Estimating neonatal length of stay for babies born very preterm

Parental Self-Efficacy and Personal Time Help Explain Impact of Parent-Staff Interactions on Parental Distress and Bonding in the NICU

OBJECTIVES

To identify factors that help explain associations between parent-staff interactions and: (1) parental depression, anxiety, and posttraumatic stress; and (2) parent-child bonding in the neonatal intensive care unit (NICU).

STUDY DESIGN

Our cross-sectional mixed methods survey investigated the ways in which parental-staff interactions relate to parental distress and parent-child bonding. Parents with babies in the NICU (N = 165) completed validated measures and open-ended questions about their experiences with staff. Using a sequential explanatory approach, we examined: (1) whether and how parental self-efficacy and personal time mediated parent-staff interactions on distress and bonding; and (2) parental written accounts of experiences with staff.

RESULTS

Multiple mediation analyses revealed that parent-staff interactions exhibited an: (1) indirect effect on parental depression (b = -.05, SE = .02, CI [-.10, -.01]), anxiety (b = -.08, SE = .04, CI [-.16, -.02]), and parent-child bonding (b = -.26, SE = .08, CI [-.43, -.11]) through parental self-efficacy; and (2) indirect effect on parental posttraumatic stress (b = -.08, SE = .04, CI [-.17, -.00], CSIE= -.06) through parental personal time. Thematic analyses revealed that emotional and instructional support from staff helped build parental self-efficacy. Trust with staff helped parents feel comfortable leaving the bedside and engage in basic needs (eg, eat, sleep).

CONCLUSIONS

Family-staff dynamics are the foundation for high quality family-centered care. Staff who empower parents to participate in care, engage in parenting tasks, and take care of themselves may reduce their distress and improve relationships among staff, parents, and babies.

Characteristics of children requiring admission to neonatal care and paediatric intensive care before the age of 2 years in England and Wales: a data linkage study

OBJECTIVE

To quantify the characteristics of children admitted to neonatal units (NNUs) and paediatric intensive care units (PICUs) before the age of 2 years.

DESIGN

A data linkage study of routinely collected data.

SETTING

National Health Service NNUs and PICUs in England and Wales PATIENTS: Children born from 2013 to 2018.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Admission to PICU before the age of 2 years.

RESULTS

A total of 384 747 babies were admitted to an NNU and 4.8% (n=18 343) were also admitted to PICU before the age of 2 years. Approximately half of all children admitted to PICU under the age of 2 years born in the same time window (n=18 343/37 549) had previously been cared for in an NNU.The main reasons for first admission to PICU were cardiac (n=7138) and respiratory conditions (n=5386). Cardiac admissions were primarily from children born at term (n=5146), while respiratory admissions were primarily from children born preterm (<37 weeks' gestational age, n=3550). A third of children admitted to PICU had more than one admission.

CONCLUSIONS

Healthcare professionals caring for babies and children in NNU and PICU see some of the same children in the first 2 years of life. While some children are following established care pathways (eg, staged cardiac surgery), the small proportion of children needing NNU care subsequently requiring PICU care account for a large proportion of the total PICU population. These differences may affect perceptions of risk for this group of children between NNU and PICU teams.

Association between Intermittent Hypoxemia and NICU Length of Stay in Preterm Infants

INTRODUCTION

Length of hospitalization varies widely in preterm infants and can be affected by multiple maternal and neonatal factors including respiratory instability. Therefore, we aimed to determine the association between postnatal intermittent hypoxemia (IH) and prolonged hospitalization.

METHODS

This prospective single-center cohort study followed infants born at <31 weeks of gestational age through 2 years corrected age with detailed oxygen saturation data captured from days 7 to 30 of age.

RESULTS

51/164 (31%) of infants were discharged after 400/7 weeks of corrected gestational age (CGA). A greater average daily number of IH events (OR per 10 events/day 1.33 [95% CI 1.03-1.72]), duration of events (OR per minute 1.14 [1.07-1.21]), and percent time with oxygen saturation <80% (OR per percent 1.88 [1.25-2.85]) on days 7-30 of age were all significantly associated with prolonged hospitalization past 400/7 weeks CGA. In survival analyses, infants with a greater average daily number of IH events (HR per 10 events/day 0.89 [0.81-0.98]), percent time with oxygen saturation <80% (HR per percent 0.79 [0.67-0.94]), and duration of events (HR per minute 0.93 [0.91-0.95]) on days 7-30 of age all had significantly lower probability of earlier discharge. In addition, there was a significant interaction with gestational age; the association between IH and prolonged hospitalization was stronger in more mature infants (p = 0.024).

CONCLUSIONS

Physiological instability on days 7-30 of age, as manifested by IH, is significantly associated with prolonged hospitalization. IH likely represents both a marker of initial severity of illness and the beginning of biological cascades, leading to prematurity-associated morbidities.

Associations between prematurity, postpartum anxiety, neonatal intensive care unit admission, and stress

Introduction

It is well established that a premature birth increases the likelihood of developing anxiety during the postpartum period, and that the environment of the neonatal intensive care unit (NICU) might be a contributing factor. Mothers of earlier premature infants may experience these anxieties to a higher degree compared to mothers of later premature infants. The aim of this study was to explore the association between prematurity and postpartum-specific anxiety, and the relationship between postpartum-specific anxiety and stress in the NICU.

Materials and methods

Mothers (N = 237) of infants aged between birth and 12 months completed an online survey containing the Postpartum Specific Anxiety Scale - Research Short Form (PSAS-RSF) and the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU). Structural equation modeling was used to analyze the relationship between gestational age and postpartum-specific anxiety, with one-way ANOVAs used to analyze this relationship with respect to categories of gestational age. Hierarchical regression models analyzed the relationship between postpartum-specific anxiety and stress in the NICU.

Results

For the PSAS-RSF, Practical Infant Care Anxieties (p = 0.001), Maternal Competence and Attachment Anxieties (p = 0.033), and Infant Safety and Welfare Anxieties (p = 0.020) were significantly associated with week of gestation. Practical Infant Care and Infant Safety and Welfare Anxieties were significantly higher for mothers of late premature infants, compared to mothers of term infants (p < 0.001; p = 0.019). There were no significant between-group differences with respect to Maternal Competence and Attachment Anxieties. After controlling for potential confounders, Infant Safety and Welfare Anxieties were significantly associated with increased stress in the NICU (p < 0.001) as measured by the PSS:NICU.

Conclusions

Our findings highlight the need for interventions for mothers with premature infants, which specifically target anxieties reflected in the PSAS-RSF, such as routine care and increasing maternal self-efficacy.

Trends in the Incidence of Bronchopulmonary Dysplasia after the Introduction of Neurally Adjusted Ventilatory Assist (NAVA)

OBJECTIVE

This study investigates the difference in the rates of bronchopulmonary dysplasia in very low birth weight infants before and after the introduction of neurally adjusted ventilatory assist (NAVA).

STUDY DESIGN

A retrospective cohort study comparing rates of Bronchopulmonary dysplasia (BPD) before and after implementation of NAVA. Eligibility criteria included all very low birth weight VLBW neonates needing ventilation. For analysis, each cohort was divided into three subgroups based on gestational age. Changes in the rate of BPD, length of stay, tracheostomy rates, invasive ventilator days, and home oxygen therapy were compared.

RESULTS

There were no differences in the incidence of BPD in neonates at 23-25 6/7 weeks' and 29-32 weeks' gestation between the two cohorts. A higher incidence of BPD was seen in the 26-28 5/7 weeks' gestation NAVA subgroup compared to controls (86% vs. 68%, p = 0.05). No significant difference was found for ventilator days, but infants in the 26-28 6/7 subgroup in the NAVA cohort had a longer length of stay (98 ± 34 days vs. 82 ± 24 days, p = 0.02), a higher percentage discharged on home oxygen therapy (45% vs. 18%, respectively, p = 0.006), and higher tracheostomy rates (3/36 vs. 0/60, p = 0.02), compared to the control group.

