Infants born at the threshold of viability in relation to neonatal mortality: Colorado, 1991 to 2003

The Mortality of Periviable and Extremely Premature Infants and Their Impact on the Overall Neonatal Mortality Rate

To investigate mortality in periviable neonates ≤23 weeks gestational age and calculate its impact on overall neonatal mortality rate over a 12-year period (1998-2009). Verify if periviable mortality decreased in the period (2010-2015). Retrospective review. Neonatal mortality rate per 1000 live births was 11.4. Three hundred forty-nine live birth infants weighed ≤500 g and 336 died. Their proportion to the total neonatal mortality rate was 48.6%; out of 298 periviables 146 (43%) were ≤20 weeks gestational age. In 269 (80%) we could not determine the cause of death. Two hundred ninety-seven neonates (88.3%) died in the delivery room. Sixteen (5%) had an autopsy. Neonatal mortality rate from periviability was 96.2% and constituted half of the overall rate in the period (1998-2009). There was not significant reduction of periviable mortality between 2010 and 2015. Current live birth definition and a reporting system that considers a 100 g periviable live birth infant as a neonatal death has placed Ohio and the United States at a significant disadvantage compared to other countries using different reporting systems.

Evaluation of Neonatal Services Provided in a Level II NICU Utilizing Hybrid Telemedicine: A Prospective Study

Objective: To evaluate the safety and efficacy of premature infant treatment managed by hybrid telemedicine versus conventional care.

Methods: Prospective, noninferiority study comparing outcomes of premature infants at Comanche County Memorial Hospital's (CCMH) Level II neonatal intensive care unit (NICU) with outcomes at OU Medical Center's (OUMC) Level IV NICU. All 32–35 weeks gestational age (GA) infants admitted between May 2015 and October 2017 were included. Infants requiring mechanical ventilation >24 h or advanced subspecialty care were excluded. Outcome variables were: length of stay (LOS), respiratory support, and time to full per oral (PO) feeds. Parents at both centers were surveyed about their satisfaction with the care provided. Between-group comparisons were performed by using Chi-square or Fisher's exact test. LOS was assessed for normality by using the Shapiro–Wilk test, and robust regression was used to construct a multivariable regression model to test the independent effect of location on LOS. All analyses were performed by using SAS v. 9.3 (SAS Institute, Cary, NC).

Results: Data from 85 CCMH and 70 OUMC neonates were analyzed. CCMH neonates had significantly shorter LOS, reached full PO feeds sooner, and had fewer noninvasive ventilation support days. Location had a significant independent effect (p = 0.001) on LOS while controlling for GA, gender, race, surfactant use, inborn/outborn status, and 5-min APGAR scores. CCMH patients had reduced LOS of 3.01 days (95% confidence interval 1.1–4.8) than OUMC patients. Eighty-five surveys at CCMH and 66 at OUMC were analyzed. Compared with CCMH, OUMC parents reported more travel distance difficulties. 92.5% reported telemedicine experience as good or excellent, whereas 1.5% reported it as poor.

Conclusion(s): Hybrid telemedicine is a safe and effective way to extend intensive neonatal care to medically underserved areas. Parental satisfaction with use of hybrid telemedicine is high and comparable to conventional care.

Impact of neonatologist availability on preterm survival without morbidities

OBJECTIVES

We assessed birth hospital level and neonatal outcomes within a model of regionalization featuring neonatologists at all levels of care, including well-baby nurseries without an accompanying neonatal intensive care unit.

METHODS

Data were analyzed by NY State adaptation of American Academy of Pediatrics defined levels of care; n = 998, 23-30 weeks gestational age, 400-1250 g birth weight, and admitted to the regional center (2006-2015). Primary outcomes were survival, neurologic survival, and intact survival.

RESULTS

Level III hospitals transferred 82% of neonates ≥24 h of life compared to ≤2% at Level I or II hospitals (p < 0.05). Primary outcomes were equivalent for Levels I vs. II born neonates with similar postnatal age at transfer and similar to inborn rates (Levels I and II vs. IV).

CONCLUSIONS

When transferred within 24 h, Levels I or II born infants had equivalent outcomes to inborn Level IV infants in a model of neonatologist availability at all deliveries.

Early Mortality and Morbidity in Infants with Birth Weight of 500 Grams or Less in Japan

OBJECTIVE

To assess the short-term prognosis of Japanese infants with a birth weight (BW) of ≤500 g.

