Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation

The aim of this research is to assess causes and circumstances of deaths in extremely low gestational age neonates (ELGANs) born in Switzerland over a 3-year period | BMJ Open

Design: Population-based, retrospective cohort study.

Setting: All nine level III perinatal centres (neonatal intensive care units (NICUs) and affiliated obstetrical services) in Switzerland.

Patients: ELGANs with a gestational age (GA) <28 weeks who died between 1 July 2012 and 30 June 2015.

Results: A total of 594 deaths were recorded with 280 (47%) stillbirths and 314 (53%) deaths after live birth. Of the latter, 185 (59%) occurred in the delivery room and 129 (41%) following admission to an NICU. Most liveborn infants dying in the delivery room had a GA ≤24 weeks and died following primary non-intervention. In contrast, NICU deaths occurred following unrestricted life support regardless of GA. End-of-life decision-making and redirection of care were based on medical futility and anticipated poor quality of life in 69% and 28% of patients, respectively. Most infants were extubated before death (87%).

Conclusions: In Switzerland, most deaths among infants born at less than 24 weeks of gestation occurred in the delivery room. In contrast, most deaths of ELGANs with a GA ≥24 weeks were observed following unrestricted provisional intensive care, end-of-life decision-making and redirection of care in the NICU regardless of the degree of immaturity.

Full reference: Berger, T.M. et al. (2017) Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation in Switzerland over a 3-year period. BMJ Open. 7:e015179

The Impact of Kangaroo Care on Premature Infant Weight Gain

Evereklian, M. & Posmontier, B. Journal of Pediatric Nursing. Published online: 12 March  2017

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Highlights:

  • Despite its known efficacy, kangaroo care is not practiced in all US hospitals.
  • Without adequate weight gain, preterm infants can experience longer hospital stays.
  • Improved weight gain can reduce hospital readmissions and developmental issues.
  • Kangaroo care is a low-cost modality that can increase preterm infant weight gain.

Read the full abstract here

The Speed of Increasing milk Feeds: RCT Protocol

Abbott, J. et al. BMC Pediatrics. Published: 28 January 2017

Background: In the UK, 1–2% of infants are born very preterm (<32 weeks of gestation) or have very low birth weight (<1500 g). Very preterm infants are initially unable to be fed nutritional volumes of milk and therefore require intravenous nutrition. Milk feeding strategies influence several long and short term health outcomes including growth, survival, infection (associated with intravenous nutrition) and necrotising enterocolitis (NEC); with both infection and NEC being key predictive factors of long term disability.

Currently there is no consistent strategy for feeding preterm infants across the UK. The SIFT trial will test two speeds of increasing milk feeds with the primary aim of determining effects on survival without moderate or severe neurodevelopmental disability at 24 months of age, corrected for prematurity. The trial will also examine many secondary outcomes including infection, NEC, time taken to reach full feeds and growth.

Read the full protocol here

Newborn Individualized Developmental Care and Assessment Program Reduces Length of Stay

Moody, C. et al. Journal of Pediatric Nursing. Published online: 3 December 2016

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Infants born at ≤32 weeks gestation are at risk of developmental delays. Review of the literature indicates NIDCAP improves parental satisfaction, minimizes developmental delays, and decreases length of stay, thus reducing cost of hospitalization.

Highlights:

  • NIDCAP is a proven framework for providing developmentally supportive care in the NICU, and can mitigate risks of prematurity
  • Earlier initiation of NIDCAP led to discharge at a younger post-menstrual age
  • Quality improvement investigations are effective in addressing critical healthcare needs

Read the full abstract here

Impact of a Transition Home Program on Rehospitalization Rates of Preterm Infants

Vohr, B. et al. The Journal of Pediatrics. Published online: 3 November 2016

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Objectives: To evaluate the effects of a transition home program on 90-day rehospitalization rates of preterm (PT) infants born at <37 weeks gestational age implemented over 3 years for infants with Medicaid and private insurance, and to identify the impact of social/environmental and medical risk factors on rehospitalization.

