Early discharge and readmission to hospital in the first month of life in the Northern Region of the UK during 1998: a case cohort study

Early readmission of exclusively breastmilk-fed infants born by means of normal birth or cesarean is multifactorial and associated with perinatal maternal mental health concerns

BACKGROUND

Late preterm and full-term infants comprise the majority of births in our hospital which serves a multicultural lower socioeconomic community. Patients give birth vaginally (normal birth, NB) or by cesarean birth (CB), and the majority of neonates are exclusively breastmilk fed until discharge. In this study we examined what factors within these two birth modes and feeding regimes of exclusive breast milk were associated with early postnatal readmission. Ideally, findings will aid initiatives to decrease readmission rates.

METHODS

A retrospective cohort study was performed on maternal-infant pairs. All neonates from 2016 to 2018, exclusively breastmilk fed at discharge, born by NB (n = 4245) or CB (n = 1691), were grouped as non-Readmitted (Reference) or Readmitted within 30 days of discharge. Readmission reason was determined, and potential associations were identified using univariate analysis and multivariable logistic regression.

RESULTS

Rates of readmission were similar for both NB and CB infants (6.8% vs. 7.3%). In order, NB concerns were jaundice, infection, and feeding-this was reversed for the CB Group. NB readmission bilirubin levels were higher (293 ± 75 vs. 236 ± 112, μmol/L, NB:CB, p < 0.001). Factors associated with readmission for both groups were similar to previously published studies. Edinburgh Postnatal Depression Score (EPDS) was higher for Readmitted infant mothers. Importantly, for non-jaundice readmission EDPS categories indicated that both CB and NB mothers were more likely to have depression.

CONCLUSION

Early readmission of exclusively breastmilk-fed infants born by means of NB or CB is multifactorial. Early pregnancy mental health issues are associated with readmission, highlighting the potential effects of perinatal depression on neonatal health.

Morbidities and rehospitalizations during the first year of life in moderate and late preterm infants: more similarities than differences?

BACKGROUND

The aim was to compare neonatal morbidities in moderate and late preterm infants and to analyze rates and causes for rehospitalizations during the first year of life.

METHODS

Prospective follow-up of a group of moderate and late preterm infants at a tertiary care hospital.

RESULTS

The study population comprised 215 infants (58% males; 60% singletons; 99 moderate and 116 late preterm infants) with a median gestational age of 34 weeks and birth weight of 2100 grams; 20% of them were small for gestational age. Moderate preterm infants more often had a diagnosis of mild respiratory distress syndrome (26% vs. 13%, P<0.01) and feeding problems with longer need for nasogastric tube feeding (median 9.5 vs. 4.2 days, P<0.01) and parenteral nutrition (3.5 vs. 2.7 days, P<0.01), and longer duration of stay at either NICU (10.6 vs. 3.7 days; P<0.01) or hospital (13 vs. 11 days; P<0.01). Fifty-two infants (24.3%) were hospitalized at 67 occasions without differences regarding readmission rates and causes between groups. Median age at readmission was 3 months, median stay 4 days. The most common diagnosis was respiratory illness (43.3%).

CONCLUSIONS

Moderate preterm infants had more neonatal morbidities diagnosed, but the same rehospitalization rates than late preterm infants.

Uncharted territory: a narrative review of parental involvement in decision-making about late preterm and early term delivery

Almost 30% of live births in England and Wales occur late preterm or early term (LPET) and are associated with increased risks of adverse health outcomes throughout the lifespan. However, very little is known about the decision-making processes concerning planned LPET births or the involvement of parents in these. This aim of this paper is to review the evidence on parental involvement in obstetric decision-making in general, to consider what can be extrapolated to decisions about LPET delivery, and to suggest directions for further research.A comprehensive, narrative review of relevant literature was conducted using Medline, MIDIRS, PsycInfo and CINAHL databases. Appropriate search terms were combined with Boolean operators to ensure the following broad areas were included: obstetric decision-making, parental involvement, late preterm and early term birth, and mode of delivery.This review suggests that parents' preferences with respect to their inclusion in decision-making vary. Most mothers prefer sharing decision-making with their clinicians and up to half are dissatisfied with the extent of their involvement. Clinicians' opinions on the limits of parental involvement, especially where the safety of mother or baby is potentially compromised, are highly influential in the obstetric decision-making process. Other important factors include contextual factors (such as the nature of the issue under discussion and the presence or absence of relevant medical indications for a requested intervention), demographic and other individual characteristics (such as ethnicity and parity), the quality of communication; and the information provided to parents.This review highlights the overarching need to explore how decisions about potential LPET delivery may be reached in order to maximise the satisfaction of mothers and fathers with their involvement in the decision-making process whilst simultaneously enabling clinicians both to minimise the number of LPET births and to optimise the wellbeing of women and babies.

Survival status and predictors of mortality among patients admitted to surgical intensive care units of Addis Ababa governmental hospitals, Ethiopia: A multicenter retrospective cohort study

Introduction

Critical care is a serious global healthcare burden. Although a high number of surgical patients are being admitted to the surgical intensive care unit (SICU), the mortality remained high, particularly in low and middle-income countries. However, there is limited data in Ethiopia. Therefore, this study aimed to investigate the survival status and predictors of mortality in surgical patients admitted to the SICUs of Addis Ababa governmental hospitals, Ethiopia.

Methods

A multicenter retrospective cohort study was conducted on 410 surgical patients admitted to the SICUs of three government hospitals in Addis Ababa selected using a simple random sampling from February 2017 to February 2020. The data were entered into Epidata version 4.6 and imported to STATA/MP version 16 for further analysis. Bi-variable and multivariable Cox regression models were fitted in the analysis to determine the predictor variables. A hazard ratio (HR) with a 95% confidence interval (CI) was computed, and variables with a p-value <0.05 were considered statistically significant.

Results

From a sample of 410 patients, 378 were included for final analysis and followed for a median follow-up of 5 days. The overall mortality among surgical patients in the SICU was 44.97% with an incidence rate of 5.9 cases per 100 person-day observation. Trauma (AHR = 1.83, 95% CI: 1.19-2.08), Glasgow coma score (GCS) <9 (AHR = 2.06, 95% CI: 1.28-3.31), readmission to the SICU (AHR = 3.52, 95% CI: 2.18-5.68), mechanical ventilation (AHR = 2.52, 95% CI: 1.23-5.15), and creatinine level (AHR = 1.09, 95% CI: 1.01-1.18) were found to be significantly associated with mortality in the SICU.

Conclusion

The mortality of surgical patients in the SICU was high. Trauma, GCS <9 upon admission, readmission to the SICU, mechanical ventilation, and increased in the creatinine level on admission to the SICU were the identified predictors of mortality in the SICU.

Risk factors associated with 31-day unplanned hospital readmission in newborns: a systematic review

The purpose of this study is to synthesize evidence on risk factors associated with newborn 31-day unplanned hospital readmissions (UHRs). A systematic review was conducted searching CINAHL, EMBASE (Ovid), and MEDLINE from January 1st 2000 to 30th June 2021. Studies examining unplanned readmissions of newborns within 31 days of discharge following the initial hospitalization at the time of their birth were included. Characteristics of the included studies examined variables and statistically significant risk factors were extracted from the inclusion studies. Extracted risk factors could not be pooled statistically due to the heterogeneity of the included studies. Data were synthesized using content analysis and presented in narrative and tabular form. Twenty-eight studies met the eligibility criteria, and 17 significant risk factors were extracted from the included studies. The most frequently cited risk factors associated with newborn readmissions were gestational age, postnatal length of stay, neonatal comorbidity, and feeding methods. The most frequently cited maternal-related risk factors which contributed to newborn readmissions were parity, race/ethnicity, and complications in pregnancy and/or perinatal period.

