EXPRESS study shows significant regional differences in 1-year outcome of extremely preterm infants in Sweden

One-year survival and outcomes of infants born at 22 and 23 weeks of gestation in Sweden 2004-2007, 2014-2016 and 2017-2019

OBJECTIVE

To explore associations between perinatal activity and survival in infants born at 22 and 23 weeks of gestation in Sweden.

DESIGN/SETTING

Data on all births at 22 and 23 weeks' gestational age (GA) were prospectively collected in 2004-2007 (T1) or obtained from national registers in 2014-2016 (T2) and 2017-2019 (T3). Infants were assigned perinatal activity scores based on 3 key obstetric and 4 neonatal interventions.

MAIN OUTCOME

One-year survival and survival without major neonatal morbidities (MNM): intraventricular haemorrhage grade 3-4, cystic periventricular leucomalacia, surgical necrotising enterocolitis, retinopathy of prematurity stage 3-5 or severe bronchopulmonary dysplasia. The association of GA-specific perinatal activity score and 1-year survival was also determined.

RESULTS

977 infants (567 live births and 410 stillbirths) were included: 323 born in T1, 347 in T2 and 307 in T3. Among live-born infants, survival at 22 weeks was 5/49 (10%) in T1 and rose significantly to 29/74 (39%) in T2 and 31/80 (39%) in T3. Survival was not significantly different between epochs at 23 weeks (53%, 61% and 67%). Among survivors, the proportions without MNM in T1, T2 and T3 were 20%, 17% and 19% for 22 weeks and 17%, 25% and 25% for 23 weeks' infants (p>0.05 for all comparisons). Each 5-point increment in GA-specific perinatal activity score increased the odds for survival in first 12 hours of life (adjusted OR (aOR) 1.4; 95% CI 1.3 to 1.6) in addition to 1-year survival (aOR 1.2; 95% CI 1.1 to 1.3), and among live-born infants it was associated with increased survival without MNM (aOR 1.3; 95% CI 1.1 to 1.4).

CONCLUSION

Increased perinatal activity was associated with reduced mortality and increased chances of survival without MNM in infants born at 22 and 23 weeks of GA.

Active approach in delivery room and survival of infants born between 22 and 26 gestational weeks are increasing in Spain

AIM

To describe the trends in the delivery room approach and survival of extremely premature infants over the past two decades.

METHODS

Time-series analysis of infants included in the Spanish SEN1500 network from 2004 to 2019. Patients born from 22 + 0 to 26 + 6 weeks were included. The primary outcome was an active approach in the delivery room. Survival and temporal trends were also studied.

RESULTS

The study population included 8284 patients. At 22 and 23 weeks, an active approach was followed in 41.4% and 80.8%. A temporal trend toward a more active approach was observed at 23 weeks. Antenatal steroids were administered in 19.6% and 58.1% at 22 and 23 weeks. From 24 weeks, an active approach was applied in nearly all cases throughout the period, and more than 80% of patients received antenatal steroids. The rates of survival after an active approach were 8.7%, 21.6%, 40.6%, 59.9%, and 74.7% at 22, 23, 24, 25, and 26 weeks and significantly increased over the period, except for infants born at 22 weeks.

CONCLUSION

Active management and survival of infants born from 23 weeks increased over the period, but the frequency of antenatal steroid administration was lower than the intention to resuscitate.

Impact of Outborn/Inborn Birth Status of Infants Born at <29 Weeks of Gestation on Neurodevelopmental Impairment: A Nationwide Cohort Study in Korea

This study designed to evaluate the short- and long-term outcomes of outborn and inborn preterm infants enhancing the regional perinatal system in South Korea. It is a prospective cohort study of the Korean neonatal network database for infants born at <29 weeks of gestation between 2013 and 2015. Of 2995 eligible infants, 312 were outborn, and 976 completed the assessment of long-term outcome at 18-24 months of corrected age. The mean gestational age was significantly younger in outborn infants than in inborn infants (p = 0.004). The mean Apgar score at 5 min was higher in inborn infants (p = 0.046). More inborn preterm infants died before discharge (p < 0.001); however, most of the other short-term outcomes occurred significantly more often in outborn infants than in inborn infants. The outborn infants had higher odds of neurodevelopmental impairment (adjusted odds ratio (aOR) 2.412, 95% confidence interval (CI) 1.585-3.670), cerebral palsy (aOR 4.460, 95% CI 2.249-8.845) and developmental impairment (aOR 2.238, 95% CI 1.469-3.408). In preterm infants, the location of birth may be a key factor influencing short- and long-term outcomes. Thus, to provide adequate care and efficiently allocate medical resources to high-risk preterm infants, nationwide regional perinatal systems need to be improved and standardized.

Retrospective evaluation of ophthalmological and neurological outcomes for infants born before 24 weeks gestational age in a Swedish cohort

OBJECTIVES

To retrospectively evaluate ophthalmological and neurological outcomes in a Swedish cohort of infants born before 24 weeks gestational age (GA) and explore risk factors for visual impairment.

SETTING

Eye and paediatric clinics in Sweden.

PARTICIPANTS

Infants screened for retinopathy of prematurity (ROP) (n=399), born before 24 weeks GA, 2007-2018. Cases were excluded if ophthalmological follow-up records could not be traced.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were ophthalmological, including visual acuity (VA), refractive error, strabismus, nystagmus and cerebral visual impairment (CVI). Secondary outcomes comprised neonatal and neurological morbidities. Data were retrospectively retrieved from medical records.

RESULTS

The 355 assessed children had a median GA of 23 weeks and 2 days and a median birth weight of 565 g. At the last available ophthalmological examination, the median age was 4.8 years (range 0.5-13.2 years). Nystagmus was recorded in 21.1%, strabismus in 34.8%, and 51.0% wore spectacles. Seventy-three of 333 (21.9%) were visually impaired, defined as being referred to a low vision clinic and/or having a VA less than 20/60 at 3.5 years of age or older. ROP treatment was a significant risk factor for visual impairment (OR 2.244, p=0.003). Visually impaired children, compared with children without visual impairment, more often had neurological deficits such as intellectual disability 63.8% versus 33.3% (p<0.001), epilepsy 21.1% versus 7.5% (p=0.001) and autism spectrum disorders 32.8% versus 20.9% (p=0.043). Nine of the 355 children had been diagnosed with CVI.

CONCLUSIONS

Children born before 24 weeks GA frequently had visual impairment in association with neurological deficits. CVI was rarely diagnosed. A multidisciplinary approach for the evaluation and habilitation of these vulnerable infants is warranted. National follow-up guidelines need to be developed and implemented.

National cohort of infants born before 24 gestational weeks showed increased survival rates but no improvement in neonatal morbidity

AIM

To describe survival and neonatal morbidities in infants born before 24 weeks of gestation during a 12-year period.

METHODS

Data were retrieved from national registries and validated in medical files of infants born before 24 weeks of gestation 2007-2018 in Sweden. Temporal changes were evaluated.

RESULTS

In 2007-2018, 282 live births were recorded at 22 weeks and 460 at 23 weeks of gestation. Survival to discharge from hospital of infants born alive at 22 and 23 weeks increased from 20% to 38% (p = 0.006) and from 45% to 67% (p < 0.001) respectively. Caesarean section increased from 12% to 22% (p = 0.038) for infants born at 22 weeks. Neonatal morbidity rates in infants alive at 40 weeks of postmenstrual age (n = 399) were unchanged except for an increase in necrotising enterocolitis from 0 to 33% (p = 0.017) in infants born at 22 weeks of gestation. Bronchopulmonary dysplasia was more common in boys than girls, 90% versus 82% (p = 0.044). The number of infants surviving to 40 weeks doubled over time.

CONCLUSION

Increased survival of infants born before 24 weeks of gestation resulted in increasing numbers of very immature infants with severe neonatal morbidities likely to have a negative impact on long-term outcome.

Reduced platelet function in preterm neonates compared with term neonates

Background

A reduced platelet function might contribute to the longer bleeding time seen in preterm neonates. However, the previously used platelet function testing in neonates is limited due to methodological limitations, mainly caused by difficulties in obtaining adequate blood volume. Therefore, the platelet function in preterm neonates is sparsely investigated. The aim of this study was to compare platelet function in preterm neonates at birth and at expected term age with platelet function in term neonates at birth.

