Nilima Karamchandani, M.D. Matthew Pellerite , M.D Joe Hageman, M.D. Betty McEntire , Ph.D.

1. A SURVEY OF U.S. NEONATOLOGISTS REGARDING MANAGEMENT OF A PREMATURE INFANT WHO RETURNS TO THE ER WITH AN ALTE AFTER DISCHARGE HOME Nilima Karamchandani, M.D. Matthew Pellerite, M.D Joe Hageman, M.D. Betty McEntire, Ph.D.

2. INTRODUCTION • Neonatologists make daily decisions regarding the timing of home discharge of premature infants. It is clear that premature infants are at increased risk for SIDS and for developmental problems. However, the direct effects of cardiorespiratory events is unclear.

3. METHODS • An anonymous online survey (surveymonkey.com.LLC) was sent to 3200 neonatologists who are members of the Perinatal Section of the AAP using the section list serv. IRB approval was obtained from the Perinatal Section of the AAP and from the Principal Investigator’s institutions (Hageman, Karamchandani) • The survey consisted of 28 questions and included multiple choice and open ended questions about demographics and questions about discharge. • There were also clinical vignettes which described a clinical scenario, with variations and discharge choices and asked the respondent what he/she would do in various situations

4. DEMOGRAPHICS • Responses were received from 368 of 1038 NICU’s (35% response rate) • 88% from neonatologists working in Level III NICU’s • 62% have units > 30 beds • Mean yearly admissions were 614 (range 80-3,000) • 52% of respondents have been in practice > 20 years • 64% work in a teaching hospital

5. DISCHARGE DECISIONS • 26% (97/367) of neonatologists perform cardiorespiratory recordings before discharge • 76% use continuous recordings

6. CLINICAL CONDITIONS UNDER WHICH RECORDINGS ARE MOST COMMONLY PERFORMED • Ongoing events (95.7%) • ALTE (83.9%) • Chronic lung disease on oxygen therapy (52.7%) • Resolved apnea of prematurity (45.2%) • Asymptomatic SIDS siblings (38.7%)

7. CLINICAL VIGNETTES In the survey, there were six clinical vignettes presented, each with a clinical scenario, variations and discharge choices. 1. Premature Infant 2. Subsequent sibling of SIDS 3. HIE after perinatal asphyxia with NG feeds 4. Premature infant brought to the ER after discharge home with an ALTE 5. Premature infant with GER 6. Premature infant on Caffeine for AOP

8. VIGNETTE REGARDING ALTE You are caring for a 6 week old infant born at 32 weeks GA who, 3 days after discharge, is brought to the ER by paramedics for an ALTE. He is admitted to the NICU and appears healthy with a normal physical and neurologic exam. The work up included a cranial ultrasound, EEG, ECG, electrolytes, blood, urine and CSF cultures, an LP, a newborn metabolic screen, a urine toxicology screen and all were normal. He is observed for 24 hours and exhibits no cardiorespiratory events.

9. Vignette regarding ALTE (cont.)

10. CONCLUSIONS • After the First ALTE : 1. 42.2% of neonatologists would continue hospitalization 2. 5.2% would discharge with no monitor 3. 52.6% would discharge on home monitor

11. CONCLUSIONS • After the second ALTE: 1. 45.6% would continue hospitalization 2. 0.8% would discharge with no monitor 3. 53.6% would discharge on home monitor

12. CONCLUSIONS • If infant required full CPR by EMT 1. 57.9% would continue hospitalization 2. 0.8% would discharge home with no monitor 3. 41.3% would discharge on home monitor

13. SUMMARY • There is no significant difference in management by neonatologists in an infant who has had one or two ALTE’s • If an infant required full CPR, most neonatologists would continue hospitalization. Upon discharge, the majority of infants would be discharged on home monitors