Survival and Impairment of Extremely Premature Infants: A Meta-analysis

Voices of experience: what Dutch parents teach us about values and intuition in periviable decisions

OBJECTIVE

When extremely premature birth at the limits of viability is imminent, shared decision-making with parents regarding the infant's treatment is widely recommended. Aligning decisions with parental values can be challenging. So, this study aims to get insight into (1) what values parents considered important in their decision, (2) whether their decision was based on intuition and/or rational analysis and (3) parental suggestions on how to help explore and articulate values during prenatal counselling.

DESIGN

A qualitative study was performed among Dutch parents who experienced (imminent) extremely premature birth. Diversity was aimed for through purposive sampling. Semistructured interviews were conducted until saturation was achieved. Transcripts were coded and themes were derived from the data.

RESULTS

Nineteen interviews were performed. Results show what parents considered important in their decision, such as the infants' future, family life and 'giving a chance'. Most parents made their decision more intuitively rather than rationally, for others both coexisted. Particularly fathers and parents who opted for palliative comfort care experienced the decision as rational. Parents would have liked to explore values, but found it challenging. They suggested strategies and conditions to help explore and articulate their values during counselling, such as a multidisciplinary approach.

CONCLUSIONS

Various considerations and underlying values were found to be important. Parents recognise the influence of emotions and intuition in decision-making and struggle to articulate their values, emphasising the need for guidance. Healthcare providers should engage in open, personalised discussions to facilitate value exploration, enabling informed decisions aligned with parental values.

Interventions and their efficacy in supporting language development among preterm children aged 0-3 years - A systematic review

BACKGROUND

Preterm children have a higher risk for linguistic delays than full-term infants but are rarely provided with language intervention at an early age. Knowledge on early language interventions targeted to preterm children is scarce, and efficacy of the interventions is rarely reported.

AIM

This systematic review aims to identify interventions for preterm children aged 0-3 years with at least one language outcome. Efficacy of the interventions and quality of the study reports were evaluated.

STUDY DESIGN

The article search was carried out in six databases: EBSCOhost, Scopus, ERIC, LLBA, Ovid, and Web of Science. Effect sizes (Hedges' g) were calculated for language outcomes. Quality of the study reports was assessed using the levels of evidence system by the American Speech-Language-Hearing Association.

RESULTS

The 28 studies identified were divided into three groups: interventions at Neonatal Intensive Care Unit, interventions during the first year, and interventions during the second and/or third years. Most of the interventions focused on supporting child-care and general development. Of the interventions, 61 % were efficacious in supporting language development of preterm children. The most promising results regarding efficacy were interventions conducted during the second and/or third years (80 %). Quality of the reports varied from high/good (89 %) to low (11 %).

CONCLUSION

The 28 existing studies provide limited evidence of the efficacy of very early interventions promoting language development of preterm children. However, especially the results for interventions conducted during the second and/or third years show promise. More studies, particularly language-focused interventions with longer follow-ups, are needed.

Doctor-Parent Disagreement for Preterm Infants Born in the Grey Zone: Do Ethical Frameworks Help?

OBJECTIVE

To examine i) how ethical frameworks can be used in concrete cases of parent-doctors' disagreements for extremely preterm infants born in the grey zone to guide such difficult decision-making; and ii) what challenges stakeholders may encounter in using these frameworks.

DESIGN

We did a case analysis of a concrete case of parent-doctor disagreement in the grey zone using two ethical frameworks: the best interest standard and the zone of parental discretion.

RESULTS

Both ethical frameworks entailed similar advantages and challenges. They have the potential 1) to facilitate decision-making because they follow a structured method; 2) to clarify the situation because all relevant ethical issues are explored; and 3) to facilitate reaching an agreement because all parties can explain their views. We identified three main challenges. First, how to objectively evaluate the risk of severe disability. Second, parents' interests should be considered but it is not clear to what extent. Third, this is a value-laden situation and different people have different values, meaning that the frameworks are at least partially subjective.

CONCLUSIONS

These challenges do not mean that the ethical frameworks are faulty; rather, they reflect the complexity and the sensitivity of cases in the grey zone.

Severe brain injury and trends of gestational-age-related neurodevelopmental outcomes in infants born very preterm: A population cohort study

AIM

To investigate the impact of severe neonatal brain injury (SNBI) on gestational age-related trends in neurodevelopmental impairment (NDI) outcome in infants born very preterm.

METHOD

A population-based cohort study recruited 1091 infants born at a gestational age of less than 31 weeks between 2011 and 2020. The trends in neonatal morbidities, mortality, and 24-month NDI severity (no/mild, moderate, severe) by epoch (2011-2015, 2016-2020) and gestational age (22-25 weeks, 26-28 weeks, 29-30 weeks) were determined in infants with and without SNBI inclusion.

RESULTS

There was increased antenatal steroid use and higher maternal education and socioeconomic status over time. The rates of neonatal morbidities and mortality had no temporal changes. Among 825 infants with follow-up, those in the 22 to 25 weeks gestational age group had declining trends in cerebral palsy and severe cognitive impairment, with decreased rates of severe NDI from 19% to 8% across epochs, particularly in those without SNBI (from 16% to 2%). Relative to its occurrence in epoch 2011 to 2015, risk of severe NDI was significantly reduced in epoch 2016 to 2020 (adjusted relative risk 0.39, 95% confidence interval 0.16-0.96) for infants born at 22 to 25 weeks gestational age, and the risk dropped even lower in these infants without SNBI (0.12, 0.02-0.84).

INTERPRETATION

Infants born at 22 to 25 weeks gestational age had decreased rates of severe NDI in the decade between 2011 and 2020, particularly those without SNBI. The improvement might be attributed to better perinatal/neonatal and after-discharge care.

Resource and Service Use after Discharge Among Infants 22-25 Weeks Estimated Gestational Age at the First High-Risk Infant Follow-Up Visit in California

OBJECTIVE

To examine resource and service use after discharge among infants born extraordinarily preterm in California who attended high-risk infant follow-up (HRIF) clinic by 12 months corrected age.

STUDY DESIGN

We included infants born 2010-2017 between 22 + 0/7 and 25 + 6/7 weeks' gestational age in the California Perinatal Quality Care Collaborative and California Perinatal Quality Care Collaborative-California Children's Services HRIF databases. We evaluated rates of hospitalization, surgeries, medications, equipment, medical service and special service use, and referrals. We examined factors associated with receiving ≥ 2 medical services, and ≥ 1 special service.

RESULTS

A total of 3941 of 5284 infants received a HRIF visit by 12 months corrected age. Infants born at earlier gestational ages used more medications, equipment, medical services, and special services and had higher rates of referral to medical and special services at the first HRIF visit. Infants with major morbidity, surgery, caregiver concerns, and mothers with more years of education had higher odds of receiving ≥ 2 medical services. Infants with Black maternal race, younger maternal age, female sex, and discharge from lower level neonatal intensive care units (NICUs) had lower odds of receiving ≥ 2 medical services. Infants with more educated mothers, multiple gestation, major morbidity, surgery, caregiver concerns, and discharge from lower level NICUs had increased odds of receiving a special service.

CONCLUSIONS

Infants born extraordinarily preterm have substantial resource use after discharge. High resource utilization was associated with maternal/sociodemographic factors and expected clinical factors. Early functional and service use information is valuable to parents and underscores the need for NICU providers to appropriately prepare and refer families.

Assessment of extremely premature lambs supported by the Extrauterine Environment for Neonatal Development (EXTEND)

BACKGROUND

Our team has previously reported physiologic support by the EXTra-uterine Environment for Neonatal Development (EXTEND) of 105 to 117 days gestational age (GA) lambs for up to 28 days with normal organ maturation. However, the fetal lamb brain matures more rapidly, requiring the study of 90-105 day GA fetal lambs to assess more neurodevelopmentally equivalent lambs to the 23-25 week GA extreme premature infant.

METHODS

Extremely preterm lambs (90-95 days of GA) were delivered by C-section and supported by EXTEND. Estimated circuit flows were maintained at around 325 ml/kg/min. After support on EXTEND, MRI and histopathologic analysis were performed and compared to 105-112 days GA control lambs.

RESULTS

The extremely preterm group includes 10 animals with a mean GA of 91.6 days, a mean weight at cannulation of 0.98 kg and a mean length of stay on EXTEND of 13.5 days (10-21 days). Hemodynamics and oxygenation showed stable parameters. Animals showed growth and physiologic cardiac function. MRI volumetric and diffusion analysis was comparable to controls. Histologic brain analysis revealed no difference between study groups.

CONCLUSION

EXTEND appears to support brain and cardiac development in an earlier gestation, less mature, lamb model.

