Outcomes for high risk New Zealand newborn infants in 1998-1999: a population based, national study

Bronchopulmonary dysplasia: temporal trend from 2010 to 2019 in the Brazilian Network on Neonatal Research

OBJECTIVE

To evaluate the temporal trend of bronchopulmonary dysplasia (BPD) in preterm infants who survived to at least 36 weeks' post-menstrual age (PMA) and BPD or death at 36 weeks' PMA, and to analyse variables associated with both outcomes.

DESIGN

Retrospective cohort with data retrieved from an ongoing national registry.

SETTING

19 Brazilian university public hospitals.

PATIENTS

Infants born between 2010 and 2019 with 23-31 weeks and birth weight 400-1499 g.

MAIN OUTCOME MEASURES

Temporal trend was evaluated by Prais-Winsten model and variables associated with BPD in survivors or BPD or death were analysed by logistic regression.

RESULTS

Of the 11 128 included infants, BPD in survivors occurred in 22%, being constant over time (annual per cent change (APC): -0.80%; 95% CI: -2.59%; 1.03%) and BPD or death in 45%, decreasing over time (APC: -1.05%; 95% CI: -1.67%; -0.43%). Being male, small for gestational age, presenting with respiratory distress syndrome, air leaks, needing longer duration of mechanical ventilation, presenting with treated patent ductus arteriosus and late-onset sepsis were associated with an increase in the chance of BPD. For the outcome BPD or death, maternal bleeding, multiple gestation, 5-minute Apgar <7, late-onset sepsis, necrotising enterocolitis and intraventricular haemorrhage were added to the variables reported above as increasing the chance of the outcome.

CONCLUSION

The frequency of BPD in survivors was constant and BPD or death decreased by 1.05% at each study year. These results show some improvement in perinatal care in Brazilian units which resulted in a reduction of BPD or death, but further improvements are still needed to reduce BPD in survivors.

Cohort protocol: Guangzhou High-Risk Infant Cohort study

INTRODUCTION

Despite the increase in the survival rate of high-risk infants (HRIs) worldwide, the prevalence of motor and neurodevelopmental sequelae in such newborns has not shown concomitant improvement. Meanwhile, there are few cohorts that explore factors related to the development of HRIs in China. Therefore, the Guangzhou High-Risk Infant Cohort (GHRIC) has been designed to examine the complex relationships among a myriad of factors influencing growth and development in such children.

METHODS AND ANALYSIS

The GHRIC study is a prospective cohort study that by the year 2023 will enrol an estimated total of 3000 HRIs from Guangzhou Women and Children's Medical Center (GWCMC) in Guangzhou, China. This study is designed to assess the growth and cognitive characteristics of HRIs and the risk factors affecting their development and prognoses. Data on risk factors, neurodevelopmental and cognitive-function evaluations, laboratory results, and specimens will be collected and analysed. Information on perinatal and clinical interventions for these infants will also be recorded during regular follow-up visits until age 6.

ETHICS AND DISSEMINATION

The protocol for this study has been approved by the Research Ethics Committee of GWCMC, which accepted responsibility for supervising all of the aspects of the study (No. 2017102712). Study outcomes will be disseminated through conference presentations, peer-reviewed publications, the Internet and social media.

TRIAL REGISTRATION NUMBER

ChiCTR-EOC-17013236.

Trends in Outcomes for Neonates Born Very Preterm and Very Low Birth Weight in 11 High-Income Countries

OBJECTIVE

To evaluate outcome trends of neonates born very preterm in 11 high-income countries participating in the International Network for Evaluating Outcomes of neonates.

STUDY DESIGN

In a retrospective cohort study, we included 154 233 neonates admitted to 529 neonatal units between January 1, 2007, and December 31, 2015, at 24^0/7 to 31^6/7 weeks of gestational age and birth weight <1500 g. Composite outcomes were in-hospital mortality or any of severe neurologic injury, treated retinopathy of prematurity, and bronchopulmonary dysplasia (BPD); and same composite outcome excluding BPD. Secondary outcomes were mortality and individual morbidities. For each country, annual outcome trends and adjusted relative risks comparing epoch 2 (2012-2015) to epoch 1 (2007-2011) were analyzed.

RESULTS

For composite outcome including BPD, the trend decreased in Canada and Israel but increased in Australia and New Zealand, Japan, Spain, Sweden, and the United Kingdom. For composite outcome excluding BPD, the trend decreased in all countries except Spain, Sweden, Tuscany, and the United Kingdom. The risk of composite outcome was lower in epoch 2 than epoch 1 in Canada (adjusted relative risks 0.78; 95% CI 0.74-0.82) only. The risk of composite outcome excluding BPD was significantly lower in epoch 2 compared with epoch 1 in Australia and New Zealand, Canada, Finland, Japan, and Switzerland. Mortality rates reduced in most countries in epoch 2. BPD rates increased significantly in all countries except Canada, Israel, Finland, and Tuscany.

CONCLUSIONS

In most countries, mortality decreased whereas BPD increased for neonates born very preterm.

