Tag: Care

Coronavirus and Pregnancy: What to Know

On March 24, 2020

In Child Health Care, Neonatal Care, Newborns, Research

Historically, viral illnesses become more serious in the very young, the elderly and in individuals having a weakened immune system. Given that victims of all ages have become infected with the coronavirus, many are understandably concerned about the effect the illness may have on expectant mothers.

Pregnancy and Covid-19

The World Health Organization reports that in a study of 147 pregnant women, eight percent developed more severe forms of the illness. One percent required critical care.

A study of nine afflicted women who gave birth indicated that none of the infants tested positive for the virus. But, the women all became infected during the last trimester of pregnancy. It remains yet unknown how the virus might affect a fetus during the early months of development.

Another study involved 10 newborn infants who developed serious forms of the illness. According to a physician from the Northwestern University Feinberg School of Medicine, the amniotic fluid, breast milk, and cord blood were tested. But, all of the fluid was negative for Covid-19. So, physicians do not believe that the illness passes from the mother to the developing infant. Theories revolving how the babies became infected include that the women may not have undergone testing and found to be afflicted before delivery. The babies may have come in contact with their infected mothers shortly after birth.

An obstetrician affiliated with the American College of Obstetricians and Gynecologists advises that pregnant women should undergo testing at their initial appointment and separated from patients who tested negative. Pregnant women are advised to use the same precautions recommended for the general public.

About Covid-19

After exposure, individuals may develop symptoms in two days to two weeks. The majority of afflicted individuals suffer symptoms that are equated with the common flu. The experience may include fever, generalized fatigue and upper respiratory symptoms. Others suffer muscle aches and diarrhea. The World Health Organization reports that the virus causes serious illness in one out of every six patients. More severe cases exhibit difficulty breathing and shortness of breath. Individuals experiencing more serious symptoms are advised to seek medical attention.

Scientists recently revealed that the virus has two strains, one of which is more aggressive than the other. Health care providers also report that it is possible for individuals to suffer a relapse, which is often more serious.

Transmission occurs through airborne droplets or coming in contact with infected animals, surfaces or fecal matter.

A Closer Look at Neonatal Macrosomia

By Dr. Allen Cherer

On October 29, 2019

In Child Health Care, Neonatal Care, Newborn Screening, Newborns

Neonatal macrosomia refers to babies weighing more than eight pounds and 13 ounces at birth. Approximately nine percent of infants are born with the condition. The larger the baby, the greater the risks to the mother and the infant. There are a variety of causes and risk factorsYour text to link… that lead to overweight newborns. Some causes are preventable.

Causes and Risks

Diabetes-Expectant mothers may have been diagnosed with diabetes before becoming pregnant. Others develop gestational diabetes during pregnancy. Blood sugars must be monitored and controlled otherwise, the infant develops with a larger amount of body fat.
Previous history-Women who have given birth to overly large infants in the past have a greater risk of having large babies in the future.
Obesity-There is a greater chance of having a baby with neonatal macrosomia if the mother is obese. Gaining too much weight during pregnancy also increases the risk.
Male infants-Neonatal macrosomia occurs more often in boy babies.

Overdue pregnancies-Pregnancies that extend two or more weeks beyond the estimated due date increase the chance that the infant will be overly large.
Mother’s age-Pregnant women over the age of 35 are more likely to have abnormally large babies.

Maternal Complications

Difficult labor-When an infant is too large, there is a likelihood that the baby becomes stuck in the birth canal, which may necessitate a C-section delivery.
Internal injuries-During the birthing process, the mother may suffer laceration or tearing of the vaginal tissues and perineal muscles.
Hemorrhaging-Internal injuries combined with the uterus’ inability to contract properly may lead to severe bleeding.
Uterine damage-Women who previously gave birth via C-section or had gynecological surgery have an increased risk of suffering from a uterine rupture.

