Prevalence, Severity Patterns and Risk Factors of Bronchopulmonary Dysplasia in Preterm Infants Younger than 32 Weeks of Gestation in a Tertiary Centre in Oman.

Objectives: This study aimed to determine the rate and severity patterns of bronchopulmonary dysplasia (BPD) and identify antenatal and postnatal factors associated with BPD in preterm infants <32 weeks of gestational age (GA). Methods: This retrospective observational study included preterm neonates <32 weeks of gestation admitted into the neonatal intensive care unit between January 2010 and December 2017 at Sultan Qaboos University Hospital, Muscat, Oman. A data set of antenatal and perinatal factors were collected. BPD was defined as the need for oxygen and/or respiratory support at 36 weeks post-menstrual age (PMA). Infants with and without BPD were compared in their antenatal and perinatal factors. Results: A total of 589 preterm infants <32 weeks were admitted. Among them, 505 (85.7%) survived to 36 weeks' PMA and 90 (17.8%) had BPD. The combined BPD and mortality rate was 28.4%. Grades 1, 2 and 3 BPD constituted 77.8%, 7.8% and 14.4%, respectively. BPD was associated with lower GA, lower birth weight, need for intubation at resuscitation, lower Apgar scores, longer duration of ventilation, surfactant therapy and higher rates of neonatal morbidities. On binary logistic regression analysis, predictors of BPD were longer duration of ventilation, intraventricular haemorrhage (IVH) and necrotising enterocolitis (NEC). Conclusion: In an Omani centre, 17.8% of preterm infants (<32 weeks GA) developed BPD. Various perinatal and neonatal factors were associated with BPD. However, longer duration of ventilation, IVH grades 1 and 2 and NEC stages II and III were significant predictors. Future multicentre research is necessary to provide the overall prevalence of BPD in Oman to help optimise the resources for BPD prevention and management in preterm infants.

Immediate postnatal prediction of death or bronchopulmonary dysplasia among very preterm and very low birth weight infants based on gradient boosting decision trees algorithm: A nationwide database study in Japan.

INTRODUCTION: Bronchopulmonary dysplasia (BPD) poses a substantial global health burden. Individualized treatment strategies based on early prediction of the development of BPD can mitigate preterm birth complications; however, previously suggested predictive models lack early postnatal applicability. We aimed to develop predictive models for BPD and mortality based on immediate postnatal clinical data. METHODS: Clinical information on very preterm and very low birth weight infants born between 2008 and 2018 was extracted from a nationwide Japanese database. The gradient boosting decision trees (GBDT) algorithm was adopted to predict BPD and mortality, using predictors within the first 6 h postpartum. We assessed the temporal validity and evaluated model adequacy using Shapley additive explanations (SHAP) values. RESULTS: We developed three predictive models using data from 39,488, 39,096, and 40,291 infants to predict "death or BPD," "death or severe BPD," and "death before discharge," respectively. These well-calibrated models achieved areas under the receiver operating characteristic curve of 0.828 (95% CI: 0.828-0.828), 0.873 (0.873-0.873), and 0.887 (0.887-0.888), respectively, outperforming the multivariable logistic regression models. SHAP value analysis identified predictors of BPD, including gestational age, size at birth, male sex, and persistent pulmonary hypertension. In SHAP value-based case clustering, the "death or BPD" prediction model stratified infants by gestational age and persistent pulmonary hypertension, whereas the other models for "death or severe BPD" and "death before discharge" commonly formed clusters of low mortality, extreme prematurity, low Apgar scores, and persistent pulmonary hypertension of the newborn. CONCLUSIONS: GBDT models for predicting BPD and mortality, designed for use within 6 h postpartum, demonstrated superior prognostic performance. SHAP value-based clustering, a data-driven approach, formed clusters of clinical relevance. These findings suggest the efficacy of a GBDT algorithm for the early postnatal prediction of BPD.

Ambient Air Pollution and Outpatient Morbidities in Bronchopulmonary Dysplasia.

