Exploring Innovations in Human Milk Analysis in the Neonatal Intensive Care Unit: A Survey of the United States

Introduction: Human milk (HM) is the ideal enteral feeding for nearly all infants and offers unique benefits to the very low birthweight (VLBW) infant population. It is a challenge to meet the high nutrient requirements of VLBW infants due to the known variability of HM composition. Human milk analysis (HMA) assesses the composition of HM and allows for individualized fortification. Due to recent U.S. Food and Drug Administration (FDA) approval, it has relatively recent availability for clinical use in the US.Aim: To identify current practices of HMA and individualized fortification in neonatal intensive care units (NICUs) across the United States (US) and to inform future translational research efforts implementing this nutrition management method.Methods: An institutional review board (IRB) approved survey was created and collected data on the following subjects such as NICU demographics, feeding practices, HM usage, HM fortification practices, and HMA practices. It was distributed from 10/30–12/21/2020 via online pediatric nutrition groups and listservs selected to reach the intended audience of NICU dietitians and other clinical staff. Each response was assessed prior to inclusion, and descriptive analysis was performed.Results: About 225 survey responses were recorded during the survey period with 119 entries included in the analysis. This represented 36 states and Washington D.C., primarily from level III and IV NICUs. HMA was reported in 11.8% of responding NICUs. The most commonly owned technology for HMA is the Creamatocrit Plus TM (EKF Diagnostics), followed by the HM Analyzer by Miris (Uppsala, Sweden). In NICUs practicing HMA, 84.6% are doing so clinically.Discussion: Feeding guidelines and fortification of HM remain standard of care, and interest in HMA was common in this survey. Despite the interest, very few NICUs are performing HMA and individualized fortification. Barriers identified include determining who should receive individualized fortification and how often, collecting a representative sample, and the cost and personnel required.Conclusions: Human milk analysis and individualized fortification are emerging practices within NICUs in the US. Few are using it in the clinical setting with large variation in execution among respondents and many logistical concerns regarding implementation. Future research may be beneficial to evaluate how practices change as HMA and individualized fortification gain popularity and become more commonly used in the clinical setting.

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Limitation of Private Attending Pediatricians' Neonatal Intensive Care Privileges in Level III Institutions Throughout the United States

PEDIATRICS ◽

10.1542/peds.94.2.190 ◽

1994 ◽

Vol 94 (2) ◽

pp. 190-193

Author(s):

Rita G. Harper ◽

Concepcion G. Sia ◽

Regina Spinazzola ◽

Raul A. Wapnir ◽

Shahnaz Orner ◽

...

Keyword(s):

United States ◽

Intensive Care ◽

Health Care Providers ◽

Curriculum Design ◽

Neonatal Intensive Care ◽

District Of Columbia ◽

The United States ◽

Geographic Region ◽

Neonatal Intensive Care Units ◽

Care Providers

Objective. To determine the privileges of Private Attending Pediatricians (PAP) in caring for newborns requiring intensive (ITC), intermediate (IMC), or continuing (CC) care in Level III neonatal intensive care units (NICUs) throughout the United States. Design. A two-page mail questionnaire was sent to 429 Level III NICUs to obtain the statement best describing the PAPs' privileges, the number of PAP, and some of the PAPs' functions. Level III NICUs were classified by geographic region as Eastern, Central, or Western United States. Results. Responses were received from 301 NICUs (70%) representing 48 states, the District of Columbia, and >9000 PAP. Twenty-two institutions had no PAP. In the remaining 279 institutions, 96% (267/279) had restricted the PAPs' privileges partially or completely. In 32% (88/279), the PAP were not allowed to render any type of NICU care. In 18% (51/279) of the institutions, the PAP were allowed to render CC only. In 27% (76/279) of the institutions, the PAP were allowed to render IMC and CC only. Limitation of PAPs' privileges were reported in all geographic areas in the U.S., were more pronounced in the Eastern than the Central or Western sections of the country, and were noted in institutions with small (≤10) as well as large (≥60) numbers of PAP. Limitation of PAPs' privileges was determined by the PAP him/herself in many institutions. Proficiency in resuscitation was considered to be a needed skill. Communication with parents of an infant under the care of a neonatologist was encouraged. Conclusions. The PAPs' privileges were limited partially or completely in most Level III NICUs. Knowledge of this restricted role impacts significantly on curriculum design for pediatric house officers, number and type of health care providers required for Level III NICUs and future house officer's career choices.