Methods

We included 43 preterm neonates born at gestational age (GA) 28 + 0 to 34 + 0 and 21 term neonates born at GA 38 + 0 to 41 + 0. Within the first 24 hours of life, 1-1.5 mL peripheral blood was obtained and for preterm neonates, resampling was performed at expected term age (GA 38 + 0 to 41 + 0). Platelet function testing included impedance aggregometry and platelet activation measured by flow cytometry. In addition, platelet count was determined.

Results

Platelet count and platelet activation were reduced in preterm neonates compared with term neonates at birth, but we found no difference in impedance aggregometry at birth. At expected term age, platelet count and aggregation exceeded term levels, but platelet activation remained impaired in the preterm.

Conclusion

Preterm neonatal function is decreased at birth and does not seem to reach term levels during the first 4 to 13 weeks of life.

Initiation and duration of skin-to-skin contact for extremely and very preterm infants: A register study

AIM

This study sought to describe how skin-to-skin contact between extremely and very preterm infants and their parents is practised in Swedish neonatal units.

METHODS

Data from the Swedish Neonatal Quality Register from 2020 to 2021 were extracted to analyse initiation time and daily duration of skin-to-skin contact in different gestational ages and regions.

RESULTS

Of the 1475 infants in the cohort, mean (range) gestational age was 28 weeks (22-31), and mean (range) birthweight was 1205 g (360-2810). For extremely preterm infants (<28 weeks), median (interquartile range) skin-to-skin contact initiation time was at 88 postnatal hours (48-156) and 5% had skin-to-skin contact on the first day. For very preterm infants (<32 weeks), the corresponding numbers were 14 h (4-36) and 34%. Median (interquartile range) daily skin-to-skin contact duration for the entire cohort during the first day, first three and seven days and the remaining hospital stay was 0 (0-0), 0.7 (0-2.7), 1.6 (0.4-3.6) and 4.4 (3.0-6.1) h, respectively.

CONCLUSION

A minority of extremely and very preterm infants were exposed to skin-to-skin contact on the first postnatal day. Daily duration during the first week of life amounted to less than two hours. Initiation time and daily duration varied among gestational ages.

Mortality and significant neurosensory impairment in preterm infants: an international comparison

OBJECTIVE

To compare mortality and rates of significant neurosensory impairment (sNSI) at 18-36 months' corrected age in infants born extremely preterm across three international cohorts.

DESIGN

Retrospective analysis of prospectively collected neonatal and follow-up data.

SETTING

Three population-based observational cohort studies: the Australian and New Zealand Neonatal Network (ANZNN), the Canadian Neonatal and Follow-up Networks (CNN/CNFUN) and the French cohort Etude (Epidémiologique sur les Petits Ages Gestationnels: EPIPAGE-2).

PATIENTS

Extremely preterm neonates of <28 weeks' gestation in year 2011.

MAIN OUTCOME MEASURES

Primary outcome was composite of mortality or sNSI defined by cerebral palsy with no independent walking, disabling hearing loss and bilateral blindness.

RESULTS

Overall, 3055 infants (ANZNN n=960, CNN/CNFUN n=1019, EPIPAGE-2 n=1076) were included in the study. Primary composite outcome rates were 21.3%, 20.6% and 28.4%; mortality rates were 18.7%, 17.4% and 26.3%; and rates of sNSI among survivors were 4.3%, 5.3% and 3.3% for ANZNN, CNN/CNFUN and EPIPAGE-2, respectively. Adjusted for gestational age and multiple births, EPIPAGE-2 had higher odds of composite outcome compared with ANZNN (OR 1.71, 95% CI 1.38 to 2.13) and CNN/CNFUN (OR 1.72, 95% CI 1.39 to 2.12). EPIPAGE-2 did have a trend of lower odds of sNDI but far short of compensating for the significant increase in mortality odds. These differences may be related to variations in perinatal approach and practices (and not to differences in infants' baseline characteristics).

CONCLUSIONS

Composite outcome of mortality or sNSI for extremely preterm infants differed across high-income countries with similar baseline characteristics and access to healthcare.

Current attitudes and beliefs toward perinatal care orientation before 25 weeks of gestation: The French perspective in 2020

The survival rate of infants born before 25 weeks of gestational age in France is extremely low compared with that of many other countries: 0%, 1%, and 31% at 22, 23, and 24 weeks' in the last national cohort study. A non-optimal regionalization and variations in practice are prevalent. Some parents in social media and support groups have reported feeling lost and confused with mixed messages leading to lack of trust. These data kindled a major debate in France around perinatal management leading to an investigation exploring neonatologists' perspectives and ways to improve care. The majority (81%) of the responding neonatologists reported more active care and higher survival rates than in 2011, although others continued preferring delivery room comfort care and limited NICU treatment at or before 24 weeks. The desire to improve was an overarching theme in all the respondents' answers to open-ended questions. Barriers to active care included an absence of expertise and of benchmarking to guide optimal care, and limited resources in the NICU and during follow-up - all leading to self-fulfilling prophecies of poor prognosis. Optimization of regionalization, perinatal teamwork and parental involvement, fostering experience by creating specific perinatal centers, stimulating benchmarking, and working with policy makers to allow better long-term outcomes could enable higher survival.

Neonatal Outcome and Treatment Perspectives of Preterm Infants at the Border of Viability

Decision-making at the border of viability remains challenging for the expectant parents and the medical team. The preterm infant is dependent on others making the decision that will impact them for a lifetime in hopefully their best interest. Besides survival and survival without neurodevelopmental impairment, other relevant outcome measures, such as the quality of life of former preterm infants and the impact on family life, need to be integrated into prenatal counselling. Recommendations and national guidelines continue to rely on arbitrarily set gestational age limits at which treatment is not recommended, can be considered and it is recommended. These guidelines neglect other individual prognostic outcome factors like antenatal steroids, birth weight and gender. Besides individual factors, centre-specific factors like perinatal treatment intensity and the attitude of healthcare professionals significantly determine the futures of these infants at the border of viability. A more comprehensive approach regarding treatment recommendations and relevant outcome measures is necessary.

The center-effect on outcomes for infants born at less than 25 weeks

Marked variation exists in the care of infants born at <25 weeks' gestation. The center or location where a fetus or infant is cared for influences outcomes at very early gestational ages. Understanding this "center-effect," including characteristics associated with centers that have high survival of births at <25 weeks' gestation, may inform future studies and guide care practices to improve outcomes. This review focuses on the impact that the location or center of birth has on survival and other important outcomes for infants born at <25 weeks' gestation. We review potential sources of variation in care practices and other factors that might explain the "center-effect."

Changes in long-term survival and neurodevelopmental disability in infants born extremely preterm in the post-surfactant era

Extremely preterm birth before 28 weeks' gestation accounts for less than 1% of births in high-income countries but is associated with high rates of perinatal and infant mortality, and of neurodevelopmental disability in surviving children. Survival rates have increased over time, both overall, and within each week of gestational age since the introduction of exogenous surfactant into clinical care in the early 1990s. However, rates of major neurodevelopmental disability in survivors, whether they be in early childhood or at school-age, have not clearly improved in parallel with the increases in survival. An important strategy to improve survival free of major neurodevelopmental disability is to birth extremely preterm infants in a tertiary perinatal center, where specialist obstetric care for the mother and ongoing intensive care for the infant can both be provided without the potential morbidities associated with postnatal transfer.

Outcomes of a uniformly active approach to infants born at 22-24 weeks of gestation

OBJECTIVE

To determine survival and outcomes in infants born at 22-24 weeks of gestation in a centre with a uniformly active approach to management of extremely preterm infants.

STUDY DESIGN

Single-centre retrospective cohort study including infants born 2006-2015. Short-term morbidities assessed included retinopathy of prematurity, necrotising enterocolitis, patent ductus arteriosus, intraventricular haemorrhage, periventricular malacia and bronchopulmonary dysplasia. Neurodevelopmental outcomes assessed included cerebral palsy, visual impairment, hearing impairment and developmental delay.