IMPACT

Prolonged (up to 21 days) physiological support of extremely preterm lambs of closer neurodevelopmental equivalence to the 24-28 gestational week human was achieved using the EXTEND system. EXTEND treatment supported brain growth and development in extremely preterm fetal lambs and was not associated with intraventricular hemorrhage or white matter injury. Daily echocardiography demonstrated physiologic heart function, absence of cardiac afterload, and normal developmental increase in cardiac chamber dimensions. This study demonstrates hemodynamic and metabolic support by the EXTEND system in the extremely preterm ovine model.

Survival and unique clinical practices of extremely preterm infants born at 22-23 weeks' gestation in Japan: a national survey

OBJECTIVES

To investigate prognosis and clinical practices of infants born at 22-23 weeks' gestational age (wkGA) in Japan.

DESIGN

A national institutional-level electronic questionnaire surveys performed in September 2021.

SETTING

All perinatal centres across Japan.

PATIENTS

Infants born at 22-23 wkGA in 2018-2020.

MAIN OUTCOME MEASURES

Proportion of active resuscitation and survival at neonatal intensive care unit (NICU) discharge, and various clinical practices.

RESULTS

In total, 255 of 295 NICUs (86%) responded. Among them, 145 took care of infants born at 22-23 wkGA and answered the questions regarding their outcomes and care. In most NICUs (129 of 145 (89%)), infants born at 22+0 wkGA can be actively resuscitated. In almost half of the NICUs (79 of 145 (54%)), infants born at ≥22+0 wkGA were always actively resuscitated. Among 341 and 757 infants born alive at 22 and 23 wkGA, respectively, 85% (291 of 341) and 98% (745 of 757) received active resuscitation after birth. Among infants actively resuscitated at birth, 63% (183 of 291) and 80% (594 of 745) of infants born at 22 and 23 wkGA survived, respectively. The survey revealed unique clinical management for these infants in Japan, including delivery with caul in caesarean section, cut-cord milking after clamping cord, immediate intubation at birth, hydrocortisone use for chronic lung disease, analgesia/sedation use for infants on mechanical ventilation, routine echocardiography and brain ultrasound, probiotics administration, routine glycerin enema and skin dressing to prevent pressure ulcers.

CONCLUSIONS

Many 22-23 wkGA infants were actively resuscitated in Japan and had a high survival rate. Various unique clinical practices were highlighted.

The Triple Aim Quality Improvement Gold Standard Illustrated as Extremely Premature Infant Care

OBJECTIVES

The Triple Aim is widely regarded as the quality improvement gold standard that enhances population health, lowers costs, and betters individual care. There have been no large-scale, sustained demonstrations of such improvement in healthcare. Illustrating the Triple Aim using relevant extremely premature infant outcomes might highlight interwoven proficiency and efficiency complexities that impede sustained value progress.

STUDY DESIGN

Ten long-term collaborating neonatal intensive care units (NICU) in the Vermont Oxford Network calculated the Triple Aim in 230/7 to 276/7-week infants using three surrogate measures: (1) population health/x-axis-eight major morbidity rates as a composite, risk-adjusted metric; (2) cost/y-axis-total hospital length of stay; and (3) individual care/z-axis-mortality, then illustrated this relationship as a sphere within a three-dimensional cube.

RESULTS

Three thousand seven hundred six infants born between January 1, 2014 and December 31, 2019, with mean (standard deviation) gestational age of 25.7 (1.4) weeks and birth weight of 803 (208) grams were analyzed. Triple Aim three-axis cube positions varied inconsistently comparing NICUs. Each NICUs' sphere illustrated mixed x- and z-axis movement (clinical proficiency), and y-axis movement (cost efficiency). No NICU demonstrated the theoretically ideal Triple Aim improvement in all three axes. Backward movement in at least one axis occurred in eight NICUs. The whole-group Triple Aim sphere moved forward along the x-axis (better morbidities metric), but moved backward in the y-axis length of stay and z-axis mortality measurements.

CONCLUSION

Illustrating the Triple Aim gold standard as extreme prematurity outcomes reveals complexities inherent to simultaneous attempts at improving interwoven quality and cost outcomes. Lack of progress using relevant Triple Aim parameters from our well-established collaboration highlights the difficulties prioritizing competing outcomes, variable potentially-better-practice applications amongst NICUs, unmeasured biologic interactions, and obscured cultural-environmental contexts that all likely affect care. Triple Aim excellence, if even remotely possible, will necessitate scalable, evidence-based methodologies, pragmatism regarding inevitable trade-offs, and wise constrained-resource decisions.

KEY POINTS

· The Triple Aim gold standard is elusive. There is no demonstration of sustained, large-scale success in healthcare and our quality improvement network has previously published benchmark extreme prematuritymorbidity improvements.. · Extreme prematurity outcomes illustrated as the Triple Aim show uneven results in relevant surrogate parameters and Triple Aim achievement, if even possible, will necessitate evidence-based methodologies that are scalable.. · Pragmatism, inevitable trade-offs, and wise constrained-resource decisions are required for Triple Aim success..

Scandinavian perspectives on life support at the border of viability

Advances in neonatal medicine have allowed us to rescue extremely preterm infants. However, both long-term vulnerability and the burden of treatment in the neonatal period increase with decreasing gestational age. This raises questions about the justification of life support when a baby is born at the border of viability, and has led to a so-called "grey zone", where many professionals are unsure whether provision of life support is in the child's best interest. Despite cultural, political and economic similarities, the Scandinavian countries differ in their approach to periviable infants, as seen in their respective national guidelines and practices. In Sweden, guidelines and practice are more rescue-focused at the lower end of the border of viability, Danish guidelines emphasizes the need to involve parental views in the decision-making process, whereas Norway appears to be somewhere in between. In this paper, I will give an overview of national consensus documents and practices in Norway, Sweden and Denmark, and reflect on the ethical justification for the different approaches.

Perinatal optimisation for periviable birth and outcomes: a 4-year network analysis (2018-2021) across a change in national guidance

Introduction

The British Association of Perinatal Medicine (BAPM) released their revised framework for extremely preterm infant management in 2019. This revised framework promotes consideration of perinatal optimisation and survival-focused care from 22 weeks gestation onwards. This was a departure from the previous BAPM framework which recommended comfort care as the only recommended management for infants <23 + 0 weeks.

Methods

Our study evaluates the clinical impact that this updated framework has had across the Northwest of England. We utilised anonymised network data from periviable infants delivered across the region to examine changes in perinatal optimisation practices and survival outcomes following the release of the latest BAPM framework.

Results

Our data show that after the introduction of the updated framework there has been an increase in perinatal optimisation practices for periviable infants and an 80% increase in the number of infants born at 22 weeks receiving survival-focused care and admission to a neonatal unit.

Discussion

There remain significant discrepancies in optimisation practices by gestational age, which may be contributing to the static survival rates that were observed in the lowest gestational ages.

Preeclampsia Onset, Days to Delivery, and Autism Spectrum Disorders in Offspring: Clinical Birth Cohort Study

BACKGROUND

Maternal preeclampsia is associated with a risk of autism spectrum disorders (ASD) in offspring. However, it is unknown whether the increased ASD risk associated with preeclampsia is due to preeclampsia onset or clinical management of preeclampsia after onset, as clinical expectant management of preeclampsia allows pregnant women with this complication to remain pregnant for potentially weeks depending on the onset and severity. Identifying the risk associated with preeclampsia onset and exposure provides evidence to support the care of high-risk pregnancies and reduce adverse effects on offspring.

OBJECTIVE

This study aimed to fill the knowledge gap by assessing the ASD risk in children associated with the gestational age of preeclampsia onset and the number of days from preeclampsia onset to delivery.

METHODS

This retrospective population-based clinical cohort study included 364,588 mother-child pairs of singleton births between 2001 and 2014 in a large integrated health care system in Southern California. Maternal social demographic and pregnancy health data, as well as ASD diagnosis in children by the age of 5 years, were extracted from electronic medical records. Cox regression models were used to assess hazard ratios (HRs) of ASD risk in children associated with gestational age of the first occurrence of preeclampsia and the number of days from first occurrence to delivery.