STUDY DESIGN

Demographic and clinical data were reviewed for 1473 live born infants with a BW ≤500 g at gestational age ≥22 weeks who were treated in the 204 affiliated hospitals of the Neonatal Research Network of Japan between 2003 and 2012.

RESULTS

Survival to hospital discharge occurred in 811 of 1473 infants (55%; 95% CI 53%-58%). The survival rates of BW ≤300 g, 301-400 g, and 401-500 g were 18% (95% CI 10%-31%), 41% (95% CI 36%-47%), and 60% (95% CI 57%-63%), respectively. In a multivariable Cox proportional hazards analysis, antenatal corticosteroid use (adjusted hazard ratio: 0.68; 95% CI 0.58-0.81; P < .01), cesarean delivery (0.69; 95% CI 0.56-0.85; P < .01), advanced gestational age per week (0.94; 95% CI 0.89-0.99; P = .02), BW per 100-g increase (0.55; 95% CI 0.49-0.64; P < .01), Apgar score ≥4 at 5 minutes (0.51; 95% CI 0.43-0.61; P < .01), and no major congenital abnormalities (0.38; 95% CI 0.29-0.51; P < .01) were associated with survival to discharge. Despite the improved survival rate over the 10-year study period (from 40% in 2003 [95% CI 30%-51%] to 68% in 2012 [95% CI 61%-75%]), at least 1 severe morbidity was present in 81%-89% of the survivors.

CONCLUSIONS

Improvements in perinatal-neonatal medicine have improved the survival, but not the rate of major morbidities, of infants with a BW ≤500 g in Japan.

County-level Variation in Infant Mortality Reporting at Early Previable Gestational Ages

BACKGROUND

Infant mortality rate (IMR), or number of infant deaths per 1000 livebirths, varies widely across the US While fetal deaths are not included in this measure, reported infant deaths do include those delivered at previable gestations, or ≤20 weeks gestation. Variation in reporting of these events may have a significant impact on IMR estimates.

METHODS

This retrospective analysis used US National Center for Health Statistics 2007-2013 data from 2391 US counties. Counties were categorised by US region, demographic characteristics, and state-level fetal death reporting requirements. County percentage of fetal deaths among all 17-20 week fetal and infant deaths was evaluated using multivariable linear regression. County-level characteristics were then included in multivariable linear regression to determine the associated change in county IMR.

RESULTS

County percentage of deaths at 17-20 weeks reported as fetal ranged from 0% to 100% (mean 63.7%). Every 1 point increase in this percentage was associated with a 0.02 point decrease in county IMR (95% confidence interval (CI) 0.02, 0.03). When county IMRs were recalculated holding the percentage of fetal vs. infant deaths at 17-20 weeks constant at 63.7%, results suggest that the predicted gap in county IMR between Northeast and Midwest regions would narrow by 0.45 points.

CONCLUSIONS

Variable reporting of previable fetal and infant deaths may compromise the validity of county IMR comparisons. Improved consistency and accuracy of fetal and infant death reporting is warranted.

Factors influencing the care provided for periviable babies in Australia: a narrative review

Survival at extreme prematurity is becoming increasingly common. Neurodisability is an increasing risk with decreasing gestation. This review outlines the risks of extreme prematurity and the attitudes of health care providers and families in Australia of periviable babies. High quality data is difficult to find due to differing definitions and methods of assessment of disability. Meta-analyses of outcomes of prematurity published from 2008 to 2013, including babies born from 1990 onwards, suggest a severe disability rate of around 20 % at 22 to 26 weeks completed gestation, with moderate disability decreasing with increasing gestation. Studies show that Australian health care providers underestimate the survival and positive outcomes of these babies. The majority of Australian health care providers state that parental preference would determine the decision to offer care to babies at 23 weeks gestation, however, all had a threshold above which parental preference would be ignored in favour of resuscitation .This ranged from 22 to 27 completed weeks gestation. The few studies examining Australian parental involvement in resuscitation decisions, showed that the majority of parents felt that health professionals alone had made the decision to resuscitate their extremely preterm babies and the parents themselves did not wish to be the primary decision makers in withholding care. The babies progressed better than parents had expected following antenatal counselling. The attitudes of health care providers, experiences and opinions of parents seem to be at odds with the current move to increase parental decision making at the most extremes of gestation. Current Australian guidelines suggest parental decision making below 25 weeks gestation, and primarily clinician decision making over this gestation. The increased risks of prematurity and adverse outcomes for the North Queensland population is also explored. This population has a high proportion of Aboriginal and Torres Strait Islanders who have increased risks which are primarily linked to poor socioeconomic factors and are highest for the most remote residents. Attitudes towards delivery of care to these highest risk babies from health professionals and in the populations themselves have not been studied.