The International Network for Evaluating Outcomes (iNeo) of neonates: evolution, progress and opportunities

Neonates born very preterm (before 32 weeks' gestational age), are a significant public health concern because of their high-risk of mortality and life-long disability. In addition, caring for very preterm neonates can be expensive, both during their initial hospitalization and their long-term cost of permanent impairments. To address these issues, national and regional neonatal networks around the world collect and analyse data from their constituents to identify trends in outcomes, and conduct benchmarking, audit and research. Improving neonatal outcomes and reducing health care costs is a global problem that can be addressed using collaborative approaches to assess practice variation between countries, conduct research and implement evidence-based practices. The International Network for Evaluating Outcomes (iNeo) of neonates was established in 2013 with the goal of improving outcomes for very preterm neonates through international collaboration and comparisons. To date, 10 national or regional population-based neonatal networks/datasets participate in iNeo collaboration. The initiative now includes data on >200,000 very preterm neonates and has conducted important epidemiological studies evaluating outcomes, variations and trends. The collaboration has also surveyed >320 neonatal units worldwide to learn about variations in practices, healthcare service delivery, and physical, environmental and manpower related factors and support services for parents. The iNeo collaboration serves as a strong international platform for Neonatal-Perinatal health services research that facilitates international data sharing, capacity building, and global efforts to improve very preterm neonate care.

Predictors of mortality for preterm infants with intraventricular hemorrhage: a population-based study

PURPOSE

The goal of this longitudinal, population-level study was to examine factors affecting mortality in preterm infants with intraventricular hemorrhage (IVH).

METHODS

The study examined patients who were born at 36 weeks estimated gestational age (EGA) or less with a diagnosis of IVH between the years 2005 and 2014 using data from the New York and Nebraska State Inpatient Databases. Potential predictors for mortality were investigated with multivariable survival analysis.

RESULTS

The cohort included 7437 preterm infants with IVH. All-cause inpatient mortality occurred in 746 (10.0%). The majority of deaths were in infants born at less than 25 weeks EGA (378 or 50.7%) and with birthweight less than 750 g (459 or 61.5%). Mortality was highest for children with grade IV IVH (306/848 or 36.1%), followed by grades III (203/955 or 21.3%), II (103/1328 or 7.8%), and I (134/4306 or 3.1%). Hydrocephalus was diagnosed within 6 months in 627 (8.4%) patients, with cerebrospinal fluid shunts required in 237 (3.2%). Shunts were eventually revised in 122 (51.5% of shunts), and 43 (18.1%) had infections. Multivariable Cox survival analyses found male sex (HR 1.3 [95% CI 1.1-1.5]), Asian race (HR 1.5 [1.1-2.2]), lower EGA (HR 9.9 [6.3-15.5] for < 25 weeks), higher IVH grade (HR 6.1 [4.9-7.6] for grade IV), gastrostomy (HR 4.0 [2.0-7.7]), tracheostomy (HR 3.5 [1.7-7.1]), and shunt infection (HR 3.2 [1.0-9.9]) to be independently associated with increased mortality risk.

CONCLUSIONS

This database is the first of its kind assembled for population-based investigations of long-term neurosurgical outcomes in preterm infants with IVH.

Incidence of neonatal necrotising enterocolitis in high-income countries: a systematic review

OBJECTIVE

To conduct a systematic review of neonatal necrotising enterocolitis (NEC) rates in high-income countries published in peer-reviewed journals.

METHODS

We searched MEDLINE, Embase and PubMed databases for observational studies published in peer-reviewed journals. We selected studies reporting national, regional or multicentre rates of NEC in 34 Organisation for Economic Co-operation and Development countries. Two investigators independently screened studies against predetermined criteria. For included studies, we extracted country, year of publication in peer-reviewed journal, study time period, study population inclusion and exclusion criteria, case definition, gestation or birth weight-specific NEC and mortality rates.

RESULTS

Of the 1888 references identified, 120 full manuscripts were reviewed, 33 studies met inclusion criteria, 14 studies with the most recent data from 12 countries were included in the final analysis. We identified an almost fourfold difference, from 2% to 7%, in the rate of NEC among babies born <32 weeks' gestation and an almost fivefold difference, from 5% to 22%, among those with a birth weight <1000 g but few studies covered the entire at-risk population. The most commonly applied definition was Bell's stage ≥2, which was used in seven studies. Other definitions included Bell's stage 1-3, definitions from the Centers for Disease Control and Prevention, International Classification for Diseases and combinations of clinical and radiological signs as specified by study authors.

CONCLUSION

The reasons for international variation in NEC incidence are an important area for future research. Reliable inferences require clarity in defining population coverage and consistency in the case definition applied. PROSPERO INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS REGISTRATION NUMBER: CRD42015030046.

