Characteristics of neonatal units that care for very preterm infants in Europe: results from the MOSAIC study

Capabilities of perinatal healthcare institutions in primary and tertiary care of low birth weight infants in the Federation of Bosnia and Herzegovina: a cross-sectional multicentric study

Introduction

Providing adequate healthcare for premature infants is an important issue in perinatal medicine. The aim of this study is to assess the level of the perinatal healthcare institution (PHI) where the newborns were delivered and the possibilities of transporting them to the cantons of the Federation of Bosnia and Herzegovina. The authors also aimed to examine the overall survival of low birth-weight infants (LBWI) in the Federation of Bosnia and Herzegovina and to compare the survival of newborns according to the PHI where they were born and the PHI where they were treated.

Materials and methods

This cross-sectional study included newborns of both sexes that were born in the maternity wards in 10 cantons of the Federation of Bosnia and Herzegovina with a gestational age between 22 and 42 weeks, and a birth weight less than 2500 g.

Result

From the PHI of the first and second level, 159 newborns were referred to the third level. A total of 159/669 (23.7%) were referred from a second level PHI to a third level PHI, and 127/669 (l8.9%) LBWI were definitely taken care of. A total of 513/669 (76.8%) LBWI were definitely taken care of in the third level PHI. Out of a total of 159 LBWI referred from other PHI, only 31 (19.5%) LBWI were transported in less than 4 h, and 128 (80.5%) newborns were admitted to the third level PHI within 4 h of birth (P<0.0001). In second level PHI, most LBWI died in the first 12 h after birth, while in third level PHI, 69.2% of LBWI died after 1 week of life.

Conclusion

Based on world experience and assessment of the situation in Federation of Bosnia and Herzegovina, it is necessary to take measures to improve perinatal care and its regional organization.

Implementation of infection prevention and control for hospitalized neonates: A narrative review

BACKGROUND

The most prevalent infections encountered in neonatal care are healthcare-associated infections. The majority of healthcare-associated infections are considered preventable with evidence-based infection prevention and control (IPC) practices. However, substantial knowledge gaps exist in IPC implementation in neonatal care. Furthermore, the knowledge of factors which facilitate or challenge the uptake and sustainment of IPC programmes in neonatal units is limited. The integration of implementation science approaches in IPC programmes in neonatal care aims to address these problems.

OBJECTIVES

The aim of this narrative review was to identify determinants which have been reported to influence the implementation of IPC programmes and best practices in inpatient neonatal care settings.

SOURCES

A literature search was conducted in PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) in May 2022. Primary study reports published in English, French, German, Spanish, Portuguese, Italian, Danish, Swedish or Norwegian since 2000 were eligible for inclusion. Included studies focused on IPC practices in inpatient neonatal care settings and reported determinants which influenced implementation processes.

CONTENT

The Consolidated Framework for Implementation Research was used to identify and cluster reported determinants to the implementation of IPC practices and programmes in neonatal care. Most studies reported challenges and facilitators at the organizational level as particularly relevant to implementation processes. The commonly reported determinants included staffing levels, work- and caseloads, as well as aspects of organizational culture such as communication and leadership.

IMPLICATIONS

The presented knowledge about factors influencing neonatal IPC can support the design, implementation, and evaluation of IPC practices.

Current attitudes and beliefs toward perinatal care orientation before 25 weeks of gestation: The French perspective in 2020

The survival rate of infants born before 25 weeks of gestational age in France is extremely low compared with that of many other countries: 0%, 1%, and 31% at 22, 23, and 24 weeks' in the last national cohort study. A non-optimal regionalization and variations in practice are prevalent. Some parents in social media and support groups have reported feeling lost and confused with mixed messages leading to lack of trust. These data kindled a major debate in France around perinatal management leading to an investigation exploring neonatologists' perspectives and ways to improve care. The majority (81%) of the responding neonatologists reported more active care and higher survival rates than in 2011, although others continued preferring delivery room comfort care and limited NICU treatment at or before 24 weeks. The desire to improve was an overarching theme in all the respondents' answers to open-ended questions. Barriers to active care included an absence of expertise and of benchmarking to guide optimal care, and limited resources in the NICU and during follow-up - all leading to self-fulfilling prophecies of poor prognosis. Optimization of regionalization, perinatal teamwork and parental involvement, fostering experience by creating specific perinatal centers, stimulating benchmarking, and working with policy makers to allow better long-term outcomes could enable higher survival.

Variations in Antibiotic Use and Sepsis Management in Neonatal Intensive Care Units: A European Survey

Management of neonatal sepsis and the use of antimicrobials have an important impact on morbidity and mortality. However, there is no recent background on which antibiotic regimens are used in different European neonatal intensive care units (NICUs). Our study aimed to describe the use of antibiotics and other aspects of early- and late-onset sepsis (EOS and LOS, respectively) management by European NICUs. We conducted an online survey among NICUs throughout Europe to collect information about antibiotic stewardship, antibiotic regimens, and general aspects of managing neonatal infections. NICUs from up to 38 European countries responded, with 271 valid responses. Most units had written clinical guidelines for EOS (92.2%) and LOS (81.1%) management. For EOS, ampicillin, penicillin, gentamicin, and amikacin were the most commonly used antibiotics. Analysis of the combinations of EOS regimens showed that the most frequently used was ampicillin plus gentamicin (54.6%). For LOS, the most frequently used antibiotics were vancomycin (52.4%), gentamicin (33.9%), cefotaxime (28%), and meropenem (15.5%). Other aspects of the general management of sepsis have also been analyzed. The management of neonatal sepsis in European NICUs is diverse. There was high self-reported adherence to the local clinical guidelines. There was homogeneity in the combination of antibiotics in EOS but less in LOS.

Means of reaching successful antenatal transfers to level 3 hospitals in cases of threatened very preterm deliveries: a national survey

INTRODUCTION

Centralization of very preterm deliveries to level 3 hospitals is recommended to improve infant survival and prevent brain injury. We studied the clinical practices of centralization from level 2 to level 3 hospitals in cases of threatening very preterm delivery in Finland.

MATERIALS AND METHODS

Obstetricians in all 16 level 2 hospitals in Finland were invited to participate in an online survey regarding antenatal transfer to level 3 hospitals among women with threatened delivery below 32 gestational weeks. We report clinical thresholds used as indications and contraindications for antenatal transfers, and logistical factors related to transfers.

RESULTS

Twelve out of 16 (75%) hospitals completed the survey. The lower gestational age threshold for antenatal transfer ranged from 22 + 0 to 23 + 0 weeks. All hospitals regarded preterm premature rupture of membranes, chorioamnionitis, and severe pre-eclampsia as indications for antenatal transfer to a level 3 hospital. Most hospitals reported transferring women in spite of regular contractions (interval over 5 min) or cervical dilatation up to 4 cm. Suspicion of placental abruption, abnormal cardiotocography tracing and poor maternal condition were the most frequently reported contraindications for antenatal transfer. The time to arrange antenatal transfer was less than 2 h in all hospitals, and overcrowding of level 3 hospitals rarely hindered antenatal transfer.

