Immediate skin-to-skin contact versus care under radiant warmer at birth in moderate to late preterm neonates - A randomized controlled trial

OBJECTIVE

To compare the effect of immediate care at birth in skin-to-skin contact (SSC) or under a radiant warmer on cardiorespiratory stability at 60 minutes of age in moderate-to-late preterm neonates.

METHODS

In this open-label, parallel-group, randomized controlled trial, neonates born at 330/7 to 366/7 weeks of gestation by vaginal delivery and breathing or crying were randomized to receive care at birth in SSC (n = 50) or under a radiant warmer (n = 50). In the SSC group, immediate care at birth including drying and clearing of the airway was provided in SSC over the mother's abdomen. SSC was maintained for an observational period of 60 minutes after birth. In the radiant warmer group, care at birth and post-birth observation was performed under an overhead radiant warmer. The primary outcome of the study was the stability of the cardio-respiratory system in late preterm infants (SCRIP) score at 60 minutes of age.

RESULTS

Baseline variables were similar in the two study groups. The SCRIP score at 60 minutes of age was similar in the two study groups (median: 5.0, IQR: 5-6 vs. 5.0, 5-6). The mean axillary temperature at 60 minutes of age was significantly lower in the SSC group (°C; 36.4 ± 0.4 vs. 36.6 ± 0.4, P = 0.004).

CONCLUSION

It was feasible to provide immediate care at birth in moderate and late preterm neonates while being positioned in SSC with the mother. However, in comparison to care under a radiant warmer, this did not lead to better cardiorespiratory stability at 60 minutes of age.

TRIAL REGISTRATION

Clinical Trial Registry of India (CTRI/2021/09/036730).

Appraising Neonatal Morbidity and Mortality in a Developing Country Categorized by Gestational Age Grouping and Implications for Targeted Interventions

Introduction

Despite the relatively higher neonatal morbidity and mortality in developing countries, there are limited data on the detailed analysis of the burden in Nigeria. With a database of over 14,000 admissions, this study presents a compelling picture of the current trends disaggregated by their gestational age groups. It provides unique opportunities for better-targeted interventions for further reducing newborn mortality in line with SDG 3, Target 3.2.

Methods

This prospective observational study involved newborn babies admitted to the Neonatal Intensive Care Unit of the University of Ilorin Teaching Hospital, Kwara State, Nigeria, between January 2007 and December 2018. The outcome was the neonatal mortality rates. The exposure variables included birth weight, gestational age (preterm versus term), and clinical diagnosis. Frequencies were generated on tables and charts, and the trends or associations were determined.

Results

Of the 14,760 neonates admitted, 9,030 (61.2%) were term babies, 4,847 (32.8%) were preterm babies, and in 792 (5%) of the admissions, the gestational ages could not be determined. Males constituted a higher proportion with 55.9%, and the total number of deaths in the study period was 14.7%. The mortality ratio was highest among babies with a birth weight of less than 1,000 g (38.0%) and gestational age of less than 28 weeks (65.5%). The trend analysis showed that the mortality rate decreased from 17.8 to 13% over the 12 years, p-value < 0.0001. For term babies, mortality decreased by 45%, from 15.7% in 2007 to 8.7% in 2018, while the decline in mortality for preterm babies was 28.4%, from 25.7% in 2007 to 18.4% in 2018. For both categories, p-values were < 0.001. Regarding morbidity in term babies, asphyxia occurred in (1:3), jaundice (1:5), sepsis (1:6), and respiratory disorders (1:6) of admissions. For mortality, asphyxia occurred in (1:2), sepsis (1:5), jaundice (1:8), and respiratory disorders (1:10) of deaths. The leading causes of morbidity among preterm babies were asphyxia (1:4), sepsis (1:5), respiratory disorders (1:9), and jaundice (1.10). For mortality, their contributions were asphyxia (≈1:2); sepsis (1:5); respiratory disorders (1:9), and jaundice (1:10).

Conclusion

There was a marked improvement in neonatal mortality trends. However, severe perinatal asphyxia, sepsis, hyperbilirubinemia, and respiratory disorders were the leading conditions contributing to 75% of the morbidities and mortalities. Measures to further accelerate the reduction in neonatal morbidity and mortality are discussed.

Delivery indication matters for perinatal outcomes in late preterm newborns

BACKGROUND

The late preterm (LP) rate in Western countries is 3-6% of all births, accounting for about two-thirds of the entire preterm population. However, all LP babies are not the same.

AIMS

To identify pregnancies at risk for adverse outcomes in the LP period, we investigated how gestational age (GA) at delivery, delivery indication and prenatal risk factors may affect neonatal outcomes.

STUDY DESIGN

Prospective cohort study among singleton infants born between 34 + 0 and 36 + 6 weeks, in Emilia Romagna, Italy, during 2013-2015.

OUTCOMES MEASURES

The primary outcome was a composite of adverse perinatal outcomes. Multivariate logistic regression models were used to, respectively, investigate the effects of GA at delivery, circumstances at parturition and prenatal risk factors, on study outcomes after controlling for confounding variable.

RESULTS

Among 1867 births, 302, 504, and 1061 infants were born at 34, 35, and 36 weeks, respectively. There were no neonatal deaths. An increased risk of composite neonatal outcome was observed among 34 and 35 weeks deliveries compared with 36 weeks, and among indicated deliveries compared with spontaneous. When studying prenatal risk factors, neonatal morbidity was associated with pre gestational diabetes, preterm premature rupture of membranes (pPROM), maternal obesity, bleeding and polyhydramnios; instead, preeclampsia had a protective effect.

CONCLUSION

LP with indicated deliveries at 34 or 35 weeks, or with specific prenatal risk factors have worse neonatal outcome when compared to 36. Such differences should be considered when counseling patients and planning interventions such as timing of delivery in LP period.

Comparison of costs related to infant hospitalisations for spontaneous, induced and Caesarean births: population-based cohort study

Objective This study examined hospitalisations and associated in-patient costs for babies during the first year of life following spontaneous labour, compared with labour induction or prelabour Caesarean section, at each gestational age. Methods Birth data for singleton liveborn babies from 33 weeks gestation in New South Wales from 2005 to 2014 were linked to hospital and death data. Generalised linear models were used to examine the association between the type of labour and the length of hospitalisations and hospital costs. Results From 2005 to 2014, 598640 women gave birth to 1187451 liveborn singleton babies. The mean total length of hospitalisations and costs of hospitalisations for babies in the first year of life decreased significantly as week of gestational age increased to 39 weeks, then plateaued. Overall, the total length of hospitalisations and hospital costs were significantly (P<0.001) lower for babies born after spontaneous labour (5.6 days and A$8405 respectively) than for babies born following labour induction (6.1 days and A$9452 respectively) or prelabour Caesarean section (8.2 days and A$12320 respectively). Conclusions Babies born following spontaneous labour spend less time in hospital and have lower hospital costs than those born following labour induction or prelabour Caesarean section. Hospitalisations and costs decrease with each week of gestational age until 39 weeks. What is known about the topic? It is known that induction of labour and prelabour Caesarean sections are increasing, and this increase has changed the distribution of gestational age towards birth at earlier ages. It is also known that babies born before 39 weeks of gestation are at increased risk of mortality and morbidity. What does this paper add? This study shows that babies born following spontaneous labour spend the least amount of time in hospital and subsequently have the lowest hospital costs at each week of gestation compared with babies born following labour induction or prelabour Caesarean section. This study also shows a small but significant economic advantage of labour induction compared with prelabour Caesarean delivery. This study quantifies the mean time babies spend in hospital in their first year of life, by week of gestational age and mode of birth. What are the implications for practitioners? The findings from this study can assist clinicians in judicious decision making when balancing the risks and benefits of early planned births. Clinicians can use the results of this study to inform women who are intending to have a planned birth of risks they may not have anticipated, such as the increased risk of rehospitalisation. The finding that hospitalisations and costs continue to decline until 39 weeks gestation can be used to reinforce the importance of continuing the pregnancy beyond 37 weeks if safe to do so, even though 37 weeks is considered term.

Neonatal Morbidities in Infants Born Late Preterm at 35-36 Weeks of Gestation: A Swedish Nationwide Population-based Study

OBJECTIVE

To assess risk for neonatal morbidities among infants born late preterm at 35-36 gestational weeks, early term (37-38 weeks), and late-term (41 weeks) infants, compared with full-term (39-40 weeks) infants.