RESULTS

Total survival was 64% (143/222), ranging from 52% at 22 weeks to 70% at 24 weeks. Of 133 (93%) children available for follow-up at 2.5 years corrected age, 34% had neurodevelopmental impairment with 11% classified as moderately to severely impaired. Treatment-requiring retinopathy of prematurity, severe bronchopulmonary dysplasia, visual impairment and developmental delay correlated with lower gestational age.

CONCLUSIONS

A uniformly active approach to all extremely preterm infants results in survival rates that are not distinctly different across the gestational ages of 22-24 weeks and more than 50% survival even in infants at 22 weeks. The majority were unimpaired at 2.5 years, suggesting that such an approach does not result in higher rates of long-term adverse neurological outcome.

Mortality and Morbidity of Infants Born Extremely Preterm at Tertiary Medical Centers in China From 2010 to 2019

IMPORTANCE

Extreme prematurity is associated with a substantial burden on health care systems worldwide. However, little is known about the prognosis of infants born extremely preterm in developing countries, such as China.

OBJECTIVE

To describe survival and major morbidity among infants born extremely preterm in China over the past decade.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted from January 1, 2010, through December 31, 2019. Included individuals were infants with gestational age less than 28 weeks discharged from 1 of 68 neonatal intensive care units located in 31 provinces in China. Data were analyzed from August through October 2020.

EXPOSURE

Extremely preterm birth.

MAIN OUTCOMES AND MEASURES

Survival to discharge and major morbidity (ie, bronchopulmonary dysplasia, grades III-IV intraventricular hemorrhage, white matter injury, stage II-III necrotizing enterocolitis, sepsis, or severe retinopathy of prematurity) were measured.

RESULTS

Among 8514 eligible infants, 5295 (62.2%) were male and 116 infants (2.0%) were small for gestational age (SGA). Overall, 5302 infants (62.3%) survived to discharge. The survival rate was 1 of 21 infants (4.8%) at 22 weeks, 13 of 71 infants (18.3%) at 23 weeks, 144 of 408 infants (35.3%) at 24 weeks, 480 of 987 infants (48.6%) at 25 weeks, 1423 of 2331 infants (61.0%) at 26 weeks, and 3241 of 4692 infants (69.1%) at 27 weeks. Survival increased from 136 of 241 infants (56.4%; 95% CI, 50.1%-62.7%) in 2010 to 1110 of 1633 infants (68.0%; 95% CI, 65.7%-70.2%) in 2019 for infants born at 24 to 27 weeks (mean difference, 11.5%; 95% CI, 4.9%-18.2%; P < .001), without a significant change for infants born at less than 24 weeks. Major morbidity was found in 5999 of 8281 infants overall, for a rate of 72.4%, which increased from 116 of 223 infants (52.0%; 95% CI, 45.4%-58.6%) to 1363 of 1656 infants (82.3%; 95% CI, 80.5%-84.1%) from 2010 to 2019 (mean difference, 30.3%; 95% CI, 23.5%-37.1%, P < .001). Regional variations in survival were identified, with an almost 2-fold increase (1.94-fold; 95% CI, 1.66-2.27; P < .001) from 188 of 474 infants (39.7%) in northwest China to 887 of 1153 infants (76.9%) in north China. Gestational age (adjusted risk ratio [aRR], 1.084; 95% CI, 1.063-1.105; P < .001), birth weight (aRR, 1.028; 95% CI, 1.020-1.036; P < .001), premature rupture of membranes (aRR, 1.025; 95% CI, 1.002-1.048; P = .03), and antenatal steroids (aRR, 1.029; 95% CI, 1.004-1.055; P = .02) were associated with improved survival, while being born SGA (aRR, 0.801; 95% CI, 0.679-0.945; P = .01), being male (aRR, 0.975; 95% CI, 0.954-0.997; P = .02), multiple birth (aRR, 0.955; 95% CI, 0.929-0.982; P = .001), having a mother with gestational diabetes (aRR, 0.946; 95% CI, 0.913-0.981; P = .002), and low Apgar score (aRR, 0.951; 95% CI, 0.925-0.977; P < .001) were found to be risk factors associated with decreased chances of survival.

CONCLUSIONS AND RELEVANCE

This study found that infants born extremely preterm were at increased risk of mortality and morbidity in China, with a survival rate that improved over time and a major morbidity rate that increased. These findings suggest that more active and effective treatment strategies are needed, especially for infants born at gestational age 25 to 27 weeks.

Survival and causes of death in extremely preterm infants in the Netherlands

OBJECTIVE

In the Netherlands, the threshold for offering active treatment for spontaneous birth was lowered from 25⁺⁰ to 24⁺⁰ weeks' gestation in 2010. This study aimed to evaluate the impact of guideline implementation on survival and causes and timing of death in the years following implementation.

DESIGN

National cohort study, using data from the Netherlands Perinatal Registry.

PATIENTS

The study population included all 3312 stillborn and live born infants with a gestational age (GA) between 24^0/7 and 26^6/7 weeks born between January 2011 and December 2017. Infants with the same GA born between January 2007 and December 2009 (N=1400) were used as the reference group.

MAIN OUTCOME MEASURES

Survival to discharge, as well as cause and timing of death.

RESULTS

After guideline implementation, there was a significant increase in neonatal intensive care unit (NICU) admission rate for live born infants born at 24 weeks' GA (27%-69%, p<0.001), resulting in increased survival to discharge in 24-week live born infants (13%-34%, p<0.001). Top three causes of in-hospital mortality were necrotising enterocolitis (28%), respiratory distress syndrome (19%) and intraventricular haemorrhage (17%). A significant decrease in cause of death either complicated or caused by respiratory insufficiency was seen over time (34% in 2011-2014 to 23% in 2015-2017, p=0.006).

CONCLUSIONS

Implementation of the 2010 guideline resulted as expected in increased NICU admissions rate and postnatal survival of infants born at 24 weeks' GA. In the years after implementation, a shift in cause of death was seen from respiratory insufficiency towards necrotising enterocolitis and sepsis.

Electroencephalography monitoring in the neonatal intensive care unit: a Chinese perspective

BACKGROUND

Electroencephalography (EEG) is an accessible technique for bedside monitoring of the cerebral function in the neonatal intensive care unit (NICU). The popularization of EEG in the field of newborns in China is relatively late compared with western countries. To learn more about current practices and improvement of EEG monitoring, we conducted a survey to describe current utilization of EEG in NICU in China.

METHODS

A cross-sectional electronic survey with 21-items about EEG using in NICU was administered for pediatricians in China on the official website of "Questionnaire Star".

RESULTS

A total of 251 participants were involved, in which 64% of them reported using EEG. EEG was employed in NICUs of Children's hospitals (97%), and grade III, class A hospitals (69%). Besides, neonatal encephalopathy and suspected seizures were the most common indications for use. In clinical practice, the vast majority of physicians managed their patients on the basis of EEG (93%). Pediatricians prefer to use conventional video-EEG (cEEG) to detect seizures and make the diagnosis of encephalopathy. Both amplitude integrated EEG (aEEG) (78%) and cEEG (56%) were mainly interpreted by neonatologists. However, only 56% of respondents had ever taken a formal EEG training course. Overall, 96% of the respondents reported that they would be interested in attending an education session on EEG in the NICU. aEEG interpretation was the most interesting part to learn (81%). For those who were not using EEG, cost (43%) and difficulty interpretation (30%) were reported as barriers to use.

CONCLUSIONS

The utilization rate of EEG in NICU in China is significantly lower than the international level. There is an urgent need for standardized training and financial support for neonatologists in the use of EEG and interpretation of aEEG results.

Multicentre survey of retinopathy of prematurity in Indonesia

BACKGROUND

The incidence of retinopathy of prematurity (ROP) is higher in Indonesia than in high-income countries. In order to reduce the incidence of the disease, a protocol on preventing, screening and treating ROP was published in Indonesia in 2010. To assist the practical implementation of the protocol, meetings were held in all Indonesia regions, calling attention to the high incidence of ROP and the methods to reduce it. In addition, national health insurance was introduced in 2014, making ROP screening and treatment accessible to more infants.

