Impact of COVID-19 on Infants followed after Discharge from the Neonatal Intensive Care Unit Using a Telemedicine Model

Abstract

Objective Coronavirus disease 2019 (COVID-19) continues to have a profound impact on infant health care and health outcomes. In this study, we aimed to characterize the social impact of the first COVID-19 lockdown on families in a neonatal follow-up program (NFP). Given the ongoing increased use of telehealth across the medicine, we also evaluated for patient-level differences in virtual visit rates to identify patients at risk of follow-up challenges.

Study Design To assess the impact of virtual health care utilization, we conducted a retrospective cohort study to describe challenges associated with telemedicine use in this vulnerable patient population during our telemedicine epoch (March 13, 2020–July 31, 2020). We also looked for patient-level factors associated with attending NFP visits as scheduled. Finally, we summarized caregiver responses to a COVID-19 Obstacles Assessment Survey and assessed for racial disparities in these responses.

Results When comparing patients who completed their virtual visit to those who did not, we found no differences by infants' sex, birth weight, gestational age at birth, or caregiver self-reported race and ethnicity. However, infants whose visits did not occur were more often discharged with equipment or covered by public insurance. Nine percent of families reported food insecurity.

Conclusion During the initial COVID-19 lockdown, families with infants discharged from a neonatal intensive care unit (NICU) faced significant obstacles caring for their infants and attending scheduled follow-up visits. Infants in families with lower socioeconomic status or with increased medical complexity faced increased challenges in attending virtual follow-up visits during this epoch. Given the ongoing reliance on telemedicine in health care and the need to better prepare for future epidemics/pandemics, this study offers critical information that can assist neonatal teams in bolstering transitions to home and creating stronger safety nets for their patients after discharge.

Key Points

• Telemedicine works well for high-risk neonatal populations.

• Infant medical complexity may be a risk factor for challenges attending neonatal follow-up visits.

• NICUs should work to prevent food insecurity postdischarge.

Keywords

COVID-19 - neonatal follow-up - telehealth - food insecurity - racial disparities

Authors' Contributions

D. M.-W. and A. F. D. conceived the study. S. G., M. M., M. H., M. M.-P., and S. B. D. contributed to the design. S. G., M. M. and M. M.-P. were responsible for data collection. M. H. conducted the analyses. D. M.-W. wrote the first draft of the manuscript; all other authors provided critical review and feedback, and approve the manuscript as written.