Rationale: Bronchopulmonary dysplasia (BPD) is the most common long-term complication of prematurity. Although socioeconomic status is associated with BPD morbidities, the drivers of this association are poorly understood. In the United States, ambient air pollution (AAP) exposure is linked to both race/ethnicity and socioeconomic status. Furthermore, AAP exposure is known to have a detrimental effect on respiratory health in children. Objectives: To assess if AAP exposure is linked to BPD morbidity in the outpatient setting. Methods: Participants with BPD were recruited from outpatient clinics at Johns Hopkins University and the Children's Hospital of Philadelphia between 2008 and 2021 (N = 800) and divided into low, moderate, and high AAP exposure groups, based on publicly available U.S. Environmental Protection Agency data. Clinical data were obtained by chart review and caregiver questionnaires. Results: Non-White race, home ventilator use, and lower median household income were associated with higher degrees of air pollution exposure. After adjustment for these factors, moderate and high air pollution exposure were associated with requiring systemic steroids (odds ratio, 1.78 and 2.17, respectively) compared with low air pollution. Similarly, high air pollution exposure was associated with emergency department visits (odds ratio, 1.59). Conclusions: This study demonstrates an association between AAP exposure and BPD morbidity after initial hospital discharge. AAP exposure was closely linked to race and median household income. As such, it supports the notion that AAP exposure may be contributing to health disparities in BPD outcomes. Further studies directly measuring exposure and establishing a link between biomarkers of exposure and outcomes are prerequisites to developing targeted interventions protecting this vulnerable population.

[Assessment of risk factors for bronchopulmonary dysplasia with pulmonary hypertension and construction of a prediction nomogram model].

Objective: To explore the risk factors of pulmonary hypertension (PH) in premature infants with bronchopulmonary dysplasia (BPD), and to establish a prediction model for early PH. Methods: This was a retrospective cohort study. Data of 777 BPD preterm infants with the gestational age of <32 weeks were collected from 7 collaborative units of the Su Xinyun Neonatal Perinatal Collaboration Network platform in Jiangsu Province from January 2019 to December 2022. The subjects were randomly divided into a training cohort and a validation cohort at a ratio of 8∶2 by computer, and non-parametric test or χ2 test was used to examine the differences between the two retrospective cohorts. Univariate Logistic regression and multivariate logistic regression analyses were used in the training cohort to screen the risk factors affecting the PH associated with BPD. A nomogram model was constructed based on the severity of BPD and its risk factors,which was internally validated by the Bootstrap method. Finally, the differential, calibration and clinical applicability of the prediction model were evaluated using the training and verification queues. Results: A total of 130 among the 777 preterm infants with BPD had PH, with an incidence of 16.7%, and the gestational age was 28.7 (27.7, 30.0) weeks, including 454 males (58.4%) and 323 females (41.6%). There were 622 preterm infants in the training cohort, including 105 preterm infants in the PH group. A total of 155 patients were enrolled in the verification cohort, including 25 patients in the PH group. Multivariate Logistic regression analysis revealed that low 5 min Apgar score (OR=0.87, 95%CI 0.76-0.99), cesarean section (OR=1.97, 95%CI 1.13-3.43), small for gestational age (OR=9.30, 95%CI 4.30-20.13), hemodynamically significant patent ductus arteriosus (hsPDA) (OR=4.49, 95%CI 2.58-7.80), late-onset sepsis (LOS) (OR=3.52, 95%CI 1.94-6.38), and ventilator-associated pneumonia (VAP) (OR=8.67, 95%CI 3.98-18.91) were all independent risk factors for PH (all P<0.05). The independent risk factors and the severity of BPD were combined to construct a nomogram map model. The area under the receiver operating characteristic (ROC) curve of the nomogram model in the training cohort and the validation cohort were 0.83 (95%CI 0.79-0.88) and 0.87 (95%CI 0.79-0.95), respectively, and the calibration curve was close to the ideal diagonal. Conclusions: Risk of PH with BPD increases in preterm infants with low 5 minute Apgar score, cesarean section, small for gestational age, hamodynamically significant patent ductus arteriosus, late-onset sepsis, and ventilator-associated pneumonia. This nomogram model serves as a useful tool for predicting the risk of PH with BPD in premature infants, which may facilitate individualized early intervention.

Healthcare Costs of Major Morbidities Associated with Prematurity in US Children's Hospitals.