OBJECTIVE

To evaluate whether the introduction of both the guideline drawing attention to the high incidence of ROP and national health insurance may have influenced the incidence of the disease in Indonesia.

SETTING

Data were collected from 34 hospitals with different levels of care: national referral centres, university-based hospitals, and public and private hospitals.

METHODS

A survey was administered with questions on admission numbers, mortality rates, ROP incidence, and its stages for 2016-2017 in relation to gestational age and birth weight.

RESULTS

We identified 12 115 eligible infants with a gestational age of less than 34 weeks. Mortality was 24% and any stage ROP 6.7%. The mortality in infants aged less than 28 weeks was 67%, the incidence of all-stage ROP 18% and severe ROP 4%. In the group aged 28-32 weeks, the mortality was 24%, all-stage ROP 7% and severe ROP 4%-5%. Both mortality and the incidence of ROP were highest in university-based hospitals.

CONCLUSIONS

In the 2016-2017 period, the infant mortality rate before 32 weeks of age was higher in Indonesia than in high-income countries, but the incidence of ROP was comparable. This incidence is likely an underestimation due to the high mortality rate. The ROP incidence in 2016-2017 is lower than in surveys conducted before 2015. This decline is likely due to a higher practitioner awareness about ROP and national health insurance implementation in Indonesia.

Impact of a Multifactorial Educational Training on the Management of Preterm Infants in the Central-Eastern European Region

Background: Differences in management and outcomes of extremely preterm infants have been reported across European countries. Implementation of standardized guidelines and interventions within existing neonatal care facilities can improve outcomes of extremely preterm infants. This study evaluated whether a multifactorial educational training (MET) course in Vienna focusing on the management of extremely preterm infants had an impact on the management of extremely preterm infants in Central-Eastern European (CEE) countries. Methods: Physicians and nurses from different hospitals in CEE countries participated in a two-day MET in Vienna, Austria with theoretical lectures, bedside teaching, and simulation trainings. In order to evaluate the benefit of the workshops, participants had to complete pre- and post-workshop questionnaires, as well as follow-up questionnaires three and twelve months after the MET. Results: 162 participants from 15 CEE countries completed the two-day MET at our department. Less invasive surfactant administration (LISA) was only used by 39% (63/162) of the participants. After the MET, 80% (122/152) were planning to introduce LISA, and 66% (101/152) were planning to introduce regular simulation training, which was statistically significantly increased three and twelve months after the MET. Thirty-six percent and 57% of the participants self-reported improved outcomes three and twelve months after the MET, respectively. Conclusion: Our standardized training in Vienna promoted the implementation of different perinatal concepts including postnatal respiratory management using LISA as well as regular simulation trainings at the participants' home departments. Moreover, our MET contributed to dissemination of guidelines, promoted best-practice, and improved self-reported outcomes.

Right Heart Structure, Geometry and Function Assessed by Echocardiography in 6-Year-Old Children Born Extremely Preterm-A Population-Based Cohort Study

Preterm birth has been associated with altered cardiac phenotype in adults. Our aim was to test the hypothesis that children surviving extremely preterm birth have important structural or functional changes of the right heart or pulmonary circulation. We also examined relations between birth size, gestational age, neonatal diagnoses of bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA) with cardiac outcomes. We assessed a population-based cohort of children born in Sweden before 27 weeks of gestation with echocardiography at 6.5 years of age (n = 176). Each preterm child was matched to a healthy control child born at term. Children born preterm had significantly smaller right atria, right ventricles with smaller widths, higher relative wall thickness and higher estimated pulmonary vascular resistance (PVR) than controls. In preterm children, PVR and right ventricular myocardial performance index (RVmpi’) were significantly higher in those with a PDA as neonates than in those without PDA, but no such associations were found with BPD. In conclusion, children born extremely preterm exhibit higher estimated PVR, altered right heart structure and function compared with children born at term.

Selection criteria for resuscitation and survivability rates for neonates at the limit of viability

AIM

To evaluate outcomes of a cohort of infants born at 23 weeks' gestational age after introducing a new selection score for resuscitation in the delivery room (DR).

METHODS

This was a retrospective charts review study using data from the maternal and newborn registry funded by the Qatar National Research Fund. Parents were consulted prenatally and their wishes were honored. The plan of resuscitation was based on the new selection score. The seven components of the score were four antenatal and three immediate postnatal in the DR. Each component received a score of zero, one, or two according to its presence, uncertainty or absence, respectively. Only a score of≥7 would receive active resuscitation unless specified otherwise during prenatal consultation.

RESULTS

The study reviewed 60 infants that were delivered over a two year period. The DR death rate was 23 of 60 (38%). Thirty-seven infants (61%) were admitted to the NICU. The score was applied only on 37 infants where all score criteria were reported in their files. Twenty infants had score <7; of them 13 (65%) died in the DR and 7 were admitted to NICU of whom two (29%) survived to discharge. Seventeen babies with scores≥7 admitted to NICU of whom nine (51%) survived to discharge. The survival rate to discharge was 13 of 37(35%). A satisfaction survey included 33 neonatal physicians; 32 neonatologists stated the score was easy to comprehend, 26 voted for easy to implement, and 30 voted for ethical relief and moral comfort.

CONCLUSIONS

Using a resuscitation score of seven was associated with improved survival until the discharge of those infants resuscitated. NICU physicians described the score as functional and convenient.

Short- and Long-Term Outcomes of Extremely Preterm Infants in Japan According to Outborn/Inborn Birth Status

OBJECTIVES

Outborn (born outside tertiary centers) infants, especially extremely preterm infants, are at an increased risk of mortality and morbidity in comparison to inborn (born in tertiary centers) infants. Extremely preterm infants require not only skilled neonatal healthcare providers but also highly specialized equipment and environment surroundings. Maternal transport at an appropriate timing must be done to avoid the delivery of extremely preterm infants in a facility without the necessary capabilities. Cases of unexpected deliveries at birth centers or level I maternity hospitals need to be attended emergently. We compared the differences in short- and long-term outcomes between outborn and inborn infants to improve our regional perinatal system.

DESIGN

Retrospective cohort study.

SETTING

Neonatal Research Network of Japan database.

PATIENTS

Extremely preterm infants (gestational age between 22 + 0 and 27 + 6 wk) in the Neonatal Research Network of Japan database between 2003 and 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 12,164 extremely preterm infants, who were divided into outborn (n = 785, 6.5%) and inborn (n = 11,379, 93.5%) groups, were analyzed. Significant differences were observed in demographic and clinical factors between the two groups. Outborn infants had higher short-term odds of severe intraventricular hemorrhage (adjusted odds ratio, 1.49; 95% CI, 1.11-2.00; p < 0.01), necrotizing enterocolitis (adjusted odds ratio, 1.49; 95% CI, 1.11-2.00; p < 0.01), and focal intestinal perforation (adjusted odds ratio, 1.58; 95% CI, 1.09-2.30; p = 0.02). There were no significant differences in long-term outcomes between the two groups, except in the rate of cognitive impairment (adjusted odds ratio, 1.49; 95% CI, 1.01-2.20; p = 0.04).

CONCLUSIONS

The frequency of severe intraventricular hemorrhage, necrotizing enterocolitis or focal intestinal perforation, and cognitive impairment was significantly higher in outborn infants. Thus, outborn/inborn birth status may play a role in short- and long-term outcomes of extremely preterm infants. However, more data and evaluation of improvement in the current perinatal environment are needed.

Survival analysis of a cohort of extremely preterm infants born in Finland during 2005-2013

OBJECTIVE

This study aimed to analyze the mortality of extremely preterm infants (ELGA born alive before 28 weeks) until the postconceptional age of 42 weeks, death, or home discharge, whichever came first. It was focused especially on studying the relationship between antenatal risk factors, the time of death, and the postnatal morbidities associated with mortality.

STUDY DESIGN

The original data obtained from the nationwide Finnish medical birth register of extremely preterm and low birthweight infants born during 2005-2013 were analyzed. The total population consisted of 1353 ELGA infants after the exclusion of 18 infants born with lethal congenital anomalies or genetic defects. Mortality risks were adjusted according to the length of gestation, the administration of antenatal steroids, and the delivery hospital.

