Regionalized long-term follow-up

Mobile applications for prematurity: a systematic review protocol

Background

Premature birth is a global epidemic of significant public health concern. Counselling and education of pregnant women at risk of preterm birth or mothers with premature infants are essential to improve mother and infant health. Mobile applications are an increasingly popular tool among parents to receive health information and education. This study aims to evaluate the usages and the effects of a mobile application designed for premature births in order to improve health outcomes.

Methods

This review will include all studies of different designs which evaluated the use and impact of interventions provided via mobile applications on pregnant women at risk of preterm birth or mothers with premature infants in order to address all health outcomes. A combination of keywords and MeSH(Medical Subject Headings) terms is used in the search strategy. Literature databases including Scopus, PubMed, ISI Web of Science, ProQuest, CINAHL and Cochrane Library will be searched to May 2021. Furthermore, eligible studies will be chosen from the reference list of retrieved papers. Two researchers will independently review the retrieved citations to decide whether they meet the inclusion criteria. Mixed Methods Appraisal Tool (MMAT) V.2018 will be used to assess the quality of studies. Relevant data are collected in a data extraction form and analysed. Results are reported under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Discussion

This systematic review will recognize and combine evidence about the usages and impact of mobile application interventions on the health improvement of pregnant women at risk of preterm birth or mothers with premature infants.

Behaviors and Attitudes of Obstetricians in Turkey Related to Cord Clamping, Cord Milking, and Skin-To-Skin Contact

Objective This study was planned to evaluate obstetricians' practices of umbilical cord clamping, milking, and skin-to-skin contact applications and to determine the related variables. Material and methods A total of 522 obstetricians participated in the study. Participants were reached via the internet and a 15-item questionnaire was applied about umbilical cord clamping, cord milking, and skin-to-skin contact. Mann-Whitney U test and Student's t-test were used for continuous data and Chi-square test or Fisher's exact test for categorical data in determining the difference between groups. For the multivariate analysis, the possible factors identified with univariate analyses were entered into the logistic regression analysis to determine further independent predictors of delayed clamping. Statistical analysis was performed using the SPSS software (version 20, IBM Corp, Armonk, USA). Results It was determined that 234 (44.8%) of the participants clamped the umbilical cord early whereas 288 (55.2%) clamped it late. It was found that the delayed clamping rates of physicians working in public hospitals were significantly lower than those working in private (p<0.001). It was observed that 132 of the participants (25.3%) did not milk the cord and 180 (34.5%) of them applied it continuously, and no significant difference was found between physicians working in the public and private sectors (p=0.130). It was observed that 384 (73.6%) physicians applied skin-to-skin contact. In the multivariate regression analysis, it was determined that working status in a private hospital with a 3.6 odds ratio (OR) (95% CI = 2.0-6.3) and a low number of patients examined daily with a 1.2 OR (95%CI= 1.0-1.4) were the most important independent factors affecting the choice of delayed clamping. Conclusion It is seen that the most important parameter affecting the birth practices of physicians in our country is the employment status in public or private institutions. The age and professional experience of the physicians who clamp the umbilical cord late were found to be higher. Obstetricians are at the key point in obstetrics practice, and the experience of physicians and the type of institution they work with affect these practices.

Differential effects of delivery hospital on mortality and morbidity in minority premature and low birth weight neonates

OBJECTIVE

To describe variation in mortality and morbidity effects of high-level, high-volume delivery hospital between racial/ethnic groups and insurance groups.

STUDY DESIGN

Retrospective cohort including infants born at 24-32 weeks gestation or birth weights ≤2500 g in California, Missouri, and Pennsylvania between 1995 and 2009 (n = 636,764). Multivariable logistic random-effects models determined differential effects of birth hospital level/volume on mortality and morbidity through an interaction term between delivery hospital level/volume and either maternal race or insurance status.

RESULT

Compared to non-Hispanic white neonates, odds of complications of prematurity were 14-25% lower for minority infants in all gestational age and birth weight cohorts delivering at high-level, high-volume centers (odds ratio (ORs) 0.75-0.86, p < 0.001-0.005). Effect size was greatest for Hispanic infants. No difference was noted by insurance status.

CONCLUSIONS

Neonates of minority racial/ethnic status derive greater morbidity benefits than non-Hispanic white neonates from delivery at hospitals with high-level, high-volume neonatal intensive care units.

Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis

BACKGROUND

The effects of delayed cord clamping of the umbilical cord in preterm infants are unclear.

