Late preterm birth: preventable prematurity?

Economic assessment of neonatal intensive care

Most of the studies on the costing of neonatal intensive care has concentrated on the costs associated with preterm infants which takes up more than half of neonatal intensive care unit (NICU) costs. The focus has been on determining the cost-effectiveness of extreme preterm infants and those at threshold of viability. While the costs of care have an inverse relationship with gestational age (GA) and the lifetime medical costs of the extreme preterm can be as high as $450,000, the total NICU expenditure are skewed towards the care of moderate and late preterm infants who form the main bulk of patients. Neonatal intensive care, has been found to be very cost-effective at $1,000 per term infant per QALY and $9,100 for extreme preterm survivor per QALY. For low and LMIC, where NICU resources are limited, the costs of NICU care is lower largely due to a patient profile of more term and preterm of greater GAs and correspondingly less intensity of care. Public health measures, neonatal resuscitation training, empowerment of nurses to do resuscitation, increasing the accessibility to essential newborn care are recommended cheaper cost-effective measures to reduce neonatal mortality in countries with high neonatal mortality rate, whilst upgraded neonatal intensive care services are needed to further reduce neonatal mortality rate once below 15 per 1,000 livebirths. Economic evaluation of neonatal intensive care should also include post discharge costs which mainly fall on the health, social and educational sectors. Strategies to reduce neonatal intensive care costs could include more widespread implementation of cost-effective methods of improving neonatal outcome and reducing neonatal morbidities, including access to antenatal care, perinatal interventions to delay preterm delivery wherever feasible, improving maternal health status and practising cost saving and effective neonatal intensive care treatment.

Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit

Despite the recent improvements in perinatal medical care leading to an increase in survival rates, adverse neurodevelopmental outcomes occur more frequently in preterm and/or high-risk infants. Medical risk factors for neurodevelopmental delays like male gender or intrauterine growth restriction and family sociocultural characteristics have been identified. Significant data have provided evidence of the detrimental impact of overhelming environmental sensory inputs, such as pain and stress, on the developing human brain and strategies aimed at preventing this impact. These strategies, such as free parental access or sleep protection, could be considered 'principles of care'. Implementation of these principles do not require additional research due to the body of evidence. We review the scientific evidence for these principles here.

The association between obstetrical interventions and late preterm birth

OBJECTIVE

There is concern that obstetric interventions (prelabor cesarean section and induced delivery) are drivers of late preterm (LP) birth. Our objective was to evaluate the independent association between obstetric interventions and LP birth and explore associated independent maternal and fetal risk factors for LP birth.

STUDY DESIGN

In this population-based cross-sectional study, the BORN Information System was used to identify all infants born between 34 and 40 completed weeks of gestation between 2005 and 2012 in Ontario, Canada. The association between obstetric interventions (preterm cesarean section and induced delivery) and LP birth (34 to 36 completed weeks' gestation vs 37 to 40 completed weeks' gestation) was assessed using generalized estimating equation regression.

RESULTS

Of 917,013 births between 34 and 40 weeks, 49,157 were LP (5.4%). In the adjusted analysis, "any obstetric intervention" (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.57-0.74), induction (RR, 0.71; 95% CI, 0.61-0.82) and prelabor cesarean section (RR, 0.66; 95% CI, 0.59-0.74) were all associated with a lower likelihood of LP vs term birth. Several independent potentially modifiable risk factors for LP birth were identified including previous cesarean section (RR, 1.28; 95% CI, 1.16-1.40), smoking during pregnancy (RR, 1.28; 95% CI, 1.21-1.36) and high material (RR, 1.1; 95% CI, 1.03-1.18) and social (RR, 1.09; 95% CI, 1.02-1.16) deprivation indices.

CONCLUSION

After accounting for differences in maternal and fetal risk, LP births had a 35% lower likelihood of obstetric interventions than term births. Obstetric care providers may be preferentially avoiding induction and prelabor cesarean section between 34 and 37 weeks' gestation.