RESULTS

During the first 48 hours, extreme immaturity was seen to be the prominent cause of death, and intrauterine growth did not influence mortality. The ELGA population surviving for at least 48 hours (N = 1135) was submitted for mortality risk analysis. After the adjustments, small-for-gestational-age (SGA) (birth weight below -2 SD) was found to be the factor with the highest risk for demise [OR 6.2; 95% CI (3.9-10.0) p < .001]. Multiple deliveries were associated with increased risk for death [OR 1.5; 95% CI (1.0-2.1), p = .048] to a lesser extent. The main neonatal morbidities associated with the risk of mortality after 48 postnatal hours of life were severe intraventricular hemorrhage (IVH) [OR 4.4; 95% CI (3.0-6.7), p < .001], respiratory distress syndrome (RDS) [OR 2.6; 95% CI (1.3-5.0), p = .006], and necrotizing enterocolitis (NEC) [OR 2.3; 95% CI (1.5-3.4), p < .001]. The major morbidities associated with deaths among non-SGA infants were severe IVH (32.1% of all deaths), NEC (19.1%), and sepsis (8.4%). In SGA infants, severe respiratory disease (RDS, severe bronchopulmonary dysplasia, pulmonary hemorrhage, or pulmonary hypertension) was the main cause of death (60.9% of all deaths). Medical or surgical PDA treatment was not found to be associated with increased risk of death [OR 0.4; 95% CI (0.2-0.5), p < .001] compared to infants who had survived for more than 2 days. Severe preeclampsia was found to be associated with 42% of all ELGA-SGA births. After the adjustments, ELGA infants from pregnancies complicated by preeclampsia of the mother exhibited a significantly lower risk of severe IVH [OR 0.3; 95% CI (0.2-0.5), p < .001] compared to the non-preeclamptic mothers' infants. The low incidence of severe IVH was evident regardless of fetal growth in this patient group.

CONCLUSIONS

SGA infants with less than 28 gestational weeks, who had survived for at least 2 days, had excessively high mortality due to severe pulmonary disease. Intrauterine growth had no influence on the risk of death, other than pulmonary causes. The infants of preeclamptic mothers exhibited an increased risk of intrauterine growth retardation; however, despite this serious complication, these infants exhibited a significant decrease in the risk for severe IVH.

Long-Term Neurodevelopmental and Functional Outcomes of Infants Born Very Preterm and/or with a Very Low Birth Weight

BACKGROUND

Birth weight (BW) is often used as a proxy for gestational age (GA) in studies on preterm birth. Recent findings indicate that, in addition to perinatal outcomes, subjects born very preterm (VP; GA < 32 weeks) differ from those with a very low birth weight (VLBW; BW < 1,500 g) in postnatal growth up to their final height.

OBJECTIVE

To study whether neurodevelopmental and functional outcomes at the age of 19 years differ in VP and/or VLBW subjects.

METHODS

705 19-year-old subjects from the Project on Preterm and Small-for-Gestational-Age Infants (POPS) cohort were classified as (1) VP+/VLBW+ (n = 354), (2) VP+/VLBW- (n = 144), or (3) VP-/VLBW+ (n = 207), and compared with regard to IQ as assessed with the Multicultural Capacity Test-intermediate level; neuromotor function using Touwen's examination of mild neurologic dysfunction; hearing loss; self- and parent-reported behavioral and emotional functioning; educational achievement and occupation; and self-assessed health using the Health Utilities Index and the London Handicap Scale.

RESULTS

VP+/VLBW- infants, on average, had 3.8-point higher IQ scores (95% confidence interval [CI] 0.5-7.1), a trend towards higher educational achievement, 3.3-dB better hearing (95% CI 1.2-5.4), and less anxious behavior, attention problems, and internalizing behavior than to VP+/VLBW+ subjects. VP-/VLBW+ infants reported 1.8 increased odds (95% CI 1.2-2.6) of poor health compared to VP+/VLBW+ subjects.

CONCLUSIONS

At the age of 19 years, subjects born VP+/VLBW+, VP+/VLBW-, and VP-/VLBW+ have different neurodevelopmental and functional outcomes, although effect sizes are small. Hence, the terms VP and VLBW are not interchangeable. We recommend, at least for industrialized countries, to base inclusion in future studies on preterm populations on GA instead of on BW.

Wide variation in severe neonatal morbidity among very preterm infants in European regions

OBJECTIVE

To investigate the variation in severe neonatal morbidity among very preterm (VPT) infants across European regions and whether morbidity rates are higher in regions with low compared with high mortality rates.

DESIGN

Area-based cohort study of all births before 32 weeks of gestational age.

SETTING

16 regions in 11 European countries in 2011/2012.

PATIENTS

Survivors to discharge from neonatal care (n=6422).

MAIN OUTCOME MEASURES

Severe neonatal morbidity was defined as intraventricular haemorrhage grades III and IV, cystic periventricular leukomalacia, surgical necrotizing enterocolitis and retinopathy of prematurity grades ≥3. A secondary outcome included severe bronchopulmonary dysplasia (BPD), data available in 14 regions. Common definitions for neonatal morbidities were established before data abstraction from medical records. Regional severe neonatal morbidity rates were correlated with regional in-hospital mortality rates for live births after adjustment on maternal and neonatal characteristics.

RESULTS

10.6% of survivors had a severe neonatal morbidity without severe BPD (regional range 6.4%-23.5%) and 13.8% including severe BPD (regional range 10.0%-23.5%). Adjusted inhospital mortality was 13.7% (regional range 8.4%-18.8%). Differences between regions remained significant after consideration of maternal and neonatal characteristics (P<0.001) and severe neonatal morbidity rates were not correlated with mortality rates (P=0.50).

CONCLUSION

Severe neonatal morbidity rates for VPT survivors varied widely across European regions and were independent of mortality rates.

Nurse Decision Making and Attitudes About Circuit Disconnection During Ventilator Therapy at a Swedish Neonatal Intensive Care Unit

BACKGROUND

There are many challenges to providing care to infants in need of ventilator therapy. Yet, few studies describe the practical handling of the ventilator circuit during nursing care.

PURPOSE

To describe neonatal intensive care unit (NICU) nurses' decision making regarding whether or not to disconnect the ventilator circuit when changing the infant's position and to investigate the grounds for their decisions.

METHODS

A descriptive questionnaire study with both quantitative and qualitative elements was conducted. In 2015, a convenience sample of nurses working in an NICU completed a questionnaire including both closed-ended and open-ended, free-text questions. Answers to the closed-ended questions were analyzed with descriptive statistics, whereas answers to the free-text questions were analyzed using qualitative content analysis.

RESULTS

Nurses' decisions on whether to disconnect or keep the ventilator circuit closed were based on the infant's needs for ventilator support. The nurses gave several reasons and motivations both for why they disconnected the circuit and for why they did not. The handling of the circuit and the reasons and motivations given were inconsistent among the nurses.

IMPLICATIONS FOR PRACTICE

This study highlights the need for continuous, repetitive education and training for NICU nurses, as well as demonstrating the importance of clear and distinct guidelines and working methods regarding the care of infants on ventilator support.

IMPLICATIONS FOR RESEARCH

Future research should continue to find ways of working and handling an infant on ventilator support that are least harmful to the infant.

Why Do Neonatologists in Scandinavian Countries and the Netherlands Make Life-and-death Decisions So Different?

An examination of the policies regarding the care of extremely premature newborns reveals unexpected differences between Scandinavian countries and the Netherlands. Three topics related to decision-making at the beginning and at the end of life are identified and discussed.

NICU Dialects: Understanding Norwegian Practice Variation

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

The Swedish Approach to Management of Extreme Prematurity at the Borderline of Viability: A Historical and Ethical Perspective

Sweden has a long tradition of being at the forefront of the management of extremely preterm infants. In this article, we explore the historical background, ethical discussions, and evidence from national surveys combined with data from quality registers that form the background of the current Swedish guidelines for the care of extremely preterm infants. The current Swedish national guidelines suggest providing active care for preterm infants from 23 weeks' gestation and considering active care from 22 weeks' gestation. The survival of infants in gestational weeks 22 and 23 has increased and now exceed 50% and 60%, respectively; importantly, the Swedish proactive approach to care at the border of viability has not resulted in an increased proportion of functional impairment among survivors.