OBJECTIVE

We sought to compare the effects of delayed vs early cord clamping on hospital mortality (primary outcome) and morbidity in preterm infants using Cochrane Collaboration neonatal review group methodology.

STUDY DESIGN

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Chinese articles, cross-referencing citations, expert informants, and trial registries to July 31, 2017, for randomized controlled trials of delayed (≥30 seconds) vs early (<30 seconds) clamping in infants born <37 weeks' gestation. Before searching the literature, we specified that trials estimated to have cord milking in >20% of infants in any arm would be ineligible. Two reviewers independently selected studies, assessed bias, and extracted data. Relative risk (ie, risk ratio), risk difference, and mean difference with 95% confidence intervals were assessed by fixed effects models, heterogeneity by I² statistics, and the quality of evidence by Grading of Recommendations, Assessment, Development, and Evaluations.

RESULTS

Eighteen randomized controlled trials compared delayed vs early clamping in 2834 infants. Most infants allocated to have delayed clamping were assigned a delay of ≥60 seconds. Delayed clamping reduced hospital mortality (risk ratio, 0.68; 95% confidence interval, 0.52-0.90; risk difference, -0.03; 95% confidence interval, -0.05 to -0.01; P = .005; number needed to benefit, 33; 95% confidence interval, 20-100; Grading of Recommendations, Assessment, Development, and Evaluations = high, with I² = 0 indicating no heterogeneity). In 3 trials in 996 infants ≤28 weeks' gestation, delayed clamping reduced hospital mortality (risk ratio, 0.70; 95% confidence interval, 0.51-0.95; risk difference, -0.05; 95% confidence interval, -0.09 to -0.01; P = .02, number needed to benefit, 20; 95% confidence interval, 11-100; I² = 0). In subgroup analyses, delayed clamping reduced the incidence of low Apgar score at 1 minute, but not at 5 minutes, and did not reduce the incidence of intubation for resuscitation, admission temperature, mechanical ventilation, intraventricular hemorrhage, brain injury, chronic lung disease, patent ductus arteriosus, necrotizing enterocolitis, late onset sepsis or retinopathy of prematurity. Delayed clamping increased peak hematocrit by 2.73 percentage points (95% confidence interval, 1.94-3.52; P < .00001) and reduced the proportion of infants having blood transfusion by 10% (95% confidence interval, 6-13%; P < .00001). Potential harms of delayed clamping included polycythemia and hyperbilirubinemia.

CONCLUSION

This systematic review provides high-quality evidence that delayed clamping reduced hospital mortality, which supports current guidelines recommending delayed clamping in preterm infants. This review does not evaluate cord milking, which may also be of benefit. Analyses of individual patient data in these and other randomized controlled trials will be critically important in reliably evaluating important secondary outcomes.

Outborns or Inborns: Where Are the Differences? A Comparison Study of Very Preterm Neonatal Intensive Care Unit Infants Cared for in Australia and New Zealand and in Canada

BACKGROUND

Very preterm infants born outside tertiary centers are at higher risks of adverse outcomes than inborn infants. Regionalization of perinatal care has been introduced worldwide to improve outcomes.

OBJECTIVE

To compare the risk-adjusted outcomes of both inborn and outborn infants cared for in tertiary neonatal intensive care units in Australia and New Zealand and in Canada.

METHODS

Deidentified data of infants <32 weeks' gestational age from the 29 Australian and New Zealand Neonatal Network units (ANZNN; n = 9,893) and 26 Canadian Neonatal Network units (CNN; n = 7,133) between 2005 and 2007 were analyzed for predischarge adverse outcomes.

RESULTS

ANZNN had lower rates of outborns compared to CNN (13 vs. 19%), particularly of late admissions (>2 days of age; 5.8 vs. 22.2% of outborns) who had high morbidity rates. After adjusting for confounding variables including gestation, ANZNN inborn infants had lower odds of chronic lung disease [CLD; 17.0 vs. 23.3%; adjusted odds ratio (AOR) = 0.70, 95% CI: 0.64-0.77], severe neurological injuries on ultrasound (SNI; 4.1 vs. 6.7%; AOR = 0.62, 95% CI: 0.53-0.73), severe retinopathy (5.6 vs. 7%; AOR = 0.71, 95% CI: 0.59-0.84) and necrotizing enterocolitis (3.5 vs. 5.4%; AOR = 0.67, 95% CI: 0.56-0.79), but no difference in mortality odds. After excluding the late outborn admissions, ANZNN outborns had lower odds of SNI (AOR = 0.43, 95% CI: 0.32-0.58) and CLD (AOR = 0.63, 95% CI: 0.49-0.81) than CNN.

