The economic burden of prematurity in Canada

Validation of a Costing Algorithm and Cost Drivers for Neonates Admitted to the Neonatal Intensive Care Unit

OBJECTIVE

 Neonatal intensive care units (NICUs) account for over 35% of pediatric in-hospital costs. A better understanding of NICU expenditures may help identify areas of improvements. This study aimed to validate the Canadian Neonatal Network (CNN) costing algorithm for seven case-mix groups with actual costs incurred in a tertiary NICU and explore drivers of cost.

STUDY DESIGN

 A retrospective cohort study of infants admitted within 24 hours of birth to a Level-3 NICU from 2016 to 2019. Patient data and predicted costs were obtained from the CNN database and were compared to actual obtained from the hospital accounting system (Coût par Parcours de Soins et de Services). Cost estimates (adjusted to 2017 Canadian Dollars) were compared using Spearman correlation coefficient (rho).

RESULTS

 Among 1,795 infants included, 169 (9%) had major congenital anomalies, 164 (9%) with <29 weeks' gestational age (GA), 189 (11%) with 29 to 32 weeks' GA, and 452 (25%) with 33 to 36 weeks' GA. The rest were term infants: 86 (5%) with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia, 194 (11%) requiring respiratory support, and 541 (30%) admitted for other reasons. Median total NICU costs varied from $6,267 (term infants admitted for other reasons) to $211,103 (infants born with <29 weeks' GA). Median daily costs ranged from $1,613 to $2,238. Predicted costs correlated with actual costs across all case-mix groups (rho range 0.78-0.98, p < 0.01) with physician and nursing representing the largest proportion of total costs (65-82%).

CONCLUSION

 The CNN algorithm accurately predicts NICU total costs for seven case-mix groups. Personnel costs account for three-fourths of in-hospital total costs of all infants in the NICU.

KEY POINTS

· Very preterm infants born below 33 weeks of gestation account for most of NICU resource use.. · Human resources providing direct patient care represented the largest portion of costs.. · The algorithm strongly predicted total costs for all case-mix groups..

Cost-effectiveness and benefits of perinatal health interventions in high-income settings: A protocol for a systematic review of economic evaluations

BACKGROUND

Despite ongoing efforts, perinatal morbidity and mortality persist across all settings, imposing a dual burden of clinical and economic strain. Besides, the fragmented nature of economic evidence on perinatal health interventions hinders the formulation of effective health policies. Our review aims to comprehensively and critically assess the economic evidence for such interventions in high-income countries, where the balance of health outcomes and fiscal prudence is paramount.

METHODS AND ANALYSIS

We will conduct a comprehensive search for studies using databases including EconLit (EBSCO), Cost Effectiveness Analysis (CEA) Registry, Medline (Ovid), Embase (Ovid), CINAHL Ultimate (EBSCO), Global Health (Ovid), and PubMed. Furthermore, we will broaden our search to include Google Scholar and conduct snowballing from the final articles included. The search terms will encompass economic evaluation, perinatal health interventions, morbidity and mortality, and high-income countries. We will include full economic evaluations focusing on cost-effectiveness, cost-benefit, cost-utility, and cost-minimisation analyses. We will exclude partial economic evaluations, reports, qualitative studies, conference papers, editorials, and systematic reviews. Date restrictions will limit the review to studies published after 2010 and those in English during the study selection process. We will use the modified Drummond checklist to evaluate the quality of each included study. Our findings will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement. A summary will include estimated costs, effectiveness, benefits, and the incremental cost-effectiveness ratio (ICER). We also plan to conduct a subgroup analysis. To aid comparability, we will standardise all costs to the United States Dollar, adjusting them to their 2022 value using country-specific consumer price index and purchasing power parity.

ETHICS AND DISSEMINATION

This systematic review will not involve human participants and requires no ethical approval. We will publish the results in a peer-reviewed journal.

TRIAL REGISTRATION

We registered our record on PROSPERO (registration #: CRD42023432232).

Joint effects of green space and air pollutant exposure on preterm birth: evidence from a nationwide study in China

An association between green space exposure and preterm birth has been reported. However, evidence on the joint effects of air pollutant and green space exposure on preterm birth from nationwide research is limited in China. Based on a nationwide cohort, this study aims to explore the effect of green space exposure on preterm birth and analyze the joint effects of green space and air pollutant. Logistic regression models were developed to analyze the effects of green space exposure, and interaction effects were evaluated by adding interaction terms between green space and air pollutants. From 2013 to 2019, this study included 2,294,188 records of newborn births, of which 82,921 were preterm births. The results show that for buffer zones with 250 m, 500 m, 1000 m, and 1500 m, every 0.1 unit increase in NDVI exposure was associated with a decrease in the risk of preterm birth by 5.5% (95% CI: 4.6-6.4%), 5.8% (95% CI: 4.9-6.6%), 6.1% (95% CI: 5.3-7.0%), and 5.6% (95% CI: 4.7-6.5%), respectively. Under high-level exposure to air pollutants, high-level NDVI exposure was more strongly negatively correlated with preterm birth than low-level NDVI exposure. High-level green space exposure might mitigate the adverse effect of air pollutants on preterm birth by promoting physical activity, reducing stress, and adsorbing pollutants. Further investigation is needed to explore how green space and air pollution interact and affect preterm birth, in order to improve risk management and provide a reference for newborn health.

[Epidemiology and risk factors for preterm births in north-western Algeria]

Introduction

preterm births continue to be the main cause of infant and child mortality as well as sensory-motor disabilities and neurodevelopmental difficulties worldwide. The rate of preterm births has been rising, in particular in Algeria. The purpose of this study is to determine the frequency of preterm births in the Oran Wilaya and to identify risk factors.

Methods

we used data from a multicentre cross-sectional study carried out in all Public Maternity Hospitals in the Oran Wilaya (13). The study included parturient women who had given birth to a live and/or stillborn child (with birthweights ≥500 g), whose gestational age was greater than or equal to 24-36 weeks of amenorrhoea. Mothers´ demographic, medical and socio-behavioural factors were recorded. Logistic regression was used to study predictors of prematurity.

Results

preterm birth rate was 9.9% (45/452). The average age of patients was 30.4±6 years; multiple pregnancies accounted for 2.2% of births. Factors related to prematurity were the risk of premature labour (aOR=4.68; 95% CI: 2.27-9.64), the lack of clinical monitoring of pregnancy (OR=2.83; CI 95%: 1.83-6.05) and gestational hypertension (aOR = 3.69, 95% CI: 1.83-8.8).

Conclusion

the rate of preterm births is in line with the rate observed in neighbouring countries. The study identified predictive factors, some of which are already targeted by the national perinatal program. However, it is essential to continue to lead efforts to improve the monitoring and management of pregnancies and premature births at all levels of care.

Economic burden of adverse perinatal outcomes from births to age 5 years in high-income settings: a protocol for a systematic review

BACKGROUND

Adverse perinatal outcomes such as preterm, small for gestational age, low birth weight, congenital anomalies, stillbirth and neonatal death have devastating impacts on individuals, families and societies, with significant lifelong health implications. Despite extensive knowledge of the significant and lifelong health implications of adverse perinatal outcomes, information on the economic burden is limited. Estimating this burden will be crucial for designing cost-effective interventions to reduce perinatal morbidity and mortality. Thus, we will quantify the economic burden of adverse perinatal outcomes from births to age 5 years in high-income countries.

METHODS AND ANALYSIS

A systematic review of all primary studies published in English in peer-reviewed journals on the economic burden for at least one of the adverse perinatal outcomes in high-income countries from 2010 will be searched in databases-MEDLINE (Ovid), EconLit, CINAHL (EBSCO), Embase (Ovid) and Global Health (Ovid). We will also search using Google Scholar and snowballing of the references list of included articles. The search terms will include three main concepts-costs, adverse perinatal outcome(s) and settings. We will use the Consolidated Health Economics Evaluation Reporting Standards 2022 and 17 criteria from the critical appraisal of cost-of-illness studies to assess the quality of each study. We will report the findings based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 statement. Costs will be converted into a common currency (US dollar), and we will estimate the pooled cost and subgroup analysis will be done. The reference lists of included papers will be reviewed.

ETHICS AND DISSEMINATION

This systematic review will not involve human participants and requires no ethical approval. The results of this review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023400215.

Cost-effectiveness analysis of nirsevimab and maternal RSVpreF vaccine strategies for prevention of Respiratory Syncytial Virus disease among infants in Canada: a simulation study

Background

The cost-effectiveness of immunisation strategies with a long-acting monoclonal antibody (nirsevimab) and/or a protein-based maternal vaccine (RSVpreF) for protecting infants from Respiratory Syncytial Virus (RSV)-associated illness has not been previously determined for Canada. We estimated the health benefits and cost-effectiveness of nirsevimab for immunising the entire birth cohort, regardless of gestational age or other risk factors. Additionally, we evaluated the health benefits and cost-effectiveness of a combined strategy of year-round vaccination of pregnant women with RSVpreF and immunisation of infants at high risk, including those born preterm or with chronic conditions, with nirsevimab during the RSV season.

