Marc Beltempo

Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth

Objective To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs). Study design Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow‐up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18‐21 months of age, corrected for prematurity. Results Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology‐II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3‐2.2), death or overall NDI (aOR 1.6, 95% CI 1.2‐2.2), death (aOR 2.1, 95% CI 1.5‐3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1‐3.3). Conclusions The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.

Respiratory Management of Extremely Preterm Infants: An International Survey

Background: There are significant international variations in chronic lung disease rates among very preterm infants yet there is little data on international variations in respiratory strategies. Objective: To evaluate practice variations in the respiratory management of extremely preterm infants born at < 29 weeks’ gestational age (GA) among 10 neonatal networks participating in the International Network for Evaluating Outcomes (iNeo) of Neonates collaboration. Methods: A web-based survey was sent to the representatives of 390 neonatal intensive care units from Australia/New Zealand, Canada, Finland, Illinois (USA), Israel, Japan, Spain, Sweden, Switzerland, and Tuscany (Italy). Responses were based on practices in 2015. Results: Overall, 321 of the 390 units responded (82%). The majority of units within networks (40–92%) mechanically ventilate infants born at 23–24 weeks’ GA on continuous positive airway pressure (CPAP) with 30–39% oxygen in respiratory distress within 48 h after birth, but the proportion of units that offer mechanical ventilation for infants born at 25–26 weeks’ GA at similar settings varied significantly (20–85% of units within networks). The most common respiratory strategy for infants born at 27–28 weeks’ GA on CPAP with 30–39% oxygen with respiratory distress within 48 h after birth used by units also varied significantly among networks: mechanical ventilation (0–60%), CPAP (3–82%), intubation and surfactant administration with immediate extubation (0–75%), and less invasive surfactant administration (0–68%). Conclusions: There are marked variations but also similarities in respiratory management of extremely preterm infants between networks. Further collaboration and exploration is needed to better understand the association of these variations in practice with pulmonary outcomes.

Variations in Oxygen Saturation Targeting, and Retinopathy of Prematurity Screening and Treatment Criteria in Neonatal Intensive Care Units: An International Survey

Background: Rates of retinopathy of prematurity (ROP) and ROP treatment vary between neonatal intensive care units (NICUs). Neonatal care practices, including oxygen saturation (SpO2) targets and criteria for the screening and treatment of ROP, are potential contributing factors to the variations. Objectives: To survey variations in SpO2 targets in 2015 (and whether there had been recent changes) and criteria for ROP screening and treatment across the networks of the International Network for Evaluating Outcomes in Neonates (iNeo). Methods: Online prepiloted questionnaires on treatment practices for preterm infants were sent to the directors of 390 NICUs in 10 collaborating iNeo networks. Nine questions were asked and the results were summarized and compared. Results: Overall, 329/390 (84%) NICUs responded, and a majority (60%) recently made changes in upper and lower SpO2 target limits, with the median set higher than previously by 2–3% in 8 of 10 networks. After the changes, fewer NICUs (15 vs. 28%) set an upper SpO2 target limit > 95% and fewer (3 vs. 5%) a lower limit < 85%. There were variations in ROP screening criteria, and only in the Swedish network did all NICUs follow a single guideline. The initial retinal examination was carried out by an ophthalmologist in all but 6 NICUs, and retinal photography was used in 20% but most commonly as an adjunct to indirect ophthalmoscopy. Conclusions: There is considerable variation in SpO2 targets and ROP screening and treatment criteria, both within networks and between countries.

Association of nursing overtime, nurse staffing and unit occupancy with medical incidents and outcomes of very preterm infants

Objective:To examine the association of nursing overtime, nursing provision and unit occupancy rate with medical incident rates in the neonatal intensive care unit (NICU) and the risk of mortality or major morbidity among very preterm infants.Study design:Single center retrospective cohort study of infants born within 23 to 29 weeks of gestational age or birth weight <1000 g admitted at a 56 bed, level III NICU. Nursing overtime ratios (nursing overtime hours/total nursing hours), nursing provision ratios (nursing hours/recommended nursing hours based on patient dependency categories) and unit occupancy rates were pooled for all shifts during NICU hospitalization of each infant. Log-binomial models assessed their association with the composite outcome (mortality or major morbidity).Results:Of the 257 infants that met the inclusion criteria, 131 (51%) developed the composite outcome. In the adjusted multivariable analyses, high (>3.4%) relative to low nursing overtime ratios (⩽3.4%) were not associated with the composite outcome (relative risk (RR): 0.93; 95% confidence interval (CI): 0.86 to 1.02). High nursing provision ratios (>1) were associated with a lower risk of the composite outcome relative to low ones (⩽1) (RR: 0.81; 95% CI: 0.74 to 0.90). NICU occupancy rates were not associated with the composite outcome (RR: 0.98; 95% CI: 0.89 to 1.07, high (>100%) vs low (⩽100%)). Days with high nursing provision ratios (>1) were also associated with lower risk of having medical incidents (RR: 0.91; 95% CI: 0.82 to 0.99).Conclusion:High nursing provision ratio during NICU hospitalization is associated with a lower risk of a composite adverse outcome in very preterm infants.