CONCLUSION

This systematic review identified a complex and diverse range of risk factors associated with 31-day UHR in newborn. Six of the 17 extracted risk factors were consistently cited by studies. Four factors were maternal (primiparous, mother being Asian, vaginal delivery, maternal complications), and two factors were neonatal (male infant and neonatal comorbidities). Implementation of evidence-based clinical practice guidelines for inpatient care and individualized hospital-to-home transition plans, including transition checklists and discharge readiness assessments, are recommended to reduce newborn UHRs.

WHAT IS KNOWN

• Attempts have been made to identify risk factors associated with newborn UHRs; however, the results are inconsistent.

WHAT IS NEW

• Six consistently cited risk factors related to newborn 31-day UHRs. Four maternal factors (primiparous, mother being Asian, vaginal delivery, maternal complications) and 2 neonatal factors (male infant and neonatal comorbidities). • The importance of discharge readiness assessment, including newborn clinical fitness for discharge and parental readiness for discharge. Future research is warranted to establish standardised maternal and newborn-related variables which healthcare providers can utilize to identify newborns at greater risk of UHRs and enable comparison of research findings.

Length-of-stay after a health facility birth and associated factors: analysis of data from three Sub-Saharan African countries

OBJECTIVES

We estimated the length-of-stay (LOS) in the health facility after childbirth and identified associated factors in three sub-Saharan African countries.

DESIGN

Secondary analysis using data from the most recent Multiple Indicator Cluster Surveys.

SETTING

Multiple Indicator Cluster Surveys from Ghana, Malawi and Eswatini were selected.

PARTICIPANTS

Women aged 15-49 years who had a facility delivery in the two years preceding the survey were included.

MAIN OUTCOME MEASURES

Length-of-stay recorded in days and weeks were converted to hours and analysed as a continuous variable.

RESULTS

Length-of-stay was estimated for 9147 women, wherein 6610 women (median LOS and IQR: 36 36,60 hours), 1698 women (median LOS and IQR 36 10,60 hours) and 839 women (median-length-stay 36 36,60 hours) were from Malawi, Ghana and Eswatini respectively. Being from Ghana [RC, -20.6 (95%CI:-25.2 - -16.0)] and then Eswatini [RC: -13.0 (95%CI: -19.9 - -9.8)] and delivery in a government hospital [RC: -4.9 (95%CI -9.9- -0.3)] were independently associated with having a shorter LOS. Having a caesarean section, assistance by Nurses/Midwives or Auxiliaries/CHOs, single birth, heavier birth weight, and death of newborn before discharge increased the duration of stay.

CONCLUSIONS

Necessitating and facility factors are important determinants of length of stay. Socio-demographic characteristics, however, have a restricted role in influencing the duration of postpartum stay in sub-Saharan Africa. Further prospective research is required to identify more determinants and provide evidence for policy formulation and clinical guidelines regarding the safest time for discharge after delivery.

FUNDING

None declared.

Readmission of late preterm and term neonates in the neonatal period

OBJECTIVE

To determine the incidence of hospital readmissions in late preterm and term neonates, the most common reasons for readmission, and analyze the risk factors for readmission in the neonatal period.

METHODS

Newborn infants admitted to a well-baby nursery ≥ 36 weeks gestation were included in this retrospective cohort study. Data for all infants born in a 3-year period and readmitted in the first 28 days of life were analyzed. Indication for readmission was one diagnosed during initial workup in the pediatric emergency room visit before readmission.

RESULTS

The final cohort consisted of 5408 infants. The readmission rate was 4.0% (219/5408). Leading readmission causes were respiratory tract infection (29.58%), jaundice (13.70%), and urinary tract infection (9.59%). The mean ± SD age of readmitted infants was 13.3 ± 7.1 days. The mean ± SD treatment duration of treatment was 5.5 ± 3.0 days. In the multivariate regression analysis, infants that were during the initial hospitalization transferred to special care/NICU had a lower chance of readmission during the neonatal period (p = 0.04, OR = 0.23, 95% CI 0.06-0.93). Infants with mothers aged from 19-24 years had a higher risk of readmission (p = 0.005, OR = 1.62, 95% CI 1.16-2.26).

CONCLUSIONS

Finding that infants that were during the initial hospitalization transferred to special care or a NICU setting were less likely to require hospitalization in the neonatal period is an interesting one. Further research into how different approach in these settings reduce the risk of readmission is necessary.

Admissions and Emergency Visits by Late Preterm Singletons and Twins in the First 5 Years: A Population-Based Cohort Study

OBJECTIVE

To compare admission and emergency visits of late preterm (34^0/7-36^6/7 weeks) versus term infants (37^0/7-41^6/7 weeks) in the first 5 years.

STUDY DESIGN

This population-based cohort study included all singletons and twins born alive at 34^0/7 to 41^6/7 weeks' gestation registered in a health administrative database in Ontario, Canada, between April 1, 2002 and December 31, 2012. Admissions and emergency visits from initial postnatal discharge to 5 years were compared between late preterm and term infants adjusting for maternal and infant characteristics.

RESULTS

A total of 1,316,931 infants (75,364 late preterm infants) were included. Late preterm infants had more frequent admissions than term infants in the first 5 years in both singletons (adjusted incidence rate ratio [95% confidence interval] = 1.46 [1.42-1.49]) and twins (1.21 [1.11-1.31]). The difference in admissions between late preterm and term infants were smaller in twins than singletons and decreased with children's ages. Twins had less frequent admissions than singletons for late preterm infants, but not for term infants. The emergency visits were more frequent in late preterm than term infants in all the periods.

CONCLUSION

Admissions and emergency visits were more frequent in late preterm than term infants through the first 5 years. Admissions were less frequent in late preterm twins than singletons.

Trends in Costs of Birth Hospitalization and Readmissions for Late Preterm Infants

Background: The objective is to study previously unexplored trends of birth hospitalization and readmission costs for late preterm infants (LPIs) in the United States between 2005 and 2016. Methods: We conducted a retrospective analysis of claims data to study healthcare costs of birth hospitalization and readmissions for LPIs compared to term infants (TIs) using a large private insurance database. We used a generalized linear regression model to study birth hospitalization and readmission costs. Results: A total of 2,123,143 infants were examined (93.2% TIs; 6.8% LPIs). The proportion of LPIs requiring readmission was 4.2% compared to 2.1% of TIs, (p < 0.001). The readmission rate for TIs decreased during the study period. LPIs had a higher mean cost of birth hospitalization (25,700 vs. 3300 USD; p < 0.001) and readmissions (25,800 vs. 14,300 USD; p < 0.001). For LPIs, birth hospitalization costs increased from 2007 to 2013, and decreased since 2014. Conversely, birth hospitalization costs of TIs steadily increased since 2005. The West region showed higher birth hospitalization costs for LPIs. Conclusions: LPIs continue to have a higher cost of birth hospitalization and readmission compared to TIs, but these costs have decreased since 2014. Standardization of birth hospitalization care for LPIs may reduce costs and improve quality of care and outcomes.