RESULTS

Preeclampsia occurred in 16,205 (4.4%) out of 364,588 pregnancies; among the 16,205 pregnancies, 2727 (16.8%) first occurred at <34 weeks gestation, 4466 (27.6%) first occurred between 34 and 37 weeks, and 9012 (55.6%) first occurred at ≥37 weeks. Median days from preeclampsia onset to delivery were 4 (IQR 2,16) days, 1 (IQR 1,3) day, and 1 (IQR 0,1) day for those first occurring at <34, 34-37, and ≥37 weeks, respectively. Early preeclampsia onset was associated with greater ASD risk (P=.003); HRs were 1.62 (95% CI 1.33-1.98), 1.43 (95% CI 1.20-1.69), and 1.23 (95% CI 1.08-1.41), respectively, for onset at <34, 34-37, and ≥37 weeks, relative to the unexposed group. Within the preeclampsia group, the number of days from preeclampsia onset to delivery was not associated with ASD risk in children; the HR was 0.995 (95% CI 0.986-1.004) after adjusting for gestational age of preeclampsia onset.

CONCLUSIONS

Preeclampsia during pregnancy was associated with ASD risk in children, and the risk was greater with earlier onset. However, the number of days from first preeclampsia onset to delivery was not associated with ASD risk in children. Our study suggests that ASD risk in children associated with preeclampsia is not increased by expectant management of preeclampsia in standard clinical practice. Our results emphasize the need to identify effective approaches to preventing the onset of preeclampsia, especially during early pregnancy. Further research is needed to confirm if this finding applies across different populations and clinical settings.

[Influence of Fetomaternal Risk Factors on Mortality and Morbidity in Extremely Preterm Infants]

INTRODUCTION

The management of pregnant women at risk of preterm delivery poses a challenge to the interdisciplinary team. At the edge of viability, it is crucial to take into consideration maternal and fetal risk factors when determining individual counseling and therapeutic approaches.

METHODS

At a level 4 perinatal center, all preterm infants (PI) born in the years 2017 to 2020 who had a gestational age between 230/7 and 246/7 weeks and were cared for with a curative therapeutic approach were enrolled in a retrospective observational study. Divided into two groups (230/7-236/7 and 240/7-246/7 weeks of gestation), the PI were compared in terms of mortality and morbidity based on maternal and fetal risk factors. Thirteen risk factors and their prognostic relevance for survival were analyzed.

RESULTS

41 mothers with 48 PI were included. 9 neonates received primary palliative treatment and were excluded from the analyses. The survival rates between the two groups (n=21, n=27) showed no significant difference (66.7% versus 74.1%, p=0.750). A significantly higher mortality was observed in PI with an increased number of risk factors (p=0.004), the most severe of which were hypertensive disorders of pregnancy and preterm premature rupture of membranes. Data regarding morbidity showed no significant difference.

CONCLUSION

Data regarding mortality correlate with national findings. Observed morbidity in the study population was recorded. The prediction of probability of survival is more precise when risk factors are taken into consideration.

Optic atrophy in prematurity: pathophysiology and clinical features

Optic atrophy is an important cause of visual impairment in children, and the aetiological profile has changed over time. Technological advancements led by neuroimaging of the visual pathway and imaging of the optic nerve with optical coherence tomography have accelerated the understanding of this condition. In the new millennium, an increasing prevalence of prematurity as a cause of optic atrophy in children has been highlighted. This new shift has been linked with increasing rates of premature births and improved neonatal survival of preterm infants. The available literature is limited to hospital and registry-based cohorts with modest sample sizes, methodological heterogeneity and selection bias limitations. Larger studies that are better designed are required to better understand the contribution of prematurity to the disease burden. In addition to considering other life-threatening aetiologies, screening for premature birth should be covered as part of a comprehensive history when evaluating a child with paediatric optic atrophy.

Effects of increased physical therapy staffing in the neonatal intensive care unit on oral feeding maturation and neurodevelopment of extremely low birth weight infants

BACKGROUND

It remains a matter of debate as to what extent early intervention may facilitate long-term functional outcomes of preterm infants in the neonatal intensive care unit (NICU). We aimed to examine the effect of increasing physical therapy (PT) staff dedicated to the NICU on temporal changes (initiation, duration) of PT interventions and functional outcomes (acquisition of full oral feeding and Hammersmith Neonatal Neurological Examination).

METHODS

Extremely low birth weight infants, retrospectively collected from an academic medical center, were allocated to two subgroups, either a baseline period (N = 48) without NICU-dedicated PT staff (non-dedicated group) or a quality improvement period (N = 42) with additional dedicated staff (dedicated group).

RESULTS

Compared to those in the non-dedicated group, NICU infants in the dedicated group started PT earlier and had increased PT treatment for additional 14 min per day when achieving full oral feeding. The infants in the dedicated group significantly achieved full oral feeding earlier than the non-dedicated group. As for Hammersmith Neonatal Neurological Examination, there were significant differences in two items (total and tone) between the groups.

CONCLUSIONS

Additional NICU-dedicated PT staff facilitated earlier intervention and increased PT treatment in terms of daily duration. Moreover, the dedication shortened the completion of full oral feeding and improved neurological development, presumably resulting in better developmental outcome.

Extreme prematurity: Factors associated with perinatal management and morbi-mortality in western Normandy, France

BACKGROUND

Extreme prematurity (birth before 26 weeks of gestation), presents complex challenges and can lead to various complications. Survival rates of extremely preterm infants are lower in France than in other countries. The choice between active and palliative care is decisive in managing these births.

OBJECTIVE

To conduct an observational study focused on factors associated with perinatal management, mortality, and morbidity outcomes among extremely preterm births in a regional perinatal network.

METHODS

We undertook a retrospective, multicenter study within the western Normandy perinatal network, encompassing live births between 230/6 and 256/6 weeks from 2015 to 2019. Data were extracted from the perinatal network database and medical records.

RESULTS

One hundred and seven infants born from 94 women were included. In the antenatal period, 79 were exposed to corticosteroids, 66 to magnesium sulfate, and 67 to antibiotics. Active care at birth was provided to 84 neonates of whom 42 survived. In total, 65 infants died. Among the 42 surviving neonates, 9 experienced no severe morbidity, 29 displayed one and 4 exhibited two criteria of severe morbidity. Active care was associated with gestational age. Neonatal survival was correlated with antenatal exposure to antibiotics and magnesium sulfate as well as with postnatal corticosteroids. We found no significant association between mortality and gestational age at birth.

CONCLUSION

Prognostic factors must be weighed to discuss active antenatal care which is crucial for survival of extremely preterm neonates. Cooperation between obstetricians and neonatal caregivers is a cornerstone on a regional perinatal network scale.

Steroid Metabolomic Signature in Term and Preterm Infants

Adrenal function is essential for survival and well-being of preterm babies. In addition to glucocorticoids, it has been hypothesized that C19-steroids (DHEA-metabolites) from the fetal zone of the adrenal gland may play a role as endogenous neuroprotective steroids. In 39 term-born (≥37 weeks gestational age), 42 preterm (30-36 weeks) and 51 early preterm (<30 weeks) infants 38 steroid metabolites were quantified by GC-MS in 24-h urinary samples. In each gestational age group, three distinctive cluster were identified by pattern analysis (k-means clustering). Individual steroidal fingerprints and clinical phenotype were analyzed at the 3rd day of life. Overall, the excretion rates of C21-steroids (glucocorticoid precursors, cortisol, and cortisone metabolites) were low (<99 μg/kg body weight/d) whereas the excretion rates of C19-steroids were up to 10 times higher. There was a shift to higher excretion rates of C19-steroids in both preterm groups compared to term infants but only minor differences in the distribution of C21-steroids. Comparable metabolic patterns were found between gestational age groups: Cluster 1 showed mild elevation of C21- and C19-steroids with the highest incidence of neonatal morbidities in term and severe intraventricular hemorrhage in early preterm infants. In cluster 2 lowest excretion in general was noted but no clinically unique phenotype. Cluster 3 showed highest elevation of C21-steroids and C19-steroids but no clinically unique phenotype. Significant differences in steroid metabolism between clusters are only partly reflected by gestational age and disease severity. In early preterm infants, higher excretion rates of glucocorticoids and their precursors were associated with severe cerebral hemorrhage. High excretion rates of C19-steroids in preterm infants may indicate a biological significance.

Outcome in very preterm infants: a population-based study from a regional center in Austria

Aim

To determine short-term morbidity and mortality rates in the first state-wide Austrian neonatal cohort and comparison to (inter)national data.

Methods

Observational, population-based cohort study, analyzing data of preterm infants (<32 + 0 weeks of gestation) born between 2007 and 2020 (n = 501) in an Austrian state who were admitted to the neonatal intensive care unit. Outcome criteria were mortality, neonatal morbidities: bronchopulmonary dysplasia (BPD), severe necrotizing enterocolitis (NEC), severe intraventricular hemorrhage (IVH grades III-IV), severe retinopathy of prematurity (ROP grades III-V) and survival-free of major complications.

