Short-term outcome predictors in infants born at 23-24 gestational weeks

Decreasing Percentage of Infants With Very Low 5-Minute Apgar Scores at a Safety-Net Level III NICU

OBJECTIVES

Low 5-minute Apgar scores predict mortality and may be associated with poor neurologic outcomes. Our percentage of infants with low 5-minute Apgar scores was higher than the national average (2.4%). Therefore, we aimed to decrease the percentage of infants with Apgar scores <4 at 5 minutes from a mean of 5.12% to <2.4% and decrease the percentage of infants receiving chest compressions (CCs) before intubation from 21% to <5%.

METHODS

We completed 4 plan-do-study-act (PDSA) cycles from April 2015 through November 2018, including providing 24-hour advanced practice provider coverage (PDSA 1), initiating advanced practice provider-led delivery room scenarios for residents and education to secure the airway before CCs (PDSA 2), developing "Go Bags" with supplies (PDSA 3), and performing multidisciplinary mock codes (PDSA 4). We used a statistical process control p-chart to evaluate our primary outcome measure of the percentage of infants with 5-minute Apgar scores <4 from January 2012 through September 2021.

RESULTS

The percent of infants with Apgar scores <4 at 5 minutes decreased from 5.12% in the baseline and intervention period to 2.16% in the sustainment period. We detected special cause with 8 points below the centerline. Infants born in the baseline period were 7.9 times more likely to receive CCs before intubation than in the intervention and sustainment periods (P = .002).

CONCLUSIONS

We decreased the percentage of infants with 5-minute Apgar scores <4 and the percentage of infants receiving chest compressions before intubation. Ultimately, rigorous education and team collaboration through frequent multidisciplinary team mock codes were critical to our success.

Prognostic Models Predicting Mortality in Preterm Infants: Systematic Review and Meta-analysis

CONTEXT

Prediction models can be a valuable tool in performing risk assessment of mortality in preterm infants.

OBJECTIVE

Summarizing prognostic models for predicting mortality in very preterm infants and assessing their quality.

DATA SOURCES

Medline was searched for all articles (up to June 2020).

STUDY SELECTION

All developed or externally validated prognostic models for mortality prediction in liveborn infants born <32 weeks' gestation and/or <1500 g birth weight were included.

DATA EXTRACTION

Data were extracted by 2 independent authors. Risk of bias (ROB) and applicability assessment was performed by 2 independent authors using Prediction model Risk of Bias Assessment Tool.

RESULTS

One hundred forty-two models from 35 studies reporting on model development and 112 models from 33 studies reporting on external validation were included. ROB assessment revealed high ROB in the majority of the models, most often because of inadequate (reporting of) analysis. Internal and external validation was lacking in 41% and 96% of these models. Meta-analyses revealed an average C-statistic of 0.88 (95% confidence interval [CI]: 0.83-0.91) for the Clinical Risk Index for Babies score, 0.87 (95% CI: 0.81-0.92) for the Clinical Risk Index for Babies II score, and 0.86 (95% CI: 0.78-0.92) for the Score for Neonatal Acute Physiology Perinatal Extension II score.

LIMITATIONS

Occasionally, an external validation study was included, but not the development study, because studies developed in the presurfactant era or general NICU population were excluded.

CONCLUSIONS

Instead of developing additional mortality prediction models for preterm infants, the emphasis should be shifted toward external validation and consecutive adaption of the existing prediction models.

Population-based risks of mortality and preterm morbidity by gestational age and birth weight

OBJECTIVE

The objective of this study is to examine the effect of small or large for gestational age (SGA/LGA) status on mortality and morbidity by gestational age.

STUDY DESIGN

Logistic binomial regression was used to calculate relative risks (RRs) and 95% confidence intervals for infant mortality and preterm morbidities for SGA or LGA compared with appropriately grown (AGA) deliveries stratified by gestational age group.

RESULTS

Compared with AGA infants of similar gestational age, SGA infants were at increased risk for infant mortality. Mortality risk was decreased for LGA infants born between 25 and 27 weeks (RR: 0.6) but increased for LGA infants born between 28 and 31 weeks (RR: 1.9). Risk of preterm morbidity was increased for SGA infants born between 28 and 38 weeks, but decreased for LGA infants born before 37 weeks.

CONCLUSION

This study demonstrates the importance of considering birth weight for gestational age when evaluating morbidity and mortality risks.

Population-based study shows that resuscitating apparently stillborn extremely preterm babies is associated with poor outcomes

AIM

This population-based study determined the delivery room management and outcomes of extremely preterm infants born with Apgar scores of 0.

