OBJECTIVES:Level III NICUs share one AAP level of care designation. We characterized variation, identified sub-classes, and compared sub-class outcomes. STUDY DESIGN:This retrospective cohort analysis of level III NICUs in Florida, Michigan, Oregon, Pennsylvania, and South Carolina used linked hospital discharge-vital statistics data (2010-2020). Included hospitals had ≥10 births annually and infants had gestational age <32 weeks and/or birth weight <1500 g. We characterized NICU-level heterogeneity; used latent class analysis (LCA) to obtain sub-classes; and compared risk-adjusted outcomes with multivariable Poisson regression. RESULTS:Among 163 NICUs (1518 hospital-years) there was significant variation. LCA identified five sub-classes (3a-e). Preterm volume and procedural intensity rose with acuity (3a lowest, 3d/3e highest). Higher acuity was associated with lower mortality but higher morbidity (3d vs. 3a: death: IRR 0.59 [95% CI 0.54-0.65]; morbidity: 2.84 [2.43-3.31]). CONCLUSIONS:Level III NICUs are heterogeneous and comprise five sub-classes with divergent outcomes. Sub-classification may facilitate risk-appropriate care.

BACKGROUND AND OBJECTIVES:Enhanced premium tax credits (PTCs) for Affordable Care Act Marketplace plans expired in 2026. We described families across income groups potentially affected by PTC policy changes and simulated net premiums. METHODS:We performed a cross-sectional simulation using the 2023 National Survey of Children's Health, classifying families by federal poverty level (FPL) into the following income groups: ineligible (above state Medicaid threshold, <100% FPL), Medicaid (below state threshold), 100-<250% FPL, 250-<400% FPL, and ≥400% FPL. We estimated family premiums using scaled state benchmarks and modeled net premium costs under (1) enhanced PTCs, (2) enhanced PTC expiration, and (3) PTC repeal using ordinary least squares regression adjusting for state fixed effects and family sociodemographics. RESULTS:Families in PTC-relevant income groups had greater material hardship and children with more health conditions but less access than higher-income families. With typical family ages, adjusted net premiums as a percentage of income would be 1.8% (100-<250% FPL), 6.3% (250-<400% FPL), and 8.4% (≥400% FPL) with enhanced PTCs; 6.2%, 9.5%, and 15.2% post-expiration; and 27.1%, 17.8%, and 13.7% with repealed PTCs. In 2023 dollars, net premiums would be $1,335, $6,137, and $9,705 with enhanced PTCs; $4,100, $9,056, and $17,711 post-expiration; and $15,963, $17,069, and $16,903 with no PTCs. CONCLUSIONS AND POLICY IMPLICATIONS:Enhanced PTC expiration would increase net premiums substantially, particularly for ≥400% FPL families; full PTC repeal would produce large, regressive premium burdens for lower-income families with children. PTCs should be re-enhanced and not repealed to support American families.

To examine the association of admission NICU capacity strain with neonatal mortality and morbidity. 2008–2021 South Carolina cohort using linked vital statistics and discharge data of 22–44 weeks GA infants, born at hospitals with ≥ level 2 unit and ≥5 births <34 weeks GA/year. The exposure was deciles of admission capacity strain, defined as the sum of infants ≤44 weeks GA with a congenital anomaly plus infants <34 weeks GA. The primary outcome was a composite of mortality and term and preterm complications. We used Poisson generalized linear mixed models to examine the association of exposure with outcome adjusting for patient and hospital characteristics. We studied 64,647 infants from 30 hospitals. High capacity strain was associated with increased risk of mortality and morbidity adjusting for patient/hospital factors (for example, tenth decile aIRR 1.14, 95% CI 1.03–1.27). Capacity strain is associated with adverse NICU outcomes.