STUDY DESIGN

This nationwide population-based cohort study included 1 650 450 non-malformed liveborn singleton infants born at 35-41 weeks between 1998 and 2016 in Sweden. The relative risks for low Apgar score (0-3) at 5 minutes; respiratory, metabolic, infectious, and neurologic morbidities; and severe neonatal morbidity (composite outcome) were adjusted for maternal, pregnancy, delivery, and infant characteristics.

RESULTS

Compared with infants born at 39-40 weeks, the adjusted relative risks and proportions of infants born at 35-36 weeks were higher for metabolic morbidity 7.79 (95%, 7.61 to 7.97; 33.75% vs 3.11%), respiratory morbidity 5.54 (95% CI, 5.24 to 5.85; 5.49% vs 0.75%), severe neonatal morbidity 2.42 (95% CI, 2.27 to 2.59; 3.40% versus 1.03%), infectious morbidity 1.98 (95% CI, 1.83 to 2.14; 2.53% vs 0.95%), neurologic morbidity 1.74 (95% CI, 1.48 to 2.03; 0.54% vs 0.23%), and low Apgar score 2.07 (95% CI, 1.72 to 2.51; 0.42% vs 0.12%). The risks for respiratory, severe neonatal morbidity, infectious, neurologic morbidities, and low Apgar score were highest at 35 weeks, gradually decreased until 39 weeks, and increased during 39-41 weeks.

CONCLUSIONS

Infants born late preterm at 35-36 weeks of gestation are at increased risk of neonatal morbidities, although the absolute risks for severe neonatal morbidities are low. Our findings reinforce the need of preventing late preterm delivery to decrease the burden of neonatal morbidity and help professionals and families with a better risk assessment.

Earlier preterm birth is associated with a worse neurocognitive outcome in a rabbit model

Background

Preterm birth (PTB) and particularly late preterm PTB has become a research focus for obstetricians, perinatologists, neonatologists, pediatricians and policy makers alike. Translational models are useful tools to expedite and guide clinical but presently no model exists that contextualizes the late PTB scenario. Herein we aimed to develop a rabbit model that echo’s the clinical neurocognitive phenotypes of early and late PTB.

Methods

Time mated rabbit does underwent caesarean delivery at a postconceptional age (PCA) of either 28 (n = 6), 29 (n = 5), 30 (n = 4) or 31 (n = 4) days, term = 31 d. Newborn rabbits were mixed and randomly allocated to be raised by cross fostering and underwent short term neurobehavioral testing on corrected post-natal day 1. Open field (OFT), spontaneous alteration (TMT) and novel object recognition (NORT) tests were subsequently performed at 4 and 8 weeks of age.

Results

PTB was associated with a significant gradient of short-term mortality and morbidity inversely related to the PCA. On postnatal day 1 PTB was associated with a significant sensory deficit in all groups but a clear motor insult was only noted in the PCA 29d and PCA 28d groups. Furthermore, PCA 29d and PCA 28d rabbits had a persistent neurobehavioral deficit with less exploration and hyperanxious state in the OFT, less alternation in TMT and lower discriminatory index in the NORT. While PCA 30d rabbits had some anxiety behavior and lower spontaneous alteration at 4 weeks, however at 8 weeks only mild anxiety driven behavior was observed in some of these rabbits.

Conclusions

In this rabbit model, delivery at PCA 29d and PCA 28d mimics the clinical phenotype of early PTB while delivery at PCA 30d resembles that of late PTB. This could serve as a model to investigate perinatal insults during the early and late preterm period.

Ovarian hyperstimulation syndrome after assisted reproductive technologies: trends, predictors, and pregnancy outcomes

OBJECTIVES

To assess trends, predictors, and perinatal outcomes of ovarian hyperstimulation syndrome (OHSS) associated with in vitro fertilization (IVF) cycles in the United States.

DESIGN

Retrospective cohort study using National Assisted Reproductive Technology Surveillance System (NASS) data.

SETTING

Not applicable.

PATIENT(S)

Fresh autologous and embryo-banking cycles performed from 2000 to 2015.

INTERVENTIONS(S)

None.

MAIN OUTCOME MEASURE(S)

OHSS, first-trimester loss, second-trimester loss, stillbirth, low birth weight, and preterm delivery.

RESULT(S)

The proportion of IVF cycles complicated by OHSS increased from 10.0 to 14.3 cases per 1,000 from 2000 to 2006, and decreased to 5.3 per 1,000 from 2006 to 2015. The risk of OHSS was highest for cycles with more than 30 oocytes retrieved (adjusted risk ratio [aRR] 3.85). OHSS was associated with a diagnosis of ovulatory disorder (aRR 2.61), tubal factor (aRR 1.14), uterine factor (aRR 1.17) and cycles resulting in pregnancy (aRR 3.12). In singleton pregnancies, OHSS was associated with increased risk of low birth weight (aRR 1.29) and preterm delivery (aRR 1.32). In twin pregnancies, OHSS was associated with an increased risk of second-trimester loss (aRR 1.81), low birth weight (aRR 1.06), and preterm delivery (aRR 1.16).

CONCLUSION(S)

Modifiable predictive factors for OHSS include number of oocytes retrieved, pregnancy following fresh embryo transfer, and the type of medication used for pituitary suppression during controlled ovarian hyperstimulation. Patients affected by OHSS had a higher risk of preterm delivery and low birth weight. Clinicians should take measures to reduce the risk of OHSS whenever possible.

Optimal delivery timing for dizygotic twins - the short- and long-term perspective

Major obstetrics and gynecology societies offer inconsistent recommendation regarding optimal delivery timing in uncomplicated dizygotic twins. We sought to investigate the impact of delivery timing within term gestation, in dizygotic twins, on the short- and long-term offspring morbidity. A prospectively analyzed cohort of dizygotic twin deliveries was conducted. All women delivered at a regional tertiary medical center, at term (≥37 0/7), between the years 1991 and 2014, were included. The primary exposure was delivery at 37 0/7-37 + 6/7 weeks, while delivery at ≥38 0/7 weeks' gestation was considered the reference. Neonatal short- and long-term outcomes according to hospitalizations of offspring up to 18 years of age due to cardiac, respiratory, hematological, neurological, and infectious morbidity were compared. Kaplan-Meier survival curves were used to compare cumulative incidences per each major-system hospitalization. Cox regression models were used to estimate the adjusted hazard ratios, while adjusting for variables with clinical importance. During the study period, 612 dizygotic twin deliveries met the inclusion criteria. Of them, 200 (31.3%) occurred at 37-37 6/7 weeks, and 412 (68.7%) occurred at ≥38 0/7 weeks' gestation. In the long-term analysis, rates of hospitalizations involving several major morbidity categories exhibited comparable rates in both groups. The Cox regression models did not demonstrate an independent association between gestational age within term and later major pediatric morbidity in offspring (total long-term morbidity: adjusted hazard ratio 1.33, 95% confidence interval 0.77-2.29). Dizygotic twin deliveries occurring at different gestational ages within term do not appear to significantly impact on major short- and long-term outcomes.

Adverse perinatal outcomes in 665,244 term and post-term deliveries-a Norwegian population-based study

OBJECTIVE

To assess the prevalence and risk of adverse perinatal outcomes in early-term (37⁺⁰-38⁺⁶ weeks), full-term (39⁺⁰-40⁺⁶ weeks), late-term (41⁺⁰-41⁺⁶ weeks), and post-term (>42⁺⁰ weeks) deliveries with spontaneous labor onset.

STUDY DESIGN

A population-based cohort with data from the Medical Birth Registry Norway (MBRN) and Statistics Norway (SSB) was conducted. The study population consisted of 665,244 women with cephalic singleton live births at term or post-term with spontaneous labor onset during the period of 1999-2014 in Norway. Maternal, obstetric, and fetal characteristics were obtained from the MBRN. Maternal education data were obtained from the SSB. The prevalence rates of adverse perinatal outcomes for each gestational age (GA) group were estimated. Inter-group differences were detected with Chi square tests. Multivariable regression analysis adjusted for maternal age, educational level, smoking, parity, maternal diabetes, and preeclampsia was used to assess adverse outcome prevalence for early- late-, and post-term births compared to full-term births.