Improvement in the Survival Rates of Very Low Birth Weight Infants after the Establishment of the Korean Neonatal Network: Comparison between the 2000s and 2010s

The survival rate (SR) of very low birth weight infants (VLBWIs) and extremely low birth weight infants (ELBWIs) is a health indicator of neonatal intensive care unit (NICU) outcomes. The Korean Neonatal Network (KNN) was established in 2013, and a system has been launched to manage the registration and quality improvement of VLBWIs. The SR of the VLBWIs significantly increased to 85.7% in the 2010s compared with 83.0% in the 2000s. There was also a significant increase in the SR of the ELBWIs from 66.1% to 70.7%. The equipment, manpower, and assistance systems of NICUs also improved in quantity and quality. In the international comparison of the SRs of VLBWIs, the SRs were 93.8%, 92.2%, 90.2%, 89.4%, 86.4%, 85.1%, and 80.6% in Japan, Australia and New Zealand, Canada, Europe, Korea, Taiwan, and United States, respectively. In conclusion, the SRs of the VLBWIs and ELBWIs improved in the 2010s compared with those in the 2000s in Korea. This improvement is considered to have been related to the role of the KNN built in 2013. However, the latest VLBWI and ELBWI SRs in 2015 are still low compared with those in Japan, Australia and New Zealand, Canada, and Europe. In the future, we must establish and develop the tasks that are presented as future tasks in this review.

The Impact of Low-Grade Germinal Matrix-Intraventricular Hemorrhage on Neurodevelopmental Outcome of Very Preterm Infants

BACKGROUND

Very preterm infants often show germinal matrix-intraventricular hemorrhage (GMH-IVH) on cranial ultrasound (cUS).

AIM

To determine the impact of low-grade GMH-IVH on early neurodevelopmental outcome in very preterm infants.

METHODS

A retrospective case-control study in very preterm infants with and without low-grade GMH-IVH on cUS. Additional magnetic resonance imaging (MRI) was available in all infants with a gestational age (GA) <28 weeks and high-risk infants >28 weeks. Infants were seen at 2 years' corrected age to assess neurodevelopment.

RESULTS

In total, 136 infants (GA 24-32 weeks) with low-grade GMH-IVH on cUS were matched with 255 controls. Outcome data was available for 342 (87%) infants. Adverse outcome (i.e., cerebral palsy [CP], neurodevelopmental delay) was present in 11 (9%) cases and 20 (9%) controls. No statistically significant differences in outcome were found between cases and controls. Additional MRI was performed in 165/391 infants (42%) and showed additional lesions in 73 (44%) infants that could explain subsequent development of CP in 2 out of 5 infants and epilepsy in 1 of 2 infants.

CONCLUSION

Very preterm infants with low-grade GMH-IVH on cUS have a similar early neurodevelopmental outcome compared with controls. Additional MRI showed mostly subtle abnormalities that were missed with cUS, but these could not explain subsequent development of CP and developmental delay in all infants.

Neonatal Outcomes of Very Low Birth Weight and Very Preterm Neonates: An International Comparison

OBJECTIVE

To compare rates of a composite outcome of mortality or major morbidity in very-preterm/very low birth weight infants between 8 members of the International Network for Evaluating Outcomes.

STUDY DESIGN

We included 58 004 infants born weighing <1500 g at 24(0)-31(6) weeks' gestation from databases in Australia/New Zealand, Canada, Israel, Japan, Spain, Sweden, Switzerland, and the United Kingdom. We compared a composite outcome (mortality or any of grade ≥3 peri-intraventricular hemorrhage, periventricular echodensity/echolucency, bronchopulmonary dysplasia, or treated retinopathy of prematurity) between each country and all others by using standardized ratios and pairwise using logistic regression analyses.

RESULTS

Despite differences in population coverage, included neonates were similar at baseline. Composite outcome rates varied from 26% to 42%. The overall mortality rate before discharge was 10% (range: 5% [Japan]-17% [Spain]). The standardized ratio (99% CIs) estimates for the composite outcome were significantly greater for Spain 1.09 (1.04-1.14) and the United Kingdom 1.16 (1.11-1.21), lower for Australia/New Zealand 0.93 (0.89-0.97), Japan 0.89 (0.86-0.93), Sweden 0.81 (0.73-0.90), and Switzerland 0.77 (0.69-0.87), and nonsignificant for Canada 1.04 (0.99-1.09) and Israel 1.00 (0.93-1.07). The adjusted odds of the composite outcome varied significantly in pairwise comparisons.

CONCLUSIONS

We identified marked variations in neonatal outcomes between countries. Further collaboration and exploration is needed to reduce variations in population coverage, data collection, and case definitions. The goal would be to identify care practices and health care organizational factors, which has the potential to improve neonatal outcomes.

Neonatal networks: clinical research and quality improvement

Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.

Early-onset neonatal group B streptococcus sepsis following national risk-based prevention guidelines

BACKGROUND

Neonatal infection with group B streptococcus (GBS) is an important cause of infant mortality. Intrapartum antibiotics reduce early-onset GBS sepsis, but recommendations vary as to whether they should be offered following antenatal screening or based on risk factors alone. We aimed to determine the incidence of early-onset GBS sepsis in New Zealand five years after the publication of national risk-based GBS prevention guidelines.

MATERIALS AND METHODS

Prospective surveillance of early-onset GBS sepsis (defined as infection in the first 48 h of life) was undertaken between April 2009 and March 2011 through the auspices of the New Zealand Paediatric Surveillance Unit as part of a survey of infection presenting in the first week of life.

RESULTS

There were 29 cases of confirmed early-onset GBS sepsis, including one case of meningitis, giving an incidence rate of 0.23 per 1000 (95% CI 0.16-0.33) live births. Three infants (10.3%) died. In 16 cases (55%), a maternal risk factor qualifying the mother for intrapartum antibiotics was present, but only five (31%) received this intervention. A retrospective review of the major hospital laboratory databases for this period identified two additional cases. A secondary sensitivity analysis taking account of these cases provided an estimated national incidence of 0.26 (95% CI 0.18-0.37) per 1000 live births.

