WHAT IS THAT RED BIRTHMARK?

"Birthmarks" are common in newborns. They can perplex clinicians and provoke anxiety on the part of parents. Which red mark is just a "nevus simplex" or "salmon patch" that is destined to disappear? Vaguely descriptive terms such as "strawberry hemangiomas," "Angel's kisses," and "port wine stains" have been used for many years to describe vascular anomalies, but their days, it appears, are numbered.

A new, uniform classification scheme for vascular anomalies (vascular tumors and vascular malformations) developed by the International Society for the Study of Vascular Anomalies (ISSVA) aims to standardize the terminology of the "angiomas."1 A common terminology and accurate diagnosis are crucial for appropriate evaluation and management of vascular lesions. Furthermore, a new classification recognizes the advances in understanding of the genetic mutations and molecular pathways involved in vascular lesions.

The new, official ISSVA classification of vascular anomalies is an interactive document and is available at http://www.issva.org. State-of-the-art information about the most common, as well as the rarer vascular anomalies, with up-to-date terminology is presented, including genetic causes (where known) and associated syndromes. It is an excellent reference when a neonate presents with anything from a simple birthmark to a more serious vascular entity, or even with the most common benign vascular tumor of infancy, infantile hemangioma.

1. Wassef M, Blei F, Adams D, et al. Vascular anomalies classification: recommendations from the International Society for the Study of Vascular Anomalies. Pediatrics. 2015;136:203-214. [Context Link]

IS NEONATAL INTENSIVE CARE OVERUSED?

A recent epidemiologic study1 concludes that newborns in the United States are increasingly likely to be admitted to the neonatal intensive care unit (NICU), and these units are caring for more normal-birth-weight and term infants. This conclusion was reached after an analysis of birth certificates of nearly 18 million liveborn infants from 38 states and the District of Columbia between 2007 and 2012. They found that throughout that 6-year period, the NICU admission rate increased from 64.0 to 77.9 per 1000 live births (relative rate, 1.22; 95% confidence interval, 1.21-1.22; P < .001). Admission rates increased for all birth-weight categories.

The increase in admission rates to NICUs is not solely a consequence of an increase in the birth rate of premature or low birth-weight infants. In fact, during the study period, newborns admitted to NICUs were, on average, larger and less premature, such that by 2012, more than half of newborns admitted to an NICU had birth weights more than 2500 g.

NICU care is costly and is not without potential harms to the infant and family, not the least of which are the separation, delayed attachment, and parental distress and anxiety prompted by an NICU admission. The investigators believe that their data raise the possibility of overuse of neonatal intensive care in some newborns, although the study does not allow for any assessment of the reasons for, or the appropriateness of NICU admission for any newborn. Further study is needed to determine the causes of the increased NICU use found in this study, as well as the implications for payers, policymakers, families, and newborns.

1. Harrison W, Goodman D. Epidemiologic trends in neonatal intensive care, 2007-2012 [published online ahead of print July 27, 2015]. JAMA Pediatr. doi: 10.1001/jamapediatrics.2015.1305. [Context Link]

CHOOSING WISELY: NEONATAL EDITION

In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely initiative, with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures. In subsequent years, leading medical specialty societies generated evidence-based lists of common tests, treatments, and procedures that should not be routinely applied in their specific fields of healthcare.

Now, neonatal medicine has joined the Choosing Wisely family.1 Dr Timmy Ho from the Beth Israel Medical Center in Boston, Massachusetts, and colleagues recruited a panel of experts (including representatives from NANN) to undergo a 2-year process to reach consensus on a list of 5 tests and procedures that should no longer be considered routine in neonatal care:

1. Avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants.

2. Avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection.

3. Avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity.

4. Avoid routine daily chest radiographs without an indication for intubated infants.

5. Avoid routine screening term-equivalent or discharge brain magnetic resonance imaging scans in preterm infants.

These 5 interventions are not necessarily the most expensive tests or procedures used in neonatal care, but in the judgment of the expert panel, the available evidence of benefit does not justify their use. Although there may be specific instances when these 5 tests and treatments are still appropriate, their use should not be automatic or routine in neonatal care. The investigators intend this list to provide some specific opportunities to provide better, higher-value neonatal care, and hope that it is used as a starting point by neonatal intensive care units to evaluate other interventions that are used routinely, but offer little value or benefit to babies.

