OBJECTIVES:To assess respiratory care guidelines and explore variations in management of very low birth weight (VLBW) infants within a collaborative care framework. Additionally, to gather clinical leaders' perspectives on guidelines and preferences for ventilation modalities. STUDY DESIGN:Leaders from each NICU participated in a practice survey regarding the prevalence of unit clinical guidelines, and management, at many stages of care. RESULTS:Units have an average of 4.3 (±2.1) guidelines, of 9 topics queried. Guideline prevalence was not associated with practice or outcomes. An FiO2 requirement of 0.3-0.4 and a CPAP of 6-7 cmH2O, are the most common thresholds for surfactant administration, which is most often done after intubation, and followed by weaning from ventilatory support. Volume targeted ventilation is commonly used. Extubation criteria vary widely. CONCLUSIONS:Results identify trends and areas of variation and suggest that the presence of guidelines alone is not predictive of outcome.

Objective This study aimed to describe maternal characteristics and clinical outcomes of infants born to mothers with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests during pregnancy at an urban, safety-net hospital in Boston. Study Design We abstracted electronic chart data from 75 pregnant women with positive SARS-CoV-2 tests at any stage of gestation until 72 hours after birth who delivered consecutively between March 31 and August 6, 2020 at our center. We collected clinical data on maternal and infant characteristics, including testing, signs, and symptoms of coronavirus disease 2019 (COVID-19), delivery outcomes, newborn care practices (skin-to-skin care, location of care, and breastfeeding) and 30-day postdischarge infant emergency room visits and readmissions. We described categorical characteristics as percentages for this case series. Results Among 75 pregnant women, 47 (63%) were Hispanic, 10 (13%) had hypertension, 23 (30%) had prepregnancy obesity, and 57 (76%) had symptomatic SARS-CoV-2 infection. Regarding birth outcomes, 32 (41%) had cesarean delivery and 14 (19%) had preterm birth. Among 75 infants, 5 (7%) had positive SARS-CoV-2 polymerase chain reaction tests in the first week of life, all of whom were born to Hispanic mothers with symptomatic SARS-CoV-2 infection and had clinical courses consistent with gestational age. Six (8%) infants visited the emergency department within 30 days of discharge; one was admitted with a non-COVID-19 diagnosis. Conclusion At our urban, safety-net hospital among pregnant women with positive SARS-CoV-2 tests, 41% had a cesarean delivery and 19% had a preterm birth. Seven percent of infants had one or more positive SARS-CoV-2 tests and all infants had clinical courses expected for gestational age. Key Points

Introduction: Mother's milk is recommended for preterm infants due to numerous health benefits. At our inner-city hospital, >80% of mothers of infants younger than 34 weeks' gestation initiated milk production, but fewer continued until discharge. Among infants younger than 34 weeks' gestation, we aimed to (1) increase any mother's milk use in the 24 hours before discharge/transfer to >75%; (2) increase exclusive mother's milk use in the 24 hours before discharge/transfer to >50%; and (3) reduce racial/ethnic disparities in mother's milk use. Methods: We conducted a quality improvement project from January 2015 to December 2017 focused on prenatal education, first milk expression <= 6 hours after birth, and skin-to-skin care in the first month. We tracked process measures and main outcomes with run and control charts among 202 infants younger than 34 weeks' gestation eligible to receive mother's milk born at our hospital; We tracked results according to maternal race/ethnicity subgroups. Results: Forty-seven percent of mothers were non-Hispanic black, 28% were Hispanic, and 13% were non-Hispanic white. We improved the rate of first milk expression <= 6 hours after birth and skin-to-skin care in the first month but did not improve rates of any/exclusive mother's milk use at discharge/transfer. Eight-five percent of infants had mothers that initiated milk production, but only 55% received any mother's milk at discharge/transfer. Conclusions: Our single-center quality improvement effort focused on infants younger than 34 weeks' gestation whose mothers were predominately Hispanic and non-Hispanic blacks. We successfully increased first milk expression <= 6 hours after birth and skin-to-skin care but did not increase mother's milk use at discharge/transfer.

