Neonatal Morbidity and 1-Year Survival of Extremely Preterm Infants

Continued improvement in morbidity reduction in extremely premature infants

OBJECTIVE

Provide a progress report updating our long-term quality improvement collaboration focused on major morbidity reduction in extremely premature infants 23-27 weeks.

METHODS

10 Vermont Oxford Network (VON) neonatal intensive care units (NICUs) (the POD) sustained a structured alliance: (A) face-to-face meetings, site visits and teleconferences, (B) transparent process and outcomes sharing, (C) utilisation of evidence-based potentially better practice toolkits, (D) family integration and (E) benchmarking via a composite mortality-morbidity score (Benefit Metric). Morbidity-specific toolkits were employed variably by each NICU according to local priorities. The eight major VON morbidities and the risk-adjusted Benefit Metric were compared in two epochs 2010-2013 versus 2014-2018.

RESULTS

5888 infants, mean (SD) gestational age 25.8 (1.4) weeks, were tracked. The POD Benefit Metric significantly improved (p=0.03) and remained superior to the aggregate VON both epochs (p<0.001). Four POD morbidities significantly improved through 2018 - chronic lung disease (48%-40%), discharge weight <10th percentile (32%-22%), any late infection (19%-17%) and periventricular leukomalacia (4%-2%). In epoch 2, 34% of survivors had none of the eight major morbidities, while 36% had just one. Mortality did not change.

CONCLUSIONS

Inter-NICU collaboration, process and outcomes sharing and potentially better practice toolkits sustain improvement in 23-27 week morbidity rates, notably chronic lung disease, extrauterine growth restriction and the lowest zero-or-one major morbidity rate reported by a quality improvement collaboration. Unrevealed biological and cultural variables affect morbidity rates, countless remain unmeasured, thus duplication to other quality improvement groups is challenging. Understanding intensive care as innumerable interactions and constant flux that defy convenient linear constructs is fundamental.

Stable incidence but regional differences in retinopathy of prematurity in Norway from 2009 to 2017

PURPOSE

To explore the changes over time and regional differences in the incidence of retinopathy of prematurity (ROP) in a national cohort of infants born <28 weeks' gestational age (GA).

METHODS

A population-based study of infants with GA <28 weeks in Norway from 2009 to 2017. Prospectively collected data on clinical variables and outcomes were obtained from the Norwegian Neonatal Network.

RESULTS

Of 1499 live-born infants transferred to a neonatal intensive care unit, 1156 were discharged alive. Four-hundred and fifty-eight infants (39.6%) had ROP, 152 (13.1%) had severe ROP, and 110 (9.5%) were treated for ROP. Eleven hundred infants (95.2%) had complete data sets. In a model comprising region of primary care, GA [odds ratios (OR): 0.65; 95% CI: 0.55-0.77], growth velocity (OR: 1.10; 95% CI: 1.00-2.00), medically treated patent ductus arteriosus (OR: 1.80; 95% CI: 1.19-2.72), weeks of supplemental oxygen (OR: 1.07; 95% CI: 1.03 to 1.11) and region of primary care (OR: 4.95; 95% CI: 3.05-8.04 for the pair of regions with the highest estimated OR) were significantly associated with severe ROP. Additionally, institutional differences for severe ROP were found, with ORs from 0.41 (95% CI: 0.05-3.23) to 5.36 (95% CI: 3.05-9.43) using the largest institution as reference. Incidences were stable over time after adjusting for GA. A larger proportion was treated with anti-vascular endothelial growth factor after 2011.

CONCLUSIONS

The incidence of severe ROP was stable between 2009 and 2017 in Norway. Regional and institutional differences need to be explored in future studies.

Early volume targeted ventilation in preterm infants born at 22-25 weeks of gestational age

BACKGROUND

Early hypocapnia in preterm infants is associated with intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). Volume targeted ventilation (VTV) has been shown to reduce hypocapnia in preterm infants. Less is known of VTV in infants born at <26 weeks gestational age (GA).

OBJECTIVES

Our aim was to investigate the short- and long-term effects of early VTV as compared to pressure limited ventilation (PLV) in extremely preterm infants on the incidence of hypocapnia, days on ventilatory support, IVH, and BPD.

STUDY DESIGN

A retrospective observational study of 104 infants born at 22-25 weeks GA (mean ± SD; 24⁺⁰  ± 1⁺¹ GA; birth weight 619 ± 146 g), ventilated with either VTV (n = 44) or PLV (n = 60) on their first day of life. Ventilatory data and blood gases were collected at admission and every fourth hour during the first day of life, together with perinatal characteristics and outcomes.

RESULTS

Peak inflation pressure (PIP) was lower in the VTV-group than in the PLV-group during the first 20 h of life (p < .05), without any difference in respiratory rate or FiO₂ . Incidence of hypocapnia (PaCO₂ < 4.5 kPa) was lower with VTV than PLV during the first day of life (32% vs. 62%; p < .01). Infants in the VTV-group were more frequently extubated at 24 h (30% vs. 13%; p < .05). IVH Grade ≥3, BPD, and time on mechanical ventilation did not differ between the groups.

CONCLUSIONS

VTV is safe to apply in infants born at <26 GA and was observed to result in a lower incidence of hypocapnia compared to infants ventilated by PLV, without any differences in outcomes.

Neonatal End-of-Life Decision Making: The Possible Behavior of Greek Physicians, Midwives, and Nurses in Clinical Scenarios

Background: This study investigates the acceptability, bioethical justification, and determinants of the provision of intensive care to extremely preterm or ill neonates among healthcare professionals serving in NICUs in Greek hospitals. Methods: Healthcare professionals (71 physicians, 98 midwives, and 82 nurses) employed full-time at all public Neonatal Intensive Care Units (NICUs) (n = 17) in Greece were asked to report their potential behavior in three clinical scenarios. Results: The majority of healthcare professionals would start and continue intensive care to (a) an extremely preterm neonate, (b) a full-term neonate with an unfavorable prognosis, and (c) a neonate with complete phocomelia. In cases (a) and (b), midwives and nurses compared to physicians (p = 0.009 and p = 0.004 in scenarios (a) and (b), respectively) and health professionals ascribing to the quality-of-life principle compared to those ascribing to the intrinsic value of life (p = 0.001 and p = 0.01 scenarios (a) and (b) respectively), tend towards withholding or withdrawing care. Religion plays an important role in all three scenarios (p = 0.005, p = 0.017 and p = 0.043, respectively). Conclusions: Understanding healthcare professionals’ therapeutic intensiveness in the face of NICU ethical dilemmas can improve NICU policies, support strategies, and, consequently, the quality of neonatal intensive care.

Primary evisceration for neonatal endogenous endophthalmitis: A report of two cases

Purpose

To present two cases of neonatal endophthalmitis with poor prognosis that were managed with primary evisceration.

Observations

Case 1 is a 27-weeks’ gestation neonate who developed Pseudomonas aeruginosa endophthalmitis complicated by globe rupture. Case 2 describes a 34-weeks’ gestation neonate with Serratia marcescens endophthalmitis. Both patients had poor prognosis and thus underwent primary evisceration with good long-term cosmetic outcomes at 15 years and 17 months, respectively.

Conclusions and Importance

Primary evisceration should be considered in neonates with endophthalmitis with a poor prognosis and can result in good long-term cosmesis.

Risk factors for re-hospitalization following neonatal discharge of extremely preterm infants in Canada

OBJECTIVE

Survivors of extremely preterm birth are at risk of re-hospitalization but risk factors in the Canadian population are unknown. Our objective is to identify neonatal, sociodemographic, and geographic characteristics that predict re-hospitalization in Canadian extremely preterm neonates.

METHODS

This is a retrospective analysis of a prospective observational cohort study that included preterm infants born 22 to 28 weeks' gestational age from April 1, 2009 to September 30, 2011 and seen at 18 to 24 months corrected gestational age in a Canadian Neonatal Follow-Up Network clinic. Characteristics of infants re-hospitalized versus not re-hospitalized are compared. The potential neonatal, sociodemographic, and geographic factors with significant association in the univariate analysis are included in a multivariate model.

RESULTS

From a total of 2,275 preterm infants born at 22 to 28 weeks gestation included, 838 (36.8%) were re-hospitalized at least once. There were significant disparities between Canadian provincial regions, ranging from 25.9% to 49.4%. In the multivariate logistic regression analysis, factors associated with an increased risk for re-hospitalization were region of residence, male sex, bronchopulmonary dysplasia, necrotizing enterocolitis, prolonged neonatal intensive care unit (NICU) stay, ethnicity, Indigenous ethnicity, and sibling(s) in the home.