CONCLUSIONS

Successful centralization of very preterm deliveries is reached in Finland by rapid and active antenatal transfers. This study identified clinical thresholds used by obstetricians in a setting of long distances and high centralization rate.

[Formula: see text] Social-environmental moderators of neurodevelopmental outcomes in youth born preterm: A systematic review

Objective: Preterm birth represents a significant medical event that places infants at a markedly greater risk for neurodevelopmental problems and delays. Although the impact of medical factors on neurodevelopment for those born preterm has been thoroughly explored, less is known about how social-environmental factors (e.g., socioeconomic status, family functioning) moderate outcomes. This review explores the quantity and methodological rigor of research on social-environmental factors as moderators of the relationship between preterm birth and neurodevelopmental outcomes.Methods: Articles published between January 1980 and December 2016 were identified from a comprehensive meta-analysis and systematic review on neurodevelopmental outcomes following preterm birth. A systematic review of MEDLINE was conducted to identify articles published from January 2017 through April 2019.Results: Eighty articles met the inclusion criteria. The majority of studies matched preterm and control groups on social-environmental factors (n = 49). The remaining studies included social-environmental factors as moderators (n = 13) or correlates (n = 11) of neurodevelopmental outcomes. Only seven studies did not include reports on social-environmental factors.Conclusions: This systematic review suggests that social-environmental factors are often considered to be ancillary risk factors to the larger medical risk imparted by prematurity. Studies typically focused on socioeconomic status rather than more modifiable parent/family factors that can be targeted through intervention (e.g., parental mental health) and evidenced mixed findings regarding the significance of social-environmental factors as moderators. Further research is needed to identify the relative influence of social-environmental factors to inform future psychosocial interventions.

Mortality and severe morbidity of very preterm infants: comparison of two French cohort studies

BACKGROUND

In Reunion Island, a French overseas department, the burden of preterm birth and perinatal mortality exceed those observed in mainland France, despite similar access to standard perinatal care. The purpose of the study was to compare the outcome of two cohorts of NICU-admitted very preterm infants born between 24 and 31 weeks of gestation (WG): the registry-based OGP (Observatoire de la Grande Prématurité, Reunion Island, 2008-2013) cohort, and the nationwide EPIPAGE-2 (mainland France, 2011) observational cohort.

METHODS

The primary outcome was adverse neonatal outcomes defined as a composite indicator of in-hospital mortality or any of three following severe morbidities: bronchopulmonary dysplasia (BPD), necrotising enterocolitis, or severe neurological injury (periventricular leukomalacia or grade III-IV intraventricular haemorrhages). Logistic regression modelling adjusting for confounders was performed.

RESULTS

A total of 1272 very preterm infants from the Reunionese OGP cohort and 3669 peers from the mainland EPIPAGE-2 cohort were compared. Adverse neonatal outcomes were more likely observed in the OGP cohort (32.6% versus 26.6%, p <  0.001), as result of both increased in-hospital mortality across all gestational age strata and increased BPD among the survivors of the 29-31 WG stratum. After adjusting for gestational age, gender and multiple perinatal factors, the risk of adverse neonatal outcomes was higher in the OGP cohort than in the EPIPAGE-2 cohort across all gestational age strata.

CONCLUSIONS

Despite similar guidelines for standard perinatal care, very preterm infants born in Reunion Island have a higher risk for death or severe morbidity compared with those born in mainland France.

Volume of Neonatal Care and Survival without Disability at 2 Years in Very Preterm Infants: Results of a French National Cohort Study

OBJECTIVES

To investigate the relation between neonatal intensive care unit (NICU) volume and survival, and neuromotor and sensory disabilities at 2 years in very preterm infants.

STUDY DESIGN

The EPIPAGE-2 (Etude Epidémiologique sur les Petits Âges Gestationnels-2) national prospective population-based cohort study was used to include 2447 babies born alive in 66 level III hospitals between 24 and 30 completed weeks of gestation in 2011. The outcome was survival without disabilities (levels 2-5 of the Gross Motor Function Classification System for cerebral palsy with or without unilateral or bilateral blindness or deafness). Units were grouped in quartiles according to volume, defined as the annual admissions of very preterm babies. Multivariate logistic regression analyses with population average models were used.

RESULTS

Survival at discharge was lower in hospitals with lower volumes of neonatal activity (aOR 0.55, 95% CI 0.33-0.91). Survival without neuromotor and sensory disabilities at 2 years increased with hospital volume, from 75% to 80.7% in the highest volume units. After adjustment for gestational age, small for gestational age, sex, maternal age, infertility treatment, multiple pregnancy, principal cause of prematurity, parental socioeconomic status, and mother's country of birth, survival without neuromotor or sensory disabilities was significantly lower in hospitals with a lower volume of neonatal activity (aOR 0.60, 95% CI 0.38-0.95) than in the highest quartile hospitals.

CONCLUSIONS

These results suggest that lower neonatal intensive care unit volume is associated with lower survival without an increase in disabilities at 2 years. These results could be useful to generate improvements of perinatal regionalization.

Breastfeeding outcomes in European NICUs: impact of parental visiting policies

OBJECTIVE

The documented benefits of maternal milk for very preterm infants have raised interest in hospital policies that promote breastfeeding. We investigated the hypothesis that more liberal parental policies are associated with increased breastfeeding at discharge from the neonatal unit.

DESIGN

Prospective area-based cohort study.

SETTING

Neonatal intensive care units (NICUs) in 19 regions of 11 European countries.

PATIENTS

All very preterm infants discharged alive in participating regions in 2011-2012 after spending >70% of their hospital stay in the same NICU (n=4407).

MAIN OUTCOME MEASURES

We assessed four feeding outcomes at hospital discharge: any and exclusive maternal milk feeding, independent of feeding method; any and exclusive direct breastfeeding, defined as sucking at the breast. We computed a neonatal unit Parental Presence Score (PPS) based on policies regarding parental visiting in the intensive care area (range 1-10, with higher values indicating more liberal policies), and we used multivariable multilevel modified Poisson regression analysis to assess the relation between unit PPS and outcomes.

RESULTS

Policies regarding visiting hours, duration of visits and possibility for parents to stay during medical rounds and spend the night in unit differed within and across countries. After adjustment for potential confounders, infants cared for in units with liberal parental policies (PPS≥7) were about twofold significantly more likely to be discharged with exclusive maternal milk feeding and exclusive direct breastfeeding.

CONCLUSION

Unit policies promoting parental presence and involvement in care may increase the likelihood of successful breastfeeding at discharge for very preterm infants.