OBJECTIVE:Unconditional cash transfers (UCTs)-no strings attached monthly payments-to low-income families may reduce financial stress and improve health outcomes. We sought to determine the feasibility and acceptability of randomizing low-income caregivers of preterm infants to a high- or low-value UCT for 4 months. STUDY DESIGN:Parallel, pilot randomized controlled trial that was preregistered (ClinicalTrials.gov NCT05930327). We enrolled 24 birthing parent-infant dyads. The intervention was a $325 monthly UCT and the active control was a $25 monthly UCT. RESULT:The intervention was feasible and universally acceptable among families in the high-value cash transfer arm. Exploratory outcomes revealed a high degree of financial strain, stress, and depressive symptoms. CONCLUSION:This study provides feasibility, acceptability, and preliminary efficacy data to inform a future, larger trial to examine the impacts of UCTs to low-income birthing parents of preterm infants. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov ID NCT05930327.

OBJECTIVE:Emerging evidence has demonstrated mixed results regarding the ability of unconditional cash transfers to intervene on the pathway between poverty and adverse term infant outcomes. Parents of preterm infants with lower incomes endure significant financial and psychological stress, yet only a single study has examined the impact of unconditional cash transfers in preterm infants. This study aimed to investigate parents' 1) experiences of the financial impact of having an infant in the neonatal intensive care unit (NICU), 2) perceptions of the impact of monthly unconditional cash transfers distributed as part of a pilot randomized controlled trial, and 3) perceptions of a NICU-based unconditional cash transfer program. METHODS:This qualitative study contains 16 parents from a pilot randomized controlled trial of unconditional cash transfers to parent-infant dyads with Medicaid-eligible income. Parents participated in semi-structured interviews analyzed using a hybrid deductive-inductive approach. RESULTS:Parents described significant financial and mental stress during and after the NICU admission. Many perceived that an unconditional cash transfer program mitigated this stress. Unconditional cash transfers were used mostly on baby and family items. Unconditional cash transfers also were associated with a sense of relief and, in some cases, increased trust. Most parents prefer that the unconditional cash transfers be delivered by debit card biweekly starting soon after birth. CONCLUSIONS:Parents of preterm infants that are Medicaid-eligible felt that a NICU-based unconditional cash transfer program provided relief from the financial and mental stress of the NICU. Future, larger studies should examine the impacts of unconditional cash transfers on neonatal and birthing parent outcomes, and trust in the NICU.

This cohort study analyzes the association of hospital financial health with provision of obstetric and neonatal intensive care unit (NICU) services.