METHODS

We linked birth, neonatal intensive care unit (NICU) and death records for babies who were born between 22 + 0 and 27 + 6 weeks of gestation with a one-minute Apgar score of 0, in New South Wales, Australia, between 1998 and 2011.

RESULTS

We classified 2173/2262 (96%) of infants with a one-minute Apgar score of 0 as stillborn. Resuscitation was provided for 48/89 (54%) live births and 40/2173 (2%) stillbirths. Cardiac massage was given to 44 infants, including three 22-week stillborn babies. Of the 13 live births admitted to an NICU, 11 survived to hospital discharge. Most (98%) of the 2212 deaths occurred on the first day of life. One baby who was classified as stillborn lived for 51 days. Resuscitation increased the mean (95% confidence interval) duration of survival from 1 (0-2) to 45 (0-104) hours (p < 0.001). No infant with a five-minute Apgar score of 0 survived.

CONCLUSION

Clinicians resuscitated extremely preterm infants without a detectable heartbeat, even at 22 weeks of gestation. No infant survived without resuscitation or if their heartbeat was not regained by five minutes.

Predicting 2-y outcome in preterm infants using early multimodal physiological monitoring

BACKGROUND

Preterm infants are at risk of adverse outcome. The aim of this study is to develop a multimodal model, including physiological signals from the first days of life, to predict 2-y outcome in preterm infants.

METHODS

Infants <32 wk gestation had simultaneous multi-channel electroencephalography (EEG), peripheral oxygen saturation (SpO2), and heart rate (HR) monitoring. EEG grades were combined with gestational age (GA) and quantitative features of HR and SpO2 in a logistic regression model to predict outcome. Bayley Scales of Infant Development-III assessed 2-y neurodevelopmental outcome. A clinical course score, grading infants at discharge as high or low morbidity risk, was used to compare performance with the model.

RESULTS

Forty-three infants were included: 27 had good outcomes, 16 had poor outcomes or died. While performance of the model was similar to the clinical course score graded at discharge, with an area under the receiver operator characteristic (AUC) of 0.83 (95% confidence intervals (CI): 0.69-0.95) vs. 0.79 (0.66-0.90) (P = 0.633), the model was able to predict 2-y outcome days after birth.

CONCLUSION

Quantitative analysis of physiological signals, combined with GA and graded EEG, shows potential for predicting mortality or delayed neurodevelopment at 2 y of age.

[Mortality in the first 24h of very low birth weight preterm infants in the Northeast of Brazil]

OBJECTIVE

To evaluate factors associated with neonatal death within 24 hours after birth in very low birth weight preterm newborns.

METHODS

Prospective cohort of live births with gestational age of 23(0/7)-31(6/7) weeks, birth weight of 500-1499g without malformations, in 19 public maternity hospitals in nine capitals in northeastern Brazil from July to December 2007. The 19 hospitals were assessed in relation to physical resources, equipment, human resources and aiming at quality in care initiatives. Hospital, maternal and neonatal characteristics, neonatal morbidity, neonatal procedures and interventions were compared between preterm newborns that died or survived up to 24 hours of life. The variables associated with death within 24 hours after birth were determined by logistic regression.

RESULTS

Of the 627 newborns enrolled in the study, 179 (29%) died within 168 hours after birth, of which 59 (33%) up to 24 hours and 97 (54%) up to 48 hours after birth. The variables associated with death <24h were: weight <1000g (2.94; 1.32-6.53), 5(th) minute Apgar <7 (7.17; 3.46-14.88), male gender (2.99; 1.39-6.47). A better hospital structure was a protective factor for early neonatal death (odds ratio: 0.34; 95% confidence interval: 0.17-0.71).

CONCLUSIONS

The high neonatal mortality on the first day of life in capital cities of Northeast Brazil is associated with biological variables such as weight and gender of the newborn, as well as low vitality at birth and a worse infrastructure of the hospital where the birth occurred.

Perinatal factors associated with early neonatal deaths in very low birth weight preterm infants in Northeast Brazil

Background

In Brazil, the prevalence of prematurity has increased in recent years and it is a major cause of death in the neonatal period. Therefore, this study aims at assessing perinatal factors associated with early neonatal deaths in very low birth weight preterm infants born in a region of Brazil with low Human Development Index.

Methods

Prospective cohort study of inborns with gestational age 23^0/7-31^6/7 weeks and birthweight 500-1499 g without malformations in 19 public reference hospitals of the state capitals of Brazil’s Northeast Region. Perinatal variables associated with early neonatal death were determined by Cox regression analysis.