Unit-Level Variations in Healthcare Professionals' Availability for Preterm Neonates <29 Weeks' Gestation: An International Survey

INTRODUCTION

The availability of and variability in healthcare professionals in neonatal units in different countries has not been well characterized. Our objective was to identify variations in the healthcare professionals for preterm neonates in 10 national or regional neonatal networks participating in the International Network for Evaluating Outcomes (iNeo) of neonates.

METHOD

Online, pre-piloted questionnaires about the availability of healthcare professionals were sent to the directors of 390 tertiary neonatal units in 10 international networks: Australia/New Zealand, Canada, Finland, Illinois, Israel, Japan, Spain, Sweden, Switzerland, and Tuscany.

RESULTS

Overall, 325 of 390 units (83%) responded. About half of the units (48%; 156/325) cared for 11-30 neonates/day and had team-based (43%; 138/325) care models. Neonatologists were present 24 h a day in 59% of the units (191/325), junior doctors in 60% (194/325), and nurse practitioners in 36% (116/325). A nurse-to-patient ratio of 1:1 for infants who are unstable and require complex care was used in 52% of the units (170/325), whereas a ratio of 1:1 or 1:2 for neonates requiring multisystem support was available in 59% (192/325) of the units. Availability of a respiratory therapist (15%, 49/325), pharmacist (40%, 130/325), dietitian (34%, 112/325), social worker (81%, 263/325), lactation consultant (45%, 146/325), parent buddy (6%, 19/325), or parents' resource personnel (11%, 34/325) were widely variable between units.

CONCLUSIONS

We identified variability in the availability and organization of the healthcare professionals between and within countries for the care of extremely preterm neonates. Further research is needed to associate healthcare workers' availability and outcomes.

Perinatal health services organization for preterm births: a multinational comparison

OBJECTIVE

To explore population characteristics, organization of health services and comparability of available information for very low birth weight or very preterm neonates born before 32 weeks' gestation in 11 high-income countries contributing data to the International Network for Evaluating Outcomes of Neonates (iNeo).

STUDY DESIGN

We obtained population characteristics from public domain sources, conducted a survey of organization of maternal and neonatal health services and evaluated the comparability of data contributed to the iNeo collaboration from Australia, Canada, Finland, Israel, Italy, Japan, New Zealand, Spain, Sweden, Switzerland and UK.

RESULTS

All countries have nationally funded maternal/neonatal health care with >90% of women receiving prenatal care. Preterm birth rate, maternal age, and neonatal and infant mortality rates were relatively similar across countries. Most (50 to >95%) between-hospital transports of neonates born at non-tertiary units were conducted by designated transport teams; 72% (8/11 countries) had designated transfer and 63% (7/11 countries) mandate the presence of a physician. The capacity of 'step-down' units varied between countries, with capacity for respiratory care available in <10% to >75% of units. Heterogeneity in data collection processes for benchmarking and quality improvement activities were identified.

CONCLUSIONS

Comparability of healthcare outcomes for very preterm low birth weight neonates between countries requires an evaluation of differences in population coverage, healthcare services and meta-data.

Pulse oximeter saturation target limits for preterm infants: a survey among European neonatal intensive care units

The optimum range of pulse oximeter oxygen saturation (SpO₂) for preterm infants remains controversial. Between November 2015 and February 2016, we conducted a web-based survey aimed to investigate the current and former practices on SpO₂ targets in European neonatal intensive care units (NICUs). We obtained valid responses from 193 NICUs, treating 8590 newborns ≤28 weeks per year, across 27 countries. Forty different saturation ranges were reported, ranging from 82-93 to 94-99%. The most frequently utilized SpO₂ ranges were 90-95% (28%), 88-95% (12%), 90-94% (5%), and 91-95% (5%). A total of 156 NICUs (81%) changed their SpO₂ limits over the last 10 years. The most frequently reported former limits were 88-92% (18%), 85-95% (9%), 88-93 (7%), and 85-92% (6%). The NICUs that increased their SpO₂ ranges expected to obtain a reduction in mortality. A 54% of the NICUs found the scientific evidence supporting their SpO₂ targeting policy strong or very strong.

CONCLUSION

We detected a high degree of heterogeneity in pulse oximeter SpO₂ target limits across European NICUs. The currently used limits are 3 to 5% higher than the former limits, and the most extreme limits, such as lower below 85% or upper above 96%, have almost been abandoned. What is Known: • For preterm infants requiring supplemental oxygen, the optimum range of pulse oximeter oxygen saturation (SpO ₂ ) to minimize organ damage, without causing hypoxic injury, remains controversial. What is New: • This survey highlights the lack of consensus regarding SpO ₂ target limits for preterm infants among European neonatal intensive care units (NICUs). We detected 40 different SpO ₂ ranges, and even the most frequently reported range (i.e., 90-95%) was used in only 28% of the 193 respondent NICUs. • A total of 156 NICUs (81%) changed their SpO ₂ limits over the last 10 years. The currently used limits are 3 to 5% higher than the former limits, and the most extreme limits, such as lower below 85% or upper above 96%, have almost been abandoned.

Modelling Neonatal Care Pathways for Babies Born Preterm: An Application of Multistate Modelling

Modelling length of stay in neonatal care is vital to inform service planning and the counselling of parents. Preterm babies, at the highest risk of mortality, can have long stays in neonatal care and require high resource use. Previous work has incorporated babies that die into length of stay estimates, but this still overlooks the levels of care required during their stay. This work incorporates all babies, and the levels of care they require, into length of stay estimates. Data were obtained from the National Neonatal Research Database for singleton babies born at 24–31 weeks gestational age discharged from a neonatal unit in England from 2011 to 2014. A Cox multistate model, adjusted for gestational age, was used to consider a baby’s two competing outcomes: death or discharge from neonatal care, whilst also considering the different levels of care required: intensive care; high dependency care and special care. The probabilities of receiving each of the levels of care, or having died or been discharged from neonatal care are presented graphically overall and adjusted for gestational age. Stacked predicted probabilities produced for each week of gestational age provide a useful tool for clinicians when counselling parents about length of stay and for commissioners when considering allocation of resources. Multistate modelling provides a useful method for describing the entire neonatal care pathway, where rates of in-unit mortality can be high. For a healthcare service focussed on costs, it is important to consider all babies that contribute towards workload, and the levels of care they require.

Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort

OBJECTIVES

 To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity.

DESIGN

 Prospective multinational population based observational study.

SETTING

 19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project.

PARTICIPANTS

 7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission.

MAIN OUTCOME MEASURES

 Combined use of four evidence based practices for infants born before 28 weeks' gestation using an "all or none" approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital.

RESULTS

 Only 58.3% (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95% confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants.

CONCLUSIONS

 More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.