Infant Complications

Hypoglycemia-Babies born with neonatal macrosomia have an increased risk of suffering from abnormally low blood sugars.
Obesity-Overly large infants are at a greater risk of becoming obese during childhood.
Metabolic syndrome-Neonatal macrosomia infants are likely to have metabolic syndrome. The condition is associated with hypertension, hyperglycemia, elevated cholesterol and excess body fat.

Prevention

Women must maintain a healthy weight before during and after pregnancy. While pregnant women should not gain ore than 35 pounds. Women diagnosed with diabetes must have their blood sugar continually monitored and controlled.

Respiratory Distress in Newborns

By Dr. Allen Cherer

On March 18, 2019

In Neonatal Care, Newborn Screening, Newborns, Research

Respiratory distress syndrome, or RDS, is a common lung complaint for infants. This is especially true in premature babies, born before 37 weeks. The more premature the baby, the greater the chance the child will develop RDS.

RDS is caused by a shortage of pulmonary surfactant. Surfactant is a liquid that helps keep air sacs in the lungs, known as alveoli, open. Alveoli are critical. They are the site of the exchange of oxygen and carbon dioxide. They make it possible for the blood to be oxygenated fully. Since surfactant makes this possible, it’s a very important substance indeed.

There are several risk factors for RDS. In addition to prematurity, babies with RDS are more likely to be white, male, and multiples. Mothers with diabetes are more likely to give birth to RDS babies. Babies delivered by c-section are also more likely to develop this problem.

Parents of babies with some of these risk factors should be aware of the symptoms of respiratory distress syndrome. Babies with RDS breathe fast. They may grunt, making an ugh sound with each breath. Their nostrils will flare every time they breathe. Finally, they can have retractions, where the skin pulls under the rib cage or in between ribs with each breath. Their skin may not be as pink as that of a typical baby.

Luckily, there is treatment for RDS these days. Delivery of oxygen by nasal cannula is one treatment. A CPAP, or continuous positive airway pressure, machine can be used to push air into an infant’s lungs. This will keep the alveoli open. Severe cases of RDS can require a ventilator.

Ventilators are a serious measure. They require intubation, or a tube being placed down the infant’s windpipe. Ventilators are only used in babies who can’t breathe well without assistance.

In addition to helping deliver more oxygen, the issue of a lack of surfactant can also be addressed. Surfactant can be delivered directly to the lungs, also via intubation. Medications to calm the infant are also used, especially when intubation is required.

RDS can sometimes also be associated with infections. In those cases, antibiotics may be given to the infant. Not every baby requires all of these treatments. In some cases, babies get worse before getting better. RDS is, in general, very treatable.

Providing Care for Drug-exposed Newborns: Time for the Next Step

By Dr. Allen Cherer

On September 6, 2016

In Child Health Care, Neonatal Care, Newborns, Research

During the years 1999-2013, the amount of prescription opioids dispensed in the United States nearly quadrupled, and since 2000, it is estimated that opioid use during pregnancy has tripled. Notably, the tragic consequences of the extreme availability of such drugs include abuse, physical dependence, and increasingly, death through inadvertent overdose.

In addition, for the individual pregnant woman, a minimum of two lives is affected: her own and that of her unborn child. The prevalence of prenatally exposed newborns to one or more illicit drugs approximates 6%. Neonatal Abstinence Syndrome (NAS) refers to the withdrawal symptoms from physical dependence experienced by the newborn exposed during pregnancy generally to illicit drugs, prescribed drugs, or to those opioids employed in medication-assisted treatment of maternal opioid addiction.

Withdrawal symptoms can vary markedly in terms of time of onset and severity but typically manifest as tremulousness, agitation, sleeplessness, and poor feeding. NAS increased threefold from 2000-2009 and frequently requires prolonged newborn hospitalization. It has been reported that aggregate hospital charges for NAS increased from 732 million dollars to 1.5 billion dollars with approximately 80% attributed to state Medicaid programs in 2012. Clearly, NAS is a costly public health problem resulting in significant human suffering and expense.