Methods

We developed a discrete-event simulation model, parameterized with the data on medically-attended RSV infections among infants under one year of age from 2010 to 2019, including outpatient care, hospitalisations, and deaths. Intervention scenarios targeting twelve monthly birth cohorts and pregnant women, reflecting the 2021 census data for Ontario, Canada were evaluated over a follow-up time horizon of one year from birth. Taking into account the costs (in 2023 Canadian dollars) associated with RSV-related outcomes, we calculated the net monetary benefit using the quality-adjusted life-year (QALY) gained. Further, we determined the range of price-per-dose (PPD) for nirsevimab and RSVpreF within which the program was cost-effective. Cost-effectiveness analyses were conducted from both healthcare and societal perspectives.

Findings

Using a willingness-to-pay of CAD$50,000 per QALY gained, we found that immunising the entire birth cohort with nirsevimab would be cost-effective from a societal perspective for a PPD of up to $290, with an annual budget impact of $83,978 for 1113 infants per 100,000 population. An alternative, combined strategy of vaccinating pregnant women and immunising only infants at high risk of severe disease would lead to a lower budget impact of $49,473 per 100,000 population with a PPD of $290 and $195 for nirsevimab and RSVpreF vaccine, respectively. This combined strategy would reduce infant mortality by 76%-85%, comparable to a 78% reduction achieved through a nirsevimab-only program of the entire birth cohort. The PPD for cost-effective programs with nirsevimab was sensitive to the target population among infants.

Interpretation

Passive immunisation of infants under 6 months of age with nirsevimab and vaccination of pregnant women with RSVpreF could be a cost-effective strategy for protecting infants during their first RSV season.

Funding

This study was supported by the Canadian Immunisation Research Network (CIRN) and the Canadian Institutes of Health Research (CIHR). Seyed M. Moghadas acknowledges support from the Natural Sciences and Engineering Research Council of Canada (MfPH and Discovery grants). Alison P. Galvani acknowledges support from the The Notsew Orm Sands Foundation.

The Association Between Maternal Short Stature and Neonatal Intensive Care Unit Admission: A Longitudinal Study in Sabah

BACKGROUND

The rising number of newborns requiring neonatal intensive care unit (NICU) care poses immediate threats to their health and places emotional and financial burdens on families and healthcare systems. This study investigates the direct effect of maternal short stature on NICU admission in Sabah, Malaysia.

METHODS

A longitudinal study at Hospital Wanita Dan Kanak-Kanak Sabah (HWKKS) from 2018 to 2022 included 254 Malaysian women with singleton pregnancies and neonates born after the 37th week, excluding significant disorders, smoking/alcohol use, fetal death, and malformations. Birth weight, gestational age, and neonatal condition were recorded. The association between maternal height, low birth weight (LBW), and NICU admission was analyzed.

RESULTS

LBW prevalence was 15.35%, with an average participant height of 147.37 cm. Maternal stature was significantly associated with LBW, with the shortest quartile (Q1) having the highest risk. LBW was significantly associated with NICU admission, with LBW newborns at a sixfold higher risk. Maternal height was also significantly associated with NICU admission, with Q1 having the highest risk. The receiver operating characteristic (ROC) curve suggested combining Q1 and Q2 for the best prediction of NICU admission, indicating that shorter mothers face a higher risk of neonates requiring NICU care.

CONCLUSION

Maternal short stature could be a valuable predictor of LBW and NICU admission risk. It may be a screening tool to assess these risks in healthcare settings. However, further research is needed to explore this association's underlying mechanisms and potential interventions.

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.

Predictors of adverse short-term outcomes in late preterm infants

BACKGROUND

Infants born between 34 weeks and 36 weeks and 6 days of gestation are defined as late preterm infants (LPIs), and they account for approximately 74% of all premature births. Preterm birth (PB) remains the leading cause of infant mortality and morbidity worldwide.

AIM

To analyse short-term morbidity and mortality and identify predictors of adverse outcomes in late preterm infants.

PATIENTS AND METHODS

In this retrospective study, we evaluated adverse short-term outcomes of LPIs admitted to the Intensive Care Unit (ICU), Clinic for Children's Diseases, University Clinical Center Tuzla, between 01.01.2020 and 31.12.2022. The analysed data included sex, gestational age, parity, birth weight, Apgar score (i.e., assessment of vitality at birth in the first and fifth minutes after birth), and length of hospitalization in NICU, as well as short-term outcome data. Maternal risk factors we observed were: age of mother, parity, maternal morbidity during pregnancy, complications and treatment during pregnancy. LPIs with major anatomic malformations were excluded from the study. Logistic regression analysis was used to identify risk factors for neonatal morbidity among LPIs.

RESULTS

We analysed data from 154 late preterm newborns, most of whom were male (60%), delivered by caesarean Sect. (68.2%) and from nulliparous mothers (63.6%). Respiratory complications were the most common outcome among all subgroups, followed by CNS morbidity, infections and jaundice requiring phototherapy. The rate of almost all of the complications in the late-preterm group decreased as gestational age increased from 34 to 36 weeks. Birth weight (OR: 1,2; 95% CI: 0,9 - 2,3; p = 0,0313) and male sex (OR: 2,5; 95% CI: 1,1-5,4; p = 0,0204) were significantly and independently associated with an increased risk for respiratory morbidity, and gestational weeks and male sex were associated with infectious morbidity. None of the risk factors analysed herein were predictors of CNS morbidity in LPIs.

CONCLUSION

A younger gestational age at birth is associated with a greater risk of short-term complications among LPIs, thus highlighting the need for increased knowledge about the epidemiology of these late preterm births. Understanding the risks of late preterm birth is critical to optimizing clinical decision-making, enhancing the cost-effectiveness of endeavours to delay delivery during the late preterm period, and reducing neonatal morbidity.

Health Care Utilization During the COVID-19 Pandemic Among Individuals Born Preterm

Importance

Limited data exist on pediatric health care utilization during the COVID-19 pandemic among children and young adults born preterm.

Objective

To investigate differences in health care use related to COVID-19 concerns during the pandemic among children and young adults born preterm vs those born at term.

Design, Setting, and Participants

In this cohort study, questionnaires regarding COVID-19 and health care utilization were completed by 1691 mother-offspring pairs from 42 pediatric cohorts in the National Institutes of Health Environmental Influences on Child Health Outcomes Program. Children and young adults (ages 1-18 years) in these analyses were born between 2003 and 2021. Data were recorded by the August 31, 2021, data-lock date and were analyzed between October 2021 and October 2022.

Exposures

Premature birth (<37 weeks' gestation).

Main Outcomes and Measures

The main outcome was health care utilization related to COVID-19 concerns (hospitalization, in-person clinic or emergency department visit, phone or telehealth evaluations). Individuals born preterm vs term (≥37 weeks' gestation) and differences among preterm subgroups of individuals (<28 weeks', 28-36 weeks' vs ≥37 weeks' gestation) were assessed. Generalized estimating equations assessed population odds for health care used and related symptoms, controlling for maternal age, education, and psychiatric disorder; offspring history of bronchopulmonary dysplasia (BPD) or asthma; and timing and age at COVID-19 questionnaire completion.

Results

Data from 1691 children and young adults were analyzed; among 270 individuals born preterm, the mean (SD) age at survey completion was 8.8 (4.4) years, 151 (55.9%) were male, and 193 (71.5%) had a history of BPD or asthma diagnosis. Among 1421 comparison individuals with term birth, the mean (SD) age at survey completion was 8.4 (2.4) years, 749 (52.7%) were male, and 233 (16.4%) had a history of BPD or asthma. Preterm subgroups included 159 individuals (58.5%) born at less than 28 weeks' gestation. In adjusted analyses, individuals born preterm had a significantly higher odds of health care utilization related to COVID-19 concerns (adjusted odds ratio [aOR], 1.70; 95% CI, 1.21-2.38) compared with term-born individuals; similar differences were also seen for the subgroup of individuals born at less than 28 weeks' gestation (aOR, 2.15; 95% CI, 1.40-3.29). Maternal history of a psychiatric disorder was a significant covariate associated with health care utilization for all individuals (aOR, 1.44; 95% CI, 1.17-1.78).

Conclusions and Relevance

These findings suggest that during the COVID-19 pandemic, children and young adults born preterm were more likely to have used health care related to COVID-19 concerns compared with their term-born peers, independent of a history of BPD or asthma. Further exploration of factors associated with COVID-19-related health care use may facilitate refinement of care models.

Very-low-birth-weight infant short-term post-discharge outcomes: A retrospective study of specialized compared to standard care

OBJECTIVE

Ongoing health care challenges, low breast milk intake, and the need for rehospitalization are common during the first year of life after hospital discharge for very low birth weight (VLBW) infants. This retrospective cohort study examined breast milk intake, growth, emergency department (ED) visits, and non-surgical rehospitalizations for VLBW infants who received specialized post-discharge follow-up in western Canada, compared to VLBW infants who received standard follow-up in central Canada.

DESIGN

Data were collected from two neonatal follow-up programs for VLBW babies (n = 150 specialized-care; n = 205 standard-care). Logistic regression was used to examine odds of breast milk intake and generalized estimating equations were used for odds of growth, ED visits and non-surgical rehospitalization by site.

RESULTS

Specialized-care was associated with enhanced breast milk intake duration; the odds of receiving breastmilk at 4 months in the specialized-care cohort was 6 times that in the standard-care cohort. The specialized-care cohort had significantly more ED visits and rehospitalizations. However, for infants with oxygen use beyond 36 weeks compared to those with no oxygen use, the standard-care cohort had over 7 times the odds of rehospitalization where as the specialized-care cohort with no increased odds of rehospitalization.

