Process and Outcome Measures for Infants Born Moderate and Late Preterm in Tertiary Canadian Neonatal Intensive Care Units.

OBJECTIVE: To describe the prevalence of and between-center variations in care practices and clinical outcomes of moderate and late preterm infants (MLPIs) admitted to tertiary Canadian neonatal intensive care units (NICUs). STUDY DESIGN: This was a retrospective cohort study including infants born at 320/7 through 366/7 weeks of gestation and admitted to 25 NICUs participating in the Canadian Neonatal Network between 2015 and 2020. Patient characteristics, process measures represented by care practices, and outcome measures represented by clinical in-hospital and discharge outcomes were reported by gestational age weeks. NICUs were compared using indirect standardization after adjustment for patient characteristics. RESULTS: Among 25 669 infants (17% of MLPIs born in Canada during the study period) included, 45% received deferred cord clamping, 7% had admission hypothermia, 47% received noninvasive respiratory support, 11% received mechanical ventilation, 8% received surfactant, 40% received antibiotics in the first 3 days, 4% did not receive feeding in the first 2 days, and 77% had vascular access. Mortality, early-onset sepsis, late-onset sepsis, or necrotizing enterocolitis occurred in <1% of the study cohort. Median (IQR) length of stay was 14 (9-21) days among infants discharged home from the admission hospital and 5 (3-9) days among infants transferred to community hospitals. Among infants discharged home, 33% were discharged on exclusive breastmilk and 75% on any breastmilk. There were significant variations between NICUs in all process and outcome measures. CONCLUSIONS: Care practices and outcomes of MLPIs varied significantly between Canadian NICUs. Standardization of process and outcome quality measures for this population will enable benchmarking and research, facilitating systemwide improvements.

Variations in Site-Specific Costs for Infants Born Extremely Preterm in Canadian Neonatal Intensive Care Units.

OBJECTIVE: To quantify site-specific costs and their association with survival without major morbidity (SWMM) in Canada for neonates <28 weeks of gestation admitted to large tertiary neonatal intensive care units. METHODS: We conducted a retrospective analysis of infants born at <28 weeks of gestation and admitted to Canadian Neonatal Network sites from 2010 through 2021. Sites that cared for at least 50 eligible infants by gestational age in weeks over the study period were included. Using a validated costing algorithm that assessed physician, nursing, respiratory therapy, diagnostic imaging, transfusions, procedural, medication, and certain indirect costs, we calculated site and resource-specific costs in 2017 Canadian dollars (CAD) and evaluated their relationship with SWMM. RESULTS: Seven sites with 8180 (range 841-1605) eligible neonates with a mean (SD) gestation of 25.4 [1.3] weeks were included. Survival to discharge or transfer was 85.3% with a mean (SD) length of stay of 75 (46) days. The mean (SD) total and daily costs per neonate varied between $94 992 ($60 283) and $174 438 ($130 501) CAD and $1833 ($916) to $2307 ($1281) CAD, respectively. Between sites, there was no relationship between costs and SWMM. CONCLUSIONS: There was marked variation in costs and SWMM between sites in Canada with universal health care. The lack of concordance between both outcomes and costs among sites may provide possibilities for outcomes improvement and cost containment.

The Trend in Costs of Tertiary-Level Neonatal Intensive Care for Neonates Born Preterm at 220/7-286/7 Weeks of Gestation from 2010 to 2019 in Canada.

OBJECTIVE: To describe the trend in costs over 10 years for tertiary-level neonatal care of infants born 220/7-286/7 weeks of gestation during an ongoing Canadian national quality improvement project. STUDY DESIGN: Clinical characteristics, outcomes, and third-party payor costs for the tertiary neonatal care of infants born 220/7-286/7 weeks of gestation between the years 2010 and 2019 were analyzed from the Canadian Neonatal Network database. Costs were estimated using resource use data from the Canadian Neonatal Network and cost inputs from hospitals, physician billing, and administrative databases in Ontario, Canada. Cost estimates were adjusted to 2017 Canadian dollars (CAD). A generalized linear mixed-effects model with gamma regression was used to estimate trends in costs. RESULTS: Between 2010 and 2019, the number of infants born <24 weeks of gestation increased from 4.4% to 7.7%. The average length of stay increased from 68 days to 75 days. Unadjusted average ± SD total costs per neonate were $120 717 ± $93 062 CAD in 2010 and $132 774 ± $93 161 CAD in 2019. After adjustment for year, center, and gestation, total costs and length of stay increased significantly, by $13 612 CAD (P < .01) and 8.1 days (P < .01) over 10 years, respectively; whereas costs accounting for LOS remained stable. CONCLUSIONS: The total costs and length of stay for infants 220/7-286/7 weeks of gestation have increased over the past decade in Canada during an ongoing national quality improvement initiative; however, there was an increase in the number and survival of neonates at the age of periviability.