Introduction: We implemented a bundle of respiratory care practices and optimized delivery of continuous positive airway pressure (CPAP) to reduce the incidence of chronic lung disease (CLD) among very low birth weight (VLBW) infants born before 33 weeks gestation. Methods: Our multidisciplinary task force utilized 6 plan-do-study-act cycles to test our interventions. The primary outcome was the quarterly percentage of infants diagnosed with CLD; other outcomes included the percentage of infants initially managed with CPAP, intubation <72 hours of age, use of a nasal cannula, and days of ventilation, oxygen, and/or CPAP. Process measures included compliance with each of the 5 components of the bundle; balancing measures included mortality and complications of prematurity. Results: Demographics were similar in the 55 infants born before and 76 infants born after the task force interventions, except for gestational age, which was lower before. CLD decreased by 55.5% (from 37.5% to 16.7%). Quarterly percentage of infants requiring intubation decreased from 87.5% to 40.8%. Quarterly average days of ventilation decreased from 11.2 to 6.1, and days of supplemental oxygen declined from 44.1 to 25.4, while the use of CPAP increased. There were no differences in adverse events including mortality, pneumothorax, use of postnatal steroids, or any retinopathy of prematurity. The incidence of patent ductus arteriosus declined from 60% to 33% (P < 0.01). Conclusions: We reduced the incidence of CLD among our very low birth weight infants born before 33 weeks gestation by over 50% without increasing any measured adverse outcomes. The incidence of patent ductus arteriosus declined.

OBJECTIVE:Language exposure is important for neurodevelopment, but is sparse in the neonatal intensive care unit (NICU). STUDY DESIGN:We introduced Reach Out and Read (ROR) in the NICU as a quality improvement initiative to increase language exposure. Measures included availability of books, accessibility of parents, and enrollment of infants, percent infants read to by their parents, and data from parental surveys. RESULT:98 infants were included (40 before, 58 after). We obtained books in the mother's language for 95% of infants, 82% eligible infants were enrolled, and 70% read to their infants (mean of 0.45 ± 0.35 times/day). Surveyed parents enjoyed reading, noted positive effect(s), and intended to read post-discharge. CONCLUSION:We launched a well-received pilot ROR program in the NICU and reached our goal of ≥50% infants being read to by their parents. Further study is needed to assess the impact of reading in the NICU on parents and infants.

Myelination is essential for proper functioning of the CNS. In this study, we have identified a mouse mutation, designated furue, which causes tremors and hypomyelination in the CNS, particularly in the spinal cord, but not in the sciatic nerve of the PNS. In the spinal cord of the furue mice, myelination of small-diameter axons was dramatically reduced, and differentiation of oligodendrocytes, the myelin-forming cells in the CNS, was inhibited. We subsequently found that the furue mutation was associated with a transgene insertion into the teneurin-4 (Ten-4, Ten-m4/Odz4) gene, encoding a transmembrane protein of unknown function. Ten-4 was strongly expressed in the spinal cord of wild-type mice and was induced during normal oligodendrocyte differentiation. In contrast, in the furue mice, the expression of Ten-4 was absent. Differentiation and cellular process formation of oligodendrocytes were inhibited in primary cell culture from the furue mice. Cell differentiation and process formation were also inhibited in the oligodendrocyte progenitor cell line CG-4 after suppression of Ten-4 expression by shRNA. Furthermore, Ten-4 positively regulated focal adhesion kinase, an essential signaling molecule for oligodendrocyte process formation and myelination of small-diameter axons. These findings suggest that Ten-4 is a novel regulator of oligodendrocyte differentiation and that it plays a critical role in the myelination of small-diameter axons in the CNS.

mune cells as macrophages can be an additional source of VEGF [3] . Serum VEGF levels have also been found to correlate with platelet count and some investigators have also stated that VEGF should be corrected for platelet counts. To correct for variation in platelet counts between patients, it has been proposed that the concentration of VEGF per platelet (pg/10 6 ) can be calculated by dividing the serum VEGF concentration (pg/ml) by the platelet count (×10 6 /ml) [4] . In the study by Levesque et al. [1], urine VEGF/protein levels increased by 72% per week (p < 0.0001) during the first postnatal month. In multivariable analysis controlling for postnatal age, lower VEGF/protein was associated with higher levels of mechanical respiratory support (p = 0.006), male gender Dear Sir, We read with great interest the study by Levesque et al. [1] , which showed that low urine VEGF/protein levels in the first postnatal month are associated with mechanical ventilation, BPD, and ROP. We have some insights for the urine VEGF levels calculation. VEGF circulating in the blood of patients may be derived from various sources. Circulating levels of VEGF are dependent on platelets [2] . Activated platelets release VEGF and platelet consumption causes increased levels of thrombopoietin, which in turn stimulates megakaryopoiesis and platelet production in the bone marrow. Newly produced platelets are larger in size than those produced during steady-state thrombopoiesis, and therefore contain an elevated amount of VEGF. Finally, host imReceived: July 3, 2013 Accepted: August 27, 2013 Published online: November 8, 2013