Effect of skin-to-skin contact at birth on early neonatal hospitalization

BACKGROUND

Skin-to-skin contact (SCC) at birth has a positive impact on breastfeeding indicators and physiological stabilization at birth. On the other hand, globally and in Colombia, morbidity and mortality have increased in intermediate- and low-risk infants. The aim of the study was to assess the effect of immediate skin-to-skin contact, compared to separation at birth, on the risk of hospitalization of intermediate- and low-risk infants prior to discharge from the maternity ward.

METHODOLOGY

A retrospective cohort study of newborn who underwent a SCC compared to habitual management was conducted. Intermediate- and low-risk neonates with spontaneous neonatal adaptation and cardiorespiratory stability at birth were included. Main outcome measure was hospital admission prior to the discharge from the maternity ward.

RESULT

A total of 816 infants were included, 672 (82.3%) in the skin-to-skin contact group and 144 (17.6%) in the habitual management group. The main causes of hospital admission were jaundice and feeding/sucking related issues. Significantly lower admission to the neonatal unit was found for infants in the contact group compared to infants who did not receive skin-to-skin contact (13.8% vs. 26.4%; OR 0.46, 95% CI 0.29-0.71, p = 0.001).

CONCLUSION

Skin-to-skin contact in newborns of intermediate and low risk has protective effects on the risk of hospital admission within the first few hours of life. SSC is proposed as a prevention strategy in second-level care scenarios.

Determinants of Length of Stay After Vaginal Deliveries in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Although length of stay (LoS) after childbirth has been diminishing in several high-income countries in recent decades, the evidence on the impact of early discharge (ED) on healthy mothers and term newborns after vaginal deliveries (VD) is still inconclusive and little is known on the characteristics of those discharged early. We conducted a population-based study in Friuli Venezia Giulia (FVG) during 2005-2015, to investigate the mean LoS and the percentage of LoS longer than our proposed ED benchmarks following VD: 2 days after spontaneous vaginal deliveries (SVD) and 3 days post instrumental vaginal deliveries (IVD). We employed a multivariable logistic as well as a linear regression model, adjusting for a considerable number of factors pertaining to health-care setting and timeframe, maternal health factors, newborn clinical factors, obstetric history factors, socio-demographic background and present obstetric conditions. Results were expressed as odds ratios (OR) and regression coefficients (RC) with 95% confidence interval (95%CI). The adjusted mean LoS was calculated by level of pregnancy risk (high vs. low). Due to a very high number of multiple tests performed we employed the procedure proposed by Benjamini-Hochberg (BH) as a further selection criterion to calculate the BH p-value for the respective estimates. During 2005-2015, the average LoS in FVG was 2.9 and 3.3 days after SVD and IVD respectively, and the pooled regional proportion of LoS > ED was 64.4% for SVD and 32.0% for IVD. The variation of LoS across calendar years was marginal for both vaginal delivery modes (VDM). The adjusted mean LoS was higher in IVD than SVD, and although a decline of LoS > ED and mean LoS over time was observed for both VDM, there was little variation of the adjusted mean LoS by nationality of the woman and by level of pregnancy risk (high vs. low). By contrast, the adjusted figures for hospitals with shortest (centres A and G) and longest (centre B) mean LoS  were 2.3 and 3.4 days respectively, among "low risk" pregnancies. The corresponding figures for "high risk" pregnancies were 2.5 days for centre A/G and 3.6 days for centre B. Therefore, the shift from "low" to "high" risk pregnancies in all three latter centres (A, B and G) increased the mean adjusted LoS just by 0.2 days. By contrast, the discrepancy between maternity centres with highest and lowest adjusted mean LoS post SVD (hospital B vs. A/G) was 1.1 days both among "low risk" (1.1 = 3.4-2.3 days) and "high risk" (1.1 = 3.6-2.5) pregnanices. Similar patterns were obseved also for IVD. Our adjusted regression models confirmed that maternity centres were the main explanatory factor for LoS after childbirth in both VDM. Therefore, health and clinical factors were less influential than practice patterns in determining LoS after VD. Hospitalization and discharge policies following childbirth in FVG should follow standardized guidelines, to be enforced at hospital level. Any prolonged LoS post VD (LoS > ED) should be reviewed and audited if need be. Primary care services within the catchment areas of the maternity centres of FVG should be improved to implement the follow up of puerperae undergoing ED after VD.

Late preterm infants - Changing trends and continuing challenges

Late preterm infants, defined as newborns born between 340/7-366/7 weeks of gestational age, constitute a unique group among all premature neonates. Often overlooked because of their size when compared to very premature infants, this population is still vulnerable because of physiological and structural immaturity. Comprising nearly 75% of babies born less than 37 weeks of gestation, late preterm infants are at increased risk for morbidities involving nearly every organ system as well as higher risk of mortality when compared to term neonates. Neurodevelopmental impairment has especially been a concern for these infants. Due to various reasons, the rate of late preterm births continue to rise worldwide. Caring for this high risk population contributes a significant financial burden to health systems. This article reviews recent trends in regarding rate of late preterm births, common morbidities and long term outcomes with special attention to neurodevelopmental outcomes.

Late preterm: a new high risk group in neonatology

Late preterm infants are those infants born between 34 0/7 weeks through 36 6/7 week of gestation. These are physiologically less mature and have limited compensatory responses to the extrauterine environment compared with term infants. Despite their increased risk for morbidity and mortality, late preterm newborns are often cared in the well-baby nurseries of hospital after birth and are discharged from the hospital by 2-3 days of postnatal age. They are usually treated like developmentally mature term infants because many of them are of same birth weight and same size as term infants. There is a steady increase in the late preterm birth rate in last decade because of either maternal, fetal, or placental/uterine causes. There has been shift in the distribution of births from term and post-term toward earlier gestations. Although late preterm infants are the largest subgroup of preterm infants, there has been little research on this group until recently. This is mainly because of labeling them as "near-term". Such infants were being looked upon as "almost mature", and were thought as neonate requiring either no or minimal concern. In the obstetric and pediatric practice, late preterm infants are often considered functionally and developmentally mature and often managed by protocols developed for full-term infants. Thus, limited efforts are taken to prolong pregnancy in cases of preterm labor beyond 34 weeks, moreover after 34 weeks most centers do not administer antenatal prophylactic steroids. These practices are based on previous studies reporting neonatal mortality and morbidity in the late preterm period to be only slightly higher in comparison with term infants and whereas in the current scenario the difference is significant. Late preterm infants have 2-3-fold increased risk of morbidities such as hypothermia, hypoglycemia, delayed lung fluid clearance, respiratory distress, poor feeding, jaundice, sepsis, and readmission rates after initial hospital discharge. This leads to huge impact on the overall health care resources. In this review, we cover various aspects of these late preterm infants like etiology, immediate and long-term outcome.

Spanish population-study shows that healthy late preterm infants had worse outcomes one year after discharge than term-born infants

AIM

This study assessed the risks associated with healthy late preterm infants and healthy term-born infants using national hospital discharge records.