Traditionally, infants who are known to be at risk for NAS have been monitored in the postpartum unit after birth for at least 96 hours and withdrawal symptoms scored based on the Finnegan Scale developed in the mid 1970’s. Typically, if the scores exceed certain values, the newborn is admitted to a Special Care Unit where pharmacologic treatment is frequently started. As withdrawal symptoms subside, dosing is gradually tapered and ultimately stopped. The newborn is observed off medication and monitored for recurrence of disabling withdrawal symptoms. The entire process can generally result in a prolonged Special Care Unit hospital stay of 2-10 weeks.

With the seemingly overnight explosion in the number of newborns demonstrating withdrawal symptoms in the early 2000’s, medical caregivers and hospitals were caught off-guard. On short notice, staff addiction education, medication and weaning protocols, general care policies, and hospital space allocation were required. After a number of years of concerted, collaborative work, much has been learned and achieved in improving the care of the substance-exposed infant.

Nevertheless, pharmacologic treatment continues to require prolonged hospital stays, often in costly Special Care Units. In addition, it effectively excludes full participation by the eventual sole primary caregivers, ideally the parents. It is with these disturbing issues in mind that it is refreshing to note the work and studies over the past several years to further optimize the care provided to infants with NAS and their families.

One of the earlier studies to suggest the therapeutic benefits of a different approach to caring for the drug-exposed infant was that of Abrahams et al. published in the Canadian Family Physician in 2007. During the same period of frenzy involving inpatient hospital transfers, guaranteeing interobserver scoring reliability, pharmacologic treatment protocols, and nursing care directives, the Canadian group with extensive previous experience in addiction medicine reported in a retrospective cohort study the benefits of a rooming-in policy whereby infants remained with their mothers as primary caretakers.

They noted that infants who roomed-in were less likely to require pharmacologic therapy for withdrawal and more likely to be discharged to mother’s care compared to infant’s who received standard nursery care. Subsequently, other retrospective cohort studies both in Europe and the United States demonstrated equally beneficial effects of rooming-in regarding decreased requirement for pharmacologic therapy and decreased duration of hospital stay.

Most recently, the results of a quality collaborative project from the Children’s Hospital at Dartmouth Hitchcock were described in the May, 2016 Pediatrics and demonstrated the beneficial effects of combined standardized protocols and family-centered care in the management of the drug-exposed infant. Over time, the project safely reduced the number of infants requiring pharmacologic therapy, average length of stay, and overall hospital costs.

Among others, key drivers to success were prenatal education of family caregivers including expressed expectation that they would provide meaningful rooming-in care, baby-centered NAS scoring including on demand feeding schedules, pharmacologic therapy when necessary with dosing adjustment based on overall infant condition rather than solely Finnegan score and determined by a consistent team, and an infant “snuggler” volunteer program to assist families when times required their absence.

Overall, the project demonstrated that despite many practical obstacles to providing high quality care for drug-exposed newborns and their families in the hospital setting, where there’s a will, there’s a way.

Antenatal Corticosteroid Use for Late Preterm Delivery

By Dr. Allen Cherer

On July 15, 2016

In Child Health Care, Neonatal Care, Research

In 1972, Drs. Liggins and Howie published their landmark study demonstrating that antenatal corticosteroids administered to women 24-36 weeks of gestation reduced the incidence of respiratory distress syndrome and neonatal mortality. Liggins had previously noted that lambs, treated with intrafetal ACTH, cortisol, or dexamethasone, delivered prematurely, and sacrificed, demonstrated partially expanded lungs.

Such alveolar stability was not typically noted until later in gestation. It suggested to Liggins that glucocorticoids might cause premature liberation of surfactant into the alveoli and served as the basis for his study. In the trial, the most significant difference in the incidence of respiratory distress syndrome among those treated vs. not treated with corticosteroids occurred in those gestations less than 32 weeks.

Although those gestations treated between 32 and 37 weeks exhibited a decreased incidence of respiratory distress, the number did not reach statistical significance. Nevertheless, even at that time, Liggins postulated that mechanisms in addition to enhanced surfactant production and release might be responsible for the improved pulmonary function noted in more advanced gestations treated with antenatal corticosteroids.