Background: Organ-specific vascular endothelial growth factor (VEGF) expression is decreased during the pathogenesis of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) several weeks before either disease can be diagnosed. Early measurement of organ-specific tissue VEGF levels might allow identification of infants at high risk for these diseases, but is not clinically feasible. Urine VEGF is easily measured and useful in early diagnosis of several diseases. Objectives: Our aims were to assess the correlation of urine VEGF levels measured in the first postnatal month with subsequent BPD or ROP diagnosis and to determine whether various infant characteristics influence urine VEGF levels. Methods: 106 subjects born at <29 weeks' gestation and surviving to 36 weeks' postmenstrual age were selected from an existing database and biorepository. Urine VEGF and total protein were measured in 2-3 samples per subject. Results: Urine VEGF/protein levels increased by 72% per week (p < 0.0001) during the first postnatal month. In multivariable analysis controlling for postnatal age, lower VEGF/protein was associated with higher levels of mechanical respiratory support (p = 0.006), male gender (p = 0.001) and early sepsis (p = 0.003) but not with fraction of inspired oxygen. Lower urine VEGF/protein and mechanical ventilation were each associated with BPD and ROP. In analyses adjusted for respiratory support, lower urine VEGF/protein and ROP remained associated but urine VEGF/protein and BPD did not. Conclusions: Low urine VEGF/protein levels in the first postnatal month are associated with mechanical ventilation, BPD, and ROP.

OBJECTIVE:We implemented 5 potentially better practices to limit mechanical ventilation (MV), supplemental oxygen, and bronchopulmonary dysplasia in newborn infants born before 33 weeks' gestation.METHODS:The methods used in this study included (1) exclusive use of bubble continuous positive airway pressure (bCPAP), (2) provision of bCPAP in the delivery room, (3) strict intubation criteria, (4) strict extubation criteria, and (5) prolonged CPAP to avoid supplemental oxygen. We excluded outborn infants and those with major anomalies and obstetric complications from analysis.RESULTS:Demographics were similar in 61 infants born before and 60 born after implementation. For infants born at 26 to 32(6/7) weeks' gestation, intubation (first 72 hours) decreased from 52% to 11% (P < .0001) and surfactant use decreased from 48% to 14% (P=.0001). In all infants, the mean ± SD fraction of inspired oxygen requirement (first 24 hours) decreased from 0.27 ± 0.08 to 0.24 ± 0.05 (P=.0005), days of oxygen decreased from 23.5 ± 44.5 to 9.3 ± 22.0 (P=.04), and days of MV decreased from 8.8 ± 27.8 to 2.2 ± 6.2 (P=.005). Hypotension decreased from 33% to 15% (P=.03). The percentage of infants with bronchopulmonary dysplasia was 17% before and 8% after (P=.27). Nurse staffing ratios remained unchanged.CONCLUSIONS:Implementation of these potentially better practices reduced the need for MV, surfactant, and supplemental oxygen as well as reduced hypotension among infants born before 33 weeks' gestation without adverse consequences. The costs for equipment and surfactant were lower.

