 1%.
This may be another case in which the training of the examiner and the environment are critical to a positive result. As I think back to the conditions in which I examined newborns, I wonder how careful I was that my auscultating was being done in a quiet environment. If I was in the nursery, there may have been other babies crying, a radio playing, or nurses conversing with one another. I may have been deluding myself that, over the years in practice, I had developed the ability to cancel out those auditory distractions. It was probably dumb luck that I didn’t miss any critical murmurs.
And then there is the timing. The investigators don’t describe how soon after birth the auscultation was performed. Is there an optimum time in relation to the neonate’s transition from his/her fetal circulation? How long did the examiners listen? Were they in a rush to get back to their offices and busy waiting room or were they hospitalists?
I found this to be an interesting study, and if repeated by other investigators, it provides an example of how technology advancement doesn’t always render our old examining skills obsolete. In fact, it may demand we sharpen them.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The widespread use of fetal ultrasound has dramatically decreased the number of delivery room surprises. In this country, most infants with a cardiac anomaly detected in utero probably are delivered at tertiary medical centers, leapfrogging over the maternity units at their local community hospitals. But infants with critical cardiac conditions continue to arrive unheralded at every hospital, both large and small. And many of these babies are asymptomatic without tachypnea or cyanosis. A study reported in the October 2017 Pediatrics by Hu et al. suggests a strategy for detecting these little masters of disguise before their lesions get them into serious trouble (doi: 10.1542/peds.2017-1154).
Pulse oximetry has been widely debated as a method for detecting congenital heart disease, because of course it misses the cases that are acyanotic. In a series of more than 150,000 asymptomatic neonates, and 92% for major congenital heart disease. Their false-positive rate for both categories was just a bit over 1%.
This may be another case in which the training of the examiner and the environment are critical to a positive result. As I think back to the conditions in which I examined newborns, I wonder how careful I was that my auscultating was being done in a quiet environment. If I was in the nursery, there may have been other babies crying, a radio playing, or nurses conversing with one another. I may have been deluding myself that, over the years in practice, I had developed the ability to cancel out those auditory distractions. It was probably dumb luck that I didn’t miss any critical murmurs.
And then there is the timing. The investigators don’t describe how soon after birth the auscultation was performed. Is there an optimum time in relation to the neonate’s transition from his/her fetal circulation? How long did the examiners listen? Were they in a rush to get back to their offices and busy waiting room or were they hospitalists?
I found this to be an interesting study, and if repeated by other investigators, it provides an example of how technology advancement doesn’t always render our old examining skills obsolete. In fact, it may demand we sharpen them.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The widespread use of fetal ultrasound has dramatically decreased the number of delivery room surprises. In this country, most infants with a cardiac anomaly detected in utero probably are delivered at tertiary medical centers, leapfrogging over the maternity units at their local community hospitals. But infants with critical cardiac conditions continue to arrive unheralded at every hospital, both large and small. And many of these babies are asymptomatic without tachypnea or cyanosis. A study reported in the October 2017 Pediatrics by Hu et al. suggests a strategy for detecting these little masters of disguise before their lesions get them into serious trouble (doi: 10.1542/peds.2017-1154).
Pulse oximetry has been widely debated as a method for detecting congenital heart disease, because of course it misses the cases that are acyanotic. In a series of more than 150,000 asymptomatic neonates, and 92% for major congenital heart disease. Their false-positive rate for both categories was just a bit over 1%.
This may be another case in which the training of the examiner and the environment are critical to a positive result. As I think back to the conditions in which I examined newborns, I wonder how careful I was that my auscultating was being done in a quiet environment. If I was in the nursery, there may have been other babies crying, a radio playing, or nurses conversing with one another. I may have been deluding myself that, over the years in practice, I had developed the ability to cancel out those auditory distractions. It was probably dumb luck that I didn’t miss any critical murmurs.
And then there is the timing. The investigators don’t describe how soon after birth the auscultation was performed. Is there an optimum time in relation to the neonate’s transition from his/her fetal circulation? How long did the examiners listen? Were they in a rush to get back to their offices and busy waiting room or were they hospitalists?
