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Razak A, Johnston E, Stewart A, Clark MAT, Stevens P, Charlton M, Wong F, McDonald C, Hunt RW, Miller S, Malhotra A. Temporal Trends in Severe Brain Injury and Associated Outcomes in Very Preterm Infants. Neonatology 2024:1-10. [PMID: 38471459 DOI: 10.1159/000537801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited. METHODS Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born <32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed. RESULTS Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71). CONCLUSION Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants.
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Affiliation(s)
- Abdul Razak
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Emily Johnston
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Alice Stewart
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Marissa A T Clark
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Penelope Stevens
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Margaret Charlton
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Flora Wong
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - C McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Rod W Hunt
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Cerebral Palsy Alliance Research, Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Atul Malhotra
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
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Christensen R, Chau V, Synnes A, Guo T, Grunau RE, Miller SP. Preterm Neurodevelopmental Trajectories from 18 Months to 4.5 Years. J Pediatr 2023; 258:113401. [PMID: 37019331 DOI: 10.1016/j.jpeds.2023.113401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE To assess the longitudinal trajectory of cognitive, language, and motor outcomes from 18 months to 4.5 years of age in children born very preterm. STUDY DESIGN This was a prospective cohort study of 163 infants born very preterm (born 24-32 weeks of gestation) followed longitudinally and assessed with neurodevelopmental scales and magnetic resonance imaging of the brain. Outcomes at 18 months and 3 years were assessed with the Bayley Scales of Infant and Toddler Development, 3rd Edition, and at 4.5 years with the Wechsler Preschool and Primary Scale of Intelligence-III and the Movement Assessment Battery for Children. Cognitive, language, and motor outcomes were categorized as below-average, average, and above-average, and compared across time. Clinical data were analyzed using ANOVA, χ2 tests, and linear regression. RESULTS Cognitive and language trajectories were stable from 18 months to 4.5 years for all outcome groups. Motor impairment increased over time, with a greater proportion of children having motor deficits at 4.5 years. Children with below-average cognitive and language outcomes at 4.5 years had more clinical risk factors, greater white matter injury, and lower maternal education. Children with severe motor impairment at 4.5 years were born earlier, had more clinical risk factors, and demonstrated greater white matter injury. CONCLUSIONS Children born preterm have stable cognitive and language trajectories, while motor impairment increased at 4.5 years. These results highlight the importance of continued developmental surveillance for children born preterm into preschool age.
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Affiliation(s)
- Rhandi Christensen
- Division of Neurology, Department of Pediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vann Chau
- Division of Neurology, Department of Pediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Ting Guo
- Division of Neurology, Department of Pediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Steven P Miller
- Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada.
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Skelton H, Psaila K, Schmied V, Foster J. Systematic Review of the Effects of Positioning on Nonautonomic Outcomes in Preterm Infants. J Obstet Gynecol Neonatal Nurs 2023; 52:9-20. [PMID: 36309067 DOI: 10.1016/j.jogn.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm infants admitted to the NICU. DATA SOURCES We searched the CINAHL, MEDLINE, Scopus, and Cochrane databases for reports of primary research studies using a three-step strategy. We also searched for gray literature and reviewed the reference lists of retrieved articles. STUDY SELECTION We included reports of quantitative studies published in English from database inception through February 2022 that focused on positioning and nonautonomic outcomes (pain, comfort, skin integrity, behavioral state, and sleep quality and duration) for preterm infants in the NICU. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria. DATA EXTRACTION Two authors independently extracted the data from the full-text articles using a standardized data extraction tool. We synthesized the data narratively because of the different designs and outcome measures among the included studies. DATA SYNTHESIS From a total of 550 records initially screened, we included 17 articles in our review. In the included articles, prone positioning improved sleep quality and duration, whereas supine positioning was associated with increased awakenings and activity. Infants demonstrated fewer self-regulatory behaviors in the prone position compared to supine or side-lying and were less stressed in the prone position. We found minimal evidence on the effect of positioning on skin integrity or pain. CONCLUSION There is limited good-quality evidence on the effect of positioning on nonautonomic outcomes in preterm infants. To inform clinical practice, high-quality randomized controlled trials focused on the positioning of premature infants are warranted.