CONCLUSIONS

ANZNN inborn and early admitted outborn infants had lower odds of neonatal morbidities than their CNN counterparts. However, compared to ANZNN, the higher CNN rates of outborns and their late admissions are likely related to the differences in regionalization and referral practices, and may explain differences in outcomes.

The effectiveness of regionalization of perinatal care services--a systematic review

BACKGROUND

Several reports recommend the implementation of perinatal regionalization for improvements in maternal and neonatal outcomes, while research evidence on the effectiveness of perinatal regionalization has been limited. The interventional studies have been assessed for robust evidence on the effectiveness of perinatal regionalization on improving maternal and neonatal health outcomes.

METHODS

Bibliographic databases of Medline, EMbase, EconLit, HMIC have been searched using sensitive search terms for interventional studies that reported important patient or process outcomes. At least two authors assessed eligibility for inclusion and the risk of biases and extracted data from the included studies. As meta-analysis was not possible, a narrative analysis as well as a 'vote-counting' analysis has been conducted for important outcomes.

RESULTS

After initial screenings 53 full text papers were retrieved. Eight studies were included in the review from the USA, Canada and France. Studies varied in their designs, and in the specifications of the intervention and setting. Only three interrupted time series studies had a low risk of bias, of which only one study reported significant reductions in neonatal and infant mortality. Studies of higher risk of bias were more likely to report improvements in outcomes.

CONCLUSIONS

Implementing perinatal regionalization programs is correlated with improvements in perinatal outcomes, but it is not possible to establish a causal link. Despite several high profile policy statements, evidence of effect is weak. It is necessary to assess the effectiveness of perinatal regionalization using robust research designs in a more diverse range of countries.

Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis

BACKGROUND/PURPOSE

The distribution of surgical care of very low birth weight (VLBW) neonates among centers with varying specialized care remains unknown. This study quantifies operations performed on VLBW neonates nationally with respect to center type.

METHODS

VLBW neonates born 2009-2012 were assessed using a prospectively collected multi-center database encompassing 80% of all VLBW neonates in the United States. Surgical centers were categorized based on availability of pediatric surgery (PS) and anesthesia (PA).

RESULTS

48,711 major procedures (29,512 abdominal operations) were performed on 24,318 neonates. Of all patients, 20,892 (85.9%) underwent surgery at centers with PS and PA available on site. 1663 (6.8%) patients were treated at centers with neither specialty on site. Neonates requiring complex operations were more likely to receive surgery at centers with both PS and PA on staff than those requiring non-complex operations (95.6% vs 93.6%).

CONCLUSION

This study confirms that most operations on VLBW neonates in the U.S. are performed at centers with pediatric surgeons and anesthesiologists on staff. Further research is necessary, however, to elucidate why a significant minority of this challenging population continues to be managed at centers without pediatric specialists.

Outcomes following periviable birth

This review is presented in three segments: (1) important background concepts, (2) recent reports from regional geographically defined cohorts, and (3) prognosis research from the National Institutes of Health Neonatal Research Network. Extending the use of intensive care to newborns of lower gestational ages will unavoidably result in a higher proportion and a higher absolute number of survivors with morbidity, unless other changes in practice offset the increased risk associated with decreasing gestational age. In geographically defined cohort studies, the proportion of periviable newborns delivered in perinatal centers and the practices around foregoing and withdrawing intensive care are two important determinants of outcomes following periviable birth. It is much easier to quantify the effect of the former than the latter. Decisions regarding comfort care vs. intensive are frequently based on gestational age as the sole predictor variable, although multiple factors can be readily used to more accurately assess the benefits and burdens of intensive care and facilitate better informed parental counseling and decision making.

The consequences of chorioamnionitis: preterm birth and effects on development

Preterm birth is a major cause of perinatal mortality and long-term morbidity. Chorioamnionitis is a common cause of preterm birth. Clinical chorioamnionitis, characterised by maternal fever, leukocytosis, tachycardia, uterine tenderness, and preterm rupture of membranes, is less common than subclinical/histologic chorioamnionitis, which is asymptomatic and defined by inflammation of the chorion, amnion, and placenta. Chorioamnionitis is often associated with a fetal inflammatory response. The fetal inflammatory response syndrome (FIRS) is defined by increased systemic inflammatory cytokine concentrations, funisitis, and fetal vasculitis. Clinical and epidemiological studies have demonstrated that FIRS leads to poor cardiorespiratory, neurological, and renal outcomes. These observations are further supported by experimental studies that have improved our understanding of the mechanisms responsible for these outcomes. This paper outlines clinical and experimental studies that have improved our current understanding of the mechanisms responsible for chorioamnionitis-induced preterm birth and explores the cellular and physiological mechanisms underlying poor cardiorespiratory, neural, retinal, and renal outcomes observed in preterm infants exposed to chorioamnionitis.