RESULTS

Deliveries at early-term were associated with an increased prevalence of neonatal jaundice, polyhydramnios, small for gestational age (SGA) status, respiratory support, and neonatal intensive care unit (NICU) admission compared with deliveries at GAs of 39-43 weeks (p < 0.001). Low 5-min Apgar scores and newborn antibiotic treatment occurred at an increased prevalence in both early-term and post-term infants, relative to the full-term group (p < 0.001). The prevalence of oligohydramnios, meconium-stained amniotic fluid, and newborn birth injuries increased with increasing GA.

CONCLUSIONS

More perinatal morbidity was observed among early-term infants compared to infants with later term deliveries, underscoring the need for cautious management of low-risk early-term deliveries.

Respiratory outcomes of late preterm infants of mothers with early and late onset preeclampsia

OBJECTIVE

To study the effect of early and late onset preeclampsia (EOPE, LOPE, respectively) on outcomes of late preterm infants.

STUDY DESIGN

Cohort study of late preterm infants admitted to a tertiary care NICU from January 2014-July 2015. Outcomes of late preterm infants of EOPE mothers were compared with the next late preterm infant of a LOPE mother and the next two late preterm infants of normotensive non-PE mothers. Primary outcome comprised use of continuous positive airway pressure, mechanical ventilation and/or surfactant in the 24 h after birth.

RESULTS

Compared to normotensives (n = 131), adjusted odds ratio (AORs) of the primary outcome was higher in the EOPE (n = 64) and LOPE (n = 65) groups but reached statistical significance only in the EOPE group, AORs 12.9, 95% CI 3.5-37 and 2.7, 95% CI 0.95-8.1, respectively.

CONCLUSIONS

Compared to late preterm infants of normotensive and LOPE mothers, infants of mothers with EOPE have significantly higher respiratory morbidity.

Frequency of Early Morbidities in Low Birth Weight Neonates at The Aga Khan University Hospital, Karachi

Background Globally, approximately 14.6% children are born with low birth weight (LBW) annually. In Pakistan, this figure however reaches approximately 16%. Low birth weight infants are vulnerable to develop early morbidities like hypothermia, hypoglycemia, respiratory distress syndrome and hypocalcemia. There is a scarcity of statistics which creates a gap in development of strategies for improving quality of care in developing countries. The aim of our study was to determine the frequency of early morbidities such as respiratory distress syndrome (RDS), hypoglycemia, hypothermia and hypocalcemia in low birth weight neonates. Methodology A prospective descriptive study was conducted via non-probability sampling technique from 1^st April 2016 to 30^th September 2016 at The Aga Khan University Hospital, Karachi. All low birth weight infants, i.e., those with birth weight < 2500 grams were included in this study and observed for early morbidities, including hypothermia, hypoglycemia, hypocalcemia and respiratory distress syndrome. Descriptive analysis was done using SPSS version 22 (IBM Corp., Armonk, NY), mean and standard deviation were determined for quantitative variables, whereas frequency and percentages were calculated for qualitative variables. Results A total of 2082 neonates were born during the study period, of which 271 (13%) were born with low birth weight. One hundred and eighty-five (68.1%) of these LBW neonates were preterm babies while 86 (31.9%) were born at term. Among LBW neonates 137 (51.0%) were males and 134 (49.0%) females. In the study population, hypoglycemia was seen in 17.3%, hypocalcemia in 13.6%, respiratory distress syndrome in 11%, and hypothermia in 2.5%. Conclusion Our study highlighted major early morbidities of LBW neonates, and their association with birth weight, gestational age and gender. Significant association of birth weight was found with hypothermia and hypocalcemia, whereas hypocalcemia and RDS were significantly associated with gestational age. However, none of the early morbidities had significant association with gender. Keeping in perspective the early morbidities in this population we propose that priority be given to providing adequate attention to low birth weight neonates.

[A clinical analysis of bacterial meningitis in full-term and preterm infants]

OBJECTIVE

To study the clinical features and prognosis of bacterial meningitis in full-term and preterm infants.

METHODS

A retrospective analysis was performed for the clinical data of 102 neonates with bacterial meningitis. According to the gestational age, they were divided into a preterm group (n=46) and a full-term group (n=56). The two groups were compared in terms of clinical manifestations, laboratory markers, imaging findings, and clinical outcomes.

RESULTS

Poor response and apnea were the major clinical manifestations in the preterm group (P<0.05), while pyrexia and convulsions were more common in the full-term group (P<0.05). The full-term group had a significantly higher glucose level in cerebrospinal fluid (CSF) than the preterm group (P<0.05). Compared with the full-term group, the preterm group had significantly higher C-reactive protein level, positive rate of blood culture, and incidence rate of poor prognosis (P<0.05). There were no significant differences between the two groups in leukocyte count in peripheral blood, levels of leukocytes and protein in CSF, and positive rate of CSF culture (P>0.05).

CONCLUSIONS

There are certain differences in the clinical manifestations between full-term and preterm infants with bacterial meningitis. Preterm infants tend to have a higher incidence rate of poor prognosis.

Late Preterm Infants: Morbidities, Mortality, and Management Recommendations

Infants born between 34 weeks 0 days and 36 weeks 6 days of gestation are termed late preterm. This group accounts for the majority of premature births in the United States, with rates increasing in each of the last 3 years. This increase is significant given their large number: nearly 280,000 in 2016 alone. Late preterm infants place a significant burden on the health care and education systems because of their increased risk of morbidities and mortality compared with more mature infants. This increased risk persists past the newborn period, leading to the need for continued health monitoring throughout life.

Respiratory Compliance in Late Preterm Infants (340/7-346/7 Weeks) after Antenatal Steroid Therapy

OBJECTIVE

To compare respiratory compliance in late preterm infants (34^0/7-34^6/7 weeks) who received antenatal steroids vs matched late preterm infants who did not receive antenatal steroids.

STUDY DESIGN

This was a single-center prospective cohort study. Patients were matched for birth weight, gestational age, race, and sex. Respiratory compliance was the primary outcome measured with the single breath occlusion technique.

RESULTS

We studied 25 late preterm infants treated with antenatal steroids and 25 matched infants who did not receive antenatal steroids. The treated infants had a significantly increased respiratory compliance/kg (adjusted 95% CI 0.05, 0.49; P = .016) and fewer required continuous positive airway pressure (P = .007) or >24 hours of supplemental oxygen (P = .046). There was no difference in surfactant therapy.

CONCLUSIONS

Respiratory compliance was significantly increased in this cohort of late preterm infants born at 34^0/7-34^6/7 weeks who received antenatal steroids compared with matched infants who did not receive antenatal steroids. Although not randomized, these data provide physiologic support for the possible beneficial effects of antenatal steroids in late preterm infants.

The association between gestational age and otitis media during childhood: a population-based cohort analysis

Otitis media (OM) carries a tremendous global health burden and potentially severe long-term consequences. The objective of this study was to determine the impact of birth at different gestational ages on the incidence of childhood OM.A population-based cohort analysis was conducted. All singleton deliveries occurring between 1991 and 2014 at a regional tertiary medical center were included. Gestational age on delivery was divided into six subgroups: early (&lt;34 weeks gestation; 0 out of 7) and late (34 weeks gestation; 0 out of 7 to 36 weeks gestation; 6 out of 7) preterm, and early (37 weeks gestation; 0 out of 7 to 38 weeks gestation; 6 out of 7), full (39 weeks gestation; 0 out of 7 to 40 weeks gestation; 6 out of 7), late (41 weeks gestation; 0 out of 7 to 41 weeks gestation; 6 out of 7) and post (⩾42 weeks 0 out of 7) term deliveries. Rates of OM-related hospitalizations up to 18 years of age were assessed. Weibull parametric hazards model was used to study the association between gestational age at birth and the risk for OM-related hospitalizations while controlling for potential confounders.During the study period, 238,622 deliveries met the inclusion criteria. OM-related hospitalizations of the offspring (n=4724) were significantly more common in the preterm (early 3.6%, late 2.4%) and early-term born children (2.2%) and decreased gradually across the full (1.9%), late (1.7%) and post (1.6%) term groups (χ2-test for trends P&lt;0.001). In the Weibull regression model, early preterm, as well as early-term deliveries exhibited an independent association with pediatric OM (adjusted hazard ratios: 1.67 and 1.09, respectively, P&lt;0.02).Deliveries occurring at preterm and early term are associated with higher rates of pediatric OM-related hospitalizations, which decrease gradually as gestational age advances.