Results

Overall survival rate was 95%, survival free of major complications was 79%. Prevalence for BPD was 11.2%, surgical NEC 4.0%, severe IVH 4.6%, and for severe ROP 2.6%, respectively. In the extremely low gestational age neonates (ELGAN) born <28 weeks of gestation (n = 158), survival was 88% and survival free of major complications 58.8%. Over time, mortality decreased significantly, predominantly driven by the improvement of infants born <28 week of gestation and survival free of major complications improved.

Conclusions

This study demonstrates a very low mortality rate that decreases over time. Short-term morbidities and survival free of major complications do not differ from (inter)national data in a similar group of very preterm infants. Standard operating procedures, simulation trainings and accordance to international trials may improve patient care and surpass center case loads.

One-year survival and outcomes of infants born at 22 and 23 weeks of gestation in Sweden 2004-2007, 2014-2016 and 2017-2019

OBJECTIVE

To explore associations between perinatal activity and survival in infants born at 22 and 23 weeks of gestation in Sweden.

DESIGN/SETTING

Data on all births at 22 and 23 weeks' gestational age (GA) were prospectively collected in 2004-2007 (T1) or obtained from national registers in 2014-2016 (T2) and 2017-2019 (T3). Infants were assigned perinatal activity scores based on 3 key obstetric and 4 neonatal interventions.

MAIN OUTCOME

One-year survival and survival without major neonatal morbidities (MNM): intraventricular haemorrhage grade 3-4, cystic periventricular leucomalacia, surgical necrotising enterocolitis, retinopathy of prematurity stage 3-5 or severe bronchopulmonary dysplasia. The association of GA-specific perinatal activity score and 1-year survival was also determined.

RESULTS

977 infants (567 live births and 410 stillbirths) were included: 323 born in T1, 347 in T2 and 307 in T3. Among live-born infants, survival at 22 weeks was 5/49 (10%) in T1 and rose significantly to 29/74 (39%) in T2 and 31/80 (39%) in T3. Survival was not significantly different between epochs at 23 weeks (53%, 61% and 67%). Among survivors, the proportions without MNM in T1, T2 and T3 were 20%, 17% and 19% for 22 weeks and 17%, 25% and 25% for 23 weeks' infants (p>0.05 for all comparisons). Each 5-point increment in GA-specific perinatal activity score increased the odds for survival in first 12 hours of life (adjusted OR (aOR) 1.4; 95% CI 1.3 to 1.6) in addition to 1-year survival (aOR 1.2; 95% CI 1.1 to 1.3), and among live-born infants it was associated with increased survival without MNM (aOR 1.3; 95% CI 1.1 to 1.4).

CONCLUSION

Increased perinatal activity was associated with reduced mortality and increased chances of survival without MNM in infants born at 22 and 23 weeks of GA.

Pain responses in preterm infants and parental stress over repeated painful procedures: a randomized pilot trial

OBJECTIVES

In this pilot study, the aims were to determine the feasibility of whether pain behavior in extremely and very preterm infants and perceived parental stress change when parents are involved in pain reducing measures, either actively, performing facilitated tucking or passively, observing the intervention, in comparison to the involvement of nurses only. In addition, the infant's pain reactivity and parental stress over three time points of measurement was of interest.

METHODS

Extremely and very preterm infants in need of subcutaneous erythropoietin were randomly assigned to the two intervention groups. The intervention encompassed that one parent of each infant was involved during the painful procedure: Either parents executed facilitated tucking themselves or stood by, observing the procedure. Usual care involved that nurse executed facilitated tucking. All infants received 0.5 ml of 30% oral glucose solution via cotton swab before the painful procedure. Infant pain was observed with the Bernese Pain Scale for Neonates (BPSN) and measured with the MedStorm skin conductance algesimeter (SCA) before, during, and after the procedure. Parents' stress levels were measured before and after the painful procedure on the infant, using the Current Strain Short Questionnaire (CSSQ). Feasibility of a subsequent trial was determined by assessing recruitment, measurement and active parental involvement. Quantitative data collection methods (i.e. questionnaires, algesimeter) were employed to determine the number of participants for a larger trial and measurement adequacy. Qualitative data (interviews) was employed to determine parents' perspectives of their involvement.

RESULTS

A total of 13 infants (98% participation rate) were included along with their mothers. Median gestational age was 27 weeks (IQR 26-28 weeks), 62% were female. Two infants (12.5%) dropped out of the study as they were transferred to another hospital. Facilitated tucking turned out to be a good method to actively involve parents in pain reducing measures. No significant differences between the two intervention and control groups were found concerning parental stress and infant pain (p = .927). Power analysis indicated that at least N = 741 infants (power of 81%, α = .05) would be needed to obtain statistically significant results in a larger trial, as effect sizes were smaller than expected. Two of the three measurement tools - i.e. the BPSN and CSSQ) - proved easy to implement and were well accepted. owever, the SCA was challenging in this context. Measurements were also found to be time-consuming and resource-intense (i.e. health professionals as assistants).

CONCLUSIONS

Although the intervention was feasible and was readily accepted by parents, the study design was found to be challenging along with the SCA. In preparation of the larger trial, the study design needs to be revisited and adjusted. Thus, issues of time and resources may be resolved. In addition, national and international collaboration with similar neonatal intensive care units (NICU) needs to be considered. Thus, it will be possible to conduct an appropriately powered larger trial, which will yield important results to improve pain management in extremely and preterm infants in NICU.

Effect of national guidance on survival for babies born at 22 weeks' gestation in England and Wales: population based cohort study

Objectives

To explore the effect of changes in national clinical recommendations in 2019 that extended provision of survival focused care to babies born at 22 weeks' gestation in England and Wales.

Design

Population based cohort study.

Setting

England and Wales, comprising routine data for births and hospital records.

Participants

Babies alive at the onset of care in labour at 22 weeks+0 days to 22 weeks+6 days and at 23 weeks+0 days to 24 weeks+6 days for comparison purposes between 1 January 2018 and 31 December 2021.

Main outcome measures

Percentage of babies given survival focused care (active respiratory support after birth), admitted to neonatal care, and surviving to discharge in 2018-19 and 2020-21.

Results

For the 1001 babies alive at the onset of labour at 22 weeks' gestation, a threefold increase was noted in: survival focused care provision from 11.3% to 38.4% (risk ratio 3.41 (95% confidence interval 2.61 to 4.45)); admissions to neonatal units from 7.4% to 28.1% (3.77 (2.70 to 5.27)), and survival to discharge from neonatal care from 2.5% to 8.2% (3.29 (1.78 to 6.09)). More babies of lower birth weight and early gestational age received survival focused care in 2020-21 than 2018-19 (46% to 64% at <500g weight; 19% to 31% at 22 weeks+0 days to 22 weeks+3 days).

Conclusions

A change in national guidance to recommend a risk based approach was associated with a threefold increase in 22 weeks' gestation babies receiving survival focused care. The number of babies being admitted to neonatal units and those surviving to discharge increased.

German obstetrician's self-reported attitudes and handling in threatening preterm birth at the limits of viability

OBJECTIVES

Antenatal treatment and information influences the course of pregnancy and parental decision-making in cases of threatened prematurity on the borderline of viability. Numerous studies have shown significant interprofessional differences in assessing ethical boundary decisions; hence, this study aimed to evaluate obstetricians attitudes, practices and antenatal parental counseling regarding threatened preterm birth in Germany.

METHODS

An anonymous online questionnaire was administered to 543 obstetricians at tertiary perinatal centers and prenatal diagnostic centers in Germany. The survey contained questions on basic ethical issues assessed using the Likert scale and a case vignette regarding the practical procedures of an imminent extreme premature birth at 23 1/7 gestational weeks.

RESULTS

In the case of unstoppable preterm birth, 15 % of clinicians said they would carry out a cesarean section; however, specialists from centers with a high number of very low birth weight infants would do so significantly more often. Among respondents, 29.8 % did not take any therapeutic measures without discussing the child's treatment options with their parents, 19.9 % refused to offer actionable advice to the parents, and 57 % said they would advise parents to seek intensive care treatment for the child with the option of changing treatment destination in the event of serious complications. Moreover, 84 % said they would provide information together with neonatologists.

CONCLUSIONS

Joint counseling with neonatologists is widely accepted. The size of the perinatal center significantly influences the practical approach to threatened preterm births. Respect for parents' decision-making autonomy regarding the child's treatment options is central and influences therapy initiation.

