Publications by authors named "Marc Collin"

11 Publications

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Predicting outcomes of mechanically ventilated premature infants using respiratory severity score.

J Matern Fetal Neonatal Med 2020 Dec 6:1-8. Epub 2020 Dec 6.

Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.

Background: Extremely low birth weight (ELBW) infants have significant morbidities and higher mortality. The major morbidities are bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP). Release of proinflammatory cytokines has been implicated in the development of systemic inflammation that contributes to BPD aND ROP. Also, cumulative oxygen exposure in the first 3 days of life and use of mechanical ventilation was associated with 3-fold increase in severe IVH. Therefore, early ventilation and oxygenation may contribute significantly to morbidities in ELBW infants. Respiratory severity score (RSS), a product of Mean airway pressure (MAP) and FiO2, is a steady-state noninvasive assessment tool useful in infants to monitor the severity of respiratory failure. We used RSS, in the first 3 days of life of ELBW infants, to predict neonatal morbidities and mortality.

Study Design: In a single-center retrospective cohort study in an urban setting, convenience sampling of ELBW infants meeting the study criteria who were mechanically ventilated at birth for the first 3 days of life were included. Time-weighted average RSS was plotted on receiver-operating characteristic (ROC) curve in the first 3 days of life to predict outcomes. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated.

Results: A total of 69 infants qualified for the study. RSS in the first 3 days significantly predicted the composite outcome of death, ROP, IVH or BPD with an area under the curve (AUC) of 0.82 ( < 0.001). Individually, RSS predicted death, severe ROP and IVH with an AUC of 0.86, 0.77 and 0.71 respectively; but did not predict severe BPD (AUC 0.61). RSS was more sensitive and specific than each of its component; FiO and MAP. Weighted RSS in the first 3 days had high-negative predictive value of 98.1% for death between 7 days and 36 weeks, 94.6% for ROP and 91.7% for IVH.

Conclusions: This study is the first to show that RSS in the first 3 days of life is a good predictor of composite neonatal outcomes: severe IVH, BPD, ROP, or mortality. Early RSS had a high positive predictive value for the composite outcome of morbidities/mortality and a high specificity for mortality, ROP, and IVH individually.
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December 2020

Staff perceptions of challenging parent-staff interactions and beneficial strategies in the Neonatal Intensive Care Unit.

Acta Paediatr 2018 Jan 12;107(1):33-39. Epub 2017 Sep 12.

Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA.

Aim: To characterise neonatal intensive care unit (NICU) staff perceptions regarding factors which may lead to more challenging staff-parent interactions, and beneficial strategies for working with families with whom such interactions occur.

Methods: A survey of 168 physician and nursing staff at two NICUs in American teaching hospitals inquired about their perceptions of challenging parent-staff interactions and situations in which such interactions were likely to occur.

Results: From a medical perspective, staff perceptions of challenging interactions were noted when infants had recent decompensation, high medical complexity, malformations or long duration of stay in the NICU. From a psychological/social perspective, a high likelihood of challenging interactions was noted with parents who were suspicious, interfere with equipment, or parents who hover in the NICU, express paranoid or delusional thoughts, repeat questions, perceive the staff as inaccessible, are managing addictions, or who require child protective services involvement. Frequent family meetings, grieving opportunities, education of parents, social work referrals, clearly defined rules, partnering in daily care and support groups were perceived as the most beneficial strategies for improving difficult interactions.

Conclusion: This study delineates what staff perceive as challenging interactions and provides support for an educational and interventional role that incorporates mental health professionals.
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January 2018

Impact of Infant-Polysomnography Studies on Discharge Management and Outcomes: A 5 Year Experience from a Tertiary Care Unit.

J Neonatal Biol 2017 31;6(2). Epub 2017 May 31.

Department of Pediatrics, Division of Neonatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, USA.

Objective: To evaluate the impact of infant-polysomnography studies performed in the NICU on management and outcomes.

Study Design: Retrospective study to collect demographics and data on infant-polysomnography studies between Jan 2010 to Dec 2014.

Results: 110 premature neonates had polysomnography study performed at 36.9 ± 2.5 weeks post menstrual age. Almost all the studies were read as abnormal and 95% of the studied infants were discharged home on a cardiorespiratory monitor. 20% of the subjects had apnea >20 s, 18% had apnea of 15-20 s and 50% of infants had apnea of 10-15 s. 24.5% infants were discharged home on caffeine, 28% on metoclopramide and 24% on antacids. There were 11 readmissions for apparent life threatening events with no until 6 month-corrected age. There was no association between polysomnography results and readmission. There was a decline in polysomnography studies performed each year.

Conclusion: Cardiorespiratory monitoring, medications and polysomnography studies do not predict outcomes.
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May 2017

Human Milk Analysis Using Mid-Infrared Spectroscopy.