CONCLUSION

Various neonatal, sociodemographic, and geographic factors predict re-hospitalization of extremely preterm infants born in Canada. The risk factors of re-hospitalization provide insights to help health care leaders explore potential preventative approaches to improve child health and reduce health care system costs.

Fetal inflammation induces acute immune tolerance in the neonatal rat hippocampus

BACKGROUND

Infants born preterm due to chorioamnionitis are frequently affected by a fetal inflammatory response syndrome (FIRS) and then by subsequent postnatal infections. FIRS and postnatal systemic inflammatory events independently contribute to poor neurocognitive outcomes of preterm infants. Developmental integrity of the hippocampus is crucial for intact neurocognitive outcomes in preterms and hippocampally dependent behaviors are particularly vulnerable to preterm systemic inflammation. How FIRS modulates the hippocampal immune response to acute postnatal inflammatory events is not well understood.

METHODS

Prenatal LPS exposed (FIRS) and control neonatal rats received i.p. LPS or saline at postnatal day (P) 5. On P7, immune response was evaluated in the hippocampus of four treatment groups by measuring gene expression of inflammatory mediators and cytosolic and nuclear NFκB pathway proteins. Microglial activation was determined by CD11b+ and Iba1+ immunohistochemistry (IHC) and inflammatory gene expression of isolated microglia. Astrocyte reactivity was measured using Gfap+ IHC.

RESULTS

Postnatal LPS resulted in a robust hippocampal inflammatory response. In contrast, FIRS induced by prenatal LPS attenuated the response to postnatal LPS exposure, evidenced by decreased gene expression of inflammatory mediators, decreased nuclear NFκB p65 protein, and fewer activated CD11b+ and Iba1+ microglia. Isolated microglia demonstrated inflammatory gene upregulation to postnatal LPS without evidence of immune tolerance by prenatal LPS.

CONCLUSION

Prenatal LPS exposure induced immune tolerance to subsequent postnatal LPS exposure in the hippocampus. Microglia demonstrate a robust inflammatory response to postnatal LPS, but only a partial immune tolerance response.

Temporal changes in rates of active management and infant survival following live birth at 22-24 weeks' gestation in Victoria

BACKGROUND

Management of livebirths at 22-24 weeks' gestation in high-income countries varies widely and has changed over time.

AIMS

Our aim was to determine how rates of active management and infant survival of livebirths at 22-24 weeks varied with perinatal variables known at birth, and over time in Victoria, Australia.

MATERIALS AND METHODS

We conducted a population-based cohort study of all 22-24 weeks' gestation live births, free of lethal congenital anomalies in 2009-2017. Rates of active management and survival to one year of age were reported. 'Active management' was defined as receiving resuscitation at birth or nursery admission for intensive care.

RESULTS

Over the nine-year period, there were 796 eligible live births. Overall, 438 (55%) were actively managed: 5% at 22 weeks, 45% at 23 weeks and 90% at 24 weeks' gestation, but rates of active management did not vary substantially over time. Of livebirths actively managed, 263 (60%) survived to one year: 0% at 22 weeks, 50% at 23 weeks and 66% at 24 weeks. Apart from gestational age, being born in a tertiary perinatal centre and increased size at birth were associated with survival in those actively managed, but sex and plurality were not. Survival rates of actively managed infants rose over time (adjusted odds ratio 1.09 per year; 95% CI 1.01-1.18; P = 0.03).

CONCLUSIONS

Although active management rates did not change substantially over time in Victoria, an overall increase in infant survival was observed. With increasing gestational age, rates of active management and infant survival rapidly rose.

Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to provide a systematic review and meta-analysis to quantify prognosis and identify factors associated with variations in reported mortality estimates among infants who were born at 22 weeks of gestation and provided proactive treatment (resuscitation and intensive care).

DATA SOURCES

PubMed, Scopus, and Web of Science databases, with no language restrictions, were searched for articles published from January 2000 to February 2020.

STUDY ELIGIBILITY CRITERIA

Reports on live-born infants who were delivered at 22 weeks of gestation and provided proactive care were included. The primary outcome was survival to hospital discharge; secondary outcomes included survival without major morbidity and survival without neurodevelopmental impairment. Because we expected differences across studies in the definitions for various morbidities, multiple definitions for composite outcomes of major morbidities were prespecified. Neurodevelopmental impairment was based on Bayley Scales of Infant Development II or III. Data extractions were performed independently, and outcomes agreed on a priori.

STUDY APPRAISAL AND SYNTHESIS METHODS

Methodological quality was assessed using the Quality in Prognostic Studies tool. An adapted version of the Grading of Recommendations Assessment, Development and Evaluation approach for prognostic studies was used to evaluate confidence in overall estimates. Outcomes were assessed as prevalence and 95% confidence intervals. Variabilities across studies attributable to heterogeneity were estimated with the I² statistic; publication bias was assessed with the Luis Furuya-Kanamori index. Data were pooled using the inverse variance heterogeneity model.

RESULTS

Literature searches returned 21,952 articles, with 2034 considered in full; 31 studies of 2226 infants who were delivered at 22 weeks of gestation and provided proactive neonatal treatment were included. No articles were excluded for study design or risk of bias. The pooled prevalence of survival was 29.0% (95% confidence interval, 17.2-41.6; 31 studies, 2226 infants; I²=79.4%; Luis Furuya-Kanamori index=0.04). Survival among infants born to mothers receiving antenatal corticosteroids was twice the survival of infants born to mothers not receiving antenatal corticosteroids (39.0% vs 19.5%; P<.01). The overall prevalence of survival without major morbidity, using a definition that includes any bronchopulmonary dysplasia, was 11.0% (95% confidence interval, 8.0-14.3; 10 studies, 374 infants; I²=0%; Luis Furuya-Kanamori index=3.02). The overall rate of survival without moderate or severe impairment was 37.0% (95% confidence interval, 14.6-61.5; 5 studies, 39 infants; I²=45%; Luis Furuya-Kanamori index=-0.15). Based on the year of publication, survival rates increased between 2000 and 2020 (slope of the regression line=0.09; standard error=0.03; P<.01). Studies were highly diverse with regard to interventions and outcomes reported.

CONCLUSION

The reported survival rates varied greatly among studies and were likely influenced by combining observational data from disparate sources, lack of individual patient-level data, and bias in the component studies from which the data were drawn. Therefore, pooled results should be interpreted with caution. To answer fundamental questions beyond the breadth of available data, multicenter, multidisciplinary collaborations, including alignment of important outcomes by stakeholders, are needed.

Trends in survival, neonatal morbidity and neurodevelopmental outcome of very preterm infants in Tainan, Southern Taiwan, 1995-2016

BACKGROUND

Using regression modeling analysis to investigate the breakpoints of the trends in survival-without-major-neonatal-morbidities (MNM) or -without-neurodevelopmental- impairment (NDI) by year and gestational age (GA) in preterm infants.

METHODS

We enrolled 2237 preterm infants (GA < 32 weeks) in Tainan, Taiwan. The trends in survival-without-MNM or -without-NDI by year (1995-2016) and GA (23-31 weeks), and the epochs and GA ranges with distinct changes were examined. Adjusted rate ratios (aRR) (95% confidence interval [CI]) were calculated using the rates in infants born at 23 weeks in 1995 as the reference.

RESULTS

For yearly trend, there were three epochs (1995-2000, 2001-2006, 2007-2016) with distinct changes in the rates of survival-without-MNM (aRR [95% CI] 1.07 [1.02-1.12], 1.04 [1.02-1.07], 1.02 [1.01-1.04]) and -without-NDI (1.03 [1.02-1.07], 1.02 [1.01-1.04], 1.01 [0.98-1.04]). For GA trend, the three GA ranges with different increases in the rates of survival-without-MNM were 23⁺⁰-26⁺⁶ (1.60 [1.31-1.94]), 27⁺⁰-28⁺⁶ (1.24 [1.14-1.34]) and 29⁺⁰-31⁺⁶ weeks (1.17 [1.02-1.34]), while those in the rates of survival-without-NDI were 23⁺⁰-25⁺⁶ (1.14 [1.03-1.25]), 26⁺⁰-28⁺⁶ (1.06 [1.02-1.12]) and 29⁺⁰-31⁺⁶ weeks (1.04 [1.02-1.07]). The trends in survival-without-MNM and -without-NDI increased over years in infants with GA 25-31 but not < 25 weeks.

CONCLUSION

The yearly trends in survival-without-MNM and -without-NDI had steady increases from 1995 to 2016 with distinct changes in three epochs, and the GA trends also increased with different rates per week in three GA ranges. Infants with GA < 25 weeks did not improve on the rates of survival-without-MNM or -without-NDI per year from 1995 to 2016.

