D Field

Neurodevelopmental outcomes following late and moderate prematurity: a population-based cohort study

Objective There is a paucity of data relating to neurodevelopmental outcomes in infants born late and moderately preterm (LMPT; 32+0–36+6 weeks). This paper present the results of a prospective, population-based study of 2-year outcomes following LMPT birth. Design 1130 LMPT and 1255 term-born children were recruited at birth. At 2 years corrected age, parents completed a questionnaire to assess neurosensory (vision, hearing, motor) impairments and the Parent Report of Childrens Abilities-Revised to identify cognitive impairment. Relative risks for adverse outcomes were adjusted for sex, socio-economic status and small for gestational age, and weighted to account for over-sampling of term-born multiples. Risk factors for cognitive impairment were explored using multivariable analyses. Results Parents of 638 (57%) LMPT infants and 765 (62%) controls completed questionnaires. Among LMPT infants, 1.6% had neurosensory impairment compared with 0.3% of controls (RR 4.89, 95% CI 1.07 to 22.25). Cognitive impairments were the most common adverse outcome: LMPT 6.3%; controls 2.4% (RR 2.09, 95% CI 1.19 to 3.64). LMPT infants were at twice the risk for neurodevelopmental disability (RR 2.19, 95% CI 1.27 to 3.75). Independent risk factors for cognitive impairment in LMPT infants were male sex, socio-economic disadvantage, non-white ethnicity, preeclampsia and not receiving breast milk at discharge. Conclusions Compared with term-born peers, LMPT infants are at double the risk for neurodevelopmental disability at 2u2005years of age, with the majority of impairments observed in the cognitive domain. Male sex, socio-economic disadvantage and preeclampsia are independent predictors of low cognitive scores following LMPT birth.

A confidential enquiry into cases of neonatal encephalopathy

Objectives: To assess the quality of care and timing of possible asphyxial events for infants with neonatal encephalopathy; to compare the quality of care findings with those relating to the deaths from the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI); and to assess whether the confidential enquiry method is a useful clinical governance tool for investigating morbidity. Design: Independent, anonymised, multidisciplinary case reviews. Setting: Trent Health Region, UK. Patients: All cases of grade II and III neonatal encephalopathy born in 1997, excluding those due to congenital malformation, inborn error of metabolism, or infection. All CESDI deaths thought to have resulted from intrapartum asphyxia in 1996 and 1997. Main measures: Quality of care provided, timing of possible asphyxial episodes, and the source and timing of episodes of suboptimal care. Results: Significant or major episodes of suboptimal care were identified for 64% of the encephalopathy cases and 75% of the deaths. An average of 2.8 and 2.5 episodes of suboptimal care were identified for the deaths and encephalopathy cases respectively. Over 90% of episodes involved the care provided by health professionals. Results were fed directly back to the units concerned on request and changes in practice have been reported. Conclusions: The findings were very similar for the encephalopathy cases and the deaths. We have demonstrated that with minor adaptations the CESDI process can be applied to serious cases of morbidity. However, explicit quality standards, control data, and a more formal mechanism for the implementation of findings would strengthen the confidential enquiry process as part of clinical governance.

Antenatal umbilical Doppler abnormalities: an independent risk factor for early onset neonatal necrotizing enterocolitis in premature infants

Background: Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) emergency seen in neonatal units. Many factors have been considered as potentially important aetiologically, including gut ischaemia, sepsis and feeding. However, evidence remains equivocal.

Extreme prematurity in the UK and Denmark: population differences in viability

Background: Previous studies comparing different models of neonatal intensive care have generally not been population based. The objective of this study was to compare the perinatal services of two total populations. Methods: Observational study based on two geographically defined populations: the whole of Demark (some centralisation of neonatal intensive care but most delivered locally by small perinatal centres—48 in total) and the Trent Health Region of the UK (no formal centralisation however deliveries almost all focussed on 16 major hospitals with > 90% of the intensive care provided by 13 hospitals). Information was recorded about the course of every liveborn infant < 28 weeks gestation and or < 1000g birth weight and ≥ 21 weeks gestation in 1994 and 1995. Results: Despite having a smaller population the number of liveborn children meeting the study criteria was significantly higher in Trent (Demark 461 (3.3 per 1000 births, 95% confidence interval (CI) 3.0 to 3.6); Trent 572 (4.9 per 1000 births, 95% CI 4.5 to 5.3)). In Denmark 91.1% of these infants were admitted for intensive care and 85.5% in Trent. Despite significantly more Trent infants being exposed to antenatal steroids their outcome was worse (median Clinical Risk Index for Babies (CRIB) score 7 v 4; proportion receiving ventilation 87.6% v 40.0% ; survival to discharge (uncorrected for disease severity) 42.3% v 35.0%). Conclusion: The population characteristics of Trent seemed to produce a higher prematurity rate compared to Denmark. These infants as a group appeared sicker and, despite more intensive care delivered by a more specialised service, outcomes were worse.