CONCLUSIONS

The NAVA mode was not associated with a reduction in BPD when compared to other modes of ventilation. Unexpected increases were seen in BPD rates, home oxygen therapy rates, tracheostomy rates, and the length of stay in the NAVA subgroup born at 26-28 6/7 weeks' gestation.

Parents' life satisfaction prior to and following preterm birth

The current study tested whether the reported lower wellbeing of parents after preterm birth, relative to term birth, is a continuation of a pre-existing difference before pregnancy. Parents from Germany (the German Socio-Economic Panel Study, N = 10,649) and the United Kingdom (British Household Panel Study and Understanding Society, N = 11,012) reported their new-born's birthweight and gestational age, subsequently categorised as very preterm or very low birthweight (VP/VLBW, < 32 weeks or < 1500 g), moderately/late preterm or low birthweight (MLP/LBW, ≥ 32 weeks and < 37 weeks/≥ 1500 g and < 2500 g), or term-born (≥ 37 weeks and ≥ 2500 g). Mixed models were used to analyse life satisfaction, an aspect of wellbeing, at four assessments-two years and six months before birth and six months and two years afterwards. Two years before birth, satisfaction of prospective term-born, MLP/LBW, or VP/VLBW mothers did not significantly differ. However, mothers of VP/VLBWs had lower satisfaction relative to mothers of term-borns at both assessments post-birth. Among fathers, satisfaction levels were similarly equivalent two years before birth. Subsequently, fathers of VP/VLBWs temporarily differed in satisfaction six months post-birth relative to fathers of term-borns. Results indicate that parents' lower life satisfaction after VP/VLBW birth is not a continuation of pre-existing life satisfaction differences.

Developing a length of stay prediction model for newborns, achieving better accuracy with greater usability

BACKGROUND

One in ten newborn children is born prematurely. The elongated length of stay (LOS) of these children in the Neonatal Intensive Care Unit (NICU) has important implications on hospital occupancy figures, healthcare and management costs, as well as the psychology of parents. In order to allow accurate planning and resource allocation, this study aims to create a generalizable and robust model to predict the NICU LOS of preterm newborns.

METHODS

Data were collected from a large tertiary center NICU between 2011 and 2018 and relates to 5,362 newborns. The selected model was externally validated using a data set of 8,768 newborns from another tertiary center NICU. This report compares several models, such as Random Forest (RF), quantile RF, and other feature selection methods, including LASSO and AIC step-forward selection. In addition, a novel step-forward selection based on False Discovery Rate (FDR) for quantile regression is presented and evaluated.

RESULTS

A high-orderquantile regression model for predicting preterm newborns' LOS that uses only four features available at birth had more attractive properties than other richer ones. The model achieved a Mean Absolute Error (MAE) of 6.26 days on the internal validation set (average LOS 27.04) and an MAE of 6.04 days on the external validation set (average LOS 29.32). The suggested model surpassed the accuracy obtained by models in the literature. It is shown empirically that the FDR-based selection has better properties than the AIC-based step-forward selection approach.

CONCLUSION

This paper demonstrates a process to create a predictive model for NICU LOS in preterm newborns, where each step is reasoned. We obtain a simple and robust model for NICU LOS prediction, which achieves far better results than the current model used for financing NICUs. Utilizing this model, we have created an easy-to-use online web application to ease parents' worries and to assist NICU management: https://tzviel.shinyapps.io/calcuLOS.

Postural Control Measurements to Predict Future Motor Impairment in Preterm Infants: A Systematic Review

Preterm infants are more likely to demonstrate developmental delays than fullterm infants. Postural measurement tools may be effective in measuring the center of pressure (COP) and asymmetry, as well as predicting future motor impairment. The objective of this systematic review was to evaluate existing evidence regarding use of pressure mats or force plates for measuring COP and asymmetry in preterm infants, to determine how measures differ between preterm and fullterm infants and if these tools appropriately predict future motor impairment. The consulted databases included PubMed, Embase, Scopus, and CINAHL. The quality of the literature and the risk of bias were assessed utilizing the ROB2: revised Cochrane risk-of bias tool. Nine manuscripts met the criteria for review. The postural control tools included were FSA UltraThin seat mat, Conformat Pressure-Sensitive mat, Play and Neuro-Developmental Assessment, and standard force plates. Studies demonstrated that all tools were capable of COP assessment in preterm infants and support the association between the observation of reduced postural complexity prior to the observation of midline head control as an indicator of future motor delay. Postural measurement tools provide quick and objective measures of postural control and asymmetry. Based on the degree of impairment, these tools may provide an alternative to standardized assessments that may be taxing to the preterm infant, inaccessible to therapists, or not sensitive enough to capture motor delays.

Estimated neonatal survival of very preterm births across the care pathway: a UK cohort 2016-2020

OBJECTIVE

Currently used estimates of survival are nearly 10 years old and relate to only those babies admitted for neonatal care. Due to ongoing improvements in neonatal care, here we update estimates of survival for singleton and multiple births at 22+0 to 31+6 weeks gestational age across the perinatal care pathway by gestational age and birth weight.

DESIGN

Retrospective analysis of routinely collected data.

SETTING

A national cohort from the UK and British Crown Dependencies.

PATIENTS

Babies born at 22+0 to 31+6 weeks gestational age from 1 January 2016 to 31 December 2020.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Survival to 28 days.

RESULTS

Estimates of neonatal survival are provided for babies: (1) alive at the onset of care during the birthing process (n=43 763); (2) babies where survival-focused care was initiated (n=42 004); and (3) babies admitted for neonatal care (n=41 158). We have produced easy-to-use survival charts for singleton and multiple births. Generally, survival increased with increasing gestational age at birth and with increasing birth weight. For all births with a birthweight over 1000 g, survival was 90% or higher at all three stages of care.

CONCLUSIONS

Survival estimates are a vital tool to support and supplement clinical judgement within perinatal care. These up-to-date, national estimates of survival to 28 days are provided based on three stages of the perinatal care pathway to support ongoing clinical care. These novel results are a key resource for policy and practice including counselling parents and informing care provision.

Risk assessment of survival and morbidity of infants born at <24 completed weeks of gestation

BACKGROUND

Infants born at the threshold of viability have a high risk of mortality and morbidity. The British Association of Perinatal Medicine (BAPM) provided updated guidance in 2019 advising a risk-based approach to balancing decisions about active versus redirected care at birth.

AIMS

To determine survival and morbidity of infants born between 22 and 24 completed weeks of gestation. To develop a scoring system to categorise infants at birth according to risk for mortality or severe adverse outcome.

METHODS

A retrospective, single centre observational study of infants who received neonatal care from 2011 to 2021. Data were collected on mortality, morbidity and two-year neurodevelopmental outcomes. Each infant was risk categorised utilising the proposed tools in the BAPM (2019) framework. A composite adverse score for either dying or surviving with severe impairment was created.

RESULTS

Four infants born at 22 weeks, 49 at 23 weeks and 105 at 24 weeks of gestation were included. The mortality rate was 23.4 %. Following risk categorisation there were 8 (5.1 %) extremely high risk, 44 (27.8 %) high risk and 106 (67.1 %) moderate risk infants. The rate of dying or surviving with severe impairment for extremely high risk, high risk and moderate risk were 100 %, 88.9 % and 53 % respectively. The proportions with the composite adverse outcome differed significantly according to the risk category (p < 0.001).

CONCLUSIONS

When applying a scoring system to risk categorise infants at birth, high rates of dying or surviving with severe impairment were found in infants born at 22 or 23 weeks of gestation.

Gestational age and hospital admission costs from birth to childhood: a population-based record linkage study in England

OBJECTIVE

To examine the association between gestational age at birth and hospital admission costs from birth to 8 years of age.

DESIGN

Population-based, record linkage, cohort study in England.

SETTING

National Health Service (NHS) hospitals in England, UK.