1. Ho T, Dukhovny D, Zupancic JA, Goldmann DA, Horbar JD, Pursley DM. Choosing wisely in newborn medicine: five opportunities to increase value [published online ahead of print July 20, 2015]. Pediatrics. doi: 10.1542/peds.2015-0737. [Context Link]

A SIMPLE WAY TO REDUCE FALSE-POSITIVE NEWBORN SCREENS

False-positive newborn screening (NBS) results are a significant problem in neonatal care, especially among preterm infants. In recent years, the practice of starting amino acid infusions on the first day of life has increased rates of NBS that come back positive because of elevated amino acid concentrations. However, we can't assume that the infant doesn't have a true metabolic disorder, so these tests must be repeated and reevaluated, sometimes causing anxiety on the part of parents.

A recent large, retrospective cohort study confirmed that this problem might have a simple solution1. The new strategy was to interrupt the neonate's parenteral nutrition infusion and substitute an equivalent concentration of dextrose for 3 hours before the blood for the NBS was drawn. Data on false-positive neonatal screens were compared before and after this new protocol was implemented.

The new protocol had a dramatic effect on the false-positive rate, which was 74% lower in infants whose amino acid infusions were stopped before the NBS was drawn. The new strategy also resulted in a significant cost savings ($17.27 per infant screened or $192.54 for each false-positive NBS prevented). The only extra cost taken into account for implementing the new protocol was the cost of the 3-hour dextrose replacement fluid. These findings were very similar to those of a smaller study, using an almost identical protocol, published last year.2 Future research should determine whether less than 3 hours might be equally effective or whether a longer period of stopping parenteral nutrition might produce an even greater reduction in false-positive NBS results. Methods to prevent false-positive NBS results from abnormal 17-hydroxyprogesterone concentrations and acylcarnitine profiles in preterm infants are also needed.

1. Tim-Aroon T, Harmon HM, Nock ML, Viswanathan SK, McCandless SE. Stopping parenteral nutrition for 3 hours reduces false positives in newborn screening [published online ahead of print May 21, 2015]. J Pediatr. 2015;167(2):312-316. doi: 10.1016/j.jpeds.2015.04.063. [Context Link]

2. Morris M, Fischer K, Leydiker K, Elliott L, Newby J, Abdenur JE. Reduction in newborn screening metabolic false-positive results following a new collection protocol. Genet Med. 2014;16:477-483. [Context Link]

MORE NURSING PILLOW-RELATED INFANT DEATHS

Improper use of a popular type of crescent-shaped pillow used by breastfeeding mothers has been implicated in the deaths of 3 infants in central Pennsylvania.1 The coroner who investigated the infant deaths believes that the infants died because the pillows were misused as devices to position or prop up sleeping infants. The infants died from "posture asphyxiation" when their heads gradually slipped down into the curve of the pillow, and then dropped forward, obstructing their airways. These 3 infant deaths were not the first associated with using a nursing pillow for infant naps.

The nursing support pillows were not manufactured for the purpose of positioning infants during sleep, and they carry warnings against doing so. They are designed to encircle the mother's waist, providing a surface to comfortably support the breastfeeding infant while the mother is awake and holding the infant. These nursing pillows are often used while infants are still in the neonatal intensive care unit, offering an opportunity for nurses to educate mothers about the dangers of using the pillows in any way other than that for which they are intended, and to reinforce safe sleeping recommendations. Nurses must also take care not to use the pillows to position hospitalized babies during sleep, because these actions may be modeled by parents at home.

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