Opportunities and Challenges of Prognostic Models for Extremely Preterm Infants

Predicting the short- and long-term outcomes of extremely preterm infants remains a challenge. Multivariable prognostic models might be valuable tools for clinicians, parents, and policymakers for providing accurate outcome estimates. In this perspective, we discuss the opportunities and challenges of using prognostic models in extremely preterm infants at population and individual levels. At a population level, these models could support the development of guidelines for decisions about treatment limits and may support policy processes such as benchmarking and resource allocation. At an individual level, these models may enhance prenatal counselling conversations by considering multiple variables and improving transparency about expected outcomes. Furthermore, they may improve consistency in projections shared with parents. For the development of prognostic models, we discuss important considerations such as predictor and outcome measure selection, clinical impact assessment, and generalizability. Lastly, future recommendations for developing and using prognostic models are suggested. Importantly, the purpose of a prognostic model should be clearly defined, and integrating these models into prenatal counselling requires thoughtful consideration.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Successful delayed interval delivery of a triplet pregnancy using conservative management

Preterm birth is a significant cause of perinatal morbidity and mortality, especially in multiple pregnancies. Delayed interval delivery can prolong pregnancy for the remaining fetus(es) in an imminent stillbirth or extremely preterm birth of the first fetus, improving the lastborn's outcomes. We present a case of delayed interval delivery of a triplet pregnancy following preterm prelabour rupture of membranes and progressive cervical insufficiency. Following vaginal delivery of the first fetus at 24+1 gestational weeks, the patient received antibiotics and tocolysis. Cerclage was not conducted as the mother had a vaginal infection. A 15-day delivery interval for the second and third fetuses was achieved. The firstborn required mechanical ventilation and inotropic support, while the others only required continuous positive airway pressure. There is no consensus on the best way to perform delayed interval delivery. We achieved a complications-free interval of 15 days with conservative management in a triplet pregnancy.

Promoting children's rights to health and well-being in the United States

The United States has a highly sophisticated pediatric healthcare system and spends more than any other country per capita on children's healthcare. However, not all children have access to needed and affordable health care and the life expectancy and health outcomes of children in the country are worse than in any other industrialized nation. These nations typically offer universal healthcare for children as part of a robust recognition of a children's rights framework. In 1989 the United Nations adopted the Convention on the Rights of the Child that recognizes the right of the child to the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. Currently the United States is the only United Nations member country that has not ratified the Convention on the Rights of the Child. This paper outlines the potential benefits of adopting a child rights approach based on the principles and provisions of the Convention on the Rights of the Child. The fact that countries who invest much less in healthcare compared to the United States can achieve better health outcomes provides the certainty that a solution is possible and within reach.

Change in neurodevelopmental outcomes for extremely premature infants over time: a systematic review and meta-analysis

OBJECTIVE

Survival rates of extremely premature infants are rising, but changes in neurodevelopmental impairment (NDI) rates are unclear. Our objective was to perform a systematic review of intrainstitutional variability of NDI over time.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ovid MEDLINE, Embase, PubMed, Cochrane Library and Google Scholar.

STUDY SELECTION

Study eligibility: (1) at least two discrete cohorts of infants born <27 weeks' gestation or <1000 g birth weight, (2) one cohort born after 1990 and at least one subsequent cohort of similar gestational age, (3) all cohorts cared for within the same Neonatal Intensive Care Unit(s) (NICU) and (4) neurodevelopmental outcomes at 18-36 months corrected age.

MAIN OUTCOME

Change in NDI rates. Quality, validity and bias were assessed using Grading of Recommendations, Assessment, Development, and Evaluation and Quality in Prognosis Studies guidelines.

RESULTS

Of 203 publications, 15 were eligible, including 13 229 infants. At the first time point, average NDI rate across study groups weighted by sample size was 41.0% (95% CI 34.0% to 48.0%). The average change in NDI between time points was -3.3% (95% CI -8·8% to 2.2%). For each added week of gestation at birth, the rate of NDI declined by 9.7% (95% CI 6.2% to 13.3%). Most studies exhibited moderate-severe bias in at least one domain, especially attrition rates.

CONCLUSIONS

When comparing discrete same-centre cohorts over time, there was no significant change in NDI rates in infants born <27 weeks' gestation or <1000 g. Higher survival rates unaccompanied by improvement in neurodevelopment highlight urgency for renewed focus on the causes of NDI and evidence-based strategies to reduce brain injury.

Resuscitation in the “Periviable” Period—Commentary of Opposing Views

The periviable period is defined as delivery between 20 0/7 weeks and 25 6/7 weeks of gestation. It has long been considered a “gray area,” as there are still no clear guidelines on initial resuscitation and subsequent treatment of the newborn. This lack of guidance compounds the uncertainty in decision-making in low- and middle-income countries with limited resources. The decision to treat or not has far-reaching economic, social, cultural, and sometimes even religious implications for the parents and family. This review explores the perspectives of parents, caregivers, and policymakers in detail to utilize the existing evidence better. We present arguments for and against resuscitation in the periviable period, discussing concerns surrounding neurodevelopmental outcomes, cost, parental concerns, nonuniformity of evidence, and ethical considerations. A large survival gap exists between developed and developing countries, and the infrastructure and clinical care network in low- and middle-income country are not strong enough to provide adequate support for these infants and their families. Antenatal factors, socioeconomic and cultural issues, center capacity, and resuscitation capacity of birthing centers should be considered when making decisions. The neonatologists are expected to be impartial, provide information, and not advise based on their beliefs and outlook; while preserving the autonomy of parents. The only way forward is for parents and caregivers to work together to develop a logical and ethical approach that can be accepted as national and institutional policies.

Being parents of extremely preterm children, from a long-term perspective: A qualitative study of parents' experiences

BACKGROUND

In recent decades, modern neonatal intensive care has improved, increasing the survival of extremely preterm children. Few studies have examined the experiences of parents of extremely preterm children from a long-term perspective.

AIM

To describe parents' experiences of parenting extremely preterm children during their childhood and transition to adulthood.

STUDY DESIGN

A qualitative interview study with a descriptive design.

SUBJECTS

Thirteen parents of eleven children born at 24 gestational weeks in Sweden, 1990-1992, participated in individual semi-structured interviews.

OUTCOME MEASURES

Data were analyzed using qualitative reflexive thematic analysis.

RESULT

Five themes forming a timeline were created in the analytic process: parenthood, at the NICU, young childhood, adolescence, and adulthood. Various aspects affecting parenthood were described throughout the timeline, and occasionally the parents experienced difficulties dealing with their children's special physical and/or mental needs. Today, some families have established a functioning situation despite their children's physical and/or mental difficulties, while some still struggle with their children's everyday life.

CONCLUSION

Having an extremely preterm family member profoundly affects the whole family for various lengths of time. Parents expressed a need for support from both healthcare and school throughout their children's childhood and in their transition to adulthood, although the need varies between parent-child pairs. By studying the parents' experiences, their need for support can be further recognized and understood, and developed and improved accordingly.

Increased Survival Concomitant with Unchanged Morbidity and Cognitive Disability among Infants Born at the Limit of Viability before 24 Gestational Weeks in 2009-2019

INTRODUCTION

The aim was to determine risk factors among mothers and outcomes for their children born at the limit of viability in 2009-2019, before and after the introduction of extended interventionist guidelines.

METHODS

A retrospective cohort study of births at 22 + 0-23 + 6 gestational weeks in a Swedish Region in 2009-2015 (n = 119), as compared to 2016-2019 (n = 86) after the introduction of new national interventionist guidelines. Infant mortality, morbidity, and cognitive functions at 2 years corrected age according to the Bayley-III Screening Test were monitored.

RESULTS

Maternal risk factors for extreme preterm birth were identified. The intrauterine fetal death rates were comparable. Among births at 22 weeks, the neonatal mortality tended to decrease (96 vs. 76% of live births (p = 0.05)), and the 2-year survival tended to increase (4 vs. 24% (p = 0.05)). Among births at 23 weeks, the neonatal mortality decreased (56 vs. 27% of live births (p = 0.01)), and the 2-year survival increased (42 vs. 64% (p = 0.03)). Somatic morbidity and cognitive disability at 2 years corrected age were unchanged.

CONCLUSION

We identified maternal risk factors that emphasize the need for standardized follow-up and counseling for women at increased risk of preterm birth at the limit of viability. The increased infant survival concomitant with unchanged morbidity and cognitive disability highlight the importance of ethical considerations regarding interventionist approaches at threatening preterm birth before 24 weeks.

Use of Fibrin Glue in the Treatment of Persistent Pneumothorax in Premature Infants at the Limit of Viability: Ethical Issues and Two and A Half Years Follow-Up

INTRODUCTION

Due to the extreme immaturity of many internal organs, including lungs, infants at the limit of viability are more predisposed to a pneumothorax (PTX). In some cases, PTX becomes persistent. Previously, only a few attempts of PTX treatment with fibrin glue were reported. However, its impact on further lung development is unknown.