Do Sociocultural Factors Influence Periviability Counseling and Treatment More Than Science? Lessons From Scandinavia

All of us (doctors, parents, bioethicists, and health policy makers) think differently about premature infants who require neonatal intensive care than we do about other patients who are critically ill. In most other clinical circumstances, those that involve patients other than premature infants, our first impulse when confronted with a patient in an emergency is to do whatever we can to rescue the patient. We offer life-sustaining treatments first and ask questions later. With extremely premature infants, by contrast, we first ask questions, ponder our options, and try to develop policies about whether it is appropriate to try to save these infants. We wonder aloud whether these tiny patients are even worth saving. In most countries that have NICUs, and in many hospitals, doctors and policy makers have explicitly specified which infants ought to be offered life-sustaining treatment and which should be allowed to die. Regarding the treatment of infants who are born at the borderline of viability, there are markedly distinct approaches in Sweden, Norway, and Denmark. In each country, the prevailing approaches were developed after careful consideration of many factors, including public sentiment, professional preferences, reported outcomes, philosophical factors, and considerations of cost and cost-effectiveness. In this article, we comment on some of these considerations and the soundness of the resulting practice variations.

Selection Bias and Outcomes for Preterm Neonates

BACKGROUND

Reported survival and neurodevelopmental outcomes at 23 weeks' gestation are based on the infants admitted to NICUs. In this study, we aim to describe the association between clinical characteristics and admission to NICU at 23, 24 and 25 weeks' gestation.

METHODS

Cohort data from 2 national databases enabled comparison of the clinical characteristics all Australian births and all NICU admissions during 2010-2013 at 23, 24, and 25 weeks' gestation.

RESULTS

NICU admission occurred in 15% of all births at 23 weeks, in comparison with 49% at 24 weeks and 64% at 25 weeks. At 23 weeks, live-born infants were less likely to be admitted to NICU with birth weight <500 g compared with >500 g (13% vs 43%, P < .0001), and boys were admitted less compared with girls (33% vs 43%, P < .018). In contrast, birth weight (including birth weight <500 g) and sex had little or no impact on NICU admission at 24 and 25 weeks. Only 8% of live births were born by caesarean delivery at 23 weeks compared with 33% at 24 weeks and 48% at 25 weeks' gestation.

CONCLUSIONS

In the Australian population, admission to the NICU is more likely to be influenced by birth weight and sex at 23 weeks' gestation when compared with 24 and 25 weeks' gestation. Survival outcomes at 23 weeks may be affected by less active perinatal care. Uncertainty exists regarding the generalizability of current data regarding survival and developmental potential of live-born 23-week infants.

End-of-life decisions and practices for very preterm infants in the Wallonia-Brussels Federation of Belgium

Background

Very preterm birth (24 to < 32 week’s gestation) is a major public health issue due to its prevalence, the clinical and ethical questions it raises and the associated costs. It raises two major clinical and ethical dilemma: (i) during the perinatal period, whether or not to actively manage a baby born very prematurely and (ii) during the postnatal period, whether or not to continue a curative treatment plan initiated at birth. The Wallonia-Brussels Federation in Belgium counts 11 neonatal intensive care units.

Methods

An inventory of key practices was compiled on the basis of an online questionnaire that was sent to the 65 neonatologists working in these units. The questionnaire investigated care-related decisions and practices during the antenatal, perinatal and postnatal periods, as well as personal opinions on the possibility of standardising and/or legislating for end-of-life decisions and practices. The participation rate was 89% (n = 58).

Results

The results show a high level of homogeneity pointing to overall agreement on the main principles governing curative practice and the gestational age that can be actively managed given the current state of knowledge. There was, however, greater diversity regarding principles governing the transition to end-of-life care, as well as opinions about the need for a common protocol or law to govern such practices.

Conclusion

Our results reflect the uncertainty inherent in the complex and diverse situations that are encountered in this extreme area of clinical practice, and call for qualitative research and expert debates to further document and make recommendations for best practices regarding several “gray zones” of end-of-life care in neonatology, so that high quality palliative care may be granted to all neonates concerned with end-of-life decisions.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1168-x) contains supplementary material, which is available to authorized users.

Survival in Very Preterm Infants: An International Comparison of 10 National Neonatal Networks

OBJECTIVES

To compare survival rates and age at death among very preterm infants in 10 national and regional neonatal networks.

METHODS

A cohort study of very preterm infants, born between 24 and 29 weeks' gestation and weighing <1500 g, admitted to participating neonatal units between 2007 and 2013 in the International Network for Evaluating Outcomes of Neonates. Survival was compared by using standardized ratios (SRs) comparing survival in each network to the survival estimate of the whole population.

RESULTS

Network populations differed with respect to rates of cesarean birth, exposure to antenatal steroids and birth in nontertiary hospitals. Network SRs for survival were highest in Japan (SR: 1.10; 99% confidence interval: 1.08-1.13) and lowest in Spain (SR: 0.88; 99% confidence interval: 0.85-0.90). The overall survival differed from 78% to 93% among networks, the difference being highest at 24 weeks' gestation (range 35%-84%). Survival rates increased and differences between networks diminished with increasing gestational age (GA) (range 92%-98% at 29 weeks' gestation); yet, relative differences in survival followed a similar pattern at all GAs. The median age at death varied from 4 days to 13 days across networks.

CONCLUSIONS

The network ranking of survival rates for very preterm infants remained largely unchanged as GA increased; however, survival rates showed marked variations at lower GAs. The median age at death also varied among networks. These findings warrant further assessment of the representativeness of the study populations, organization of perinatal services, national guidelines, philosophy of care at extreme GAs, and resources used for decision-making.

Peripherally inserted central catheter in extremely preterm infants: Characteristics and influencing factors

OBJECTIVE

To evaluate the duration of catheter stay, incidence of non-elective removal and rates of complications associated with peripherally inserted central catheters (PICCs) in relation to different catheter positions in extremely preterm infants (EPT, <28 weeks of gestation).

METHODS

A retrospective analysis of Peripherally Inserted Central Catheters (PICCs) inserted in EPT infants over a 10-year period, from January 2004 through December 2013 (mean gestational age, 25.2 weeks; mean birth weight, 727 g).

RESULTS

Of the 379 PICCs analyzed, the majority of lines (68%) were placed in the central position, and 259 PICCs (56%) were removed electively after fulfilment of the treatment. Significantly more PICCs in the lower extremities compared to the upper extremities were in central positions (86% vs 61%, p < 0.001, respectively). Significantly more PICCs that were removed electively after fulfilment of the treatment were in a central position compared to a non-central position (p < 0.001). Of the 166 catheters that were removed because of complications, most (71%) of them had mechanical problems, and 13% had sepsis resulting in an incidence rate of 4.4/1000 catheter days.

CONCLUSION

PICCs inserted in the lower extremity were more likely to have a centrally placed tip position compared to PICC lines inserted in the upper extremities.

Early neonatal death: A challenge worldwide

Early neonatal death (ENND), defined as the death of a newborn between zero and seven days after birth, represents 73% of all postnatal deaths worldwide. Despite a 50% reduction in childhood mortality, reduction of ENND has significantly lagged behind other Millennium Developmental Goal achievements and is a growing contributor to overall mortality in children aged <5 years. The etiology of ENND is closely related to the level of a country's industrialization. Hence, prematurity and congenital anomalies are the leading causes in high-income countries. Furthermore, sudden unexpected early neonatal deaths (SUEND) and collapse have only recently been identified as relevant and often preventable causes of death. Concomitantly, perinatal-related events such as asphyxia and infections are extremely relevant in Africa, South East Asia, and Latin America and, together with prematurity, are the principal contributors to ENND. In high-income countries, according to current research evidence, survival may be improved by applying antenatal and perinatal therapies and immediate newborn resuscitation, as well as by centralizing at-risk deliveries to centers with appropriate expertise available around the clock. In addition, resources should be allocated to the close surveillance of newborn infants, especially during the first hours of life. Many of the conditions leading to ENND in low-income countries are preventable with relatively easy and cost-effective interventions such as contraception, vaccination of pregnant women, hygienic delivery at a hospital, training health care workers in resuscitation practices, simplified algorithms that allow for early detection of perinatal infections, and early initiation of breastfeeding and skin-to-skin care. The future is promising. As initiatives undertaken in previous decades have led to substantial reduction in childhood mortality, it is expected that new initiatives targeting the perinatal/neonatal periods are bound to reduce ENND and provide these babies with a better future.