Although the neonatal intensive care unit (NICU) is best known to care for small, sick infants, the majority of NICU care is for lower-acuity, less premature infants.1 In this issue of Pediatrics, Schulman et al report that lower-acuity inborn NICU admissions ("LAINA," or infants >1500 g and 32 weeks' gestational age [GA] or beyond without markers of acuity) comprise 59% of all admissions and are most common in community units. The authors of this study describe how common LAINA diagnoses (suspected infection, hyperbilirubinemia, and feeding difficulty) may be treatable in lower-acuity settings.2 More research is needed to understand how to optimize outcomes for less acute infants in less acute settings.First, LAINAs are not a monolith. They consist of 2 distinct populations: (1) moderate and late preterm infants between 1500 and 2000 g and between 32 and 35 weeks' GA requiring specialized nursing care to supporting emerging feeding and developmental skills, and (2) term infants with diagnoses potentially treatable in the newborn nursery, including hyperbilirubinemia and observation for early-onset sepsis. Solutions for optimizing care for each population may differ dramatically.More population-level data on both subpopulations are needed to understand how to optimize outcomes. The Vermont Oxford Network all-admissions database includes more than 400 000 lower-acuity infants but is not a national, population-level data set, limiting its generalizability.3–5 Internationally, databases such as the Australian Generation Victoria special care registry are emerging to fill this gap, but they only assess the region from which they collect data.6 US clinicians, health systems, and networks should collect lower-acuity patient population data along with unit organization and staffing data in a coordinated national effort to best understand how to structure care to optimize LAINA outcomes.Research focused on NICU organization may improve care for preterm LAINAs who require lower-acuity specialized NICU care. Schulman et al introduces the concept of a "neonatal comprehensive care unit" to acknowledge that the NICU provides care for several different types of low- and high-acuity infants. But how and where to deliver these different care models remains open for debate. Prior work demonstrates that strain (increased care demand relative to resources) may negatively affect lower-acuity infants.7 For example, there is an elevated risk of sepsis when the census of infants of fewer than 32 weeks' gestation is greater8 and when there is more missed nursing care during periods of acuity.9 One proposed mitigation strategy is creating a separate "lower acuity neonatal unit," or intermediate care nursery. This facilitates care of lower-acuity patients in a dedicated unit where they can receive condition-specific attention, such as specialized nursing care. Units for higher-acuity infants, such as the small baby unit, are already being implemented to improve high-acuity patient outcomes.10 Given the heterogeneity in intermediate care nursery services, future work should focus on how to best use these nurseries.11 In smaller units where care specialization may be more challenging given patient volumes, investing resources in staff development to ensure expertise in all patient populations may be an alternate strategy.Identifying the optimal staffing for term LAINAs is critical to increase the frequency of their care in the nursery. The variability in nursery staffing (pediatric hospitalists, family physicians, neonatologists) may limit the diagnoses cared for in this setting.12 Indeed, there is national variability in which diagnoses are cared for in the nursery, with certain "discretionary" admissions,12,13 such as observation for early-onset sepsis,14 transitioning from the NICU to the nursery in recent years. Additionally, the rise in newborn rooming in with the birth parent has led to nurse:birth parent-infant dyads ratios of 1:3 or 1:4. These nursing ratios, as well as the need for diverse nursing skills, may prevent term LAINA infant care in the nursery. Focusing on what resources, training, and staffing are needed in the nursery, particularly in community units where LAINAs are more prevalent, to make care for lower-acuity newborns feasible and cost-effective in the nursery is a critical next step.Finally, revised reimbursement models are needed to ensure such care delivery structures are financially viable. Newborn care is more heavily government funded and thus more poorly reimbursed compared with adult services.15 Hospitals may fund less profitable service lines through more profitable ones, a process known as cross-subsidization.16 Given the costly nature of high-acuity infant care, lower-acuity infant care may be relatively more profitable and thus more desirable for a NICU's financial viability. Hospitals may be incentivized to keep lower-acuity patients in higher-acuity settings with higher reimbursement. Alternate payment models focused on optimizing outcomes for this lower-acuity patient population should be considered.Ultimately, the prevalence of LAINAs highlighted by Schulman et al calls not only for the collection of coordinated outcomes data for both preterm and term LAINAs but also for the close study of the organizing, staffing, and financing of this care. Although term LAINA care may be optimized through alternate staffing strategies in the newborn nursery, preterm LAINA care requires considering the need for an intermediate care nursery. Given the investment required for each of these strategies, careful consideration of aligning financial incentives is critical to make improving LAINA care a possibility.

OBJECTIVE:To evaluate whether community factors that differentially affect the health of pregnant people contribute to geographic differences in infant mortality across the US. STUDY DESIGN:This retrospective cohort study sought to characterize the association of a novel composite measure of county-level maternal structural vulnerabilities, the Maternal Vulnerability Index (MVI), with risk of infant death. We evaluated 11 456 232 singleton infants born at 22 0 of 7 through 44 6 of 7 weeks' gestation from 2012 to 2014. Using county-level MVI, which ranges from 0 to 100, multivariable mixed effects logistic regression models quantified associations per 20-point increment in MVI, with odds of death clustered at the county level and adjusted for state, maternal, and infant covariates. Secondary analyses stratified by the social, physical, and health exposures that comprise the overall MVI score. Outcome was also stratified by cause of death. RESULTS:Rates of death were higher among infants from counties with the greatest maternal vulnerability (0.62% in highest quintile vs 0.32% in lowest quintile, [P < .001]). Odds of death increased 6% per 20-point increment in MVI (aOR: 1.06, 95% CI 1.04, 1.07). The effect estimate was highest with theme of Mental Health and Substance Abse (aOR 1.08; 95% CI 1.06, 1.09). Increasing vulnerability was associated with 6 of 7 causes of death. CONCLUSIONS:Community-level social, physical, and healthcare determinants indicative of maternal vulnerability may explain some of the geographic variation in infant death, regardless of cause of death. Interventions targeted to county-specific maternal vulnerabilities may reduce infant mortality.