METHOD

We used the minimum basic data set of the Spanish hospital discharge records database for 2012-2013 to analyse the hospitalisation of newborn infants. The outcomes were in-hospital mortality and hospital re-admissions at 30 days and one year after their first discharge.

RESULTS

Of the 95 011 newborn infants who were discharged, 2940 were healthy late preterm infants, born at 34 + 0-36 + 6 weeks, and 18 197 were healthy term-born infants. The mean and standard deviation (SD) length of hospital stay were 6.0 (4.5) days in late preterm infants versus 2.8 (1.3) days in term-born infants (p < 0.001). Re-admissions were also higher in the late preterm group at 30 days (9.0% versus 4.4%) and one year (22.0% versus 12.4) (p < 0.001). The relative risk for death at one year was 4.9 in the late preterm group, when compared to the term-born infants (p = 0.026).

CONCLUSION

The hospital discharge codes for otherwise healthy newborn preterm infants were associated with significantly worse 30-day and one-year outcomes when their re-admission and mortality rates were compared with healthy term-born newborn infants.

Severe neonatal hyperbilirubinaemia is frequently associated with long hospitalisation for emergency care in Nigeria

AIM

This study investigated the frequency and predictors of a long hospital stay (LHS) for severe neonatal hyperbilirubinaemia in Nigeria.

METHODS

Length of stay (LOS) for severe hyperbilirubinaemia was examined among neonates consecutively admitted to the emergency department of a children's hospital in Lagos from January 2013 to December 2014. The median LOS was used as the cut-off for LHS. Multivariate logistic regression determined the independent predictors of LHS based on demographic and clinical factors significantly associated with the log-transformed LOS in the bivariate analyses.

RESULTS

We enrolled 622 hyperbilirubinaemic infants with a median age of four days (interquartile range 2-6 days) and 276 (44.4%) had LHS based on the median LOS of five days. Regardless of their birth place, infants were significantly more likely to have LHS if they were admitted in the first two days of life (p = 0.008) - especially with birth asphyxia - or had acute bilirubin encephalopathy (p = 0.001) and required one (p = 0.020) or repeat (p = 0.022) exchange transfusions. Infants who required repeat exchange transfusions had the highest odds for LHS (odds ratio 4.98, 95% confidence interval 1.26-19.76).

CONCLUSION

Severe hyperbilirubinaemia was frequently associated with long hospitalisation in Nigeria, especially if neonates had birth asphyxia or required exchange transfusions.

Health Services Use by Late Preterm and Term Infants From Infancy to Adulthood: A Meta-analysis

CONTEXT

Late-preterm infants born at 34 to 36 weeks' gestation have increased risks of various health problems. Health service utilization (HSU) of late-preterm infants has not been systematically summarized before.

OBJECTIVES

To summarize the published literature on short- and long-term HSU by late-preterm infants versus term infants from infancy to adulthood after initial discharge from the hospital.

DATA SOURCES

We searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO.

STUDY SELECTION

Cohort and case-control studies that compared HSU (admissions, emergency department visits, etc) between late-preterm infants and term infants were included.

DATA EXTRACTION

Data extracted included study design, setting, population, HSU, covariates, and effect estimates.

RESULTS

Fifty-two articles were included (50 cohort and 2 case-control studies). Meta-analyses with random effect models that used the inverse-variance method found that late-preterm infants had higher chances of all-cause admissions than term infants during all the time periods. The magnitude of the differences decreased with age from the neonatal period through adolescence, with adjusted odds ratios from 2.34 (95% confidence intervals 1.19-4.61) to 1.09 (1.05-1.13) and adjusted incidence rate ratios from 2.62 (2.52-2.72) to 1.14 (1.11-1.18). Late-preterm infants had higher rates of various cause-specific HSU than term infants for jaundice, infection, respiratory problems, asthma, and neurologic and/or mental health problems during certain periods, including adulthood.

LIMITATIONS

Considerable heterogeneity existed and was partially explained by the variations in the adjustment for multiple births and gestational age ranges of the term infants.

CONCLUSIONS

Late-preterm infants had higher risks for all-cause admissions as well as for various cause-specific HSU during the neonatal period through adolescence.

Breastfeeding the late preterm infant: experiences of mothers and perceptions of public health nurses

BACKGROUND

The promotion and maintenance of breastfeeding with late preterm infants (LPIs) remain under examined topics of study. This dearth of research knowledge, especially for this population at-risk for various health complications, requires scientific investigation. In this study, we explore the experiences of mothers and the perceptions of public health nurses (PHNs) about breastfeeding late preterm infants in Calgary, Alberta, Canada.

METHODS

We used an exploratory mixed methods design with a convenience sample of 122 mothers to gather quantitative data about breastfeeding. We collected qualitative data by means of individual face-to-face interviews with 11 mothers and 10 public health nurses. Data were collected from April 2013 to June 2014. We then employed an interpretive thematic analysis to identify central themes and relationships across narratives.

RESULTS

We collected 74 complete data sets about breastfeeding. During the first 6-8 weeks postpartum, 61 mothers breastfed their infants. Of these, 51 partially breastfed and 10 exclusively breastfed. For qualitative purposes, the researchers interviewed 11 mothers with late preterm babies and three themes emerged: significant difficulty with breastfeeding, failing to recognize the infant's feeding distress and disorganized behavior, and the parental stress caused by the multiple feeding issues. The public health nurses' comments reinforced and expanded on what the mothers reported. The themes for the nurses included: challenges with initiating breastfeeding, challenges during breastfeeding, and the need for stimulation during breastfeeding.

CONCLUSION

Mothers face challenges when breastfeeding their late preterm infants and public health nurses can guide them through this experience. Families with a late preterm infant need to be informed about the challenges associated with breastfeeding a late preterm infant. It is necessary for all health care professionals to receive proper training on safe and effective breastfeeding of late preterm infants. It is essential for public health nurses to communicate effectively with families of late preterm infants to provide anticipatory guidance about potential challenges and strategies to resolve any breastfeeding problems.

Outcomes of infants born near term

Most research on outcomes of preterm birth has centred on babies born at <32 weeks gestation and at highest risk of mortality and serious morbidity. Recent years have seen a dramatic increase in studies focusing on late preterm infants (34-36 weeks gestation). Early epidemiological studies demonstrated increased risks of mortality and adverse neonatal outcomes in this group, prompting further investigations. These increased risks have been confirmed and more recent studies have also included babies born at 37-38 weeks, now defined as 'early-term' births. It now seems that it is inappropriate to consider term and preterm as a dichotomy; gestational age rather represents a continuum in which risk and severity of adverse outcomes increase with decreasing gestational age, but where measurable effects can be detected even very close to full term. In this review, we summarise current evidence for the outcomes of infants born at late preterm and early-term gestations.

Early discharge following birth - What characterises mothers and newborns?

BACKGROUND

Early postnatal discharge has increased over the past 50 years and today we lack the knowledge on who is discharged early that would allow us to improve quality of postnatal care. The aim of this study was to describe maternal and infant predictors for early postnatal discharge in a country with equal access to health care.

METHODS

An observational study of 2786 mothers, recruited in pregnancy was conducted from April 2013 to August 2014 in four of the five regions in Denmark. Data were analysed using Kaplan-Meier method and multinomial regression models. Outcome variable was time of discharge after birth.

