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1.  Surgery and Neurodevelopmental Outcome of Very Low Birth Weight Infants 
JAMA pediatrics  2014;168(8):746-754.
IMPORTANCE
Reduced death and neurodevelopmental impairment among infants is a goal of perinatal medicine.
OBJECTIVE
To assess the association between surgery during the initial hospitalization and death or neurodevelopmental impairment of very low birth weight infants.
DESIGN
Retrospective cohort analysis of patients enrolled in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database from 1998–2009 and evaluated at 18–22 months’ corrected age.
SETTING
22 academic neonatal intensive care units.
PARTICIPANTS
Inclusion criteria were: birth weight 401–1500 g; survival to 12 hours; available for follow-up. Some conditions were excluded. 12 111 infants were included in analyses, 87% of those eligible.
EXPOSURES
Surgical procedures; surgery also classified by expected anesthesia type as major (general anesthesia) or minor surgery (non-general anesthesia).
MAIN OUTCOME MEASURES
Multivariable logistic regression analyses planned a priori were performed for the primary outcome of death or neurodevelopmental impairment and for the secondary outcome of neurodevelopmental impairment among survivors. Multivariable linear regression analyses were performed as planned for the adjusted means of Bayley Scales of Infant Development, Second Edition, Mental Developmental Index and Psychomotor Developmental Index for patients born before 2006.
RESULTS
There were 2186 major, 784 minor and 9141 no surgery patients. The risk-adjusted odds ratio of death or neurodevelopmental impairment for all surgery patients compared with those who had no surgery was 1.29 (95% confidence interval 1.08–1.55). For patients who had major surgery compared with those who had no surgery the risk-adjusted odds ratio of death or neurodevelopmental impairment was 1.52 (95% confidence interval 1.24–1.87). Patients classified as having minor surgery had no increased adjusted risk. Among survivors who had major surgery compared with those who had no surgery the adjusted odds ratio for neurodevelopmental impairment was 1.56 (95% confidence interval 1.26–1.93) and the adjusted mean Mental Developmental Index and mean Psychomotor Developmental Index values were lower.
CONCLUSIONS AND RELEVANCE
Major surgery in very low birth weight infants is independently associated with a greater than 50% increased risk of death or neurodevelopmental impairment and of neurodevelopmental impairment at 18–22 months’ corrected age. The role of general anesthesia is implicated but remains unproven.
doi:10.1001/jamapediatrics.2014.307
PMCID: PMC4142429  PMID: 24934607
2.  Increased Risk of Death among Uninsured Neonates 
Health Services Research  2013;48(4):1232-1255.
Objective
To estimate the contribution of health insurance status to the risk of death among hospitalized neonates.
Data Sources
Kids' Inpatient Databases (KID) for 2003, 2006, and 2009.
Study Design
KID 2006 subpopulation of neonatal discharges was analyzed by weighted frequency distribution and multivariable logistic regression analyses for the outcome of death, adjusted for insurance status and other variables. Multivariable linear regression analyses were conducted for the outcomes mean adjusted length of stay and hospital charges. The death analysis was repeated with KID 2003 and 2009.
Principal Findings
Of 4,318,121 estimated discharges in 2006, 5.4 percent were uninsured. There were 17,892 deaths; 9.5 percent were uninsured. The largest risks of death were five clinical conditions with adjusted odds ratios (AOR) of 13.7–3.1. Lack of insurance had an AOR of 2.6 (95 percent CI: 2.4, 2.8), greater than many clinical conditions; AOR estimates in alternate models were 2.1–2.7. Compared with insureds, uninsureds were less likely to have been admitted in transfer, more likely to have died in rural hospitals and to have received fewer resources. Similar death outcome results were observed for 2003 and 2009.
Conclusions
Uninsured neonates had decreased care and increased risk of dying.
doi:10.1111/1475-6773.12042
PMCID: PMC3725523  PMID: 23402526
Death; insurance; neonate
3.  Maternal Intention to Breastfeed and Breastfeeding Outcomes in Term and Preterm Infants: PRAMS 2000–2003 
Public health nutrition  2011;15(4):702-710.
Objective
To determine the effect of intention to breastfeed on short-term breastfeeding outcomes in women delivering term and preterm infants
Design
Data from the CDC Pregnancy Risk Assessment Monitoring System (PRAMS) for three states, Ohio, Michigan and Arkansas during 2000–2003 were analyzed. SAS 9.1.3 and SUDAAN 10 were used for analyses.