Periviable birth: executive summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (for example, antenatal steroid, tocolytic agents and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect and understanding, and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation) and the treatment options for the newborn infant. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (eg, antenatal steroid, tocolytic agents, and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation, and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect, and understanding and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Survival of pre-viable preterm infants in the United States: a systematic review and meta-analysis

The objective of this paper is to review observational studies that addressed the survival of pre-viable gestations in the United States. We searched PubMed, Ovid, CINAHL, and Web of Knowledge for studies reporting survival of infants born at <24 gestational weeks and/or <500g in the United States and published between January 2003 and January 2013. The full texts of 70 articles were examined and a total of 15 studies qualified and were selected. We analyzed fixed-effect and random-effects models for eight studies on survival to discharge. Pooled survival to discharge in the random-effects model was 45.9% (95% CI: 41.1-51.7) and 39.7% in the fixed-effect model (95% CI: 38.8-40.7). Studies differed by pre-viable survival measures and epochs (1985-2009). Protective factors included antenatal corticosteroids, neonatal resuscitation, and intensive care. The current survival threshold for pre-viable infants warrants reconsideration of the limits of viability. Protective factors that enhance survival should be considered in the management of these infants.

The changing profile of infant mortality from bacterial, viral and fungal infection over two decades

AIM

Infection is an important cause of neonatal and infant mortality. We evaluated changes in infant deaths from infections from 1988 to 2008 in the North of England.

METHODS

We interrogated a population-based survey and reviewed infant deaths from infection. Proportional contribution to deaths, pathogens identified and risk factors were analysed.

RESULTS

Thirteen percentage of 4366 infant deaths from a population of 704 536 livebirths were infectious. The absolute numbers of infant deaths from infection fell over time but the proportion of deaths from infection increased (12.1%, 13.6% and 14.9%). Significantly preterm infants were increasingly represented in successive epochs (14%, 24% and 38%). Infant mortality rate (IMR) from meningococcus and Group B Streptococcus (GBS) fell in the latest epoch, but there was a corresponding increase from Escherichia coli and candida.

DISCUSSION

This large study shows that infections have become proportionately more important causes of death especially in very preterm infants. Recent significant reductions in death from meningococcus and GBS are likely to represent successful achievements of vaccination and antibiotic prophylactic policies. Increases in IMR from E. coli may relate to GBS prophylaxis and increases in candida to the increase from preterm populations. Further efforts to understand these changing patterns and develop additional prevention and treatment strategies and vaccines remain an urgent priority.

Deaths in preterm infants: changing pathology over 2 decades

OBJECTIVE

To establish how cause of death for live-born preterm infants (24-31 weeks gestation) has changed in a single large UK population over 2 decades.

STUDY DESIGN

This was an interrogation of a population-based survey of >680, 000 live births (between 1988 and 2008) for deaths in the first postnatal year. We collected cause of death grouped into major etiologies: respiratory, infection, malformation, necrotizing enterocolitis (NEC), and other. Data were analyzed in three 7-year epochs and 2 gestational groups (<27 and 28-31 weeks). Numbers, rates per 1000 live births, and proportional contributions to each epoch were analyzed.

RESULTS

A total of 1504 deaths occurred. The infants who died had a median gestational age of 26 weeks (IQR, 25-28 weeks) and a median birth weight of 880 g (IQR, 700-1170 g). The number of deaths decreased with each later epoch (from 671 to 473 and then to 360), as did the proportion of deaths from respiratory causes (64% to 62% and then to 49%). The proportion of deaths occurring after 40 weeks postmenstrual age remained stable across the 3 epochs (8.8%, 8%, and 8%). Deaths from infection and NEC increased with time (from 11% to 13% and then to 21%), as did median time to death (from 2.7 to 3.8 days).

CONCLUSION

Infection and NEC are increasingly prevalent causes of death in preterm infants.