RESULTS

In total 34% mothers were discharged within 12 hours (very early) and 25% between 13 and 50 hours (early), respectively. Vaginal birth and multiparity were the most influential predictors, as Caesarean section compared to vaginal birth had an OR of 0.35 (CI 0.26-0.48) and primiparous compared to multiparous had an OR of 0.22 (CI 0.17-0.29) for early discharge. Other predictors for early discharge were: no induction of labour, no epidural painkiller, bleeding less than 500 ml during delivery, higher gestational age, early expected discharge and positive breastfeeding experience. Smoking, favourable social support and breastfeeding knowledge were significantly associated with discharge within 12 hours. Finally time of discharge varied significantly according to region and time of day of birth.

CONCLUSIONS

Parity and birth related factors were the strongest predictors of early discharge. Psycho-social predictors indicate that the parents are involved in the decision of when to be discharge.

Maturational, comorbid, maternal and discharge domain impact on preterm rehospitalizations: a comparison of planned and unplanned rehospitalizations

OBJECTIVE

To determine the predictive value of (1) maternal, (2) maturational, (3) comorbid and (4) discharge domains associated with preterm infant rehospitalization.

STUDY DESIGN

Retrospective, cohort study of preterm infants discharged home from a level IV neonatal intensive care unit. Rates of unplanned and planned 6-month readmissions were assessed. The four domains were modeled incrementally and separately to predict relative and combined contributions to the readmission risk.

RESULT

Out of 504 infants, 5% had 30-day readmissions (22 unplanned, three planned). By 6 months, 13% were rehospitalized (52 unplanned, 15 planned). Sixty-seven infants had 96 readmission events with 30% of readmission events elective. The four domains together predicted 78% of total 1-month, all 6-month and unplanned 6-month readmissions. Discharge complexity was as predictive as comorbidity in all models.

CONCLUSION

These four-domain models were more predictive than single domains. Many total readmission events were planned, suggesting parsing planned and unplanned rehospitalizations may benefit quality-improvement efforts.

Towards reducing variations in infant mortality and morbidity: a population-based approach

Background

Our aims were (1) to improve understanding of regional variation in early-life mortality rates and the UK’s poor performance in international comparisons; and (2) to identify the extent to which late and moderately preterm (LMPT) birth contributes to early childhood mortality and morbidity.

Objective

To undertake a programme of linked population-based research studies to work towards reducing variations in infant mortality and morbidity rates.

Design

Two interlinked streams: (1) a detailed analysis of national and regional data sets and (2) establishment of cohorts of LMPT babies and term-born control babies.

Setting

Cohorts were drawn from the geographically defined areas of Leicestershire and Nottinghamshire, and analyses were carried out at the University of Leicester.

Data sources

For stream 1, national data were obtained from four sources: the Office for National Statistics, NHS Numbers for Babies, Centre for Maternal and Child Enquiries and East Midlands and South Yorkshire Congenital Anomalies Register. For stream 2, prospective data were collected for 1130 LMPT babies and 1255 term-born control babies.

Main outcome measures

Detailed analysis of stillbirth and early childhood mortality rates with a particular focus on factors leading to biased or unfair comparison; review of clinical, health economic and developmental outcomes over the first 2 years of life for LMPT and term-born babies.

Results

The deprivation gap in neonatal mortality has widened over time, despite government efforts to reduce it. Stillbirth rates are twice as high in the most deprived as in the least deprived decile. Approximately 70% of all infant deaths are the result of either preterm birth or a major congenital abnormality, and these are heavily influenced by mothers’ exposure to deprivation. Births at < 24 weeks’ gestation constitute only 1% of all births, but account for 20% of infant mortality. Classification of birth status for these babies varies widely across England. Risk of LMPT birth is greatest in the most deprived groups within society. Compared with term-born peers, LMPT babies are at an increased risk of neonatal morbidity, neonatal unit admission and poorer long-term health and developmental outcomes. Cognitive and socioemotional development problems confer the greatest long-term burden, with the risk being amplified by socioeconomic factors. During the first 24 months of life each child born LMPT generates approximately £3500 of additional health and societal costs.

Conclusions

Health professionals should be cautious in reviewing unadjusted early-life mortality rates, particularly when these relate to individual trusts. When more sophisticated analysis is not possible, babies of < 24 weeks’ gestation should be excluded. Neonatal services should review the care they offer to babies born LMPT to ensure that it is appropriate to their needs. The risk of adverse outcome is low in LMPT children. However, the risk appears higher for some types of antenatal problems and when the mother is from a deprived background.

Future work

Future work could include studies to improve our understanding of how deprivation increases the risk of mortality and morbidity in early life and investigation of longer-term outcomes and interventions in at-risk LMPT infants to improve future attainment.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Newborn Readmissions to Slovenian Children's Hospitals in One Summer Month and One Autumn Month: A Retrospective Study

BACKGROUND

With the shortening length of stay of newborns in hospitals after birth, concerns have been raised about the possible rise in readmission rates. In Slovenia, where the normal length of stay is 3 days, no data on readmissions were available. We sought to determine the frequency and causes for readmissions.

METHODS

We conducted a retrospective study on all newborns readmitted to Slovenian children's hospitals and wards in June 2012 and November 2012. We obtained basic demographic data for newborns and mothers, analyzed the frequency of diagnoses, and compared the duration of treatment between summer months and autumn months.

RESULTS

The proportion of readmissions in June 2012 and November 2012 was 6% and 5.9%, respectively. Around 10% more boys were readmitted in June 2012 and November 2012. In June 2012, the mean age was 12.2 days, and the mean birth weight was 3444 g. In November, the mean age was 10.5 days, and the mean birth weight was 3271 g. Around 50% of mothers were primiparous, and their mean age was around 31 years. Most received > 10 prenatal check-ups and participated in a prenatal class. The most common diagnosis in June 2012 and November 2012 was jaundice. The duration of treatment did not statistically significantly differ between summer months and autumn months, but it was associated with the admission diagnosis and infants' characteristics.

CONCLUSION

Our study showed that the readmission rate in Slovenia was much higher than in some other developed countries. Prospective studies are needed to further confirm the findings and highlight the possible causes for this observation.

Survival, Hospitalization, and Acute-Care Costs of Very and Moderate Preterm Infants in the First 6 Years of Life: A Population-Based Study

OBJECTIVES

To investigate survival, hospitalization, and acute-care costs of very (28-31 weeks' gestation) and moderate preterm (32-33 weeks' gestation) infants in the first 6 years of life and compare outcomes with the more widely studied extremely preterm infants (24-27 weeks' gestation) and to full term (low risk) infants (39-40 weeks' gestation).

STUDY DESIGN

Birth data from all women residing in New South Wales, Australia, with gestational ages between 24-33 and 39-40 weeks in 2001-2011 were linked probabilistically to hospitalization and mortality data. Study outcomes were evaluated with the use of descriptive and multivariable analyses at birth (N = 559,532), discharge (N = 540,240), and at 1 (N = 487,447) and 6 years of age (N = 230,498).