I found this to be an interesting study, and if repeated by other investigators, it provides an example of how technology advancement doesn’t always render our old examining skills obsolete. In fact, it may demand we sharpen them.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Hep C screening falling short in neonatal abstinence syndrome infants
SAN DIEGO – A review of care for neonates born with neonatal abstinence syndrome (NAS) found that screening for hepatitis C virus (HCV) infection is low, based on Medicaid data from the state of Kentucky.
“These children are at high risk for HCV, and the screening rate should really be 100%. We think that it is important to get the message out there,” said Michael Smith, MD, of the department of pediatrics at the Duke University, Durham, N.C.
According to the Kentucky Medicaid data, the rates of NAS are not evenly distributed in the state. Stratifying the incidence rates by eight regions, Dr. Smith reported that 33% of the NAS births in 2016 were in region 8. Although region 8 is a rural Appalachian section on the eastern border of the state, the proportion in this region was more than 50% greater than any other region, including the more populated regions containing Louisville, the largest city, and Lexington, the capital.
Statewide, approximately one in three newborns with NAS were screened for HCV, but the rate was as low as 5% in some areas, and low rates were more common in those counties with the highest rates of opioid use and NAS, Dr. Smith said at an annual scientific meeting on infectious diseases. Although he acknowledged that rates of HCV screening in newborns with NAS appeared to be increasing when 2015 and 2012 data were compared, “there is still a long way to go.”
“Why is this important? There are a couple of reasons. One is that, if you get children into care early, you are more likely to have follow-up,” Dr. Smith said. Follow-up will be important if, as Dr. Smith predicted, HCV therapies become available for children. When providers know which children are infected, treatment can be initiated more efficiently, and this has implications for risk of transmission and, potentially, for outcomes.
At the University of Louisville, children with NAS are typically screened for HCV, HIV, and other transmissible infections that “travel together,” such as syphilis. The evaluation of the Medicaid data suggested that there were no differences in likelihood of HCV testing for sex and race, but Dr. Smith noted that children placed in foster care were significantly more likely to be tested, likely a reflection of processing regulations.
Overall, there are striking differences in the rates of opioid use, rates of NAS, and likelihood of HCV testing in NAS neonates in eastern Appalachian regions of Kentucky and those in regions in the center of the state closer to academic medical centers. The three regions near the University of Louisville, University of Kentucky in Lexington, and the Ohio River border with Cincinnati are known as “the Golden Triangle,” according to Dr. Smith; these regions are where HCV testing rates in neonates with NAS are higher, but testing still is not uniform.
Currently, HCV testing is mandated for adults in several states, but Dr. Smith emphasized that children with NAS are particularly “vulnerable.” He called for policy changes that would require testing in these children and urged HCV screening regardless of whether official policies are established.
SAN DIEGO – A review of care for neonates born with neonatal abstinence syndrome (NAS) found that screening for hepatitis C virus (HCV) infection is low, based on Medicaid data from the state of Kentucky.
“These children are at high risk for HCV, and the screening rate should really be 100%. We think that it is important to get the message out there,” said Michael Smith, MD, of the department of pediatrics at the Duke University, Durham, N.C.
According to the Kentucky Medicaid data, the rates of NAS are not evenly distributed in the state. Stratifying the incidence rates by eight regions, Dr. Smith reported that 33% of the NAS births in 2016 were in region 8. Although region 8 is a rural Appalachian section on the eastern border of the state, the proportion in this region was more than 50% greater than any other region, including the more populated regions containing Louisville, the largest city, and Lexington, the capital.
Statewide, approximately one in three newborns with NAS were screened for HCV, but the rate was as low as 5% in some areas, and low rates were more common in those counties with the highest rates of opioid use and NAS, Dr. Smith said at an annual scientific meeting on infectious diseases. Although he acknowledged that rates of HCV screening in newborns with NAS appeared to be increasing when 2015 and 2012 data were compared, “there is still a long way to go.”
