American Academy of Pediatrics – Section on Perinatal Pediatrics

July 20, 2015

  1. 1

    Avoid routine use of anti-reflux medications for treatment of symptomatic gastroesophageal reflux disease (GERD) or for treatment of apnea and desaturation in preterm infants.

    Gastroesophageal reflux is normal in infants. There is minimal evidence that reflux causes apnea and desaturation. Similarly, there is little scientific support for the use of H2 antagonists, proton-pump inhibitors, and motility agents for the treatment of symptomatic reflux. Importantly, several studies show that their use may have adverse physiologic effects as well as an association with necrotizing enterocolitis, infection and, possibly, intraventricular hemorrhage and mortality.

  2. 2

    Avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection.

    There is insufficient evidence to support antibiotic treatment for more than 48 hours to rule out bacterial infection in asymptomatic term and preterm infants. Current blood culturing systems identify the great majority of pathologic organisms prior to 48 hours. Prolonged antibiotic use may be associated with necrotizing enterocolitis and death in extremely low birthweight infants.

  3. 3

    Avoid routine use of pneumograms for pre-discharge assessment of ongoing and/or prolonged apnea of prematurity.

    Cardio-respiratory events are common in both term and preterm infants. Although there may be a role for pneumograms in selected cases where the etiology of the events is in doubt, they have not been shown to reduce acute life-threatening events or mortality from their routine use.

  4. 4

    Avoid routine daily chest radiographs without an indication for intubated infants.

    Although intermittent chest radiographs may identify unexpected findings, there is no evidence documenting the effectiveness of daily chest X-rays to reduce adverse outcomes. Further, this practice is associated with increased radiation exposure.

  5. 5

    Avoid routine screening term-equivalent or discharge brain MRIs in preterm infants.

    Findings on term-equivalent magnetic resonance imaging (MRI) correlate with neurodevelopmental outcomes at discharge and at 2 and 5 years of age. There is, however, insufficient evidence that the routine use of term-equivalent or discharge screening brain MRIs in preterm infants improves long-term outcome.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Academy of Pediatrics is an organization of 62,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. The Section on Perinatal Pediatrics, the largest specialty subgroup of the Academy, is the home organization for 3500 specialists in Neonatal-Perinatal Medicine and focuses on ensuring the optimal health and well-being of babies and mothers through core activities in advocacy, education, outreach, and clinical and academic support.

How This List Was Created

The American Academy of Pediatrics Section on Perinatal Pediatrics (SoPPe) Executive Committee employed a national survey of representative newborn medicine providers from SoPPe and the Vermont-Oxford Network. Survey recipients were asked to consider the range of testing and treatments conducted on high and low risk newborns. They were then asked them to provide examples of tests and treatments that, in their opinion, best met any or all of the following criteria: there is evidence of lack of efficacy, there is insufficient evidence of efficacy, or the test or treatment unnecessarily utilized staffing or material resources. Among the recipients, 1047 responded with a total of 2870 suggestions of tests and treatments. These responses were then collated and presented to an expert panel of 51 individuals representing 28 national and regional stakeholder perinatal care organizations. A modified Delphi process utilizing electronic survey techniques was used to narrow the list to the Top 5 over three rounds. During the initial round, the panel reduced the top 22 general categories of tests and treatments to 13. The reintroduction of specific clinical contexts, derived from the original survey, resulted in 24 items that were reduced to 12 in the second round. In the final round, the panel was provided with GRADE (Grades of Recommendation, Assessment, Development and Evaluation) literature summaries of the top 12 to ensure that all current evidence was considered. The final list was reviewed and approved by the Academy’s Board of Directors and Executive Committee.

AAP’s disclosure and conflict of interest policy can be found at www.aap.org.

Sources

  1. Beck-Sague CM, Azimi P, Fonseca SN, Baltimore RS, Powell DA, Bland LA, Arduino MJ, McAllister SK, Huberman RS, Sinkowitz RL, et al. Bloodstream infections in neonatal intensive care unit patients: results of a multicenter study. Pediatr Infect Dis J. 1994 Dec;13(12):1110–6.

    Bianconi S, Gudavalli M, Sutija VG, Lopez AL, Barillas-Arias L, Ron N. Ranitidine and late-onset sepsis in the neonatal intensive care unit. J Perinat Med. 2007; 35(2):147–50.

    Chung EY, Yardley J. Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease? Hosp Pediatr. 2013 Jan;3(1):16-23.

    Guillet R, Stoll BJ, Cotten CM, Gantz M, McDonald S, Poole WK, Phelps DL; National Institute of Child Health and Human Development Neonatal Research Network. Association of H2-blocker therapy and higher incidence of necrotizing enterocolitis in very low birth weight infants. Pediatrics. 2006 Feb;117(2):e137-42.