Impact of service changes on neonatal transfer patterns over 10 years.

Introduction: Many changes have been made to the staffing and organisation of neonatal care in the UK in the past 10 years. This study assessed the extent to which these changes had affected the transfer of babies between different parts of the service. Methods: Data from the Trent Neonatal Survey, an ongoing study of neonatal intensive care activity in the former Trent Health Region of the UK, were used to evaluate neonatal inter-hospital transfers over a 10-year period, from 1 January 1995 to 31 December 2004. The number of transfers and the types of transfer were analysed and trends in gestation and disease severity over the study period were assessed. Rates of “inappropriate transfer” were also identified. Results: 8105 babies were transferred over the period; 2294 babies underwent urgent postnatal transfer and this equates to approximately two such transfers every three days. The maximum number of journeys by any one baby was eight. Intensive care activity rose during the 10 years but the number of inappropriate transfers remained persistently high. Conclusions: Organisational changes in neonatal care during the 10-year period have been insufficient to deal with the rising demand, as reflected by the persistently high rate of inappropriate transfers.

4.2 Infant neurodevelopmental outcomes following late and moderately preterm birth

Introduction Very preterm (<32 weeks) infants are at high risk for neurodevelopmental sequelae. Less is known about outcomes following birth at late and moderately preterm gestations (LMPT; 32–36 weeks). Methods 1130 LMPT and 1255 term-born (≥37 weeks) babies were recruited at birth to the Late and Moderately Preterm Birth Study (LAMBS). At 2-years, parents completed the Parent Report of Children’s Abilities-Revised (PARCA-R) to assess cognitive impairment and a questionnaire to assess neurosensory (vision, hearing, motor) impairment. Neurodevelopmental disability was defined where the child had a moderate/severe impairment in at least one domain. Results Parents of 651 (59%) LMPT and 771 (62%) term-born children responded at 2 years. Overall, 1.6% of LMPT infants and 0.3% of controls had a neurosensory impairment (RR 6.00; 95%CI 1.32, 27.28). Rates of cognitive impairment were higher in general (LMPT 15.6%; Term 10.0%) and LMPT infants at increased risk of cognitive delay (RR 1.56; 95% CI 1.18, 2.06). Overall, 16% of LMPT and 10% of term-born infants had neurodevelopmental disability (RR 1.57; 95% CI 1.19, 2.07). Male sex, non-white ethnicity, lower socio-economic status, pre-pregnancy hypertension, preeclampsia and recreational drug use were risk factors for neurodevelopmental disability among LMPT children. Conclusions Children born LMPT are at increased risk for neurodevelopmental disability; although the risk was largest for neurosensory impairment, the number of children affected by cognitive problems was far greater. Preeclampsia and antenatal recreational drug use are markers of poor outcome and may be potentially modifiable factors for reducing adverse outcomes following LMPT birth.

The challenges of interventional trials in fetal therapy

Fetal therapy is an advancing specialty but the assessment of effectiveness for many therapies has been limited to observational data1 ,2 with randomised controlled trials (RCTs) employed with varying success.3 ,4 More recently systematic reviews have been used to assess the quality and summarise the outcomes of this evidence.5 ,6nnOur experiences from one such trial (the PLUTO study4) highlight the difficulties of such research. Congenital lower urinary tract obstruction (LUTO) may be identified using prenatal ultrasound and is associated with high mortality and morbidity (perinatal and childhood), due to pulmonary hypoplasia and chronic renal impairment.7–9 Ultrasound-directed, in utero, vesicoamniotic shunting (VAS) bypasses the congenital urethral obstruction with the aim of improving fetal outcome.1 ,2 ,10 Counselling parents faced with the difficult and distressing news that their baby has a significant problem antenatally is complex and compounded by uncertainties around the effectiveness of the often limited number of options. Providing clinicians with high quality evidence on which to base their counselling affords parents the opportunity to make informed choices and can help to remove some of the anxiety. The PLUTO study aimed to determine the effectiveness, cost-effectiveness and patient acceptability of VAS for fetal LUTO, compared with conservative management. It comprised a multicentre, international RCT and a non-randomised cohort of pregnancies with LUTO (not recruited to the RCT due to patient or clinician preference).4 All fetal medicine centres within England, Scotland and The Republic of Ireland agreed to take part in the study along with the Dutch Obstetric Research Consortium. Expert opinions on the relative benefits of VAS and conservative management were elicited from fetal medicine specialists, paediatric nephrologists and paediatric urologists for use in a Bayesian analysis.11 The planned sample size of the trial was 150, …

PPO.16 Understanding the impact of socioeconomic risk factors on late and moderate preterm birth: A population-based cohort study