PARTICIPANTS

1 018 136 live, singleton births in NHS hospitals in England between 1 January 2005 and 31 December 2006.

MAIN OUTCOME MEASURES

Hospital admission costs from birth to age 8 years, estimated by gestational age at birth (<28, 28-29, 30-31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 42 weeks).

RESULTS

Both birth admission and subsequent admission hospital costs decreased with increasing gestational age at birth. Differences in hospital admission costs between gestational age groups diminished with increasing age, particularly after the first 2 years following birth. Children born extremely preterm (<28 weeks) and very preterm (28-31 weeks) still had higher average hospital admission costs (£699 (95% CI £419 to £919) for <28 weeks; £434 (95% CI £305 to £563) for 28-31 weeks) during the eighth year of life compared with children born at 40 weeks (£109, 95% CI £104 to £114). Children born extremely preterm had the highest 8-year cumulative hospital admission costs per child (£80 559 (95% CI £79 238 to £82 019)), a large proportion of which was incurred during the first year after birth (£71 997 (95% CI £70 866 to £73 097)).

CONCLUSIONS

The association between gestational age at birth and hospital admission costs persists into mid-childhood. The study results provide a useful costing resource for future economic evaluations focusing on preventive and treatment strategies for babies born preterm.

Incidence of infant Gram-negative invasive bacterial infections in England, 2011-2019: an observational study using population-wide surveillance data

OBJECTIVE

Invasive bacterial infections account for an estimated 15% of infant deaths worldwide. We aimed to estimate the incidence and trends in invasive bacterial infections in infants caused by Gram-negative pathogens in England during 2011-2019.

METHODS

Laboratory-confirmed invasive bacterial infections in infants (<1 year old) were identified in the UK Health Security Agency national laboratory surveillance data from April 2011 to March 2019. Polymicrobial infections were defined as two or more bacterial species from the same normally sterile sample site. Early-onset infections were defined as <7 days from birth and late-onset as ≥7 days (neonates 7-28 days; infants ≥29 days). Trend analyses were carried out using Poisson (for episodes/incidence) and beta (for proportions) regression.

RESULTS

The annual incidence of invasive bacterial infections increased by 35.9%, from 189.8 to 258.0 cases per 100 000 live births (p<0.001). Late-onset infections in both neonates and infants increased substantially over the study period (p<0.001), whereas early-onset infections increased slightly (p=0.002). Escherichia coli was the most common Gram-negative pathogen isolated and accounted for 27.2% of the overall rise in Gram-negative infant disease incidence. Polymicrobial infections almost doubled, increasing from 29.2 to 57.7 per 100 000 live births (p<0.001), and mostly involved two species (81.3%, 1604/1974 episodes).

CONCLUSIONS

The incidence of Gram-negative invasive bacterial infections in infants increased between 2011/2012 and 2018/2019 in England, driven mainly by an increase in late-onset infections. Further work is required to elucidate the risk factors and drivers of this increased incidence so that opportunities for prevention can be identified.

Impact of Technology on Neonatal Intensive Care Unit Admissions and Length of Stay: A Retrospective Study

Background Neonatal intensive care units (NICU) provide essential medical care to neonates; however, they are associated with hospital-acquired infections, less maternal-newborn bonding, and high costs. Implementing strategies to lower NICU admission rates and shorten NICU length of stay (LOS) is essential. This study uses causal-inference methods to evaluate the impact of care managers using new technology to identify and risk stratify pregnancies on NICU admissions and NICU LOS. The NICU LOS will decrease as a result of the use of new technology by care managers. Study design This retrospective study utilized delivery claims data of pregnant women from the CareFirst BlueCross BlueShield Community Health Plan District of Columbia from 2013 to 2022, which includes the pre-intervention period before the use of new technology by care managers and the post-intervention period with the use of new technology by care managers. Our sample had 4,917 deliveries whose maternal comorbidities were matched with their neonate's outcomes. Methods To evaluate the impact of the technological intervention, both Generalized Linear Models (GLMs) and Bayesian Structural Time-Series (BSTS) models were used. Results Our findings from the GLM models suggest an overall average reduction in the odds of NICU admissions of 29.2% and an average decrease in NICU LOS from 7.5%-58.5%. Using BSTS models, we estimate counterfactuals for NICU admissions and NICU LOS, which suggest an average reduction in 48 NICU admissions and 528 NICU days per year. Conclusion Equipping care managers with better technological tools can lead to significant improvements in neonatal health outcomes as indicated by a reduction in NICU admissions and NICU LOS.

Sociodemographic factors and family use of remote infant viewing in neonatal intensive care

OBJECTIVE

We aimed to determine whether the use of remote infant viewing (RIV) in a neonatal intensive care unit (NICU) differed based on maternal sociodemographic factors.

METHODS

The number of RIV camera views and view duration were obtained for NICU patients between 10/01/2019 and 3/31/2021 and standardized relative to patient days. Maternal sociodemographic and neonatal characteristics were obtained from institutional databases.

RESULTS

Families in which mothers were unmarried (aOR 1.42, 95% CI 1.03-1.95), did not require an interpreter (aOR 2.86, 95% CI 1.54-5.32), were multiparous (aOR 1.56, 95% CI 1.16-2.10), delivered prior to 37 weeks' gestation (aOR 1.57, 95% CI 1.17-2.12), or resided ≥50 miles from the NICU (aOR 1.38, 95% CI 1.02-1.87) were significantly more likely to use RIV.

CONCLUSION

Family use of RIV in the NICU varied by multiple sociodemographic factors. Further investigation to understand and to address potential equity gaps revealed or created by RIV are warranted.

Neonatal intensive care unit occupancy rate and probability of discharge of very preterm infants

OBJECTIVE

To assess the association of NICU occupancy with probability of discharge and length of stay (LOS) among infants born <33 weeks gestational age (GA).

STUDY DESIGN

Retrospective study of 3388 infants born 23-32 weeks GA, admitted to five Level 3/4 NICUs (2014-2018) and discharged alive. Standardized ratios of observed-to-expected number of discharges were calculated for each quintile of unit occupancy. Multivariable linear regression models were used to assess the association between occupancy and LOS.

RESULTS

At the lowest unit occupancy quintiles (Q1 and Q2), infants were 12% and 11% less likely to be discharged compared to the expected number. At the highest unit occupancy quintile (Q5), infants were 20% more likely to be discharged. Highest occupancy (Q5) was also associated with a 4.7-day (95% CI 1.7, 7.7) reduction in LOS compared Q1.

CONCLUSION

NICU occupancy was associated with likelihood of discharge and LOS among infants born <33 weeks GA.

Burden of Treatments for Respiratory Complications in Extremely Premature Infants: Interviews with Caregivers

Introduction

Extremely premature (EP) infants (<28 weeks gestational age) with respiratory conditions after discharge from the neonatal intensive care unit (NICU) impose a significant burden on caregivers. This study explored caregiver burden post-NICU discharge and perceptions of meaningful change in infant chronic respiratory morbidity.

Methods

Adult primary caregivers of EP infants 3-14 months corrected age were recruited through patient advocacy organizations or hospital centers in the USA, Northern Ireland, Germany, and Japan and interviewed by phone. Interviews explored caregiver experiences with infants with respiratory conditions, associated treatment burden, and meaningful change in infant respiratory morbidity as measured by treatment use. Qualitative analysis of interview data was performed using MAXQDA software. Sociodemographic data were summarized using descriptive statistics.

Results

Forty-five caregivers (95.6% female) of EP infants were interviewed. Respiratory morbidities post-NICU discharge included coughing (78%), breathing difficulties (76%), wheezing (58%), and bronchopulmonary dysplasia/chronic lung disease of prematurity (56%). Respiratory medications were required by 87% of infants, 80% used home respiratory technology support (e.g., supplemental oxygen), 38% were re-hospitalized, and 33% had emergency department visits. Caregivers considered visits to the emergency department to be the most burdensome treatment requirement they experienced, and reduction in the number of emergency department visits was considered the most meaningful change in treatment use.