CONCLUSIONS

Ten years after a similar survey and five years after promoting a single, risk-based prevention protocol nationally, the incidence of early-onset GBS disease in New Zealand has more than halved, but opportunities remain to further reduce the rate.

Maternal and perinatal outcomes of pregnancies delivered at 23 weeks' gestation

OBJECTIVE

To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation.

METHODS

This prospective cohort study included women in the Canadian Perinatal Network who were admitted to one of 16 Canadian tertiary perinatal units between August 1, 2005, and March 31, 2011, and who delivered at 23+0 to 23+6 weeks' gestation. Women were included in the network if they were admitted with spontaneous preterm labour with contractions, a short cervix without contractions, prolapsing membranes with membranes at or beyond the external os or a dilated cervix, preterm premature rupture of membranes, intrauterine growth restriction, gestational hypertension, or antepartum hemorrhage. Maternal outcomes included Caesarean section, placental abruption, and serious complication. Perinatal outcomes were mortality and serious morbidity.

RESULTS

A total of 248 women and 287 infants were included in the study. The rate of Caesarean section was 10.5% (26/248) and 40.3% of women (100/248) had a serious complication, the most common being chorioamnionitis (38.6%), followed by blood transfusion (4.5%). Of infants with known outcomes, perinatal mortality was 89.9% (223/248) (stillbirth 23.3% [67/287] and neonatal death 62.9% [156/248]). Of live born neonates with known outcomes (n = 181), 38.1% (69/181) were admitted to NICU. Of those admitted to NICU, neonatal death occurred in 63.8% (44/69). Among survivors at discharge, the rate of severe brain injury was 44.0% (11/25), of retinopathy of prematurity 58.3% (14/24), and of any serious neonatal morbidity 100% (25/25). Two subgroup analyses were performed: in one, antepartum stillbirths were excluded, and in the other only centres that indicated they offered fetal monitoring at 23 weeks' gestation were included and antepartum stillbirths were excluded. In each of these, perinatal outcomes similar to the overall group were found.

CONCLUSION

Pregnant women delivering at 23 weeks' gestation are at risk of morbidity. Their infants have high rates of serious morbidity and mortality. Further research is needed to identify strategies and forms of management that not only increase perinatal survival but also reduce morbidities in these extremely low gestational age infants and reduce maternal morbidity.

Changes in perinatal care and outcomes in newborns at the limit of viability in Spain: the EPI-SEN Study

BACKGROUND

Advances in perinatal care can influence morbidity and mortality in newborns at the limit of viability. Knowledge of these changes over time may help improve clinical decision making, optimize resource allocation and increase quality of care.

OBJECTIVES

To evaluate the influence on morbidity and mortality of changes introduced in the perinatal care of preterm infants (22-26 weeks' gestational age, GA) in Spain between two consecutive periods (2002-2006 and 2007-2011).

METHODS

An analysis of prospectively collected data in a national database network (SEN1500) was performed. All live newborn infants of 22-26 weeks' GA born in or transferred to referral centers of the SEN1500 network in the first 28 days of life were included. Perinatal interventions, clinical management, neonatal morbidity, and survival until hospital discharge were retrieved.

RESULTS

A total of 5,470 newborns were included (2,533 and 2,937 in each period, respectively). The major changes introduced during the second period were as follows: (1) lower proportion of extramural births (11.0 vs. 8.9%, p = 0.01), (2) increase in antenatal steroids (69.5 vs. 80.8%, p < 0.001), (3) delivery by C-section (41.8 vs. 48.3%, p < 0.001) and (4) use of CPAP during resuscitation (7.8 vs. 20.7%, p < 0.001). Death in the delivery room decreased from 5.1 to 3.2% (p < 0.001). Survival increased from 49.9 to 57.9% (p < 0.001), and survival without major morbidity increased from 18.1 to 21.2% (p = 0.006).

CONCLUSIONS

During the second period, a greater attachment to practices proven to have a beneficial impact on survival and reduction of morbidity in the extremely preterm infant was noted, and survival and survival without major morbidity increased. A more conservative approach was detected for newborns of 22 weeks' GA.

Randomized controlled trial of oxygen saturation targets in very preterm infants: two year outcomes

OBJECTIVE

To assess whether an oxygen saturation (Spo2) target of 85%-89% compared with 91%-95% reduced the incidence of the composite outcome of death or major disability at 2 years of age in infants born at <28 weeks' gestation.

STUDY DESIGN

A total 340 infants were randomized to a lower or higher target from <24 hours of age until 36 weeks' gestational age. Blinding was achieved by targeting a displayed Spo2 of 88%-92% using a saturation monitor offset by ±3% within the range 85%-95%. True saturations were displayed outside this range. Follow-up at 2 years' corrected age was by pediatric examination and formal neurodevelopmental assessment. Major disability was gross motor disability, cognitive or language delay, severe hearing loss, or blindness.