Current empirical research in neonatal bioethics

Ethical dilemmas in neonatology can be analysed using both the theoretical tools of analytic philosophy and the empirical tools of clinical epidemiology and health services research. Both yield important insights into ways to think about the ethical issues that arise in clinical neonatology. In this paper, we review recent empirical research in neonatal bioethics. Studies published in the last 5 years shed light on issues that arise in prenatal consultation, prognostication, outcomes, quality-of-life and cost-effectiveness in neonatal intensive care. These studies show ways in which doctors vary in their decisions from country to country, hospital to hospital and for babies and children with different conditions but similar prognoses. Empirical research in bioethics can answer questions about what doctors and parents think and do. It does not answer questions about what they ought to do.

CONCLUSION

  Good ethics starts with good facts, even if good facts are not sufficient to get us to good ethics.

Trends in cause-specific mortality at a Canadian outborn NICU

OBJECTIVE

To retrospectively review changes in the causes of death of infants dying in the NICU at Canada's largest outborn pediatric center.

PATIENTS AND METHODS

All inpatient deaths at the Hospital for Sick Children's NICU that occurred in the years 1997, 2002, and 2007 were retrospectively reviewed to identify the primary cause of death. Classification of the cause of death was based on a modified version of the Perinatal Society of Australia and New Zealand's Neonatal Death Classification.

RESULTS

The annual mortality rate remained relatively constant (average of 7.6 deaths per 100 admissions between 1988 and 2007). A total of 156 deaths were analyzed: 53 in 1997; 50 in 2002; and 53 in 2007. The chronological age at which premature infants died increased significantly over the 3 time periods (P = .01). The proportion of deaths attributable to extreme prematurity and intraventricular hemorrhage decreased over the study period, whereas the proportion of deaths attributed to gastrointestinal causes (specifically necrotizing enterocolitis and focal intestinal perforation) increased. The proportion of infants for whom there was a decision to limit care before death was stable at between 83% and 92%.

CONCLUSIONS

A larger proportion of outborn premature infants admitted to the Hospital for Sick Children's NICU seem to be surviving the early problems of prematurity only to succumb to late complications.

The regionalization of pediatric health care

Regionalization of health care is a method of providing high-quality, cost-efficient health care to the largest number of patients. Within pediatric medicine, regionalization has been undertaken in 2 areas: neonatal intensive care and pediatric trauma care. The supporting literature for the regionalization of these areas demonstrates the range of studies within this field: studies of neonatal intensive care primarily compare different levels of hospitals, whereas studies of pediatric trauma care primarily compare the impact of institutionalizing a trauma system in a single geographic region. However, neither specialty has been completely regionalized, possibly because of methodologic deficiencies in the evidence base. Research with improved study designs, controlling for differences in illness severity between different hospitals; a systems approach to regionalization studies; and measurement of parental preferences will improve the understanding of the advantages and disadvantages of regionalizing pediatric medicine and will ultimately optimize the outcomes of children.

Neonatal regionalization through telemedicine using a community-based research and education core facility

INTRODUCTION

Although regionalization of neonatal intensive care is associated with improved outcomes, implementation has been difficult because of increased deliveries of sicker neonates in smaller nurseries. Telemedicine has been used successfully for medical care and education but it has never been utilized to modify patterns of delivery in an established state network.

METHODS

The Community Based Research and Education Core Facility of the Center for Translational Neuroscience established a network of 15 telemedicine units with real-time teleconferencing and diagnostic quality imaging, called Telenursery, placed in neonatal intensive care units, using T1 lines to link these units with a large academic neonatal practice. Weekly educational conferences were conducted to establish guidelines for obstetrical, neonatal and pediatric care in a program called PedsPLACE (Physician Learning and Collaborative Education). Patterns of delivery were assessed through a linked Medicaid database before and after the Telenursery initiative to determine if the most at-risk neonates were transferred to the academic perinatal center for delivery. Clinician satisfaction with the PedsPLACE educational conference was high as assessed through written survey instruments.

RESULTS

Medicaid deliveries at the regional perinatal centers increased from 23.8% before the intervention to 33% in neonates between 500 and 999 grams (P < .05) and was unchanged in neonates between 2001-2500 grams.

CONCLUSION

Telemedicine is an effective way to translate evidence-based medicine into clinical care when combined with a general educational conference. Patterns of deliveries appear to be changing so that those newborns at highest risk are being referred to the regional perinatal centers.