Conclusion

These findings underscore the significant burden faced by caregivers of EP infants with respiratory morbidities. Development of treatments for respiratory complications should take into consideration the concerns and preferences of caregivers in order to provide a meaningful benefit.

Risk factors for length of NICU stay of newborns: A systematic review

Background

The improvement in survival of preterm infants is accompanied by an increase in neonatal intensive care unit (NICU) admissions. Prolonged length of stay in the NICU (LOS-NICU) increases the incidence of neonatal complications and even mortality and places a significant economic burden on families and strain on healthcare systems. This review aims to identify risk factors influencing LOS-NICU of newborns and to provide a basis for interventions to shorten LOS-NICU and avoid prolonged LOS-NICU.

Methods

A systematic literature search was conducted in PubMed, Web of Science, Embase, and Cochrane library for studies that were published in English from January 1994 to October 2022. The PRISMA guidelines were followed in all phases of this systematic review. The Quality in Prognostic Studies (QUIPS) tool was used to assess methodological quality.

Results

Twenty-three studies were included, 5 of which were of high quality and 18 of moderate quality, with no low-quality literature. The studies reported 58 possible risk factors in six broad categories (inherent factors; antenatal treatment and maternal factors; diseases and adverse conditions of the newborn; treatment of the newborn; clinical scores and laboratory indicators; organizational factors).

Conclusions

We identified several of the most critical risk factors affecting LOS-NICU, including birth weight, gestational age, sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, and retinopathy of prematurity. As only a few high-quality studies are available at present, well-designed and more extensive prospective studies investigating the risk factors affecting LOS-NICU are still needed in the future.

Burden of Comorbidities and Healthcare Resource Utilization Among Medicaid-Enrolled Extremely Premature Infants

Background: The effect of gestational age (GA) on comorbidity prevalence, healthcare resource utilization (HCRU), and all-cause costs is significant for extremely premature (EP) infants in the United States. Objectives: To characterize real-world patient characteristics, prevalence of comorbidities, rates of HCRU, and direct healthcare charges and societal costs among premature infants in US Medicaid programs, with respect to GA and the presence of respiratory comorbidities. Methods: Using International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes, diagnosis and medical claims data from 6 state Medicaid databases (1997-2018) of infants born at less than 37 weeks of GA (wGA) were collected retrospectively. Data from the index date (birth) up to 2 years corrected age or death, stratified by GA (EP, ≤28 wGA; very premature [VP], >28 to <32 wGA; and moderate to late premature [M-LP], ≥32 to <37 wGA), were compared using unadjusted and adjusted generalized linear models. Results: Among 25 573 premature infants (46.1% female; 4462 [17.4%] EP; 2904 [11.4%] VP; 18 207 [71.2%] M-LP), comorbidity prevalence, HCRU, and all-cause costs increased with decreasing GA and were highest for EP. Total healthcare charges, excluding index hospitalization and all-cause societal costs (US dollars), were 2 to 3 times higher for EP than for M-LP (EP $74 436 vs M-LP $27 541 and EP $28 504 vs M-LP $15 892, respectively). Conclusions: Complications of preterm birth, including prevalence of comorbidities, HCRU, and costs, increased with decreasing GA and were highest among EP infants during the first 2 years in this US analysis.

How parents and health professionals experience prematurity in an Italian neonatal intensive care: A grounded theory study

PURPOSE

The aim of this study was to explore prematurity as a psycho-social process from the point of view of both parents and healthcare professionals.

DESIGN AND METHODS

We conducted a Grounded Theory study through semi-structured interviews. Participants were from an Italian Neonatal Intensive Care Unit, including parents of premature children, and health professionals. Interviews were analyzed according to Grounded Theory coding strategies, to hypothesize a theoretical model.

RESULTS

On one side, behaviors, emotions, and feelings of parental couples; on the other one, the activities and reactions of professionals have been interpreted in a four-phase negotiated process: 1) the initial breakup; 2) the floating family; 3) the event processing; 4) the reconstruction of a new family.

CONCLUSIONS

Managing prematurity is a negotiated process which could be better managed through a family-centered approach as fundamental in neonatal and pediatric services. Being open in listening, coherent in the given answers, and knowing the entire process and story of being suddenly parents of a premature child can make the difference in the future definition of a new family.

PRACTICE IMPLICATIONS

Perinatal care would benefit from the following suggested practical implications: i) reducing feelings of separation and solitude by integrating diverse professionals around the family systems; ii) expediting prematurity-related changes through peer-support during hospitalization and attention to rooms' organization; iii) enhancing information exchange between all professionals involved in the care of dyads/parents and new-borns, starting since the pregnancy and continuing after the child's birth by implementing multidisciplinary meetings or appropriate care pathways.

Measuring quality of care in moderate and late preterm infants

OBJECTIVE

To examine quality measures for moderate and late preterm (MLP) infants.

STUDY DESIGN

By prospectively analyzing Vermont Oxford Network's all NICU admissions database, we adapted Baby-MONITOR, a composite quality measure for extremely/very preterm infants, for MLP infants. We examined correlations between the adapted MLP quality measure (MLP-QM) in MLP infants and Baby-MONITOR in extremely and very preterm infants.

RESULT

We studied 376,219 MLP (30-36 weeks GA) and 57,595 extremely/very preterm (25-29 weeks GA) infants from 465 U.S. hospitals born from 2016 to 2020. MLP-QM summary scores in MLP infants had weak correlation with Baby-MONITOR scores in extremely and very preterm infants (r = 0.47). There was weak correlation among survival (r = 0.19), no pneumothorax (r = 0.35), and no infection after 3 days (r = 0.45), but strong correlation among human milk at discharge (r = 0.79) and no hypothermia (r = 0.76).

CONCLUSION

Modest correlation among hospital care measures in two preterm populations suggests the need for MLP-specific care measures.

Outcomes in relation to early parenteral nutrition use in preterm neonates born between 30 and 33 weeks' gestation: a propensity score matched observational study

OBJECTIVE

To evaluate whether in preterm neonates parenteral nutrition use in the first 7 postnatal days, compared with no parenteral nutrition use, is associated with differences in survival and other important morbidities. Randomised trials in critically ill older children show that harms, such as nosocomial infection, outweigh benefits of early parenteral nutrition administration; there is a paucity of similar data in neonates.

DESIGN

Retrospective cohort study using propensity matching including 35 maternal, infant and organisational factors to minimise bias and confounding.

SETTING

National, population-level clinical data obtained for all National Health Service neonatal units in England and Wales.

PATIENTS

Preterm neonates born between 30⁺⁰ and 32⁺⁶ weeks^+days.

INTERVENTIONS

The exposure was parenteral nutrition administered in the first 7 days of postnatal life; the comparator was no parenteral nutrition.

MAIN OUTCOME MEASURES

The primary outcome was survival to discharge from neonatal care. Secondary outcomes comprised the neonatal core outcome set.

RESULTS

16 292 neonates were compared in propensity score matched analyses. Compared with matched neonates not given parenteral nutrition in the first postnatal week, neonates who received parenteral nutrition had higher survival at discharge (absolute rate increase 0.91%; 95% CI 0.53% to 1.30%), but higher rates of necrotising enterocolitis (absolute rate increase 4.6%), bronchopulmonary dysplasia (absolute rate increase 3.9%), late-onset sepsis (absolute rate increase 1.5%) and need for surgical procedures (absolute rate increase 0.92%).

CONCLUSIONS

In neonates born between 30⁺⁰ and 32⁺⁶ weeks' gestation, those given parenteral nutrition in the first postnatal week had a higher rate of survival but higher rates of important neonatal morbidities. Clinician equipoise in this area should be resolved by prospective randomised trials.

TRIAL REGISTRATION NUMBER

NCT03767634.