“Why is this important? There are a couple of reasons. One is that, if you get children into care early, you are more likely to have follow-up,” Dr. Smith said. Follow-up will be important if, as Dr. Smith predicted, HCV therapies become available for children. When providers know which children are infected, treatment can be initiated more efficiently, and this has implications for risk of transmission and, potentially, for outcomes.
At the University of Louisville, children with NAS are typically screened for HCV, HIV, and other transmissible infections that “travel together,” such as syphilis. The evaluation of the Medicaid data suggested that there were no differences in likelihood of HCV testing for sex and race, but Dr. Smith noted that children placed in foster care were significantly more likely to be tested, likely a reflection of processing regulations.
Overall, there are striking differences in the rates of opioid use, rates of NAS, and likelihood of HCV testing in NAS neonates in eastern Appalachian regions of Kentucky and those in regions in the center of the state closer to academic medical centers. The three regions near the University of Louisville, University of Kentucky in Lexington, and the Ohio River border with Cincinnati are known as “the Golden Triangle,” according to Dr. Smith; these regions are where HCV testing rates in neonates with NAS are higher, but testing still is not uniform.
Currently, HCV testing is mandated for adults in several states, but Dr. Smith emphasized that children with NAS are particularly “vulnerable.” He called for policy changes that would require testing in these children and urged HCV screening regardless of whether official policies are established.
SAN DIEGO – A review of care for neonates born with neonatal abstinence syndrome (NAS) found that screening for hepatitis C virus (HCV) infection is low, based on Medicaid data from the state of Kentucky.
“These children are at high risk for HCV, and the screening rate should really be 100%. We think that it is important to get the message out there,” said Michael Smith, MD, of the department of pediatrics at the Duke University, Durham, N.C.
According to the Kentucky Medicaid data, the rates of NAS are not evenly distributed in the state. Stratifying the incidence rates by eight regions, Dr. Smith reported that 33% of the NAS births in 2016 were in region 8. Although region 8 is a rural Appalachian section on the eastern border of the state, the proportion in this region was more than 50% greater than any other region, including the more populated regions containing Louisville, the largest city, and Lexington, the capital.
Statewide, approximately one in three newborns with NAS were screened for HCV, but the rate was as low as 5% in some areas, and low rates were more common in those counties with the highest rates of opioid use and NAS, Dr. Smith said at an annual scientific meeting on infectious diseases. Although he acknowledged that rates of HCV screening in newborns with NAS appeared to be increasing when 2015 and 2012 data were compared, “there is still a long way to go.”
“Why is this important? There are a couple of reasons. One is that, if you get children into care early, you are more likely to have follow-up,” Dr. Smith said. Follow-up will be important if, as Dr. Smith predicted, HCV therapies become available for children. When providers know which children are infected, treatment can be initiated more efficiently, and this has implications for risk of transmission and, potentially, for outcomes.
At the University of Louisville, children with NAS are typically screened for HCV, HIV, and other transmissible infections that “travel together,” such as syphilis. The evaluation of the Medicaid data suggested that there were no differences in likelihood of HCV testing for sex and race, but Dr. Smith noted that children placed in foster care were significantly more likely to be tested, likely a reflection of processing regulations.
Overall, there are striking differences in the rates of opioid use, rates of NAS, and likelihood of HCV testing in NAS neonates in eastern Appalachian regions of Kentucky and those in regions in the center of the state closer to academic medical centers. The three regions near the University of Louisville, University of Kentucky in Lexington, and the Ohio River border with Cincinnati are known as “the Golden Triangle,” according to Dr. Smith; these regions are where HCV testing rates in neonates with NAS are higher, but testing still is not uniform.
Currently, HCV testing is mandated for adults in several states, but Dr. Smith emphasized that children with NAS are particularly “vulnerable.” He called for policy changes that would require testing in these children and urged HCV screening regardless of whether official policies are established.
AT ID WEEK 2017
Key clinical point: In Kentucky, which has one of the highest rates of neonates with NAS, screening rates for HCV remain low.
Major finding:
Data source: Retrospective data analysis of Kentucky Medicaid data.