CONCLUSION

Specialized neonatal nursing follow-up was associated with continued breastmilk intake beyond discharge. Infants in the specialized-care cohort used the ED and were hospitalized more often than the standard-care cohort with the exception of infants with long term oxygen needs.

The Impact of Prematurity at Birth on Short-Term Postoperative Outcomes Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

Prematurity is associated with surgical complications. This study sought to determine the risk of prematurity on 30-day complications, reoperations, and readmissions following ≥7-level PSF for AIS which has not been established. Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)-Pediatric dataset, all AIS patients undergoing ≥7-level PSF from 2012-2016 were identified. Cases were 1:1 propensity score-matched to controls by age, sex, and number of spinal levels fused. Prematurity sub-classifications were also evaluated: extremely (<28 weeks), very (28-31 weeks), and moderate-to-late (32-36 weeks) premature. Univariate analysis with post hoc Bonferroni compared demographics, hospital parameters, and 30-day outcomes. Multivariate logistic regression identified independent predictors of adverse 30-day outcomes. 5531 patients (term = 5099; moderate-to-late premature = 250; very premature = 101; extremely premature = 81) were included. Premature patients had higher baseline rates of multiple individual comorbidities, longer mean length of stay, and higher 30-day readmissions and infections than the term cohort. Thirty-day readmissions increased with increasing prematurity. Very premature birth predicted UTIs, superficial SSI/wound dehiscence, and any infection, and moderate-to-late premature birth predicted renal insufficiency, deep space infections, and any infection. Prematurity of AIS patients differentially impacted rates of 30-day adverse outcomes following ≥7-level PSF. These results can guide preoperative optimization and postoperative expectations.

Comparative evaluation of the health utilities index mark 3 and the short form 6D: evidence from an individual participant data meta-analysis of very preterm and very low birthweight adults

BACKGROUND

The most appropriate preference-based health-related quality of life (HRQoL) instruments for trials or research studies that ascertain the consequences of individuals born very preterm and/or low birthweight (VP/VLBW) are not known. Agreement between the HUI3 and SF-6D multi-attribute utility measures have not been previously investigated for VP/VLBW and normal birthweight or term-born controls. This study examined the agreement between the outputs of the HUI3 and SF-6D measures among adults born VP/VLBW and normal birthweight or term born controls.

METHODS

We used two prospective cohorts of individuals born VP/VLBW and controls contributing to the 'Research on European Children and Adults Born Preterm' (RECAP) consortium which assessed HRQoL using two preference-based measures. The combined dataset of individual participant data (IPD) included 407 adult VP/VLBW survivors and 367 controls, ranging in age from 18 to 26 years. Bland-Altman plots, intra-class correlation coefficients, and generalized linear mixed models in a one-step approach were used to examine agreement between the measures.

RESULTS

There was significant discordance between the HUI3 and SF-6D multi-attribute utility measures in the VP/VLBW sample, controls, and in the combined samples. Agreement between the HUI3 and SF-6D multi-attribute utility measures was weaker in controls compared with VP/VLBW individuals.

CONCLUSIONS AND RELEVANCE

The HUI3 and SF-6D each provide unique information on different aspects of health status across the groups. The HUI3 better captures preterm-related changes to HRQoL in adulthood compared to SF-6D. Studies focused on measuring physical or cognitive aspects of health will likely benefit from using the HUI3 instead of the SF-6D, regardless of gestational age at birth and birthweight status.

The price of neonatal intensive care outcomes - in-hospital costs of morbidities related to preterm birth

BACKGROUND

Neonatal care for preterm babies is prolonged and expensive. Our aim was to analyze and report costs associated with common preterm diagnoses during NICU stay.

METHODS

We analyzed data from the Ontario healthcare data service. Diagnoses were collated by discharge ICD codes, and categorized by gestational age. We calculated typical non parametric statistics, and for each diagnosis we calculated median shifts and generalized linear mode.

RESULTS

We included data on 12,660 infants between 23 and 30 weeks gestation in 2005-2017. Calculated cost increment with diagnosis were: Intestinal obstruction: $94,738.08 (95%CI: $70,093.3, $117,294.2), Ventriculoperitoneal shunt: $86,456.60 (95%CI: $60,773.7, $111,552.2), Chronic Lung Disease $77,497.70 (95%CI: $74,937.2, $80,012.8), Intestinal perforation $57,997.15 (95%CI:$45,324.7, $70,652.6), Retinopathy of Prematurity: $55,761.80 (95%CI: $53,916.2, $57,620.1), Patent Ductus Arteriosus $53,453.70 (95%CI: $51,206.9, $55692.7, Post-haemorrhagic ventriculomegaly $41,822.50 (95%CI: $34,590.4, $48,872.4), Necrotizing Enterocolitis $39,785 (95%CI: $35,728.9, $43,879), Meningitis $38,871.85 (95%CI: $25,272.7, $52,224.4), Late onset sepsis $32,954.20 (95%CI: $30,403.7, 35.515), Feeding difficulties $24,820.90 (95%CI: $22,553.3, $27,064.7), Pneumonia $23,781.70 (95%CI: $18,623.8, $28,881.6), Grade >2 Intraventricular Haemorrhage $14,777.38 (95%CI: $9,821.7, $20,085.2). Adjusted generalized linear model of diagnoses as coefficients for cost confirmed significance and robustness of the model.

CONCLUSION

Cost of care for preterm infant is expensive, and significantly increases with prematurity complication. Interventions to reduce those complications may enable resource allocation and better understanding of the needs of the neonatal health services.

Health-Related Quality-of-Life Outcomes of Very Preterm or Very Low Birth Weight Adults: Evidence From an Individual Participant Data Meta-Analysis

BACKGROUND AND OBJECTIVE

Assessment of health-related quality of life for individuals born very preterm and/or low birthweight (VP/VLBW) offers valuable complementary information alongside biomedical assessments. However, the impact of VP/VLBW status on health-related quality of life in adulthood is inconclusive. The objective of this study was to examine associations between VP/VLBW status and preference-based health-related quality-of-life outcomes in early adulthood.

METHODS

Individual participant data were obtained from five prospective cohorts of individuals born VP/VLBW and controls contributing to the 'Research on European Children and Adults Born Preterm' Consortium. The combined dataset included over 2100 adult VP/VLBW survivors with an age range of 18-29 years. The main exposure was defined as birth before 32 weeks' gestation (VP) and/or birth weight below 1500 g (VLBW). Outcome measures included multi-attribute utility scores generated by the Health Utilities Index Mark 3 and the Short Form 6D. Data were analysed using generalised linear mixed models in a one-step approach using fixed-effects and random-effects models.

RESULTS

VP/VLBW status was associated with a significant difference in the Health Utilities Index Mark 3 multi-attribute utility score of - 0.06 (95% confidence interval - 0.08, - 0.04) in comparison to birth at term or at normal birthweight; this was not replicated for the Short Form 6D. Impacted functional domains included vision, ambulation, dexterity and cognition. VP/VLBW status was not associated with poorer emotional or social functioning, or increased pain.

CONCLUSIONS

VP/VLBW status is associated with lower overall health-related quality of life in early adulthood, particularly in terms of physical and cognitive functioning. Further studies that estimate the effects of VP/VLBW status on health-related quality-of-life outcomes in mid and late adulthood are needed.

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.

Catch-Up Growth as a Risk Factor for Rapid Weight Gain, Earlier Menarche and Earlier Pubertal Growth Spurt in Girls Born Small for Gestational Age (SGA)-A Longitudinal Study

Most children born small for gestational age (SGA) have rapid postnatal growth. Despite its positive aspects, catch-up growth may affect the level of adipose tissue in the pre-pubertal and pubertal periods and therefore affect the age of puberty. The aim of this study was to determine the associations between size at birth, catch-up growth in infancy, BMI in peripubertal period, age at menarche, and the parameters of adolescent growth spurt of body height in girls born SGA. For 297 girls (22.6% SGA; 77.4% appropriate for gestational age (AGA)) complete body weight and height measurements and age at menarche were obtained. Adolescent growth spurt parameters were estimated using the JPA2 model (AUXAL SSI 3.1). Calculations were made in the Statistica 13 program using the Kruskal-Wallis and Kaplan-Meier tests. Girls born SGA with catch-up had the highest BMIs at the age of 8 years (H = 94.22, p < 0.001) and at menarche (H = 58.21, p < 0.001), experienced menarche earliest (H = 21.77, p < 0.001), same as the onset (H = 6.54, p = 0.012) and peak height velocity (H = 11.71, p = 0.003) of their adolescent growth spurt compared to SGA girls without catch-up and AGA girls. In SGA girls, catch-up growth has far-reaching consequences such as increased risk of fat accumulation and a rapid transition to puberty.

Healthcare Costs of Major Morbidities Associated with Prematurity in US Children's Hospitals

OBJECTIVE

To evaluate the healthcare costs attributed to major morbidities associated with prematurity, namely, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage, necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and nosocomial infections.

STUDY DESIGN

This was a retrospective analysis of infants born at 24-30 weeks of gestation, admitted to children's hospitals in the Pediatric Health Information System between 2009 and 2018. Charges were adjusted by geographical price index, converted to costs using cost-to-charge ratios, inflated to 2018 US$, and total costs were accumulated for the initial hospitalization. Quantile regressions, which are less prone to bias from extreme outliers, were used to examine the incremental costs attributed to each morbidity across the entire cost distribution, including the median.