Variations in length of stay among survived very preterm infants admitted to Chinese neonatal intensive care units

BACKGROUND

This study aimed to describe length of stay (LOS) to discharge and site variations among very preterm infants (VPIs) admitted to 57 Chinese neonatal intensive care units (NICUs) and to investigate factors associated with LOS for VPIs.

METHODS

This retrospective multicenter cohort study enrolled all infants < 32 weeks' gestation and admitted to 57 NICUs which had participated in the Chinese Neonatal Network, within 7 days after birth in 2019. Exclusion criteria included major congenital anomalies, NICU deaths, discharge against medical advice, transfer to non-participating hospitals, and missing discharge date. Two multivariable linear models were used to estimate the association of infant characteristics and LOS.

RESULTS

A total of 6580 infants were included in our study. The overall median LOS was 46 days [interquartile range (IQR): 35-60], and the median corrected gestational age at discharge was 36 weeks (IQR: 35-38). LOS and corrected gestational age at discharge increased with decreasing gestational age. The median corrected gestational age at discharge for infants at 24 weeks, 25 weeks, 26 weeks, 27-28 weeks, and 29-31 weeks were 41 weeks, 39 weeks, 38 weeks, 37 weeks and 36 weeks, respectively. Significant site variation of LOS was identified with observed median LOS from 33 to 71 days in different hospitals.

CONCLUSIONS

The study provided concurrent estimates of LOS for VPIs which survived in Chinese NICUs that could be used as references for medical staff and parents. Large variation of LOS independent of infant characteristics existed, indicating variation of care practices requiring further investigation and quality improvement.

Toy story: A cross-sectional survey of toy populations in tertiary neonatal units

Thousands of babies are given toys for their zeroth birthday … But what happens if that baby is admitted to neonatal intensive care? In a global first, we describe the population of toys found in incubators on neonatal intensive care unit.

Predicting in-hospital length of stay for very-low-birth-weight preterm infants using machine learning techniques

BACKGROUND/PURPOSE

The in-hospital length of stay (LOS) among very-low-birth-weight (VLBW, BW < 1500 g) infants is an index for care quality and affects medical resource allocation. We aimed to analyze the LOS among VLBW infants in Taiwan, and to develop and compare the performance of different LOS prediction models using machine learning (ML) techniques.

METHODS

This retrospective study illustrated LOS data from VLBW infants born between 2016 and 2018 registered in the Taiwan Neonatal Network. Among infants discharged alive, continuous variables (LOS or postmenstrual age, PMA) and categorical variables (late and non-late discharge group) were used as outcome variables to build prediction models. We used 21 early neonatal variables and six algorithms. The performance was compared using the coefficient of determination (R²) for continuous variables and area under the curve (AUC) for categorical variables.

RESULTS

A total of 3519 VLBW infants were included to illustrate the profile of LOS. We found 59% of mortalities occurred within the first 7 days after birth. The median of LOS among surviving and deceased infants was 62 days and 5 days. For the ML prediction models, 2940 infants were enrolled. Prediction of LOS or PMA had R² values less than 0.6. Among the prediction models for prolonged LOS, the logistic regression (ROC: 0.724) and random forest (ROC: 0.712) approach had better performance.

CONCLUSION

We provide a benchmark of LOS among VLBW infants in each gestational age group in Taiwan. ML technique can improve the accuracy of the prediction model of prolonged LOS of VLBW.

Surveillance for Colonization, Transmission, and Infection With Methicillin-Susceptible Staphylococcus aureus in a Neonatal Intensive Care Unit

IMPORTANCE

Staphylococcus aureus is one of the leading causes of infections in neonatal intensive care units (NICUs). Most studies in this patient group focus on methicillin-resistant S aureus or the outbreak setting, whereas data for methicillin-susceptible S aureus are limited.

OBJECTIVES

To identify risk factors for S aureus colonization and infections in hospitalized newborns and to investigate S aureus transmission and its dynamics in a nonoutbreak setting.

DESIGN, SETTING, AND PARTICIPANTS

This monocentric cohort study in a tertiary NICU in Heidelberg, Germany, enrolled all hospitalized neonates (n = 590) with at least 1 nasal screening swab positive for S aureus. Data were collected from January 1, 2018, to December 31, 2019.

EXPOSURES

Weekly screening for S aureus colonization was performed for all newborns until discharge.

MAIN OUTCOMES AND MEASURES

The primary end point was any S aureus infection until hospital discharge. Transmission of S aureus and performance of routine typing to detect transmissions were defined as the secondary outcomes of the study.

RESULTS

In total, 590 newborns were enrolled (276 [46.8%] female and 314 [53.2%] male; 220 [37.3%] with birthweight <1500 g; 477 [80.8%] preterm; 449 [76.1%] singletons; 419 [71.5%] delivered via cesarean section). The median length of stay was 26 (range, 10-62) days. Overall, 135 infants (22.9%) were colonized by S aureus at some time during their hospital stay. The median time to first detection was 17 (interquartile range, 11-37) days. The overall incidence of S aureus infection was 1.7% (10 of 590). Low birth weight (<1500 g [odds ratio, 9.3; 95% CI, 5.9-14.6; P < .001]) and longer hospital stay (odds ratio, 2.3; 95% CI, 1.9-2.7; P < .001) were associated with colonization. Nasal carriage was significantly associated with S aureus infection (odds ratio, 8.2; 95% CI, 2.1-32.3; P = .002). A total of 123 of 135 colonization isolates were sequenced. All recoverable infection isolates (4 of 7) of newborns with colonization were genetically identical to the colonizing isolate. Whole-genome sequencing indicated 23 potential transmission clusters.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that nasal colonization is a relevant risk factor for S aureus infection in a nonoutbreak NICU setting. In colonized newborns, infection and colonization isolates were genetically identical, suggesting that eradication of colonization may be a useful measure to prevent infection. Further investigations are necessary to validate and assess the generalizability of our findings.

Sex-Specific Long-Term Trends in Length of Hospital Stay, Postmenstrual Age at Discharge, and Survival in Very Low Birth Weight Infants

INTRODUCTION

In very low birth weight (<1,500 g, VLBW) infants, morbidity and mortality have decreased substantially during the past decades, and both are known to be lower in girls than in boys. In this study, we assessed sex-specific changes over time in length of hospital stay (LOHS) and postmenstrual age at discharge (PAD), in addition to survival in VLBW infants.

METHODS

This is a single-center retrospective cohort analysis based on quality assurance data of VLBW infants born from 1978 to 2018. Estimation of sex-specific LOHS over time was based on infants discharged home from neonatal care or deceased. Estimation of sex-specific PAD over time was based on infants discharged home exclusively. Analysis of in-hospital survival was performed for all VLBW infants.

RESULTS

In 4,336 of 4,499 VLBW infants admitted from 1978 to 2018 with complete data (96.4%), survival rates improved between 1978-1982 and 1993-1997 (70.8 vs. 88.3%; hazard ratio (HR) 0.20, 95% confidence interval 0.14, 0.30) and remained stable thereafter. Boys had consistently higher mortality rates than girls (15 vs. 12%, HR 1.23 [1.05, 1.45]). Nonsurviving boys died later compared to nonsurviving girls (adjusted mean survival time 23.0 [18.0, 27.9] vs. 20.7 [15.0, 26.3] days). LOHS and PAD assessed in 3,166 survivors displayed a continuous decrease over time (1978-1982 vs. 2013-2018: LOHS days 82.9 [79.3, 86.5] vs. 60.3 [58.4, 62.1] days); PAD 40.4 (39.9, 40.9) vs. 37.4 [37.1, 37.6] weeks). Girls had shorter LOHS than boys (69.4 [68.0, 70.8] vs. 73.0 [71.6, 74.4] days) and were discharged with lower PAD (38.6 [38.4, 38.8] vs. 39.2 [39.0, 39.4] weeks).

DISCUSSION/CONCLUSIONS

LOHS and PAD decreased over the last 40 years, while survival rates improved. Male sex was associated with longer LOHS, higher PAD, and higher mortality rates.