Underlying maternal and pregnancy-related conditions account for a substantial proportion of neonatal morbidity in late preterm infants

AIM

We studied the impact of maternal and pregnancy-related conditions and the effect of gestational age itself, on the health of infants born late preterm.

METHODS

Singletons born in gestational weeks 34 + 0 to 41 + 6 in 1995-2013 in the southern region of Sweden were identified from a perinatal register. We found 14 030 infants born late preterm and 294 814 born at term. A hierarchical system was developed to examine the impact of pregnancy complications. The outcomes studied were as follows: neonatal death, central nervous system (CNS) or respiratory disease, infection, neonatal admission and respiratory support. Odds ratios (OR) and 95% confidence intervals (95% CI) were obtained using logistic regression analyses.

RESULTS

Late preterm infants were at increased risk for all outcomes compared to term infants, with adjusted ORs from 13.1 (95% CI: 12.7-13.6) for neonatal admission to 2.3 (95% CI: 1.8-2.9) for infections. Late preterm birth after preterm prelabour rupture of membranes was associated with an overall lower risk compared to late preterm births due to other causes. Exposure to antepartum haemorrhage or maternal diabetes increased the risk for CNS and respiratory morbidity.

CONCLUSION

Morbidity decreased in late preterm infants with increasing gestational age. Underlying conditions accounted for a substantial part of the morbidity.

High preterm birth at Cipto Mangunkusumo Hospital as a national referral hospital in Indonesia

Background: Preterm birth is the leading direct that causes neonatal death. Indonesia was listed as one of the countries with the greatest number of preterm birth in 2010. This study aims to identify the prevalence and the potential risk factors of preterm birth among women underwent delivery in Cipto Mangunkusumo Hospital, an Indonesian national reference hospital.Methods: This retrospective cohort study involved 2,612 women who delivered between January and December 2013. Any clinical data which related to the potential risk factors and outcomes were recorded. The data were managed using chi-square for bivariate analysis and t-test or Mann-Whitney for numerical data followed by multiple logistic regression for multivariate analysis in SPSS version 20.0.Results: Preterm birth affected 1,020 of 2,616 pregnancies (38.5%). Non-booked patients increased nearly twice risk for preterm delivery (OR 1.89, 95% CI 1.37–2.61). While women with singleton pregnancy (OR 0.17, 95% CI 0.12–0.25), head presentation (OR 0.75, 95% CI 0.63–0.89), and regular ANC (OR 0.67, 95% CI 0.54–0.84) had lower risk for preterm birth. Apgar score, birthweight, and mode of delivery were significantly different between the pre-term group and the full-term group.Conclusion: Prevalence of preterm birth in Cipto Mangunkusumo Hospital was approximately 2.5 times higher compared to the national number. Several factors reducing preterm birth rate include singleton pregnancy, head presentation, and regular ANC.

Maternal and neonatal outcomes of respiratory failure during pregnancy

BACKGROUND

Obstetric patients comprise a limited portion of intensive care unit patients, but they often present with unfamiliar conditions and exhibit the potential for catastrophic deterioration. This study evaluated the maternal and neonatal outcomes of respiratory failure during pregnancy.

METHODS

Information on 71 patients at >25 weeks gestation in the ICU with respiratory failure was recorded between 2009 and 2013. The characteristics and outcomes of mothers and fetuses were determined through a retrospective chart review and evaluated using Student's t test, chi-square test, and Fisher's exact test.

RESULTS

The leading causes of respiratory failure were postpartum hemorrhage and severe preeclampsia in the obstetric causes group and pneumonia in the nonobstetric causes group during pregnancy and the peripartum period. The non-obstetric causes group exhibited a higher incidence of acute respiratory distress syndrome and renal replacement therapy as well as requiring more ventilator days. The patients in the obstetric causes group showed significant improvement after delivery in the partial pressure of arterial oxygen to the fraction of inspired oxygen and peak inspiratory pressure decrease. Both groups exhibited high incidences of neonatal respiratory distress syndrome. Neonatal complications resulting from meconium aspiration syndrome (MAS) and sepsis were more common in the non-obstetric causes group; however, neurological development impairment was more common in the obstetric causes group.

CONCLUSION

Obstetric cause was associated with longer ventilator free days and fewer episodes of ARDS after delivery. Neonatal complications resulting from different etiologies of respiratory failure were found to differ.

Gestational age and 1-year hospital admission or mortality: a nation-wide population-based study

Background

Describe the 1-year hospitalization and in-hospital mortality rates, in infants born after 31 weeks of gestational age (GA).

Methods

This nation-wide population-based study used the French medico-administrative database to assess the following outcomes in singleton live-born infants (32–43 weeks) without congenital anomalies (year 2011): neonatal hospitalization (day of life 1 – 28), post-neonatal hospitalization (day of life 29 – 365), and 1-year in-hospital mortality rates. Marginal models and negative binomial regressions were used.

Results

The study included 696,698 live-born babies. The neonatal hospitalization rate was 9.8%. Up to 40 weeks, the lower the GA, the higher the hospitalization rate and the greater the likelihood of requiring the highest level of neonatal care (both p < 0.001). The relative risk adjusted for sex and pregnancy-related diseases (aRR) reached 21.1 (95% confidence interval [CI]: 19.2-23.3) at 32 weeks. The post-neonatal hospitalization rate was 12.1%. The raw rates for post-neonatal hospitalization fell significantly from 32 – 40 and increased at 43 weeks and this persisted after adjustment (aRR = 3.6 [95% CI: 3.3–3.9] at 32 and 1.5 [95% CI: 1.1–1.9] at 43 compared to 40 weeks). The main causes of post-neonatal hospitalization were bronchiolitis (17.2%), gastroenteritis (10.4%) ENT diseases (5.4%) and accidents (6.2%). The in-hospital mortality rate was 0.85‰, with a significant decrease (p < 0.001) according to GA at birth (aRR = 3.8 [95% CI: 2.4–5.8] at 32 and 6.6 [95% CI: 2.1–20.9] at 43, compared to 40 weeks.

Conclusion

There’s a continuous change in outcome in hospitalized infants born above 31 weeks. Birth at 40 weeks gestation is associated with the lowest 1-year morbidity and mortality.

Effects of ultrasound pregnancy dating on neonatal morbidity in late preterm and early term male infants: a register-based cohort study

Background

Assessing gestational age by ultrasound can introduce a systematic bias due to sex differences in early growth.

Methods

This cohort study included data on 1,314,602 births recorded in the Swedish Medical Birth Register. We compared rates of prematurity-related adverse outcomes in male infants born early term (gestational week 37–38) or late preterm (gestational week 35–36), in relation to female infants, between a time period when pregnancy dating was based on the last menstrual period (1973–1978), and a time period when ultrasound was used for pregnancy dating (1995–2010), in order to assess the method’s influence on outcome by fetal sex.

Results

As expected, adverse outcomes were lower in the later time period, but the reduction in prematurity-related morbidity was less marked for male than for female infants. After changing the pregnancy dating method, male infants born early term had, in relation to female infants, higher odds for pneumothorax (Cohort ratio [CR] 2.05; 95 % confidence interval [CI] 1.33–3.16), respiratory distress syndrome of the newborn (CR 1.99; 95 % CI 1.33–2.98), low Apgar score (CR 1.26; 5 % CI 1.08–1.47), and hyperbilirubinemia (CR 1.12; 95 % CI 1.06–1.19), when outcome was compared between the two time periods. A similar trend was seen for late preterm male infants.

Conclusion

Misclassification of gestational age by ultrasound, due to size differences, can partially explain currently reported sex differences in early term and late preterm infants’ adverse neonatal outcomes, and should be taken into account in clinical decisions and when interpreting study results related to fetal sex.

Electronic supplementary material

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Asphyxia, Neurologic Morbidity, and Perinatal Mortality in Early-Term and Postterm Birth

BACKGROUND AND OBJECTIVES

Neonatal outcomes vary by gestational age. We evaluated the association of early-term, full-term, and postterm birth with asphyxia, neurologic morbidity, and perinatal mortality.

METHODS

Our register-based study used retrospective data on 214 465 early-term (37(+0)-38(+6) gestational weeks), 859 827 full-term (39(+0)-41(+6)), and 55 189 postterm (≥42(+0)) live-born singletons during 1989-2008 in Finland. Asphyxia parameters were umbilical cord pH and Apgar score at 1 and 5 minutes. Neurologic morbidity outcome measures were cerebral palsy (CP), epilepsy, intellectual disability, and sensorineural defects diagnosed by the age of 4 years. Newborns with major congenital anomalies were excluded from perinatal deaths.