RESULTS

There were 19 232 patients from 30 children's hospitals who were eligible. Higher costs were seen in lower gestational age, more severe morbidity, and those with higher number of comorbidities. Patients with surgical NEC, severe ROP, and severe BPD were the costliest with median total costs of $430 860, $413 825, and $399 495, respectively. Quantile regressions showed surgical NEC had the highest adjusted median incremental total cost ($48 621; 95% CI, $39 617-$57 626) followed by severe BPD ($35 773; 95% CI, $32 018-$39 528) and severe ROP ($22 561; 95% CI, $16 699-$28 423). Quantile regressions also revealed that surgical NEC, severe BPD, and severe ROP had increasing incremental costs at higher total cost percentiles, indicating these morbidities have a greater cost impact on the costliest patients.

CONCLUSIONS

Severe BPD, surgical NEC, and severe ROP are the costliest morbidities and contribute the most incremental costs especially for the higher costs patients.

Preterm, early term, and post-term infants from Riyadh mother and baby multicenter cohort study: The cohort profile

Background

Birth before 37 or beyond 42 gestational weeks is associated with adverse neonatal and maternal outcomes. Studies investigating determinants and outcomes of these deliveries are scarce. The objective of this study was to determine the neonatal birth profile in relation to the gestational age at delivery and to evaluate its influence on the immediate maternal and neonatal outcomes.

Methods

This is a multicenter cohort study of 13,403 women conducted in three hospitals in Riyadh. Collected data included sociodemographic characteristics, obstetric history, and physical and laboratory measurements. Regression models were developed to estimate the adjusted odds ratio (OR) and confidence intervals (CI) to determine factors associated with preterm, early term, and post-term births and to evaluate common maternal and neonatal risks imposed by deliveries outside the full term.

Results

The incidence of preterm, early term, and post-term delivery was 8.4%, 29.8%, and 1.4%, respectively. Hypertensive events during pregnancy consistently increased the risk of all grades of preterm births, from more than 3-fold for late preterm (OR = 3.40, 95% CI = 2.21-5.23) to nearly 7-fold for extremely early preterm (OR = 7.11, 95% CI = 2.24-22.60). Early term was more likely to occur in older mothers (OR = 1.30, 95% CI = 1.13-1.49), grand multiparous (OR = 1.21, 95% CI = 1.06-1.38), pregestational diabetes (OR = 1.91, 95% CI = 1.49-2.44), and gestational diabetes women (OR = 1.18, 95% CI = 1.05-1.33). The risk of post-term birth was higher in primiparous. In preterm births, the adverse outcome of neonates having an APGAR score of <7 at 5 min and admission to neonatal intensive care units increased progressively as the gestational age decreased. Post-term births are 2-fold more likely to need induction of labor; meanwhile, preterm births were more likely to deliver by cesarean section.

Conclusion

This large cohort study was the first in Saudi Arabia to assess the delivery profile across a continuum of gestational age and the associated maternal and neonatal adverse outcomes of deliveries outside the full-term period. The study showed that the prevalence of preterm and post-term birth in Saudi Arabia is similar to the prevalence in other high-income countries. The immediate adverse pregnancy outcomes inversely increased with the decrease in gestational age at delivery. In addition, maternal age, hypertension, diabetes, and parity influenced the gestational age at delivery.

Investigating the Developmental Trajectory of Long-term Oral Feeding Problems in 'Healthy' Preterm Infants

PURPOSE

To investigate the occurrence of oral feeding problems in preterm infants up to one year after hospital discharge.

METHODS

Thirty-six infants born <34 weeks gestation were enrolled in a prospective exploratory longitudinal pilot study prior to hospital discharge. Parents of eligible infants completed telephone questionnaires at 3, 6, and 12 months corrected gestational age. The occurrence and type of feeding problems; medical problems; and rehabilitation services received were collected.

RESULTS

A total of 26 (72.2%) parents responded, with 11 (42%) identifying feeding problems that developed within the first year of life. Avoidant behavior (including crying, agitated/fussy, and refusing to eat) was the most common feeding problem that occurred.

CONCLUSION

Feeding problems in 'healthy' preterm infants may occur at any point in development within the first year of life. Increased screening after hospitalization is needed for early identification and to make appropriate referrals in a timely manner to prevent and/or reduce the severity of long-term feeding problems.

Effect of family integrated care on physical growth and language development of premature infants: a retrospective study

BACKGROUND

Premature birth (PTB) increases the long-term risk of diseases such as hypertension, heart disease, and diabetes in adulthood. It is an independent disease with the largest global burden in terms of high mortality and lifelong negative health impacts. The purpose of this study was to analyze the physical growth and language development of premature infants (PIs) at the age of 18 months, and to explore the impact of family integrated care (FIcare) on PI.

METHODS

This study retrospectively included mothers and their PIs born in the Neonatal Pediatrics Department, Affiliated Hospital of Nantong University from January 2018 to September 2020 and hospitalized in the neonatal intensive care unit (NICU) within 24 hours after birth. The weight, head circumference, body length, and language development of each child were followed up at the age of 1, 3, 6, 12, and 18 months and recorded, and the relationship between FIcare and physical growth and language development of PIs was evaluated.

RESULTS

The development quotient (DQ) score and language development score of the FIcare group were always higher than those of the control group from 6 to 18 months, and the difference was statistically significant (P<0.05). Multiple regression analysis showed that the body length of the FIcare group participants was longer than that of control group participants. The head circumference of infants was positively correlated with gestational age, birth head circumference, and family average monthly income. The head circumference of FIcare group participants was longer than that of control group participants. The DQ score was positively correlated with gestational age, and the FIcare group participants scored higher than control group participants. Logistic regression analysis showed that early language milestone (ELM) scale score and gestational age were positively correlated with mother's education, and the score of FIcare group participants was higher than that of control group participants (P<0.05).

CONCLUSIONS

Compared with the traditional nursing model, the implementation of FIcare for the hospitalized PIs in the NICU can actively promote the physical growth and language development of infants.

The effect of rapid exome sequencing on downstream health care utilization for infants with suspected genetic disorders in an intensive care unit

PURPOSE

This study aimed to compare downstream utilization of medical services among critically ill infants admitted to intensive care units who received rapid exome sequencing (ES) and those who followed alternative diagnostic testing pathways.

METHODS

Using propensity score-weighted regression models including sex, age at admission, and severity indicators, we compared a group of 47 infants who underwent rapid ES with a group of 211 infants who did not receive rapid ES. Utilization and cost indicators were compared between cohorts using negative binomial models for utilization and two-part models for costs.

RESULTS

After controlling for patients' sociodemographic and clinical characteristics, we found no statistically significant difference in outpatient visits, hospitalizations, intensive care unit or total length of stay, or length of stay-associated costs between the cohorts at 12- or 26-month follow-up. Similarly, there was no evidence of higher utilization or costs by the ES group when infants who died were removed from the analysis.

CONCLUSION

When examining utilization during and beyond the diagnostic trajectory, there is no evidence that ES changes frequency of outpatient visits or use of in-hospital resources in critically ill infants with suspected genetic disorders.

2.5 Million Annual Deaths-Are Neonates in Low- and Middle-Income Countries Too Small to Be Seen? A Bottom-Up Overview on Neonatal Morbi-Mortality

(1) Background: Every year, 2.5 million neonates die, mostly in low- and middle-income countries (LMIC), in total disregard of their fundamental human rights. Many of these deaths are preventable. For decades, the leading causes of neonatal mortality (prematurity, perinatal hypoxia, and infection) have been known, so why does neonatal mortality fail to diminish effectively? A bottom-up understanding of neonatal morbi-mortality and neonatal rights is essential to achieve adequate progress, and so is increased visibility. (2) Methods: We performed an overview on the leading causes of neonatal morbi-mortality and analyzed the key interventions to reduce it with a bottom-up approach: from the clinician in the field to the policy maker. (3) Results and Conclusions: Overall, more than half of neonatal deaths in LMIC are avoidable through established and well-known cost-effective interventions, good quality antenatal and intrapartum care, neonatal resuscitation, thermal care, nasal CPAP, infection control and prevention, and antibiotic stewardship. Implementing these requires education and training, particularly at the bottom of the healthcare pyramid, and advocacy at the highest levels of government for health policies supporting better newborn care. Moreover, to plan and follow interventions, better-quality data are paramount. For healthcare developments and improvement, neonates must be acknowledged as humans entitled to rights and freedoms, as stipulated by international law. Most importantly, they deserve more respectful care.

Medical Utilization and Costs in Preterm Infants in the First 6 Years of Life After Discharge From Neonatal Intensive Care Unit: A Nationwide Population-Based Study in Korea

BACKGROUND

The improvement in the survival rate of preterm infants has paradoxically raised the risk of morbidities in childhood. Our objectives were to assess the medical utilization and costs in preterm infants following discharge from the neonatal intensive care unit in the first 6 years of life.

METHODS

We conducted a population-based study using the National Health Information Database (2011-2017) provided by the Korean National Health Insurance Service (NHIS). A total of 361,190 children born in Korea between January 1 and December 31, 2011 were divided into four groups according to the gestational age at birth: extremely preterm (less than 28 weeks), very preterm (28-31 weeks), moderate to late preterm (32-36 weeks), and full term (37-41 weeks). The cumulative number of outpatient visits, cumulative length of hospital stay, rate of hospital and intensive care unit admissions, and cumulative medical costs for inpatients and outpatients were compared for each gestational age group.