Study design: In this prospective cohort study of 954 early, moderate, and late PT infants, all families received comprehensive transition home services provided by social workers and family resource specialists (trained peers) working with the medical team. Rehospitalization data were obtained from a statewide database and parent reports. Group comparisons were made by insurance type. Regression models were run to identify factors associated with rehospitalization and duration of rehospitalization.

Results: In bivariable analyses, Medicaid was associated with more infants hospitalized, more than 1 hospitalization, and more days of hospitalization. Early PT infants had more rehospitalizations by 90 days than moderate (P = .05) or late PT infants (P = .01). In regression modeling, year 3 of the transition home program vs year 1 was associated with a lower risk for rehospitalization by 90 days (OR, 0.57; 95% CI, 0.36-0.93; P = .03). Medicaid (P = .04), non–English-speaking (P = .02), multiple pregnancies (P = .05), and bronchopulmonary dysplasia (P = .001) were associated with increased risk. Both bronchopulmonary dysplasia and Medicaid were associated with increased days of rehospitalization in adjusted analyses. The major cause of rehospitalization was respiratory illness (61%).

Conclusions: Transition home prevention strategies must be directed at both social/environmental and medical risk factors to decrease the risk of rehospitalization.

Read the abstract here

Effect of Delayed Cord Clamping on Systemic Blood Flow: A Randomized Controlled Trial

Popat, H et al. (2016) The Journal of Pediatrics178. pp. 81–86.e2

Objective: To determine whether delayed cord clamping improves systemic blood flow compared with immediate cord clamping in very preterm infants in the first 24 hours.

Study design: Women delivering at <30 weeks’ gestation at 5 tertiary centers were randomized to receive immediate cord clamping (<10 seconds) or delayed cord clamping (≥60 seconds). Echocardiography and cardiorespiratory data were collected at 3, 9, and 24 hours after birth. The primary outcome was mean lowest superior vena cava (SVC) flow.

Results: Of 266 infants enrolled, 133 were randomized to immediate cord clamping and 133 to delayed cord clamping. The 2 groups were similar at baseline, including mean gestation (immediate cord clamping 28 weeks vs delayed cord clamping 28 weeks) and birth weight (immediate cord clamping 1003 g vs delayed cord clamping 1044 g). There was no significant difference between groups in the primary outcome of mean lowest SVC flow (immediate cord clamping 71.4 mL/kg/min [SD 28.1] vs delayed cord clamping 70.2 mL/kg/min [SD 26.9]; P = .7). For secondary outcomes, hemoglobin increased by 0.9 g/dL at 6 hours in the group with delayed cord clamping (95% CI 3.9, 14.4; P = .0005, adjusted for baseline). The group with delayed cord clamping had lower right ventricular output (−21.9 mL/kg/min, 95% CI −39.0, −4.7; P = .01). Rates of treated hypotension, ductus arteriosus size and shunt direction, and treatment of the ductus arteriosus were similar.

Conclusions: Delayed cord clamping had no effect on systemic blood flow measured as mean lowest SVC flow in the first 24 hours in infants <30 weeks’ gestation.

Read the abstract here

NICE calls for increased use of magnesium sulfate in preterm labour

NICE | Published online: 19 October 2016

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Image source: NICE

The new quality standard highlights the key areas where preterm labour and birth services need to improve.

Studies show the risk of cerebral palsy in babies is significantly lower when women who may give birth early are treated with magnesium sulfate, which can protect developing babies’ brains.

The standard also calls for women who have previously lost a baby mid-trimester or had a previous preterm birth to be offered treatment to prevent the cervix opening early to delay labour and birth.

Professor Gillian Leng, deputy chief executive of NICE, said:

“We know the risks of long-term developmental problems are greater the earlier a baby is born. This quality standard highlights key issues, originally raised in the NICE guideline on Preterm labour and birth, where care needs to improve. For instance the quality standard calls for greater use of magnesium sulfate in women at risk of a preterm birth, which we know has significant potential to reduce disability among babies born preterm.”

The guidance also recommends certain pregnant women are offered maternal corticosteroids, which help with babies’ lung development.

Read the overview here

Read the full guidance here