Disclosures: Dr. Smith reported no financial relationships relevant to this study.
CDC: Zika-exposed newborns need intensified eye, hearing, and neurological testing
Infants with possible prenatal Zika exposure who test positive for the virus should receive an in-depth ophthalmologic exam, intensified hearing testing, and a thorough neurological evaluation with brain imaging within 1 month of birth, according to new interim guidance set forth by the Centers for Disease Control and Prevention.
The new clinical management guidelines, published in the Oct. 20 issue of the Morbidity and Mortality Weekly Report, supersede the most recent CDC guidance, issued in August 2016. The agency deemed the update necessary after a recent convocation sponsored by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The meeting drew dozens of practicing clinicians and federal agency representatives, who reviewed the ever-evolving body of knowledge on how to best manage the care of these infants. Since Zika emerged as a public health threat, clinicians have reported postnatal onset of some symptoms, including eye abnormalities, a developing microcephaly in infants with a normal head circumference at birth, EEG abnormalities, and diaphragmatic paralysis.
The guidance focuses on three groups: infants with clinical findings of Zika syndrome born to mothers with possible Zika exposure during pregnancy; infants without clinical findings of Zika syndrome whose mothers had lab-confirmed Zika exposure; and infants without symptoms whose mothers might have been exposed, but who did not have laboratory-confirmed infection (MMWR. 2017 Oct 20;66[41]:1089-120).
Infants with clinical findings consistent with Zika syndrome and mothers with possible prenatal Zika exposure
These infants should be tested for Zika virus with serum and urine tests. If those are negative and there is no other apparent cause of the symptoms, they should have a cerebrospinal fluid sample tested for Zika RNA and IgM Zika antibodies.
By 1 month, these infants need a head ultrasound and a detailed ophthalmologic exam. The eye exam should pick up any anomalies of the anterior and posterior eye, including microphthalmia, coloboma, intraocular calcifications, optic nerve hypoplasia and atrophy, and macular scarring with focal pigmentary retinal mottling.
A comprehensive neurological exam also is part of the recommendation. Seizures are sometimes part of Zika syndrome, but infants can also have subclinical EEG abnormalities. Advanced neuroimaging can identify both obvious and subtle brain abnormalities: cortical thinning, corpus callosum abnormalities, calcifications at the white/gray matter junction, and ventricular enlargement are possible findings.
As infants grow, clinicians should be alert for signs of increased intracranial pressure that could signal postnatal hydrocephalus. Diaphragmatic paralysis also has been seen; this manifests by respiratory distress. Dysphagia that interferes with feeding can develop as well.
The complicated clinical picture calls for a team approach, Dr. Adebanjo said. “The follow-up care of [these infants] requires a multidisciplinary team and an established medical home to facilitate the coordination of care and ensure that abnormal findings are addressed.”
Infants without clinical findings, whose mothers have lab-confirmed Zika exposure
Initially, these infants should have the same early head ultrasound, hearing, and eye exams as those who display clinical findings. All of these infants also should be tested for Zika virus in the same way as those with clinical findings.
If tests return a positive result, they should have all the investigations and follow-ups recommended for babies with clinical findings. If lab testing is negative, and clinical findings are normal, Zika infection is highly unlikely and they can receive routine care, although clinicians and parents should be on the lookout for any new symptoms that might suggest postnatal Zika syndrome.
Infants without clinical findings, whose mothers had possible, but unconfirmed, Zika exposure
This is a varied and large group, which includes women who were never tested during pregnancy, as well as those who could have had a false negative test. “Because the latter issue is not easily discerned, all mothers with possible exposure to Zika virus infection, including those who tested negative with currently available technology, should be considered in this group,” Dr. Adebanjo said.
CDC does not recommend further Zika evaluation for these infants unless additional testing confirms maternal infection. For older infants, parents and clinicians should decide together whether any further evaluations would be helpful. But, Dr. Adebanjo said, “If findings consistent with congenital Zika syndrome are identified at any time, referrals to appropriate specialties should be made, and subsequent evaluation should follow recommendations for infants with clinical findings consistent with congenital Zika.”