Drosophila trachealess (Trl), master regulator of tracheogenesis, has no known functional mammalian homolog. We hypothesized that genes similar to trachealess regulate lung development. Quantitative (Q)RT-PCR and immunostaining were used to determine spatial and temporal patterns of npas1 gene expression in developing murine lung. Immunostaining for alpha-smooth muscle actin demonstrated myofibroblasts, and protein gene product (PGP)9.5 identified neuroendocrine cells. Branching morphogenesis of embryonic lung buds was analyzed in the presence of antisense or sense oligodeoxynucleotides (ODN). Microarray analyses were performed to screen for changes in gene expression in antisense-treated lungs. QRT-PCR was used to validate the altered expression of key genes identified on the microarrays. We demonstrate that npas1 is expressed in murine embryonic lung. npas1 mRNA peaks early at Embryonic Day (E)10.5-E11.5, then drops to low levels. Sequencing verifies the identity of npas1 transcripts in embryonic lung. NPAS1 immunostaining occurs in nuclei of parabronchial mesenchymal cells, especially at the tracheal bifurcation. Arnt, the murine homolog of Tango (the heterodimerization partner for Trl) is also expressed in developing lung but at constant levels. npas1- or arnt-antisense ODN inhibit lung branching morphogenesis, with altered myofibroblast development and increased pulmonary neuroendocrine cells. On microarrays, we identify > 50 known genes down-regulated by npas1-antisense, including multiple genes regulating cell migration and cell differentiation. QRT-PCR confirms significantly decreased expression of the neurogenic genes RBP-Jk and Tle, and three genes involved in muscle development: beta-ig-h3, claudin-11, and myocardin. Npas1 can regulate myofibroblast distribution, branching morphogenesis, and neuroendocrine cell differentiation in murine embryonic lung.

Early gestation lung development is characterized by branching morphogenesis of the airways and basic lung structure formation. Androgens delay late-gestation lung development if the androgen exposure begins in early gestation. We hypothesized that there would be effects of early gestation androgens on lung development. Embryonic mouse lungs (d 11.5) were cultured with dihydrotestosterone (DHT), DHT plus flutamide, or with nothing as controls. Branching morphogenesis was significantly increased after 24, 48, and 72 h of culture. This effect was blocked by simultaneous flutamide treatment. Fetal sex did not influence the DHT response. DHT increased cell proliferation as measured by [3H]thymidine incorporation into DNA. Autoradiography showed prominent [3H]thymidine labeling of epithelia and mesenchyme in regions of new bud formation. DHT treatment significantly increased the thymidine-labeling index of fibroblasts and airway epithelial cells. Programmed cell death, which is found in developing organs in association with cell proliferation during structure formation and tissue remodeling, was studied using terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick end labeling assay. In control lungs, programmed cell death occurred in the peripheral mesenchyme surrounding newly forming buds and underlying airway branch points. DHT treatment increased programmed cell death in association with increased branching morphogenesis. Evaluation of near-adjacent sections (control and DHT-treated lungs) showed that apoptotic mesenchymal cells were flanked by [3H]thymidine-labeled fibroblasts and epithelial cells, suggesting a coordination of these processes in the progression of branching morphogenesis. We conclude that androgen enhances the process of early lung morphogenesis by increasing cell proliferation and programmed cell death and by promoting the structural progression of branching morphogenesis.

The objective of this study was to establish normal values for pulse oximetry saturation (POS) in healthy newborn infants in the nursery. POS values were obtained from the right (R) hand and R foot at admission, 24 hr, and at discharge. The following information was recorded: postnatal age, activity state, gender, gestational age (GA), birth weight (BW), mode of delivery (MOD), and Apgar scores. Charts were reviewed and follow-up information was obtained for newborns with measurements < or =92%. The study group consisted of a convenience sample of newborn infants, excluding those on supplemental oxygen. Seven hundred eighteen patients were studied: 51% males, 28% cesarean sections, gestational age 39.3+/-1.6 weeks (mean +/- SD), birth weight 3370+/-550 g, and median Apgar scores 8 and 9. The mean POS was 97.2 +/-1.6%, and the median value was 97%. Only postnatal age and activity state affected POS significantly. POS increased 0.17% per 24 hr in the nursery (P = 0. 0001). POS values obtained while the infants were fussy and crying were lower compared to measurements obtained while sleeping [mean decreases: 0.44% while fussy (P = 0.001), 0.98% while crying (P = 0.0001)]. We conclude that newborns in the nursery have an overall mean POS of 97.2% (+/-2 SD: 94-100%). Mean POS values increase to a small degree with increasing postnatal age. Fussy and crying newborns have lower POS values compared to quiet and sleeping newborns. These reference data can be used in the evaluation of POS measurements in symptomatic newborn infants.