RESULTS

Multivariate analysis showed that, compared with full-term pregnancies, early-term birth increased the risk for low Apgar score (<4) at 1 and 5 minutes (odds ratio 1.03, 95% confidence interval 1.03-1.04 and 1.24, 1.04-1.49, respectively), CP (1.40, 1.27-1.55), epilepsy (1.14, 1.06-1.23), intellectual disability (1.39, 1.27-1.53), sensorineural defects (1.24, 1.17-1.31), and perinatal mortality (2.40, 2.14-2.69), but risk for low umbilical artery pH ≤7.10 was decreased (0.83, 0.79-0.87). Postterm birth increased the risk for low Apgar score (<4) at 1 minute (1.26, 1.26-1.26) and 5 minutes (1.80, 1.43-2.34), low umbilical artery pH ≤7.10 (1.26, 1.19-1.34), and intellectual disability (1.19, 1.00-1.43), whereas risks for CP (1.03, 0.84-1.26), epilepsy (1.00, 0.87-1.15), sensorineural defects (0.96, 0.86-1.07), and perinatal mortality (0.91, 0.69-1.22) were not increased.

CONCLUSIONS

Early-term birth was associated with low Apgar score, increased neurologic morbidity, and perinatal mortality. Asphyxia and intellectual disability were more common among postterm births, but general neurologic morbidity and perinatal mortality were not increased.

Particulate air pollution, fetal growth and gestational length: The influence of residential mobility in pregnancy

BACKGROUND

It remains unclear as to whether neglecting residential mobility during pregnancy introduces bias in studies investigating air pollution and adverse perinatal outcomes, as most studies assess exposure based on residence at birth. The aim of this study was to ascertain whether such bias can be observed in a study on the effects of PM10 on risk of preterm birth and fetal growth restriction.

METHODS

This was a retrospective study using four pregnancy cohorts of women recruited in Connecticut, USA (N=10,025). We ascertained associations with PM10 exposure calculated using first recorded maternal address, last recorded address, and full address histories. We used a discrete time-to-event model for preterm birth, and logistic regression to investigate associations with small for gestational age (SGA) and term low birth weight (LBW).

RESULTS

Pregnant women tended to move to areas with lower levels of PM10. For all outcomes, there was negligible difference between effect sizes corresponding to exposures calculated with first, last and full address histories. For LBW, associations were observed for exposure in second trimester (OR 1.09; 95% CI: 1.04-1.14 per 1μg/m(3) PM10) and whole pregnancy (OR 1.08; 95% CI: 1.02-1.14). For SGA, associations were observed for elevated exposure in second trimester (OR 1.02; 95% CI: 1.00-1.04) and whole pregnancy (OR 1.03; 95% CI: 1.01-1.05). There was insufficient evidence for association with preterm birth.

CONCLUSION

PM10 was associated with both SGA and term LBW. However, there was negligible benefit in accounting for residential mobility in pregnancy in this study.

Variations in Multiple Birth Rates and Impact on Perinatal Outcomes in Europe

OBJECTIVE

Infants from multiple pregnancies have higher rates of preterm birth, stillbirth and neonatal death and differences in multiple birth rates (MBR) exist between countries. We aimed to describe differences in MBR in Europe and to investigate the impact of these differences on adverse perinatal outcomes at a population level.

METHODS

We used national aggregate birth data on multiple pregnancies, maternal age, gestational age (GA), stillbirth and neonatal death collected in the Euro-Peristat project (29 countries in 2010, N = 5 074 643 births). We also used European Society of Human Reproduction and Embryology (ESHRE) data on assisted conception and single embryo transfer (SET). The impact of MBR on outcomes was studied using meta-analysis techniques with random-effects models to derive pooled risk ratios (pRR) overall and for four groups of country defined by their MBR. We computed population attributable risks (PAR) for these groups.

RESULTS

In 2010, the average MBR was 16.8 per 1000 women giving birth, ranging from 9.1 (Romania) to 26.5 (Cyprus). Compared to singletons, multiples had a nine-fold increased risk (pRR 9.4, 95% Cl 9.1-9.8) of preterm birth (<37 weeks GA), an almost 12-fold increased risk (pRR 11.7, 95% CI 11.0-12.4) of very preterm birth (<32 weeks GA). Pooled RR were 2.4 (95% Cl 1.5-3.6) for fetal mortality at or after 28 weeks GA and 7.0 (95% Cl 6.1-8.0) for neonatal mortality. PAR of neonatal death and very preterm birth were higher in countries with high MBR compared to low MBR (17.1% (95% CI 13.8-20.2) versus 9.8% (95% Cl 9.6-11.0) for neonatal death and 29.6% (96% CI 28.5-30.6) versus 17.5% (95% CI 15.7-18.3) for very preterm births, respectively).

CONCLUSIONS

Wide variations in MBR and their impact on population outcomes imply that efforts by countries to reduce MBR could improve perinatal outcomes, enabling better long-term child health.

Neonatal outcomes and delivery of care for infants born late preterm or moderately preterm: a prospective population-based study

OBJECTIVE

To describe neonatal outcomes and explore variation in delivery of care for infants born late (34-36  weeks) and moderately (32-33 weeks) preterm (LMPT).

DESIGN/SETTING

Prospective population-based study comprising births in four major maternity centres, one midwifery-led unit and at home between September 2009 and December 2010. Data were obtained from maternal and neonatal records.

PARTICIPANTS

All LMPT infants were eligible. A random sample of term-born infants (≥37 weeks) acted as controls.

OUTCOME MEASURES

Neonatal unit (NNU) admission, respiratory and nutritional support, neonatal morbidities, investigations, length of stay and postnatal ward care were measured. Differences between centres were explored.

RESULTS

1146 (83%) LMPT and 1258 (79% of eligible) term-born infants were recruited. LMPT infants were significantly more likely to receive resuscitation at birth (17.5% vs 7.4%), respiratory (11.8% vs 0.9%) and nutritional support (3.5% vs 0.3%) and were less likely to be fed breast milk (64.2% vs 72.2%) than term infants. For all interventions and morbidities, a gradient of increasing risk with decreasing gestation was evident. Although 60% of late preterm infants were never admitted to a NNU, 83% required medical input on postnatal wards. Clinical management differed significantly between services.

CONCLUSIONS

LMPT infants place high demands on specialist neonatal services. A substantial amount of previously unreported specialist input is provided in postnatal wards, beyond normal newborn care. Appropriate expertise and planning of early care are essential if such infants are managed away from specialised neonatal settings. Further research is required to clarify optimal and cost-effective postnatal management for LMPT babies.

Evidence-based practice to improve outcomes for late preterm infants

Infants born between 34 weeks 0 days to 36 weeks 6 days gestation have been identified as late preterm infants (LPIs) and account for 70% of preterm births and 9% of all births. The rise in elective deliveries in the past decade is believed to have contributed to the number of late preterm births. An interprofessional team including labor and delivery, neonatal intensive care, and postpartum care providers collaborated to address this issue at an urban academic medical center.

Timing of elective delivery in gastroschisis: a decision and cost-effectiveness analysis

OBJECTIVE

To determine the most cost-effective timing of delivery in pregnancies complicated by gastroschisis, using a decision-analytic model.

METHODS

We created a decision-analytic model to compare planned delivery at 35, 36, 37, 38 and 39 weeks' gestation. Outcomes considered were stillbirth, death within 1 year of birth and respiratory distress syndrome (RDS). Probability estimates of events (stillbirth, complex gastroschisis and RDS for each gestational age at delivery and risk of death with simple and complex gastroschisis), utilities and costs assigned to the outcomes were obtained from the published literature. Cost analysis was assessed from a societal perspective, using a willingness-to-pay threshold of $100,000 per surviving infant. Outcomes and costs were considered throughout 1 year of postnatal life. Multiway sensitivity analysis was performed to address uncertainties in baseline assumptions.