RESULTS

Earlier gestational age was significantly associated with an increased risk of the cumulative number of outpatient visits, cumulative length of hospital stay, and rate of hospital and intensive care unit admissions for the first 6 years of life. The mean cumulative inpatient and outpatient costs per child significantly decreased with increasing gestational age. When assessed based on population size, the total cumulative medical costs were highest for moderate to late preterm children.

CONCLUSION

Earlier gestational age was strongly associated with increased healthcare resource utilization and medical costs. Our findings on the potential long-term socioeconomic impact on public health are expected to aid the development of future health care policies for preterm children.

Residential proximity to greenness and adverse birth outcomes in urban areas: Findings from a national Canadian population-based study

BACKGROUND

Over the last decade, several studies have reported that residential proximity to vegetation, or 'greenness', is associated with improved birth outcomes, including for term birth weight (TBW), preterm birth (PTB), and small for gestational age (SGA). However, there remain several uncertainties about these possible benefits including the role of air pollution, and the extent to they are influenced socioeconomic status.

METHODS

We addressed these gaps using a national population-based study of 2.2 million singleton live births in Canadian metropolitan areas between 1999 and 2008. Exposures to greenness, fine particulate matter (PM_2.5), and nitrogen dioxide (NO₂) were assigned to infants using the postal code of their mother's residence at the time of birth. The Normalized Difference Vegetation Index (NDVI) was used to characterize greenness, while estimates of ambient PM_2.5 and NO₂ were estimated using remote sensing, and a national land-use regression surface, respectively. Multivariable regression analysis was performed to describe associations between residential greenness and the birth outcomes. Stratified analyses explored whether these associations were modified by neighbourhood measures of socioeconomic status.

RESULTS

Mothers who lived in greener areas had a lower risk of low TBW, PTB, and SGA babies. These associations persisted after adjustment for ambient NO₂ and PM_2.5. Specifically, in fully adjusted models, an interquartile range (IQR = 0.16) increase in the NDVI within a residential buffer of 250 m yielded odds ratios of 0.93 (95% confidence interval (CI): 0.92, 0.94), 0.94 (95% CI: 0.92, 0.95), and 0.94 (95% CI: 0.93, 0.95) for the outcomes of PTB, low TBW, and SGA, respectively. Similarly, an IQR increase in greenness was associated with a 16.3 g (95% CI: 15.3, 17.4) increase in TBW. We found inverse associations between greenness and the occurrence of adverse birth outcomes regardless of the socioeconomic status of the neighbourhood.

INTERPRETATION

Our findings support the hypothesis that residential greenness contributes to healthier pregnancies, that these associations are independent from exposure to air pollution. , and that proximity to greenness benefits all mothers regardless of socioeconomic status.

Thrombospondin-1 Plays a Major Pathogenic Role in Experimental and Human Bronchopulmonary Dysplasia

RATIONALE

Extremely preterm infants develop bronchopulmonary dysplasia (BPD), a chronic lung injury that lacks effective treatment. Thrombospondin-1 is an anti-angiogenic protein that activates TGF-β1, a cytokine strongly linked to both experimental and human BPD.

OBJECTIVES

1) To examine effects of inhibiting thrombospondin-1-mediated TGF-β1 activation (LSKL) in neonatal rats with bleomycin-induced lung injury, 2) To examine effects of a thrombospondin-1-mimic (ABT-510) on lung morphology, and 3) To determine whether thrombospondin-1 and related signaling peptides are increased in lungs of human preterm infants at risk for BPD.

METHODS

From postnatal days 1-14, rat pups received daily i.p. bleomycin (1 mg/kg) or vehicle combined with daily s.c. LSKL (20 mg/kg) or vehicle. Separate animals were treated with vehicle or ABT-510 (30 mg/kg/d). Paraffin-embedded lung tissues from 47 autopsies (controls; death <28 days, n=30 and BPD at risk; death ≥28 days, n=17) performed on infants born <29 completed weeks' gestation were semi-quantified for injury markers (collagen, macrophages, 3-nitrotyrosine), thrombospondin-1 and TGF-β1.

MEASUREMENTS AND MAIN RESULTS

Bleomycin or ABT-510 increased lung TGF-β1 activity and macrophage influx, caused pulmonary hypertension and led to alveolar and microvascular hypoplasia. Treatment with LSKL partially prevented abnormal lung morphology secondary to bleomycin. Lungs from human infants at-risk for BPD had increased contents of thrombospondin-1 and TGF-β1 when compared to controls. TGF-β1 content correlated with markers of lung injury.

CONCLUSIONS

Thrombospondin-1 inhibits alveologenesis in neonatal rats, in part via up-regulated activity of TGF-β1. Observations in human lung suggest a similar pathogenic role for thrombospondin-1 in infants at-risk for BPD.

The financial burden experienced by families of preterm infants after NICU discharge

BACKGROUND AND OBJECTIVES

Describe the financial burden and worry that families of preterm infants experience after discharge from the neonatal intensive care unit (NICU).

METHODS

We surveyed 365 parents of preterm infants in a cross-sectional study regarding socio-demographics, supplemental security income (SSI), and financial worry. We completed a multivariable logistic regression model to examine the adjusted association of financial worry with modifiable factors.

RESULTS

We found that 53% of participants worried about healthcare costs after NICU discharge. After adjusting for socio-demographic and infant characteristics, we identified that, aOR (95% CI), out-of-pocket costs from the NICU index hospitalization, 3.51 (1.7, 7.26) and durable medical equipment use, 2.41 (1.11, 5.23) was associated with increased financial worry while enrollment in SSI, 0.38 (0.19, 0.76) was associated with decreased financial worry.

CONCLUSIONS

We identified factors that could contribute to financial burden after NICU discharge that may advise future work to target financial support systems.

Length of stay in health facilities after childbirth and associated maternal and neonatal factors in Ethiopia: a cross-sectional study from a national survey

OBJECTIVE

This study aimed to assess the length of stay in health facilities after childbirth and associated maternal and neonatal factors in Ethiopia.

DESIGN

A cross-sectional study.

SETTING

Ethiopia.

PARTICIPANTS

2260 mothers who participated in the 2016 Ethiopian Demographic and Health Survey were included in the study.

OUTCOME

Length of stay in health facilities after childbirth was the outcome variable of the study.

RESULT

In Ethiopia, the mean duration of postpartum stay for mothers in health facilities was 21.96 (19.97-23.94) hours. Nine hundred and sixty-eight (34.80%) women remained in health institutions for ≥24 hours after delivery. Gestational age, birth weight and mode of delivery were significantly associated with length of stay. Gestational age was found to be inversely associated with length of stay. Mothers who had a vaginal delivery were 8.89% (adjusted HR (AHR) 8.89, 95% CI (4.28 to 18.46), p<0.001) more likely to discharge earlier from health facilities after delivery, compared with those who had a caesarian section. Women with larger size neonates during birth were 19% (AHR=0.81, 95% CI (0.67 to 0.96), p=0.019) more likely to stay longer in health facilities than women with average size neonates. Women with a smaller size neonate during birth were 16% (AHR=0.84, 95% CI (0.70 to 0.99), p=0.040) more likely to stay longer at a health facility, compared with those with an average size neonate.

CONCLUSION

A small percentage of Ethiopian mothers stayed in health facilities for 24 hours or more after delivery. Encouraging mothers to stay in health facilities for the recommended period after childbirth can play a significant role in reducing maternal and neonatal deaths.

Implementation Barriers for Practicing Continuous Kangaroo Mother Care from the Perspective of Neonatologists and Nurses

Introduction: Kangaroo mother care (KMC), as a complement to incubator care, is one of the ten recommendations of the World Health Organization (WHO) for the care of preterm infants. The KMC stabilizes the heart rate, improves oxygen saturation, makes weight gain better, and reduces crying in the infant. In order to launch KMC unit, the barriers for implementing this type of care should be recognized.

Methods: This qualitative research was conducted using a focus group discussion and individual semi-structured interview with nurses, doctors, executive and management staff of a neonatal unit of a third level teaching hospital in Tabriz, northwest Iran. The participants were selected using purposeful sampling. Content analysis was used for analyzing data. Data were analyzed by MAXQDA 10 software.

Results: After analyzing data, four main themes were extracted including mother-related barriers, father-related barriers, physician- related barriers, and system-related barriers.

Conclusion: Based on the findings of the research, it seems that in order to facilitate practicing continuous KMC, much emphasis should be placed on training the parents and health care providers. Furthermore, in some cases, reforming the payment system for physicians, providing an instruction for performing continuous KMC, and continuous assessment of hospitals annually are necessary.

COVID-19 mental health impact among children with early brain injury and associated conditions

This study describes the impact of COVID-19 among a clinical research sample of children with early brain injury and associated conditions. Between March 2020 and March 2021, 64 children and their parents participated. Children ranged in age between 3 and 14 years (M = 6 years, 3 months; SD = 2 years, 4 months) with a range of diagnoses (i.e., neonatal stroke, hypoxic ischemic encephalopathy (HIE), congenital heart disease (CHD) and preterm birth (<32 weeks)). The abbreviated CoRonavIrus Health Impact Survey (CRISIS) was completed by parents as part of their child's routine intake for neuropsychological services. Questions included COVID-19 specific ratings of child mental health impact, child, and parent stressors, with open-ended questions regarding negative and positive COVID-19 related changes. Over 40% of parents described moderate to extreme influence of COVID-19 on their child's mental health. Common child stressors reported included restrictions on leaving the home and social isolation. Among parents, the most common stress reported was caring for their child's education and daily activities. Children's mental health impact was associated with social isolation, parent mental health, COVID-19 economic concern, and number of siblings in the home. Child's age, sex, brain injury severity, or intellectual functioning were not associated with reported COVID-19 mental health impact. Some COVID-19 positives were identified, namely increased quality family time. Findings reflect the significant pandemic mental health impact among neurologically at-risk children and their families. Implications to future clinical needs and considerations for neuropsychological practice are discussed.