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Variation in Performance of Neonatal Intensive Care Units in the United States

JAMA Pediatrics ◽

10.1001/jamapediatrics.2016.4396 ◽

2017 ◽

Vol 171 (3) ◽

pp. e164396 ◽

Cited By ~ 120

Author(s):

Jeffrey D. Horbar ◽

Erika M. Edwards ◽

Lucy T. Greenberg ◽

Kate A. Morrow ◽

Roger F. Soll ◽

...

Keyword(s):

United States ◽

Intensive Care ◽

Intensive Care Units ◽

Neonatal Intensive Care ◽

The United States ◽

Neonatal Intensive Care Units

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The prevalence of and attitudes toward neonatal functional echocardiography use and training in the United States: A survey of neonatal intensive care unit medical directors

Journal of Neonatal-Perinatal Medicine ◽

10.3233/npm-1474013 ◽

2014 ◽

Vol 7 (2) ◽

pp. 125-130 ◽

Cited By ~ 5

Author(s):

S. Schachinger ◽

R.B. Stansfield ◽

G. Ensing ◽

R. Schumacher

Keyword(s):

United States ◽

Intensive Care Unit ◽

Intensive Care ◽

Neonatal Intensive Care Unit ◽

Neonatal Intensive Care ◽

The United States ◽

Medical Directors ◽

And Training

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Shiva’s Babies

Religion and Ethics in the Neonatal Intensive Care Unit ◽

10.1093/med/9780190636852.003.0008 ◽

2019 ◽

pp. 124-141

Author(s):

Swasti Bhattacharyya

Keyword(s):

United States ◽

Intensive Care Unit ◽

Intensive Care ◽

High Risk ◽

Neonatal Intensive Care ◽

Newborn Infants ◽

Nationwide Survey ◽

The United States ◽

Cultural Humility ◽

Religious Perspectives

Discussing religious views from within any tradition is challenging because they are not monolithic. However, it is worth exploring religious perspectives because they are often the foundation, whether conscious or not, of the reasoning underlying people’s decisions. Following a brief discussion on the importance of cultural humility and understanding the worldview of patients, the author focuses on Hindu perspectives regarding the care of infants in the neonatal intensive care unit. Along with applying six elements of Hindu thought (underlying unity of all life, multivalent nature of Hindu traditions, dharma, emphasis on societal good, karma, and ahimsa), the author incorporates perspectives of Hindu adults, living in the United States, who responded to a nationwide survey regarding the care of high-risk newborn infants in the hospital.

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Food safety and quality of distribution of raw human milk from a University Hospital

Revista de Nutrição ◽

10.1590/1678-98652018000600004 ◽

2018 ◽

Vol 31 (6) ◽

pp. 547-556

Author(s):

Marina Aparecida da Silva MORENO ◽

Lucíola Sant’Anna de CASTRO ◽

Ana Cristina Freitas de Vilhena ABRÃO ◽

Kelly Pereira COCA

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Neonatal Intensive Care Unit ◽