CASE REPORT

We present a case of an extremely preterm infant with persistent PTX who was successfully treated with fibrin glue. In addition, we present a two-and-a-half-year corrected age follow-up focusing on respiratory problems, motor development and sensory organs. Furthermore, we touch upon the related ethical issues.

CONCLUSIONS

Fibrin glue should be used to treat persistent PTX even in an extremely preterm infant. No adverse effects were observed. At the two-and-a-half-year corrected age follow-up, despite severe bronchopulmonary dysplasia development, no serious pulmonary problems were observed. However, the child's development is uncertain. This situation raises important ethical issues concerning saving the lives of infants at the limit of viability.

Thermoregulation and golden hour practices in extremely preterm infants: an international survey

BACKGROUND

Are thermoregulation and golden hour practices in extremely preterm (EP) infants comparable across the world? This study aims to describe these practices for EP infants based on the neonatal intensive care unit's (NICUs) geographic region, country's income status and the lowest gestational age (GA) of infants resuscitated.

METHODS

The Director of each NICU was requested to complete the e-questionnaire between February 2019 and August 2021.

RESULTS

We received 848 responses, from all geographic regions and resource settings. Variations in most thermoregulation and golden hour practices were observed. Using a polyethylene plastic wrap, commencing humidity within 60 min of admission, and having local protocols were the most consistent practices (>75%). The odds for the following practices differed in NICUs resuscitating infants from 22 to 23 weeks GA compared to those resuscitating from 24 to 25 weeks: respiratory support during resuscitation and transport, use of polyethylene plastic wrap and servo-control mode, commencing ambient humidity >80% and presence of local protocols.

CONCLUSION

Evidence-based practices on thermoregulation and golden hour stabilisation differed based on the unit's region, country's income status and the lowest GA of infants resuscitated. Future efforts should address reducing variation in practice and aligning practices with international guidelines.

IMPACT

A wide variation in thermoregulation and golden hour practices exists depending on the income status, geographic region and lowest gestation age of infants resuscitated. Using a polyethylene plastic wrap, commencing humidity within 60 min of admission and having local protocols were the most consistent practices. This study provides a comprehensive description of thermoregulation and golden hour practices to allow a global comparison in the delivery of best evidence-based practice. The findings of this survey highlight a need for reducing variation in practice and aligning practices with international guidelines for a comparable health care delivery.

Temporal Trend, Causes, and Timing of Neonatal Mortality of Moderate and Late Preterm Infants in São Paulo State, Brazil: A Population-Based Study

Moderate and late preterm newborns comprise around 85% of live births < 37 weeks gestation. Data on their neonatal mortality in middle-income countries is limited. This study aims to analyze the temporal trend, causes and timing of neonatal mortality of infants with 320/7–366/7 weeks gestation without congenital anomalies from 2004–2015 in the population of São Paulo State, Brazil. A database was built by deterministic linkage of birth and death certificates. Causes of death were classified by ICD-10 codes. Among 7,317,611 live births in the period, there were 545,606 infants with 320/7–366/7 weeks gestation without congenital anomalies, and 5782 of them died between 0 and 27 days. The neonatal mortality rate decreased from 16.4 in 2004 to 7.6 per thousand live births in 2015 (7.47% annual decrease by Prais–Winsten model). Perinatal asphyxia, respiratory disorders and infections were responsible, respectively, for 14%, 27% and 44% of the 5782 deaths. Median time to death was 24, 53 and 168 h, respectively, for perinatal asphyxia, respiratory disorders, and infections. Bottlenecks in perinatal health care are probably associated with the results that indicate the need for policies to reduce preventable neonatal deaths of moderate and late preterm infants in the most developed state of Brazil.

Extremely premature birth bioethical decision-making supported by dialogics and pragmatism

Moral values in healthcare range widely between interest groups and are principally subjective. Disagreements diminish dialogue and marginalize alternative viewpoints. Extremely premature births exemplify how discord becomes unproductive when conflicts of interest, cultural misunderstanding, constrained evidence review, and peculiar hierarchy compete without the balance of objective standards of reason. Accepting uncertainty, distributing risk fairly, and humbly acknowledging therapeutic limits are honorable traits, not relativism, and especially crucial in our world of constrained resources. We think dialogics engender a mutual understanding that: i) transitions beliefs beyond bias, ii) moves conflict toward pragmatism (i.e., the truth of any position is verified by subsequent experience), and iii) recognizes value pluralism (i.e., human values are irreducibly diverse, conflicting, and ultimately incommensurable). This article provides a clear and useful Point-Counterpoint of extreme prematurity controversies, an objective neurodevelopmental outcomes table, and a dialogics exemplar to cultivate shared empathetic comprehension, not to create sides from which to choose. It is our goal to bridge the understanding gap within and between physicians and bioethicists. Dialogics accept competing relational interests as human nature, recognizing that ultimate solutions satisfactory to all are illusory, because every choice has downside. Nurturing a collective consciousness via dialogics and pragmatism is congenial to integrating objective evidence review and subjective moral-cultural sentiments, and is that rarest of ethical constructs, a means and an end.

[Delayed-Interval Delivery of an Extremely Preterm Twin after Abort of the First Twin and Emergency Total Cervical Occlusion at 19+1 Weeks of Gestation - a Case Report]

We report on the obstetric and neonatal course of a 34-year-old woman pregnant with twins, who presented at our clinic at 16+1 weeks of gestation with preterm premature rupture of membranes. We started intravenous antibiotic therapy with inpatient monitoring owing to the vitality and regular development of both twins, with anhydramnios in the leading twin. After a missed abortion of the leading twin at 19+1 weeks of gestation we decided on surgical intervention with assisted delivery of the aborted twin, leaving the placenta in situ with subsequent emergency total cervical occlusion. Afterwards, the single pregnancy could be continued until the 24th week of gestation. An urgent Caesarean section for early labor, premature rupture of membranes, and increasing signs of maternal infection was later performed. Overall, the postnatal course of the extremely preterm neonate was a success considering the gestational age. We conclude that the option of surgical interventions should be taken into account in similar cases in the future.

Gestational age-specific neonatal mortality in Hong Kong: a population-based retrospective study

BACKGROUND

The neonatal period is the most vulnerable period during childhood, with the risk of death being the highest even in developed countries/regions. Hong Kong's neonatal mortality (1‰) is among the world's lowest and has remained similar for 15 years. This study aimed to explore neonatal deaths in Hong Kong in detail and determine whether neonatal mortality is reducible at such a low level.

METHODS

Live births in public hospitals in Hong Kong during 01 Jan 2006-31 Dec 2017 were included. Relevant data were extracted from the electronic medical records. Gestational age-specific mortality was calculated, and the trends were analyzed using the Cochran-Armitage trend test. Causes of death were summarized, and risk factors were identified in multivariate logistic regression analysis.

RESULTS

In 490,034 live births, 755 cases (1.54‰) died during the neonatal period, and 293 (0.6‰) died during the post-neonatal period. The neonatal mortality remained similar overall (P = 0.17) and among infants born at 24-29 weeks' gestation (P = 0.4), while it decreased in those born at 23 (P = 0.04), 30-36 (P < 0.001) and ≥ 37 (P < 0.001) weeks' gestation. Neonates born at < 27 weeks' gestation accounted for a significantly increased proportion among cases who died (27.6% to 51.9%), with hemorrhagic conditions (24%) being the leading cause of death. Congenital anomalies were the leading cause of death in neonates born ≥ 27 weeks' gestation (52%), but its cause-specific mortality decreased (P = 0.002, 0.6‰ to 0.41‰), with most of the decrease attributed to trisomy 13/18 and multiple anomalies.

CONCLUSION

Reduction of neonatal mortality in developed regions may heavily rely on improved quality of perinatal and neonatal care among extremely preterm infants.

A scoping review of parental values during prenatal decisions about treatment options after extremely premature birth

AIM

To describe what is known in the literature about parental perspectives in making prenatal decisions regarding treatment after birth at the limit of viability, as a better understanding of parental values can help professionals support parents as they decide.

METHODS

PubMed, Cochrane, Embase, CINAHL, PsycINFO and Web of Science were searched to identify relevant literature from 1 January 2010 to 22 April 2022 on parental decision making. Data were extracted from selected studies and organised into themes. The final themes were formed through collaboration with the parents of a premature infant born at 24 weeks.

RESULTS

Of the 15,159 papers examined, 17 were included. Parental perspectives were described in terms of long-term outcomes for the infant, survival, protection against the burden of neonatal treatment, long-term impact on the family, religion and spiritual beliefs, to do everything possible, hope, sense of responsibility, wanting the best, doing what is right, giving a chance and the influence of experience.