Work environment, volume of activity and staffing in neonatal intensive care units in Italy: results of the SONAR-nurse study

Background

Neonatal units’ volume of activity, and other quantitative and qualitative variables, such as staffing, workload, work environment, care organization and geographical location, may influence the outcome of high risk newborns. Data about the distribution of these variables and their relationships among Italian neonatal units are lacking.

Methods

Between March 2010-April 2011, 63 neonatal intensive care units adhering to the Italian Neonatal Network participated in the SONAR Nurse study. Their main features and work environment were investigated by questionnaires compiled by the chief and by physicians and nurses of each unit. Twelve cross-sectional monthly-repeated surveys on different shifts were performed, collecting data on number of nurses on duty and number and acuity of hospitalized infants.

Results

Six hundred forty five physicians and 1601 nurses compiled the questionnaires. In the cross-sectional surveys 702 reports were collected, with 11082 infant and 3226 nurse data points. A high variability was found for units’ size (4–50 total beds), daily number of patients (median 14.5, range 3.4-48.7), number of nurses per shift (median 4.2, range 0.7-10.8) and number of team meetings per month. Northern regions performed better than Central and Southern regions for frequency of training meetings, qualitative assessment of performance, motivation within the unit and nursing work environment; mean physicians’ and nurses’ age increased moving from North to South. After stratification by terciles of the mean daily number of patients, the median number of nurses per shift increased at increasing volume of activity, while the opposite was found for the nurse-to-patient ratio adjusted by patients’ acuity. On average, in units belonging to the lower tercile there was 1 nurse every 2.5 patients, while in those belonging to the higher tercile the ratio was 1 nurse every 5 patients.

Conclusions

In Italy, there is a high variability in organizational characteristics and work environment among neonatal units and an uneven distribution of human resources in relation to volume of activity, suggesting that the larger the unit the greater the workload for each nurse. Urgent modifications in planning and organization of services are needed in order to pursue more efficient, homogeneous and integrated regionalized neonatal care systems.

Variations and Determinants of Mortality and Length of Stay of Very Low Birth Weight and Very Low for Gestational Age Infants in Seven European Countries

The EuroHOPE very low birth weight and very low for gestational age infants study aimed to measure and explain variation in mortality and length of stay (LoS) in the populations of seven European nations (Finland, Hungary, Italy (only the province of Rome), the Netherlands, Norway, Scotland and Sweden). Data were linked from birth, hospital discharge and mortality registries. For each infant basic clinical and demographic information, infant mortality and LoS at 1 year were retrieved. In addition, socio-economic variables at the regional level were used. Results based on 16,087 infants confirm that gestational age and Apgar score at 5 min are important determinants of both mortality and LoS. In most countries, infants admitted or transferred to third-level hospitals showed lower probability of death and longer LoS. In the meta-analyses, the combined estimates show that being male, multiple births, presence of malformations, per capita income and low population density are significant risk factors for death. It is essential that national policies improve the quality of administrative datasets and address systemic problems in assigning identification numbers at birth. European policy should aim at improving the comparability of data across jurisdictions.

Integrating neurocritical care approaches into neonatology: should all infants be treated equitably?

To improve the neurologic outcomes for infants with brain injury, neonatal providers are increasingly implementing neurocritical care approaches into clinical practice. Term infants with brain injury have been principal beneficiaries of neurologically-integrated care models to date, as evidenced by the widespread adoption of therapeutic hypothermia protocols for hypoxic-ischemic encephalopathy. Innovative therapeutic and diagnostic support for very low birth weight infants with brain injury has lagged behind. Given that concern for significant future neurodevelopmental impairment can lead to decisions to withdraw life supportive care at any gestational age, providing families with accurate prognostic information is essential for all infants. Current variable application of multidisciplinary neurocritical care approaches to infants at different gestational ages may be ethically problematic and reflect distinct perceptions of brain injury for infants born extremely premature.

Mortality and Length of Stay of Very Low Birth Weight and Very Preterm Infants: A EuroHOPE Study

The objective of this paper was to compare health outcomes and hospital care use of very low birth weight (VLBW), and very preterm (VLGA) infants in seven European countries. Analysis was performed on linkable patient-level registry data from seven European countries between 2006 and 2008 (Finland, Hungary, Italy (the Province of Rome), the Netherlands, Norway, Scotland, and Sweden). Mortality and length of stay (LoS) were adjusted for differences in gestational age (GA), sex, intrauterine growth, Apgar score at five minutes, parity and multiple births. The analysis included 16,087 infants. Both the 30-day and one-year adjusted mortality rates were lowest in the Nordic countries (Finland, Sweden and Norway) and Scotland and highest in Hungary and the Netherlands. For survivors, the adjusted average LoS during the first year of life ranged from 56 days in the Netherlands and Scotland to 81 days in Hungary. There were large differences between European countries in mortality rates and LoS in VLBW and VLGA infants. Substantial data linkage problems were observed in most countries due to inadequate identification procedures at birth, which limit data validity and should be addressed by policy makers across Europe.

Investigating the use of support vector machine classification on structural brain images of preterm-born teenagers as a biological marker

Preterm birth has been shown to induce an altered developmental trajectory of brain structure and function. With the aid support vector machine (SVM) classification methods we aimed to investigate whether MRI data, collected in adolescence, could be used to predict whether an individual had been born preterm or at term. To this end we collected T1-weighted anatomical MRI data from 143 individuals (69 controls, mean age 14.6y). The inclusion criteria for those born preterm were birth weight ≤ 1500g and gestational age < 37w. A linear SVM was trained on the grey matter segment of MR images in two different ways. First, all the individuals were used for training and classification was performed by the leave-one-out method, yielding 93% correct classification (sensitivity = 0.905, specificity = 0.942). Separately, a random half of the available data were used for training twice and each time the other, unseen, half of the data was classified, resulting 86% and 91% accurate classifications. Both gestational age (R = -0.24, p<0.04) and birth weight (R = -0.51, p < 0.001) correlated with the distance to decision boundary within the group of individuals born preterm. Statistically significant correlations were also found between IQ (R = -0.30, p < 0.001) and the distance to decision boundary. Those born small for gestational age did not form a separate subgroup in these analyses. The high rate of correct classification by the SVM motivates further investigation. The long-term goal is to automatically and non-invasively predict the outcome of preterm-born individuals on an individual basis using as early a scan as possible.

Nasal high-frequency oscillation ventilation in neonates: a survey in five European countries

Nasal high-frequency oscillation ventilation (nHFOV) is a non-invasive ventilation mode that applies an oscillatory pressure waveform to the airways using a nasal interface. nHFOV has been shown to facilitate carbon dioxide expiration, but little is known about its use in neonates. In a questionnaire-based survey, we assessed nHFOV use in neonatal intensive care units (NICUs) in Austria, Switzerland, Germany, the Netherlands, and Sweden. Questions included indications for nHFOV, equipment used, ventilator settings, and observed side effects. Of the clinical directors of 186 NICUs contacted, 172 (92 %) participated. Among those responding, 30/172 (17 %) used nHFOV, most frequently in premature infants <1500 g (27/30) for the indication nasal continuous positive airway pressure (nCPAP) failure (27/30). Binasal prongs (22/30) were the most common interfaces. The median (range) mean airway pressure when starting nHFOV was 8 (6-12) cm H2O, and the maximum mean airway pressure was 10 (7-18) cm H2O. The nHFOV frequency was 10 (6-13) Hz. Abdominal distension (11/30), upper airway obstruction due to secretions (8/30), and highly viscous secretions (7/30) were the most common nHFOV side effects.