Human Milk ◽

Gestational Age ◽

Neonatal Intensive Care ◽

Energy Content ◽

University Hospital ◽

Milk Analysis

ABSTRACT Objective To evaluate the quality of raw human milk distributed in the Neonatal Intensive Care Unit of a University Hospital of the city of São Paulo. Methods A cross-sectional study with raw human milk samples from mothers who attended the Human Milk Collection Station of a University Hospital, analyzed between May 2016 and January 2017, excluding mothers of twins. The quality of the raw human milk was assessed by verifying the presence of dirt, the coloration of the milk, the titratable acidity using the Dornic method, and through its energy content. Kruskal-Wallis and Mann-Whitney tests were used for the analysis of the energy profile and the degree of Dornic acidity, according to the stage of the raw human milk and the gestational age of the child. Results The study was composed of 40 samples of 40 different women, with a mean age of 27 years, an average of 11.8 years of education, most of them were multiparous and with a partner. Regarding milk analysis, 55.0% was classified as colostrum, 27.5% as mature milk and 17.5% as transitional milk. All samples presented negative results for dirt and normal coloration. The mean milk acidity was 3.24º Dornic and most of the samples were classified as hypercaloric energy content. There was no association between the lactation stage and gestational age with the acidity value and energy content. Conclusion The quality of raw human milk distributed in the Neonatal Intensive Care Unit of the institution evaluated was considered adequate and the samples analyzed had a high energy content and excellent Dornic acidity.

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Acculturative Stress and Bicultural Stress

10.1093/oxfordhb/9780190215217.013.8 ◽

2017 ◽

Author(s):

Andrea Romero ◽

Brandy Piña-Watson

Keyword(s):

Mental Health ◽

United States ◽

Acculturative Stress ◽

Immigration Policy ◽

The United States ◽

Cultural Conflict ◽

Future Research ◽

Policy Context ◽

The Us ◽

Bicultural Stress

This chapter discusses the concepts of acculturative and bicultural stress, the theory and method behind the measurement, and the implications of the US immigration policy context for stress. The central sources of acculturative and bicultural stress are reviewed, including intergroup discrimination, language stress, intragroup marginalization, and family cultural conflict. In particular, literature is reviewed that examines the association between mental health and acculturative or bicultural stress. Extant research does demonstrate that degree of stress varies for individuals and that acculturative/bicultural stress is experienced not only by immigrants but also by minorities in the United States. Therefore, the present chapter reviews literature that connects the acculturative/bicultural stress process across generations. The immigration context is considered for future research in the area of acculturation and stress.

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Polarization and the Judiciary

Annual Review of Political Science ◽

10.1146/annurev-polisci-051317-125141 ◽

2019 ◽

Vol 22 (1) ◽

pp. 261-276 ◽

Cited By ~ 1

Author(s):

Richard L. Hasen

Keyword(s):

United States ◽

Supreme Court ◽

Separation Of Powers ◽

The United States ◽

Future Research ◽

Political Actors ◽

The Us ◽

Us Supreme Court ◽

Selection Mechanisms ◽

Federal Judges

The increased polarization in the United States among the political branches and citizenry affects the selection, work, perception, and relative power of state and federal judges, including justices of the US Supreme Court. Polarization in the United States over the last few decades matters to the American judicial system in at least four ways. First, polarization affects judicial selection, whether the selection method is (sometimes partisan-based) elections or appointment by political actors. In times of greater polarization, governors and presidents who nominate judges, legislators who confirm judges, and voters who vote on judicial candidates are more apt to support or oppose judges on the basis of partisan affiliation or cues. Second, driven in part by selection mechanisms, polarization may be reflected in the decisions that judges make, especially on issues that divide people politically, such as abortion, guns, or affirmative action. The Supreme Court, for example, often divides along party and ideological lines in the most prominent and highly contested cases. Those ideological lines now overlap with party as we enter a period in which all the Court liberals have been appointed by Democratic presidents and all the Court conservatives have been appointed by Republican presidents. Third, increasingly polarized judicial decisions appear to be causing the public to view judges and judicial decision making (at least on the US Supreme Court) through a more partisan lens. Fourth, polarization may affect the separation of powers, by empowering courts against polarized legislative bodies sometimes paralyzed by gridlock. The review concludes by considering how increased polarization may interact with the judiciary and judicial branch going forward and by suggesting areas for future research.