Vascular Endothelial Function Assessed by Flow-Mediated Vasodilatation in Young Adults Born Very Preterm or With Extremely Low Birthweight: A Regional Cohort Study

Background: Preterm birth and low birthweight have been associated with increased risk of cardiovascular disease in young adults. Endothelial dysfunction is established as an early marker for development of atherosclerotic cardiovascular disease. Previous studies of endothelial function in young adults born very preterm or with extremely low birthweight have, however, shown diverging results. Objective: We aimed to evaluate the risk of cardiovascular disease as measured by vascular endothelial function in young adults born very preterm (<29 weeks of gestation) or with extremely low birthweight (<1,000 g), compared with term-born controls. Methods: This study included 50 young adults born very preterm or with extremely low birthweight and 49 term-born controls born in Norway in the periods 1982-1985, 1991-1992, and 1999-2000 at mean age 28 (±6) years. The endothelial function was assessed by ultrasound measured flow-mediated dilatation (FMD) of the right brachial artery. The arterial diameter was measured at baseline, after release of 5 min of occlusion, and after sublingual administration of nitroglycerine. FMD was reported as absolute and percentage diameter change from baseline and relative to nitroglycerine-induced dilatation. Results: The participants were mainly normal weight non-smokers, without hypertension, diabetes, or established cardiovascular disease. The cases and controls had mean blood pressure 112/71 (SD 12/9) and 112/69 (SD 11/8) mmHg, body mass index 24.0 (SD 4.2) and 24.4 (SD 4.5) kg/m², and HbA1c 32.7 (SD 2.5) and 33.0 (SD 2.6) mmol/mol, respectively. For both groups, 4 (8%) were smokers. Mean FMD for the adults born very preterm or with extremely low birthweight was 0.17 mm (95% CI 0.14, 0.21) vs. 0.24 mm (95% CI 0.20, 0.28) for the controls (p = 0.01), corresponding to a percentage increase of 5.4% (95% CI 4.2, 6.6) and 7.6% (95% CI 6.2, 8.9), respectively (p = 0.02). The FMD relative to maximal nitroglycerine-induced dilatation was 20% and 31%, respectively (p = 0.001). Conclusions: Young adults born very preterm or with extremely low birthweight have significantly lower FMD compared with the term-born controls suggesting an increased risk of cardiovascular disease.

Development of a Nomogram for Moderate-to-Severe Bronchopulmonary Dysplasia or Death: Role of N-Terminal Pro-brain Natriuretic Peptide as a Biomarker

Objectives: This study aimed to explore the clinical value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in predicting moderate-to-severe bronchopulmonary dysplasia (BPD)/death, and to establish an effective clinical predictive nomogram. Methods: We retrospectively analyzed very low birth weight infants (VLBWs) with gestational age ≤ 32 weeks. The NT-proBNP values were determined on the 1st, 3rd, 7th, 14th, 21st, and 28th days after birth. The correlation between NT-proBNP level and moderate-to-severe BPD/death was evaluated. Receiver operating characteristic (ROC) curve analysis was used to evaluate the prediction ability. Then, we used multivariable logistic regression to build the prediction model and nomogram, and calibration of the model was assessed by calibration curve. Results: In total, 556 VLBWs were involved, among whom 229 developed BPD (mild: n = 109; moderate: n = 68; severe: n = 52) and 18 died. The NT-proBNP level in the moderate-to-severe BPD/death group was significantly higher than that in the no-to-mild BPD group from the 3rd to 28th day (P < 0.001). When the natural logarithm of the serum NT-ProBNP level increased by 1 unit at day 7 (±2 days) of life, the risk of moderate and severe BPD/death was the highest (OR = 3.753; 95% CI: 2.984~4.720), and ROC analysis identified an optimal cutoff point of 3360 ng/L (sensitivity: 80.0%; specificity: 86.2%; AUC: 0.861). After adjusting for confounding factors, the level of NT-proBNP at day 7 (±2 days) of life still had important predictive value for the development of moderate-to-severe BPD/death, significantly improving the predictive ability of the model. Conclusion: The level of NT-proBNP at day 7 (±2 days) of life can be used as an early promising biomarker for VLBWs to develop moderate-to-severe BPD/death. We constructed an early predictive nomogram to help clinicians identify high-risk populations.

Duration of Mechanical Ventilation and Extubation Success among Extremely Premature Infants

OBJECTIVE

The objective of this study was to examine the duration of mechanical ventilation (MV) in days until the first successful extubation and the cumulative duration of MV until discharge of infants with gestational age (GA) <26 weeks. We also aimed to explore associations between early clinical variables and the cumulative duration of MV.

DESIGN AND SETTING

This population-based study analysed data reported to the Norwegian Neonatal Network on extremely premature infants admitted between January 1, 2013, and December 31, 2018.

RESULTS

A total of 406 infants were included, of which 293 (72%) survived to discharge. The proportion successfully extubated on their first attempt was 34% of the infants born at GA 22-23 weeks, 50% at GA 24 weeks, and 70% at GA 25 weeks. Median postmenstrual age (PMA) at the first successful extubation was 27 weeks. The median duration of MV was 35, 24, and 12 days for infants born at GA 22-23, 24, and 25 weeks, respectively. Male sex and low 5-min Apgar score were independent early predictors for prolonged MV duration adjusted for GA in regression analyses.

CONCLUSIONS

Most of the infants born at GA 25 weeks were successfully extubated on the first attempt. However, half of the infants born <26 weeks experienced unsuccessful extubations, indicating a lack of useful clinical predictors of successful extubation. The median duration of MV in survivors was 4 weeks longer for infants at GA 22-23 weeks than for infants born at GA 25 weeks, while the difference in median PMA at the first successful extubation was 2 weeks.

Sonographic Assessment of Fetal Growth Abnormalities

Fetal growth abnormalities have significant consequences for pregnancy management and maternal and fetal well-being. The accurate diagnosis of fetal growth abnormalities contributes to optimal antenatal management, which may minimize the sequelae of inadequate or excessive fetal growth. An accurate diagnosis of abnormal fetal growth depends on accurate pregnancy dating and serial growth measurements. The fetal size at any given stage of pregnancy is either appropriate or inappropriate for the given gestational age (GA). Pregnancy dating is most accurate in the first trimester, as biologic variability does not come into play until the second and third trimesters. The authors describe the determination of GA with use of standard US measurements and how additional parameters can be used to confirm dating. Once dates are established, serial measurements are used to identity abnormal growth patterns. The sometimes confusing definitions of abnormal growth are clarified, the differentiation of a constitutionally small but healthy fetus from a growth-restricted at-risk fetus is described, and the roles of Doppler US and other adjunctive examinations in the management of growth restriction are discussed. In addition, the definition of selective growth restriction in twin pregnancy is briefly discussed, as is the role of Doppler US in the classification of subtypes of selective growth restriction in monochorionic twinning. The criteria for diagnosing macrosomia and the management of affected pregnancies also are reviewed. The importance of correct pregnancy dating in the detection and surveillance of abnormal fetal growth and for prevention of perinatal maternal and fetal morbidity and mortality cannot be overstated. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

The Prognosis of Preterm Infants Born at the Threshold of Viability: Fog Over the Gray Zone - Population-Based Studies of Extremely Preterm Infants

The limit of viability for premature newborns has changed in recent decades, but whether to initiate or withhold active care for periviable infants remains a subject of debate because the chances of survival and the extent of severe neurological impairment can be unclear. In our review, we analyzed large population-based studies of periviable infants from the past 2 decades. We compared survival rates and the incidence of early complications among survivors, including bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, and necrotizing enterocolitis. Moreover, we assessed the perinatal factors that may affect the survival of preterm infants. We analyzed 15 studies reporting data on preterm infants born between 22 and 28 gestational weeks. None of these studies reported survival of an infant born before 22 gestational weeks. Survival rates of infants born at 24 weeks’ gestation were above 50% in most studies. The incidence of each complication was also higher among infants born at ≤24 weeks. Of the analyzed perinatal factors, antenatal corticosteroid therapy, birth weight, female sex, cesarean delivery, singleton pregnancy, and birth in a tertiary-level Neonatal Intensive Care Unit were found to be associated with improved survival in some studies. The different methodologies of the studies limited comparison of the results. Further investigations are needed to gain up-to-date information on the limit of viability, and standardized methods in future studies would enable more accurate comparisons of findings.