RESULTS

In the base-case analysis, delivery at 38 weeks' gestation was the most cost-effective strategy. Planned delivery at 35 weeks was associated with the fewest stillbirths and deaths within 1 year of delivery, owing largely to a lower ongoing risk of stillbirth. In Monte Carlo simulation when every variable was varied over its entire range, delivery at 38 weeks was cost-effective compared to delivery at 39 weeks in 76% of trials and delivery at 37 weeks was cost-effective in 69% of trials. Delivery at 38 weeks resulted in three additional cases of RDS for every 100 stillbirths or deaths within 1 year that were prevented.

CONCLUSIONS

For pregnancies complicated by gastroschisis, the most cost-effective timing of delivery is at 38 weeks. Few additional cases of RDS are caused for every one stillbirth or death within 1 year that was prevented with delivery at 37-38 weeks compared with at 39 weeks.

Respiratory consequences of late preterm birth

In developed countries most preterm births occur between 34 and 37 weeks' gestation. Deliveries during this 'late preterm' period are increasing and, since even mild prematurity is now recognised to be associated with adverse health outcomes, this presents healthcare challenges. Respiratory problems associated with late preterm birth include neonatal respiratory distress, severe RSV infection and childhood wheezing. Late preterm birth prematurely interrupts in utero lung development and is associated with maternal and early life factors which adversely affect the developing respiratory system. This review considers 1) mechanisms underlying the association between late preterm birth and impaired respiratory development, 2) respiratory morbidity associated with late preterm birth, particularly long-term outcomes, and 3) interventions which might protect respiratory development by addressing risk factors affecting the late preterm population, including maternal smoking, early life growth restriction and vulnerability to viral infection.

Late preterm birth, post-term birth, and abnormal fetal growth as risk factors for severe mental disorders from early to late adulthood

BACKGROUND

Late preterm births constitute the majority of preterm births. However, most evidence suggesting that preterm birth predicts the risk of mental disorders comes from studies on earlier preterm births. We examined if late preterm birth predicts the risks of severe mental disorders from early to late adulthood. We also studied whether adulthood mental disorders are associated with post-term birth or with being born small (SGA) or large (LGA) for gestational age, which have been previously associated with psychopathology risk in younger ages.

METHOD

Of 12 597 Helsinki Birth Cohort Study participants, born 1934-1944, 664 were born late preterm, 1221 post-term, 287 SGA, and 301 LGA. The diagnoses of mental disorders were identified from national hospital discharge and cause of death registers from 1969 to 2010. In total, 1660 (13.2%) participants had severe mental disorders.

RESULTS

Individuals born late preterm did not differ from term-born individuals in their risk of any severe mental disorder. However, men born late preterm had a significantly increased risk of suicide. Post-term birth predicted significantly increased risks of any mental disorder in general and particularly of substance use and anxiety disorders. Individuals born SGA had significantly increased risks of any mental and substance use disorders. Women born LGA had an increased risk of psychotic disorders.

CONCLUSIONS

Although men born late preterm had an increased suicide risk, late preterm birth did not exert widespread effects on adult psychopathology. In contrast, the risks of severe mental disorders across adulthood were increased among individuals born SGA and individuals born post-term.

Risk score comprising maternal and obstetric factors to identify late preterm infants at risk for neonatal intensive care unit admission

AIM

The aim of this study was to develop and validate an antepartum risk score based on maternal and obstetric characteristics to predict the requirement for neonatal intensive care unit (NICU) admission among late preterm infants.

MATERIAL AND METHODS

A chart review was performed of 455 singleton late preterm deliveries at our institution between July 2010 and December 2011. Logistic regression analysis was used to develop a risk score, which was derived from β coefficients of the significant variables. A receiver-operator curve was plotted to determine the optimal cut-off score for predicting NICU admission. Validation of the score was tested in another cohort of 450 women who delivered a singleton late preterm infant between January 2012 and June 2013.

RESULTS

A total of 98 infants (21.5%) in the development cohort were admitted to the NICU. The significant factors for NICU admission included: premature rupture of membranes, antepartum hemorrhage, medical disorders during pregnancy, prenatal estimation of fetal weight, gestational age at delivery, and mode of delivery. These six variables were integrated into a risk-scoring model, which ranged from -2 to 9 points. A cut-off score of ≥1 produced the maximum area under the receiver-operator curve of 0.764. At this cut-off point, the sensitivity was 79.6% and specificity was 73.1%. When the risk score was tested in the validation cohort, similar results were demonstrated.

CONCLUSION

An antepartum risk score was developed to predict the requirement for NICU admission among late preterm infants and was validated in an independent cohort.

Early neonatal morbidities and associated modifiable and non-modifiable risk factors in a cohort of infants born at 34-35 weeks of gestation

OBJECTIVE

To ascertain the most common early morbidities in a cohort of infants born at 34-35 weeks gestation and to identify the risk factors associated with these morbidities.

METHODS

Retrospective analysis of data collected prospectively for all 235 infants born at 34-35 weeks of gestation during an eight-month period at a single tertiary medical center. Study group infants (SG) were compared with 470 term infants (TI), matched both for gender and for mode of delivery.

RESULTS

Jaundice requiring phototherapy (32%), respiratory disease (19.1%) and cyanotic episodes (15.7%) were the most frequent early morbidities, followed by hypoglycemia, temperature instability and feeding intolerance. The risk of having a complication was 13.3-times higher in the SG compared with the TI group (95% CI 8.9-19.6, p < 0.001). Modifiable interventions associated with these morbidities were antenatal steroids, MgSO4 and mode of delivery. Non-modifiable factors were maternal age, parity, twins and gender.

CONCLUSIONS

Jaundice requiring phototherapy, respiratory disease and cyanotic episodes are the most frequent early morbidities among infants born at 34-35 weeks. Medically modifiable factors were found to be associated with the above morbidities. Whether specific recommendations for the care of these infants will affect early morbidities needs to be studied in controlled prospective studies.

Short-term respiratory outcomes in late preterm infants

Objective

To evaluate short-term respiratory outcomes in late preterm infants (LPI) compared with those of term infants (TI).

Methods

A retrospective study conducted in a single third level Italian centre (2005–2009) to analyse the incidence and risk factors of composite respiratory morbidity (CRM), the need for adjunctive therapies (surfactant therapy, inhaled nitric oxide, pleural drainage), the highest level of respiratory support (mechanical ventilation – MV, nasal continuous positive airway pressure – N-CPAP, nasal oxygen) and the duration of pressure support (hours in N-CPAP and/or MV).

Results

During the study period 14,515 infants were delivered. There were 856 (5.9%) LPI and 12,948 (89.2%) TI. CRM affected 105 LPI (12.4%), and 121 TI (0.9%), with an overall rate of 1.6%. Eighty-four LPI (9.8%) and 73 TI (0.56%) received respiratory support, of which 13 LPI (1.5%) and 16 TI (0.12%) were ventilated. The adjusted OR for developing CRM significantly increased from 3.3 (95% CI 2.0-5.5) at 37 weeks to 40.8 (95% CI 19.7-84.9%) at 34 weeks. The adjusted OR for the need of MV significantly increased from 3.4 (95% CI 1.2-10) at 37 weeks to 34.4 (95% CI 6.7-180.6%) at 34 weeks. Median duration of pressure support was significantly higher at 37 weeks (66.6 h vs 40.5 h). Twin pregnancies were related to a higher risk of CRM (OR 4.3, 95% CI 2.6-7.3), but not independent of gestational age (GA). Cesarean section (CS) was associated with higher risk of CRM independently of GA, but the OR was lower in CS with labour (2.2, 95% CI 1.4-3.4 vs 3.0, 95% CI 2.1-4.2).

Conclusions

In this single third level care study late preterm births, pulmonary diseases and supportive respiratory interventions were lower than previously documented. LPI are at a higher risk of developing pulmonary disease than TI. Infants born from elective cesarean sections, late preterm twins in particular and 37 weekers too might benefit from preventive intervention.

Risk assessment of neonatal excipient exposure: lessons from food safety and other areas

Newborn babies can require significant amounts of medication containing excipients intended to improve the drug formulation. Most medicines given to neonates have been developed for adults or older children and contain excipients thought to be safe in these age groups. Many excipients have been used widely in neonates without obvious adverse effects. Some excipients may be toxic in high amounts in which case they need careful risk assessment. Alternatively, it is conceivable that ill-founded fears about excipients mean that potentially useful medicines are not made available to newborn babies. Choices about excipient exposure can occur at several stages throughout the lifecycle of a medicine, from product development through to clinical use. Making these choices requires a scalable approach to analysing the overall risk. In this contribution we examine these issues.