Importance:Immigrant birthing people have lower rates of preterm birth compared with their US-born counterparts. This advantage and associated racial and ethnic disparities across the gestational age spectrum have not been examined nationally. Objective:To examine associations of maternal nativity, ethnicity, and race with preterm birth. Design, Setting, and Participants:This cohort study used birth certificates from the National Vital Statistics System to analyze in-hospital liveborn singleton births in the US between January 1, 2009, and December 31, 2018. Data were analyzed from January to June 2023. Exposure:Mutually exclusive nativity, ethnicity, and race subgroups were constructed using nativity (defined as US-born or non-US-born), ethnicity (defined as Hispanic or non-Hispanic), and race (defined as American Indian or Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, White, or other [individuals who selected other race or more than 1 race]). Main Outcomes and Measures:The primary outcome of interest was preterm birth. Modified Poisson and multinomial logistic regression models quantified relative risk (RR) of preterm birth overall (<37 weeks' gestation) and by gestational category (late preterm: 34-36 weeks' gestation; moderately preterm: 29-33 weeks' gestation; and extremely preterm: <29 weeks' gestation) for each maternal nativity, ethnicity, and race subgroup compared with the largest group, US-born non-Hispanic White (hereafter, White) birthing people. The RR of preterm birth overall and by category was also measured within each racial and ethnic group by nativity. Models were adjusted for maternal demographic and medical covariates, birth year, and birth state. Results:A total of 34 468 901 singleton live births of birthing people were analyzed, with a mean (SD) age at delivery of 28 (6) years. All nativity, ethnicity, and race subgroups had an increased adjusted risk of preterm birth compared with US-born White birthing people except for non-US-born White (adjusted RR, 0.85; 95% CI, 0.84-0.86) and Hispanic (adjusted RR, 0.98; 95% CI, 0.97-0.98) birthing people. All racially and ethnically minoritized groups had increased adjusted risks of extremely preterm birth compared with US-born White birthing people. Non-US-born individuals had a decreased risk of preterm birth within each subgroup except non-Hispanic Native Hawaiian or Other Pacific Islander individuals, in which immigrants had significantly increased risk of overall (adjusted RR, 1.07; 95% CI, 1.01-1.14), moderately (adjusted RR, 1.10; 95% CI, 0.92-1.30), and late (adjusted RR, 1.11; 95% CI, 1.02-1.22) preterm birth than their US-born counterparts. Conclusions and Relevance:Results of this cohort study suggest heterogeneity of preterm birth across maternal nativity, ethnicity, and race and gestational age categories. Understanding these patterns could aid the design of targeted preterm birth interventions and policies, especially for birthing people typically underrepresented in research.