CDC also reiterated its special recommendations for infants who had a prenatal diagnosis of Zika infection. For now, these remain unchanged from 2016, although “as more data become available, understanding of the diagnostic role of prenatal ultrasound and amniocentesis will improve and guidance will be updated.”
No one has yet identified the optimal timing for a Zika diagnostic ultrasound. CDC recommends serial ultrasounds be done every 3-4 weeks for women with lab-confirmed prenatal Zika exposure. Women with possible exposure need only routine ultrasound screenings.
While Zika RNA has been identified in amniotic fluid, there is no consensus on the value of amniocentesis as a prenatal diagnostic tool. Investigations of serial amniocentesis suggests that viral shedding into the amniotic fluid might be transient. If the procedure is done for other reasons, Zika nucleic acid testing can be incorporated.
A shared decision-making process is key when making screening decisions that should be individually weighed, Dr. Adebanjo said. “For example, serial ultrasounds might be inconvenient, unpleasant, and expensive, and might prompt unnecessary interventions; amniocentesis carries additional known risks such as fetal loss. These potential harms of prenatal screening for congenital Zika syndrome might outweigh the clinical benefits for some patients. Therefore, these decisions should be individualized.”
Neither Dr. Adebanjo nor any of the coauthors had any financial disclosures.
Infants with possible prenatal Zika exposure who test positive for the virus should receive an in-depth ophthalmologic exam, intensified hearing testing, and a thorough neurological evaluation with brain imaging within 1 month of birth, according to new interim guidance set forth by the Centers for Disease Control and Prevention.
The new clinical management guidelines, published in the Oct. 20 issue of the Morbidity and Mortality Weekly Report, supersede the most recent CDC guidance, issued in August 2016. The agency deemed the update necessary after a recent convocation sponsored by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The meeting drew dozens of practicing clinicians and federal agency representatives, who reviewed the ever-evolving body of knowledge on how to best manage the care of these infants. Since Zika emerged as a public health threat, clinicians have reported postnatal onset of some symptoms, including eye abnormalities, a developing microcephaly in infants with a normal head circumference at birth, EEG abnormalities, and diaphragmatic paralysis.
The guidance focuses on three groups: infants with clinical findings of Zika syndrome born to mothers with possible Zika exposure during pregnancy; infants without clinical findings of Zika syndrome whose mothers had lab-confirmed Zika exposure; and infants without symptoms whose mothers might have been exposed, but who did not have laboratory-confirmed infection (MMWR. 2017 Oct 20;66[41]:1089-120).
Infants with clinical findings consistent with Zika syndrome and mothers with possible prenatal Zika exposure
These infants should be tested for Zika virus with serum and urine tests. If those are negative and there is no other apparent cause of the symptoms, they should have a cerebrospinal fluid sample tested for Zika RNA and IgM Zika antibodies.
By 1 month, these infants need a head ultrasound and a detailed ophthalmologic exam. The eye exam should pick up any anomalies of the anterior and posterior eye, including microphthalmia, coloboma, intraocular calcifications, optic nerve hypoplasia and atrophy, and macular scarring with focal pigmentary retinal mottling.
A comprehensive neurological exam also is part of the recommendation. Seizures are sometimes part of Zika syndrome, but infants can also have subclinical EEG abnormalities. Advanced neuroimaging can identify both obvious and subtle brain abnormalities: cortical thinning, corpus callosum abnormalities, calcifications at the white/gray matter junction, and ventricular enlargement are possible findings.
As infants grow, clinicians should be alert for signs of increased intracranial pressure that could signal postnatal hydrocephalus. Diaphragmatic paralysis also has been seen; this manifests by respiratory distress. Dysphagia that interferes with feeding can develop as well.
The complicated clinical picture calls for a team approach, Dr. Adebanjo said. “The follow-up care of [these infants] requires a multidisciplinary team and an established medical home to facilitate the coordination of care and ensure that abnormal findings are addressed.”