Result

Among 627 neonates, 179 (29%) died with 0–6 days after birth. Early death was associated to: absence of antenatal steroids (HR 1.59; 95% CI 1.11-2.27), multiple gestation (1.95; 1.28-3.00), male sex (2.01; 1.40-2.86), 5th minute Apgar <7 (2.93; 2.03-4.21), birthweight <1000 g (2.58; 1.70-3.88), gestational age <28 weeks (2.07; 1.42-3.02), use of surfactant (1.65; 1.04-2.59), and non-use of a pain scale (1.89; 1.24-2.89).

Conclusion

Biological variables and factors related to the quality of perinatal care were associated with the high chance of early death of preterm infants born in reference hospitals of Northeast Brazil.

Prediction of neonatal outcomes in extremely preterm neonates

OBJECTIVE

To develop and validate a statistical prediction model spanning the severity range of neonatal outcomes in infants born at ≤ 30 weeks' gestation.

METHODS

A national cohort of infants, born at 23 to 30 weeks' gestation and admitted to level III NICUs in Canada in 2010-2011, was identified from the Canadian Neonatal Network database. A multinomial logistic regression model was developed to predict survival without morbidities, mild morbidities, severe morbidities, or mortality, using maternal, obstetric, and infant characteristics available within the first day of NICU admission. Discrimination and calibration were assessed using a concordance C-statistic and the Cg goodness-of-fit test, respectively. Internal validation was performed using a bootstrap approach.

RESULTS

Of 6106 eligible infants, 2280 (37%) survived without morbidities, 1964 (32%) and 1251 (21%) survived with mild and severe morbidities, respectively, and 611 (10%) died. Predictors in the model were gestational age, small (<10th percentile) for gestational age, gender, Score for Neonatal Acute Physiology version II >20, outborn status, use of antenatal corticosteroids, and receipt of surfactant and mechanical ventilation on the first day of admission. High model discrimination was confirmed by internal bootstrap validation (bias-corrected C-statistic = 0.899, 95% confidence interval = 0.894-0.903). Predicted probabilities were consistent with the observed outcomes (Cg P value = .96).

CONCLUSIONS

Neonatal outcomes ranging from mortality to survival without morbidity in extremely preterm infants can be predicted on their first day in the NICU by using a multinomial model with good discrimination and calibration. The prediction model requires additional external validation.

Management of an extremely premature infant in the out-of-hospital environment

The rate of premature infant mortality has decreased over the last several decades, with an accompanying decrease in the gestational age of premature infants who survive to hospital discharge. Emergency medical services (EMS) providers are sometimes called to provide prehospital care for infants born at the edge of viability. Such extremely premature infants (EPIs) present medical and ethical challenges. In this case report, we describe an infant born at 24 weeks into a toilet by a mother who thought she had miscarried. The EMS providers evaluated the infant as nonviable and placed him in a plastic bag for transport to a local emergency department (ED). The ED staff found the infant to have a bradycardic rhythm, initiated resuscitation, and admitted him to the neonatal intensive care unit. The infant died seven days later. We review the literature for recommendations in resuscitation of EPIs and discuss the ethics regarding their management in the prehospital setting.

Prediction of mortality in very premature infants: a systematic review of prediction models

Context

Being born very preterm is associated with elevated risk for neonatal mortality. The aim of this review is to give an overview of prediction models for mortality in very premature infants, assess their quality, identify important predictor variables, and provide recommendations for development of future models.

Methods

Studies were included which reported the predictive performance of a model for mortality in a very preterm or very low birth weight population, and classified as development, validation, or impact studies. For each development study, we recorded the population, variables, aim, predictive performance of the model, and the number of times each model had been validated. Reporting quality criteria and minimum methodological criteria were established and assessed for development studies.

Results

We identified 41 development studies and 18 validation studies. In addition to gestational age and birth weight, eight variables frequently predicted survival: being of average size for gestational age, female gender, non-white ethnicity, absence of serious congenital malformations, use of antenatal steroids, higher 5-minute Apgar score, normal temperature on admission, and better respiratory status. Twelve studies met our methodological criteria, three of which have been externally validated. Low reporting scores were seen in reporting of performance measures, internal and external validation, and handling of missing data.

Conclusions

Multivariate models can predict mortality better than birth weight or gestational age alone in very preterm infants. There are validated prediction models for classification and case-mix adjustment. Additional research is needed in validation and impact studies of existing models, and in prediction of mortality in the clinically important subgroup of infants where age and weight alone give only an equivocal prognosis.