A review of stillbirth definitions: A rationale for change

Stillbirth definitions vary between countries around the globe. The purpose of this paper was to explore stillbirth definitions used by high income countries around the world, specifically compared to Ireland, their stillbirth and mortality rates and to examine how these rates are influenced by standards of care, especially resuscitation efforts within the delivery room for very preterm infants. A literature review was performed using PubMed, Academic Search Complete, MEDLINE, and CINAHL. These databases were searched with the terms "(stillbirth OR still birth OR stillborn) AND (definition OR registration OR registry)" and "(fetal OR neonatal OR neonate) AND Viability AND Gestational Age" in two separate searches. The database searches returned 1081 results involving stillbirths and 164 results for neonatal viability. After title, abstract, full text review, and reference review 33 papers remained for use in this study. Within the European Union (EU), 59.2 % (n = 16), 14.8 % (n = 4), 11.1 % (n = 3), and 3.7 % (n = 1) countries classify stillbirths at gestational ages of ≥22 weeks, ≥24 weeks, ≥28 weeks, and ≥180 gestational days respectively. The median stillbirth rate in Europe using ≥28 weeks gestational age as a cut-off was 2.7 per 1000 births, but this increased to 3.3 per 1000 births when stillbirths from 24 to 27 weeks gestation were included. Of the thirteen countries whose mortality data was examined, survival rates for liveborn infants ranged from 0-37.3 %, 1.1-64.5 %, 31.0-77.7 %, and 59.1-85.7 % for the gestational ages of 22, 23, 24, and 25 weeks, respectively. In 1995, survival rates for the United Kingdom and Ireland were only 26 % for those born at 24 weeks gestation, however this has almost doubled in Ireland to 56.6 % in 2014-2017. Survival rates have improved to the point that, in 2014-2017, the survival rate of infants born at 23 weeks gestation (32.3 %) was 6 % higher than the rate for those born at 24 weeks gestation in 1995. Due to the improvement in survival rates, multiple international organisations recommend recording stillbirths from 22 weeks gestation and/or 500 g. Based on the findings from this review, and due to improving survival rates for periviable infants, it is recommended the stillbirth definition in Ireland should be updated to ≥22 weeks' gestation and ≥400 g to comply with improved medical developments.

Intestinal Dysbiosis As a Possible Predictor of Very Early Preterm Labor in Pregnant Women With Metabolic Syndrome

The work assessed the state of the intestinal microbiocenosis in 52 puerperae at the in whom the pregnancy developed against the background of the metabolic syndrome. The diagnosis of metabolic syndrome was determined according to the criteria approved by the World Health Organization for pregnant women. The state of intestinal microbiocenosis was assessed by a bacteriological examination of feces immediately after delivery. The content of the main representatives of the obligate microflora (bifidobacteria, lactobacilli, native intestinal bacilli, fecal streptococci) and facultative (conditionally pathogenic) microorganisms (representatives of the genus Prоteus, Klebsiella, pathogenic strains of E. coli, Staphylococcus epidermidis, Enterobacter, Citrobacter, Clostridium difficile, Candida fungi) was determined. Cultures were made on appropriate growth media.

At the time of birth, all patients of group I showed signs of intestinal microbiocenosis disorder. At the same time, 13 (54.2%) puerperae were diagnosed signs of dysbiosis of II degree, 9 (37.5%) with signs of III degree, which were generally characterized by a significant decrease in the content of the main representatives of obligate microflora (Bifidobacterium, Lactobacillus, Escherichia coli, Fecal streptococci) with simultaneous high contamination of Candida albicans and Clostridium difficile. So, it can be considered as a possible predictor of very early preterm birth in women with MS. In pregnant women with MS, but who gave timely birth (group II), dysbiotic disorders were detected to a lesser extent. Thus, in 13 (46.4%) patients, initial signs of intestinal dysbiosis (first degree) were detected in 4 (14.3%) patients (second degree). In 11 (39.3%) puerperae of group II, microbial indices indicated normal eubiotic ratios.

Early prediction of moderate to severe bronchopulmonary dysplasia in extremely premature infants

BACKGROUND

Bronchopulmonary Dysplasia (BPD) is the commonest morbidity in extremely preterm infants (PTIs). Risk factors for BPD have been described in the era before the widespread availability of non-invasive ventilation (NIV) in the delivery room (DR). The objective of this study is to identify risk factors for Moderate/Severe BPD in an era of widespread availability of NIV in the DR.

METHODS

Detailed antenatal and postnatal data were abstracted for PTIs, 23^0/7-27^6/7 weeks GA. Multivariate logistic regression and classification and regression tree analyses (CART) identified predictors for the primary outcome of Moderate/Severe BPD.

RESULTS

Of 263 eligible infants, 59% had Moderate/Severe BPD. Moderate/Severe BPD was significantly associated with birthweight, gender, DR intubation and surfactant compared to No/Mild BPD. Of infants not intubated in the DR, 40% with No/Mild BPD and 80% with Moderate/Severe BPD received intubation by 48 hours (p < 0.05). Infants with Moderate/Severe BPD received longer duration of oxygen and mechanical (MV). On logistic regression, birthweight, gender, oxygen concentration, cumulative duration of oxygen and MV, surfactant, and blood transfusions predicted Moderate/Severe BPD. Both CART analysis and logistic regression showed duration of oxygen and MV to be the most important predictors for Moderate/Severe BPD.

CONCLUSIONS

In an era of increasing availability of NIV in the DR, lower birthweight, male gender, surfactant treatment, blood transfusions and respiratory support in the first 2-3 weeks after birth predict Moderate/Severe BPD with high sensitivity and specificity. The majority of these infants received intubation within 48 hours of birth (97%). These data suggest that early failures of NIV represent opportunities for improvement of NIV techniques and of non-invasive surfactant to avoid intubation in the first 48 hours. Furthermore, these risk factors may allow earlier identification of infants most likely to benefit from interventions to prevent or decrease severity of BPD.

Effects of a Parent-Administered Exercise Program in the Neonatal Intensive Care Unit: Dose Does Matter-A Randomized Controlled Trial

BACKGROUND

Despite the risk of delayed motor development in infants born preterm, knowledge about interventions in the neonatal intensive care unitt (NICU) and the effects of dosing is sparse.

OBJECTIVE

The objectives of this study were to examine the effectiveness of a parent-administered exercise program in the NICU on motor outcome at 3 months corrected age (CA) and the effect of dosing on motor performance.

DESIGN

This was a randomized clinical trial.

SETTING

The study was conducted at 3 university hospitals in Tromsø, Trondheim, and Oslo, Norway.

PARTICIPANTS

A total of 153 infants with gestational age <32 weeks at birth were randomly assigned to intervention or control groups.

INTERVENTION

A 3-week parent-administered intervention designed to facilitate movements in preterm infants was performed in the NICU. Parents were asked to administer the intervention 10 minutes twice a day.

MEASUREMENTS

Test of Infant Motor Performance (TIMP) was used to assess short-term outcome at 3 months CA.

RESULTS

No significant difference in the TIMP z-score was found between intervention and control groups at follow-up 3 months CA, but a significant positive relationship was found between total intervention dose and TIMP z-scores. The adjusted odds of having a clinical z-score < 0 at 3 months CA was about 6 times higher for infants with less than median intervention time than for infants with a longer intervention time.

LIMITATIONS

The number of infants born before 28 weeks was small. A spillover effect in favor of the control group was possible. We do not know if the infants received physical therapy after discharge from the hospital.

CONCLUSIONS

There was no difference in motor performance between the intervention group and the control group at 3 months CA. However, an increased intervention dose was positively associated with improved motor outcome.

Neonatal clinical blood sampling led to major blood loss and was associated with bronchopulmonary dysplasia

AIM

Studies indicate that reduced foetal haemoglobin levels are related to increased neonatal morbidity rates. This study investigated the relationships between sampling-related blood loss and adult blood transfusions administered during postnatal days 1-14 and the development of severe neonatal morbidities in extremely preterm infants born before 28 weeks of gestation.

METHODS

The medical files of 149 extremely preterm infants born at two university hospitals in Sweden from 2013 to 2018 were investigated.

RESULTS

Blood sampling resulted in a 58% depletion of the endogenous blood volume postnatal days 1-14 (median 40.4 mL/kg, interquartile range 23.9-53.3 mL/kg) and correlated with the adult erythrocyte transfusion volume (r_S  = 0.870, P < .001). Sampling-related blood loss on postnatal days 1-7, adjusted for gestational age at birth and birth weight standard deviation score, was associated with the development of bronchopulmonary dysplasia (BPD) (odds ratio by a 10-unit increase 2.4, 95% confidence interval 1.1-5.4) (P = .03). No associations were found between blood sampling and intraventricular haemorrhage or necrotising enterocolitis in the full statistical model. The largest proportion of sampling-related blood was used for blood gas analyses (48.7%).

CONCLUSION

Diagnostic blood sampling led to major endogenous blood loss replaced with adult blood components and was associated with the development of BPD.