Infants without clinical findings, whose mothers have lab-confirmed Zika exposure
Initially, these infants should have the same early head ultrasound, hearing, and eye exams as those who display clinical findings. All of these infants also should be tested for Zika virus in the same way as those with clinical findings.
If tests return a positive result, they should have all the investigations and follow-ups recommended for babies with clinical findings. If lab testing is negative, and clinical findings are normal, Zika infection is highly unlikely and they can receive routine care, although clinicians and parents should be on the lookout for any new symptoms that might suggest postnatal Zika syndrome.
Infants without clinical findings, whose mothers had possible, but unconfirmed, Zika exposure
This is a varied and large group, which includes women who were never tested during pregnancy, as well as those who could have had a false negative test. “Because the latter issue is not easily discerned, all mothers with possible exposure to Zika virus infection, including those who tested negative with currently available technology, should be considered in this group,” Dr. Adebanjo said.
CDC does not recommend further Zika evaluation for these infants unless additional testing confirms maternal infection. For older infants, parents and clinicians should decide together whether any further evaluations would be helpful. But, Dr. Adebanjo said, “If findings consistent with congenital Zika syndrome are identified at any time, referrals to appropriate specialties should be made, and subsequent evaluation should follow recommendations for infants with clinical findings consistent with congenital Zika.”
CDC also reiterated its special recommendations for infants who had a prenatal diagnosis of Zika infection. For now, these remain unchanged from 2016, although “as more data become available, understanding of the diagnostic role of prenatal ultrasound and amniocentesis will improve and guidance will be updated.”
No one has yet identified the optimal timing for a Zika diagnostic ultrasound. CDC recommends serial ultrasounds be done every 3-4 weeks for women with lab-confirmed prenatal Zika exposure. Women with possible exposure need only routine ultrasound screenings.
While Zika RNA has been identified in amniotic fluid, there is no consensus on the value of amniocentesis as a prenatal diagnostic tool. Investigations of serial amniocentesis suggests that viral shedding into the amniotic fluid might be transient. If the procedure is done for other reasons, Zika nucleic acid testing can be incorporated.
A shared decision-making process is key when making screening decisions that should be individually weighed, Dr. Adebanjo said. “For example, serial ultrasounds might be inconvenient, unpleasant, and expensive, and might prompt unnecessary interventions; amniocentesis carries additional known risks such as fetal loss. These potential harms of prenatal screening for congenital Zika syndrome might outweigh the clinical benefits for some patients. Therefore, these decisions should be individualized.”
Neither Dr. Adebanjo nor any of the coauthors had any financial disclosures.
Infants with possible prenatal Zika exposure who test positive for the virus should receive an in-depth ophthalmologic exam, intensified hearing testing, and a thorough neurological evaluation with brain imaging within 1 month of birth, according to new interim guidance set forth by the Centers for Disease Control and Prevention.
The new clinical management guidelines, published in the Oct. 20 issue of the Morbidity and Mortality Weekly Report, supersede the most recent CDC guidance, issued in August 2016. The agency deemed the update necessary after a recent convocation sponsored by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The meeting drew dozens of practicing clinicians and federal agency representatives, who reviewed the ever-evolving body of knowledge on how to best manage the care of these infants. Since Zika emerged as a public health threat, clinicians have reported postnatal onset of some symptoms, including eye abnormalities, a developing microcephaly in infants with a normal head circumference at birth, EEG abnormalities, and diaphragmatic paralysis.
The guidance focuses on three groups: infants with clinical findings of Zika syndrome born to mothers with possible Zika exposure during pregnancy; infants without clinical findings of Zika syndrome whose mothers had lab-confirmed Zika exposure; and infants without symptoms whose mothers might have been exposed, but who did not have laboratory-confirmed infection (MMWR. 2017 Oct 20;66[41]:1089-120).
Infants with clinical findings consistent with Zika syndrome and mothers with possible prenatal Zika exposure
These infants should be tested for Zika virus with serum and urine tests. If those are negative and there is no other apparent cause of the symptoms, they should have a cerebrospinal fluid sample tested for Zika RNA and IgM Zika antibodies.