BACKGROUND Although postnatal transfer patterns among high-risk (eg, extremely preterm or surgical) infants have been described, transfer patterns among lower-risk populations are unknown. The objective was to examine transfer frequency, indication, timing, and trajectory among very and moderate preterm infants. METHODS Observational study of the US Vermont Oxford Network all NICU admissions database from 2016 to 2021 of inborn infants 280/7 to 346/7 weeks. Infants’ first transfer was assessed by gestational age, age at transfer, reason for transfer, and transfer trajectory. RESULTS Across 467 hospitals, 294 229 infants were eligible, of whom 12 552 (4.3%) had an initial disposition of transfer. The proportion of infants transferred decreased with increasing gestational age (9.6% [n = 1415] at 28 weeks vs 2.4% [n = 2646] at 34 weeks) as did the median age at time of transfer (47 days [interquartile range 30–73] at 28 weeks vs 8 days [interquartile range 3–16] at 34 weeks). The median post menstrual age at transfer was 34 or 35 weeks across all gestational ages. The most common reason for transfer was growth or discharge planning (45.0%) followed by medical and diagnostic services (30.2%), though this varied by gestation. In this cohort, 42.7% of transfers were to a higher-level unit, 10.2% to a same-level unit, and 46.7% to a lower-level unit, with indication reflecting access to specific services. CONCLUSIONS Over 4% of very and moderate preterm infants are transferred. In this population, the median age of transfer is later and does not reflect immediate care needs after birth, but rather the provision of risk-appropriate care.

To address socioeconomic disparities in the health outcomes of preterm infants, we must move beyond describing these disparities and focus on the development and implementation of interventions that disrupt the factors contributing to them. Unconditional cash transfers (UCTs), which provide unrestricted payments to individuals or households, can help mitigate income disparities and improve health outcomes. While UCTs have been utilized for other vulnerable populations, their full potential has yet to be realized for low-income families with preterm infants, who face significant financial strain. In this perspective, we review evidence supporting UCTs as an intervention for children in the U.S. (including those born term and preterm), discuss the potential benefits of recurring UCTs to low-income families of preterm infants, and propose a conceptual model through which UCTs may improve outcomes for preterm infants. We conclude with potential policy levers for implementing UCTs and key unanswered questions for researchers.

OBJECTIVE:Evaluate the relationship of neonatal unit level of care (LOC) and volume with mortality or morbidity in moderate-late preterm (MLP) (32-36 weeks' gestation) infants. DESIGN:Retrospective cohort study of 650,865 inborn MLP infants in 4976 hospitals-years using 2003-2015 linked administrative data from 4 states. Exposure was combined neonatal LOC and MLP annual volume. The primary outcome was death or morbidity (respiratory distress syndrome, severe intraventricular hemorrhage, necrotizing enterocolitis, sepsis, infection, pneumothorax, extreme length of stay) with components as secondary outcomes. Poisson regression models adjusted for patient characteristics with a random effect for unit were used. RESULTS:In adjusted models, high-volume level 2 units had a lower risk of the primary outcome compared to low-volume level 3 units (aIRR 0.90 [95% CI 0.83-0.98] vs. aIRR 1.13 [95% CI 1.03-1.24], p < 0.001) CONCLUSION: MLP infants had improved outcomes in high-volume level 2 units compared to low-volume level 3 units in adjusted analysis.