CONCLUSION

The extracted parental perspectives show the complexity of these decisions. Some perspectives were clear, but others were multi-interpretable. Increasing the understanding of common parental perspectives can help improve shared prenatal decisions and lead to further improvement and personalisation of the process.

Associations between unit workloads and outcomes of first extubation attempts in extremely premature infants below a gestational age of 26 weeks

Objective

The objective was to explore whether high workloads in neonatal intensive care units were associated with short-term respiratory outcomes of extremely premature (EP) infants born <26 weeks of gestational age.

Methods

This was a population-based study using data from the Norwegian Neonatal Network supplemented by data extracted from the medical records of EP infants <26 weeks GA born from 2013 to 2018. To describe the unit workloads, measurements of daily patient volume and unit acuity at each NICU were used. The effect of weekend and summer holiday was also explored.

Results

We analyzed 316 first planned extubation attempts. There were no associations between unit workloads and the duration of mechanical ventilation until each infant's first extubation or the outcomes of these attempts. Additionally, there were no weekend or summer holiday effects on the outcomes explored. Workloads did not affect the causes of reintubation for infants who failed their first extubation attempt.

Conclusion

Our finding that there was no association between the organizational factors explored and short-term respiratory outcomes can be interpreted as indicating resilience in Norwegian neonatal intensive care units.

Identifying neonatal intensive care (NICU) admissions using administrative claims data

BACKGROUND

To define a method for identifying neonatal intensive care unit (NICU) admissions using administrative claims data.

METHODS

This was a retrospective cohort study using claims from Optum's de-identified Clinformatics® Data Mart Database (CDM) from 2016 -2020. We developed a definition to identify NICU admissions using a list of codes from the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPT), and revenue codes frequently associated with NICU admissions. We compared agreement between codes using Kappa statistics and calculated positive predictive values (PPV) and 95% confidence intervals (CI).

RESULTS

On average, revenue codes (3.3%) alone identified more NICU hospitalizations compared to CPT codes alone (1.5%), whereas the use of CPT and revenue (8.9%) and CPT or revenue codes (13.7%) captured the most NICU hospitalizations, which aligns with rates of preterm birth. Gestational age alone (4.2%) and birthweight codes alone (2.0%) identified the least number of potential NICU hospitalizations. Setting CPT codes as the standard and revenue codes as the "test,", revenue codes resulted in identifying 86% of NICU admissions (sensitivity) and 97% of non-NICU admissions (specificity).

CONCLUSIONS

Using administrative data, we developed a robust definition for identifying neonatal admissions. The identified definition of NICU codes is easily adaptable, repeatable, and flexible for use in other datasets.

The clinical burden of extremely preterm birth in a large medical records database in the United States: complications, medication use, and healthcare resource utilization

INTRODUCTION

Approximately 5% of global preterm births are extremely premature (EP), defined as occurring at less than 28 weeks gestational age. Advances in care have led to an increase in the survival of EP infants during the neonatal period. However, EP infants have a higher risk of developing complications such as bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). BPD and other respiratory morbidities are particularly prevalent among this population. To understand the healthcare resource utilization (HRU) of EP infants in the United States, the clinical and economic burden of extreme prematurity was examined in this retrospective study of data extracted from electronic medical records in the Kaiser Permanente Northern California (KPNC) health system.

METHODS

The analysis included data from EP infants live-born between January 1997 and December 2016, and focused on complications and HRU up to 3 years corrected age (CA), covering the period up to December 2018. Stillbirths, infants born at <22 weeks gestational age, and infants with major congenital malformations were excluded. Complications of interest (BPD, IVH, and ROP) and medication use were compared by age group (≤1 year, >1 year and ≤2 years, and >2 years and ≤3 years CA). Analysis of HRU included hospital readmissions, ambulatory visits, and emergency room (ER) visits.

RESULTS

A total of 2154 EP births (0.32% of total live births and 4.0% of preterm births that met the inclusion/exclusion criteria) were analyzed. The prevalence of EP birth showed a declining trend over time. ROP was the most commonly recorded complication during the birth hospitalization (37.1% any stage; 2.9% Stages 3 and 4). BPD was recorded in 34.3% of EP infants. IVH (any grade) was recorded in 22.7% of EP infants (6.4% Grades III and IV). A majority (78.7%) of EP infants were diagnosed with at least one respiratory condition during the first year CA, the most common being pneumonia (68.9%); the prevalence of respiratory conditions decreased over the second and third years CA. During the first 3 years CA, the most common medications prescribed to children born EP were inhaled bronchodilators (approximately 30% of children); at least 15% of children received systemic corticosteroids and inhaled steroids during this period. During the first 3 years CA, at least one hospital readmission was recorded for 16.4% of children born EP; 57.1% of these readmissions were related to respiratory conditions. At least one ER visit was recorded for 33.8% of children born EP, for which 53.1% were due to a respiratory condition. Ambulatory visits were recorded for 54.2% of EP children, for which 82.9% were due to a respiratory condition.

CONCLUSIONS

The short- and long-term clinical burden of EP birth was high. The onset of BPD, IVH, and ROP was common during the birth hospitalization for EP infants. Medication use, hospital readmission, and clinic visits (ER and ambulatory) occurred frequently in these children during the first 3 years CA, and were commonly due to respiratory conditions. Strategies prioritizing the reduction of risk and severity of respiratory conditions may alleviate the clinical burden of EP birth over the long term.

Postponed Withholding: Balanced Decision-Making at the Margins of Viability

Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.

Two-year motor outcomes associated with the dose of NICU based physical therapy: The Noppi RCT

BACKGROUND

Interventions involving both the parent and the preterm infant have demonstrated lasting effects on cognitive outcomes, but motor effects are less salient. It remains unclear when to commence early intervention and if dosages have impact on motor outcomes.

AIMS

To examine the effect on motor performance at 24-months corrected age following a parent-administered intervention performed with infants born preterm in the NICU. Intervention dosing and longitudinal motor performance were also analyzed.

STUDY DESIGN

Single-blinded randomized multicenter clinical trial.

SUBJECTS

153 infants born, gestational age ≤ 32 weeks at birth, were randomized into intervention or control group.

OUTCOME MEASURES

Infant Motor Performance Screening Test, Test of Infant Motor Performance, Peabody Developmental Motor Scales-2.

RESULTS

No significant difference was found between the intervention and the control group assessed with the PDMS-2 at 24-months CA. However, a significant positive association was found between dosing and the Gross Motor and Total Motor PDMS-2 scores. Analysis of longitudinal motor performance showed a decreasing motor performance between 6- and 24-months corrected age in both groups.

CONCLUSIONS

There was no difference in motor performance between groups at 24-months corrected age. However, increased intervention dosage was positively associated with improved motor outcome.

Patient Decisions Regarding Fetal Monitoring in the Periviable Period and Perinatal and Maternal Outcomes

OBJECTIVE

Management of delivery at periviable gestation requires complex counseling and decision making, including difficult choices about monitoring and potential cesarean delivery (CD) for fetal benefit. Our objective was to characterize decisions that patients make regarding fetal monitoring and potential CD for fetal benefit when delivering in the periviable period, and associations with perinatal and obstetric outcomes. We hypothesize that a significant number of patients forgo monitoring and potential CD for fetal benefit in the periviable period when offered the opportunity to do so.

STUDY DESIGN

Retrospective cohort study of nonanomalous singleton pregnancies delivering between 23^0/7 and 25^6/7 weeks at a tertiary care center from 2015 to 2020 as based on our institutional clinical practice. Since 2015, these patients are offered the ability to accept or decline fetal monitoring, potential CD for fetal benefit, and active resuscitation of a liveborn neonate. The frequency of patients desiring potential CD for fetal benefit was identified, and associations with CD and intrapartum demise were analyzed.

RESULTS

Fifty subjects were included. Seventy-eight percent (n = 39) desired monitoring and potential CD for fetal benefit, and 84% (n = 42) desired resuscitation if the neonate was born alive. This varied by gestational age: 55% (6/11) of patients delivering between 23^0/7 and 23^6/7 weeks desired fetal monitoring and potential CD for fetal benefit, while 90% (19/21) of patients delivering between 25^0/7 and 25^6/7 weeks desired fetal monitoring and potential CD for fetal benefit (p = 0.02). Sixty-nine percent of pregnancies in which potential CD for fetal benefit was desired resulted in CD (27/39), of which 85% were classical (23/27). Intrapartum fetal demise occurred in 45% (5/11) of pregnancies in which monitoring was not performed.