CONCLUSION

In a number of European NICUs, clinicians use nHFOV. The present survey identified differences in nHFOV equipment, indications, and settings. Controlled clinical trials are needed to investigate the efficacy and side effects of nHFOV in neonates.

The effects of designation and volume of neonatal care on mortality and morbidity outcomes of very preterm infants in England: retrospective population-based cohort study

OBJECTIVE

To examine the effects of designation and volume of neonatal care at the hospital of birth on mortality and morbidity outcomes in very preterm infants in a managed clinical network setting.

DESIGN

A retrospective, population-based analysis of operational clinical data using adjusted logistic regression and instrumental variables (IV) analyses.

SETTING

165 National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing and Clinical Outcomes Project.

PARTICIPANTS

20 554 infants born at <33 weeks completed gestation (17 995 born at 27-32 weeks; 2559 born at <27 weeks), admitted to neonatal care and either discharged or died, over the period 1 January 2009-31 December 2011.

INTERVENTION

Tertiary designation or high-volume neonatal care at the hospital of birth.

OUTCOMES

Neonatal mortality, any in-hospital mortality, surgery for necrotising enterocolitis, surgery for retinopathy of prematurity, bronchopulmonary dysplasia and postmenstrual age at discharge.

RESULTS

Infants born at <33 weeks gestation and admitted to a high-volume neonatal unit at the hospital of birth were at reduced odds of neonatal mortality (IV regression odds ratio (OR) 0.70, 95% CI 0.53 to 0.92) and any in-hospital mortality (IV regression OR 0.68, 95% CI 0.54 to 0.85). The effect of volume on any in-hospital mortality was most acute among infants born at <27 weeks gestation (IV regression OR 0.51, 95% CI 0.33 to 0.79). A negative association between tertiary-level unit designation and mortality was also observed with adjusted logistic regression for infants born at <27 weeks gestation.

CONCLUSIONS

High-volume neonatal care provided at the hospital of birth may protect against in-hospital mortality in very preterm infants. Future developments of neonatal services should promote delivery of very preterm infants at hospitals with high-volume neonatal units.

Modelling time to death or discharge in neonatal care: an application of competing risks

BACKGROUND

Understanding length of stay for babies in neonatal care is vital for planning services and for counselling parents. While previous work has focused on the length of stay of babies who survive to discharge, when investigating resource use within neonatal care, it is important to also incorporate information on those babies who die while in care. We present an analysis using competing risks methodology which allows the simultaneous modelling of babies who die in neonatal care and those who survive to discharge.

METHODS

Data were obtained on 2723 babies born at 24-28 weeks gestational age in 2006-10 and admitted to neonatal care. Death and discharge alive are two mutually exclusive events and can be treated as competing risks. A flexible parametric modelling approach was used to analyse these two competing events and obtain estimates of the absolute probabilities of death or discharge.

RESULTS

The absolute probabilities of death or discharge are presented in graphical form showing the cause-specific cumulative incidence over time by gender, gestational age and birthweight. The discharge of babies alive generally occurred over a longer time period for babies of lower gestational age and smaller birthweight than for bigger babies.

CONCLUSION

This study has presented a useful statistical method for modelling the length of stay where there are significant rates of in-unit mortality. In health care systems that are increasingly focusing on costs and resource planning, it is essential to consider not only length of stay of survivors but also for those patients who die before discharge.

Cause-specific mortality of very preterm infants and antenatal events

OBJECTIVE

To assess the relationship between antenatal factors and cause-specific risk of death in a large area-based cohort of very preterm infants.

STUDY DESIGN

The ACTION (Accesso alle Cure e Terapie Intensive Ostetriche e Neonatali) study recruited during an 18-month period all infants 22-31 weeks' gestational age admitted to neonatal care in 6 Italian regions (n=3040). We analyzed the data of 2974 babies without lethal or acutely life-threatening malformations. Cause-specific risks of death adjusted for competing causes were calculated, and region-stratified multiple Cox regression analyses were used to study the association between cause-specific mortality and infants' characteristics, pregnancy complications, antenatal steroids, and place of birth.

RESULTS

Deaths attributable to respiratory problems and intraventricular hemorrhage prevailed in the first 2 weeks of life, and those attributable to infections and gastrointestinal diseases afterwards. Antepartum hemorrhage was associated with respiratory deaths (hazard ratio [HR] 1.6, 95% CI 1.1-2.4), and maternal infection with deaths attributable to asphyxia (HR 32.5, 95% CI 4.1-259.4) and to respiratory problems (HR 2.8, 95% CI 1.6-5.2). Preterm premature rupture of membranes increased the likelihood of deaths due to neonatal infection (HR 1.8, 95% CI 1.0-3.1), and preterm labor/contractions of those due to respiratory (HR 1.5, 95% CI 1.1-2.0) and gastrointestinal diseases (HR 5.8, 95% CI 2.1-16.3). In addition, a birth weight z-score<-1 was associated with increasing hazards of death resulting from asphyxia, late infections, respiratory, and gastrointestinal diseases.

CONCLUSIONS

Different complications of pregnancy lead to different cause-specific mortality patterns in very preterm infants.

Quantifying the potential bias when directly comparing standardised mortality ratios for in-unit neonatal mortality

INTRODUCTION

The Standardised Mortality Ratio (SMR) is increasingly used to compare the performance of different healthcare providers. However, it has long been known that differences in the populations of the providers can cause biased results when directly comparing two SMRs. This is potentially a particular problem in neonatal medicine where units provide different levels of care.

METHODS

Using data from The Neonatal Survey (TNS), babies born at 24 to 31 weeks gestational age from 2002 to 2011 and admitted to one of 11 UK neonatal units were identified. Risk-adjusted SMRs were calculated for each unit using a previously published model to estimate the expected number of deaths. The model parameters were then re-estimated based on data from each individual neonatal unit ("reference" unit) and these then applied to each of the other units to estimate the number of deaths each unit would have observed if they had the same underlying mortality rates as each of the "reference" hospitals. The ratios of the SMRs were then calculated under the assumption of identical risk-specific probabilities of death.

RESULTS

7243 babies were included in all analyses. When comparing between Network Neonatal Units (Level 3) the ratio of SMRs ranged from 0.92 to 1.00 and for the comparisons within Local Neonatal Units (Level 2) ranged from 0.79 to 1.56. However when comparing between neonatal units providing different levels of care ratios up to 1.68 were observed.