Prediction Model for Bronchopulmonary Dysplasia in Preterm Newborns

OBJECTIVE: To develop a multifactorial model that allows the prediction of bronchopulmonary dysplasia (BPD) in preterm newborns. MATERIALS AND METHODS: A single-center retrospective study of infants born below 32 + 0 weeks gestational age. We created a receiver operating characteristic curve to assess the multifactorial BPD risk and calculate the BPD risk accuracy using the area under the curve (AUC). BPD risk was categorized using a multifactorial predictive model based on the weight of the evidence. RESULTS: Of the 278 analyzed preterm newborns, 127 (46%) developed BPD. The significant risk factors for BPD in the multivariate analysis were gestational age, number of red blood cell concentrate transfusions, number of surfactant administrations, and hemodynamically significant patent ductus arteriosus. The combination of these factors determined the risk of developing BPD, with an AUC value of 0.932. A multifactorial predictive model based on these factors, weighted by their odds ratios, identified four categories of newborns with mean BPD risks of 9%, 59%, 82%, and 100%. CONCLUSION: A multifactorial model based on easily available clinical factors can predict BPD risk in preterm newborns and inform potential preventive measures.

Assessment of Dispersion and Bubble Entropy Measures for Enhancing Preterm Birth Prediction Based on Electrohysterographic Signals

One of the remaining challenges for the scientific-technical community is predicting preterm births, for which electrohysterography (EHG) has emerged as a highly sensitive prediction technique. Sample and fuzzy entropy have been used to characterize EHG signals, although they require optimizing many internal parameters. Both bubble entropy, which only requires one internal parameter, and dispersion entropy, which can detect any changes in frequency and amplitude, have been proposed to characterize biomedical signals. In this work, we attempted to determine the clinical value of these entropy measures for predicting preterm birth by analyzing their discriminatory capacity as an individual feature and their complementarity to other EHG characteristics by developing six prediction models using obstetrical data, linear and non-linear EHG features, and linear discriminant analysis using a genetic algorithm to select the features. Both dispersion and bubble entropy better discriminated between the preterm and term groups than sample, spectral, and fuzzy entropy. Entropy metrics provided complementary information to linear features, and indeed, the improvement in model performance by including other non-linear features was negligible. The best model performance obtained an F1-score of 90.1 ± 2% for testing the dataset. This model can easily be adapted to real-time applications, thereby contributing to the transferability of the EHG technique to clinical practice.

Parenteral Nutrition and Oxidant Load in Neonates

Neonates with preterm, gastrointestinal dysfunction and very low birth weights are often intolerant to oral feeding. In such infants, the provision of nutrients via parenteral nutrition (PN) becomes necessary for short-term survival, as well as long-term health. However, the elemental nutrients in PN can be a major source of oxidants due to interactions between nutrients, imbalances of anti- and pro-oxidants, and environmental conditions. Moreover, neonates fed PN are at greater risk of oxidative stress, not only from dietary sources, but also because of immature antioxidant defences. Various interventions can lower the oxidant load in PN, including the supplementation of PN with antioxidant vitamins, glutathione, additional arginine and additional cysteine; reduced levels of pro-oxidant nutrients such as iron; protection from light and oxygen; and proper storage temperature. This narrative review of published data provides insight to oxidant molecules generated in PN, nutrient sources of oxidants, and measures to minimize oxidant levels.

The health and educational costs of preterm birth to 18 years of age in Australia

BACKGROUND

Preterm birth is the greatest cause of death up to five years of age and an important contributor to lifelong disability. There is increasing evidence that a meaningful proportion of early births may be prevented, but widespread introduction of effective preventive strategies will require financial support.

AIMS

This study estimated the economic cost to the Australian government of preterm birth, up to 18 years of age.

MATERIALS AND METHODS

A decision-analytic model was developed to estimate the costs of preterm birth in Australia for a hypothetical cohort of 314 814 children, the number of live births in 2016. Costs to Australia's eight jurisdictions included medical expenditures and additional costs to educational services.

RESULTS

The total cost of preterm birth to the Australian government associated with the annual cohort was estimated at $1.413 billion (95% CI 1047-1781). Two-thirds of the costs were borne by healthcare services during the newborn period and one-quarter of the costs by educational services providing special assistance. For each child, the costs were highest for those born at the earliest survivable gestational age, but the larger numbers of children born at later gestational ages contributed heavily to the overall economic burden.

CONCLUSION

Preterm birth leaves many people with lifelong disabilities and generates a significant economic burden to society. The costs extend beyond those to the healthcare system and include additional educational needs. Assessments of economic costs should inform economic evaluations of interventions aimed at the prevention or treatment of preterm birth.

Cost of neonatal intensive care for extremely preterm infants in Canada

BACKGROUND

Neonatal intensive care is expensive and prolonged. Extremely preterm infants are routinely supported. The costs for this practice at the age of borderline viability are of interest to clinicians and policymakers.

METHODS

We analyzed data from the Canadian national administrative database on total cost and length of hospital care from a public payor perspective for 23-28-week premature infants from 2011 to 2015. We also compared total and daily costs for 23-25-week newborns. Each comparison evaluated the total cohort and infants who lived more than 3 days. We used non-parametric tests, correlation tests, and generalized linear models for cost difference analysis, adjusting for survival, length of stay, and year.

RESULTS

We analyzed 6,932 infants' cost records. For all infants, median length of hospital stay was 41 days (IQR, 1-77 days). For infants who survived the first 3 days, median length of stay was 61 days (IQR, 34-90 days). The median total cost was $66,669 (IQR, $4,920-$125,550). For infants who survived the first 3 days, median total cost was $91,137 (IQR, $56,596-$188,757). For infants who survived the first 3 days, median total costs were $147,835 (IQR, $44,711-$233,847) for 23-week infants, $154,736 (IQR, $61,160-$248,290) for 24-week infants, and $130,317 (IQR, $79,737-$229,058) for 25-week infants. These amounts did not differ (P>0.7).

CONCLUSIONS

Total and daily costs of neonatal intensive care are high. Total cost was not different between surviving 23-25-week infants. These findings highlight the need for a funding strategy for the routine support of these fragile infants.

Transcriptional control of parturition: insights from gene regulation studies in the myometrium

The onset of labour is a culmination of a series of highly coordinated and preparatory physiological events that take place throughout the gestational period. In order to produce the associated contractions needed for foetal delivery, smooth muscle cells in the muscular layer of the uterus (i.e. myometrium) undergo a transition from quiescent to contractile phenotypes. Here, we present the current understanding of the roles transcription factors play in critical labour-associated gene expression changes as part of the molecular mechanistic basis for this transition. Consideration is given to both transcription factors that have been well-studied in a myometrial context, i.e. activator protein 1, progesterone receptors, oestrogen receptors, and nuclear factor kappa B, as well as additional transcription factors whose gestational event-driving contributions have been demonstrated more recently. These transcription factors may form pregnancy- and labour-associated transcriptional regulatory networks in the myometrium to modulate the timing of labour onset. A more thorough understanding of the transcription factor-mediated, labour-promoting regulatory pathways holds promise for the development of new therapeutic treatments that can be used for the prevention of preterm labour in at-risk women.

Risk-adjusted rates between hospitals for adverse outcomes of very-low-birth-weight infants

BACKGROUND/PURPOSE

To analyze the amount of variation in these risk-adjusted adverse outcomes corresponding to the care of premature births. In addition, hospitals were ranked according to their unadjusted and adjusted rates, and we assessed the degree of concordance between these rankings. Finally, the correlations of hospital-adjusted adverse outcomes were also tested.

METHODS

The study utilized the 5-year Taiwan Premature Infant Follow-up Network (TPFN) database in Taiwan from 2014 to 2018, and the sample size was 6482. We calculated the "observed over expected" (OE) ratio every year to form the risk-adjusted adverse outcome rate for each hospital.

RESULTS

There was a larger variation in the risk-adjusted rate for NEC and the second-largest variation for IVH. Regarding the concordances between the unadjusted and adjusted ranks, the ranks for mortality had the lowest concordance (coefficient of concordance 0.64), and only a few of the risk-adjusted rates between outcomes were significantly correlated.

CONCLUSION

The results of the TPFN show that there is room to improve performance in terms of large variations in NEC and IVH. Furthermore, risk adjustment is important, especially for mortality, since the ranks for mortality have the lowest concordance. Finally, we cannot generate a conclusion regarding whether a hospital is high in quality if we only take 1 or 2 adverse outcomes as profiling measures because only a few of the risk-adjusted rates between outcomes were significantly correlated.