Publication History

Received: 22 July 2022

Accepted: 15 November 2022

Accepted Manuscript online:
30 November 2022

Article published online:
16 January 2023

• References

• 1 Hintz SR, Gould JB, Bennett MV. et al. Referral of very low birth weight infants to high-risk follow-up at neonatal intensive care unit discharge varies widely across California. J Pediatr 2015; 166 (02) 289-295
• 2 Wolke D, Söhne B, Ohrt B, Riegel K. Follow-up of preterm children: important to document dropouts. Lancet 1995; 345 (8947): 447
• 3 Tin W, Fritz S, Wariyar U, Hey E. Outcome of very preterm birth: children reviewed with ease at 2 years differ from those followed up with difficulty. Arch Dis Child Fetal Neonatal Ed 1998; 79 (02) F83-F87
• 4 Warfield ME, Krauss MW, Hauser-Cram P, Upshur CC, Shonkoff JP. Adaptation during early childhood among mothers of children with disabilities. J Dev Behav Pediatr 1999; 20 (01) 9-16
• 5 Bailey Jr DB, Hebbeler K, Spiker D, Scarborough A, Mallik S, Nelson L. Thirty-six-month outcomes for families of children who have disabilities and participated in early intervention. Pediatrics 2005; 116 (06) 1346-1352
• 6 Fazzi E, Galli J. New clinical needs and strategies for care in children with neurodisability during COVID-19. Dev Med Child Neurol 2020; 62 (07) 879-880
• 7 Harmon SL, Conaway M, Sinkin RA, Blackman JA. Factors associated with neonatal intensive care follow-up appointment compliance. Clin Pediatr (Phila) 2013; 52 (05) 389-396
• 8 Campbell MK, Halinda E, Carlyle MJ, Fox AM, Turner LA, Chance GW. Factors predictive of follow-up clinic attendance and developmental outcome in a regional cohort of very low birth weight infants. Am J Epidemiol 1993; 138 (09) 704-713
• 9 Barfield WD, Clements KM, Lee KG, Kotelchuck M, Wilber N, Wise PH. Using linked data to assess patterns of early intervention (EI) referral among very low birth weight infants. Matern Child Health J 2008; 12 (01) 24-33
• 10 Leventhal T, Brooks-Gunn J, McCormick MC, McCarton CM. Patterns of service use in preschool children: correlates, consequences, and the role of early intervention. Child Dev 2000; 71 (03) 802-819
• 11 Hill JL, Brooks-Gunn J, Waldfogel J. Sustained effects of high participation in an early intervention for low-birth-weight premature infants. Dev Psychol 2003; 39 (04) 730-744
• 12 Patel S, Corter C, Pelletier J, Bertrand J. “Dose-response” relations between participation in integrated early childhood services and children's early development. Early Child Res Q 2016; 35: 49-62
• 13 Ye S, Kronish I, Fleck E. et al. Telemedicine expansion during the COVID-19 pandemic and the potential for technology-driven disparities. J Gen Intern Med 2021; 36 (01) 256-258
• 14 Lemmon ME, Chapman I, Malcolm W. et al. Beyond the first wave: consequences of COVID-19 on high-risk infants and families. Am J Perinatol 2020; 37 (12) 1283-1288
• 15 Smith CB, Bhardwaj AS. Disparities in the use of telehealth during the COVID-19 pandemic. J Clin Oncol 2020; 38 (29, suppl): 87
• 16 Menon DU, Belcher HME. COVID-19 pandemic health disparities and pediatric health care-the promise of telehealth. JAMA Pediatr 2021; 175 (04) 345-346
• 17 Cutler DM, Nikpay S, Huckman RS. The business of medicine in the era of COVID-19. JAMA 2020; 323 (20) 2003-2004
• 18 Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: evidence from the field. J Am Med Inform Assoc 2020; 27 (07) 1132-1135
• 19 Caporali C, Pisoni C, Naboni C, Provenzi L, Orcesi S. Challenges and opportunities for early intervention and neurodevelopmental follow-up in preterm infants during the COVID-19 pandemic. Child Care Health Dev 2021; 47 (01) 140-141
• 20 Marcin JP, Shaikh U, Steinhorn RH. Addressing health disparities in rural communities using telehealth. Pediatr Res 2016; 79 (1–2): 169-176
• 21 Demographics of mobile device ownership and adoption in the United States. Accessed March 4, 2021 at: https://www.pewresearch.org/internet/fact-sheet/mobile/
• 22 Velasquez D, Mehrotra A. Ensuring the growth of telehealth during COVID-19 does not exacerbate disparities in care. Health Affairs Blog; . Accessed February 23, 2022 at: https://www.healthaffairs.org/do/10.1377/forefront.20200505.591306/full/