CONCLUSIONS

If the populations of healthcare providers differ considerably then it is likely that bias will be an issue when directly comparing SMRs. In neonatal care, the comparison of Network Neonatal Units is likely to be useful but caution is required when comparing Local Neonatal Units or between units of different types. Tools to quantify the likely bias are required.

Increased morbidity and mortality in very preterm/VLBW infants with congenital heart disease

PURPOSE

To study the association between congenital heart diseases (CHD) and in-hospital mortality and morbidity of very preterm/very low birth weight (VLBW) infants.

METHODS

The area-based prospective cohort study ACTION included all infants with gestational age (GA) 22-31 weeks or birth weight <1,500 g admitted to neonatal care between July 2003 and June 2005 in six Italian regions (n = 3,684). CHD were coded according to ICD9-CM. Cluster multivariable logistic regression analyses were used to assess the relationship between CHD and mortality and selected morbidities [neonatal infection, ultrasound brain abnormalities, retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD)] adjusting for potential confounders.

RESULTS

Seventy-one patients had CHD [19.3 ‰, 95 % confidence interval (CI) 15.1-24.2 ‰]. The most common lesions were isolated atrial and ventricular septal defects (31.1 and 26.8 %, respectively), pulmonary valvar stenosis (12.7 %), and tetralogy of Fallot (5.6 %). Compared with other infants, CHD patients showed significantly higher GA and frequency of small for gestational age (SGA, i.e., birth weight ≤3rd centile). After adjustment for GA, sex, SGA, presence of extracardiac malformations or chromosomal anomalies, and region of birth, CHD patients had a significantly higher likelihood of infection, BPD, ROP, and, after 27 weeks gestation only, hospital mortality. The increased risk of ROP appeared to be partly due to infection.

CONCLUSIONS

In very preterm/VLBW infants CHD are more prevalent than in the general liveborn population, and confer an increased risk of death and serious morbidities independently of other risk factors. These results may be useful to better tailor prognostic assessment and diagnostic and therapeutic interventions for these children.

Population-based estimates of in-unit survival for very preterm infants

BACKGROUND

Estimates of the probability of survival of very preterm infants admitted to NICU care are vital for counseling parents, informing care, and planning services. In 1999, easy-to-use charts of survival according to gestation, birth weight, and gender were published in the United Kingdom. These charts are widely used in clinical care and for benchmarking survival, and they form the core of the Clinical Risk Index for Babies II score. Since their publication, the survival of preterm infants has improved, and the charts therefore need updating.

METHODS

A logistic model was fitted with gestational age, birth weight, and gender. Nonlinear functions were estimated by using fractional polynomials. Bootstrap methods were used to assess the internal validity of the final model. The final model was assessed both overall and for subgroups of infants by using Farrington's statistic, the c-statistic, Cox regression coefficients, and the Brier score.

RESULTS

A total of 2995 white singleton infants born at 23(+0) to 32(+6) weeks' gestation in 2008 through 2010 were identified; 2751 (91.9%) infants survived to discharge. A prediction model was estimated and good model fit confirmed (area under receiver-operating characteristics curve = 0.86). Survival ranged from 27.7% (23 weeks) to 99.1% (32 weeks) for boys and from 34.5% (23 weeks) to 99.3% (32 weeks) for girls. Updated charts were produced showing estimated survival according to gestation, birth weight and gender, together with contour plots displaying points of equal survival.

CONCLUSIONS

These survival charts have been updated and will be of use to clinicians, parents, and managers.

Parental involvement and kangaroo care in European neonatal intensive care units: a policy survey in eight countries

OBJECTIVE

To compare, in a large representative sample of European neonatal intensive care units, the policies and practices regarding parental involvement and holding babies in the kangaroo care position as well as differences in the tasks mothers and fathers are allowed to carry out.

DESIGN

Prospective multicenter survey.

SETTING

Neonatal intensive care units in eight European countries (Belgium, Denmark, France, Italy, The Netherlands, Spain, Sweden, and the United Kingdom).

PATIENTS

Patients were not involved in this study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A structured questionnaire was mailed to 362 units (response rate 78%); only units with ≥50 very-low-birth-weight annual admissions were considered for this study. Facilities for parents such as reclining chairs near the babies' cots, beds, and a dedicated room were common, but less so in Italy and Spain. All units in Sweden, Denmark, the United Kingdom, and Belgium reported encouraging parental participation in the care of the babies, whereas policies were more restrictive in Italy (80% of units), France (73%), and Spain (41%). Holding babies in the kangaroo care position was widespread. However, in the United Kingdom, France, Italy, and Spain, many units applied restrictions regarding its frequency (sometimes or on parents request only, rather than routinely), method (conventional rather than skin-to-skin), and clinical conditions (especially mechanical ventilation and presence of umbilical lines) that would prevent its practice. In these countries, fathers were routinely offered kangaroo care less frequently than mothers (p < .001) and less often it was skin-to-skin (p < .0001).

CONCLUSIONS

This study showed that, although the majority of units in all countries reported a policy of encouraging both parents to take part in the care of their babies, the intensity and ways of involvement as well as the role played by mothers and fathers varied within and between countries.

Neuroanatomical consequences of very preterm birth in middle childhood

Individuals born preterm can demonstrate reductions in brain volume, cortical surface area and thickness. However, the extent of these neuroanatomical deficits and the relation among these measures in middle childhood, a critical developmental period, have not been determined. We assessed differences in brain structure by acquiring high-resolution T(1)-weighted scans in 25 children born very preterm (<32 weeks gestational age) without significant post-natal neurological sequelae and 32 age-matched term-born children (7-10 years). Children born very preterm had decreased brain volume, surface area and cortical thickness compared to term-born children. Furthermore, children born preterm did not display the robust relation between total brain volume and basal ganglia and thalamic volume apparent in the term-born children. Cortical thickness analyses revealed that the cortex was thinner for children born preterm than term-born children in the anterior cingulate cortex/supplementary motor area, isthmus of the cingulate gyrus, right superior temporal sulcus, right anterior insula, postcentral gyrus and precuneus. Follow-up analyses revealed that right precuneus thickness was correlated with gestational age. Thus, even without significant postnatal medical sequelae, very preterm-born children showed atypical brain structure and developmental patterns in areas related to higher cognitive function. Disruptions of the typical neurodevelopmental trajectory in the third trimester of pregnancy likely underlie these differences persisting into middle childhood.