RESULTS

The primary outcome was known for 335 infants with 33 using surrogate language information. Targeting a lower compared with a higher Spo2 target range had no significant effect on the rate of death or major disability at 2 years' corrected age (65/167 [38.9%] vs 76/168 [45.2%]; relative risk 1.15, 95% CI 0.90-1.47) or any secondary outcomes. Death occurred in 25 (14.7%) and 27 (15.9%) of those randomized to the lower and higher target, respectively, and blindness in 0% and 0.7%.

CONCLUSIONS

Although there was no benefit or harm from targeting a lower compared with a higher saturation in this trial, further information will become available from the prospectively planned meta-analysis of this and 4 other trials comprising a total of nearly 5000 infants.

The International Network for Evaluating Outcomes of very low birth weight, very preterm neonates (iNeo): a protocol for collaborative comparisons of international health services for quality improvement in neonatal care

BACKGROUND

The International Network for Evaluating Outcomes in Neonates (iNeo) is a collaboration of population-based national neonatal networks including Australia and New Zealand, Canada, Israel, Japan, Spain, Sweden, Switzerland, and the UK. The aim of iNeo is to provide a platform for comparative evaluation of outcomes of very preterm and very low birth weight neonates at the national, site, and individual level to generate evidence for improvement of outcomes in these infants.

METHODS/DESIGN

Individual-level data from each iNeo network will be used for comparative analysis of neonatal outcomes between networks. Variations in outcomes will be identified and disseminated to generate hypotheses regarding factors impacting outcome variation. Detailed information on physical and environmental factors, human and resource factors, and processes of care will be collected from network sites, and tested for association with neonatal outcomes. Subsequently, changes in identified practices that may influence the variations in outcomes will be implemented and evaluated using quality improvement methods.

DISCUSSION

The evidence obtained using the iNeo platform will enable clinical teams from member networks to identify, implement, and evaluate practice and service provision changes aimed at improving the care and outcomes of very low birth weight and very preterm infants within their respective countries. The knowledge generated will be available worldwide with a likely global impact.

Counselling and management for anticipated extremely preterm birth

Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.

Does facility based newborn care improve neonatal outcomes? A review of evidence

CONTEXT

Facility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality.

OBJECTIVE

To assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes.

EVIDENCE ACQUISITION

Electronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966-Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered.

RESULTS

A total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories- regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths.

CONCLUSIONS

Countries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.

Reduction in late-onset sepsis on relocating a neonatal intensive care nursery

AIMS

The aims of this study were to compare rates of late-onset sepsis (LOS) in very preterm or very low birthweight infants before and after relocation to a new nursery and to determine risk factors for LOS.

METHODS

The study was undertaken at The Royal Women's Hospital, Melbourne, which relocated to a new site in June 2008. Infants with birthweight <1500 g or <32 weeks' gestation, born between July and December 2007 (n= 149) and July and December 2008 (n= 152) were included. Each septic episode was identified from blood cultures taken from patients >48 h after birth and was categorised as definite, probable, uncertain or no sepsis.

RESULTS

Overall, 117 infants had 218 septic episodes. The proportion of infants with clinical LOS decreased from 29.5% in 2007 to 22.4% in 2008 after the relocation, although this was not statistically significant. There was a significant (P < 0.05) reduction in the severity (definite LOS = most severe) of sepsis in 2008 compared with 2007, and in rates of coagulase-negative staphylococcal LOS. Significant risk factors for LOS were: lower birthweight (g; mean -351, 95% confidence interval (CI) -446, -256); lower gestational age (weeks; mean -2.3, 95% CI -2.8, -1.7) and presence of a percutaneous inserted central catheter (odds ratio (OR) 2.56, 95% CI 1.03, 6.67).

CONCLUSIONS

There was a significant reduction in the severity of LOS in very preterm and/or very low birthweight infants that correlated with the relocation from the old to new nursery. Smaller and more immature infants with percutaneous central catheters were more at risk.

Assessment of special care newborn units in India

The neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) have been set up to provide quality level II newborn-care services in several district hospitals to meet this challenge. The units are located in some remotest districts where the burden of neonatal deaths is high, and access to special newborn care is poor. The study was conducted to assess the functioning of SCNUs in eight rural districts of India. The evaluation was based on an analysis of secondary data from the eight units that had been functioning for at least one year. A cross-sectional survey was also conducted to assess the availability of human resources, equipment, and quality care. Descriptive statistics were used for analyzing the inputs (resources) and outcomes (morbidity and mortality). The rate of mortality among admitted neonates was taken as the key outcome variable to assess the performance of the units. Chi-square test was used for analyzing the trend of case-fatality rate over a period of 3-5 years considering the first year of operationalization as the base. Correlation coefficients were estimated to understand the possible association of case-fatality rate with factors, such as bed:doctor ratio, bed:nurse ratio, average duration of stay, and bed occupancy rate, and the asepsis score was determined. The rates of admission increased from a median of 16.7 per 100 deliveries in 2008 to 19.5 per 100 deliveries in 2009. The case-fatality rate reduced from 4% to 40% within one year of their functioning. Proportional mortality due to sepsis and low birthweight (LBW) declined significantly over two years (LBW <2.5 kg). The major reasons for admission and the major causes of deaths were birth asphyxia, sepsis, and LBW/prematurity. The units had a varying nurse:bed ratio (1:0.5-1:1.3). The bed occupancy rate ranged from 28% to 155% (median 103%), and the average duration of stay ranged from two days to 15 days (median 4.75 days). Repair and maintenance of equipment were a major concern. It is possible to set up and manage quality SCNUs and improve the survival of newborns with LBW and sepsis in developing countries, although several challenges relating to human resources, maintenance of equipment, and maintenance of asepsis remain.

Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: a report from the Canadian Pediatric Surgery Network

BACKGROUND

Perinatal management of congenital diaphragmatic hernia (CDH) and gastroschisis (GS) remains nonstandardized and institution specific. This analysis describes practice and outcome variation across a national network.

METHODS

A national, prospective, disease-specific database for CDH and GS was evaluated over 4 years. Centers were evaluated individually and defined as low (low-volume center [LVC]) or high (high-volume center [HVC]) volume based on case mean.

RESULTS

Congenital diaphragmatic hernia. Two hundred fifteen liveborn cases were studied (mean, 14.3 cases/center) across 15 centers (8 LVCs and 7 HVCs). Significant interinstitutional practice variation was noted in rates of termination (0%-40%) and cesarean delivery (0%-61%). Centers demonstrated marked variation in ventilation strategies, vasodilator and paralytic use, timing of surgery, and rates of primary closure. Overall survival was 81.4% (LVC, 76.9%; HVC, 82.4%; P = .43). Gastroschisis. Four hundred sixteen cases were investigated (mean, 26 cases/center; range, 6-72) across 16 centers (10 LVCs and 6 HVCs). Cesarean delivery rates varied widely between centers (0%-86%) as did timing of closure (early vs delayed, 1%-100%). There was no difference in length of stay, days on total parenteral nutrition, and overall survival (94.3% vs 97.2%; P = .17) between LVCs and HVCs.

CONCLUSIONS

The existence of perinatal practice and outcome variation for GS and CDH suggests targets for improved delivery of care and justifies efforts to standardize treatment on a national basis.

The role of systemic hemodynamic disturbances in prematurity-related brain injury

Premature infants who experience cerebrovascular injury frequently have acute and long-term neurologic complications. In this article, we explore the relationship between systemic hemodynamic insults and brain injury in this patient population and the mechanisms that might be at play.

The establishment of the Australian and New Zealand Neonatal Network

The Australian and New Zealand Neonatal Network was established in 1994 to monitor high-risk newborns admitted for care. Uniquely, all units in both countries have participated since inception, making it integral to the care of babies. The network's objectives include auditing care, publishing aggregated results annually, providing feedback to units, monitoring technologies and developing clinical indicators. Networking provides a forum for clinicians and a consortium of knowledge and advice. It facilitates collaborative research and clinical groups, producing projects from observational studies to randomised controlled trials. Members take a major role in reviewing the evidence for care and ensuring its effective use in clinical practice.

Elevated cerebral pressure passivity is associated with prematurity-related intracranial hemorrhage

OBJECTIVES

Cerebral pressure passivity is common in sick premature infants and may predispose to germinal matrix/intraventricular hemorrhage (GM/IVH), a lesion with potentially serious consequences. We studied the association between the magnitude of cerebral pressure passivity and GM/IVH.

PATIENTS AND METHODS

We enrolled infants <32 weeks' gestational age with indwelling mean arterial pressure (MAP) monitoring and excluded infants with known congenital syndromes or antenatal brain injury. We recorded continuous MAP and cerebral near-infrared spectroscopy hemoglobin difference (HbD) signals at 2 Hz for up to 12 hours/day and up to 5 days. Coherence and transfer function analysis between MAP and HbD signals was performed in 3 frequency bands (0.05-0.25, 0.25-0.5, and 0.5-1.0 Hz). Using MAP-HbD gain and clinical variables (including chorioamnionitis, Apgar scores, gestational age, birth weight, neonatal sepsis, and Score for Neonatal Acute Physiology II), we built a logistic regression model that best predicts cranial ultrasound abnormalities.

RESULTS

In 88 infants (median gestational age: 26 weeks [range 23-30 weeks]), early cranial ultrasound showed GM/IVH in 31 (37%) and parenchymal echodensities in 10 (12%) infants; late cranial ultrasound showed parenchymal abnormalities in 19 (30%) infants. Low-frequency MAP-HbD gain (highest quartile mean) was significantly associated with early GM/IVH but not other ultrasound findings. The most parsimonious model associated with early GM/IVH included only gestational age and MAP-HbD gain.

CONCLUSIONS

This novel cerebrovascular monitoring technique allows quantification of cerebral pressure passivity as MAP-HbD gain in premature infants. High MAP-HbD gain is significantly associated with GM/IVH. Precise temporal and causal relationship between MAP-HbD gain and GM/IVH awaits further study.

Differences in rates and short-term outcome of live births before 32 weeks of gestation in Europe in 2003: results from the MOSAIC cohort

OBJECTIVES

Advances in perinatal medicine increased survival after very preterm birth in all countries, but comparative population-based data on these births are not readily available. This analysis contrasts the rates and short-term outcome of live births before 32 weeks of gestation in 10 European regions.