Long-term outcomes of moderately preterm, late preterm, and early term infants

At present, moderate preterm (MPT) infants born at 32 to 33 weeks' gestation and late preterm (LPT) infants born at 34 to 36 weeks' gestation make up the largest subgroup of preterm infants and contribute to more than 80% of premature births in the United States. There is increasing evidence that both MPT and LPT infants are at increased risk of neurologic impairments, developmental disabilities, school failure, and behavior and psychiatric problems. Population studies suggest that for each 1 week decrease in gestational age below 39 weeks, there are stepwise increases in adverse outcomes after adjusting for confounders.

Hospital readmissions and emergency department visits in moderate preterm, late preterm, and early term infants

The increased vulnerability of late preterm infants is no longer a novel concept in neonatology, with many studies documenting excess morbidity and mortality in these infants during the birth hospitalization. Because outcomes related to gestational age constitute a continuum, it is important to analyze data from the gestational age groups that bookend late preterm infants infants-moderate preterm infants (31-32 weeks) and early term infants (37-38 weeks). This article evaluates hospital readmissions and emergency department visits in the first 30 days after discharge from birth hospitalization in a large cohort of infants greater than or equal to 31 weeks' gestation.

Late preterm infants: near term but still in a critical developmental time period

Late preterm (LP) infants are defined as those born at 34-0/7 to 36-6/7 weeks' gestational age. LP infants were previously referred to as near term infants. The change in terminology resulted from the understanding that these infants are not fully mature and that the last 6 weeks of gestation represent a critical period of growth and development of the fetal brain and lungs, and of other systems. There is accumulating evidence of higher risks for health complications in these infants, including serious morbidity and a threefold higher infant mortality rate compared with term infants. This information is of critical importance because of its scientific merits and practical implications. However, it warrants a critical and balanced review, given the apparent overall uncomplicated outcome for the majority of LP infants. Others reviewed the characteristics of LP infants that predispose them to a higher risk of morbidity at the neonatal period. This review focuses on the long-term neurodevelopmental and respiratory outcomes, with the main aim to suggest putative prenatal, neonatal, developmental, and environmental causes for these increased morbidities. It demonstrates parallelism in the trajectories of pulmonary and neurologic development and evolution as a model for fetal and neonatal maturation. These may suggest the critical developmental time period as the common pathway that leads to the outcomes. Disruption in this pathway with potential long-term consequences in both systems may occur if the intrauterine milieu is disturbed. Finally, the review addresses the practical implications on perinatal and neonatal care during infancy and childhood.

Hospitalization of early preterm, late preterm, and term infants during the first year of life by gestational age

OBJECTIVES

The goal of this study was to describe hospitalizations of infants during the first year of life according to week of gestational age (GA). We hypothesized that odds of any hospitalization would generally decrease with increasing GA, with late preterm infants experiencing additional increased risk of specific hospitalizations, such as hyperbilirubinemia.

METHODS

Birth certificates for > 6.6 million infants born in California hospitals between 1993 and 2005 and surviving to discharge were linked to hospital discharge records during the first year of life. Odds of any hospitalization and any hospitalization for specific diagnoses during the first year of life were determined for infants 23 to 44 weeks' GA. Further analysis determined odds of any hospitalization within 14, 30, and 90 days of birth discharge, and observed odds were compared with expected odds obtained through quadratic modeling.

RESULTS

Odds of any hospitalization within the first year of life decreased with advancing GA, but observed odds of any hospitalization exceeded expected odds for 35-, 36-, and 37-week GA infants for all time periods after discharge. Odds of any hospitalization for hyperbilirubinemia were greatest for infants 33 to 38 weeks' GA (peak odds ratio at 36 weeks' GA: 2.86 [95% confidence interval: 2.73-3.00]), and a relative peak in odds of any hospitalization for specific infections was observed among infants 33 to 36 weeks' GA.

CONCLUSIONS

Odds of any hospitalization during the first year of life exceeded expected odds of hospitalization for 35-, 36-, and 37-week GA infants. GAs at risk overlapped with, but were not identical to, GAs identified as late preterm infants.

Preterm birth time trends in Europe: a study of 19 countries

Objective

To investigate time trends in preterm birth in Europe by multiplicity, gestational age, and onset of delivery.

Design

Analysis of aggregate data from routine sources.

Setting

Nineteen European countries.

Population

Live births in 1996, 2000, 2004, and 2008.

Methods

Annual risk ratios of preterm birth in each country were estimated with year as a continuous variable for all births and by subgroup using log-binomial regression models.

Main outcome measures

Overall preterm birth rate and rate by multiplicity, gestational age group, and spontaneous versus non-spontaneous (induced or prelabour caesarean section) onset of labour.

Results

Preterm birth rates rose in most countries, but the magnitude of these increases varied. Rises in the multiple birth rate as well as in the preterm birth rate for multiple births contributed to increases in the overall preterm birth rate. About half of countries experienced no change or decreases in the rates of singleton preterm birth. Where preterm birth rates rose, increases were no more prominent at 35–36 weeks of gestation than at 32–34 weeks of gestation. Variable trends were observed for spontaneous and non-spontaneous preterm births in the 13 countries with mode of onset data; increases were not solely attributed to non-spontaneous preterm births.

Conclusions

There was a wide variation in preterm birth trends in European countries. Many countries maintained or reduced rates of singleton preterm birth over the past 15 years, challenging a widespread belief that rising rates are the norm. Understanding these cross-country differences could inform strategies for the prevention of preterm birth.

Early term birth: the impact of practice patterns on rates and outcomes

The American College of Obstetricians and Gynecologists guidelines discourage elective deliveries before 39 weeks gestation, but clinicians continue to schedule elective inductions and cesareans resulting in births at 37 0/7 to 38 6/7 weeks gestation. These "early term" (ET) infants incur more morbidity and mortality than their 39-to-41-week counterparts. Using the Quality Health Outcomes Model, four hypotheses were tested: Among hospitals in one southwestern U.S. county, there are different rates of ET births, ET births preceded by elective labor induction, ET births preceded by elective cesarean section, and Neonatal Intensive Care Unit (NICU) admissions of ET infants. Analyses of 75,625 birth certificates involved 26,199 ET and 49,426 full term births in 16 hospitals. Chi-square analyses revealed significant differences in rates among hospitals for ET births, ET births preceded by elective labor induction, and ET births preceded by elective cesarean section, but no significant differences in NICU admissions. Wide variance across hospitals demonstrated practice patterns amenable to improvements.

Case-control study of birth characteristics and the risk of hepatoblastoma

BACKGROUND

Hepatoblastoma is a malignant embryonal tumor typically diagnosed in children younger than five years of age. Little is known on hepatoblastoma etiology.

METHODS

We matched California Cancer Registry records of hepatoblastomas diagnosed in children younger than age 6 from 1988 to 2007 to birth records using a probabilistic record linkage program, yielding 261 cases. Controls (n=218,277), frequency matched by birth year to all cancer cases in California for the same time period, were randomly selected from California birth records. We examined demographic and socioeconomic information, birth characteristics, pregnancy history, complications in pregnancy, labor and delivery, and abnormal conditions and clinical procedures relating to the newborn, with study data taken from birth certificates.

RESULTS

We observed increased risks for hepatoblastoma among children with low [1500-2499 g, Odds Ratio (OR)=2.02, 95% confidence interval (CI) 1.29-3.15] and very low birthweight (<1500 g, OR=15.4, 95% CI 10.7-22.3), preterm birth <33 weeks (OR=7.27, 95% CI 5.00, 10.6), small size for gestational age (OR=1.75, 95% CI 1.25-2.45), and with multiple birth pregnancies (OR=2.52, 95% CI 1.54-4.14). We observed a number of pregnancy and labor complications to be related to hepatoblastoma, including preeclampsia, premature labor, fetal distress, and congenital anomalies.

CONCLUSION

These findings confirm previously reported associations with low birthweight and preeclampsia. The relation with multiple birth pregnancies has been previously reported and may indicate a relation to infertility treatments.