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Measuring Job Creation, Growth, and Survival among the Universe of Start-ups in the United States Using a Combined Start-up Panel Data Set

ILR Review ◽

10.1177/0019793919862764 ◽

2019 ◽

Vol 72 (5) ◽

pp. 1262-1277 ◽

Cited By ~ 1

Author(s):

Robert W. Fairlie ◽

Javier Miranda ◽

Nikolas Zolas

Keyword(s):

United States ◽

Panel Data ◽

The United States ◽

Future Research ◽

Data Set ◽

Growth And Survival ◽

Start Up ◽

The Us ◽

Start Ups ◽

The Universe

The field of entrepreneurship is growing rapidly and expanding into new areas. This article presents a new compilation of administrative panel data on the universe of business start-ups in the United States, which will be useful for future research in entrepreneurship. To create the US start-up panel data set, the authors link the universe of non-employer firms to the universe of employer firms in the Longitudinal Business Database (LBD). Start-up cohorts of more than five million new businesses per year, which create roughly three million jobs, can be tracked over time. To illustrate the potential of the new start-up panel data set for future research, the authors provide descriptive statistics for a few examples of research topics using a representative start-up cohort.

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What Is the Legal `Standard of Medical Care' When There Is No Standard Medical Care? A Survey of the Use of Home Apnea Monitoring by Neonatology Fellowship Training Programs in the United States

PEDIATRICS ◽

10.1542/peds.89.6.1083 ◽

1992 ◽

Vol 89 (6) ◽

pp. 1083-1088

Author(s):

William Meadow ◽

David Mendez ◽

John Lantos ◽

Robert Hipps ◽

Michele Ostrowski

Keyword(s):

United States ◽

Intensive Care ◽

Medical Care ◽

Neonatal Intensive Care ◽

Training Programs ◽

The United States ◽

Supplemental Oxygen ◽

Expert Opinions ◽

Legal Standard ◽

Apnea Monitoring

In treating a patient, a doctor is obliged to use the skill and care that is ordinarily used by reasonably well-qualified doctors in similar cases. In addition, the only way in which a juror may decide whether the defendant used the skill and care which the law required of him or her is from evidence presented by doctors called as expert witnesses (cf Illinois Pattern Jury Instructions). However, what should be done if expert opinions differ concerning the care that is "ordinarily used"? Home apnea monitoring (HAM) is prescribed at times for graduates of neonatal intensive care units despite the fact that indications for its use are not well established and efficacy is completely unknown. The authors attempted to determine standards for HAM as it is currently practiced in neonatology training programs. The primary teaching hospital for each of the 99 neonatology training programs in the United States was identified. Both the medical director (MD) and a neonatal intensive care unit nurse manager (RN) were asked about the use of HAM in their own nursery for four clinical vignettes. Each vignette depicted a 1000-g birth weight infant, currently 7 weeks old and ready for discharge. In three vignettes, the infant had demonstrated no apnea, mild apnea (resolved by 2 weeks of age), or moderate apnea (requiring theophylline therapy at discharge) during the hospital course. In the fourth vignette, the infant had no apnea but was to be discharged home with supplemental oxygen. For 67 of 99 training programs, paired responses of RN managers and MD directors were obtained. For infants with no apnea or mild apnea, approximately 85% of RN/MD pairs agreed that HAM would not be used at their institution, 2% would use HAM, and 12% responded that they might use HAM depending on individual circumstances. In contrast, for the premature infant with moderate apnea, there was much less agreement. Sixteen percent of RN/MD pairs responded that HAM would not be used, 39% would use HAM, and 19% might. Remarkably, for this vignette 25% of the RN/MD responses disagreed on the practice of HAM at their own center. Similarly, for the infant with home oxygen, 15% of RN/MD responses agreed that HAM would not be used, 49% answered that HAM would be used, 10% were uncertain, and 25% disagreed on the use of HAM at their own center. It is concluded that (1) for premature infants with no or mild apnea, HAM is currently prescribed by a minority of fellowship-associated neonatology programs, and (2) no obvious consensus exists for HAM in the context of moderate apnea or home oxygen therapy. For many infants, there is no "standard care" for HAM in the neonatology community at this time. "Expert" opinions of the legal "standard of care" for HAM should reflect this fact.

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