METHODS

The Models of Organizing Access to Intensive Care for Very Preterm Births (MOSAIC) study collected prospective data on all very preterm births in 10 European regions covering 494,463 total live births in 2003. The analysis sample was live births between 24 and 31 weeks of gestation without lethal congenital anomalies (N = 4908). Outcomes were rates of preterm birth, in-hospital mortality, intraventricular hemorrhage grades III and IV or cystic periventricular leukomalacia and bronchopulmonary dysplasia. Mortality and morbidity rates were standardized for gestational age and gender.

RESULTS

Live births between 24 and 31 weeks of gestation were 9.9 per 1000 total live births with a range from 7.6 to 13.0 in the MOSAIC regions. Standardized mortality was doubled in high versus low mortality regions (18%-20% vs 7%-9%) and differed for infants < or = 28 weeks of gestation as well as 28 to 31 weeks of gestation. Morbidity among survivors also varied (intraventricular hemorrhage/periventricular leukomalacia ranged from 2.6% to < or = 10% and bronchopulmonary dysplasia from 10.5% to 21.5%) but differed from mortality rankings. A total of 85.2 very preterm infants per 10,000 total live births were discharged from the hospital alive with a range from 64.1 to 117.1; the range was 10 to 31 per 10,000 live births for infants discharged with a diagnosis of neurologic or respiratory morbidity.

CONCLUSIONS

Very preterm mortality and morbidity differed between European regions, raising questions about variability in treatment provided to these infants. Comparative follow-up studies are necessary to evaluate the impact of these differences on rates of cerebral palsy and other disabilities associated with preterm birth.

Perinatal care at the borderlines of viability: a consensus statement based on a NSW and ACT consensus workshop

Perinatal care at the borderlines of viability demands a delicate balance between parents' wishes and autonomy, biological feasibility, clinicians' responsibilities and expectations, and the prospects of an acceptable long-term outcome - coupled with a tolerable margin of uncertainty. A multi-professional workshop with consumer involvement was held in February 2005 to agree on management of this issue in New South Wales and the Australian Capital Territory. Participants discussed and formulated consensus statements after an extensive consultation process. Consensus was reached that the "grey zone" is between 23 weeks' and 25 weeks and 6 days' gestation. While there is an increasing obligation to treat with increasing length of gestation, it is acceptable medical practice not to initiate intensive care during this period if parents so wish, after appropriate counselling. Poor condition at birth and the presence of serious congenital anomalies have an important influence on any decision not to initiate intensive care within the grey zone. Women at high risk of imminent delivery within the grey zone should receive appropriate and skilled counselling with the most relevant up-to-date outcome information. Management plans can thus be made before birth. Information should be simple, factual and consistent. The consensus statements developed will provide a framework to assist parents and clinicians in communication, decision making and managing these challenging situations.

Factors associated with neurodevelopmental outcome at 2 years after very preterm birth: the population-based Nord-Pas-de-Calais EPIPAGE cohort

OBJECTIVE

We sought to (1) evaluate at 2 years the postsurfactant era developmental outcome of children who were born before 33 weeks of gestational age (GA) in the Nord-Pas-de-Calais area in France in 1997 and (2) identify risk factors of poor developmental quotient (DQ). Children were part of the EPIPAGE study, which included all of these births in 9 French regions.

METHODS

A prospective observational study was conducted of all births before 33 weeks in 1997. Risk factors of poor DQ were obtained from a multiple linear regression, and results were expressed as DQ differences with 95% confidence intervals.

RESULTS

A total of 546 births were included in the study. A total of 461 (84.4%) had a clinical evaluation at 2 years of age, and 380 (69.6%) had an assessment with the use of the Brunet-Lezine scale of infant development. Their mean GA was 29.9 weeks (29.7-30.1 weeks), and mean birth weight was 1378 g (1338-1418 g). A total of 9% had a recognizable pattern of cerebral palsy, 0.2% were blind, and 0.8% required hearing aids. The mean DQ was 94 +/- 11 and decreased from 97 at 32 weeks to 86 at 24 to 25 weeks. After multivariate analysis, children who were born at 24 to 25 weeks had a mean DQ reduction of 11 points (-20 to -1) compared with those who were born at 32 weeks, but minor differences were found from 26 to 32 weeks. Boys had a DQ 4 points lower than girls (-7 to -1).

CONCLUSION

In this study, the outcome of extremely preterm infants was poor. After 25 weeks, outcome was related mainly to the sociocultural level of the family and to the presence of severe cerebral ultrasound abnormalities. Consequently, in the postsurfactant era, we have to propose follow-up programs to children who are born extremely preterm and to concentrate our efforts on children with less-than-optimal social and family setting.

General obstetrics: A randomised controlled trial of metronidazole for the prevention of preterm birth in women positive for cervicovaginal fetal fibronectin: the PREMET Study

OBJECTIVE

To determine whether metronidazole reduces early preterm labour in asymptomatic women with positive vaginal fetal fibronectin (fFN) in the second trimester of pregnancy.

DESIGN

Randomised placebo-controlled trial.

SETTING

Fourteen UK hospitals (three teaching).

POPULATION

Pregnancies with at least one previous risk factor, including mid-trimester loss or preterm delivery, uterine abnormality, cervical surgery or cerclage.