Determining the Effect of Birth Weight on Therapeutic Hypothermia in Neonates with Hypoxic-Ischemic Encephalopathy.

OBJECTIVE: We examine the effect of birth weight (BW) for gestational age (GA) on the temperatures reached during the treatment of neonatal hypoxic-ischemic encephalopathy (HIE) with therapeutic hypothermia (TH). STUDY DESIGN: Retrospective data of 1,736 neonates with HIE who received TH were extracted from the Canadian Neonatal Network database for neonates admitted from 2010 to 2017. Neonates were stratified into three BW groups: small for GA < 10th centile, large for GA > 90th centile, and according to GA 10th to 89th centile at a given gestation using Canadian population data norms. RESULTS: There was no significant difference in the lowest temperature reached, the likelihood of overshooting temperatures < 32.5°C during TH, or the change of encephalopathy stages among the three groups. CONCLUSION: BW for GA did not appear to influence the temperatures neonates reached during hypothermia or encephalopathy stage following TH. KEY POINT: · Therapeutic hypothermia is well tolerated irrespective of weight for age. · SGA infants achieved and maintained target temperature similar to AGA and LGA babies. · Change in the Sarnat stage after hypothermia was similar across all birth weight groups.

Association between Umbilical Catheters and Neonatal Outcomes in Extremely Preterm Infants.

OBJECTIVE: The objective of this study was to examine the association between umbilical catheters and a composite outcome of mortality or major neonatal morbidity in extremely preterm infants. STUDY DESIGN: Data were abstracted from the Canadian Neonatal Network database for infants born at <29 weeks' gestational age and admitted to 29 neonatal intensive care units between January 2010 and December 2012. Four groups were identified: those with no umbilical catheters, umbilical venous catheters (UVCs), umbilical artery catheters (UACs), and those with both UVCs and UACs. The outcomes were compared among the groups using univariate and multivariable analyses. RESULTS: Of 4,623 eligible infants, 820 (17.7%) had no catheters, 1,032 (22.3%) a UVC only, 120 (2.6%) a UAC only, and 2,651 (57.3%) had both catheters. After adjustment for acuity and other potential confounders, umbilical catheters were associated with higher odds of mortality or any major morbidity (UVC vs. no catheter: adjusted odds ratio [aOR]: 1.47; 95% CI: 1.18-1.85; UAC vs. no catheter: aOR: 1.67; 95% CI: 1.05-2.63; and both UVC + UAC vs. no catheter: aOR: 2.17; 95% CI: 1.79-2.70). CONCLUSION: Most of the infants born at <29 weeks' gestation had UVC and/or UAC placement. The presence of either catheter was associated with mortality or major morbidity, and the association was stronger when both catheters were present.

Health Service Use and Costs Associated with Low Birth Weight--A Population Level Analysis.

OBJECTIVES: To examine differences in health services utilization (HSU) costs in the first year of life between low birth weight (LBW) and normal birth weight (NBW) infants, identify maternal and child characteristics associated with HSU costs, and estimate annual HSU cost of LBW infants for the province of Alberta, Canada. STUDY DESIGN: A retrospective cohort study including all live births between 2004 and 2010. Data from the Alberta Perinatal Health Program database were linked to health care administrative data including inpatient, outpatient, and practitioner claims to identify HSU within the first year of life. RESULTS: One-year HSU costs among LBW infants (n = 16,209) were $33,096 compared with $3942 among NBW infants (n = 189,586). There was a strong negative correlation between HSU costs and increasing birth weight, with health care costs among extreme LBW (<1000 g), very LBW (1000 and 1499 g), and moderate LBW (1500 and 2499 g) of $117,000, $84,000, and, $20,000, respectively. Maternal characteristics such as high prepregnancy weight, aboriginal status, and lower socioeconomic status were associated with higher HSU costs among the infants. LBW accounted for 7% of all infants but 37% of the total costs, amounting to $108 million annually. CONCLUSIONS: Compared with NBW infants, LBW infants consume more health resources not only in terms of initial hospitalization but also of re-hospitalizations, outpatient, and physician visits during the first year of their life. Interventions targeting social determinants of health are required to improve birth weight outcomes in Alberta.

Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial: a protocol for a multicentre, stepped-wedge cluster randomized trial.