• 23 Walker DM, Hefner JL, Fareed N, Huerta TR, McAlearney AS. Exploring the digital divide: age and race disparities in use of an inpatient portal. Telemed J E Health 2020; 26 (05) 603-613
• 24 Das A, Cina L, Mathew A, Aziz H, Aly H. Telemedicine, a tool for follow-up of infants discharged from the NICU? Experience from a pilot project. J Perinatol 2020; 40 (06) 875-880
• 25 Szanton SL, Gill JM. Facilitating resilience using a society-to-cells framework: a theory of nursing essentials applied to research and practice. ANS Adv Nurs Sci 2010; 33 (04) 329-343
• 26 Schiariti V. The human rights of children with disabilities during health emergencies: the challenge of COVID-19. Dev Med Child Neurol 2020; 62 (06) 661
• 27 The Hunger Vital Sign. Children's HealthWatch. Published November 8, 2018. Accessed February 10, 2022 at: https://childrenshealthwatch.org/public-policy/hunger-vital-sign/
• 28 Bell EF, Hintz SR, Hansen NI. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Mortality, in-hospital morbidity, care practices, and 2-year outcomes for extremely preterm infants in the US, 2013-2018. JAMA 2022; 327 (03) 248-263
• 29 Odoms-Young A, Bruce MA. Examining the impact of structural racism on food insecurity: implications for addressing racial/ethnic disparities. Fam Community Health 2018; 41 (Suppl 2 FOOD INSECURITY AND OBESITY): S3-S6
• 30 Racism and discrimination contribute to housing instability for black families during the pandemic. Child Trends. Published March 17, 2021. Accessed February 3, 2022 at: https://www.childtrends.org/publications/racism-and-discrimination-contribute-to-housing-instability-for-black-families-during-the-pandemic
• 31 Kim Y, Ganduglia-Cazaban C, Chan W, Lee M, Goodman DC. Trends in neonatal intensive care unit admissions by race/ethnicity in the United States, 2008-2018. Sci Rep 2021; 11 (01) 23795
• 32 Haynes N, Ezekwesili A, Nunes K, Gumbs E, Haynes M, Swain J. “Can you see my screen?” Addressing racial and ethnic disparities in telehealth. Curr Cardiovasc Risk Rep 2021; 15 (12) 23
• 33 Pagán VM, McClung KS, Peden CJ. An observational study of disparities in telemedicine utilization in primary care patients before and during the COVID-19 pandemic. Telemed J E Health 2022; 28 (08) 1117-1125
• 34 Robinson C, Gund A, Sjöqvist BA, Bry K. Using telemedicine in the care of newborn infants after discharge from a neonatal intensive care unit reduced the need of hospital visits. Acta Paediatr 2016; 105 (08) 902-909
• 35 DeMauro SB, Duncan AF, Hurt H. Telemedicine use in neonatal follow-up programs - What can we do and what we can't - Lessons learned from COVID-19. Semin Perinatol 2021; 45 (05) 151430
• 36 Litt JS, Edwards EM, Lainwala S. et al. Optimizing high-risk infant follow-up in nonresearch-based paradigms: the New England Follow-up Network. Pediatr Qual Saf 2020; 5 (03) e287
• 37 Fraiman YS, Stewart JE, Litt JS. Race, language, and neighborhood predict high-risk preterm Infant Follow Up Program participation. J Perinatol 2022; 42 (02) 217-222
• 38 Coleman-Jensen A, Gregory C, Singh A. Household food security in the United States in 2013. September 1, 2014. USDA-ERS Economic Research Report Number 173. Accessed February 24, 2022 at SSRN: https://ssrn.com/abstract=2504067
• 39 Fitzpatrick KM, Harris C, Drawve G, Willis DE. Assessing food insecurity among US adults during the COVID-19 pandemic. J Hunger Environ Nutr 2021; 16 (01) 1-18
• 40 Ahn S, Norwood FB. Measuring food insecurity during the COVID-19 pandemic of spring 2020. Appl Econ Perspect Policy 2021; 43 (01) 162-168
• 41 Cassidy-Vu L, Way V, Spangler J. The correlation between food insecurity and infant mortality in North Carolina. Public Health Nutr 2022; 25 (04) 1038-1044
• 42 Patient Safety Network. Never events. Agency for Healthcare Research and Quality. Published September 7, 2019. Accessed July 14, 2022 at: https://psnet.ahrq.gov/primer/never-events
• 43 Montoya-Williams D, Fraiman YS, Peña MM, Burris HH, Pursley DM. Antiracism in the field of neonatology: a foundation and concrete approaches. Neoreviews 2022; 23 (01) e1-e12