RESULTS

Mortality was greatest among extremely preterm infants (eg, 31.2% within 6 years) and decreased with increasing gestational age. Likewise, hospitalization within the first year of life increased with decreasing gestational age (aOR 5.5 [95% CI 4.7-6.4], 3.7 [3.4-4.0], and 2.6 [2.5-2.8] for birth at 24-27, 28-31, and 32-33 weeks' gestation, relative to 39-40 weeks' gestation). Hospitalization remained significantly increased with preterm birth at each year of age up to 6 years (aORs 1.3-1.6 at 6 years). Cumulative costs were significantly greater with preterm birth within the first year of life, and also between 1 and 6 years of age.

CONCLUSIONS

The risks of adverse health outcomes were significantly greater in very and moderately preterm infants relative to full term infants but lower than extremely preterm infants. Crucially, preterm birth was associated with prolonged increased odds of hospitalization (up to age 6 years), contributing to greater resource use.

Prevalence and risk factors for reduced sound tolerance (hyperacusis) in children

OBJECTIVE

To estimate the prevalence of reduced sound tolerance (hyperacusis) in a UK population of 11-year-old children and examine the association of early life and auditory risk factors with report of hyperacusis.

DESIGN

A prospective UK population-based study.

STUDY SAMPLE

A total of 7097 eleven-year-old children within the Avon longitudinal study of parents and children (ALSPAC) were asked about sound tolerance; hearing and middle-ear function was measured using audiometry, otoacoustic emissions, and tympanometry. Information on neonatal risk factors and socioeconomic factors were obtained through parental questionnaires.

RESULTS

3.7% (95% CI 3.25, 4.14) children reported hyperacusis. Hyperacusis report was less likely in females (adj OR 0.64, 95% CI 0.49, 0.85), and was more likely with higher maternal education level (adj OR 1.72, 95% CI 1.08, 2.72) and with readmission to hospital in first four weeks (adj OR 1.98, 95% CI 1.20, 3.25). Report of hyperacusis was associated with larger amplitude otoacoustic emissions but with no other auditory factors.

CONCLUSIONS

The prevalence of hyperacusis in the population of 11-year-old UK children is estimated to be 3.7%. It is more common in boys.

Hospital, infants and feeding: The importance of audit

AIM

Infant feeding can be the reason for presentation and/or admission to hospital. The aim of this study was to identify if infant feeding history was documented in charts of infants presenting and/or admitted to a paediatric hospital.

METHODS

A systematic random sample of hospital charts of infants who had presented to the emergency department between 1 July 2011 and 30 June 2012 was audited for presence of documentation of feeding.

RESULTS

In total, 465 charts were audited, representing 12.5% of infants who presented to the emergency department in the year. Frequency of documentation for feeding measures was as follows: feeding mode, 263 (57%); feeding type, 228 (49%); feeding frequency, 119 (26%); and with changes 89 (19%) since birth. Increasing infant age was significantly associated with less frequent recording of feeding mode, type, frequency and changes.

CONCLUSION

A comprehensive feeding history is not recorded on many occasions of infant presentation and/or admission to hospital. The recording of feeding mode, type, frequency and changes is needed in order to explore the existence, or otherwise, of a relationship between feeding and the reason for presentation and/or admission.

Hospitalisations from 1 to 6 years of age: effects of gestational age and severe neonatal morbidity

BACKGROUND

To investigate whether the adverse infant health outcomes associated with early birth and severe neonatal morbidity (SNM) persist beyond the first year of life and impact on paediatric hospitalisations for children up to 6 years of age.

METHODS

The study population included all singleton live births, >32 weeks gestation in New South Wales, Australia, in 2001-2005, with follow-up to 6 years of age. Birth data were probabilistically linked to hospitalisation data (n = 392 964). The odds of hospitalisation, mean hospital length of stay (LOS) and costs, and cumulative LOS were evaluated by gestational age and SNM using multivariable analyses.

RESULTS

A total of 74 341 (18.9%) and 41 404 (10.5%) infants were hospitalised once and more than once, respectively. SNM was associated with increased odds of hospitalisation once (adjusted odds ratio [aOR] 1.16 [95% confidence interval 1.10, 1.22]) and more than once [aOR 1.51 (1.43, 1.61)]. Decreasing gestational age was associated with increasing odds of hospitalisation more than once from aOR 1.19 at 37-38 weeks to 1.49 at 33-34 weeks. Average LOS and costs per hospital admission were increased with SNM but not with decreasing gestational age. Cumulative LOS was significantly increased with SNM and decreasing gestational age.

CONCLUSIONS

Adverse effects of SNM and early birth persist between 1 and 6 years of age. Strategies to prevent early birth and reduce SNM, and to increase health monitoring of vulnerable infants throughout childhood may help reduce paediatric hospitalisations.

Hospital admissions and gestational age at birth: 18 years of follow up in Western Australia

BACKGROUND

Infants born moderate to late preterm are twice as likely to be rehospitalised within the first few weeks following discharge from the birth admission. It is not understood how rehospitalisation risk changes with age or how risks have changed over time.

METHODS

A retrospective birth cohort study of all live, singleton births in Western Australia 1 January 1980-31 December 2010, without congenital anomalies, followed to 18 years of age. Rehospitalisation rates for gestational age categories (<28, 28-31, 32-33, 34-36, 37-38 and ≥42 weeks) were compared with term births (39-41 weeks) using negative binomial regression. To assess whether rehospitalisation risk changed with age or over time, analyses were conducted for different age intervals and for 5-year birth cohorts.

RESULTS

Rehospitalisation rates were higher up to 18 years for all preterm and early term categories including early term (37-38 weeks) [130.2/1000 person-years at risk (pyr); 95% confidence interval 129.1, 131.4]; late preterm (34-36 weeks) (164.2/1000 pyr; 161.1, 167.4), and post-term (≥42 weeks) (115.3/1000 pyr; 111.7, 119.0) compared with term births (109.1/1000 pyr; 108.5, 109.7). The effect of gestational age on rehospitalisation was highest during the first year of life and declined by adolescence [e.g. 34-36 weeks: rate ratio = 2.10 (2.04, 2.15) for 29 days-1 year; 1.14 (1.11, 1.18) for 12-18 years]. The risk of rehospitalisation up to 1 year of age has declined since 1980, except for those born <32 weeks.

CONCLUSIONS

Rehospitalisation risk is greater for singleton children born at all gestational ages compared with those born full term. This effect of gestational age on rehospitalisation is highest in the first year post-discharge, but has almost disappeared by adolescence.

Factors associated with readmission in late-preterm infants: a matched case-control study

OBJECTIVE

The goal of this study was to evaluate risk factors for readmission among late-preterm (34-36 weeks' gestation) infants in clinical practice.

METHODS

This was a retrospective, matched case-control study of late-preterm infants receiving care across 8 regional hospitals in 2009 in the United States. Those readmitted within 28 days of birth were matched to non-readmitted infants at a ratio of 1:3 according to birth hospital, birth month, and gestational age. Step-wise modeling with likelihood ratio tests were used to develop a multivariable logistic regression model. A subgroup analysis of hyperbilirubinemia readmissions was also performed.

RESULTS

Of 1861 late-preterm infants delivered during the study period, 67 (3.6%) were readmitted within 28 days of birth. These were matched to 201 control infants, for a final sample of 268 infants. In multivariable regression, each additional day in length of stay was associated with a significantly reduced odds ratio (OR) for readmission (0.57, P = .004); however, for those infants delivered vaginally, there was no significant association between length of stay and readmission (adjusted OR: 1.08, P = .16). A stronger inverse relationship was observed in subgroup analysis for hyperbilirubinemia readmissions, with the adjusted OR associated with increased length of stay 0.40 (P = .002) for infants born by cesarean delivery but 1.14 (P = .27) for those delivered vaginally.