Altered local cerebellar and brainstem development in preterm infants

BACKGROUND

Premature birth is associated with high prevalence of neurodevelopmental impairments in surviving infants. The putative role of cerebellar and brainstem dysfunction remains poorly understood, particularly in the absence of overt structural injury.

METHOD

We compared in-utero versus ex-utero global, regional and local cerebellar and brainstem development in healthy fetuses (n ​= ​38) and prematurely born infants without evidence of structural brain injury on conventional MRI studies (n ​= ​74) that were performed at two time points: the first corresponding to the third trimester, either in utero or ex utero in the early postnatal period following preterm birth (30-40 weeks of gestation; 38 control fetuses; 52 premature infants) and the second at term equivalent age (37-46 weeks; 38 control infants; 58 premature infants). We compared 1) volumetric growth of 7 regions in the cerebellum (left and right hemispheres, left and right dentate nuclei, and the anterior, neo, and posterior vermis); 2) volumetric growth of 3 brainstem regions (midbrain, pons, and medulla); and 3) shape development in the cerebellum and brainstem using spherical harmonic description between the two groups.

RESULTS

Both premature and control groups showed regional cerebellar differences in growth rates, with the left and right cerebellar hemispheres showing faster growth compared to the vermis. In the brainstem, the pons grew faster than the midbrain and medulla in both prematurely born infants and controls. Using shape analyses, premature infants had smaller left and right cerebellar hemispheres but larger regional vermis and paravermis compared to in-utero control fetuses. For the brainstem, premature infants showed impaired growth of the superior surface of the midbrain, anterior surface of the pons, and inferior aspects of the medulla compared to the control fetuses. At term-equivalent age, premature infants had smaller cerebellar hemispheres bilaterally, extending to the superior aspect of the left cerebellar hemisphere, and larger anterior vermis and posteroinferior cerebellar lobes than healthy newborns. For the brainstem, large differences between premature infants and healthy newborns were found in the anterior surface of the pons.

CONCLUSION

This study analyzed both volumetric growth and shape development of the cerebellum and brainstem in premature infants compared to healthy fetuses using longitudinal MRI measurements. The findings in the present study suggested that preterm birth may alter global, regional and local development of the cerebellum and brainstem even in the absence of structural brain injury evident on conventional MRI.

Validation of a new predictive model to improve risk stratification in bronchopulmonary dysplasia

We need a better risk stratification system for the increasing number of survivors of extreme prematurity suffering the most severe forms of bronchopulmonary dysplasia (BPD). However, there is still a paucity of studies providing scientific evidence to guide future updates of BPD severity definitions. Our goal was to validate a new predictive model for BPD severity that incorporates respiratory assessments beyond 36 weeks postmenstrual age (PMA). We hypothesized that this approach improves BPD risk assessment, particularly in extremely premature infants. This is a longitudinal cohort of premature infants (≤32 weeks PMA, n = 188; Washington D.C). We performed receiver operating characteristic analysis to define optimal BPD severity levels using the duration of supplementary O2 as predictor and respiratory hospitalization after discharge as outcome. Internal validation included lung X-ray imaging and phenotypical characterization of BPD severity levels. External validation was conducted in an independent longitudinal cohort of premature infants (≤36 weeks PMA, n = 130; Bogota). We found that incorporating the total number of days requiring O2 (without restricting at 36 weeks PMA) improved the prediction of respiratory outcomes according to BPD severity. In addition, we defined a new severity category (level IV) with prolonged exposure to supplemental O2 (≥120 days) that has the highest risk of respiratory hospitalizations after discharge. We confirmed these findings in our validation cohort using ambulatory determination of O2 requirements. In conclusion, a new predictive model for BPD severity that incorporates respiratory assessments beyond 36 weeks improves risk stratification and should be considered when updating current BPD severity definitions.

Impact of early caffeine therapy in preterm newborns on infant lung function

OBJECTIVE

To know the effect of caffeine therapy on infant lung function in preterm infants with a gestational age less than 31 weeks.

MATERIAL AND METHODS

Forced vital capacity (FVC), forced expiratory volume at 0.5 seconds (FEV_0.5 ), and forced expiratory flows were measured by raised volume rapid thoracoabdominal compression technique; functional residual capacity was measured by plethysmography (FRC_pleth ). Compliance of the respiratory system was measured by a single interruption technique (Crs). The Student t test was used to compare lung function measurements between the two groups: treated versus nontreated with caffeine. A multivariate analysis was carried out considering each and every lung function parameter (z-score) as the dependent variable; and gender, gestational age, birth weight (z-score), corrected age, invasive mechanical ventilation (yes/no), and bronchopulmonary dysplasia (BPD) diagnosis (yes/no) as independent ones. Additionally, stratified analyses by BPD diagnosis were performed.

RESULTS

The multivariate analysis showed significant higher z-scores of FVC and FEV_0.5 in preterm infants treated with caffeine (P = .004 and P = .024, respectively). This result only being significant in the group of non-BPD infants (P = .021 and P = .042), after stratifying by BPD diagnosis. Differences were not found in z-scores of FEV0.5/FVC, FEF75, FEF25-75, FRCpleth, nor Crs.

CONCLUSION

Lung function (FVC and FEV_0.5 ) is improved in infants born under 31 weeks of gestation when treated with caffeine. This improvement is driven by the group of infants who did not suffer from BPD. Overall, our results show that there is an early beneficial effect of caffeine treatment in infant lung function.

Periviability: A Review of Key Concepts and Management for Perinatal Nursing

One of the most complex clinical problems in obstetrics and neonatology is caring for pregnant women at the threshold of viability. Births near viability boundaries are grave events that carry a high prevalence of neonatal death or an increased potential for severe lifelong complications and disabilities among those who survive. Compared with several decades ago, premature infants receiving neonatal care by today's standards have better outcomes than those born in other eras. However, preterm labor at periviability represents a more complex counseling and management challenge. Although preterm birth incidence between 20/7 and 25/7 weeks has remained unchanged, survival rates at earlier gestational ages have increased as perinatal and neonatal specialties have become more adept at caring for this at-risk population. Women face difficult choices about obstetric and neonatal interventions in light of uncertainties around survival and outcomes. This article reviews current neonatal statistics in reference to short- and long-term outcomes, key concepts in obstetric clinical management of an anticipated periviable birth, and counseling guidance to ensure shared-decision making.

Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns

AIM

Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23-27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress.

METHODS

We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality-morbidity score (Benefit Metric).

RESULTS

A total of 4709 infants, mean (SD) gestational age 25.8 (1.4) weeks, admitted to 10 NICUs 1.01.2010 to 12.31.2016. The orchestrated matrix offered 45 potentially better practices; NICUs implemented mean 29 (range 19-40). There was widespread adoption of delivery room, respiratory care and infection prevention practices, but no uniform pattern. Our Benefit Metric was significantly greater than the Vermont Oxford Network all seven years (p < 0.001). Six major morbidities decreased, two significantly (p < 0.05), mortality unchanged (14%). 34% of survivors had no morbidities, 35% just one.

CONCLUSION

Cultivating trust, transparent outcomes sharing, and tailored, potentially better practice selection is associated with encouraging improvement in 23- to 27-week survival without morbidity. Our outcomes are objective but the optimal implementation pathway to sustain progress remains murky, reflective of NICUs as complex adaptive networks.

Effect of written outcome information on attitude of perinatal healthcare professionals at the limit of viability: a randomized study

Background

Differences in perception and potential disagreements between parents and professionals regarding the attitude for resuscitation at the limit of viability are common. This study evaluated in healthcare professionals whether the decision to resuscitate at the limit of viability (intensive care versus comfort care) are influenced by the way information on incurred risks is given or received.

Methods

This is a prospective randomized controlled study. This study evaluated the attitude of healthcare professionals by testing the effect of information given through graphic fact sheets formulated either optimistically or pessimistically. The written educational fact sheet included three graphical presentations of survival and complication/morbidity by gestational age. The questionnaire was submitted over a period of 4 months to 5 and 6-year medical students from the Geneva University as well as physicians and nurses of the neonatal unit at the University Hospitals of Geneva. Our sample included 102 healthcare professionals.

Results

Forty-nine responders (48%) were students (response rate of 33.1%), 32 (31%) paediatricians (response rate of 91.4%) and 21 (20%) nurses in NICU (response rate of 50%). The received risk tended to be more severe in both groups compared to the graphically presented facts and current guidelines, although optimistic representation favoured the perception of “survival without disability” at 23 to 25 weeks. Therapeutic attitudes did not differ between groups, but healthcare professionals with children were more restrained and students more aggressive at very low gestational ages.