METHODS

Nine hundred pregnancies were screened for fFN at 24 and 27 weeks of gestation. Positive cases were randomised to a week's course of oral metronidazole or placebo.

MAIN OUTCOME MEASURES

Primary outcome was delivery before 30 weeks of gestation. Secondary outcomes included delivery before 37 weeks.

RESULTS

The Trial Steering Committee (TSC) recommended the study be stopped early; 21% of women receiving metronidazole (11/53) delivered before 30 weeks compared with 11% (5/46) taking placebo [risk ratio 1.9, 95% confidence interval (CI) 0.72-5.09, P = 0.18]. There were significantly more preterm deliveries (before 37 weeks) in women treated with metronidazole 33/53 (62%) versus placebo 18/46 (39%), risk ratio 1.6, 95% CI 1.05-2.4. fFN was a good predictor of early preterm birth in these asymptomatic women; positive and negative predictive values (24 weeks of gestation) for delivery by 30 weeks were 26% and 99%, respectively (positive and negative likelihood ratios 15, 0.35).

CONCLUSION

Metronidazole does not reduce early preterm birth in high risk pregnant women selected by history and a positive vaginal fFN test. Preterm delivery may be increased by metronidazole therapy.

Fetal fibronectin test predicts delivery before 30 weeks of gestation in high risk women, but increases anxiety

OBJECTIVE

To assess efficacy of cervico-vaginal fetal fibronectin as a predictor of spontaneous preterm birth in a high risk antenatal population, and to evaluate the psychological impact of fetal fibronectin testing.

DESIGN

An observational study.

SETTING

The antenatal clinic at a tertiary referral hospital.

POPULATION

One hundred and forty-six pregnant women with known risk factors for spontaneous preterm birth.

METHODS

Women designated as 'at risk' for preterm delivery by clinical history were screened for fetal fibronectin at 24 and again at 27 weeks of gestation. Anxiety levels were assessed by questionnaire and compared with anxiety levels of 206 low risk women also tested for fetal fibronectin. Fetal fibronectin results were disclosed to the woman and her clinician.

MAIN OUTCOME MEASURES

Maternal anxiety and efficacy of the 24-week fetal fibronectin test to predict delivery before 30, 34 and 37 weeks of gestation.

RESULTS

Maternal anxiety was higher pretesting in those at high risk compared with low risk women undergoing the test. Among the high risk women, anxiety was raised to clinically significant levels in those receiving a positive fetal fibronectin screening test result. In all women, 5%, 9% and 21% delivered <30, <34 or <37 weeks of gestation, respectively. Nine percent (n= 13) tested positive for fetal fibronectin at 24 weeks. Predictive power for fetal fibronectin (24 weeks) was greatest for delivery <30 weeks of gestation, with a likelihood ratio of 15 for a positive test (6/13 positive women delivered before 30 weeks).

CONCLUSIONS

Fetal fibronectin was most efficient as a predictor of preterm spontaneous delivery <30 weeks of gestation, but was associated with high levels of anxiety.

Clinical risk management in newborn and neonatal resuscitation

This chapter aims to provide an overview of aspects of risk management as they might be applied to the practice of resuscitation of the newborn using general principles of risk management and specific standards where they apply. Section 1 considers the matter of hazard and risk and how they may be classified. Figures are presented to provide a clinical perspective on resuscitation with a discussion on the hierarchy of clinical risks operating upon the baby. Section 2 centres on a discussion of those aspects that operate to modify the risks to the baby during a resuscitation, including environmental considerations (location, clinical setting and equipment); staffing issues (establishment, competency, induction and training) and logistics (process, communication and documentation). Section 3 debates the place of cord gases in the context of the diagnosis of perinatal hypoxaemia.

The EPIBEL study: outcomes to discharge from hospital for extremely preterm infants in Belgium

OBJECTIVE

To determine mortality and morbidity at discharge from the hospital of a large population-based cohort of infants who were born at <or=26 weeks' gestation.

METHODS

Perinatal data were collected on extremely preterm infants who were alive at the onset of labor and born between January 1, 1999, and December 31, 2000, in all 19 Belgian perinatal centers.

RESULTS

A total of 525 infants were recorded. Life-supporting care was provided to 322 liveborn infants, 303 of whom were admitted for intensive care. The overall survival rate of liveborn infants was 54%. Of the infants who were alive at the age of 7 days, 82% survived to discharge. Vaginal delivery, shorter gestation, air leak, longer ventilator dependence, and higher initial oxygen need all were independently associated with death; gender, plurality, and surfactant therapy were not. Among the 175 survivors, 63% had 1 or more of the 3 major adverse outcome variables at the time of discharge (serious neuromorbidity, chronic lung disease at 36 weeks' postmenstrual age, or treated retinopathy of prematurity). The chance of survival free from serious neonatal morbidity at the time of hospital discharge was <15% (21 of 158) for the admitted infants with a gestation <26 weeks.

CONCLUSIONS

If for the time being prolongation of pregnancy is unsuccessful, then outcome perspectives should be discussed and treatment options including nonintervention explicitly be made available to parents of infants of <26 weeks' gestation within the limits of medical feasibility and appropriateness.