European survey on the use of prophylactic fluconazole in neonatal intensive care units

Neonatal fungal infections are associated with substantial mortality and morbidity. Although prophylactic use of several antifungals has been proposed, this practice remains controversial. In order to evaluate the use of fluconazole prophylaxis in European NICUs, we conducted a cross-sectional survey by means of a structured questionnaire that was sent to European level II and III neonatal intensive care units, over a 9-month period, as part of a neonatal research FP7 European project. A total of 193 questionnaires from 28 countries were analysed. Use of antifungal prophylaxis was reported by 55% of the responders, and the most frequently used antifungal agent was fluconazole (92%). Main indications for prophylaxis were low gestational age (<28 weeks) and birth weight (<1,000 g). A dose of 3 mg/kg was used in 66% of NICUs using fluconazole, with an administration interval of 72 h in 52% of them. All responders acknowledged the need for additional trials on the efficacy of prophylactic fluconazole. Non-users of fluconazole prophylaxis were more likely to be influenced by the local incidence of candidiasis, the risk of increasing antifungal resistance and the absence of specific recommendations by paediatric societies.

CONCLUSIONS

Major concerns about the use of fluconazole prophylaxis include its efficacy, the risk of emergence of resistant species and the absence of clear consensus to support routine use. Future studies that address these issues will contribute to a more rational use of fluconazole prophylaxis.

Effects of preterm birth on cortical thickness measured in adolescence

Despite the extensive research into brain development after preterm birth, few studies have investigated its long-term effects on cortical thickness. The Stockholm Neonatal Project included infants between 1988 and 1993 with birth weight (BW) ≤ 1500 g. Using a previously published method, cortical thickness was estimated on T(1)-weighted 3D anatomical images acquired from 74 ex-preterm and 69 term-born adolescents (mean age 14.92 years). The cortex was significantly thinner in ex-preterm individuals in focal regions of the temporal and parietal cortices as indicated by voxel-wise t-tests. In addition, large regions around the central sulcus and temporal lobe as well as parts of the frontal and occipital lobes tended also to be thinner in the ex-preterm group. Although these results were not significant on voxel-wise tests, the spatially coherent arrangement of the thinning in ex-preterm individuals made it notable. When the group of ex-preterm individuals was divided by gestational age or BW, the thinning tended to be more pronounced in the anterior and posterior poles in those born nearer term or with a BW closer to 1500 g. These results support the notion that preterm birth is a risk factor for long-term development of cortical thickness.

Impact of fetal growth restriction on mortality and morbidity in a very preterm birth cohort

OBJECTIVE

To assess the impact of being small for gestational age (SGA) on very preterm mortality and morbidity rates by using different birthweight percentile thresholds and whether these effects differ by the cause of the preterm birth.

STUDY DESIGN

The study included singletons and twins alive at onset of labor between 24 and 31 weeks of gestation without congenital anomalies from the Models of Organising Access to Intensive Care for very preterm births very preterm cohort in 10 European regions in 2003 (n = 4525). Outcomes were mortality, intraventricular hemorrhage grade III and IV, cystic periventricular leukomalacia, and bronchopulmonary dysplasia (BPD). Birthweight percentiles in 6 classes were analyzed by pregnancy complication.

RESULTS

The mortality rate was higher for infants with birthweights <25th percentile when compared with the 50th to 74th percentile (adjusted odds ratio, 3.98 [95% CI, 2.79-5.67] for <10th; adjusted odds ratio, 2.15 [95% CI, 1.54-3.00] for 10th-24th). BPD declined continuously with increasing birthweight. There was no association for periventricular leukomalacia or intraventricular hemorrhage. Seventy-five percent of infants with birthweights <10th percentile were from pregnancies complicated by hypertension or indicated deliveries associated with growth restriction. However, stratifying for pregnancy complications yielded similar risk patterns.

CONCLUSIONS

A 25th percentile cutoff point was a means of identifying infants at higher risk of death and a continuous measure better described risks of BPD. Lower birthweights were associated with poor outcomes regardless of pregnancy complications.

Access to level III perinatal care for pregnancies of very short duration (<32 weeks)

AIMS

To evaluate to which extent pregnancies of very short duration (<32 weeks' gestation) are concentrated in level III centers.

METHODS

Area-based study in the 57 maternity units of the Lazio Region (Italy), years 2003-2004, including: 1012 live births (gestational age 22-31 weeks), 261 fetal losses (22-31 weeks) and 209 induced abortions (22-25 weeks). Variables associated with access to a level III unit were evaluated through multivariable logistic regression models.

RESULTS

83.7% of all pregnancies <32 weeks (88.8% of live births, 71.6% of fetal losses and 75.1% of induced abortions) were admitted to a level III perinatal center; 23.4% of live newborns, delivered in a level III hospital, were subsequently transferred to a same level facility. The probability that a fetal loss was not treated in a level III perinatal unit was higher for women without pregnancy complication, with lower education level, and living outside the metropolitan area.

CONCLUSIONS

Regionalization of perinatal care in Lazio is not satisfactory. Concentration of high-risk deliveries in level III centers is good, but in utero transfer is insufficient. This study can help to define the effectiveness of different organizational systems on access to locally available perinatal facilities and to optimize general organizational patterns of perinatal care.

Parents, siblings and grandparents in the Neonatal Intensive Care Unit. A survey of policies in eight European countries

OBJECTIVE

To describe policies towards family visiting in Neonatal Intensive Care Units (NICU) and compare findings with those of a survey carried out 10 years earlier.

METHODS

A questionnaire on early developmental care practices was mailed to 362 units in eight European countries (Sweden, Denmark, the UK, the Netherlands, Belgium, France, Spain and Italy). Of them 78% responded, and among those responded, 175 reported caring for at least 50 very low birth weight infants every year and their responses were analysed further.

RESULTS

A majority of all units allowed access at any time for both parents. This was almost universal in northern Europe and the UK, whereas it was the policy of less than one-third of NICU in Spain and Italy, with France in an intermediate position. Restrictions on visiting of grandparents, siblings and friends, as well as restricting parents' presence during medical rounds and procedures followed the same pattern. A composite visiting score was computed using all the variables related to family visiting. Lower median values and larger variability were obtained for the southern countries, indicating more restrictive attitudes and lack of national policy.

CONCLUSIONS

The presence of parents and other family members in European NICUs has improved over a 10-year period. Several barriers, however, are still in place, particularly in the South European countries.

Structural correlates of preterm birth in the adolescent brain

OBJECTIVE

The Stockholm Neonatal Project involves a prospective, cross-sectional, population-based, cohort monitored for 12 to 17 years after birth; it was started with the aim of investigating the long-term structural correlates of preterm birth and comparing findings with reports on similar cohorts.

METHODS

High-resolution anatomic and diffusion tensor imaging data measuring diffusion in 30 directions were collected by using a 1.5-T MRI scanner. A total of 143 adolescents (12.18-17.7 years of age) participated in the study, including 74 formerly preterm infants with birth weights of <or=1500 g (range: 645-1486 g) and 69 term control subjects. The 2 groups were well matched with respect to demographic and socioeconomic data. The anatomic MRI data were used for calculation of total brain volumes and voxelwise comparison of gray matter (GM) volumes. The diffusion tensor imaging data were used for voxelwise comparison of white matter (WM) microstructural integrity.