Conclusion

Written information on mortality and morbidity given to healthcare professionals in graphic form encourages them to overestimate the risk. However, perception in healthcare staff may not be directly transferable to parental perception during counselling as the later are usually naïve to the data received. This parental information are always communicated in ways that subtly shape the decisions that follow.

Outcomes of infants born at 23 and 24 weeks' gestation with gut perforation

PURPOSE

The provision of neonatal intensive care to infants born at 23 or 24 weeks' gestation poses medical, surgical and ethical challenges. Gastrointestinal perforation is a well-recognized complication of preterm birth, occurring most often as a result of necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Given the risk of morbidity and mortality in these 'periviable' infants, this complication may prompt transition from active management to palliative care. In our institution, the surgical care of periviable infants with gut perforation has not been dictated by gestational age. This study reports our outcomes.

METHODS

A retrospective cohort analysis of integrated neonatal medical and surgical care of all infants born between 23⁺⁰ and 24⁺⁶ weeks' gestation admitted to a tertiary level neonatal intensive care unit (NICU) during a 16 year period (2002-2017).

RESULTS

A total of 198 periviable neonates (73 born at 23 weeks' gestation and 125 born at 24 weeks) were admitted during the 16-year period; most were inborn with only 26 retrieved from regional centers. Twenty-six of these infants developed gut perforation: 14 SIP, 8 NEC, 3 esophageal perforation and one after reduction of an incarcerated inguinal hernia. Twelve (46%) periviable infants with gut perforation survived to discharge home, seven of whom had no/mild disability at 2-3 years corrected gestational age. Of the 198 periviable infants admitted to NICU, 116 (58%) were alive at a corrected gestational age of 2-3 years and 29 of the 56 (51%) assessed had mild or no disability.

CONCLUSIONS

In the setting of combined medical and surgical care in a tertiary level NICU almost half of all periviable infants with a gut perforation survived, many with no/mild disability at 2-3 years corrected gestational age. Rigid protocols that rely on gestational age alone to guide treatment are not appropriate. These results support the contention that, when possible, extremely preterm infants should be born and cared for in units with combined medical and surgical expertise.

LEVEL OF EVIDENCE

Level III cohort study.

Global incidence of bronchopulmonary dysplasia among extremely preterm infants: a systematic literature review

BACKGROUND

Infants born extremely preterm (<28 weeks gestational age (GA)) face a high risk of neonatal mortality. Bronchopulmonary dysplasia (BPD) is the most common morbidity of prematurity.

OBJECTIVE

To evaluate the global incidence of BPD among infants born extremely preterm.

DESIGN

A systematic review of the literature was conducted in Embase and MEDLINE (via PubMed) using a prespecified search strategy for BPD and prematurity. Observational studies published in English between 16 May 2006 and 16 October 2017 reporting on the occurrence of BPD in infants born <28 weeks GA were included.

RESULTS

Literature searches yielded 103 eligible studies encompassing 37 publications from Europe, 38 publications from North America, two publications from Europe and North America, 19 publications from Asia, one publication from Asia and North America, six publications from Oceania, and zero publications from Africa or South America. The reported global incidence range of BPD was 10-89% (10-73% in Europe, 18-89% in North America, 18-82% in Asia, and 30-62% in Oceania). When only population-based observational studies that defined BPD as requiring supplemental oxygen at 36 weeks postmenstrual age were included, the global incidence range of BPD was 17-75%. The wide range of incidences reflected interstudy differences in GA (which was inversely related to BPD incidence), birthweight, and survival rates across populations and institutions.

CONCLUSIONS

BPD is a common health morbidity occurring with extremely preterm birth. Further study of factors that impact incidence, aside from low GA, may help to elucidate modifiable risks.

Mortality rate-dependent variations in the survival without major morbidities rate of extremely preterm infants

The effects of improved survival of EPT infants on morbidity among survivors remain largely controversial. This retrospective cohort study of the Korean Neonatal Network data investigated whether the mortality rate of 23-24 weeks' gestation was associated with survival without major morbidities in periviable 25-26 weeks' gestation infants. The 2,083 eligible infants with 23-26 weeks' gestation were grouped based on institutional mortality rate (group 1 and 2 ≤50% and >50% mortality rate, respectively, for 23-24 weeks' gestation) and were further divided into 23-24 and 25-26 weeks' gestation subgroups. The mortality rate of 23-24 weeks' gestation infants was significantly lower in group 1 (32.7%) than in group 2 (69.9%). The survival without major morbidities rate for 25-26 weeks' gestation infants was significantly higher in group 1 (31.2%) than in group 2 (18.5%). Antenatal steroid use and Apgar score at 5 min in group 1 were associated with decreased mortality and survival without major morbidities in 23-24 and 25-26 weeks' gestation infants, respectively. In the multivariate analyses, decreased mortality rates in 23-24 weeks' gestation infants were associated with higher survival without major morbidities rates in 25-26 weeks' gestation infants due to decreased bronchopulmonary dysplasia, periventricular leukomalacia, and late-onset sepsis. Evidence-based perinatal and neonatal practices, including antenatal steroid use and better delivery room care contributing to decreased mortality in periviable 23-24 weeks' gestation infants, were associated with lower morbidity and higher survival without major morbidities in more mature 25-26 weeks' gestation infants.

Neutrophil extracellular traps (NETs) exacerbate severity of infant sepsis

Background

Neutrophil extracellular traps (NETs) are innate defense mechanisms that are also implicated in the pathogenesis of organ dysfunction. However, the role of NETs in pediatric sepsis is unknown.

Methods

Infant (2 weeks old) and adult (6 weeks old) mice were submitted to sepsis by intraperitoneal (i.p.) injection of bacteria suspension or lipopolysaccharide (LPS). Neutrophil infiltration, bacteremia, organ injury, and concentrations of cytokine, NETs, and DNase in the plasma were measured. Production of reactive oxygen and nitrogen species and release of NETs by neutrophils were also evaluated. To investigate the functional role of NETs, mice undergoing sepsis were treated with antibiotic plus rhDNase and the survival, organ injury, and levels of inflammatory markers and NETs were determined. Blood samples from pediatric and adult sepsis patients were collected and the concentrations of NETs measured.

Results

Infant C57BL/6 mice subjected to sepsis or LPS-induced endotoxemia produced significantly higher levels of NETs than the adult mice. Moreover, compared to that of the adult mice, this outcome was accompanied by increased organ injury and production of inflammatory cytokines. The increased NETs were associated with elevated expression of Padi4 and histone H3 citrullination in the neutrophils. Furthermore, treatment of infant septic mice with rhDNase or a PAD-4 inhibitor markedly attenuated sepsis. Importantly, pediatric septic patients had high levels of NETs, and the severity of pediatric sepsis was positively correlated with the level of NETs.

Conclusion

This study reveals a hitherto unrecognized mechanism of pediatric sepsis susceptibility and suggests that NETs represents a potential target to improve clinical outcomes of sepsis.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2407-8) contains supplementary material, which is available to authorized users.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Outcomes and resource usage of infants born at ≤ 25 weeks gestation in Canada

Objectives

To determine the outcomes and resource usage of infants born at ≤ 25 weeks gestational age (GA).

Methods

Retrospective study of infants born between April 2009 and September 2011 at ≤ 25 weeks' GA in all neonatal intensive care units in Canada with follow-up in the neonatal follow-up clinics. Short-term morbidities, neurodevelopmental impairment, significant neurodevelopmental impairment, and resource utilization of infants born at ≤ 24 weeks were compared with neonates born at 25 weeks.

Results

Of 803 neonates discharged alive, 636 (80.4%) infants born at ≤ 25 weeks' GA were assessed at 18 to 24 months. Caesarean delivery, lower birth weight, and less antenatal steroid exposure were more common in infants born ≤ 24 weeks as compared with 25 weeks. They had significantly higher incidences of ductus arteriosus ligation, severe intracranial hemorrhage, retinopathy of prematurity as well as longer length of stay, central line days, days on respiratory support, days on total parenteral nutrition, days on antibiotics, and need for postnatal steroids. Neurodevelopmental impairment rates were 68.9, 64.5, and 55.6% (P=0.01) and significant neurodevelopmental impairment rates were 39.3, 29.6, and 20.9% (P<0.01) for infants ≤ 23, 24, and 25 weeks GA, respectively. Postdischarge service referrals were higher for those ≤ 23 weeks. Nonsurviving infants born at 25 weeks GA had higher resource utilization during admission than infants born less than 25 weeks.

Conclusions

Adverse outcomes and resource usage were significantly higher among infants born ≤ 24 weeks GA as compared with 25 weeks GA.