Nutritional management of the low birth weight/preterm infant in community settings: a perspective from the developing world

Globally, about 20 million infants are born with low birth weight (LBW; <2500 g). Of all LBW infants, approximately 95% are born in developing countries. The greatest incidence of LBW occurs in South-Central Asia; the second greatest is in Africa. The two main reasons for LBW are preterm birth (<37 weeks) and intrauterine growth restriction (IUGR), which are risk factors for increased morbidity and mortality in newborn infants. Maternal nutrition status is one of the most important risk factors for LBW/IUGR. Providing balanced protein energy and multiple micronutrient supplements to pregnant women will reduce incidence of IUGR. Calcium supplementation during pregnancy will reduce the incidence of pre-eclampsia and preterm birth in developing countries. Exclusive breastfeeding is protective for a mother and her infant and has been shown to reduce morbidity and mortality in infancy. Kangaroo mother care for preterm infants will reduce severe morbidity and mortality as well. Community-based intervention packages are among the most effective methods of reducing morbidity and mortality in mothers and children. Future research should focus on improving triage of preterm and IUGR infants. Exclusive breastfeeding should be promoted, and appropriate alternative food supplements should be provided when breastfeeding is not possible.

Risks associated with delivering infants 2 to 6 weeks before term--a review of recent data

BACKGROUND

There is an increasing trend towards delivery before 39 weeks of gestational age. The short- and long-term effects of early delivery on the infant have only recently received scientific attention.

METHODS

Selective review of the literature

RESULTS

Delivery at any time before 39 weeks is associated with significantly higher infant mortality and with an increase of the risk of impairments after birth from 8% to 11%. The increase in risks of various kinds is disproportionately more pronounced the earlier the child is delivered. For example, the risk of needing respiratory support or artificial ventilation after birth increases from 0.3% with delivery at 39-41 weeks of gestational age to 1.4% at 37 weeks and 10% at 35 weeks, while the risk of death or neurological complications increases from 0.15% at 39-41 weeks of gestation to 0.66% at 35 weeks. Delivery at 34.0 to 36.6 weeks of gestation also has long-term effects. Compared to delivery at term, the frequency of cerebral palsy rises threefold, from 0.14% to 0.43%; the risk of death in early adulthood rises by about half, from 0.046 to 0.065%; and the risk of dependence on government benefits in early adulthood also rises by about half, from 1.7% to 2.5%.

CONCLUSION

Studies from the USA have shown that the number of medically indicated deliveries before 39 weeks can be lowered by 70% to 80% through consistently applied measures for quality improvement. If similar results could be achieved in Germany, the iatrogenic complications of delivery would become less common in this country as well.

Increased risk for respiratory distress among white, male, late preterm and term infants

OBJECTIVE

To determine whether race/ethnicity and sex independently increase risk of respiratory distress syndrome (RDS) in late preterm and term infants.

STUDY DESIGN

Using a cohort design, we studied the risk of RDS associated with race/ethnicity and sex in infants with gestational age (GA) 34 to 42 weeks born between 1 January 2000 and 31 December 2009 (n=286 454) within 12 hospitals in the Northern California Kaiser Permanente Medical Care Program.

RESULT

Male sex (adjusted odds ratio (aOR) 1.68; 95% confidence interval 1.45 to 1.93) and White race/ethnicity (vs Asians (aOR 0.57; 95% confidence interval 0.47 to 0.70), Blacks (aOR 0.66; 95% confidence interval 0.50 to 0.87), and Hispanics (aOR 0.76; 95% confidence interval 0.64 to 0.90)) independently increase risk for RDS regardless of GA. A GA <39 weeks, operative delivery, maternal diabetes, and chorioamnionitis also increased RDS risk in this cohort.

CONCLUSION

Male sex and White race/ethnicity independently increase risk for RDS in late preterm and term infants. Timing of elective delivery should acknowledge these risks.

Early term birth: understanding the health risks to infants

Early term birth, which occurs at 37 to 38 weeks gestation, is often elective and can carry significant health risks to infants, including short-term and long-term health outcomes. Nurses and other health care providers involved in the care of pregnant women and infants need to be aware of these infants' physiologic vulnerability and potential short- term and long-term care requirements. Nurses can educate patients and raise awareness of the risks associated with early term birth.

'The influence of gestational age and socioeconomic status on neonatal outcomes in late preterm and early term gestation: a population based study'

Background

Infants born late preterm (34 + 0 to 36 + 6 weeks GA (gestational age)) are known to have higher neonatal morbidity than term (37 + 0 to 41 + 6 weeks GA) infants. There is emerging evidence that these risks may not be homogenous within the term cohort and may be higher in early term (37 + 0 to 38 + 6 weeks GA). These risks may also be affected by socioeconomic status, a risk factor for preterm birth.

Methods

A retrospective population based cohort of infants born at 34 to 41 weeks of GA was assembled; individual and area-level income was used to develop three socioeconomic (SES) groups. Neonatal morbidity was grouped into respiratory distress syndrome (RDS), other respiratory disorders, other complications of prematurity, admission to a Level II/III nursery and receipt of phototherapy. Regression models were constructed to examine the relationship of GA and SES to neonatal morbidity while controlling for other perinatal variables.

Results

The cohort contained 25 312 infants of whom 6.1% (n = 1524) were born preterm and 32.4% (n = 8203) were of low SES. Using 39/40 weeks GA as the reference group there was a decrease in neonatal morbidity at each week of gestation. The odds ratios remained significantly higher at 37 weeks for RDS or other respiratory disorders, and at 38 weeks for all other outcomes. SES had an independent effect, increasing morbidity with odds ratios ranging from 1.2–1.5 for all outcomes except for the RDS group, where it was not significant.

Conclusions

The risks of morbidity fell throughout late preterm and early term gestation for both respiratory and non-respiratory morbidity. Low SES was associated with an independent increased risk. Recognition that the morbidities associated with prematurity continue into early term gestation and are further compounded by SES is important to develop strategies for improving care of early term infants, avoiding iatrogenic complications and prioritizing public health interventions.

NEONATAL OUTCOMES FOLLOWING LATE PRETERM BIRTH

It is well recognised that birth before 32 weeks of gestation is associated with substantial neonatal morbidity and mortality and these risks have been extensively reported. The focus of perinatal research for many years has therefore been very preterm and extremely preterm delivery, since the likelihood and severity of adverse neonatal outcomes are highest within this group. In contrast, until recently, more mature preterm infants have been understudied and indeed, almost ignored by researchers.

Neonatal problems of late and moderate preterm infants

Late and moderate preterm infants account for >80% of premature births. These newborns experience considerable mortality and morbidity in comparison with full-term born infants. The purpose of this paper is to summarise the most common morbidities of late and moderate preterm infants in the neonatal period, their incidence, severity, risk factors and need for admission to the different levels of care. The recent findings on preventive strategies and management priorities for clinical care of these vulnerable babies are also reviewed.

Late-preterm birth by delivery circumstance and its association with parent-reported attention problems in childhood

OBJECTIVE

Late-preterm birth (LPB, 34-36 wk) has been associated with an increased risk of attention problems in childhood relative to full-term birth (FTB, ≥37 wk), but little is known about factors contributing to this risk. The authors investigated the contributions of clinical circumstances surrounding delivery using follow-up data from the Pregnancy Outcomes and Community Health (POUCH) Study.

METHODS

Women who delivered late preterm or full term and completed the sex- and age-referenced Conners' Parent Rating Scales-Short Form: Revised were included in the present analysis (N = 762; children's age, 3-9 y). The Conners' Parent Rating Scales-Short Form: Revised measures dimensions of behavior linked to attention problems, including oppositionality, inattention, hyperactivity, and a global attention problem index. Using general linear models, the authors evaluated whether LPB subtype (medically indicated [MI] or spontaneous) was associated with these dimensions relative to FTB.

RESULTS

After adjustment for parity, sociodemographics, child age, and maternal symptoms of depression and serious mental illness during pregnancy and at the child survey, only MI LPB was associated with higher hyperactivity and global index scores (mean difference from FTB = 3.8 [95% confidence interval {CI}: 0.5, 7.0] and 3.1 [95% CI 0.0, 6.2]). These findings were largely driven by children between 6 and 9 years. Removal of women with hypertensive disorders during pregnancy (N = 85) or placental findings related to hypertensive conditions (obstruction, decreased maternal spiral artery conversion; N = 134) reduced the differences below significance thresholds.

CONCLUSIONS

Among LPBs, only MI LPB was associated with higher levels of parent-reported childhood attention problems, suggesting that complications motivating medical intervention during the late-preterm period mark increased risk for such problems. Hypertensive disorders seem to play a role in these associations.