Graham’s Foundation is proud to introduce Dr. Samudragupta Bora as a regular contributor to the Graham’s Foundation blog. We look forward to sharing his professional insight with the Graham’s Foundation community.
Dr. Samudragupta Bora
Nothing is more important in the treatment of a preemie in the neonatal intensive care unit than open and frank communications between parents, physicians, nurses, and others in the care team. As a young pediatrics researcher, my mentor would often say, “children do not grow up in test-tubes, but in families.” This is vital to remember when talking about which medical procedures are needed or will improve a preterm born infant’s chances of better developmental outcomes. More tests and treatments do not necessarily translate into better quality care or improve outcomes and quality of life of a fragile preterm infant. What will help is if parents and the clinical care team are communicating and working together to determine what is in the best interest of their baby.
Although the idea of excess and sometimes unnecessary medical procedures is not entirely unheard of, a recent report published in Pediatrics, the official journal of the American Academy of Pediatrics, compiles a list of five tests and treatments in newborn medicine that should be scaled back and prohibited for “routine” use. The word “routine” is the most critical word when interpreting the report’s findings.
In order to increase quality of medical care and reduce wasteful costs, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign in 2011. This initiative encouraged professional medical societies to identify five “overused” tests and treatments whose effectiveness is not supported by evidence, duplicate other procedures, are potentially harmful, or unnecessary.
As part of the Choosing Wisely campaign, the American Academy of Pediatrics Section on Perinatal Pediatrics conducted a survey of 1,047 newborn care stakeholders comprising 766 neonatologists, 192 nurses, 53 nurse practitioners, 12 respiratory therapists, 15 family members, a social worker, and 8 other respondents. Participants were asked to consider all tests and treatments performed on both low- and high-risk newborns and identify 1−10 practices that have evidence of not being effective, lacking enough evidence in support of being effective, or unnecessary use of staff or resources. This generated 2,870 suggestions (1,648 tests and 1,222 treatments) that were meticulously reviewed by an expert panel of 51 newborn care specialists during a three-stage process including a systematic literature review for the top 12 candidates.
Based on this study, the final Choosing Wisely list of five tests and treatments in newborn medicine that were deemed as of low value, wasteful, or unnecessary if used routinely are as follows in no particular order.
- Antireflux medications for treatment of symptomatic gastroesophageal reflux disease (acid reflux) or apnea (frequent pauses in breathing) and desaturation (decrease of oxygen percentage in blood) in preterm infants.
- Antibiotics beyond 48 hours without evidence of a bacterial infection.
- Pneumograms (breathing test) before discharge for assessing ongoing or prolonged apnea in preterm infants.
- Daily chest X-rays for infants with a breathing tube without any clinical indication for the need of this test.
- Brain magnetic resonance imaging (MRI) scans at term-equivalent or discharge for screening later risk of neurodevelopment impairments in preterm infants.
The authors noted that two of these five items (routine use of antireflux medications and antibiotics beyond 48 hours) could be harmful to infants, while the remaining three items (routine use of pneumograms, daily chest x-rays, and screening brain MRIs) currently do not have enough evidence supporting its benefit and effectiveness in improving outcomes.
There is always the risk that parents as well as newborn care professionals may interpret this Choosing Wisely list of clinical practices as low value tests and treatments in general. However, we need to be cautious, as the take-home message is somewhat different. As the authors’ have emphasized, these practices meet the criteria for overused and low utility procedures only if used on a “routine” basis. In fact, they may have high or sometimes even outstanding value in delivering quality care and improve outcomes of the small and sick preterm infant if used within reasonable clinical contexts. By no means, this list is intended to restrict these tests and treatments in the neonatal intensive care unit, but can serve as a resource and empower parents and families to question their babies’ care team about the need of certain procedures and if there is any evidence-based short- or long-term benefit.
For instance, findings from this study recommend against the routine use of brain MRI at term-equivalent or discharge in preterm born infants to identify potential risk of long-term neurodevelopmental impairments. The authors have reported that as of now there is a lack of sufficient evidence supporting benefits of term-equivalent MRI to “improve” outcomes. I believe the core of the problem is not in the inadequacy of MRI results, but the way they are interpreted and communicated to families. While there may not yet be any “gold standard” randomized controlled trial (study design where patients are randomly allocated to one of several interventions), there are a large number of methodologically robust observational cohort studies and a meta-analysis (where results from different studies are systematically pooled together) consistently showing term-equivalent MRI results to be a strong predictor of later neurodevelopmental outcomes.
Specifically, abnormalities of white matter (brain’s communicating cables) as identified on term-equivalent MRI are strongly associated with poor motor functioning and relatively limited but still superior to other neonatal factors for predicting cognitive and behavioral deficits. It seems implausible that any single neonatal clinical factor will have excellent risk prediction accuracy on its own for neurodevelopmental outcomes, particularly cognition, language, and behavioral adjustment. There is abundant evidence highlighting the critical role of family environment and parenting in determining the risk and resilience for child’s developmental outcomes following adverse early experiences. Term-equivalent MRI results need to be carefully considered in conjunction with other neonatal and psychosocial factors for better identification of preterm infants at high-risk of long-term neurodevelopmental impairments and optimal counseling to families. Though these MRI results may not directly improve outcomes, they can potentially inform us concerning developmental surveillance and targeted early intervention that can hugely impact outcomes. Can we justify the high costs associated with MRI in relation to it value? That’s a pretty contentious issue!
Nonetheless, instead of viewing this Choosing Wisely list for newborn medicine as a ”Not-To-Do” list, this should act as a valuable resource for parents and families to facilitate frank conversations with the clinical care team of their preemie in the neonatal intensive care unit around issues of safety and overuse of medical procedures.
Disclaimer: This blog post reflects author’s personal views and opinions and has no relation and do not represent the views and opinions of any academic institutions, medical centers, and professional organizations with which the author is currently affiliated. The author has no financial relationship or potential conflict of interest relevant to this blog post to disclose.