Variations in Neonatal Length of Stay of Babies Born Extremely Preterm: An International Comparison Between iNeo Networks

OBJECTIVE

To compare length of stay (LOS) in neonatal care for babies born extremely preterm admitted to networks participating in the International Network for Evaluating Outcomes of Neonates (iNeo).

STUDY DESIGN

Data were extracted for babies admitted from 2014 to 2016 and born at 24 to 28 weeks of gestational age (n = 28 204). Median LOS was calculated for each network for babies who survived and those who died while in neonatal care. A linear regression model was used to investigate differences in LOS between networks after adjusting for gestational age, birth weight z score, sex, and multiplicity. A sensitivity analysis was conducted for babies who were discharged home directly.

RESULTS

Observed median LOS for babies who survived was longest in Japan (107 days); this result persisted after adjustment (20.7 days more than reference, 95% CI 19.3-22.1). Finland had the shortest adjusted LOS (-4.8 days less than reference, 95% CI -7.3 to -2.3). For each week's increase in gestational age at birth, LOS decreased by 12.1 days (95% CI -12.3 to -11.9). Multiplicity and male sex predicted mean increases in LOS of 2.6 (95% CI 2.0-3.2) and 2.1 (95% CI 1.6-2.6) days, respectively.

CONCLUSIONS

We identified between-network differences in LOS of up to 3 weeks for babies born extremely preterm. Some of these may be partly explained by differences in mortality, but unexplained variations also may be related to differences in clinical care practices and healthcare systems between countries.

Duration of and trends in respiratory support among extremely preterm infants

OBJECTIVE

To evaluate annual trends in the administration and duration of respiratory support among preterm infants.

DESIGN

Retrospective cohort study.

SETTING

Tertiary neonatal intensive care units in the Canadian Neonatal Network.

PATIENTS

8881 extremely preterm infants born from 2010 to 2017 treated with endotracheal and/or non-invasive positive pressure support (PPS).

MAIN OUTCOME MEASURES

Competing risks methods were used to investigate the outcomes of mortality and time to first successful extubation, definitive extubation, weaning off PPS, and weaning PPS and/or low-flow oxygen, according to gestational age (GA). Cox proportional hazards and regression models were fitted to evaluate the trend in duration of respiratory support, survival and surfactant treatment over the study period.

RESULTS

The percentages of infants who died or were weaned from respiratory support were presented graphically over time by GA. Advancing GA was associated with ordinally earlier weaning from respiratory support. Year over year, infants born at 23 weeks were initially and definitively weaned from endotracheal and all PPS earlier (HR 1.06, 95% CI 1.01 to 1.11, for all outcomes), while survival simultaneously increased (OR 1.11, 95% CI 1.03 to 1.18). Infants born at 26 and 27 weeks remained on non-invasive PPS longer (HR 0.97, 95% CI 0.95 to 0.98 and HR 0.97, 95% CI 0.95 to 0.99, respectively). Early surfactant treatment declined among infants born at 24-27 weeks GA.

CONCLUSIONS

Infants at the borderline of viability have experienced improved survival and earlier weaning from all forms of PPS, while those born at 26 and 27 weeks are spending more time on PPS in recent years. GA-based estimates of the duration of respiratory support and survival may assist in counselling, benchmarking, quality improvement and resource planning.

Identification of variation in nutritional practice in neonatal units in England and association with clinical outcomes using agnostic machine learning

We used agnostic, unsupervised machine learning to cluster a large clinical database of information on infants admitted to neonatal units in England. Our aim was to obtain insights into nutritional practice, an area of central importance in newborn care, utilising the UK National Neonatal Research Database (NNRD). We performed clustering on time-series data of daily nutritional intakes for very preterm infants born at a gestational age less than 32 weeks (n = 45,679) over a six-year period. This revealed 46 nutritional clusters heterogeneous in size, showing common interpretable clinical practices alongside rarer approaches. Nutritional clusters with similar admission profiles revealed associations between nutritional practice, geographical location and outcomes. We show how nutritional subgroups may be regarded as distinct interventions and tested for associations with measurable outcomes. We illustrate the potential for identifying relationships between nutritional practice and outcomes with two examples, discharge weight and bronchopulmonary dysplasia (BPD). We identify the well-known effect of formula milk on greater discharge weight as well as support for the plausible, but insufficiently evidenced view that human milk is protective against BPD. Our framework highlights the potential of agnostic machine learning approaches to deliver clinical practice insights and generate hypotheses using routine data.

Gestational age and hospital admissions during childhood: population based, record linkage study in England (TIGAR study)

OBJECTIVE

To examine the association between gestational age at birth and hospital admissions to age 10 years and how admission rates change throughout childhood.

DESIGN

Population based, record linkage, cohort study in England.

SETTING

NHS hospitals in England, United Kingdom.

PARTICIPANTS

1 018 136 live, singleton births in NHS hospitals in England between January 2005 and December 2006.

MAIN OUTCOME MEASURES

Primary outcome was all inpatient hospital admissions from birth to age 10, death, or study end (March 2015); secondary outcome was the main cause of admission, which was defined as the World Health Organization's first international classification of diseases, version 10 (ICD-10) code within each hospital admission record.

RESULTS

1 315 338 admissions occurred between 1 January 2005 and 31 March 2015, and 831 729 (63%) were emergency admissions. 525 039 (52%) of 1 018 136 children were admitted to hospital at least once during the study period. Hospital admissions during childhood were strongly associated with gestational age at birth (<28, 28-29, 30-31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42 weeks). In comparison with children born at full term (40 weeks' gestation), those born extremely preterm (<28 weeks) had the highest rate of hospital admission throughout childhood (adjusted rate ratio 4.92, 95% confidence interval 4.58 to 5.30). Even children born at 38 weeks had a higher rate of hospital admission throughout childhood (1.19, 1.16 to 1.22). The association between gestational age and hospital admission decreased with increasing age (interaction P<0.001). Children born earlier than 28 weeks had an adjusted rate ratio of 6.34 (95% confidence interval 5.80 to 6.85) at age less than 1 year, declining to 3.28 (2.82 to 3.82) at ages 7-10, in comparison with those born full term; whereas in children born at 38 weeks, the adjusted rate ratios were 1.29 (1.27 to 1.31) and 1.16 (1.13 to 1.19), during infancy and ages 7-10, respectively. Infection was the main cause of excess hospital admissions at all ages, but particularly during infancy. Respiratory and gastrointestinal conditions also accounted for a large proportion of admissions during the first two years of life.

CONCLUSIONS

The association between gestational age and hospital admission rates decreased with age, but an excess risk remained throughout childhood, even among children born at 38 and 39 weeks of gestation. Strategies aimed at the prevention and management of childhood infections should target children born preterm and those born a few weeks early.

Maternal Diet Quality, Body Mass Index and Resource Use in the Perinatal Period: An Observational Study

The impact of pre-pregnancy obesity and maternal diet quality on the use of healthcare resources during the perinatal period is underexplored. We assessed the effects of body mass index (BMI) and diet quality on the use of healthcare resources, to identify whether maternal diet quality may be effectively targeted to reduce antenatal heath care resource use, independent of women’s BMI. Cross-sectional data and inpatient medical records were gathered from pregnant women attending publicly funded antenatal outpatient clinics in Newcastle, Australia. Dietary intake was self-reported, using the Australian Eating Survey (AES) food frequency questionnaire, and diet quality was quantified from the AES subscale, the Australian Recommended Food Score (ARFS). Mean pre-pregnancy BMI was 28.8 kg/m² (range: 14.7 kg/m²–64 kg/m²). Mean ARFS was 28.8 (SD = 13.1). Higher BMI was associated with increased odds of caesarean delivery; women in obese class II (35.0–39.9 kg/m²) had significantly higher odds of caesarean delivery compared to women of normal weight, (OR = 2.13, 95% CI 1.03 to 4.39; p = 0.04). Using Australian Refined Diagnosis Related Group categories for birth admission, the average cost of the birth admission was $1348 more for women in the obese class II, and $1952 more for women in the obese class III, compared to women in a normal BMI weight class. Higher ARFS was associated with a small statistically significant reduction in maternal length of stay (RR = 1.24, 95% CI 1.00, 1.54; p = 0.05). There was no evidence of an association between ARFS and mode of delivery or “midwifery-in-the-home-visits”.