By 1 month, these infants need a head ultrasound and a detailed ophthalmologic exam. The eye exam should pick up any anomalies of the anterior and posterior eye, including microphthalmia, coloboma, intraocular calcifications, optic nerve hypoplasia and atrophy, and macular scarring with focal pigmentary retinal mottling.
A comprehensive neurological exam also is part of the recommendation. Seizures are sometimes part of Zika syndrome, but infants can also have subclinical EEG abnormalities. Advanced neuroimaging can identify both obvious and subtle brain abnormalities: cortical thinning, corpus callosum abnormalities, calcifications at the white/gray matter junction, and ventricular enlargement are possible findings.
As infants grow, clinicians should be alert for signs of increased intracranial pressure that could signal postnatal hydrocephalus. Diaphragmatic paralysis also has been seen; this manifests by respiratory distress. Dysphagia that interferes with feeding can develop as well.
The complicated clinical picture calls for a team approach, Dr. Adebanjo said. “The follow-up care of [these infants] requires a multidisciplinary team and an established medical home to facilitate the coordination of care and ensure that abnormal findings are addressed.”
Infants without clinical findings, whose mothers have lab-confirmed Zika exposure
Initially, these infants should have the same early head ultrasound, hearing, and eye exams as those who display clinical findings. All of these infants also should be tested for Zika virus in the same way as those with clinical findings.
If tests return a positive result, they should have all the investigations and follow-ups recommended for babies with clinical findings. If lab testing is negative, and clinical findings are normal, Zika infection is highly unlikely and they can receive routine care, although clinicians and parents should be on the lookout for any new symptoms that might suggest postnatal Zika syndrome.
Infants without clinical findings, whose mothers had possible, but unconfirmed, Zika exposure
This is a varied and large group, which includes women who were never tested during pregnancy, as well as those who could have had a false negative test. “Because the latter issue is not easily discerned, all mothers with possible exposure to Zika virus infection, including those who tested negative with currently available technology, should be considered in this group,” Dr. Adebanjo said.
CDC does not recommend further Zika evaluation for these infants unless additional testing confirms maternal infection. For older infants, parents and clinicians should decide together whether any further evaluations would be helpful. But, Dr. Adebanjo said, “If findings consistent with congenital Zika syndrome are identified at any time, referrals to appropriate specialties should be made, and subsequent evaluation should follow recommendations for infants with clinical findings consistent with congenital Zika.”
CDC also reiterated its special recommendations for infants who had a prenatal diagnosis of Zika infection. For now, these remain unchanged from 2016, although “as more data become available, understanding of the diagnostic role of prenatal ultrasound and amniocentesis will improve and guidance will be updated.”
No one has yet identified the optimal timing for a Zika diagnostic ultrasound. CDC recommends serial ultrasounds be done every 3-4 weeks for women with lab-confirmed prenatal Zika exposure. Women with possible exposure need only routine ultrasound screenings.
While Zika RNA has been identified in amniotic fluid, there is no consensus on the value of amniocentesis as a prenatal diagnostic tool. Investigations of serial amniocentesis suggests that viral shedding into the amniotic fluid might be transient. If the procedure is done for other reasons, Zika nucleic acid testing can be incorporated.
A shared decision-making process is key when making screening decisions that should be individually weighed, Dr. Adebanjo said. “For example, serial ultrasounds might be inconvenient, unpleasant, and expensive, and might prompt unnecessary interventions; amniocentesis carries additional known risks such as fetal loss. These potential harms of prenatal screening for congenital Zika syndrome might outweigh the clinical benefits for some patients. Therefore, these decisions should be individualized.”
Neither Dr. Adebanjo nor any of the coauthors had any financial disclosures.
FROM MMWR
Rapid genomic testing can diagnose critically ill infants
Rapid, targeted genomic sequencing shows promise in quickly diagnosing critically ill infants for whom standard clinical work-ups were unsuccessful, according to Cleo C. van Diemen, PhD, of the University of Groningen (the Netherlands), and associates.
