COMMENTARY
Giving Birth to Evidence-Based Care for Newborns
Benjamin Franklin is widely credited with saying, “In this world nothing can be said to be certain, except death and taxes,” and it follows that birth is assumed to have occurred before these 2 events. In fact, as the authors of the Better Outcomes Through Research for Newborns (BORN) Delphi study1 note in this issue, birth is by far the most common reason for pediatric care in a hospital setting in the United States. The Centers for Disease Control and Prevention recently reported that the rate of out-of-hospital births in the United States has risen to 1.36% in 2012, 2 but most infants born in the United States are cared for in hospitals. As providers of care to newborns we must ask ourselves, “On what basis are we determining the best care for these infants?” For some practices, such as administering hepatitis B vaccine and vitamin K at the time of delivery, the evidence is strong. In other cases, there are gaps in our understanding of how to implement the best evidence. For instance, counseling on safe sleep positioning and the avoidance of secondhand smoke exposure are potentially high-impact interventions,3,4 but the content and delivery of this counseling (when, by whom, and how) are not always well studied or universally implemented when evidence does exist to guide practice. In still other cases, including neonatal abstinence syndrome and care of the late preterm infant, best evidence is almost completely lacking. The BORN network study published in this issue proposes an agenda for what we need to add to the evidence regarding newborn care. BORN membership consists of almost 350 practitioners representing 60 discrete nurseries in more than 22 states. The authors of the current study used a combination of surveys and interviews of network members to determine a research agenda for this new network. They identified 3 key issues as the highest priorities for future research: breastfeeding promotion and support, evaluation of infants at risk for infection, and management of neonatal abstinence syndrome. Numerous other clinical issues such as hyperbilirubinemia, screening for congenital heart disease, and care of late preterm infants were also deemed significant by the network. In total, 20 research themes were enumerated, and it could be argued that anyone who provides care for newborns can find a potential area of scholarly pursuit on this list. Leveraging the power of such a large and coordinated group of scholars offers substantial opportunity to gather significant clinical data and perform studies of sufficient size to begin to answer these questions.
AUTHOR Carl J. Seashore, MD, FAAP Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina KEY WORDS newborns, evidence-based, newborn care, neonatology ABBREVIATION BORN: Better Outcomes Through Research for Newborns www.hospitalpediatrics.org doi:10.1542/hpeds.2014-0060 Address correspondence to Carl J. Seashore, MD, FAAP, Associate Professor of Pediatrics, UNC School of Medicine, Division of General Pediatrics and Adolescent Medicine, 231 MacNider Hall, CB#7225, Chapel Hill, NC 27599-7225. E-mail: [email protected] HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
How many blood sugar tests does an infant of a diabetic mother need to ensure he is euglycemic? How about a late preterm infant, or one who is growth restricted? What is the best way to ascertain an infant’s risk for neonatal withdrawal after
Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
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HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
exposure to opiates in the womb, and for how long does she need to be observed before discharge? How do you balance family-centeredness, breastfeeding support, and safe sleep education in the hospital while eliminating the risk of falls or accidental suffocation from cosleeping? These and countless other questions deserve rigorous scientific study, but very few nurseries are equipped to perform such studies on their own. Small studies have begun to explore these questions, but collaborative study through a well-organized research network is the next step to advance our knowledge and improve our practice. Finally, the Centers for Disease Control and Prevention finding of an increase in out-of-hospital births should serve
204 |
as a reminder to first do no harm when delivering care to healthy newborns. More care does not always equal better care, and attention to familycentered practices and a focus on the unique wellness that healthy newborn hospitalizations represent are of the utmost importance. Regardless of what complications might arise, most parents rightfully approach the birth of their child as a time of health, not sickness. Most healthy babies and mothers need simple postpartum care in a supportive environment where they are free to bond and learn the new routines of parenting. Refraining from overmedicalization of the care of this population is as important as determining the best possible ways to care for babies who need more medical expertise around the time of birth.