SNAP-II for prediction of mortality and morbidity in extremely preterm infants

Abstract Objective: To determine the specific Score of Neonatal Acute Physiology (SNAP-II) cut-off scores associated with outcomes in extremely preterm infants, and to examine its contribution to predictive models that include nonmodifiable birth predictors. Study design: Retrospective observational study of 9240 infants born at 22–28 weeks’ gestation and admitted to the Canadian Neonatal Network from 2010 to 2015. Outcomes included early and hospital mortality, composite of mortality/morbidity and individual morbidities. The SNAP-II cut-off to predict each outcome was determined using the Youden index. Additional contributions were evaluated using a base model that adjusted for gestational age, birth weight z-score and sex and by comparing the area under the curve (AUC). Results: The mortality/morbidity rate was 63% (5859/9240). Specific SNAP-II cut-offs ranged from 12 to 20 and were associated with each adverse outcome. Adding SNAP-II cut-offs to predictive models that included birth variables significantly improved (p < .05) the prediction of early mortality (AUC 0.84 versus 0.79), hospital mortality (AUC 0.80 versus 0.78), mortality/morbidity (AUC 0.76 versus 0.75), and severe neurological injury (AUC 0.69 versus 0.66) but had little or no effect on predictive models for retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, and nosocomial infection. Conclusions: SNAP-II cut-offs were independently associated with each adverse outcome and using the proposed SNAP-II cut-offs improved the performance of predictive models for certain short-term outcomes.

Association of Maternal Diabetes With Neonatal Outcomes of Very Preterm and Very Low-Birth-Weight Infants: An International Cohort Study

Importance Diabetes in pregnancy is associated with a 2-times to 3-times higher rate of very preterm birth than in women without diabetes. Very preterm infants are at high risk of death and severe morbidity. The association of maternal diabetes with these risks is unclear. Objective To determine the associations between maternal diabetes and in-hospital mortality, as well as neonatal morbidity in very preterm infants with a birth weight of less than 1500 g. Design, Setting, Participants This retrospective cohort study was conducted at 7 national networks in high-income countries that are part of the International Neonatal Network for Evaluating Outcomes in Neonates and used prospectively collected data on 76 360 very preterm, singleton infants without malformations born between January 1, 2007, and December 31, 2015, at 24 to 31 weeks’ gestation with birth weights of less than 1500 g, 3280 (4.3%) of whom were born to diabetic mothers. Exposures Any type of diabetes during pregnancy. Main Outcomes and Measures The primary outcome was in-hospital mortality. The secondary outcomes were severe neonatal morbidities, including intraventricular hemorrhages of grade 3 to 4, cystic periventricular leukomalacia, retinopathy of prematurity needing treatment and bronchopulmonary dysplasia, and other morbidities, including respiratory distress, treated patent ductus arteriosus, and necrotizing enterocolitis. Odds ratios (ORs) with 95% confidence intervals were estimated, adjusted for potential confounders, and stratified by gestational age (GA), sex, and network. Results The mean (SD) birth weight of offspring born to mothers with diabetes was significantly higher at 1081 (262) g than in offspring born to mothers without diabetes (mean [SD] birth weight, 1027 [270] g). Mothers with diabetes were older and had more hypertensive disorders, antenatal steroid treatments, and deliveries by cesarean delivery than mothers without diabetes. Infants of mothers with diabetes were born at a later GA than infants of mothers without diabetes. In-hospital mortality (6.6% vs 8.3%) and the composite of mortality and severe morbidity (31.6% vs 40.6%) were lower in infants of mothers with diabetes. However, in adjusted analyses, no significant differences in in-hospital mortality (adjusted OR, 1.16 (95% CI, 0.97-1.39) or the composite of mortality and severe morbidity (adjusted OR, 0.99 (95% CI, 0.88-1.10) were observed. With few exceptions, outcomes of infants born to mothers with and without diabetes were similar regardless of infant sex, GA, or country of birth. Conclusions and Relevance In high-resource settings, maternal diabetes is not associated with an increased risk of in-hospital mortality or severe morbidity in very preterm infants with a birth weight of fewer than 1500 g.