BACKGROUND: Evidence-based Practice for Improving Quality (EPIQ) is a collaborative quality improvement method adopted by the Canadian Neonatal Network that led to decreased mortality and morbidity in very preterm neonates. The Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial aims to evaluate the impact of EPIQ collaborative quality improvement strategies in moderate and late preterm neonates in Alberta, Canada. METHODS: In a 4-year, multicentre, stepped-wedge cluster randomized trial involving 12 neonatal intensive care units (NICUs), we will collect baseline data with the current practices in the first year (all NICUs in the control arm). Four NICUs will transition to the intervention arm at the end of each year, with 1 year of follow-up after the last group transitions to the intervention arm. Neonates born at 32 + 0 to 36 + 6 weeks' gestation with primary admission to NICUs or postpartum units will be included. The intervention includes implementation of respiratory and nutritional care bundles using EPIQ strategies, including quality improvement team building, quality improvement education, bundle implementation, quality improvement mentoring and collaborative networking. The primary outcome is length of hospital stay; secondary outcomes include health care costs and short-term clinical outcomes. Neonatal intensive care unit staff will complete a survey in the first year to assess quality improvement culture in each unit, and a sample will be interviewed 1 year after implementation in each unit to evaluate the implementation process. INTERPRETATION: The ABC-QI Trial will assess whether collaborative quality improvement strategies affect length of stay in moderate and late preterm neonates. It will provide detailed population-based data to support future research, benchmarking and quality improvement. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT05231200.

Perinatal and childhood morbidity and mortality in congenital analbuminemia.

Albumin, a serum transport protein, provides 80% of colloid osmotic pressure. Congenital analbuminemia (CAA) is an autosomal recessive disorder characterized by absence of serum albumin. Fifty cases of CAA have been reported throughout the world; however, little is known about its clinical impact. Most reported cases have few clinical signs and symptoms. Twelve local cases from the northwestern central plains region in Saskatchewan were identified and reviewed to ascertain morbidity and mortality related with CAA. All the cases are from two remote First Nations communities. Cases had frequent hospital admissions and recurrent respiratory tract infections. Placental abnormalities included hydropic placentas, placental infarcts and microcalcifications. One-half of the cases were born preterm and one-quarter were small for their gestational age. There were three mortalities in the case series. The present case series suggests increased morbidity and mortality during infancy in patients with CAA. The long-term risks of CAA in this population are unknown and a longitudinal study is recommended.

L'albumine, une protéine du transport sérique, fournit 80 % de la pression colloïdo-osmotique. L'analbuminémie congénitale (AAC) est un trouble autosomique récessif caractérisé par l'absence d'albumine sérique. Cinquante cas d'AAC ont été signalés dans le monde, mais on ne sait pas grand-chose de ses répercussions cliniques. La plupart des cas déclarés s'associaient à peu de signes et symptômes cliniques. Les chercheurs ont dépisté 12 cas locaux, originaires de la région du nord-ouest des plaines centrales, en Saskatchewan, et les ont analysés afin de déterminer la morbidité et la mortalité liées à l'AAC. Tous les cas provenaient de deux communautés éloignées des Premières nations. Ils étaient souvent hospitalisés et avaient des infections respiratoires récurrentes. Les anomalies placentaires incluaient des placentas hydropiques, des infarctus placentaires et des microcalcifications. La moitié des cas étaient prématurés et le quart d'entre eux étaient petits par rapport à leur âge gestationnel. Trois mortalités ont été constatées. Cette série a démontré une augmentation de la morbidité et de la mortalité pendant l'enfance chez les patients ayant une AAC. On ne connaît pas les risques à long terme de l'AAC au sein de cette population. Une étude longitudinale est recommandée.

Do transport factors increase the risk of severe brain injury in outborn infants <33 weeks gestational age?

OBJECTIVE: We evaluated transport factors and postnatal practices to identify modifiable risk factors for SBI. STUDY DESIGN: Retrospective review of Canadian Neonatal Transport Network data linked to Canadian Neonatal Network data for outborns <33 weeks gestational age (GA), during January 2014 to December 2015. SBI was defined as grade 3 or 4 intraventricular hemorrhage or parenchymal echogenicity, including hemorrhagic and/or ischemic lesions. RESULT: Among 781 infants, 115 (14.7%) had SBI with range 5.6-40% among transport teams. In multivariable analysis, SBI was associated with GA [0.77 (0.71, 0.85)] per week, receipt of chest compressions and/or epinephrine at delivery [1.81 (1.08, 3.05)] and receipt of fluid boluses [1.61 (1.00, 2.58)]. CONCLUSIONS: Risk factors for SBI were related to the condition at birth and immediate postnatal management and not related to transport factors. These results highlight the importance of maternal transfer to perinatal centers to allow optimization of perinatal management.

Patent ductus arteriosus and small for gestational age infants: Treatment approaches and outcomes.