Adequacy of antenatal steroids, rather than place of birth, determines survival to discharge in extreme prematurity in North Queensland

AIM

The Townsville Hospital cares for babies in a large geographical area, many of who are outborn, are of Aboriginal or Torres Strait Islander origin and have families who reside in areas of deprivation. This study examined the outcomes of babies born at all locations in North Queensland to assess the predictors of poor outcomes.

METHODS

A retrospective observational study examined the survival of 313 babies born from 22 completed weeks gestation to 27 + 6 weeks gestation in North Queensland between January 2010 and December 2016. Additional analyses were performed for the 300 non-syndromal babies whose mothers usually resided in North Queensland, studying demographics of gestation, gender, birthweight, Indigenous status, regionality of maternal residence and adequacy of antenatal steroids. Short-term morbidities of intraventricular haemorrhage/periventricular leukomalacia (IVH/PVL), surgical necrotizing enterocolitis, retinopathy of prematurity requiring treatment and chronic lung disease and death were studied in relation to demographic factors and clinical treatment.

RESULTS

Adequacy of steroids was significantly associated with a decreased mortality odds ratio of 2.872 (95% confidence interval 1.228-6.715), whilst no difference in outcome was seen by retrieval status or ethnic origin. Babies from remote locations were at increased risk for IVH/PVL, 2.334 (1.037-5.255). Male babies suffered more chronic lung disease, 1.608 (1.010-2.561), and IVH/PVL, 2.572 (1.215-5.445). Aboriginal and Torres Strait Islander babies were at lower risk of IVH/PVL.

CONCLUSIONS

Steroids should be administered wherever there is any possibility of the provision of intensive care for periviable babies. Place of birth and ethnicity of mother should not unduly influence antenatal counselling.

Survival and Impairment of Extremely Premature Infants: A Meta-analysis

CONTEXT

Survival of infants born at the limit of viability varies between high-income countries.

OBJECTIVE

To summarize the prognosis of survival and risk of impairment for infants born at 22 + 0/7 weeks' to 27 + 6/7 weeks' gestational age (GA) in high-income countries.

DATA SOURCES

We searched 9 databases for cohort studies published between 2000 and 2017 in which researchers reported on survival or neurodevelopmental outcomes.

STUDY SELECTION

GA was based on ultrasound results, the last menstrual period, or a combination of both, and neurodevelopmental outcomes were measured by using the Bayley Scales of Infant Development II or III at 18 to 36 months of age.

DATA EXTRACTION

Two reviewers independently extracted data and assessed the risk of bias and quality of evidence.

RESULTS

Sixty-five studies were included. Mean survival rates increased from near 0% of all births, 7.3% of live births, and 24.1% of infants admitted to intensive care at 22 weeks' GA to 82.1%, 90.1%, and 90.2% at 27 weeks' GA, respectively. For the survivors, the rates of severe impairment decreased from 36.3% to 19.1% for 22 to 24 weeks' GA and from 14.0% to 4.2% for 25 to 27 weeks' GA. The mean chance of survival without impairment for infants born alive increased from 1.2% to 9.3% for 22 to 24 weeks' GA and from 40.6% to 64.2% for 25 to 27 weeks' GA.

LIMITATIONS

The confidence in these estimates ranged from high to very low.

CONCLUSIONS

Survival without impairment was substantially lower for children born at <25 weeks' GA than for those born later.

Bedside Measurement of Volatile Organic Compounds in the Atmosphere of Neonatal Incubators Using Ion Mobility Spectrometry

Background: Early and non-invasive diagnosis of common diseases is of great importance in the care of preterm infants. We hypothesized that volatile organic compounds (VOC) can be successfully measured in the neonatal incubator atmosphere. Methods: This is a feasibility study to investigate whether the discrimination of occupied and unoccupied neonatal incubators is possible by bedside measurement of volatile organic compounds (VOCs) on the neonatal intensive care unit. VOC profiles were measured in the incubator air using ion mobility spectrometry coupled to multi-capillary columns (BreathDiscovery B&S Analytik GmbH, Dortmund, Germany). Results: Seventeen incubators occupied by preterm infants (50 measurements) and nine unoccupied neonatal incubators were sampled, using 37 room air measurements as controls. Three VOC signals that allow the discrimination between occupied and unoccupied incubators were identified. The best discrimination was reached by peak P20 exhibiting a sensitivity, specificity, positive predictive value and negative predictive value of 94.0, 88.9, 97.3, and 72.3%, respectively. Use of a decision tree improved these values to 100.0, 88.9, 98.0, and 100.0%, respectively. Discussion: A bedside method that allows the characterization of VOC profiles in the neonatal incubator atmosphere using ion mobility spectrometry was established. Occupied and unoccupied incubators could be discriminated by characterizing VOC profiles. This technique has the potential to yield results within minutes. Thus, future studies are recommended to test the hypothesis that VOCs within neonatal incubators are useful biomarkers for non-invasive diagnostics in preterm neonates.

Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study

OBJECTIVES

To determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation.

DESIGN SETTING AND PATIENTS

A prospective observational study in an unselected population at Stavanger University Hospital, Norway, from October 2016 until September 2017.

INTERVENTIONS

Using a data collection form and video recordings, we registered and analysed resuscitative interventions.

MAIN OUTCOME MEASURES

Incidence of continuous positive airway pressure (CPAP), positive pressure ventilation (PPV), intubation, chest compressions and intravenous fluid or epinephrine boluses. Short-term outcomes of resuscitated newborns.

RESULTS

All 4693 newborns in the study period were included in the study. Two hundred and ninety-one (6.2%) newborns received interventions in the first minutes of life beyond drying and stimulation. PPV was provided in 170 (3.6%) while CPAP (without PPV) was provided in 121 (2.6%) newborns. Duration of PPV was median (IQR) 106 s (54-221). Intubations were performed in 19 (0.4%) newborns, with a mean (SD) intubation time of 47 (21) s. Ten (0.2%) newborns received chest compressions and epinephrine was administrated in three (0.1%) newborns. Sixty-three per cent of the treated newborns from 34 weeks' gestational age were returned to parental care without further follow-up.

CONCLUSIONS

The need for resuscitative interventions after birth was frequent in this unselected population in a high-resource setting, but full cardiopulmonary resuscitation was rare. Short-term outcomes were good, suggesting that most newborns treated with resuscitative interventions were not severely affected.

Does earlier arrival of the retrieval team improve short-term outcomes in outborn extremely premature infants?

AIM

The risk of mortality and morbidity is increased in outborn, extremely premature infants. We aim to determine whether earlier arrival of the retrieval team after the birth of infants less than 29 weeks gestation improves short-term mortality and morbidity.

METHODS

This is a retrospective analysis of a cohort of infants less than 29 weeks gestation who were retrieved to the Royal Brisbane and Women's Hospital (RBWH) over a 5-year period. Demographic information regarding the infant and mother, retrieval team arrival time and outcome data was collected. Primary outcomes investigated were mortality prior to discharge from hospital or a composite of mortality or severe intraventricular haemorrhage (IVH).

RESULTS

Data on 105 infants were analysed; 88 infants (83.8%) survived to discharge home, and 79 (75.2%) survived to discharge without severe IVH. On univariate analysis, there was no significant association between age at arrival of the retrieval team and death prior to discharge (P = 0.94) or death prior to discharge or severe IVH (P = 0.83). On logistic regression analysis, age at arrival of retrieval team remained non-significant for a reduction in death prior to discharge and composite of death or severe IVH (P = 0.70 and P = 0.99, respectively).

CONCLUSION

The earlier arrival of the retrieval team is not associated with improved short-term outcomes in outborn, extremely preterm infants who are retrieved and admitted to a tertiary neonatal intensive care unit - for infants where the retrieval team arrived within about 8 h of birth.

Gestational Age, Health, and Educational Outcomes in Adolescents

BACKGROUND AND OBJECTIVES

As outcomes for extremely premature infants improve, up-to-date, large-scale studies are needed to provide accurate, contemporary information for clinicians, families, and policy makers. We used nationwide New Zealand data to explore the impact of gestational age on health and educational outcomes through to adolescence.

METHODS

We performed a retrospective cohort study of all births in New Zealand appearing in 2 independent national data sets at 23 weeks' gestation or more. We report on 2 separate cohorts: cohort 1, born January 1, 2005 to December 31, 2015 (613 521 individuals), used to study survival and midterm health and educational outcomes; and cohort 2, born January 1, 1998 to December 31, 2000, and surviving to age 15 years (146 169 individuals), used to study high school educational outcomes. Outcomes described by gestational age include survival, hospitalization rates, national well-being assessment outcomes at age 4 years, rates of special education support needs in primary school, and national high school examination results.

RESULTS

Ten-year survival increased with gestational age from 66% at 23 to 24 weeks to >99% at term. All outcomes measured were strongly related to gestational age. However, most extremely preterm children did not require special educational support and were able to sit for their national high school examinations.