CONCLUSIONS

Infants born via cesarean delivery with longer length of hospital stay have a decreased risk for readmission. As hospitals implement protocols to standardize length of stay, mode of delivery may be a useful factor to identify late-preterm infants at higher risk for readmission.

Individualized follow up programme and early discharge in term neonates

BACKGROUND

Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration.

METHODS

During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge.

RESULTS

During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%).

CONCLUSIONS

Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.

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.

Risk factors and costs of hospital admissions in first year of life: a population-based study

OBJECTIVE

To identify the maternal and infant risk factors associated with hospital admission in the first year and estimate the associated costs of infant hospitalization.

STUDY DESIGN

Data from the Perinatal Data Collection for 599753 liveborn infants born in New South Wales, Australia, 2001-2007 were linked to hospital admission data. Logistic regression models were used to investigate the association between maternal and infant characteristics and admission to hospital once, and more than once in the first year; and average costs for total hospital admissions were calculated.

RESULTS

Almost 15% of infants were admitted to hospital once and 4.6% had multiple admissions. Gestational age <37 weeks was most strongly associated with admission to hospital once, and severe neonatal morbidity was most strongly associated with multiple admissions (aOR 2.60; 95% CI 2.47-2.75). Infants born <39 weeks gestational age, to adolescent mothers, mothers who smoke, are not married, or had a planned delivery also have an increased risk of multiple admissions. Infants with severe neonatal morbidity contributed 27% of total infant hospital costs. With each increasing week of gestational age the mean annual cost decreased on average 10% and 27% for infants with and without neonatal morbidity respectively.

CONCLUSIONS

Infants born with severe neonatal morbidity have increased hospitalizations in the first year; however, the majority of burden on health system is by infants without severe neonatal morbidity. Hospitalizations, and associated costs, increased with decreasing gestational age, even for infants born at 37-38 weeks. Targeted public health strategies may reduce the burden of infant hospitalizations.

Neonatal visits to the pediatric emergency center and its implications on postnatal discharge practices in qatar

BACKGROUND

An early discharge from postnatal policy has been practiced at Women's Hospital, Hamad Medical Corporation.

AIM

This observational cohort study was conducted to evaluate the effect of early postnatal discharge practice on neonatal morbidity in the State of Qatar.

SETTING AND DESIGN

This is a data-based cohort study. All neonates ≤28 days visiting the Pediatric Emergency Centers (PEC) were evaluated for the need for re-hospitalization, referral for clinic appointments, or observation at the PEC setting.

MATERIALS AND METHODS

Differences in outcome rates were compared in neonates who visited in the first 24 hours postnatal discharge (2-3 days of life) and those who visited after the third day of life.

STATISTICAL ANALYSIS

Crude differences in incidence rate assessed by χ(2) or Fisher exact test were applicable.

RESULTS

Of 3528 PEC visits for 1915 neonates, 1.7% required admission (3.1% of neonates), 8.4% were observed, 1.1% were referred to a clinic, and the remaining were discharged home. There was no significant difference in re-hospitalization rates of neonates visiting PEC in the first 3 days and those visiting at a later age (OR 0.78, 95% CL 0.19-3.23, P=1). However, early presentations to PEC was more likely to result in periods of observation (OR 1.88, 95% CL 1.17-3.04, P=0.01), or clinic referral (OR 4.96, 95% CL 2.16-11.38, P=0.001) when compared to older neonates. Moreover, those who presented early were significantly more likely to revisit any of the PECs with in the 28 days period (OR 3.20, 95% CL 2.17-4.97, P<0.0001).

CONCLUSION

These results clearly demonstrate the need for a structured early post-discharge follow-up service that addresses the needs of all neonates and their families. The results, however, do not provide sufficient evidence that delaying postnatal discharges for apparently healthy neonates will provide significant health benefits to these neonates and their families.

A common problem for neonatal intensive care units: late preterm infants, a prospective study with term controls in a large perinatal center

Compared with term infants, late preterm infants are immature physiologically and metabolically, and have higher risks for medical complications such as respiratory distress, hypoglycemia, hyperbilirubinemia, sepsis, feeding difficulty and poor neurodevelopmental outcomes. The incidence of late preterm birth is increasing. We evaluated the clinical and demographic characteristics, short-term outcomes and clinical courses of late preterm infants admitted to our neonatal intensive care unit (NICU). Data from NICU admissions of 605 late preterm and 1477 term infants in the 1-year period between June 2010 and May 2011 were analyzed. There were 2004 late preterm deliveries and 18,854 total deliveries. Of late preterm infants, 30% were admitted to the NICU. The mean gestational age and birth weight were 35(1/7) weeks and 2352 g, respectively. The admission diagnoses were respiratory distress (46.5%), low birth weight (17.5%), jaundice (13.7%), feeding difficulty (13.1%), polycythemia (8.1%) and hypoglycemia (4%); these morbidity rates were higher than those in term infants (p < 0.001). The overall mean hospitalization period was 7.5 ± 9.1 days. The respective mortality and rehospitalization rates were 2.1% and 4.4%, which were higher than those for term infants (p < 0.001). In conclusion, late preterm infants should be followed closely for the complications just after birth, and preventive strategies should be developed.

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.

Health outcomes in infancy and childhood of moderate and late preterm infants

There has been a long-held belief that outcomes for babies born at moderate and late preterm gestations do not differ substantially from those of infants born at full term. This has recently been challenged by studies highlighting an increased risk of adverse neonatal outcomes, and of poorer cognitive, behavioural and educational outcomes in this population. Data about the effects of birth at moderate and late preterm gestations on later health outcomes are limited, but emerging evidence suggests that ongoing physical health may also be worse in those born just a few weeks before full term. This review summarises the available evidence, considers the factors influencing health outcomes and discusses the implications for the planning and provision of children's health care services.

Effects of gestational age at birth on health outcomes at 3 and 5 years of age: population based cohort study

OBJECTIVE

To investigate the burden of later disease associated with moderate/late preterm (32-36 weeks) and early term (37-38 weeks) birth.

DESIGN

Secondary analysis of data from the Millennium Cohort Study (MCS).

SETTING

Longitudinal study of infants born in the United Kingdom between 2000 and 2002.

PARTICIPANTS

18,818 infants participated in the MCS. Effects of gestational age at birth on health outcomes at 3 (n = 14,273) and 5 years (n = 14,056) of age were analysed.

MAIN OUTCOME MEASURES

Growth, hospital admissions, longstanding illness/disability, wheezing/asthma, use of prescribed drugs, and parental rating of their children's health.

RESULTS

Measures of general health, hospital admissions, and longstanding illness showed a gradient of increasing risk of poorer outcome with decreasing gestation, suggesting a "dose-response" effect of prematurity. The greatest contribution to disease burden at 3 and 5 years was in children born late/moderate preterm or early term. Population attributable fractions for having at least three hospital admissions between 9 months and 5 years were 5.7% (95% confidence interval 2.0% to 10.0%) for birth at 32-36 weeks and 7.2% (1.4% to 13.6%) for birth at 37-38 weeks, compared with 3.8% (1.3% to 6.5%) for children born very preterm (<32 weeks). Similarly, 2.7% (1.1% to 4.3%), 5.4% (2.4% to 8.6%), and 5.4% (0.7% to 10.5%) of limiting longstanding illness at 5 years were attributed to very preterm birth, moderate/late preterm birth, and early term birth.