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Al-Haddad BJS, Bergam B, Johnson A, Kolnik S, Thompson T, Perez KM, Kennedy J, Enquobahrie DA, Juul SE, German K. Effectiveness of a care bundle for primary prevention of intraventricular hemorrhage in high-risk neonates: a Bayesian analysis. J Perinatol 2022:10.1038/s41372-022-01545-9. [PMID: 36309564 DOI: 10.1038/s41372-022-01545-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether an intraventricular hemorrhage (IVH) prevention bundle featuring midline-elevated positioning reduced IVH among high-risk infants. STUDY DESIGN In a retrospective study design, we compared outcomes of infants <1250 grams birth weight or <30 weeks gestation before (N = 205) and after (N = 360) implementation of an IVH prevention bundle, using Bayesian and frequentist logistic regression to determine whether the intervention decreased any grade IVH. RESULTS In both the Bayesian and frequentist analyses, there was no difference in odds of any grade IVH before and after the implementation of the prevention bundle (OR 0.993; 95% Credible Interval 0.751-1.323 and OR 1.23; 95% Confidence Interval 0.818-1.864 respectively). Bias analyses suggested that these results were robust to bias from potential deaths attributable to IVH. CONCLUSION In this retrospective analysis, we found no evidence for a protective effect of an IVH prevention bundle on IVH incidence among high-risk neonates at a level IV NICU.
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Affiliation(s)
- Benjamin J S Al-Haddad
- University of Minnesota Department of Pediatrics, Division of Neonatology, Minneapolis, MN, USA.
| | - Brittany Bergam
- University of Washington School of Medicine, Seattle, WA, USA
| | - Alicia Johnson
- Macalester College, Mathematics, Statistics, and Computer Science, St. Paul, MN, USA
| | - Sarah Kolnik
- University of Washington Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Taylor Thompson
- University of Washington School of Medicine, Seattle, WA, USA
| | - Krystle M Perez
- University of Washington Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Jacob Kennedy
- University of Washington School of Medicine, Seattle, WA, USA
| | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Sandra E Juul
- University of Washington Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Kendell German
- University of Washington Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
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Benlamri A, Murthy P, Zein H, Thomas S, Scott JN, Abou Mehrem A, Esser MJ, Lodha A, Noort J, Tang S, Metcalfe C, Kowal D, Irvine L, Scotland J, Leijser LM, Mohammad K. Neuroprotection care bundle implementation is associated with improved long-term neurodevelopmental outcomes in extremely premature infants. J Perinatol 2022; 42:1380-1384. [PMID: 35831577 DOI: 10.1038/s41372-022-01443-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/08/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature. STUDY DESIGN An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation. RESULTS Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17-0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12-0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12-0.94; P = 0.039), any motor, language, or cognitive composite score <70 (aOR, 0.48; 95% CI: 0.26-0.90; P = 0.021). CONCLUSION Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.
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Affiliation(s)
- Amina Benlamri
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Prashanth Murthy
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Hussein Zein
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Sumesh Thomas
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - James N Scott
- Department of Diagnostic Imaging, Division of Neuroradiology, University of Calgary, Calgary, AB, Canada
| | - Ayman Abou Mehrem
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Michael J Esser
- Department of Pediatrics, Section of Neurology, University of Calgary, Calgary, AB, Canada
| | - Abhay Lodha
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Jennessa Noort
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Selphee Tang
- Department of Obstetrics and Gynecology, Alberta Health Services, Calgary, AB, Canada
| | - Cathy Metcalfe
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Derek Kowal
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Leigh Irvine
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Jillian Scotland
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Lara M Leijser
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada.