BACKGROUND: The current treatment approach in patent ductus arteriosus suggests the identification of high-risk infants that may benefit the most from treatment. Small for gestational age infants are a high-risk population in which the treatment approach to the patent ductus arteriosus and outcomes have not been described. AIM: To compare the patent ductus arteriosus treatment approach and outcomes in small for gestational age and appropriate for gestational age infants. STUDY DESIGN: Retrospective analysis of infants born between January 1, 2011 and December 31, 2015 at <33 weeks' GA and admitted to neonatal intensive care units (NICU) part of the Canadian Neonatal Network. RESULTS: 595 of 2507 small for gestational age infants (23.7%) and 4714 of 20,002 appropriate for gestational age infants (23.6%) had a patent ductus arteriosus. The patent ductus arteriosus treatment approach (conservative, medical, surgical) was similar in both groups. Small for gestational age infants with and without a patent ductus arteriosus had increased risk of the composite outcome of death or bronchopulmonary dysplasia (aOR 3.40; 95% CI 2.73, 4.24; and aOR 2.72; 95% CI 2.24, 3.31) respectively. CONCLUSIONS: Patent ductus arteriosus management did not differ between small for gestational age and appropriate for gestational age infants. Small for gestational age infants had increased risk of death or bronchopulmonary dysplasia regardless of their patent ductus arteriosus status.

Epidemiology of Meningitis in Canadian Neonatal Intensive Care Units.

BACKGROUND: Meningitis is a serious disease that occurs more commonly in the neonatal period than in any other age group. Recent data from large national cohorts are needed to determine if the epidemiology of neonatal meningitis (NM) has changed. AIM: To assess the rates, causative organisms, risk factors, temporal trends and short-term outcomes of NM in Canadian Neonatal Intensive Care Units (NICUs). METHODS: A retrospective review of newborn infants admitted to NICUs participating in the Canadian Neonatal Network between January 2010 and December 2016. Patients with meningitis were reviewed. Outcomes of patients with meningitis were compared with 1:2 matched (for gestation, sex and birth weight) neonates without meningitis. RESULTS: Rates of NM ranged between 2.2 and 3.5/1000 NICU admissions during the 7-year study period with the majority of patients (87%) having late-onset meningitis (at >3 days after birth). The most common bacterial organism for both early- and late-onset meningitis was Escherichia coli followed by group B streptococci. Only 31% [95% confidence interval (CI): 24.06-38.63) of neonates with meningitis had simultaneous bacteremia. NM was associated with increased seizures [odds ratio (OR): 8.63; 95% CI: 4.73-15.7], retinopathy of prematurity (OR: 3.23; 95% CI: 1.30-8.02), bronchopulmonary dysplasia (OR: 1.93; 95% CI: 1.11-3.35), days of mechanical ventilation (OR: 1.03; 95% CI: 1.02-1.04) and length of hospital stay (OR: 1.02; 95% CI: 1.01-1.02), but not with mortality before discharge (OR: 1.29; 95% CI: 0.74-2.23). CONCLUSIONS: The rate of NM remains largely unchanged in Canadian NICUs. NM was associated with increased major morbidities and longer hospital stay but not with mortality before discharge.

Disparity in childhood immunizations.

BACKGROUND: Incomplete immunization coverage is common in low-income families and Aboriginal children in Canada. OBJECTIVE: To determine whether child immunization coverage rates at two years of age were lower in low-income neighbourhoods of Saskatoon, Saskatchewan. METHODS: Parents who were and were not behind in child immunization coverage were contacted to determine differences in knowledge, beliefs and opinions on barriers and solutions. A multivariate regression model was designed to determine whether Aboriginal cultural status was associated with being behind in childhood immunizations after controlling for low-income status. RESULTS: Reviewing the past five years in Saskatoon, the six low-income neighbourhoods had complete child immunization coverage rates of 43.7% (95% CI 41.2 to 45.9) for measles-mumps-rubella, and 42.6% (95% CI 40.1 to 45.1) for diphtheria, pertussis, tetanus, polio and Haemophilus influenzae type B. The five affluent neighbourhoods had 90.6% (95% CI 88.9 to 92.3) immunization coverage rates for measles-mumps-rubella, and 78.6% (95% CI 76.2 to 81.0) for diphtheria, pertussis, tetanus, polio and H influenzae type B. Parents who were behind in immunization coverage for their children were more likely to be single, of Aboriginal or other (non-Caucasian or non-Aboriginal) cultural status, have lower family income and have significant differences in reported beliefs, barriers and potential solutions. In the final regression model, Aboriginal cultural status was no longer associated with lower immunization status. INTERPRETATION: Child immunization coverage rates in Saskatoon's six low-income neighbourhoods were approximately one-half the rate of the affluent neighbourhoods. The covariates with the strongest independent association with complete childhood immunization status were low income and other cultural status. Aboriginal cultural status was not associated with low child immunization rates after controlling for income status.