Nurturing and quiet intervention (NeuroN-QI) on preterm infants' neurodevelopment and maternal stress and anxiety: A pilot randomized clinical trial protocol

OBJECTIVES

Primary objective of this pilot study is to evaluate the feasibility and acceptability of the NeuroN-QI and the study procedures. Secondary objectives are to assess the feasibility and acceptability of the NeuroN-QI by the nurses, assess the nurses' training needs about the components of the NeuroN-QI, and estimate the preliminary effects of the NeuroN-QI on infants' neurodevelopment as well as maternal stress and anxiety at infants' 36 weeks of gestational age.

DESIGN

A two-group pilot parallel randomized clinical trial stratified by center.

METHODS

The pilot study will be conducted in two neonatal intensive care units (NICUs). A sample of 24 mother-infant dyads born between 26 and 31^6/7 gestational age will be randomized into an experimental or control group. Fifty nurses will be recruited. The NeuroN-QI consists of four 2-hour skin-to-skin contact sessions/week with a 15-minute auditory stimulation by mothers with controlled ambient levels of light and noise. A 1-hour quiet period will follow where infants will rest in their incubator/crib with their mother's milk for olfactory stimulation and where the light and noise control will be continued. In the control group, mother-infant dyads will do four skin-to-skin contacts per week and receive standard care. Acceptability and feasibility of the NeuroN-QI in addition to maternal stress and anxiety will be measured through questionnaires, while infants' neurodevelopment will be assessed with Assessment of Preterm Infant Behaviour and General Movement Assessment.

CONCLUSIONS

This pilot trial will address knowledge gaps and generate evidence in neonatal care by evaluating the feasibility and acceptability of a multi-component developmental care intervention.

IMPACT

This project is an innovative step towards optimizing the neurodevelopmental trajectory of infants in NICUs and consequently promoting their long-term health outcomes.

TRIAL REGISTRATION

NCT04593095.

Patterns of respiratory health services utilization from birth to 5 years of children who experienced adverse birth outcomes

Introduction

Adverse birth outcomes have important consequences for future lung health. We evaluated patterns of respiratory health services utilization in early childhood among children born preterm (PTB), small and large for gestational age at term (SGA and LGA, respectively), and appropriate-for-gestational age at term.

Materials and methods

We conducted a population-based retrospective cohort study using administrative health data of all singleton live births in Alberta, Canada between 2005–2010. Data on hospitalizations and emergency department (ED) visits from birth to 5 years were collected for asthma, bronchitis, bronchiolitis, croup, influenza, pneumonia, and other acute upper and lower respiratory tract infections (other URTI and other LRTI, respectively). Adjusted rate ratios were estimated for respiratory ED visits and hospitalizations for adverse birth outcomes using the appropriate-for-gestational age at term group as reference. Age-specific trajectories of total respiratory health services utilization rates for each group were estimated in Poisson models.

Results

A total of 293,764 episodes of respiratory care from 206,994 children were analyzed. Very PTB children had the highest rates of health services use for all respiratory conditions, particularly for asthma, pneumonia, and bronchiolitis hospitalizations. Moderate/late PTB children also had elevated ED visits and hospitalizations for all respiratory conditions. Children born SGA showed high rates of ED visits for other LRTI, and of hospitalizations for bronchitis, bronchiolitis, and other URTI. Children born LGA had high rates of croup and other URTI ED visits, and of bronchiolitis and bronchiolitis hospitalizations. Age-specific trajectories showed a decreasing trend in the rates of total respiratory health service utilization from birth to five years of age for all groups studied. Children born PTB and LGA at term significantly required more respiratory health services over time compared to the reference group.

Conclusion

Patterns of paediatric respiratory health services utilization vary according to gestational age and fetal growth.

Costs of Neonatal Intensive Care for Canadian Infants with Preterm Birth

OBJECTIVE

To develop and validate an itemized costing algorithm for in-patient neonatal intensive care unit (NICU) costs for infants born prematurely that can be used for quality improvement and health economic analyses.

STUDY DESIGN

We sourced patient resource use data from the Canadian Neonatal Network database, with records from infants admitted to 30 tertiary NICUs in Canada. We sourced unit cost inputs from Ontario hospitals, schedules of benefits, and administrative sources. Costing estimates were generated by matching patient resource use data to the appropriate unit costs. All cost estimates were in 2017 Canadian dollars and assigned from the perspective of a provincial public payer. Results were validated using previous estimates of inpatient NICU costs and hospital case-cost estimates.

RESULTS

We assigned costs to 27 742 infants born prematurely admitted from 2015 to 2017. Mean (SD) gestational age and birth weight of the cohort were 31.8 (3.5) weeks and 1843 (739) g, respectively. The median (IQR) cost of hospitalization before NICU discharge was estimated as $20 184 ($9739-51 314) for all infants; $11 810 ($6410-19 800) for infants born at gestational age of 33-36 weeks; $30 572 ($16 597-$51 857) at gestational age of 29-32 weeks; and $100 440 ($56 858-$159 3867) at gestational age of <29 weeks. Cost estimates correlated with length of stay (r = 0.97) and gestational age (r = -0.65). The estimates were consistent with provincial resource estimates and previous estimates from Canada.

CONCLUSIONS

NICU costs for infants with preterm birth increase as gestation decreases and length of stay increases. Our cost estimates are easily accessible, transparent, and congruent with previous cost estimates.

Predicting the outcomes of preterm neonates beyond the neonatal intensive care unit: What are we missing?

Preterm infants are a population at high risk for mortality and adverse health outcomes. With recent improvements in survival to childhood, increasing attention is being paid to risk of long-term morbidity, specifically during childhood and young-adulthood. Although numerous tools for predicting the functional outcomes of preterm neonates have been developed in the past three decades, no studies have provided a comprehensive overview of these tools, along with their strengths and weaknesses. The purpose of this article is to provide an in-depth, narrative review of the current risk models available for predicting the functional outcomes of preterm neonates. A total of 32 studies describing 43 separate models were considered. We found that most studies used similar physiologic variables and standard regression techniques to develop models that primarily predict the risk of poor neurodevelopmental outcomes. With a recently expanded knowledge regarding the many factors that affect neurodevelopment and other important outcomes, as well as a better understanding of the limitations of traditional analytic methods, we argue that there is great room for improvement in creating risk prediction tools for preterm neonates. We also consider the ethical implications of utilizing these tools for clinical decision-making. IMPACT: Based on a literature review of risk prediction models for preterm neonates predicting functional outcomes, future models should aim for more consistent outcomes definitions, standardized assessment schedules and measurement tools, and consideration of risk beyond physiologic antecedents. Our review provides a comprehensive analysis and critique of risk prediction models developed for preterm neonates, specifically predicting functional outcomes instead of mortality, to reveal areas of improvement for future studies aiming to develop risk prediction tools for this population. To our knowledge, this is the first literature review and narrative analysis of risk prediction models for preterm neonates regarding their functional outcomes.

Ten-year time trends in preterm birth during a sociodemographic transition period: a retrospective cohort study in Shenzhen, China

OBJECTIVES

To investigate time trends of preterm birth and estimate the contributions of risk factors to the changes in preterm birth rates over a decade (2009-2018) of transitional period in Shenzhen, China.

DESIGN

Retrospective cohort study between 2009 and 2018.

SETTING

All births in Baoan during January 2009 and December 2018 registered in the Shenzhen Birth Registry Database.

PARTICIPANTS

478 044 live births were included with sociodemographic and medical records for both women and infants.

OUTCOME MEASURES

The incidence rate of preterm birth stratified by different maternal and infant characteristics. Multiple logistic regression was used to identify significant risk factors associated with preterm birth. The population attributable risk fraction of each factor was calculated to estimate its contribution to variations of preterm birth rate over the 10 years.

RESULTS

A total of 27 829 preterm births from 478 044 (5.8%) live births were recorded and the preterm birth rate increased from 5.5% in 2009 to 6.2% in 2018. Medically induced preterm birth rate increased from 2.0% in 2009 to 3.4% in 2018 while spontaneous preterm labour rate decreased from 3.3% to 2.7% over the decade years. Risk factors including multiple pregnancy (0.28% increase) drove the rise of preterm birth rate, whereas changes in maternal educational attainment (0.22% reduction) and prenatal care utilisation (0.45% reduction) had contributed to the decline in preterm birth rate.

CONCLUSIONS

An uptrend of preterm birth rate was observed in an area under rapid sociodemographic transitions during 2009-2018 and the changes were associated with these sociodemographic transitions. Continued investments in girls' education and prenatal care have the potential of reducing preterm birth rate.

Indications and Clinical Profile of Neonatal Admissions: A Cross-Sectional Descriptive Analysis from a Single Academic Center in Jordan

PURPOSE

To review the indications and clinical profile of neonatal admissions at King Abdullah University Hospital in Jordan.

MATERIALS AND METHODS

We conducted a cross-sectional review of all neonates admitted to the neonatal intensive care unit between September 2016 and September 2018. Collected data include demographic characteristics, indications for admission, morbidities and mortality, and discharge outcomes. Findings were reported among term and preterm infants.

RESULTS

A total of 1444 infants were admitted during the study period of whom 1332 (92.2%) were inborn and 612 (42.4%) were term neonates. Of the 832 preterm infants, 545 were late preterm (34-36 6/7 gestation) and 125 had very low birth weight (˂ 1500 grams); 925 (64%) were born by cesarean section. Respiratory failure of the newborn (41.2%) and prematurity (33.3%) were the main indications for admission among the whole cohort. Maternal prolonged premature rupture of membranes (PROM) was observed in nearly half the admissions of term infants. Hypoxic ischemic encephalopathy (3.2% vs 0.7%, p 0.01) and congenital anomalies (5% vs 1.2%, p 0.03) were more common in term infants. The rate of bronchopulmonary dysplasia was 39% among <28-week and 28% among <32-week premature infants. Sepsis was encountered in 59 infants. The overall mortality rate was 3.8%. Prematurity was the main predisposing factor for mortality (Adjusted OR: 9.9, 95% CI: 3.5, 27.6).