Perhaps someone will use this new network to study why the rate of outof-hospital births is rising.
REFERENCES 1. Prioritizing a research agenda: A Delphi study of the Better Outcomes Through Research for Newborns (BORN) Network. Hosp Pediatr. 2. MacDorman MF, Mathews TJ, Declercq E. Trends in Out-of-Hospital Births in the United States, 1990–2012. NCHS data brief no. 144. Hyattsville, MD: National Center for Health Statistics; 2014. 3. Monson SA, Henry E, Lambert DK, Schmutz N, Christensen RD. In-hospital falls of newborn infants: data from a multihospital health care system. Pediatrics. 2008;122(2). Available at: www.pediatrics.org/cgi/content/ full/122/2/e277. 4. Winickoff JP, Healey EA, Regan S, et al. Using the postpartum hospital stay to address mothers’ and fathers’ smoking: the NEWS study. Pediatrics. 2010;125(3):518–525.
VOLUME 4 • ISSUE 4 www.hospitalpediatrics.org Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
Giving Birth to Evidence-Based Care for Newborns Carl J. Seashore Hospital Pediatrics 2014;4;203 DOI: 10.1542/hpeds.2014-0060
Updated Information & Services
including high resolution figures, can be found at: http://hosppeds.aappublications.org/content/4/4/203
References
This article cites 1 articles, 1 of which you can access for free at: http://hosppeds.aappublications.org/content/4/4/203#BIBL
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Evidence-Based Medicine http://hosppeds.aappublications.org/cgi/collection/evidence-based_m edicine_sub Fetus/Newborn Infant http://hosppeds.aappublications.org/cgi/collection/fetus:newborn_inf ant_sub
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://hosppeds.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://hosppeds.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
Giving Birth to Evidence-Based Care for Newborns Carl J. Seashore Hospital Pediatrics 2014;4;203 DOI: 10.1542/hpeds.2014-0060
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/4/4/203
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
Giving Birth to Evidence-Based Care for Newborns
Benjamin Franklin is widely credited with saying, “In this world nothing can be said to be certain, except death and taxes,” and it follows that birth is assumed to have occurred before these 2 events. In fact, as the authors of the Better Outcomes Through Research for Newborns (BORN) Delphi study1 note in this issue, birth is by far the most common reason for pediatric care in a hospital setting in the United States. The Centers for Disease Control and Prevention recently reported that the rate of out-of-hospital births in the United States has risen to 1.36% in 2012, 2 but most infants born in the United States are cared for in hospitals. As providers of care to newborns we must ask ourselves, “On what basis are we determining the best care for these infants?” For some practices, such as administering hepatitis B vaccine and vitamin K at the time of delivery, the evidence is strong. In other cases, there are gaps in our understanding of how to implement the best evidence. For instance, counseling on safe sleep positioning and the avoidance of secondhand smoke exposure are potentially high-impact interventions,3,4 but the content and delivery of this counseling (when, by whom, and how) are not always well studied or universally implemented when evidence does exist to guide practice. In still other cases, including neonatal abstinence syndrome and care of the late preterm infant, best evidence is almost completely lacking. The BORN network study published in this issue proposes an agenda for what we need to add to the evidence regarding newborn care. BORN membership consists of almost 350 practitioners representing 60 discrete nurseries in more than 22 states. The authors of the current study used a combination of surveys and interviews of network members to determine a research agenda for this new network. They identified 3 key issues as the highest priorities for future research: breastfeeding promotion and support, evaluation of infants at risk for infection, and management of neonatal abstinence syndrome. Numerous other clinical issues such as hyperbilirubinemia, screening for congenital heart disease, and care of late preterm infants were also deemed significant by the network. In total, 20 research themes were enumerated, and it could be argued that anyone who provides care for newborns can find a potential area of scholarly pursuit on this list. Leveraging the power of such a large and coordinated group of scholars offers substantial opportunity to gather significant clinical data and perform studies of sufficient size to begin to answer these questions.