Nutr Clin Pract 2016 Apr 5;31(2):266-72. Epub 2015 Aug 5.

Department of Pediatrics, Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio.

Background: The composition of human milk is known to vary with length of gestation, stage of lactation, and other factors. Human milk contains all nutrients required for infant health but requires fortification to meet the needs of low-birth-weight infants. Without a known nutrient profile of the mother's milk or donor milk fed to a baby, the composition of the fortified product is only an estimate. Human milk analysis has the potential to improve the nutrition care of high-risk newborns by increasing the information about human milk composition. Equipment to analyze human milk is available, and the technology is rapidly evolving. This pilot study compares mid-infrared (MIR) spectroscopy to reference laboratory milk analysis.

Methods: After obtaining informed consent, we collected human milk samples from mothers of infants weighing <2 kg at birth. Duplicate samples were analyzed for macronutrients by MIR and by reference laboratory analysis including Kjeldahl for protein, Mojonnier for fat, and high-pressure liquid chromatography for lactose. Intraclass correlation coefficients, Bland-Altman scatter plots, and paired t tests were used to compare the two methods.

Results: No significant differences were detected between the macronutrient content of human milk obtained by MIR vs reference laboratory analysis.

Conclusions: MIR analysis appears to provide an accurate assessment of macronutrient content in expressed human milk from mothers of preterm infants. The small sample size of this study limits confidence in the results. Measurement of lactose is confounded by the presence of oligosaccharides. Human milk analysis is a potentially useful tool for establishing an individualized fortification plan.
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April 2016

A comparison of manual versus automated saturation of peripheral oxygenation in the neonatal intensive care unit.

J Matern Fetal Neonatal Med 2016 24;29(10):1631-5. Epub 2015 Jun 24.

d Division of Neonatology, Department of Pediatrics, Metro Health Medical Center, Case Western Reserve University , Cleveland , OH , USA.

Background: It is vital to maintain the saturation of peripheral oxygenation (SpO2) in a targeted range in extremely premature infants to improve survival without significant morbidities.

Objectives: To compare manual versus automated monitor documentations of daily upper and lower values of SpO2 in premature infants.

Methods: In a prospective observational study, the highest and lowest daily SpO2 manually recorded values from electronic medical records were compared with automatically recorded values from bedside cardiorespiratory monitors.

Results: Eighteen infants were monitored for 605 patient days, with a mean birth weight of 859 ± 183 g, and gestational age of 26.0 ± 1.3 wks. Within the lowest SpO2 values, manually recorded values were consistently higher than the simultaneous automatically recorded monitor values. The highest SpO2 point differences in documentation was seen in patients with SpO2 range ≤ 70% (16 ± 13 points), followed by 71-80% (10 ± 7 points) and 81-90% (7 ± 4 points); p < 0.01.

Conclusions: The difference between manually and automatically recorded SpO2 is large in lower SpO2 ranges and small in higher SpO2 ranges. Automated oxygen administering systems should be considered to reduce potential errors.
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December 2016

Neonatal Serum Phosphorus Levels and Enamel Defects in Very Low Birth Weight Infants.

JPEN J Parenter Enteral Nutr 2016 08 2;40(6):835-41. Epub 2015 Mar 2.

Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA.

Background: Very low birth weight (VLBW) infants miss out on the period of greatest mineral accretion that occurs during the last trimester of pregnancy and are at higher risk of enamel defects. No studies have well described the relationship between neonatal nutrition and dental outcomes in preterm, VLBW infants. The objective of this study was to assess the differences in nutrition biomarkers, feeding intake, and comorbidities among VLBW infants with and without enamel defects.

Methods: A retrospective chart review of VLBW infants recruited for an ongoing longitudinal dental study between 2007 and 2010 was done. Participants were classified as cases and controls according to the presence/absence of developmental defects of enamel at 8 and/or 18-20 and/or 36 months. Demographics and medical and nutrition data were abstracted from 76 subjects' medical charts.

Results: Of the 76 VLBW subjects, 62% had enamel defects (hypoplasia and/or opacity). The only significant variable in the logistic regression analysis was that infants with a 1-mg/dL increase in serum phosphorus levels had a 68% reduction in the odds of having enamel hypoplasia (odds ratio, 0.322; P = .024).

Conclusion: Neonatal lower serum phosphorus levels are significantly associated with enamel hypoplasia in VLBW infants younger than 3 years.
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August 2016

Standardized Slow Enteral Feeding Protocol and the Incidence of Necrotizing Enterocolitis in Extremely Low Birth Weight Infants.

JPEN J Parenter Enteral Nutr 2015 Aug 14;39(6):644-54. Epub 2014 Oct 14.

Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio.

Background: Compared with early enteral feeds, the delayed introduction and slow advancement of enteral feedings to reduce the incidence of necrotizing enterocolitis (NEC) are not well studied in extremely low birth weight (ELBW) infants.

Objective: To study the effects of a standardized slow enteral feeding (SSEF) protocol in ELBW infants.

Methods: ELBW infants who followed an SSEF protocol (September 2009 to December 2012) were compared with a similar group of historical controls (January 2003 to July 2009). Short-term outcomes between the 2 groups were compared by propensity score (PS) analysis.

Results: One hundred twenty-five infants in the SSEF group were compared with 294 historical controls. Compared with the controls, feeding initiation day, full enteral feeding day, parenteral nutrition (PN) days, and total central line days were longer in the SSEF group. There was no significant difference in overall NEC (5.6% vs 11.2%, respectively; P = .10) or surgical NEC (1.6% vs 4.8%, respectively; P = .17) between the SSEF group and controls. However, in infants with birth weight <750 g, NEC (2.1% vs 16.2%, respectively; P < .01) or combined NEC/death (12.8% vs 29.5%, respectively; P = .03) was significantly less in the SSEF group compared with controls. In infants who survived to discharge, there was no significant difference in the discharge weight or length of stay in PS-adjusted analysis.

Conclusions: An SSEF protocol significantly reduces the incidence of NEC and combined NEC/death in infants with birth weight <750 g. Despite taking longer to achieve full enteral feeding on this protocol, surviving ELBW infants demonstrated comparable weight gain at discharge without prolonging their hospital stay.
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August 2015

Improving health care usage in a very low birth weight population.

World J Pediatr 2015 Aug 28;11(3):239-44. Epub 2014 Jun 28.

Department of Pediatrics, Division of Neonatology, Case Western Reserve, Metrohealth Medical Center, 2500 Metrohealth Drive, Cleveland, OH, 44109, USA,

Background: Prematurity is the biggest contributor to admissions in the neonatal intensive care unit (NICU). The period following hospital discharge is a vital continuum for the very low birth weight (VLBW) infant. The objective of this study was to assess the impact of a unique discharge and follow-up process on the outcomes of VLBW infants leaving the NICU.

Methods: All outpatient health care usage by VLBW infants born in the study year (cases) was retrospectively tracked through 12 months of age. A cohort of healthy newborn infants were matched by birthdate to each VLBW infant (controls) and similarly tracked.

Results: In this study, there were 85 cases and 85 controls. The mean gestational age at birth for the cases was 29.1 ± 2.7 weeks with a mean birth weight of 1079 ± 263 g. That of the controls was 38.9 ± 1.3 weeks and 3202 ± 447 g. Over 90% of both populations had Medicaid coverage. All VLBW infants received care at the Special Care Developmental Follow-Up Clinic. When compared with the controls, VLBW infants discharged from the NICU made fewer acute, unscheduled visits to the Emergency Department or Urgent Care Clinic (2.3 ± 2.5 vs. 3.7 ± 3.5; P=0.007) despite their high-risk medical and social status. Their growth pattern showed significant "catch-up" and was similar to the matched controls at the last scheduled visit for each group.

Conclusions: Outcomes including health care utilization in high-risk infants can be improved through meticulous discharge planning and follow-up measures that utilize existing hospital infrastructure to provide affordable comprehensive care.
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August 2015

Impact of weight loss between pregnancies on recurrent preterm birth.

Am J Obstet Gynecol 2006 Sep;195(3):818-21

Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH, USA.

Objective: Low maternal pre-pregnancy body-mass index (BMI) has been associated with preterm birth (PTB). Women delivering preterm are at increased for recurrent PTB. Our goal was to determine whether change in BMI between pregnancies alters the risk of PTB.

Study Design: From our electronic perinatal database, we identified women who delivered consecutive pregnancies at our institution. Women were grouped by prepregnancy BMI category (underweight: <18.5, normal: 18.5-24.9, overweight: 25-29.9, obese: >30 kg/m2). They were then grouped based on change in actual BMI ("increase": >5 kg/m2, "stable": within 5 kg/m2, "decrease": >5 kg/m2) and change in BMI category between pregnancies. The risk of PTB was correlated to change in BMI. P < .05 was considered significant.

Results: One thousand two hundred forty-one women met inclusion criteria. Women with a PTB in their first pregnancy had more PTB in their second than those with a term birth in their first pregnancy (33.6% vs 8.0%, P < .001). Women whose BMI decreased more than 5 kg/m2 had more frequent PTB in the second pregnancy than those who did not (21.1% vs 9.3%, P = .01). For those with a term birth in the first pregnancy, PTB in the second did not increase with declining BMI. However, for women with a PTB in the first pregnancy, PTB was more frequent in the second if their BMI decreased a BMI category (53.8% vs 27.6%, P = .05) or if BMI decreased more than 5 kg/m2 (80.0% vs 28.2%, P = .01).