RESULTS

The formerly preterm individuals possessed 8.8% smaller GM volume and 9.4% smaller WM volume. The GM and WM volumes of individuals depended on gestational age and birth weight. The reduction in GM could be attributed bilaterally to the temporal lobes, central, prefrontal, orbitofrontal, and parietal cortices, caudate nuclei, hippocampi, and thalami. Lower fractional anisotropy was observed in the posterior corpus callosum, fornix, and external capsules.

CONCLUSIONS

Although preterm birth was found to be a risk factor regarding long-term structural brain development, the outcome was milder than in previous reports. This may be attributable to differences in social structure and neonatal care practices.

Organisation of obstetric services for very preterm births in Europe: results from the MOSAIC project

OBJECTIVE

To study the impact of the organisation of obstetric services on the regionalisation of care for very preterm births.

DESIGN

Cohort study.

SETTING

Ten European regions covering 490 000 live births.

POPULATION

All children born in 2003 between 24 and 31 weeks of gestation.

METHOD

The rate of specialised maternity units per 10 000 total births, the proportion of total births in specialised units and the proportion of very preterm births by referral status in specialised units were compared.

MAIN OUTCOME MEASURE

Birth in a specialised maternity unit (level III unit or unit with a large neonatal unit (at least 50 annual very preterm admissions).

RESULTS

The organisation of obstetric care varied in these regions with respect to the supply of level III units (from 2.3 per 10 000 births in the Portuguese region to 0.2 in the Polish region), their characteristics (annual number of deliveries, 24 hour presence of a trained obstetrician) and the proportion of all births (term and preterm) that occur in these units. The proportion of very preterm births in level III units ranged from 93 to 63% in the regions. Different approaches were used to obtain a high level of regionalisation: high proportions of total deliveries in specialised units, high proportions of in utero transfers or high proportions of high-risk women who were referred to a specialised unit during pregnancy.

CONCLUSION

Consensus does not exist on the optimal characteristics of specialised units but regionalisation may be achieved in different models of organisation of obstetric services.

Cerebral MRI findings in a cohort of ex-preterm and control adolescents

AIM

Newborn infants were entered between 1988 and 1993 into a prospective, long-term, follow-up study. We aimed to investigate how the outcome of preterm-born individuals on cerebral magnetic resonance imaging (MRI) compared to that reported on similar cohorts internationally.

METHODS

The 74 ex-preterm (12.38-17.7 years, 51% girls) and 69 control participants (12.18-16.47 years, 53% girls) underwent a MRI examination on a 1.5T scanner. Two experienced neuroradiologists examined the T1- and T2-weighted images first independently and then in consensus without knowledge of group adherence.

RESULTS

Only 21 (4 controls) of the 143 sets of scans showed any abnormalities. All but one of these were of mild extent. Among the ex-preterm adolescents two showed only incidental findings while the other 15 had either gliosis or white matter loss. Eleven subjects had white matter loss, seven of which had no other abnormalities. Four subjects had gliosis, three of which had no other abnormalities. The extent, severity or frequency of injury was not related to being born small for gestational age.

CONCLUSION

Although the rate of structural abnormalities was higher in the group of adolescents born preterm, this rate was well below that reported from other centres around the world. We attribute this to the minimally invasive neonatal care and to different social structures in Sweden compared to that of other reports on similar cohorts.

[Respiratory care in neonatal intensive care units. Situation in the year 2005]

AIM

To learn the characteristic of the neonatal intensive care units (NICUs) that offer neonatal respiratory assistance in Spain.

MATERIAL AND METHOD

A structured survey was developed and sent to all Spanish neonatal units to learn about the respiratory care offered in 2005.

RESULTS

A total of 96 Units answered the survey, with an estimated representatively of 63%, with a range from 3 to 92%, depending on the geographical area. Level IIIc Units were in the upper range. Answer the survey 26 units type IIb (27%), 16 IIIa (17%), 40 IIIb (42%) and 14 IIIc (14%). The total number of level III NICU beds was 541 (1.2 beds per 1000 livebirths; range, 0.7-1.7). The mean number of beds per NICU was 4.1 in level IIIa Units, 2.8 in those IIIb and 14.6 in type IIIc NICUs. In level III NICUs, the bed per physician ratio was 2.4 and that of beds per registered nurse was 2.8 (2.2 in level IIIc NICUs). There were a total 13,219 admissions, 54% of those needed mechanical ventilation (36% in IIIa and 65% in level IIIc NICUs). Oxygen blenders for resuscitation at birth were available in 42% of level IIIb and IIIc NICUs. NICUs had one neonatal ventilator per bed, and 63% of units had high frequency ventilation available. All units had nasal-CPAP systems, 25% of level IIIa Units, 58% IIIb and 64% of those type IIIc had systems for nasal ventilation. All level IIIc and 93% of level IIIb NICUs were able to provide inhaled nitric oxygen therapy. Four NICUS offered ECMO.

CONCLUSIONS

The mean number of NICU beds per 1000 livebirths is within the lower limits of those been recommended, and there were wide variations among different geographical areas. A 54% of those babies admitted to NICUs required mechanical ventilation. The mean number of NICU beds per registered nurse was 2.8. There was an adequate number of neonatal ventilators (one per bed) and 63% were able to provide HFV. All NICUs hand n-CPAP systems.

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.

Risk factors for not delivering in a level III unit before 32 weeks of gestation: results from a population-based study in Paris and surrounding districts in 2003

Delivery of very preterm babies in maternity units with on-site neonatal intensive care (level III units) is associated with lower mortality and morbidity. This analysis explores risk factors for not delivering in a level III unit, using data from a population-based study of very preterm births in Paris and surrounding districts in 2003. The sample for analysis included resident women with a fetus alive at the onset of labour between 24 and 31 weeks of gestation (n = 641). Characteristics of women delivering in and those not in level III units were compared using logistic regression. Further analysis was carried out for the subgroup of women not already scheduled to deliver in a level III unit. Twenty-nine per cent of women did not deliver in level III units; in the subgroup scheduled to deliver in level I or II units, 43% were not transferred. Women were less likely to deliver in a level III unit if they had a singleton pregnancy, a gestation of <26 weeks or at 31 weeks, experienced antenatal haemorrhaging, lived in socially deprived neighbourhoods or at a greater distance from the nearest level III. Women scheduled to deliver in a maternity unit with a special care nursery were also less likely to deliver in a level III unit. In contrast, preterm rupture of membranes and fetal growth restriction increased the likelihood of a level III delivery. These results underline the importance of controlling for clinical characteristics when analysing perinatal outcome by place of delivery and show how socioeconomic factors, known to impact on the risk of having a preterm birth, can also affect access to appropriate care.