Interestingly, despite the findings of the initial study and similar results in multiple subsequent studies , the 1994 NIH Consensus report on the effect of corticosteroids for fetal maturation on perinatal outcomes found that only 20% of women who delivered newborns 501-1500 grams received the benefit of antenatal steroids. After a thorough review of available evidence, including 12 year neurodevelopmental follow up showing no adverse outcomes, the Consensus Panel felt the benefits of antenatal administration of corticosteroids vastly outweigh the risks and all fetuses between 24 and 34 weeks gestation at risk of preterm delivery should be considered candidates for antenatal treatment.

Only in those few pregnancies where corticosteroids would have an adverse effect on the mother or delivery was imminent should steroid treatment be withheld. In addition, although Grade 1 evidence existed at the time to support the use of antenatal corticosteroids for gestations greater than 34 weeks, it was judged insufficient to recommend their use.

Since the Consensus statement, the use of antenatal corticosteroid use has become common and has resulted in considerable reduction in mortality and morbidity, as well as total health care costs. In addition, further neurodevelopmental follow up, including the original Auckland steroid trial participants, continues to demonstrate no adverse effects on psychological functioning and health-related quality of life. Other studies have demonstrated a decrease in overall respiratory disease in infants born beyond 34 weeks who had previously been exposed to antenatal corticosteroids when compared to unexposed infants born at similar gestations.

More than 300,000 pregnancies deliver in the late preterm period (34 0/7 – 36 6/7 weeks gestation) each year in the United States. Seventy per cent of Intensive Care Nursery admissions are late preterm newborns. Their increasing numbers and the broad range and severity of respiratory disorders with which they present beg for a re-evaluation of antenatal corticosteroid use in this range of gestations. This is especially appropriate with a better understanding of the multiple actions of corticosteroids as gestation approaches term.

A recent study, titled Antenatal Late Preterm Steroids (ALPS), a Randomized Trial to Reduce Neonatal Respiratory Morbidity, was published in The New England Journal of Medicine in April, 2016. The study enrolled over 2800 women with singleton pregnancies at high risk for late preterm delivery.

The participants were randomized to receive antenatal betamethasone by injection or a matching placebo. Greater than 80% of women in the trial delivered prior to 37 weeks gestation. The primary outcome was a neonatal composite of treatment in the first 72 hours (CPAP or High Flow Nasal Cannula for at least 2 hours, supplemental oxygen with fraction of inspired oxygen of at least 0.3 for at least 4 hours, mechanical ventilation, or ECMO) or stillbirth or neonatal death within 72 hours of birth.

The study found a significant decrease in neonatal respiratory complications in the group given the steroid treatment (11.6% vs. 14.4%). In addition, severe respiratory complications occurred significantly less frequently in the betamethasone group. The incidence of neonatal hypoglycemia was increased in those treated with betamethasone (24% vs. 14.9%), but no other adverse neonatal outcomes were noted between the groups.

The study is authoritative due to its size, generalizability, and methodologic rigor. Although the issue of long term follow up cannot be specifically addressed, follow up studies of similar treatment in earlier gestations are reassuring. Late preterm births comprise a high risk group for hypoglycemia regardless of maternal antenatal steroid treatment and warrant vigilant monitoring during the newborn period. In sum, the findings of the Antental Late Preterm Steroids study are consistent with other randomized controlled trials of antenatal corticosteroids administered at gestations less than 34 weeks.

Both the American College of Obstetrics and Gynecology with an endorsement by the American Academy of Pediatrics and the Society for Maternal-Fetal Medicine have addressed and published recommendations based on the study’s findings. Although the recommendations do not establish exclusive standards of care, the organizations approve the use of antenatal corticosteroids in certain defined late preterm pregnancies. It is only with thoughtful application of the recommendations and further studies that the efficacy and safety of antenatal steroids in the late preterm pregnancy will be realized. It is a significant start.