IMPORTANCE Appreciation for the effects of neighborhood conditions and community factors on perinatal health is increasing. However, community-level indices specific to maternal health and associations with preterm birth (PTB) have not been assessed. OBJECTIVE To examine the association of the Maternal Vulnerability Index (MVI), a novel county-level index designed to quantify maternal vulnerability to adverse health outcomes, with PTB. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used US Vital Statistics data from January 1 to December 31, 2018. Participants included 3659099 singleton births at 22 plus 0/7 to 44 plus 6/7 weeks of gestation born in the US. Analyses were conducted from December 1, 2021, through March 31, 2023. EXPOSURE The MVI, a composite measure of 43 area-level indicators, categorized into 6 themes reflecting physical, social, and health care landscapes. Overall MVI and theme were stratified by quintile (very low to very high) by maternal county of residence. MAIN OUTCOMES AND MEASURES The primary outcome was PTB (gestational age <37 weeks). Secondary outcomes were PTB categories: extreme (gestational age <= 28 weeks), very (gestational age 29-31 weeks), moderate (gestational age 32-33 weeks), and late (gestational age 34-36 weeks). Multivariable logistic regression quantified associations of MVI, overall and by theme, with PTB, overall and by PTB category. RESULTS Among 3659099 births, 298847 (8.2%) were preterm (male, 51.1%; female, 48.9%). Maternal race and ethnicity included 0.8% American Indian or Alaska Native, 6.8% Asian or Pacific Islander, 23.6% Hispanic, 14.5% non-Hispanic Black, 52.1% non-Hispanic White, and 2.2% with more than 1 race. Compared with full-term births, MVI was higher for PTBs across all themes. Very high MVI was associated with increased PTB in unadjusted (odds ratio [OR], 1.50 [95% CI, 1.45-1.56]) and adjusted (OR, 1.07 [95% CI, 1.01-1.13]) analyses. In adjusted analyses of PTB categories, MVI had the largest association with extreme PTB (adjusted OR, 1.18 [95% CI, 1.07-1.29]). Higher MVI in the themes of physical health, mental health and substance abuse, and general health care remained associated with PTB overall in adjusted models. While the physical health and socioeconomic determinant themes were associated with extreme PTB, physical health, mental health and substance abuse, and general health care themes were associated with late PTB. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that MVI was associated with PTB even after adjustment for individual-level confounders. The MVI is a useful measure for county-level PTB risk that may have policy implications for counties working to lower preterm rates and improve perinatal outcomes.

Importance:A higher level of care improves outcomes in extremely and very preterm infants, yet the impact of neonatal intensive care unit (NICU) level on moderate and late preterm (MLP) care quality is unknown.Objective:To examine the association between NICU type and care quality in MLP (30-36 weeks' gestation) and extremely and very preterm (25-29 weeks' gestation) infants.Design, Setting, and Participants:This cohort study was a prospective analysis of 433 814 premature infants born in 465 US hospitals between January 1, 2016, and December 31, 2020, without anomalies and who survived more than 12 hours and were transferred no more than once. Data were from the Vermont Oxford Network all NICU admissions database.Exposures:NICU types were defined as units with ventilation restrictions without surgery (type A with restrictions, similar to American Academy of Pediatrics [AAP] level 2 NICUs), without surgery (type A) and with surgery not requiring cardiac bypass (type B, similar to AAP level 3 NICUs), and with all surgery (type C, similar to AAP level 4 NICUs).Main Outcomes and Measures:The primary outcome was gestational age (GA)-specific composite quality measures using Baby-Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR) for extremely and very preterm infants and an adapted MLP quality measure for MLP infants. Secondary outcomes were individual component measures of each scale. Composite scores were standardized observed minus expected scores, adjusted for patient characteristics, averaged, and expressed with a mean of 0 and SD of 1. Between May 2021 and October 2022, Kruskal-Wallis tests were used to compare scores by NICU type.Results:Among the 376 219 MLP (204 181 [54.3%] male, 172 038 [45.7%] female; mean [SD] GA, 34.2 [1.7] weeks) and 57 595 extremely and very preterm (30 173 [52.4%] male, 27 422 [47.6%] female; mean [SD] GA, 27.7 [1.4] weeks) infants included, 6.6% received care in type A NICUs with restrictions, 29.3% in type A NICUs without restrictions, 39.7% in type B NICUs, and 24.4% in type C NICUs. The MLP infants had lower MLP-QM scores in type C NICUs (median [IQR]: type A with restrictions, 0.4 [-0.1 to 0.8]; type A, 0.4 [-0.4 to 0.9]; type B, 0.1 [-0.7 to 0.7]; type C, -0.7 [-1.6 to 0.4]; P < .001). No significant differences were found in extremely and very preterm Baby-MONITOR scores by NICU type. In type C NICUs, MLP infants had lower scores in no extreme length of stay and change-in-weight z score.Conclusions and Relevance:In this cohort study, composite quality scores were lower for MLP infants in type C NICUs, whereas extremely and very preterm composite quality scores were similar across NICU types. Policies facilitating care for MLP infants at NICUs with less complex subspecialty services may improve care quality delivered to this prevalent, at-risk population.

