Our sample included 773 infants (95.1%) out of the 813 infants identified who weighed ≤ 1750 grams, excluding only the three infants (0.4%) who were transferred before four hours and 37 (4.5%) whose medical records did not include all of the data elements included in our analysis. Hospital 1 accounted for 13% of the infant sample, Hospital 2 accounted for 20% of the sample, and Hospital 3 accounted for 67% of the sample. Of our infant sample, 25% were White, 34% were African American, 31% were Latino, and 10% were of other race/ethnicity. Forty-three percent had Medicaid, the mean birth weight was 1199 grams (standard deviation of 397 grams), mean gestational age was 29.3 weeks (standard deviation of 3.7), and the median 5-minute Apgar score was 7.0 (interquartile range of 3). () Of the 773 infants, 227 infants (29.4%) developed signs of respiratory distress syndrome as defined by the local community standard within the first two hours of life and 264 infants (34.2%) developed signs of RDS within the first four hours of life. Among the 227 infants who developed RDS, 38% were African American, 21% were white, 33% were Latino and 7% were other racial/ethnic groups, which was not significantly different than the overall racial/ethnic breakdown of the infant sample.
Characteristics of Infant Sample (N=773)
Thirty-seven percent of the 227 infants with signs of respiratory distress syndrome at two hours of age received surfactant within two hours of birth (). Bivariate analyses revealed higher rates of treatment were associated with lower birth weight, lower 5-minute Apgar, insurance, hospital of birth, weekend birth, and time of birth. By four hours of age, 71% of the infants with signs of RDS within 2 hours of life had received surfactant.
Association between Infant and Delivery Characteristics and Use of Surfactant by two hours of age (N=227)
In the multivariable model predicting discordance from the recommendation to deliver surfactant at two hours of age, increasing birth weight was associated with failure to receive surfactant whereas being born at night was associated with lower odds. Hospital of birth remained significant in the multivariable model ().
Multivariable Logistic Regression for Failure to Receive Surfactant within 2 hours of birth
Audits of care at the four hour time point found that 70% (186/264) of low birth weight infants who had shown signs of RDS by that time had received surfactant. Eighty-five percent of white, 80% of other, 67% of Latino, and 61% of African American infants with RDS had received surfactant within 4 hours of life. Variation across the hospitals remained significant at four hours, as did birth weight. (). The multivariable model predicting failure to use surfactant for children with community-defined RDS by four hours old, identified 100 grams of birth weight (OR=1.22, 95% CI 1.10–1.34), African American race (4.10, 1.30–12.99), and hospital of birth as factors associated with increased odds of failure to treat ().
Association between Infant Characteristics and Underuse of Surfactant (w/in 4 hours)
Multivariable Logistic Regression for Risk of Underuse of Surfactant within 4 hours of births
Of the 78 infants who had signs of respiratory distress syndrome by 4 hours of birth but had not received surfactant, 30 received surfactant during their hospital stay. Of the remaining 48 infants who had signs of respiratory distress but never received surfactant during their hospital stay, four were White, 30 were African American, one was Latino, and 13 were from other racial/ethnic categories. In other words, by discharge, 6% of whites, 33% of African Americans, and 1% of Latino children who had signs of RDS within 4 hours of life had not received surfactant by discharge (p<.001).