Newborn Screening and Severe Combined Immune Deficiency

By Dr. Allen Cherer

On May 15, 2016

In Child Health Care, Neonatal Care

April (April 22-29) has been designated as National Primary Immunodeficiency Awareness Month and provides an opportunity to better understand the more than 250 rare, genetic disorders in which the body’s normal immune system is absent or functions improperly. Since an important function of the immune system is to protect against infection, patients with primary immune deficiency have an increased susceptibility to infection.

Severe Combined Immune Deficiency (SCID), popularized in the 1976 movie “The Boy in the Plastic Bubble”, is generally considered to be the most serious of the primary immunodeficiencies. There are at least 13 different genetic defects that can cause the disease; all of which are present at birth, involve missing T lymphocytes which are important in identifying and attacking perceived “invaders”, and affect the function of B lymphocytes which produce antibodies against infection.

The absence of T lymphocytes and antibody immunity results in severe infections, diarrhea, and failure to thrive. Regardless of the genetics, patients invariably succumb to an early death due to overwhelming infection. New approaches to diagnosis and management have changed what at one time was a dismal prognosis.

Treatment options have come a long way over the past 4 decades and include enzyme replacement, bone marrow transplant, and gene therapy. Paramount to this change is early diagnosis before the infant has had a chance to develop any serious infections.

The most effective therapy to date is immune reconstitution via stem cell transplant which has been shown to be highly successful (94%) if performed by 3.5 months of age. Hence, timing is crucial in terms of diagnosis and treatment.

Typically, infants with SCID appear totally normal at birth and have no family history of immunodeficiency. In the past, patients were primarily identified either by previous family history, physical manifestations, or after onset of life-threatening infection. Early identification of SCID has been achieved through the use of the 7-cell receptor excision circle (TREC) assay as part of the routine newborn screening program.

Absent or low TREC levels can indicate insufficient T lymphocyte production characteristic of SCID, as well as low T lymphocyte, non-SCID conditions as seen in DiGeorge Syndrome, Trisomy 21, CHARGE Syndrome, and ataxia telangiectasia. On May 21, 2010, The U.S. Department of Health and Human Services (HHS) recommended that every state include the assay as part of the newborn screen.

In the landmark study based on retrospective data on more than 3 million infants from 11 newborn screening programs using the TREC methodology conducted by Jennifer Puck, MD and colleagues and published August 20, 2014 in The Journal of the American Medical Association, the value of early detection and treatment of SCID was confirmed.

In addition, the study found an incidence rate almost twice as great (1 in 58,000 births) as had been previously estimated. Since the point of newborn screening is to identify conditions for which early treatment is life-saving, the study was a crucial step in the adoption of universal screening.

As of April 1, 2016, all, except for 11, states have adopted routine newborn screening programs for SCID. A 2016 study published in the Journal of Pediatrics by Ding and others provided an eloquent cost-benefit analysis of newborn screening in the treatment of Severe Combined Immune Deficiency.

Based on data obtained from 86,000 infants in Washington state, the study showed that newborn screening for SCID is clearly cost-effective. Hopefully, the study provides additional support in economic terms for the adoption of universal screening programs in all 50 states.

Reflections on Cesarean Section Rates

By Dr. Allen Cherer

On May 9, 2016

In Child Health Care, Neonatal Care

Cesarean section delivery is among the most common surgical procedures. It is estimated that in 2012 alone, over 22 million cesarean deliveries were performed worldwide. Data from the National Vital Statistics show that the total cesarean section rate in the U.S. in 1996 was approximately 21%.

Since that time, there has been a rapid increase in the rate, such that in 2011, close to 1 in 3 mothers delivered by cesarean. Although the rate has leveled since then, there remains no evidence that such a significant increase has been accompanied by a concomitant decrease in maternal or neonatal mortality.

Although cesarean delivery can be life-saving for the fetus, the mother, or both in certain cases, the concern exists that cesarean delivery is overused. Hence, the matter is a global health issue. Since one of the main driving forces for the increased total cesarean rate has been a marked shift to repeat cesarean delivery following a previous primary cesarean section, a concerted effort over the past several years has been to examine closely the factors related to the safe management of the nulliparous pregnancy.