AUTHOR Carl J. Seashore, MD, FAAP Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina KEY WORDS newborns, evidence-based, newborn care, neonatology ABBREVIATION BORN: Better Outcomes Through Research for Newborns www.hospitalpediatrics.org doi:10.1542/hpeds.2014-0060 Address correspondence to Carl J. Seashore, MD, FAAP, Associate Professor of Pediatrics, UNC School of Medicine, Division of General Pediatrics and Adolescent Medicine, 231 MacNider Hall, CB#7225, Chapel Hill, NC 27599-7225. E-mail: [email protected] HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
How many blood sugar tests does an infant of a diabetic mother need to ensure he is euglycemic? How about a late preterm infant, or one who is growth restricted? What is the best way to ascertain an infant’s risk for neonatal withdrawal after
Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
| 203
HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
exposure to opiates in the womb, and for how long does she need to be observed before discharge? How do you balance family-centeredness, breastfeeding support, and safe sleep education in the hospital while eliminating the risk of falls or accidental suffocation from cosleeping? These and countless other questions deserve rigorous scientific study, but very few nurseries are equipped to perform such studies on their own. Small studies have begun to explore these questions, but collaborative study through a well-organized research network is the next step to advance our knowledge and improve our practice. Finally, the Centers for Disease Control and Prevention finding of an increase in out-of-hospital births should serve
204 |
as a reminder to first do no harm when delivering care to healthy newborns. More care does not always equal better care, and attention to familycentered practices and a focus on the unique wellness that healthy newborn hospitalizations represent are of the utmost importance. Regardless of what complications might arise, most parents rightfully approach the birth of their child as a time of health, not sickness. Most healthy babies and mothers need simple postpartum care in a supportive environment where they are free to bond and learn the new routines of parenting. Refraining from overmedicalization of the care of this population is as important as determining the best possible ways to care for babies who need more medical expertise around the time of birth.
Perhaps someone will use this new network to study why the rate of outof-hospital births is rising.
REFERENCES 1. Prioritizing a research agenda: A Delphi study of the Better Outcomes Through Research for Newborns (BORN) Network. Hosp Pediatr. 2. MacDorman MF, Mathews TJ, Declercq E. Trends in Out-of-Hospital Births in the United States, 1990–2012. NCHS data brief no. 144. Hyattsville, MD: National Center for Health Statistics; 2014. 3. Monson SA, Henry E, Lambert DK, Schmutz N, Christensen RD. In-hospital falls of newborn infants: data from a multihospital health care system. Pediatrics. 2008;122(2). Available at: www.pediatrics.org/cgi/content/ full/122/2/e277. 4. Winickoff JP, Healey EA, Regan S, et al. Using the postpartum hospital stay to address mothers’ and fathers’ smoking: the NEWS study. Pediatrics. 2010;125(3):518–525.
VOLUME 4 • ISSUE 4 www.hospitalpediatrics.org Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
Giving Birth to Evidence-Based Care for Newborns Carl J. Seashore Hospital Pediatrics 2014;4;203 DOI: 10.1542/hpeds.2014-0060
Updated Information & Services
including high resolution figures, can be found at: http://hosppeds.aappublications.org/content/4/4/203
References
This article cites 1 articles, 1 of which you can access for free at: http://hosppeds.aappublications.org/content/4/4/203#BIBL
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Evidence-Based Medicine http://hosppeds.aappublications.org/cgi/collection/evidence-based_m edicine_sub Fetus/Newborn Infant http://hosppeds.aappublications.org/cgi/collection/fetus:newborn_inf ant_sub
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://hosppeds.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://hosppeds.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
Giving Birth to Evidence-Based Care for Newborns Carl J. Seashore Hospital Pediatrics 2014;4;203 DOI: 10.1542/hpeds.2014-0060
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/4/4/203
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
Downloaded from http://hosppeds.aappublications.org/ at Yale Univ-Cushing/Whitney Med Lib on July 2, 2015