(Abstracted from JAMA Network Open 2023;6(5):e2315306) In the United States, approximately 1 in 10 births are considered preterm, or born at <37 weeks of gestation. Historically, studies on preterm birth (PTB) have focused on maternal characteristics. However, an appreciation for the impact of community factors, such as poverty, air pollution, and other measures of neighborhood quality, on PTB is growing.

Objective To examine quality measures for moderate and late preterm (MLP) infants. Study design By prospectively analyzing Vermont Oxford Network’s all NICU admissions database, we adapted Baby-MONITOR, a composite quality measure for extremely/very preterm infants, for MLP infants. We examined correlations between the adapted MLP quality measure (MLP-QM) in MLP infants and Baby-MONITOR in extremely and very preterm infants. Result We studied 376,219 MLP (30–36 weeks GA) and 57,595 extremely/very preterm (25–29 weeks GA) infants from 465 U.S. hospitals born from 2016 to 2020. MLP-QM summary scores in MLP infants had weak correlation with Baby-MONITOR scores in extremely and very preterm infants ( r = 0.47). There was weak correlation among survival ( r = 0.19), no pneumothorax ( r = 0.35), and no infection after 3 days ( r = 0.45), but strong correlation among human milk at discharge ( r = 0.79) and no hypothermia ( r = 0.76). Conclusion Modest correlation among hospital care measures in two preterm populations suggests the need for MLP-specific care measures.

BACKGROUND Although delivery room (DR) intervention decreases with increasing gestational age (GA), little is known about DR management of moderate and late preterm (MLP) infants. METHODS Using the Vermont Oxford Network database of all NICU admissions, we examined the receipt of DR interventions including supplemental oxygen, positive pressure ventilation, continuous positive airway pressure, endotracheal tube ventilation, chest compressions, epinephrine, and surfactant among MLP infants (30 to 36 weeks' ) without congenital anomalies born from 2011 to 2020. Pneumothorax was examined as a potential resuscitation-associated complication. Intervention frequency was assessed at the infant- and hospital-level, stratified by GA and over time. RESULTS Overall, 55.3% of 616 110 infants (median GA: 34 weeks) from 483 Vermont Oxford Network centers received any DR intervention. Any DR intervention frequency decreased from 89.7% at 30 weeks to 44.2% at 36 weeks. From 2011 to 2020, there was an increase in the provision of continuous positive airway pressure (17.9% to 47.8%, P ≤.001) and positive pressure ventilation (22.9% to 24.9%, P ≤.001) and a decrease in endotracheal tube ventilation (6.9% to 4.0% P ≤.001), surfactant administration (3.5% to 1.3%, P ≤.001), and pneumothorax (1.9% to 1.6%, P ≤.001). Hospital rates of any DR intervention varied (median 54%, interquartile range 47% to 62%), though the frequency was similar across hospitals with different NICU capabilities after adjustment. CONCLUSIONS The DR management of MLP infants varies at the individual- and hospital-level and is changing over time. These findings illustrate the differing interpretation of resuscitation guidelines and emphasize the need to study MLP infants to improve evidence-based DR care.

Critical illness affects more than 5 million adults, children, and neonates annually in the United States (1). Adult, pediatric, and neonatal intensive care units (ICUs) manage vulnerable populations with complex diseases that are impacted by their environments. Social determinants of health (SDOH)—defined by the World Health Organization as “conditions in which people are born, grow, live, work, and age” (2)—account for 30–55% of health outcomes (2), contribute to mortality in critical care (3), and severely impact health spending (4). Given their importance, several national societies call for the integration of SDOH in healthcare delivery (5, 6). However, the role of addressing SDOH remains understudied. As aspiring intensivists, we reflect on personal experiences with vulnerable patients and describe how trainees can play a key role in integrating SDOH and critical care.