Advancing the Evidence Base in the Care of Term and Late Preterm Infants

In 2019, there were ∼3.7 million births registered in the United States, of which 89.8% were delivered at ≥37 weeks’ gestation (term) and 7.5% were delivered between 34 and 36 weeks’ gestation (late preterm).¹  The vast majority of births in the United States occur in the hospital (98.64% in 2012),²  and most otherwise healthy term infants and late preterm infants (LPIs) are cared for in maternity and well-newborn units. Clinicians managing the care of neonates admitted to the well-newborn unit are pediatric hospitalists, general pediatricians, neonatologists, and advance practice providers. Their scope of practice includes well-newborn care, management of common newborn concerns, and providing anticipatory guidance to parents.³  For pediatric hospitalists choosing subspecialty certification in pediatric hospital medicine, competency in newborn care is expected.⁴  The term “newborn hospitalist” can include clinicians practicing primarily in the NICU, but for the purposes of this commentary, our focus is on the care of term infants and LPIs on maternity and well-newborn units and, in some cases, on the pediatric wards. Term infants and LPIs make up a large proportion of the hospital volume, and major advancements in areas such as the management of sepsis and neonatal weight loss have occurred over the last decade.^5,6  However, the evidence base for the care of term infants and LPIs has many gaps, and this month’s Hospital Pediatrics newborn issue sheds light on some topics that newborn hospitalists grapple with.

An area of newborn hospital medicine that has received much attention in the past several years is the care of infants with neonatal opioid withdrawal syndrome (NOWS). In 2017, there were 7.3 infants with NOWS per 1000 newborn hospitalizations, and rates in the United States continue to rise.⁷  Practices such as rooming-in, functional assessment of withdrawal, and emphasis on nonpharmacologic measures as primary management have been shown to significantly decrease hospital length of stay and cost.⁸  Despite such advances, there is considerable practice variation across US hospitals.⁹  In several institutions, infants are managed by newborn hospitalists initially on well-newborn units and then transferred to the pediatric inpatient units for further management, but many infants with NOWS are still routinely admitted to the NICU and treated with pharmacotherapy.⁹  Although our understanding of the management and assessment of withdrawal symptoms in infants with NOWS has deepened, we are beginning to learn more about longer-term outcomes. In this month’s Hospital Pediatrics newborn issue, investigators used data from the Pediatric Health Information System to compare readmission rates between infants with a NOWS diagnosis and all other infants.¹⁰  Investigators found that infants with NOWS were more likely to be readmitted within the first year of life and that readmissions were of higher acuity, were more costly, and led to longer lengths of stay.¹⁰  Why this is the case remains to be understood, but the differences in management across institutions makes this difficult to fully interpret. Newborn hospitalists must continue to lead research in this area to inform best practices during the hospitalization of infants with NOWS that result in positive outcomes after discharge and reduce the risk for readmission in this vulnerable population.

Neonatal circumcision is a common practice in newborn units, and depending on the institution, many newborn hospitalists perform the procedure routinely. In 2010, the national rate of newborn circumcision was 58.3%, with highest rates in the Midwest.¹¹  Neonatal circumcision is a relatively safe procedure when performed by an experienced professional. The American Academy of Pediatrics and other professional organizations endorse the elective procedure for male newborns given the potential health benefits and low risk.^12,13  The Gomco clamp is a common technique that uses a crushing mechanism to achieve hemostasis. The “clamp time” refers to the number of minutes the Gomco clamp remains tightened to the bell, causing the crush injury, which provides hemostasis.¹⁴  Despite the widespread use of the Gomco clamp since its invention in 1935, the optimal clamp time has not been established, and this is another hot topic in newborn medicine that lacks evidence. Many clinicians observe a minimum clamp time of 5 minutes.¹⁴  In this month’s Hospital Pediatrics newborn issue, investigators evaluated the difference in postprocedure bleeding when using a clamp time of 5 minutes versus no minimum clamp time.¹⁵  In the study, which included 23 physicians and 1252 newborns, the average clamp time was 2 minutes and 5 seconds for the group without a time minimum.¹⁵  There was no significant difference in postprocedure bleeding between the groups, and the authors concluded that a 5-minute clamp time is unnecessary.¹⁵  These findings may have major implications for decreasing the newborn’s discomfort by reducing the time spent restrained on the Circumstraint board, thereby improving the quality of care.

One group trying to address gaps in the care of term infants and LPIs is the Better Outcomes through Research for Newborns (BORN) network, a core activity of the Academic Pediatric Association.¹⁶  The network was founded in 2010 with a goal to increase the evidence base for the care of term infants and LPIs through collaborative research projects.¹⁶  The BORN network has grown since inception and currently includes >100 well-newborn units across the United States (∼400 000 annual deliveries; ∼10% of US live births). Membership comprises newborn clinicians and medical directors from academic and community settings. Over the last decade, researchers have highlighted practice variation across well-newborn units in many areas and have brought attention to topics in newborn medicine that lack a robust evidence base, such as car seat tolerance screening, for example. In this month’s Hospital Pediatrics newborn issue, the BORN network was used in 2 studies.^17,18  In one study, investigators surveyed clinicians in the BORN network about skin care management of newborns across well-newborn units and report on mixed messages given to parents about their infant’s skin care.¹⁷  Investigators importantly highlight the lack of evidence behind anticipatory guidance on newborn skin care given to thousands of parents across different institutions. The study also brings to attention a hot topic in newborn medicine, specifically, the differences in the timing of the newborn bath and that in some institutions, newborns are not bathed during the birth hospitalization at all. In the second study, well-newborn medical directors shared their experience navigating the early stages of the coronavirus disease 2019 (COVID-19) pandemic, including managing early controversial recommendations from the American Academy of Pediatrics to separate all COVID-19-positive mothers from their newborns and to discourage direct breastfeeding.¹⁸  The initial recommendations to separate COVID-19-positive mothers from their newborns were reversed on the basis of subsequent research revealing incredibly low risk of COVID-19 transmission from the mother to the newborn.¹⁹  The study highlights the experiences of well-newborn unit directors caught between changing recommendations and the stresses of a relatively new pandemic at the time while creatively trying to keep mother-infant dyads safe and healthy. The reach of the BORN network and collaboration across institutions creates research opportunities to share experiences and bring to attention and both question and challenge historical and dogmatic practices that affect millions of newborns and that often do not have the attention or interest of agencies that typically fund research.

Newborn hospitalists are key stakeholders in improving the care of term infants and LPIs during the birth hospitalization in both community and academic hospital settings. Many questions on current practices remain unanswered. For example, hypoglycemia screening and management in well-appearing at-risk infants remains a nebulous topic, and significant practice variation exists across the United States.²⁰  Neonatal hypoglycemia may result in admission to the NICU and separation from the mother, which negatively impacts breastfeeding.²¹  Professional organizations cannot agree on a definition of asymptomatic hypoglycemia, and the current major recommendations were written primarily by neonatologists and pediatric endocrinologists.^22,23  There is also much work to be done to better understand and address racial and ethnic health disparities and inequities in the care of term infants and LPIs. In the United States, Black infants have the highest rate of infant mortality, with rates 2.3 times that of non-Hispanic white infants.²⁴  According to the Centers for Disease Control and Prevention, in 2015, only 69.4% of non-Hispanic Black infants were initiated on breastfeeding, compared to 85.9% of non-Hispanic white infants.^24,25  One study found that Black women and their newborns were 1.5 times more likely to have drug testing performed compared with non-Black dyads.²⁶  Addressing inequities is essential to improving health outcomes for all mothers and newborns, and newborn hospitalists are in an important position to affect change.