Changes in management policies for extremely preterm births and neonatal outcomes from 2003 to 2012: two population-based studies in ten European regions

OBJECTIVE

To investigate changes in maternity and neonatal unit policies towards extremely preterm infants (EPTIs) between 2003 and 2012, and concurrent trends in their mortality and morbidity in ten European regions.

DESIGN

Population-based cohort studies in 2003 (MOSAIC study) and 2011/2012 (EPICE study) and questionnaires from hospitals.

SETTING

70 hospitals in ten European regions.

POPULATION

Infants born at <27 weeks of gestational age (GA) in hospitals participating in both the MOSAIC and EPICE studies (1240 in 2003, 1293 in 2011/2012).

METHODS

We used McNemar's Chi² test, paired t-tests and conditional logistic regression for comparisons over time.

MAIN OUTCOMES MEASURES

Reported policies, mortality and morbidity of EPTIs.

RESULTS

The lowest GA at which maternity units reported performing a caesarean section for acute distress of a singleton non-malformed fetus decreased from an average of 24.7 to 24.1 weeks (P < 0.01) when parents were in favour of active management, and 26.1 to 25.2 weeks (P = 0.01) when parents were against. Units reported that neonatologists were called more often for spontaneous deliveries starting at 22 weeks GA in 2012 and more often made decisions about active resuscitation alone, rather than in multidisciplinary teams. In-hospital mortality after live birth for EPTIs decreased from 50% to 42% (P < 0.01). Units reporting more active management in 2012 than 2003 had higher mortality in 2003 (55% versus 43%; P < 0.01) and experienced larger declines (55 to 44%; P < 0.001) than units where policies stayed the same (43 to 37%; P = 0.1).

CONCLUSIONS

European hospitals reporting changes in management policies experienced larger survival gains for EPTIs.

TWEETABLE ABSTRACT

Changes in reported policies for management of extremely preterm births were related to mortality declines.

Thin-for-gestational age infants are at increased risk of neurodevelopmental delay at 2 years

BACKGROUND

Infants born small-for-gestational age (SGA) are at increased risk of developmental difficulties. Identifying those most at risk is challenging. We examined the effect of neonatal body composition and customised birthweight centiles on neurocognitive and behavioural outcomes at age 2.

STUDY DESIGN

Prospective cohort study of term infants from the Cork BASELINE Birth Cohort Study classified into the following exposure groups: a birth weight <10th customised centile (SGA, n=51); body fat percentage at birth <10th centile (thin-for-gestational age (TGA, n=51)) or both SGA and TGA infants (small- and thin-for-gestational age (STGA), n=13). The SGA, TGA and STGA groups were compared with a reference (unexposed) group of appropriate-for-gestational age (AGA, n=189) infants. Outcome was assessed at 24 months using the Bayley Scales of Infant Development Version III and the Child Behaviour Checklist.

RESULTS

Outcomes in the SGA infants did not differ significantly from the AGA group. TGA infants had significantly lower scores across all three domains, with a 0.35, 0.38 and 0.41 SD reduction in language, cognitive and motor scale scores, respectively. STGA infants had poorer cognitive outcome with a median cognitive scale score of 90 (IQR 85-95) compared with 95 (IQR 90-100) in the AGA reference group, p=0.005. The adjusted OR of developmental delay at 2 years was 5.00 (95% CI 1.46 to 17.13, p=0.010) in the STGA group.

CONCLUSION

TGA infants, in particular those born STGA, are at increased risk of developmental delay at 2 years compared with the AGA infants.

Variability in Very Preterm Stillbirth and In-Hospital Mortality Across Europe

BACKGROUND AND OBJECTIVE

Stillbirth and in-hospital mortality rates associated with very preterm births (VPT) vary widely across Europe. International comparisons are complicated by a lack of standardized data collection and differences in definitions, registration, and reporting. This study aims to determine what proportion of the variation in stillbirth and in-hospital VPT mortality rates persists after adjusting for population demographics, case-mix, and timing of death.

METHODS

Standardized data collection for a geographically defined prospective cohort of VPTs (22⁺⁰-31⁺⁶ weeks gestation) across 16 regions in Europe. Crude and adjusted stillbirth and in-hospital mortality rates for VPT infants were calculated by time of death by using multinomial logistic regression models.

RESULTS

The stillbirth and in-hospital mortality rate for VPTs was 27.7% (range, 19.9%-35.9% by region). Adjusting for maternal and pregnancy characteristics had little impact on the variation. The addition of infant characteristics reduced the variation of mortality rates by approximately one-fifth (4.8% to 3.9%). The SD for deaths <12 hours after birth was reduced by one-quarter, but did not change after risk adjustment for deaths ≥12 hours after birth.

CONCLUSIONS

In terms of the regional variation in overall VPT mortality, over four-fifths of the variation could not be accounted for by maternal, pregnancy, and infant characteristics. Investigation of the timing of death showed that these characteristics only accounted for a small proportion of the variation in VPT deaths. These findings suggest that there may be an inequity in the quality of care provision and treatment of VPT infants across Europe.

Neonatal Morbidity and 1-Year Survival of Extremely Preterm Infants

OBJECTIVE

To determine 1-year survival and major neonatal morbidities (intracranial hemorrhage grade >2, cystic periventricular leukomalacia, retinopathy of prematurity grade >2, necrotizing enterocolitis, severe bronchopulmonary dysplasia) among extremely preterm infants in Norway in 2013-2014, and to compare the results to the first Norwegian Extreme Prematurity Study 1999-2000 and similar contemporary European population-based studies.

METHODS

Population-based study of all infants born at 22 through 26 weeks' gestation in Norway in 2013-2014. Prospectively collected data were obtained by linking data in the Norwegian Neonatal Network to the Medical Birth Registry of Norway.

RESULTS

Of 420 infants (incidence 3.5 per 1000 births), 145 were stillborn (34.5%), 275 were live-born (82.3% of the 334 fetuses alive at admission for obstetrical care), and 251 (91.3% of live-born infants) were admitted to a neonatal unit. The survival among live-born infants was 18% at 22 weeks, 29% at 23 weeks, 56% at 24 weeks, 84% at 25 weeks and 90% at 26 weeks (for each week increment in gestational age: odds ratio 3.3; 95% confidence interval, 2.4-4.4). Among infants surviving to 1 year of age, major neonatal morbidity was diagnosed in 55%. Decreasing gestational age was moderately associated with rates of major morbidity (odds ratio 1.6; 95% confidence interval, 1.2-2.2).

CONCLUSIONS

Compared to the previous 1999-2000 cohort, the rate of stillbirth before admission to an obstetrical unit increased, whereas the survival rate among live born infants was similar in our 2013-2014 cohort. Neonatal morbidity rates remain high among extremely preterm infants.

Attitudes towards decisions about extremely premature infants differed between Swiss linguistic regions in population-based study

AIM

Studies have provided insights into the different attitudes and values of healthcare professionals and parents towards extreme prematurity. This study explored societal attitudes and values in Switzerland with regard to this patient group.

METHODS

A nationwide trilingual telephone survey was conducted in the French-, German- and Italian-speaking regions of Switzerland to explore the general population's attitudes and values with regard to extreme prematurity. Swiss residents of 18 years or older were recruited from the official telephone registry using quota sampling and a logistic regression model assessed the influence of socio-demographic factors on end-of-life decision-making.

RESULTS

Of the 5112 people contacted, 1210 (23.7%) participated. Of these 5% were the parents of a premature infant and 26% knew parents with a premature infant. Most participants (77.8%) highlighted their strong preference for shared decision-making, and 64.6% said that if there was dissent then the parents should have the final word. Overall, our logistic regression model showed that regional differences were the most significant factors influencing decision-making.