Conclusion: Women whose BMI declines between pregnancies are at increased risk for PTB, particularly if they delivered a prior preterm gestation.
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September 2006

Periviable birth at 20 to 26 weeks of gestation: proximate causes, previous obstetric history and recurrence risk.

Am J Obstet Gynecol 2005 Sep;193(3 Pt 2):1175-80

Department of Reproductive Biology, MetroHealth Medical Center at Case Western Reserve University, Cleveland, OH, USA.

Objective: Early preterm birth at 20 to 26 weeks of gestation (periviable birth) carries extreme risks of infant death and morbidities. Prevention of periviable birth could improve infant outcomes significantly. We sought to characterize the causes of periviable birth and to determine whether periviable birth can be predicted by previous pregnancy outcome.

Study Design: We evaluated 104,921 pregnancies (1974-2004) and assessed the frequency and causes of periviable birth. Women who were delivered of both their first and second pregnancies at >20 weeks of gestation at our institution were identified. Predictive values of the first pregnancy outcomes for second pregnancy outcomes were determined.

Results: Periviable birth complicated 1981 deliveries (1.9%). Seventy-nine percent of the women with periviable births had no history of periviable births; 44% of the women had no previous deliveries, and 35% of the women had previous term deliveries only. Causes of periviable birth were labor (36%), premature rupture of membranes (34%), bleeding (10%), and preeclampsia (4%). Four percent of the gestations were multiple gestations. Among 7970 pregnancies at >20 weeks of gestation, periviable birth in the first pregnancy was associated with preterm birth and periviable birth in the second pregnancy (35.6%, 6.9%; relative risk, 3.3 and 8.6; P < .0001). Periviable birth and preterm birth in the first pregnancy were insensitive for periviable birth in the second pregnancy (8.8%, 36.8%, respectively).

Conclusion: Although periviable birth is associated with subsequent periviable birth and preterm birth, preterm birth and periviable birth are insensitive markers for recurrences in the next pregnancy. Early pregnancy or preconceptional markers for prediction of periviable birth are needed.
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September 2005

Perinatal intervention and neonatal outcomes near the limit of viability.

Am J Obstet Gynecol 2004 Oct;191(4):1398-402

Departments of Reproductive Biology and Obstetrics and Gynecology, Case Western University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA.

Objective: The purpose of this study was to evaluate trends in the level of obstetric and neonatal intervention near the limit of viability and perinatal morbidity and mortality rates over time.

Study Design: In this retrospective chart review, live-born infants who were delivered at 23 to 26 weeks of gestation and who weighed between 500 and 1500 g between 1990 and 2001 in an urban tertiary care center were identified. Maternal charts were reviewed for clinical characteristics and antenatal and intrapartum course. Neonatal charts were reviewed for short-term morbidities that included respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and survival. The study group was divided into 2 cohorts (group I:1990-95; group II:1996-2001); the obstetrician's willingness to intervene, neonatal resuscitation efforts, infant mortality (in gestational age subgroups) rate, and short-term morbidity rate were compared. Multivariate analyses, which controlled for obstetrician willingness to intervene, neonatal resuscitation, cohort, and gestational age, were performed to evaluate infant survival in the entire cohort and for morbidity in the survivors.

Results: Records for 260 mothers and 293 newborn infants were evaluated. Comparing the 2 cohorts (group I vs II), we found increases over time in intent to intervene for fetal indication (70% vs 89%; P = .0007), cesarean delivery for malpresentation (20% vs 42%; P = .0003), and survival (54% vs 70%; P = .003). Pregnancies in group 1 were less likely to have received antenatal steroids (7.7% vs 60%) or surfactant (39% vs 73%; P <.0001 for each). Survival increased with advancing delivery gestation (24%, 51%, 68%, and 85% at 23, 24, 25, and 26 weeks of gestation, respectively; P <.0001). However, among survivors, the incidences of necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, respiratory distress syndrome, sepsis, and bronchopulmonary dysplasia did not decline significantly with advancing gestational age, after controlling for other factors.

Conclusion: Obstetric intervention and aggressive neonatal resuscitation have increased for pregnancies delivered between 23 and 26 weeks of gestation over the past decade. Although survival has increased over time and with advancing gestational age at delivery, short-term morbidity in survivors is similar, regardless of gestational age in this cohort. A brief delay in delivery of those pregnancies who are at risk for delivery between 23 and 26 weeks of gestation may improve survival, although short-term morbidity in survivors will not be affected substantially.
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October 2004