As early as 1985, the World Health Organization (WHO) stated there was no justification for any region to have a cesarean delivery rate greater than 10-15 /100 live births. Nevertheless, the rates continued to increase worldwide with no scientific evidence indicative of substantial maternal or perinatal benefit.

In fact, a number of studies have associated higher rates of cesarean deliveries with negative consequences, including increased maternal and neonatal morbidity and mortality as well as increased consumption of limited health resources by procedures without medical indications.

In March 2014, a consensus report was issued by the American College of Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine on the safe prevention of the primary cesarean section. Among other points, it addressed management guidelines for the most frequent indications for primary cesarean deliveries, namely, labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

The report encouraged obstetricians to allow more time to progress through a vaginal delivery without intervention, recommended improved and standardized fetal heart rate interpretation and management, and advocated access to non-medical interventionsduring labor, such as continuous labor and delivery support.

A study by researchers at Harvard Medical School and the Stanford University School of Medicine published December 2015 in The Journal of the American Medical Association suggested that based on analyses of cesarean section rates and maternal and neonatal outcomes among 194 WHO member countries the ideal rate of childbirth by cesarean section approximates 19% of all births as opposed tothe previously considered optimal rate of 10-15%. Although the finding is higher than the former target, it remains significantly lower than the current rate in U.S. hospitals.

In its April 2015 position statement on cesarean delivery, the WHO moved away from any target rate. Rather, it emphasized that every effort should be made to ensure cesarean sections are provided to the women in need and only be performed when medically necessary.

It is gratifying that the concept of “target rate” is no longer tied to the delivery of quality medical care. Primarily due to the lack of a consistent classification system to monitor and compare different obstetric profiles, meaningful data relative to cesarean section rates is missing.

It is only when such systems as the Robson Ten Group Classification System are widely adopted by institutions that valid “risk-adjusted”cesarean section rates can potentially be developed and comparisons be made between institutions, regions, and countries.

Approaching a Birth Plan

By Dr. Allen Cherer

On February 14, 2016

In Neonatal Care

Pregnancy is an exciting time for expectant parents, and childbirth is a miraculous event. Nevertheless,due to the innate unknowns, it can result in considerable anxiety and sense of loss of control. One means of combating these feelings is through thoughtful preparation of a birth plan based on realistic and trustful communication among all the parties who will be involved.

Since the early Roman period, pregnant women in labor had been attended by friends, relatives, or others experienced in aiding with childbirth. As time progressed, the management of the laboring woman became more involved and the advancement of technologies to better monitor the unborn child and the mother required a change in the birth place and the sophistication of the caregivers.

Currently,the vast majority (>98%) of deliveries in the U.S. occur in the hospital setting and are attended by midwives or physicians. In association with these changes came the option of operative delivery (cesarean section) which in 2012 accounted for close to 30% of all births in the United States, according to the Centers for Disease Control and Prevention (CDC). Cesarean sections are known to be medically indicated for a number of reasons to safeguard the well being of baby and/or mother.

At the same time, for most pregnancies that are low risk, cesarean section may pose greater risks than vaginal delivery, especially risks related to future pregnancies. Due to the recent rapid increase in the cesarean section rate and concerns that operative delivery is overused without clear evidence of improved maternal or newborn outcomes, the American College of Obstetricians and Gynecologists (ACOG) issued in 2014 new recommendations targeted at preventing women from having cesarean sections with their first birth and at decreasing the national cesarean rate.

Pain management is a significant component of the birth plan. Although most mothers report only mild discomfort during early labor, as contractions become stronger, longer, and more frequent, pain intensifies and may require relief with either spinal or epidural anesthesia.

Although the medications are generally considered safe, very rare complications can occur. For those women opting for a more natural childbirth, the participation in a yoga program during pregnancy or the use of hypnosis have been described.

Whatever birth plan is developed for an individual pregnancy, it should always be tempered based onthe saying “the best laid plans of mice and men often go awry”. The overriding goal should always be a safe birth for both mother and baby. If communication and trust exist among all parties, childbirth can be a magnificent process.