CONCLUSION

The majority of the Swiss population clearly favoured shared decision-making. The context of sociocultural demographics, especially the linguistic region in which the decision-making took place, strongly influenced attitudes towards extreme prematurity and decision-making.

Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section

OBJECTIVE

To investigate the maternal complications associated with cesarean section (CS) in the extremely preterm period according to the gestational week (GW) and to indication of delivery.

STUDY DESIGN

This is a retrospective case-referent study with a review of medical records of women who delivered at 22-27 weeks of gestation (n=647) at two level III units in Sweden. For abdominal delivery, gestational length was stratified into 22-24 (n=105) and 25-27 (n=301) weeks. For comparison, data on women who underwent a CS at term were identified in a register-based database.

RESULTS

The rate of CS in extremely preterm births was 62.8%. There was no difference in the complication rates, but types of incisions other than the low transverse incision were required more often at 22-24 (18.1%) weeks than at 25-27 GWs (9.6%) (P=0.02). Major maternal complications occurred in 6.6% compared with 2.1% in the extremely preterm and term CS, respectively (P<0.01). A maternal indication of extremely preterm CS increased the risk of complications.

CONCLUSIONS

Almost two-thirds of the births at 22-27 GWs had an abdominal delivery. No increase in short-term morbidity was observed at 22-24 weeks compared to 25-27 weeks. CS performed extremely preterm had more major complications recorded than cesarean at term. The complications are driven by the underlying maternal condition.

Early and long-term outcome of infants born extremely preterm

There is no question that birth at extremely low gestational ages presents a significant threat to an infant's survival, health and development. Growing evidence suggests that gestational age may be conceptualised as a continuum in which births before 28 weeks of gestation (extremely preterm: EP) represent the severe end of a spectrum of health and developmental adversity. Although comprising just 1%-2% of all births, EP deliveries pose the greatest challenge to neonatal medicine and to health, education and social services for the provision of ongoing support for survivors with additional needs. Studying the outcomes of these infants remains critical for evaluating and enhancing clinical care, planning long-term support and for advancing our understanding of the life-course consequences of immaturity at birth. Here we review literature relating to early and long-term neurodevelopmental, cognitive, behavioural and educational outcomes following EP birth focusing on key themes and considering implications for intervention.

Thirteen-year mortality and morbidity in preterm infants in Switzerland

OBJECTIVE

To report the population-based, gestational age (GA)-stratified mortality and morbidity for very preterm infants over 13 years in Switzerland.

DESIGN

A prospective, observational study including 95% of Swiss preterm infants (GA <32 weeks) during three time periods: 2000-2004 (P1), 2005-2008 (P2) and 2009-2012 (P3).

SETTING

The Swiss Neonatal Network, covering all level III neonatal intensive care units (NICUs) and affiliated paediatric hospitals.

PATIENTS

8899 live-born preterm infants with GA <32 weeks.

MAIN OUTCOME MEASURES

Trends in GA-specific mortality (overall, delivery room and NICU), 'survival free of major complications' and major short-term morbidities: bronchopulmonary dysplasia (BPD, oxygen requirement at 36 weeks), grades 3 and 4 intraventricular haemorrhage (IVH 3-4), necrotising enterocolitis (NEC) and cystic periventricular leukomalacia (cPVL).

RESULTS

Survival rate was 84.4%; 5.7% died in the delivery room and 9.9% died in the NICU. Neonatal mortality was 8.6% and post-neonatal mortality in NICU admissions was 1.3%. Reductions were observed in overall mortality from 18.4% (95% CI 17.0% to 19.8%) in P1 to 13.8% (13% to 15%) in P3, NICU mortality from 12.6% (11.4% to 13.8%) to 8.2% (7.2% to 9.2%) and IVH 3-4 from 7.8% (6.8% to 8.7%) to 5.8% (4.9% to 6.6%). There was no change in the incidence of cPVL and NEC. The BPD (oxygen requirement at 36 weeks) incidence displayed a U-shaped distribution across the three time periods. Overall, 71.0% (70.0% to 72.0%) had 'survival free of major complications' at the time of hospital discharge, and this significantly improved from 66.7% (65.0% to 68.4%) to 72.4% (70.8% to 74.0%) between P1 and P3.

CONCLUSIONS

Survival rates of very preterm infants increased with decreasing delivery room and neonatal mortalities, mostly in extremely preterm infants. The incidence of IVH 3-4 decreased, whereas the incidences of cPVL, NEC and BPD (oxygen requirement at 36 weeks) remained largely unchanged from 2000 to 2012 in Switzerland.

Reporting Outcomes of Extremely Preterm Births

Published reports of extremely preterm birth outcomes provide important information to families, clinicians, and others and are widely used to make clinical and policy decisions. Misreporting or misunderstanding of outcome reports may have significant consequences. This article presents 7 recommendations to improve reporting of extremely preterm birth outcomes in both the primary and secondary literature. The recommendations should facilitate clarity in communication about extremely preterm birth outcomes and increase the value of existing and future work in this area.

Improved survival and neurodevelopmental outcomes among extremely premature infants born near the limit of viability

BACKGROUND

Infants born near the limit of viability are at high risk for death or adverse neurodevelopmental outcomes. It is unclear whether these outcomes have improved over the past 15 years.

AIM

To determine if death and neurodevelopmental impairment have declined over the past 15 years in infants born at 22 to 24 weeks' gestation.

STUDY DESIGN

Retrospective cohort study.

SUBJECTS

We identified infants born at 22 to 24 weeks' gestation in our center in two epochs: 1998-2004 (Epoch 1) and 2005-2011 (Epoch 2).

OUTCOME MEASURES

The primary outcome, death or neurodevelopmental impairment, was evaluated at 17-25 months' corrected gestational age with neurologic exams and Bayley Scales of Infant Development. Perinatal characteristics, major morbidities, and outcomes were compared between epochs.

RESULTS

Birth weight and gestational age were similar between 170 infants in Epoch 1 and 187 infants in Epoch 2. Mortality was significantly lower in Epoch 2, 55% vs. 42% (p=0.02). Among surviving infants, late-onset sepsis (p<0.01), bronchopulmonary dysplasia (p<0.01), and surgical necrotizing enterocolitis (p=0.04) were less common in Epoch 2. Neurodevelopmental impairment among surviving infants declined from 68% in Epoch 1 to 47% in Epoch 2, p=0.02. Odds of death or NDI were significantly lower in Epoch 2 vs. Epoch 1, OR=0.31 (95% confidence interval; 0.16, 0.58).

CONCLUSION

Risk of death or neurodevelopmental impairment decreased over time in infants born at 22 to 24 weeks' gestation.

Low energy intake during the first 4 weeks of life increases the risk for severe retinopathy of prematurity in extremely preterm infants

OBJECTIVES

Poor weight gain during the first weeks of life in preterm infants is closely associated with the risk of developing the retinopathy of prematurity (ROP) and insufficient nutrition might be an important contributing factor. This study aimed to evaluate the effect of energy and macronutrient intakes during the first 4 weeks of life on the risk for severe ROP (stages 3-5).

STUDY DESIGN

A population-based study including all Swedish extremely preterm infants born before 27 gestational weeks during a 3-year period. Each infant was classified according to the maximum stage of ROP in either eye as assessed prospectively until full retinal vascularisation. The detailed daily data of actual intakes of enteral and parenteral nutrition and growth data were obtained from hospital records.

RESULTS

Of the included 498 infants, 172 (34.5%) had severe ROP and 96 (19.3%) were treated. Energy and macronutrient intakes were less than recommended and the infants showed severe postnatal growth failure. Higher intakes of energy, fat and carbohydrates, but not protein, were significantly associated with a lower risk of severe ROP. Adjusting for morbidity, an increased energy intake of 10 kcal/kg/day was associated with a 24% decrease in severe ROP.

CONCLUSIONS

We showed that low energy intake during the first 4 weeks of life was an independent risk factor for severe ROP. This implies that the provision of adequate energy from parenteral and enteral sources during the first 4 weeks of life may be an effective method for reducing the risk of severe ROP in extremely preterm infants.