Improvement in mortality of very low birthweight infants and the changing pattern of neonatal mortality: the 50-year experience of one perinatal centre

AIM

Neonatology is a relatively new sub-specialty so we aimed to review survival data in the context of advances in neonatal care.

METHOD

Review of neonatal survival for very low birthweight babies over the last 50 years.

RESULTS

In the data collected from a single tertiary neonatal unit, survival for babies 501-1000 g improved from below 10% in 1959 to over 60% in 2009. Similarly, survival for babies 1001 to 1500 g has improved from approximately 50% to over 90%. During the study period, death due to extreme prematurity or cardiorespiratory problems, namely respiratory distress syndrome, fell from 90% in 1964 to only 45% of neonatal deaths in 2008.

CONCLUSION

In addition to reporting the remarkable improvement in neonatal survival over this period, we have highlighted items of historical context.

[SEN1500: design and implementation of a registry of infants weighing less than 1,500 g at birth in Spain]

OBJECTIVE

To design and implement a registry of infants weighing less than 1,500 g at birth in Spain.

MATERIAL AND METHODS

Prospective, cohort, multicenter study. All live born infants weighing less than 1,500 g in several voluntarily participating neonatal units in public and private hospitals were included.

RESULTS

In the first 4 years of the registry (2002 to 2005), 9,638 very-low-birth-weight infants were born in the 65 neonatal units that have so far joined the program.

CONCLUSIONS

The goal of very-low-birth-weight infant databases is to try to improve the quality and safety of the medical care given to these newborns and their families. This type of program helps to coordinate and promote several areas, including those of health education, training of medical staff, research and development, surveillance and quality improvement.

International comparison of care for very low birth weight infants: parents' perceptions of counseling and decision-making

OBJECTIVE

To characterize parent perceptions and satisfaction with physician counseling and delivery-room resuscitation of very low birth weight infants in countries with neonatal intensive care capacity.

STUDY DESIGN

Convenience sample of 327 parents of 379 inborn very low birth weight infants (<1501 g) who had received resuscitation and neonatal intensive care in 9 neonatal intensive care units (NICUs) in 6 Pacific Rim countries and in 2 California hospitals. The sample comprised mostly parents whose infants survived, because in some centers interviews of parents of nonsurviving infants were culturally inappropriate. Of 359 survivors for whom outcome data were asked of parents, 29% were reported to have long-term sequelae. Half-hour structured interviews were performed, using trained interpreters as necessary, at an interval of 13.7 months after the infant's birth. We compared responses to interview questions that detailed counseling patterns, factors taken into consideration in decisions, and acceptance of parental decision-making.

RESULTS

Parents' recall of perinatal counseling differed among centers. The majority of parents assessed physician counseling on morbidity and mortality as adequate in most, but not all, centers. They less commonly perceived discussions of other issues as adequate to their needs. The majority (>65%) of parents in all centers felt that they understood their infant's prognosis after physician counseling. The proportion of parents who expected long-term sequelae in their infant varied from 15% (in Kuala Lumpur, Malaysia) to 64% (in Singapore). The majority (>70%) of parents in all centers, however, perceived their infant's outcome to be better than they expected from physician counseling. A majority of parents across all centers feared that their infant would die in the NICU, and approximately one third continued to fear that their infant might die at home after nursery discharge. The parents' regard for physicians' and, to a lesser extent, partners' opinions was important in decision-making. Less than one quarter of parents perceived that physicians had made actual life-support decisions on their own except in Melbourne, Australia, and Tokyo, Japan (where 74% and 45% of parents, respectively, reported sole physician decision-making). Parents would have preferred to play a more active, but not autonomous, role in decisions made for their infants. Counseling may heighten parents' anxiety during and after their infant's hospitalization, but that does not diminish their recalled satisfaction with counseling and the decision-making process.

CONCLUSIONS

Counseling differs by center among these centers in Australasia and California. Given that parents desire to play an active role in decision-making for their premature infant, physicians should strive to provide parents the medical information critical for informed decision-making. Given that parents do not seek sole decision-making capacity, physicians should foster parental involvement in life-support decisions to the extent appropriate for local cultural norms.