Results
16839 subjects were included, 9.7% delivered preterm. 52.5% expressed definite intention to breastfeed, 16.8% tentative intention, 4.3% were uncertain, 26.8% had no intention to breastfeed. 65.2% initiated breastfeeding, 45.2% breastfed ≥ 4weeks, 30% breastfed ≥ 10 weeks. Women with definite intention were more likely to initiate (OR 24.3, 95% CI 18.4, 32.1), to breastfeed ≥ 4 weeks (OR 7.12, 95% CI 5.95, 8.51), and to breastfeed ≥ 10 weeks (OR 2.75, 95% CI 2.2, 3.45) compared to tentative intention. Levels of intention did not differ between women delivering preterm and term. Women delivering at < 34 weeks were more likely to initiate breastfeeding (OR 2.24, 95% CI 1.64, 3.06), and to breastfeed ≥ 4 weeks (OR 2.58, 95% CI 1.96, 3.41), but less likely to breastfeed ≥ 10 weeks (OR 0.55, 95% CI 0.44, 0.68) compared to term. Women delivering between 34 and 36 weeks were less likely to breastfeed ≥ 10 weeks than those delivering at term (OR 0.63, 95% CI 0.49, 0.81).
Conclusions
Prenatal intention to breastfeed is a powerful predictor of short-term breastfeeding outcomes in women delivering both at term and prematurely.
doi:10.1017/S1368980011002229
PMCID: PMC3505725  PMID: 21936968
breastfeeding; preterm infant; breastfeeding outcomes; breastfeeding intention
4.  Cytochrome P450 (CYP2D6) Genotype is Associated with Elevated Systolic Blood Pressure in Preterm Infants Following NICU Discharge 
The Journal of pediatrics  2011;159(1):104-109.
Objective
To determine genetic and clinical risk factors associated with elevated systolic blood pressure (ESBP) in preterm infants following discharge.
Study design
A convenience cohort of infants <32 weeks gestational age was followed after discharge; we retrospectively identified a subgroup of subjects with ESBP (SBP > 90th percentile for term infants). Genetic testing identified alleles associated with ESBP. Multivariable logistic regression analysis was performed for the outcome ESBP with clinical characteristics and genotype as independent variables.
Results
Predictors of ESBP were: CYP2D6 (rs28360521) CC genotype (OR 2.92; 95% CI 1.48, 5.79), adjusted for outpatient oxygen therapy (OR 4.53, 95%CI 2.23, 8.81) and history of urinary tract infection (OR 4.68, 95% CI 1.47, 14.86). Maximum SBP was modeled by multivariable linear regression analysis: Maximum SBP = 84.8 mmHg + 6.8 mmHg (if CYP2D6 CC genotype) + 6.8 mmHg (if discharged on supplemental oxygen) + 4.4 mmHg (if received inpatient glucocorticoids) (p=0.0002).
Conclusion
ESBP is common among preterm infants with residual lung disease following NICU discharge. This study reveals clinical factors associated with ESBP, identifies a candidate gene for further testing, and supports the recommendation that BP be monitored sooner than at age 3 years as suggested for term infants.
doi:10.1016/j.jpeds.2011.01.002
PMCID: PMC3115515  PMID: 21353244
Genetics; Hypertension; Oxygen; Polymorphism; SNP
5.  Impact of Timing of Birth and Resident Duty-Hour Restrictions on Outcome of Small Preterm Infants 
Pediatrics  2010;126(2):222-231.
OBJECTIVE
To examine the impact of birth at night, on the weekend, and during July or August – the first months of the academic year – and the impact of resident duty-hour restrictions on mortality and morbidity of VLBW infants.
METHODS
Outcomes were analyzed for 11,137 infants with birth weight 501–1250 grams enrolled in the NICHD Neonatal Research Network registry 2001–2005. Approximately half were born before the introduction of resident duty-hour restrictions in 2003. Follow-up assessment at 18–22 months was completed for 4,508 infants. Mortality (7-day and 28-day), short-term morbidities, and neurodevelopmental outcome were examined with respect to the timing of birth: night vs day, weekend vs weekday, and July or August vs other months, and after vs before implementation of resident duty-hour restrictions.
RESULTS
There was no effect of hour, day, or month of birth on mortality and no impact on the risks of short-term morbidities except the risk of ROP requiring operative treatment was lower for infants born during the late night hours than during the day. There was no impact of timing of birth on neurodevelopmental outcome except the risk of hearing impairment or death was slightly lower among infants born in July or August compared with other months. The introduction of resident and fellow duty-hour restrictions had no impact on mortality or neurodevelopmental outcome. The only change in short-term morbidity after duty-hour restrictions were introduced was an increase in the risk of ROP (stage 2 or higher).
CONCLUSION
In this network of academic centers, the timing of birth and the introduction of duty-hour restrictions had little effect on the risks of mortality and morbidity of VLBW infants, suggesting that staffing patterns were adequate to provide consistent care.
doi:10.1542/peds.2010-0456
PMCID: PMC2924191  PMID: 20643715
Neonatal; preterm infants; morbidity/mortality; resident education/training; workforce

Results 1-5 (5)