CONCLUSIONS

These results suggest that health outcomes of moderate/late preterm and early term babies are worse than those of full term babies. Additional research should quantify how much of the effect is due to maternal/fetal complications rather than prematurity itself. Irrespective of the reason for preterm birth, large numbers of these babies present a greater burden on public health services than very preterm babies.

Health-related quality of life, emotional and behavioral problems in mild to moderate prematures at (pre-)school age

BACKGROUND

There is a gap in the knowledge of longterm outcome of mild to moderate prematures compared to the extreme prematures or very low birth weight infants.

AIM

Determine health-related quality of life (HRQoL) and prevalence of emotional and behavioral problems in (pre-)school age children born at 32 to 36 weeks' gestation.

STUDY DESIGN

A descriptive cohort study in a non-Neonatal Intensive Care Unit. Patient characteristics, diagnoses, treatment and social economic status (SES) were analyzed. Study tools were the TNO-AZL Preschool Quality of Life (TAPQoL) and Child Behavior Checklist (CBCL).

SUBJECTS

362 children born between 32 and 36 weeks' gestation who had a follow-up evaluation at 2-5 years of age.

OUTCOME MEASURE

Health-related quality of life and the occurrence of emotional and behavioral problems.

RESULTS

Main characteristics (mean±SD) were: gestation 34.7±1 weeks and birth weight 2360±444 g. Most families were two-parent middle-class households with parents employed at their educational level. Questionnaire response rate was 62.7%. The 12-item TAPQoL showed significantly lower scores for stomach and liveliness, while scores for behavior, communication and sleep were significantly higher compared to the general population. The TAPQoL subscale score for lung problems was significantly lower for children who had received continuous positive airway pressure (CPAP). CBCL scores were within the validated normal range although the study-population scored higher on emotionally reactive, somatic complaints and attention problems compared to their full-term peers.

CONCLUSION

Children born at 32 to 36 weeks' gestational age do not experience an overall lower HR-QoL at 2 to 5 years of age. CPAP results in lower HRQoL scores for lung problems. The overall occurrence of behavioral and emotional problems does not differ from the general term-born pediatric population. Several subitems need further attention.

Morbidity and mortality in late preterm and early term newborns: a continuum

Late preterm and early term infants are at higher risk for short-term and long-term morbidities and mortality than term infants. Such outcomes are influenced by many factors, the strongest of which is gestational age. Counseling and educating women and families about risks of late preterm and early term births is helpful for timing and route of delivery, managing the pregnancy and infant, and prognosticating outcomes for infants.

[Short-term complications of late preterm infants]

INTRODUCTION

Late preterm infants, born at 34-36(+6) weeks gestation, are physiologically more immature than term infants. As a consequence, they have an increased risk of morbidity and mortality. Since health outcomes in prematurity may change depending on local factors we have proposed determine the short-term medical problems of these infants in our hospital.

PATIENTS AND METHODS

A retrospective observational study was carried out on all newborn ≥ 34 weeks gestation admitted to Virgen del Rocio hospital from May 2005 to December 2008. We divided this cohort into late preterm (34-36(+6) weeks, n=769) and term (37-41(+6) weeks, n=1460) groups. We compared mortality and morbidity data between the 2 groups.

RESULTS

Late preterm group was associated with assisted reproduction, twin pregnancy, caesarean delivery and preeclampsia during pregnancy. The risk of hospitalization was six times greater in these infants and neonatal intensive care admissions were twice as common. The hospital stay was double in this group. Neonatal respiratory morbidity and jaundice were greater in the preterm group. The use of surfactant, oxygen and respiratory support (CPAP and CMV) was also higher. There were no significant differences in hypoglycaemia and neonatal mortality between both groups.

CONCLUSIONS

Late preterm infants represent a well-defined risk group for developing complications and should be available the necessary resources should be made available for their special care.

The paradox of breastfeeding-associated morbidity among late preterm infants

OBJECTIVE

To synthesize the published research pertaining to breastfeeding establishment and outcomes among late preterm infants and to describe the state of the science on breastfeeding within this population.

DATA SOURCES

Online databases Ovid MEDLINE, CINAHL, PubMed, and reference lists of reviewed articles.

STUDY SELECTION

Nine data-based research articles examining breastfeeding patterns and outcomes among infants born between 34 0/7 and 36 6/7 weeks gestation or overlapping with this time period by at least 2 weeks.

DATA EXTRACTION

Effect sizes and descriptive statistics pertaining to breastfeeding initiation, duration, exclusivity, and health outcomes among late preterm breastfed infants.

DATA SYNTHESIS

Among late preterm mother/infant dyads, breastfeeding initiation appears to be approximately 59% to 70% (U.S.), whereas the odds of breastfeeding beyond 4 weeks or to the recommended 6 months (exclusive breastfeeding) appears to be significantly less than for term infants, and possibly less than infants ≤34 to 35 weeks gestation. Breastfeeding exclusivity is not routinely reported. Rehospitalization, often related to "jaundice" and "poor feeding," is nearly twice as common among late preterm breastfed infants as breastfed term or nonbreastfed late preterm infants. Barriers to optimal breastfeeding in this population are often inferred from research on younger preterm infants, and evidence-based breastfeeding guidelines are lacking.

CONCLUSIONS

Late preterm infants are at greater risk for breastfeeding-associated rehospitalization and poor breastfeeding establishment compared to their term (and possibly early preterm) counterparts. Contributing factors have yet to be investigated systematically.

Neonatal jaundice, autism, and other disorders of psychological development

OBJECTIVES

The goals were to study the association between neonatal jaundice and disorders of psychological development in a national, population-based cohort and to study whether gestational age, parity, and season of birth influenced that association.

METHODS

A population-based, follow-up study of all children born alive in Denmark between 1994 and 2004 (N = 733,826) was performed, with data collected from 4 national registers. Survival analysis was used to calculate hazard ratios (HRs).

RESULTS

Exposure to jaundice in neonates was associated with increased risk of disorders of psychological development for children born at term. The excess risk of developing a disorder in the spectrum of psychological development disorders after exposure to jaundice as a neonate was between 56% (HR: 1.56 [95% confidence interval [CI]: 1.05-2.30]) and 88% (HR: 1.88 [95% CI: 1.17-3.02]). The excess risk of infantile autism was 67% (HR: 1.67 [95% CI: 1.03-2.71]). This risk for infantile autism was higher if the child was conceived by a parous woman (HR: 2.71 [95% CI: 1.57-4.66]) or was born between October and March (HR: 2.21 [95% CI: 1.24-3.94]). The risk for infantile autism disappeared if the child was conceived by a primiparous woman (HR: 0.58 [95% CI: 0.18-1.83]) or was born between April and September (HR: 1.02 [95% CI: 0.41-2.50]). Similar risk patterns were found for the whole spectrum of autistic disorders.

CONCLUSIONS

Neonatal jaundice in children born at term is associated with disorders of psychological development. Parity and season of birth seem to play important roles.