CONCLUSIONS

Within a publicly funded health system, high-quality survival is achievable for most infants born at periviable gestations. Outcomes show improvement with gestational ages to term. Outcomes at early-term gestation are poorer than for children born at full term.

NICU Dialects: Understanding Norwegian Practice Variation

In Norway, a national consensus-based guideline used to address thresholds for offering life support at extreme preterm birth was issued in 1998. Since then, therapeutic advances may have changed attitudes and expectations to treatment, both within the medical community and the public, and there are concerns that systematic variations in treatment practices may exist. With this article, we describe current practices and relate them to other ethical and legal comparable areas in health care. We conclude that a revision of the 1998 guideline is warranted to obtain a common understanding of prognoses and appropriate decision processes at the limit of viability.

An International Comparison of Death Classification at 22 to 25 Weeks' Gestational Age

OBJECTIVES

To explore international differences in the classification of births at extremely low gestation and the subsequent impact on the calculation of survival rates.

METHODS

We used national data on births at 22 to 25 weeks' gestation from the United States (2014; n = 11 144), Canada (2009-2014; n = 5668), the United Kingdom (2014-2015; n = 2992), Norway (2010-2014; n = 409), Finland (2010-2015; n = 348), Sweden (2011-2014; n = 489), and Japan (2014-2015; n = 2288) to compare neonatal survival rates using different denominators: all births, births alive at the onset of labor, live births, live births surviving to 1 hour, and live births surviving to 24 hours.

RESULTS

For births at 22 weeks' gestation, neonatal survival rates for which we used live births as the denominator varied from 3.7% to 56.7% among the 7 countries. This variation decreased when the denominator was changed to include stillbirths (ie, all births [1.8%-22.3%] and fetuses alive at the onset of labor [3.7%-38.2%]) or exclude early deaths and limited to births surviving at least 12 hours (50.0%-77.8%). Similar trends were seen for infants born at 23 weeks' gestation. Variation diminished considerably at 24 and 25 weeks' gestation.

CONCLUSIONS

International variation in neonatal survival rates at 22 to 23 weeks' gestation diminished considerably when including stillbirths in the denominator, revealing the variation arises in part from differences in the proportion of births reported as live births, which itself is closely connected to the provision of active care.

Changes in survival and neurodevelopmental outcomes of infants born at <25 weeks' gestation: a retrospective observational study in tertiary centres in Japan

OBJECTIVE

To evaluate changes in the outcomes of infants born at <25 weeks' gestation in the past decade.

DESIGN

Retrospective observational study.

SETTINGS

A multicentre database of the Neonatal Research Network, Japan.

PATIENTS

A total of 3318 infants born at 22-24 weeks' gestation between periods 1 (2003-2007) and 2 (2008-2012) from 52 tertiary centres.

MAIN OUTCOME MEASURES

We compared death and neurodevelopmental impairments (NDIs) at 3 years of age, including cerebral palsy (CP), visual impairments (VIs), hearing impairments (HIs) and the developmental quotient (DQ) of the Kyoto Scale of Psychological Development test <70, between two periods using multivariate logistic regression analyses adjusted for the centre, gender, multiple gestation, maternal age, caesarean delivery, antenatal steroid use, pregnancy-related hypertension, clinical chorioamnionitis, congenital anomalies and birth weight.

RESULTS

A total of 496/1479 infants (34%) in period 1 and 467/1839 (25%) in period 2 died by 3 years of age (adjusted OR 0.70, 95% CIs 0.59 to 0.83). Follow-up data were collected from 631 infants (64% of survivors) in period 1 and 832 (61% of survivors) in period 2. The proportions of CP with Gross Motor Function Classification System ≥2, VI and HI in the infants evaluated were lower, while that of DQ <70 was higher in period 2 than in period 1. Using multiple imputations to account for missing data, death or NDI decreased from 54% in period 1 to 47% in period 2 (0.83, 0.71 to 0.97). Significant decreases were observed in death or CP (0.65, 0.55 to 0.76), death or VI (0.59, 0.50 to 0.69) and death or HI (0.69, 0.58 to 0.81), but not in death or DQ <70 (0.91, 0.78 to 1.06).

CONCLUSION

Along with improved survival, CP, VI and HI, but not cognitive impairments decreased in infants born at <25 weeks' gestation between the two periods examined in the last decade. Further strategies are needed to reduce cognitive impairments in these infants.

Volume-targeted versus pressure-limited ventilation in neonates

BACKGROUND

Damage caused by lung overdistension (volutrauma) has been implicated in the development of bronchopulmonary dysplasia (BPD). Modern neonatal ventilation modes can target a set tidal volume as an alternative to traditional pressure-limited ventilation (PLV) using a fixed inflation pressure. Volume-targeted ventilation (VTV) aims to produce a more stable tidal volume in order to reduce lung damage and stabilise the partial pressure of carbon dioxide (pCO2).

OBJECTIVES

To determine whether VTV compared with PLV leads to reduced rates of death and death or BPD in newborn infants and to determine whether use of VTV affected outcomes including air leak, cranial ultrasound findings and neurodevelopment.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 12), MEDLINE via PubMed (1966 to 13 January 2017), Embase (1980 to 13 January 2017) and CINAHL (1982 to 13 January 2017). We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We contacted the principal investigators of studies to obtain supplementary information.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing VTV versus PLV in infants of less than 44 weeks' postmenstrual age and reporting clinically relevant outcomes.

DATA COLLECTION AND ANALYSIS

We assessed risk of bias for each trial using Cochrane methodology. We evaluated quality of evidence for each outcome using GRADE criteria. We tabulated mortality, rates of BPD, short-term clinical outcomes and long-term developmental outcomes.

STATISTICS

for categorical outcomes, we calculated typical estimates for risk ratios (RR), risk differences (RD) and number needed to treat for an additional beneficial outcome (NNTB). For continuous variables, we calculated typical estimates for mean differences (MD). We used 95% confidence intervals (CI) and assumed a fixed-effect model for meta-analysis.

MAIN RESULTS

Twenty randomised trials met our inclusion criteria; 16 parallel trials (977 infants) and four cross-over trials (88 infants). No studies were blinded and the quality of evidence for outcomes assessed varied from moderate to low.We found no difference in the primary outcome, death before hospital discharge, between VTV modes versus PLV modes (typical RR 0.75, 95% CI 0.53 to 1.07; low quality evidence). However, there was moderate quality evidence that the use of VTV modes resulted in a reduction in the primary outcome, death or BPD at 36 weeks' gestation (typical RR 0.73, 95% CI 0.59 to 0.89; typical NNTB 8, 95% CI 5 to 20) and the following secondary outcomes: rates of pneumothorax (typical RR 0.52, 95% CI 0.31 to 0.87; typical NNTB 20, 95% CI 11 to 100), mean days of mechanical ventilation (MD -1.35 days, 95% CI -1.83 to -0.86), rates of hypocarbia (typical RR 0.49, 95% CI 0.33 to 0.72; typical NNTB 3, 95% CI 2 to 5), rates of grade 3 or 4 intraventricular haemorrhage (typical RR 0.53, 95% CI 0.37 to 0.77; typical NNTB 11, 95% CI 7 to 25) and the combined outcome of periventricular leukomalacia with or without grade 3 or 4 intraventricular haemorrhage (typical RR 0.47, 95% CI 0.27 to 0.80; typical NNTB 11, 95% CI 7 to 33). VTV modes were not associated with any increased adverse outcomes.

AUTHORS' CONCLUSIONS

Infants ventilated using VTV modes had reduced rates of death or BPD, pneumothoraces, hypocarbia, severe cranial ultrasound pathologies and duration of ventilation compared with infants ventilated using PLV modes. Further studies are needed to identify whether VTV modes improve neurodevelopmental outcomes and to compare and refine VTV strategies.

Home Visiting and the Health of Preterm Infants

The results of home visiting programs which target medically fragile low-birth-weight preterm infants (LBWPT) have been inconsistent. We provided nurse/social worker home visits to families of LBWPT infants on a regular schedule. Teams were trained in approaches to improve the health and development of the infants. The completion of immunization series was sigmificantly higher and the infant mortality rates of the home visits childen were significanly lower compared to national and state rates. We used state Medicaid data and examined frequency of hospitalization, emergency department visits, routine and nonscheduled visits to primary care physician, and pharmacy use of the home-visited subjects compared with a propensity-matched group. The home-visited group had more routine and nonscheduled visits but no more hospitalizations or E.D. visits. Home visiting teams improved important markers of child health, including completed immunizations and mortality rate, perhaps by the careful monitoring of health status and assuring health care when needed.