Background Standardized practices for the management of neonatal abstinence syndrome (NAS) are associated with shorter lengths of stay, but optimal protocols are not established. Aim Identify practice variations for newborns with in-utero chronic opioid exposure among hospitals in the Better Outcomes through Research for Newborns (BORN) network. Methods Nursery site leaders completed a survey about hospitals’ policies and practices regarding care for infants with chronic opioid exposure (≥3 weeks). Results The 76/95 (80%) respondent hospitals were in 34 states, varied in size (<500–>8000 births and <10–>200 opioid-exposed infants/year), with most affiliated with academic centers (89%). Most (85%) had protocols for newborn drug exposure screening; 95% used risk-based approaches. Specimens included urine (81%), meconium (73%) and umbilical cords (10%). Of sites (88%) with NAS management protocols, 77% addressed medical management, 72% nursing care, 72% pharmacologic treatment and 58% supportive care. Morphine was the most common first-line pharmacotherapy followed by methadone. Observation periods for opioid-exposed newborns varied; 57% observed short-acting opioid exposure for 2–3 days while 30% observed for ≥5 days. For long-acting opioids, 71% observed for 4–5 days, 19% for 2–3 days and 8% for ≥7 days. Observation for NAS occurred mostly in Level 1 nurseries (86%); however most (84%) transferred to NICUs when pharmacologic treatment was indicated. Conclusion Most BORN hospitals had protocols for the care of opioid-exposed infants, but policies varied widely and characterize areas of needed research. Identification of variation is the first step toward establishing best practice standards to improve care for this rapidly growing population.

Background: Human milk reduces morbidities in extremely low birth weight (ELBW) infants. However, clinical instability often precludes ELBW infants from receiving early enteral feeds. This study compared clinical outcomes before and after implementing an oropharyngeal colostrum (COL) protocol in a cohort of inborn (born at our facility) ELBW infants. Study Design: This is a retrospective cohort study of inborn ELBW infants admitted to the Duke Intensive Care Nursery from January 2007 to September 2011. In November 2010, we initiated a COL protocol for infants not enterally fed whose mothers were providing breastmilk. Infants received 0.1 mL of fresh COL to each cheek every 4 hours for 5 days beginning in the first 48 postnatal hours. We assessed demographics, diagnoses, feeding history, and mortality and for the presence of medical necrotizing enterocolitis (NEC), surgical NEC, and spontaneous perforation. Between-group comparisons were made using Fisher's exact test or Wilcoxon rank sum testing where appropriate. Results: Of the 369 infants included, 280 (76%) were born prior to the COL protocol (Pre-COL Cohort [PCC]), and 89 (24%) were born after (COL Cohort [CC]). Mortality and the percentage of infants with surgical NEC and spontaneous perforations were statistically similar between the groups. The CC weighed an average (interquartile range) of 1,666 (1,399, 1,940) g at 36 weeks versus 1,380 (1,190, 1,650) g for the PCC ( p < 0.001). In a multivariable analysis with birth weight as a covariable, weight at 36 weeks was significantly greater (37 g; p < 0.01). Conclusions: Initiating oropharyngeal COL in ELBW infants in the first 2 postnatal days appears feasible and safe and may be nutritionally beneficial. Further research is needed to determine if early COL administration reduces neonatal morbidity and mortality.

Purpose Entrustment has become a popular assessment framework in recent years. Most research in this area has focused on how frontline assessors determine when a learner can be entrusted. However, less work has focused on how these entrustment decisions are made. The authors sought to understand the key factors that pediatric residency program clinical competency committee (CCC) members consider when recommending residents to a supervisory role. Method CCC members at 14 pediatric residency programs recommended residents to one of five progressive supervisory roles (from not serving as a supervisory resident to serving as a supervisory resident in all settings). They then responded to a free-text prompt, describing the key factors that led them to that decision. The authors analyzed these responses, by role recommendation, using a thematic analysis. Results Of the 155 CCC members at the participating programs, 84 completed 769 supervisory role recommendations during the 2015–2016 academic year. Four themes emerged from the thematic analysis: (1) Determining supervisory ability follows from demonstrated trustworthiness; (2) demonstrated performance matters, but so does experience; (3) ability to lead a team is considered; and (4) contextual considerations external to the resident are at play. Conclusions CCC members considered resident and environmental factors in their summative entrustment decision making. The interplay between these factors should be considered as CCC processes are optimized and studied further.