Physiologic underpinnings for clinical problems in moderately preterm and late preterm infants

This article highlights some of the important developmental characteristics that underpin common problems seen in moderate and late preterm infants. Preterm birth is associated with an increased prevalence of clinical problems caused by functional immaturities in a wide variety of organ systems, acquired problems, and problems associated with inadequate monitoring and/or follow-up plans. There are variations in the degree of maturation among infants of similar gestational ages because the developmental process is nonlinear. Therefore, different organ systems mature at rates and trajectories that are specific to their functions. A better understanding of these principles can help guide optimal treatment strategies.

Newborn clinical outcomes of the AWHONN late preterm infant research-based practice project

OBJECTIVE

To describe the neonatal health risks (hypothermia, hypoglycemia, hyperbilirubinemia, respiratory distress, the need for a septic workup, and feeding difficulties) experienced by late preterm infants (LPIs) from a large multisite study and determine how these risks were affected by gestational age at birth.

DESIGN

Descriptive analysis of prospective data obtained as part of the AWHONN Late Preterm Infant Research-Based Practice Project.

SETTING

Fourteen hospitals located through the United States and Canada.

PARTICIPANTS

Late preterm infants (802) born at gestational ages between 34 0/7 and 36 6/7 weeks.

METHODS

Nurses at each site obtained consent from the mother of the infant. The data about the infant were gathered from the infant's medical record.

RESULTS

Thirty-six percent of LPIs were initially cared for in a special care nursery; approximately one half of these infants were eventually transferred to a well-baby nursery. Of the 64% of LPIs initially cared for in a routine nursery, 10% were transferred to a special care unit or neonatal intensive care unit (NICU). More than one half of LPIs experienced hypothermia, hypoglycemia, feeding difficulties, hyperbilirubinemia, and respiratory distress and/or needed a septic workup. The risk for these problems was higher in infants of younger gestational ages. Thirty-two percent of the infants were bathed during the first 2 hours of life, and by 4 hours, more than two thirds had had their first bath. Fifty-two percent received kangaroo care during the first 48 hours of life.

CONCLUSION

These findings support those of smaller studies indicating that LPIs are at high risk for developing health problems during their neonatal hospitalization. Nurses may be able to ameliorate some of these health problems through early identification of problems and simple, inexpensive interventions such as avoiding early bathing and promoting kangaroo care.

The underestimation of immaturity in late preterm infants

PURPOSE

Late preterm infants with gestational ages between 34 0/7 and 36 6/7 weeks are known to be at higher risk of mortality and morbidity than term newborns. This study aims to investigate the nature and frequency of neonatological complications in the late preterm population resulting in neonatal intensive care unit admissions as well as to draw obstetrical conclusions from the results.

METHODS

Neonatological outcomes of 893 consecutively born late preterm infants were evaluated and classified by the frequency of occurrence in relation to potential maternal or fetal risk factors.

RESULTS

Out of 893 late preterm infants, 528 (59.1 %) required intensive neonatal care. The incidence of apnea and bradycardia, the occurrence of feeding difficulties and the requirement of continuous positive airway pressure (CPAP) were inversely proportional to gestational age (p < 0.001). Gestational diabetes of the mother was more frequently associated with hypoglycemia (p < 0.001), but showed a reduced risk of hypothermia (p < 0.001). Small for gestational age neonates had a significantly lower rate of respiratory disorders (p < 0.001), but were more often affected by feeding difficulties (p < 0.01). Normal vaginal delivery had a significant advantage with regard to the necessity of CPAP (p < 0.01) and the occurrence of feeding difficulties (p < 0.05). Infants born by cesarean section were at higher risk of hypoglycemia (p < 0.001), but at lower risk of hyperbilirubinemia (p < 0.001).

CONCLUSIONS

The high risk of a problematic neonatological outcome in late preterms requires fundamental reconsideration. All efforts to prolong a pregnancy should be made beyond the 34th week of gestation.