The effect of donor human milk on the length of hospital stay in very low birthweight infants: a systematic review and meta-analysis

BACKGROUND

Donor human milk (DHM) is an alternative to preterm infant formula if the mother's own milk is not available. Since the lactation period and preservation treatment of DHM are different from those of mother's own milk, we aimed to determine the reduction in the length of hospital stay by DHM compared to preterm infant formula.

METHODS

In this systematic review, we searched PubMed/MEDLINE, EMBASE, and the Cochrane Library to retrieve studies on the impact of DHM on the clinical outcomes of preterm infants published before 1 November 2019. The study included very low birthweight (VLBW) infants taking either DHM or infant formula with data on the length of hospital stay. Data were analysed using Review Manager 5.3 software.

RESULTS

The literature search yielded 136 articles, and four randomised controlled trials (RCTs) and eight observational studies met the inclusion criteria. A meta-analysis of the RCTs (N = 725) showed no reduction in the length of hospital stay in both the DHM and infant formula groups (- 0.22 days; 95% CI -6.38, 5.95 days), whereas that of the eight observational studies (N = 2496) showed a significant reduction in the length of hospital stay in the DHM group (- 11.72 days; 95% CI -22.07, - 1.37 days). A subgroup analysis of the RCTs revealed that the incidence of necrotising enterocolitis (NEC) was significantly lower in the DHM group when the analysis included high-quality RCTs (RR = 0.32; 95% CI 0.15, 0.69).

CONCLUSIONS

This systematic review of RCTs showed that DHM neither prolonged nor shortened the length of hospital stay in VLBW infants compared to preterm infant formula; however, it reduced the incidence of NEC, further validating the protective role of DHM in the health and safety of VLBW infants.

Predictors of length of hospital stay among preterm infants admitted to neonatal intensive care unit: Data from a multicentre collaborative network from India (INNC: Indian National Neonatal Collaborative)

AIM

Prediction of length of stay (LOS) among preterm neonates is important for counselling of parents and for assessing neonatal intensive care unit (NICU) census and economic burden. The aim of this study is to evaluate perinatal and postnatal factors that influence LOS in preterm infants (25-33 weeks of gestation) admitted to participating NICUs of Indian National Neonatal Collaborative (INNC).

METHODS

From the INNC database, the data which were prospectively entered using uniformed pre-defined criteria were analysed.

RESULTS

A total of 3095 infants were included from 12 centres. Every week decrease in gestation increased LOS by 9 days. The median LOS for infants with gestational age of 25, 26, 27, 28, 29, 30, 31, 32 and 33 weeks were 86, 70, 62, 52, 40, 30, 23, 16 and 10 days, respectively. On multivariate analysis, abnormal antenatal umbilical artery doppler, severe small for gestational age (SGA), requirement of resuscitation, respiratory distress syndrome (RDS), seizures, sepsis, necrotising enterocolitis (NEC), major malformations and bronchopulmonary dysplasia (BPD) increased LOS by 5.4 (3.5-7.4), 21.6 (19-23.9), 4.7 (3.3-6.1), 3 (1.7-4.3), 15.2 (8.5-22.1), 11.2 (9.1-13.2), 9.8 (5.2-14.4), 8.8 (4.4-13.3) and 5.6 (0.5-10.7) days, respectively.

CONCLUSIONS

Apart from lower gestation and birth weight, abnormal antenatal umbilical artery doppler, severe SGA, resuscitation need, major malformations, RDS, seizures, sepsis, NEC and BPD influenced LOS in preterm infants. In comparison with other networks or data from developed countries, LOS in our network was comparatively less for similar gestational age infants.

Emotional disorganization: The prominent experience of Iranian mothers with preterm neonate: A qualitative study

When a preterm neonate is born and needs to be taken care of in the neonatal intensive care unit (NICU), the mother experiences a different process of mothering. A grounded theory study was conducted to explore the maternal role attainment in mothers of preterm infants. The authors of this paper report the most prominent experience of Iranian mothers with preterm neonates during their stay in the NICU that emerged as part of the process of maternal role attainment. Data were collected through in-depth semi-structured interviews with mothers in the NICU. We found four categories as emerged from experiences that formed the concept of "emotional disorganization". We argue that these findings can help caregivers and nurses to provide sensitive and supportive care to mothers of preterm neonates.

Evaluation of goodness of fit of semiparametric and parametric models in analysis of factors associated with length of stay in neonatal intensive care unit

BACKGROUND

Length of stay is a significant indicator of care effectiveness and hospital performance. Owing to the limited number of healthcare centers and facilities, it is important to optimize length of stay and associated factors.

PURPOSE

The present study aimed to investigate factors associated with neonatal length of stay in the neonatal intensive care unit (NICU) using parametric and semiparametric models and compare model fitness according to Akaike information criterion (AIC) between 2016 and 2018.

METHODS

This retrospective cohort study reviewed 600 medical records of infants admitted to the NICU of Bandar Abbas Hospital. Samples were identified using census sampling. Factors associated with NICU length of stay were investigated based on semiparametric Cox model and 4 parametric models including Weibull, exponential, log-logistic, and log-normal to determine the best fitted model. The data analysis was conducted using R software. The significance level was set at 0.05.

RESULTS

The study findings suggest that breastfeeding, phototherapy, acute renal failure, presence of mechanical ventilation, and availability of central venous catheter were commonly identified as factors associated with NICU length of stay in all 5 models (P<0.05). Parametric models showed better fitness than the Cox model in this study.

CONCLUSION

Breastfeeding and availability of central venous catheter had protective effects against length of stay, whereas phototherapy, acute renal failure, and mechanical ventilation increased length of stay in NICU. Therefore, the identification of factors associated with NICU length of stay can help establish effective interventions aimed at decreasing the length of stay among infants.

Safety and Parental Satisfaction With Early Discharge of Preterm Infants on Nasogastric Tube Feeding and Outpatient Clinic Follow-Up

Aim: To evaluate our early discharge program of preterm infants with nasogastric tube feeding (NTF) and close outpatient clinic follow-up with regard to safety, parent satisfaction and parental stress level. Methods: 119 preterm infants were discharged on NTF from our tertiary care neonatal unit (median gestational age 31.0 weeks, median birthweight 1,650 g). Parental satisfaction was evaluated by a standardized questionnaire. For safety assessment growth until term equivalent age and re-hospitalizations within 2 months after discharge were evaluated. Results: Infants were discharged home at a median gestational age of 35.4 weeks after a median hospital stay of 22 days. Follow up was attained in 95 of 104 parent-infant dyads. The majority of parents (94%) reported that they had made the right decision in taking their infant home on NTF. At the time of discharge 86% of parents felt very well-prepared to perform NTF. 70% Of parents rated their stress level at home as low (≤2 out of 5). There were no NTF associated readmissions and no growth faltering until term equivalent age. Conclusion: Early discharge of preterm infants with NTF together with outpatient clinic follow-up is very well-accepted by parents and appears to be safe.

Associations between VEGF isoforms and impending retinopathy of prematurity

BACKGROUND/OBJECTIVE

Vascular Endothelial Growth Factor (VEGF) is the main driver of angiogenesis during neurodevelopment (i.e., brain and retina). VEGF165 and VEGF121 are the two most prevalent human VEGF isoforms. Although retinopathy of prematurity (ROP), a neuroretinal disorder, is associated with VEGF dysregulation, little is known about the interaction of VEGF isoforms on neuroretinal angiogenesis. We hypothesized that: (a) A specific VEGF165/VEGF121 correlation, at a given time point, is associated with normal retinal development (no ROP) and (b) An altered correlation, of such, is associated with aberrant retinal development (ROP). Utilizing pre-collected dried blood spots (DBS) from <1-week-old preterm infants, we aimed to determine whether correlations between VEGF165 and VEGF121 precede the diagnosis of early stage, non-proliferative ROP (NP-ROP).