Illness Severity Predicts Death and Brain Injury in Asphyxiated Newborns Treated with Hypothermia

Objective To determine if illness severity during the first days of life predicts adverse outcome in asphyxiated newborns treated with hypothermia. Study Design We conducted a retrospective cohort study of asphyxiated newborns treated with hypothermia. Illness severity was calculated daily during the first 4 days of life using the Score for Neonatal Acute Physiology II (SNAP‐II score). Adverse outcome (death and/or brain injury) was recorded. Differences in SNAP‐II scores between the newborns with and without adverse outcome were assessed. Result 214 newborns were treated with hypothermia. The average SNAP‐II score over the first 4 days of life was significantly worse in newborns developing adverse outcome. The average SNAP‐II score was an excellent predictor of death (area under the curve [AUC]: 0.93; p < 0.001) and a fair predictor of adverse outcome (AUC: 0.73; p < 0.001). The average SNAP‐II score remained a significant predictor of adverse outcome (odds ratio [95% confidence interval]: 1.08 [1.04‐1.12]; p < 0.001), after adjusting for baseline characteristics, degree of initial asphyxial event, and initial severity of encephalopathy. Conclusion In asphyxiated newborns treated with hypothermia, not only the initial asphyxial event but also the illness severity during the first days of life was a significant predictor of death or brain injury.

Association of Resident Duty Hour Restrictions, Level of Trainee, and Number of Available Residents with Mortality in the Neonatal Intensive Care Unit

Objective This article assesses the effect of reducing consecutive hours worked by residents from 24 to 16 hours on yearly total hours worked per resident in the neonatal intensive care unit (NICU) and evaluates the association of resident duty hour reform, level of trainee, and the number of residents present at admission with mortality in the NICU. Study Design This is a 6‐year retrospective cohort study including all pediatric residents working in a Level 3 NICU (N = 185) and infants admitted to the NICU (N = 8,159). Adjusted odds ratios (aOR) were estimated for mortality with respect to Epoch (2008‐2011 [24‐hour shifts] versus 2011‐2014 [16‐hour shifts]), level of trainee, and the number of residents present at admission. Results The reduction in maximum consecutive hours worked was associated with a significant reduction of the median yearly total hours worked per resident in the NICU (381 hour vs. 276 hour, p < 0.01). Early mortality rate was 1.2% (50/4,107) before the resident duty hour reform and 0.8% (33/4,052) after the reform (aOR, 0.57; 95% confidence interval [CI], 0.33‐0.98). Neither level of trainee (aOR, 1.22; 95% CI, 0.71‐2.10; junior vs. senior) nor the number of residents present at admission (aOR, 2.08; 95% CI, 0.43‐10.02, 5‐8 residents vs. 0‐2 residents) were associated with early mortality. Resident duty hour reform was not associated with hospital mortality (aOR, 0.73; 95% CI, 0.50‐1.07; after vs. before resident duty hour reform). Conclusion Resident duty hour restrictions were associated with a reduction in the number of yearly hours worked by residents in the NICU as well as a significant decrease in adjusted odds of early mortality but not of hospital mortality in admitted neonates.

Association of Nursing Overtime, Nurse Staffing, and Unit Occupancy with Health Care–Associated Infections in the NICU

Objective This study aims to assess the association of nursing overtime, nurse staffing, and unit occupancy with health care‐associated infections (HCAIs) in the neonatal intensive care unit (NICU). Study Design A 2‐year retrospective cohort study was conducted for 2,236 infants admitted in a Canadian tertiary care, 51‐bed NICU. Daily administrative data were obtained from the database “Logibec” and combined to the patient outcomes database. Median values for the nursing overtime hours/total hours worked ratio, the available to recommended nurse staffing ratio, and the unit occupancy rate over 3‐day periods before HCAI were compared with days that did not precede infections. Adjusted odds ratios (aOR) that control for the latter factors and unit risk factors were also computed. Results A total of 122 (5%) infants developed a HCAI. The odds of having HCAI were higher on days that were preceded by a high nursing overtime ratio (aOR, 1.70; 95% confidence interval [95% CI], 1.05‐2.75, quartile [Q]4 vs. Q1). High unit occupancy rates were not associated with increased odds of infection (aOR, 0.85; 95% CI, 0.47‐1.51, Q4 vs. Q1) nor were higher available/recommended nurse ratios (aOR, 1.16; 95% CI, 0.67‐1.99, Q4 vs. Q1). Conclusion Nursing overtime is associated with higher odds of HCAI in the NICU.