CONCLUSION

The majority of neonatal admissions at our institution are term and late preterm infants delivered by cesarean section. Prematurity, respiratory failure of the newborn, and suspected sepsis due to maternal PROM are the leading causes of admission. The mortality rate is within WHO target to achieve Sustainable Development Goal 3. Population-based studies are needed to make better conclusions that represent the whole Jordanian population. A revisit for the indications of cesarean deliveries may help to improve the neonatal outcomes.

Caffeine for the Treatment of Apnea in the Neonatal Intensive Care Unit: A Systematic Overview of Meta-Analyses

BACKGROUND

Caffeine is a common treatment for neonatal intensive care management of the developmental complication of apnea of prematurity in preterm infants. There are several systematic reviews (SRs) on the performance of caffeine in the treatment of apnea. The evidence provided by those, however, is depressed by an information overload due to high heterogeneity in the characteristics as well as the quality of these SRs.

OBJECTIVE

The aim was to provide a systematic overview of SRs on the use of caffeine for the management of neonatal apnea. Such overviews are a recent method used to assess and filter top evidence among SRs, enabling enhanced access to targeted information of interest.

METHODS

A comprehensive literature search was conducted via EMBASE, Cochrane Database of Systematic Reviews (CDSR), and PubMed since inception to January 2020. Two reviewers independently conducted study selection and data extraction, and assessed the quality of methods and the risk of bias in included SRs based on A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) and Risk of Bias in Systematic Reviews (ROBIS) tools. Extracted data related to study type, characteristics, patients, intervention, comparator, regimen, and outcome measures.

RESULTS

Seven SRs with meta-analyses (SRMAs) were included in the current overview, involving a total of 63,315 neonates. SRMAs included randomized clinical and observational studies, with various types of patients, comparators, and outcomes. The quality of SRMAs ranged from critically low (n = 1), low (n = 1), moderate (n = 2), to high (n = 3), and the risk of bias was unclear (n = 2), low (n = 4), and high (n = 1). The effectiveness of caffeine with regard to treatment success and the rate of apnea was not significantly different from that of theophylline or doxapram in two SRMAs. Against control, in one SRMA, while caffeine reduced the rate of failure as well as the need for pressure ventilation, it did not significantly reduce mortality. This comparative effectiveness of caffeine was based on high-quality SRMAs with a low risk of bias. The effectiveness against apnea seems to be enhanced via the administration of early (0-2 days) or high doses of caffeine in one and three SRMAs, respectively. This, nevertheless, was based on lower-quality SRMAs with a higher risk of bias. Safety outcomes were mostly based on comparative SRMAs of different drug regimens, whereby, less tachycardia and lower risk for complications were reported with lower and earlier caffeine administrations, respectively. The evidence behind this, however, was limited in quantity and quality.

CONCLUSION

While limited in quantity, there is evidence of non-inferior effectiveness of caffeine against other methylxanthines or doxapram for the management of apnea in neonates. Owing to the limited quality, however, limited evidence exists in support of an optimal administration regimen for caffeine. Further controlled studies are, therefore, needed to confirm the comparative usefulness of caffeine as well as to assess its different potential regimens, including in relation to safety.

The impact of high intensity care around birth on long-term neurodevelopmental outcomes

BACKGROUND

An equitable and affordable healthcare system requires a constant search for the optimal way to deliver increasingly expensive neonatal care. Therefore, evaluating the impact of hospital intensity around birth on long-term health outcomes is necessary if we are to assess the value of high intensity neonatal care against its costs.

METHODS

This study exploits uneven geographical distribution of high intensity birth hospitals across Canada to generate comparisons across similar Cerebral Palsy (CP) related births treated at hospitals with different intensities. We employ a rich dataset from the Canadian Multi-Regional CP Registry (CCPR) and instrumental variables related to the mother's location of residence around birth.

RESULTS

We find that differences in hospitals' intensities are not associated with differences in clinically relevant, long-term CP health outcomes.

CONCLUSIONS

Our results suggest that existing matching mechanism of births to hospitals within large metropolitan areas could be improved by early detection of high risk births and subsequent referral of these births to high intensity birthing centers. Substantial hospitalization costs might be averted to Canadian healthcare system ($16 million with a 95% CI of $6,131,184 - $24,103,478) if CP related births were assigned to low intensity hospitals and subsequently transferred if necessary to high intensity hospitals.

Space-time hot spots of critically ill small for gestational age newborns and industrial air pollutants in major metropolitan areas of Canada

We assessed the association of spatiotemporal hot spots of critically ill small for gestational age (ciSGA) newborns and industrial air emissions. Using neonatal admission data from the Canadian Neonatal Network between 2006 and 2010 (n = 32,836 infants), we aggregated maternal residential postal codes from nineteen census metropolitan areas (CMA) into space-time cubes and applied emerging hot spot analyses. Using National Pollutant Release Inventory data (n = 161 chemicals) and Environment Canada weather station data (n = 19 sites), we estimated monthly wind-dispersion of air emissions and calculated hot spots. We associated the patterns using logistic regression, with covariates for low socioeconomic status, NO₂ pollution, and number of infants. A total of 5465 infants were identified as ciSGA and the larger CMAs had more and larger hot spots (i.e. accumulation of events in space and time). Seventy-eight industrial chemical hot spots were associated with ciSGA hot spots. The highest number of positive associations were for 28 different pollutants, which differed by CMA. Twenty-one were known or suspected developmental toxicants, such as particulate matter, carbon monoxide, heavy metals, and volatile organic compounds. Associations with hot spots of industrial chemical emissions were geographically specific and may help explain the space-time trends of ciSGA.

Association of Maternal Opioid Use in Pregnancy With Adverse Perinatal Outcomes in Ontario, Canada, From 2012 to 2018

IMPORTANCE

A recent epidemic of opioid abuse has been described in many communities, although population-based data on trends in use in pregnancy and perinatal outcomes after in utero exposure remain limited.

OBJECTIVE

To assess trends in prenatal opioid use and the potential association between prenatal opioid use and preterm birth and adverse perinatal outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study covered live births and stillbirths among adolescents and women 15 years and older from April 1, 2012, to March 31, 2018, in Ontario, Canada. Data were analyzed from July 29 to October 15, 2019.

EXPOSURES

Any opioid use in pregnancy, ascertained through self-reporting and routine prenatal care.

MAIN OUTCOME AND MEASURES

The primary outcome was preterm birth before a gestational age of 37 weeks. Separate indicators for birth occurring at gestational ages of 34 to 36 weeks (plus 6 to 7 days; late preterm), 32 to 33 weeks (plus 6 to 7 days), 28 to 31 weeks (plus 6 to 7 days), and less than 28 weeks (very preterm birth). Secondary outcomes included small for gestational age, stillbirth, transfer to neonatal intensive care, and 5-minute Apgar score. Coarsened exact matching techniques and Poisson regression models were used to estimate the risk difference and relative risk (RR) of outcomes associated with cannabis exposure to control for confounding.

RESULTS

Among 710 911 women included in the analytic sample (mean [SD] age, 30.4 [5.3] years), 8059 used opioids (1.1%), with prevalence decreasing from 1.31% (95% CI, 1.25%-1.38%) in fiscal year 2012-2013 to 1.05% (95% CI, 0.99%-1.11%) in fiscal year 2017-2018 (P < .001 for trend). Use was highest among women in the lowest quintile of area-level income (2.36% vs 0.56% in the highest quintile; RR, 3.86; 95% CI, 3.58-4.15) and did not decrease over time in this group (from 2.63% [95% CI, 2.41%-2.87%] in 2012-2013 to 2.35% [95% CI, 2.14%-2.58%] in 2017-2018; P = .23 for trend). The crude rate of preterm birth at a gestational age of less than 37 weeks was 14.0% (n = 1127) among women with reported use in pregnancy and 6.0% (n = 42 226) among women who did not use opioids in the unmatched cohort. The adjusted RR for preterm birth before a gestational age of 37 weeks was 1.63 (95% CI, 1.52-1.75) among opioid users compared with nonusers and 1.77 (95% CI, 1.35-2.31) for preterm birth before 32 weeks. Among newborns, risk for neonatal intensive care was 40.5% with perinatal exposure to opioids compared with 13.9% in unexposed infants (RR, 2.91; 95% CI, 2.80-3.03).

CONCLUSIONS AND RELEVANCE

Rates of opioid use in pregnancy have declined in recent years, although use remains significantly higher among lower-income women. In this large population-based cohort, opioid use in pregnancy was associated with an increased risk of preterm birth and admission to a neonatal intensive care unit.

A Novel Use of Long-Term Subcutaneous Hydration Therapy for a Pediatric Patient With Intestinal Failure and Chronic Dehydration: A Case Report

Long-term subcutaneous hydration has not been described in pediatrics. A case of a 4-year-old born prematurely with subsequent intestinal failure, large vessel thrombi, and repeated central line-associated bloodstream infections prompting catheter removal is discussed. Chronic dehydration ensued and was managed with long-term subcutaneous fluid infusions with no serious complications.