METHODOLOGY

We conducted a case/control study, utilizing DBS from 65 preterm infants. We measured DBS levels of VEGF165 on the Mesoscale Discovery Platform and VEGF121 via Cloud Clone Elisa Assay.

RESULTS

In infants with NP-ROP, VEGF165 is significantly higher in males (than females). In infants without ROP, there is a significant correlation between VEGF165 and VEGF121 in females (but not males). In infants with NP-ROP, the opposite is so; there is a significant correlation between VEGF165 and VEGF121 in males (but not females).

CONCLUSIONS

This pilot study, utilizing de-identified data, suggests the potential importance of examining interactions between VEGF isoforms, at <1 week after birth, to better understand ROP development. Our study also suggests that retinal angiogenesis may not be a sex-neutral process. A prospective study is needed to confirm our novel findings.

The association between high levels of luteinizing hormone and proliferative retinopathy of prematurity in female preterm infants

BACKGROUND

Luteinizing hormone (LH) and human chorionic gonadotropin (hCG), generally considered reproductive hormones, have potent proangiogenic properties. Both of these hormones and their joint receptor (CG/LH receptor) are found in the human eye. We hypothesized that an excess of these hormones is associated with proliferative retinopathy of prematurity (P-ROP).

METHODS

Dried blood spots (DBS) were used to perform a cross-sectional study of infants (gestational age of <26 weeks) with and without P-ROP, born in Michigan between August 1, 2012, and March 15, 2015. The DBS were collected at 1 week and 4 weeks of age from 45 preterm infants (27 no-ROP and 18 P-ROP). The DBS were linked to hospital records and then deidentified. ICD-9 codes were used to identify P-ROP cases. Hormones levels were measured via electrochemiluminescence assays on the Meso Scale Discovery platform. Associations between hormone levels at 1 and 4 weeks of age and the presence or absence of P-ROP were assessed.

RESULTS

In female infants, we noted a trend toward higher LH levels in ROP cases at week 1 (P = 0.11) and significantly higher LH levels in cases at week 4 (P = 0.03). In male infants, no ROP-related differences in LH levels were found at either time point. For hCG levels, no associations with P-ROP were found in either sex at either time point.

CONCLUSIONS

The association of high LH with P-ROP in female but not male infants raises the possibility that there are sex-specific hormonal determinants of aberrant retinal angiogenesis.

Do most premature babies get discharged by the expected date of delivery?

OBJECTIVE

To compare the length of stay (LOS) against the expected date of delivery (EDD) and to describe mortality and LOS outcomes by gestational age (GA) categories over the years.

STUDY DESIGN

Healthcare Cost and Utilization Project Kids' Inpatient database discharge records for years 2003, 2006, 2009, 2012, and 2016 were analyzed. For premature infants after inclusion-exclusion, actual, and calculated LOS were compared. Mortality and LOS outcomes were analyzed by GA and years.

RESULTS

The majority (99%) of infants >28 weeks were discharged by EDD while, for neonate ≤28 weeks, about three-quarters (75%) of infants were discharged by calculated EDD. LOS is increasing while mortality is decreasing by GA categories in recent years.

CONCLUSIONS

This is the largest study of mortality and LOS in the United States. Our study provides evidence-based numbers comparing actual LOS against EDD, which can be used in perinatal settings to counsel parents.

Practice variations and rates of late onset sepsis and necrotizing enterocolitis in very preterm born infants, a review

The burden of late onset sepsis (LOS) and necrotizing enterocolitis (NEC) remains high for newborns in low- and high-income countries. Very preterm born infants born below 32 weeks gestation are at highest risk because their immune system is not yet adapted to ex-utero life, providing intensive care frequently compromises their skin or mucosa and they require a long duration of hospital stay. An epidemiological overview is difficult to provide because there is no mutually accepted definition available for either LOS or NEC. LOS incidence proportions are generally reported based on identified blood culture pathogens. However, discordance in minimum day of onset and whether coagulase negative staphylococci or fungi should be included into the reported proportions lead to variation in reported incidences. Complicating the comparison are the absence of biomarkers, ancillary lab tests or prediction models with sufficiently high positive and/or negative predictive values. The only high negative predictive values result from negative blood culture results with negative lab results allowing to discontinue antibiotic treatment. Similar difficulties exist in reporting and diagnosing NEC. Although most publications base their proportions on a modified version of Bell's stage 2 or 3, comparisons are made difficult by the multifactorial nature of the disease reflecting several pathways to intestinal necrosis, the absence of a reliable biomarker and the unclear differentiation from spontaneous intestinal perforations. Comparable reports in very low birthweight infants range between 5% and 30% for LOS and 1.6% to 7.1% for NEC. Evidence based guidelines to support treatment are missing. Treatment for LOS remains largely empirical and focused mainly on antibiotics. In the absence of a clear diagnosis, even unspecific early warning signals need to be met with antibiotic treatment. Cessation after negative blood culture is difficult unless the child was asymptomatic from the beginning. As a result, antibiotics are the most commonly prescribed medications, but unnecessary exposure may result in increased risk for mortality, NEC, further infections and childhood obesity or asthma. Finding ways to limit antibiotic use are thus important and have shown a large potential for improvement of care and limitation of cost. Over recent decades, none of the attempts to establish novel therapies have succeeded. LOS and NEC proportions remained mostly stable. During the past 10 years however, publications emerged reporting a reduction, sometimes by almost 50%. Most concern units participating in a surveillance system using quality improvement strategies to prevent LOS or NEC (e.g., hand hygiene, evidence based "bundles", feeding onset, providing own mother's milk). We conclude that these approaches display a potential for wider spread reduction of LOS and NEC and for a subsequently more successful development of novel therapies as these often address the same pathways as the prevention strategies.

Information technology infrastructure, quality improvement and research: the UK National Neonatal Research Database

Technological developments, coupled with strengthened governance and data security have led to increasing recognition of the potential of real-world health data to benefit patient care and health services. Real-world health data are those captured in the course of routine care. Here I describe a mature source of real-world health data, the UK National Neonatal Research Database and provide examples of the many types of uses it supports.

Perspectives of time: a qualitative study of the experiences of parents of critically ill newborns in the neonatal nursery in North Queensland interviewed several years after the admission

DESIGN

A qualitative study informed by grounded theory principles to explore the experiences of parents who had extremely preterm or babies with antenatally diagnosed life-threatening diagnoses who were cared for in a regional tertiary neonatal unit. The study was conducted when the child was old enough to be diagnosed with long-term neurodevelopmental or medical sequelae.

SETTING

North Queensland is a large area in Eastern Australia of 500 000 km², which is served by one tertiary neonatal unit.

PARTICIPANTS

Seventeen families representing 21 extremely preterm babies and one baby with congenital malformations who was not expected to survive prior to delivery (but did) were interviewed using grounded theory principles. Interviews were coded and themes derived.

RESULTS

Parents who recollect their neonatal experiences from 3 to 7 years after the baby was cared for in the neonatal intensive care described negative themes of grief and loss, guilt and disempowerment. Positive enhancers of care included parental strengths, religion and culture, family supports and neonatal unit practices. Novel findings included that prior pregnancy loss and infertility formed part of the narrative for parents, and hope was engendered by religion for parents who did not usually have a religious faith.

CONCLUSIONS

An understanding of both the negative aspects of neonatal care and the positive enhancers is necessary to improve the neonatal experience for parents. Parents are able to contextualise their previous neonatal experiences within both the long-term outcome for the child and their own life history.