    Hibbs AM, Lorch SA. Metoclopramide for the treatment of gastroesophageal reflux disease in infants: a systematic review. Pediatrics. 2006 Aug;118(2):746-52.

    Rojas MA, Efird MM, Lozano JM, Bose CL, Rojas MX, Rondón MA, Ruiz G, Piñeros JG, Rojas C, Robayo G, Hoyos A, Gosendi MH, Cruz H, O’Shea M, Leon A. Risk factors for nosocomial infections in selected neonatal intensive care units in Colombia, South America. J Perinatol. 2005 Aug;25(8):537–41.

    Terrin G, Passariello A, De Curtis M, Manguso F, Salvia G, Lega L, Messina F, Paludetto R, Canani RB. Ranitidine is associated with infections, necrotizing enterocolitis, and fatal outcome in newborns. Pediatrics. 2012 Jan;129(1):e40-5.

    van der Pol RJ, Smits MJ, van Wijk MP, Omari TI, Tabbers MM, Benninga MA. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35.

    Wheatley E, Kennedy KA. Cross-over trial of treatment for bradycardia attributed to gastroesophageal reflux in preterm infants. J Pediatrics. 2009 Oct;155(4):516-21.

  2. Cotten CM, Smith PB. Duration of empirical antibiotic therapy for infants suspected of early-onset sepsis. Curr Opin Pediatr. 2013 Apr;25(2):167-71.

    Cotten CM, Taylor S, Stoll B, Goldberg RN, Hansen NI, Sánchez PJ, Ambalavanan N, Benjamin DK Jr; NICHD Neonatal Research Network. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics. 2009 Jan;123(1):58-66.

    Garcia-Prats JA, Cooper TR, Schneider VF, Stager CE, Hansen TN. Rapid detection of microorganisms in blood cultures of newborn infants utilizing an automated blood culture system. Pediatrics. 2000 Mar;105(3 Pt 1):523-7.

  3. Di Fiore T. Use of sleep studies in the neonatal intensive care unit. Neonatal Netw. 2005 Jan;24(1):23-30.

    Ramanathan R, Corwin MJ, Hunt CE, Lister G, Tinsley LR, Baird T, Silvestri JM, Crowell DH, Hufford D, Martin RJ, Neuman MR, Weese-Mayer DE, Cupples LA, Peucker M, Willinger M, Keens TG; Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Cardiorespiratory events recorded on home monitors: Comparison of healthy infants with those at increased risk for SIDS. JAMA. 2001 May 2;285(17):2199-207.

  4. Greenough A, Dimitriou G, Alvares BR, Karani J. Routine daily chest radiographs in ventilated, very low birth weight infants. Eur J Pediatr. 2001 Mar;160(3):147-9.

    Spitzer AR, Greer JG, Antunes M, Szema KF, Gross GW. The clinical value of screening chest radiography in the neonate with lung disease. Clin Pediatr (Phila). 1993 Sep;32(9):514-9.

  5. Iwata S, Nakamura T, Hizume E, Kihara H, Takashima S, Matsuishi T, Iwata O. Qualitative brain MRI at term and cognitive outcomes at 9 years after very preterm birth. Pediatrics. 2012 May;129(5):e1138-47.

    Janvier A, Barrington K. Trying to predict the future of ex-preterm infants: who benefits from a brain MRI at term? Acta Paediatr. 2012 Oct;101(10):1016-7.

    Miller SP, Ferriero DM, Leonard C, Piecuch R, Glidden DV, Partridge JC, Perez M, Mukherjee P, Vigneron DB, Barkovich AJ. Early brain injury in premature newborns detected with magnetic resonance imaging is associated with adverse early neurodevelopmental outcome. J Pediatr. 2005 Nov;147(5):609-16.

    Nongena P, Ederies A, Azzopardi DV, Edwards AD. Confidence in the prediction of neurodevelopmental outcome by cranial ultrasound and MRI in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2010 Nov; 95(6):F388-90.

    Pearce R, Baardsnes J. Term MRI for small preterm babies: do parents really want to know and why has nobody asked them? Acta Paediatr. 2012 Oct;101(10):1013-5.

    Setänen S, Haataja L, Parkkola R, Lind A, Lehtonen L. Predictive value of neonatal brain MRI on the neurodevelopmental outcome of preterm infants by 5 years of age. Acta Paediatr. 2013 May;102(5):492-7.

    Woodward LJ, Anderson PJ, Austin NC, Howard K, Inder TE. Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. N Engl J Med. 2006 Aug 17; 355(7):685-94.

    Woodward LJ, Clark CA, Bora S, Inder TE. Neonatal white matter abnormalities an important predictor of neurocognitive outcome for very preterm children. PLoS One. 2012;7(12):e51879.