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Lai GY, Shlobin N, Garcia RM, Wescott A, Kulkarni AV, Drake J, Dizon ML, Lam SK. Global incidence proportion of intraventricular haemorrhage of prematurity: a meta-analysis of studies published 2010-2020. Arch Dis Child Fetal Neonatal Ed 2022; 107:513-519. [PMID: 34930831 DOI: 10.1136/archdischild-2021-322634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/25/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate differences and calculate pooled incidence of any intraventricular haemorrhage (IVH), severe IVH (Grade III/IV, sIVH) and ventriculoperitoneal shunt (VPS) placement in preterm infants across geographical, health and economic regions stratified by gestational age (GA). DESIGN MEDLINE, Embase, CINAHL and Web of Science were searched between 2010 and 2020. Studies reporting rates of preterm infants with any IVH, sIVH and VPS by GA subgroup were included. Meta-regression was performed to determine subgroup differences between study designs and across United Nations geographical regions, WHO mortality strata and World Bank lending regions. Incidence of any IVH, sIVH and VPS by GA subgroups<25, <28, 28-31, 32-33 and 34-36 weeks were calculated using random-effects meta-analysis. RESULTS Of 6273 publications, 97 met inclusion criteria. Incidence of any IVH (37 studies 87 993 patients) was: 44.7% (95% CI 40.9% to 48.5%) for GA <25 weeks, 34.3% (95% CI 31.2% to 37.6%) for GA <28 weeks, 17.4% (95% CI 13.8% to 21.6%) for GA 28-31 weeks, 11.3% (95% CI 7.3% to 17.0%) for GA32-33 weeks and 4.9% (95% CI 1.4% to 15.2%) for GA 34-36 weeks. Incidence of sIVH (49 studies 328 562 patients) was 23.7% (95% CI 20.9% to 26.7%) for GA <25 weeks, 15.0% (95% CI 13.1% to 17.2%) for GA <28 weeks, 4.6% (95% CI 3.5% to 6.1%) for GA 28-31 weeks, 3.3% (95% CI 2.1% to 5.1%) for GA 32-33 weeks and 1.8% (95% CI 1.2% to 2.8%) for GA 34-36 weeks. Europe had lower reported incidence of any IVH and sIVH relative to North America (p<0.05). Proportion of VPS across all GA groups was 8.4% (95% CI 4.7% to 14.7%) for any IVH and 17.2% (95% CI 12.2% to 26.2%) for sIVH. Heterogeneity was high (I2 >90%) but 64%-85% of the variance was explained by GA and study inclusion criteria. CONCLUSIONS We report the first pooled estimates of IVH of prematurity by GA subgroup. There was high heterogeneity across studies suggesting a need for standardised incidence reporting guidelines.
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Affiliation(s)
- Grace Y Lai
- Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
| | - Nathan Shlobin
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Roxanna M Garcia
- Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
| | - Annie Wescott
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Abhaya V Kulkarni
- University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Drake
- University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maria Lv Dizon
- Neonatology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Sandi K Lam
- Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA.,Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Optimizing Care for the Preterm Infant. CHILDREN 2022; 9:children9060778. [PMID: 35740715 PMCID: PMC9221890 DOI: 10.3390/children9060778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/07/2022] [Indexed: 12/17/2022]
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Impact of a “Brain Protection Bundle” in Reducing Severe Intraventricular Hemorrhage in Preterm Infants <30 Weeks GA: A Retrospective Single Centre Study. CHILDREN 2021; 8:children8110983. [PMID: 34828696 PMCID: PMC8624779 DOI: 10.3390/children8110983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022]
Abstract
Background: despite advances in perinatal care, periventricular/intraventricular hemorrhage (IVH) continues to remain high in neonatal intensive care units (NICUs) worldwide. Studies have demonstrated the benefits of implementing interventions during the antenatal period, stabilization after birth (golden hour management) and postnatally in the first 72 h to reduce the incidence of IVH. Objective: to compare the incidence of severe intraventricular hemorrhage (IVH ≥ Grade III) before and after implementation of a “brain protection bundle” in preterm infants <30 weeks GA. Study design: a pre- and post-implementation retrospective cohort study to compare the incidence of severe IVH following execution of a “brain protection bundle for the first 72 h from 2015 to 2018. Demographics, management practices at birth and in the NICU, cranial ultrasound results and short-term morbidities were compared. Results: a total of 189 and 215 infants were included in the pre- and post-implementation phase, respectively. No difference in the incidence of severe IVH (6.9% vs. 9.8%, p = 0.37) was observed on the first cranial scan performed after 72 h of age. Conclusion: the implementation of a “brain protection bundle” was not effective in reducing the incidence of severe IVH within the first 72 h of life in our centre.
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