CONCLUSION

While a majority of patients delivering between 23^0/7 and 25^6/7 weeks desired monitoring and potential CD for fetal benefit, this varied significantly by gestational age. The decision to perform monitoring and potential CD for fetal benefit was associated with a high frequency of CD, while the decision to forgo monitoring was associated with high frequency of intrapartum demise.

KEY POINTS

· Patients desires vary in the setting of periviable delivery.. · Periviable monitoring is associated with cesarean delivery.. · Forgoing monitoring is associated with intrapartum demise..

The administration of a pre-digested fat-enriched formula prevents necrotising enterocolitis-induced lung injury in mice

Necrotising enterocolitis (NEC) is a devastating gastrointestinal disease of prematurity that typically develops after the administration of infant formula, suggesting a link between nutritional components and disease development. One of the most significant complications that develops in patients with NEC is severe lung injury. We have previously shown that the administration of a nutritional formula that is enriched in pre-digested Triacylglyceride that do not require lipase action can significantly reduce the severity of NEC in a mouse model. We now hypothesise that this 'pre-digested fat (PDF) system' may reduce NEC-associated lung injury. In support of this hypothesis, we now show that rearing newborn mice on a nutritional formula based on the 'PDF system' promotes lung development, as evidenced by increased tight junctions and surfactant protein expression. Mice that were administered this 'PDF system' were significantly less vulnerable to the development of NEC-induced lung inflammation, and the administration of the 'PDF system' conferred lung protection. In seeking to define the mechanisms involved, the administration of the 'PDF system' significantly enhanced lung maturation and reduced the production of reactive oxygen species (ROS). These findings suggest that the PDF system protects the development of NEC-induced lung injury through effects on lung maturation and reduced ROS in the lung and also increases lung maturation in non-NEC mice.

Two-year neurodevelopmental outcome in children born extremely preterm: the EPI-DAF study

OBJECTIVE

In 2010, the Dutch practice regarding initiation of active treatment in extremely preterm infants was lowered from 25 completed weeks' to 24 completed weeks' gestation. The nationwide Extremely Preterm Infants - Dutch Analysis on Follow-up Study was set up to provide up-to-date data on neurodevelopmental outcome at 2 years' corrected age (CA) after this guideline change. Design: National cohort study.

PATIENTS

All live born infants between 24^0/7 weeks' and 26^6/7 weeks' gestational age who were 2 years' CA in 2018-2020.

MAIN OUTCOME MEASURE

Impairment at 2 years' CA, based on cognitive score (Bayley-III-NL), neurological examination and neurosensory function.

RESULTS

651 of 991 live born infants (66%) survived to 2 years' CA, with data available for 554 (85%). Overall, 62% had no impairment, 29% mild impairment and 9% moderate-to-severe impairment (further defined as neurodevelopmental impairment, NDI). The percentage of survivors with NDI was comparable for infants born at 24 weeks', 25 weeks' and 26 weeks' gestation. After multivariable analysis, severe brain injury and low maternal education were associated with higher odds on NDI. NDI-free survival was 48%, 67% and 75% in neonatal intensive care unit (NICU)-admitted infants at 24, 25 and 26 weeks' gestation, respectively.

CONCLUSIONS

Lowering the threshold has not been accompanied by a large increase in moderate-to-severely impaired infants. Among live-born and NICU-admitted infants, an increase in NDI-free survival was observed from 24 weeks' to 26 weeks' gestation. This description of a national cohort with high follow-up rates gives an accurate description of the range of outcomes that may occur after extremely preterm birth.

Prevalence of Preterm Births and Complications of Prematurity: A Comparison Between First Year of COVID-19 Pandemic and the Previous Year

Background: COVID-19 pandemic imposed significant challenges on the health systems. COVID-19 management policies such as lockdown have made access to the health centers difficult. Pregnant women are a high-risk group whose pregnancy outcomes may be affected by COVID-19 pandemic. So, it is necessary to determine changes in the prevalence of preterm births and complications of prematurity during the pandemic. Objectives: This study aimed to determine the prevalence of preterm births and complications of prematurity during the first year of COVID-19 pandemic compared with the previous year. Methods: In this cross-sectional study, we included all live births born between March 2019 to March 2021 in Mahdieh hospital, Tehran, Iran. We reviewed medical records to extract the prevalence of preterm births and prematurity complications. Then, the prevalence of preterm births and prematurity complications during COVID-19 pandemic compared with the previous year. We used Chi-square test to analyze categorical variables. Results: A total of 10,830 live births were included in this study. During COVID-19 pandemic, the prevalence of moderate or late prematurity had a 4.64% reduction (P < 0.001), and the prevalence of term birth increased by 5.37% (P < 0.001) compared with the previous year. The prevalence of respiratory distress syndrome (RDS) decreased significantly during COVID-19 pandemic compared with the previous year (23.64% vs. 26.56%, P < 0.001). The prevalence of retinopathy of prematurity (ROP) significantly increased during COVID-19 pandemic compared with the previous year (3.97% vs. 2.28%, P < 0.001). Additionally, sepsis was significantly more prevalent during COVID-19 pandemic compared with the previous year (6.84% vs. 1.23%, P < 0.001). Moreover, intraventricular hemorrhage (IVH) significantly increased during COVID-19 pandemic in comparison to the previous year (1.10% vs. 0.08%, P < 0.001). Conclusions: The prevalence of preterm birth decreased during COVID-19 lockdown. Also, major complications of prematurity such as RDS, ROP, sepsis, and IVH may be affected by COVID-19 lockdown.

Changes Overtime in Perinatal Management and Outcomes of Extremely Preterm Infants in One Tertiary Care Romanian Center

Background and Objectives: Extremely preterm infants were at increased risk of mortality and morbidity. The purpose of this study was to: (1) examine changes over time in perinatal management, mortality, and major neonatal morbidities among infants born at 25⁰–28⁶ weeks’ gestational age and cared for at one Romanian tertiary care unit and (2) compare the differences with available international data. Material and Methods: This study consisted of infants born at 25⁰–28⁶ weeks in one tertiary neonatal academic center in Romania during two 4-year periods (2007–2010 and 2015–2018). Major morbidities were defined as any of the following: severe intraventricular hemorrhage (IVH), severe retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), and bronchopulmonary dysplasia (BPD). Adjusted logistic regression models examined the association between the mortality and morbidity outcome and the study period. Results: The two cohorts differed with respect to antenatal antibiotics and rates of cesarean birth but had similar exposure to antenatal steroids and newborn referral to the tertiary care center. In logistic regression analyses, infants in the newer compared to the older cohort had a lower incidence of death (OR: 0.19; 95% CI: 0.11–0.35), a lower incidence of IVH (OR: 0.26; 95% CI: 0.15–0.46), and increased incidence of NEC (OR: 19.37; 95% CI: 2.41–155.11). Conclusions: Changes over time included higher use of antenatal antibiotics and cesarean delivery and no change in antenatal steroids administration. Overall mortality was lower in the newer cohort, especially for infants 25⁰–26⁶ weeks’ gestation, NEC was higher while BPD and ROP were not different.

Hepatic Function in Premature Lambs Supported by the Artificial Placenta and Total Parenteral Nutrition

The artificial placenta (AP) promotes organ development and reduces organ injury in a lamb model of extreme prematurity. This study evaluates hepatic outcomes after AP support with total parenteral nutrition (TPN) administration. Premature lambs (116-121 days estimated gestational age; term = 145) were cannulated for 7 days of AP support. Lambs received TPN with SMOFlipid (n = 7) or Intralipid (n = 5). Liver function and injury were compared between the two groups biochemically and histologically. Groups were compared by ANOVA with Tukey's multiple comparisons or linear-mixed effects models. From baseline to day 7, total bilirubin (Intralipid 2.6 ± 2.3 to 7.9 ± 4.4 mg/dl; SMOFlipid 0.3 ± 0.1 to 5.5 ± 2.3 mg/dl), alanine aminotransferase, and gamma-glutamyl transferase increased in both groups ( p < 0.001 for all). Direct bilirubin (0.3 ± 0.2 to 1.8 ± 1.4 mg/dl; p = 0.006) and AST (27 ± 5 to 309 ± 242 mg/dl; p < 0.001) increased in SMOFlipid group (not measured in Intralipid group). On liver histology, Intralipid showed more cholestasis than SMOFlipid; both groups showed more than tissue controls. The Intralipid group alone showed hepatocyte injury and had more congestion than controls. Lambs supported by the AP with TPN administration maintain normal hepatic function and sustain minimal hepatic injury. SMOFlipid is associated with decreased cholestasis and hepatic injury versus Intralipid.