Introduction Very preterm birth rates (<32 weeks) have been shown to rise with increasing socioeconomic deprivation but less is known about the impact of socioeconomic deprivation on birth at late and moderate preterm gestations (LMPT; 32–36 weeks). Methods A geographical population-based birth cohort study of 938 LMPT and 939 term-born (≥37 weeks) singleton babies. Socio-demographic, economic, lifestyle and stress factors were collected in a maternal interview after birth. Maternal education level was explored as a risk factor for late and moderate preterm birth, using multivariable Binomial regression analyses. Further models assessed whether demographic, lifestyle and economic factors explained any of this variation. Results The odds of delivering a LMPT infant increased with decreasing levels of education (OR 1.60 (1.23 to 2.09) for degree level education compared to no qualifications P = 0.002). This changed little after adjusting for maternal age and ethnicity. Three key economic and lifestyle risk factors explained this variation with education levels: access to a car (OR 1.30 (1.03 to 1.66); smoking during pregnancy (OR 1.28 (1.01 to 1.63) and low levels of fruit and vegetable consumption (OR 1.26 (0.99 to 1.62)) Conclusions Mothers with low levels of education were at greatest risk of delivering LMPT. Lifestyle behaviours (smoking during pregnancy and poor diet) and access to a car which may limit access to health care services appeared to explain this differential. These findings highlight that socioeconomic risk factors continue to impact on prematurity up until 36 weeks gestation.

5.9 Behavioural, social and emotional outcomes following late and moderately preterm birth

Introduction Very preterm (<32 weeks) infants are at high risk for behaviour problems. Relatively little is known about behavioural outcomes following birth at late and moderately preterm gestations (LMPT; 32–36 weeks). Methods 1130 LMPT and 1255 term-born (≥37 weeks) babies were recruited to the Late and Moderate Preterm Birth Study (LAMBS). At 2-years, parents completed the Brief Infant and Toddler Social Emotional Assessment (BITSEA) questionnaire to screen for socio-emotional and behaviour problems, and the Modified-Checklist for Autism in Toddlers (M-CHAT) questionnaire to screen for autistic features. Parents of children with positive M-CHAT screens completed a follow-up interview to improve specificity of screening over use of the questionnaire alone. Results Parents of 651 (59%) LMPT and 771 (62%) term-born infants responded at 2-years. Overall, 38% of LMPT and 30% of term-born children had positive BITSEA screens (RR 1.23, 95%CI 1.06 to 1.42); however, LMPT children were at increased risk for delayed social-emotional competence (RR 1.42, 1.17 to 1.73) but not behaviour problems (RR 1.15, 0.93 to 1.42). LMPT children had significantly higher risk of positive M-CHAT screens (15% vs. 9%; 1.58, 1.18 to 2.11). After follow-up, LMPT children remained at significantly higher risk for autistic features (2.4% vs. 0.5%; 4.52, 1.51 to 13.56). Conclusions LMPT children are at increased risk for social-emotional but not behaviour problems at 2 years of age. This is the first study to show an increased risk for autistic features in LMPT infants. Longer term follow-up is needed to determine how these behavioural sequelae evolve throughout childhood.

PC.10 Neonatal outcomes of singleton and multiple births at 32–36 Weeks of Gestation: Results from the Late And Moderately preterm Birth Study (LAMBS)

Background There is a paucity of recent, prospectively collected data comparing outcomes between singletons and twins born at late and moderately preterm (32–36 weeks; LMPT) gestations. Methods In a prospective, geographically defined, population-based study of babies born at 32–36 weeks gestation we compared neonatal outcomes in normally formed singletons and multiples. Results We recruited 200 LMPT and 274 term-born multiples, together with 907 live-born LMPT singletons. Within the LMPT group a greater proportion of singletons than multiples had jaundice (9.3% v 6.5%; P = 0.049) and hypoglycaemia (21.9% v 15.5%; P = 0.055). Other outcomes were similar between groups. Among multiples, those born LMPT were more likely to require resuscitation at birth (20.5% v 11.3%; P = 0.007), neonatal unit admission (43.0% v 8.4%; P < 0.001) and respiratory support (28.0% v 0.7%; P < 0.001). There were higher rates of jaundice (15.5% v 1.5%; P > 0.001) and hypothermia (6.5% v 2.6%; P = 0.042) in LMPT multiples and breast-feeding at discharge was lower (53.5% v 64.6%; P = 0.018) compared with term-born multiples. Conclusions Our results suggest that many neonatal outcomes are similar between singletons and multiples and but some morbidities are reduced in multiples. LMPT multiples have poorer outcomes than their term-born counterparts. Differing maternal health, socioeconomic status, and indications for delivery in singletons and twins are likely to be key influences on neonatal outcome; postnatal management may also be important. Further analysis will explore factors contributing to birth at 32–36 weeks of gestation and neonatal outcomes. Follow-up will be crucial to determine any differences in long-term outcome related to prematurity or plurality.