Over the course of 1 year, 23 critically ill infants younger than 12 months who had no clear diagnosis after standard clinical work-ups underwent rapid, targeted genomics, with 7 receiving a genetic diagnosis. The median turnaround time was 12 days, falling from roughly 3 weeks at the beginning of the study to a maximum of 8 days by the end of the study.
Compound heterozygous mutations in the EPG5, RMND1, and EIF2B5 genes allowed for diagnoses of Vici syndrome, combined oxidative phosphorylation deficiency-11, and vanishing white matter, respectively. Homozygous mutations in the KLHL41, GFER, and GLB1 genes allowed for diagnoses of nemaline myopathy, progressive mitochondrial myopathy, and GM1-gangliosidosis, respectively. In addition, a 1p36.33p36.32 microdeletion was discovered in an infant with cardiomyopathy.
“The clinical relevance of rapid genome diagnostics lies in the fact that these results can be used in the clinical decisions made in caring for critically ill children in ICUs, in better genetic counseling of the parents, and in guiding their future reproductive choices,” the investigators noted.
Find the full study in Pediatrics (2017 Sep 22. doi: 10.1542/ peds.2016-2854).
Rapid, targeted genomic sequencing shows promise in quickly diagnosing critically ill infants for whom standard clinical work-ups were unsuccessful, according to Cleo C. van Diemen, PhD, of the University of Groningen (the Netherlands), and associates.
Over the course of 1 year, 23 critically ill infants younger than 12 months who had no clear diagnosis after standard clinical work-ups underwent rapid, targeted genomics, with 7 receiving a genetic diagnosis. The median turnaround time was 12 days, falling from roughly 3 weeks at the beginning of the study to a maximum of 8 days by the end of the study.
Compound heterozygous mutations in the EPG5, RMND1, and EIF2B5 genes allowed for diagnoses of Vici syndrome, combined oxidative phosphorylation deficiency-11, and vanishing white matter, respectively. Homozygous mutations in the KLHL41, GFER, and GLB1 genes allowed for diagnoses of nemaline myopathy, progressive mitochondrial myopathy, and GM1-gangliosidosis, respectively. In addition, a 1p36.33p36.32 microdeletion was discovered in an infant with cardiomyopathy.
“The clinical relevance of rapid genome diagnostics lies in the fact that these results can be used in the clinical decisions made in caring for critically ill children in ICUs, in better genetic counseling of the parents, and in guiding their future reproductive choices,” the investigators noted.
Find the full study in Pediatrics (2017 Sep 22. doi: 10.1542/ peds.2016-2854).
Rapid, targeted genomic sequencing shows promise in quickly diagnosing critically ill infants for whom standard clinical work-ups were unsuccessful, according to Cleo C. van Diemen, PhD, of the University of Groningen (the Netherlands), and associates.
Over the course of 1 year, 23 critically ill infants younger than 12 months who had no clear diagnosis after standard clinical work-ups underwent rapid, targeted genomics, with 7 receiving a genetic diagnosis. The median turnaround time was 12 days, falling from roughly 3 weeks at the beginning of the study to a maximum of 8 days by the end of the study.
Compound heterozygous mutations in the EPG5, RMND1, and EIF2B5 genes allowed for diagnoses of Vici syndrome, combined oxidative phosphorylation deficiency-11, and vanishing white matter, respectively. Homozygous mutations in the KLHL41, GFER, and GLB1 genes allowed for diagnoses of nemaline myopathy, progressive mitochondrial myopathy, and GM1-gangliosidosis, respectively. In addition, a 1p36.33p36.32 microdeletion was discovered in an infant with cardiomyopathy.
“The clinical relevance of rapid genome diagnostics lies in the fact that these results can be used in the clinical decisions made in caring for critically ill children in ICUs, in better genetic counseling of the parents, and in guiding their future reproductive choices,” the investigators noted.
Find the full study in Pediatrics (2017 Sep 22. doi: 10.1542/ peds.2016-2854).
FROM PEDIATRICS