Apoptosis is becoming recognized as an important mechanistic process in embryonic structural development. Branching morphogenesis of the embryonic lung involves incompletely characterized complex interactions between the developing epithelium and mesenchyme. The involvement of apoptosis in this process not known. We hypothesized that apoptosis is actively involved in the formation of new buds in the embryonic lung, and that apoptosis is altered by factors which stimulate branching morphogenesis. Day 11.5 Swiss Webster mouse lung explants were cultured for 48 hours in serum free BGJb medium with either DHT, DHT plus a 10fold excess of Flutamide (an androgen receptor blocker), or equal volumes of diluent as control. Branching morphogenesis was evaluated by counting the number of terminal buds of the left lung at 0, 24, and 48 hrs under light microscopy. At 24 and 48 hrs individual lungs were harvested, formalin fixed, embedded in OCT, and sectioned (5 microns). After treatment with Proteinase K, endogenous peroxidase activity was quenched with 2% Hydrogen Peroxide. Apoptosis was evaluated using the ApopTag Detection Kit(Oncor) by direct immunoperoxidase detection of digoxigeninlabeled DNA. DHT(106 and 107M) treatment increased the number of terminal buds after 24 and 48 hrs (DHT 106M: 127±6% of control after 48 hrs, P<0.005). This was blocked by a 10fold excess of Flutamide (DHT 106M Flutamide 105M: 109±6% of control after 48 hrs, P=NS). In control lungs apoptosis was present nearly exclusively in distal new bud structures, where intermittent clusters of mesenchymal cells in the thin septa, and occasional adjacent low cuboidal epithelial cells showed apoptosis. Rare mesenchymal cells in the more central areas were also positive. Columnar and cuboidal cells of established airways were negative. DHTtreated lungs showed a similar restriction of apoptosis to cells of new bud structures, but more new structures, and more cells per structure were positive. We speculate that apoptosis occurs in cells of newly forming terminal buds to facilitate the progressive development of new bud structures. This process is enhanced by a growth factor (DHT) that stimulates branching morphogenesis. (Supported by HL37930)

DHT affects late gestation lung development by increasing the proliferation of fibroblasts and Type II cells and delaying surfactant production. Based on these findings, it has been suggested that DHT prolongs late gestation (fetal) lung growth resulting in males having larger lungs than females. We postulated that DHT also affects the early gestation (embryonic) lung growth and morphogenesis. We tested this hypothesis by examining the effect of DHT on branching morphogenesis and thymidine incorporation into DNA in embryonic day 11 1/2 mouse lung explants. Lungs were cultured for 72 hours in serum free BGJb medium with either 10-8M DHT or an equal volume (10 μl/ml) of diluent as control. Branching morphogenesis was evaluated at 0, 24, 48, and 72 hours by counting the total number of terminal buds of the left lung under light microscopy. These evaluations were done without knowledge of treatment group. At 48 hours 3H-thymidine (1μCi/ml) was added to all cultures. At 72 hours lung explants were harvested and thymidine incorporation into DNA was determined. The number of terminal buds was similar in the two groups at time zero. Thereafter, the number of terminal buds in the DHT treated group was significantly increased compared to control at 24 hours (DHT: 6.3±0.7 buds; Control: 4.0±0.4 buds; mean±SEM, P=0.006), at 48 hours (DHT: 10.8±0.7; Control 6.4±0.6, P=0.0001), and at 72 hours (DHT: 16.5±1.7; Control 11.1±1.1, P=0.01). The velocity of terminal bud formation, defined as the increase in buds within a given lung over time, was significantly greater in the DHT treated group for the time intervals of zero to 24 hours (DHT: 2.6±0.5; Control: 1.1±0.3; mean±SEM, P=0.02), zero to 48 hours (DHT: 7.1±0.6; Control: 3.5±0.7, P=0.0008), and zero to 72 hours (DHT: 12.8±1.3; Control: 8.2±1.2, P=0.01). Thymidine incorporation into DNA between 48 and 72 hours was decreased in DHT treated lungs (DHT 76%±15% of control; mean±SEM). These data suggest that DHT increases the early velocity of terminal bud formation in the embryonic lung. We speculate that DHT has divergent effects on the growth of airway epithelium versus mesenchymal tissue in embryonic lung, resulting in increased terminal bud formation but decreased overall thymidine incorporation. Supported by HL37930