OBJECTIVE: To evaluate the healthcare costs attributed to major morbidities associated with prematurity, namely, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage, necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and nosocomial infections. STUDY DESIGN: This was a retrospective analysis of infants born at 24-30 weeks of gestation, admitted to children's hospitals in the Pediatric Health Information System between 2009 and 2018. Charges were adjusted by geographical price index, converted to costs using cost-to-charge ratios, inflated to 2018 US$, and total costs were accumulated for the initial hospitalization. Quantile regressions, which are less prone to bias from extreme outliers, were used to examine the incremental costs attributed to each morbidity across the entire cost distribution, including the median. RESULTS: There were 19 232 patients from 30 children's hospitals who were eligible. Higher costs were seen in lower gestational age, more severe morbidity, and those with higher number of comorbidities. Patients with surgical NEC, severe ROP, and severe BPD were the costliest with median total costs of $430 860, $413 825, and $399 495, respectively. Quantile regressions showed surgical NEC had the highest adjusted median incremental total cost ($48 621; 95% CI, $39 617-$57 626) followed by severe BPD ($35 773; 95% CI, $32 018-$39 528) and severe ROP ($22 561; 95% CI, $16 699-$28 423). Quantile regressions also revealed that surgical NEC, severe BPD, and severe ROP had increasing incremental costs at higher total cost percentiles, indicating these morbidities have a greater cost impact on the costliest patients. CONCLUSIONS: Severe BPD, surgical NEC, and severe ROP are the costliest morbidities and contribute the most incremental costs especially for the higher costs patients.

The clinical burden of extremely preterm birth in a large medical records database in the United States: complications, medication use, and healthcare resource utilization.

INTRODUCTION: Approximately 5% of global preterm births are extremely premature (EP), defined as occurring at less than 28 weeks gestational age. Advances in care have led to an increase in the survival of EP infants during the neonatal period. However, EP infants have a higher risk of developing complications such as bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). BPD and other respiratory morbidities are particularly prevalent among this population. To understand the healthcare resource utilization (HRU) of EP infants in the United States, the clinical and economic burden of extreme prematurity was examined in this retrospective study of data extracted from electronic medical records in the Kaiser Permanente Northern California (KPNC) health system. METHODS: The analysis included data from EP infants live-born between January 1997 and December 2016, and focused on complications and HRU up to 3 years corrected age (CA), covering the period up to December 2018. Stillbirths, infants born at <22 weeks gestational age, and infants with major congenital malformations were excluded. Complications of interest (BPD, IVH, and ROP) and medication use were compared by age group (≤1 year, >1 year and ≤2 years, and >2 years and ≤3 years CA). Analysis of HRU included hospital readmissions, ambulatory visits, and emergency room (ER) visits. RESULTS: A total of 2154 EP births (0.32% of total live births and 4.0% of preterm births that met the inclusion/exclusion criteria) were analyzed. The prevalence of EP birth showed a declining trend over time. ROP was the most commonly recorded complication during the birth hospitalization (37.1% any stage; 2.9% Stages 3 and 4). BPD was recorded in 34.3% of EP infants. IVH (any grade) was recorded in 22.7% of EP infants (6.4% Grades III and IV). A majority (78.7%) of EP infants were diagnosed with at least one respiratory condition during the first year CA, the most common being pneumonia (68.9%); the prevalence of respiratory conditions decreased over the second and third years CA. During the first 3 years CA, the most common medications prescribed to children born EP were inhaled bronchodilators (approximately 30% of children); at least 15% of children received systemic corticosteroids and inhaled steroids during this period. During the first 3 years CA, at least one hospital readmission was recorded for 16.4% of children born EP; 57.1% of these readmissions were related to respiratory conditions. At least one ER visit was recorded for 33.8% of children born EP, for which 53.1% were due to a respiratory condition. Ambulatory visits were recorded for 54.2% of EP children, for which 82.9% were due to a respiratory condition. CONCLUSIONS: The short- and long-term clinical burden of EP birth was high. The onset of BPD, IVH, and ROP was common during the birth hospitalization for EP infants. Medication use, hospital readmission, and clinic visits (ER and ambulatory) occurred frequently in these children during the first 3 years CA, and were commonly due to respiratory conditions. Strategies prioritizing the reduction of risk and severity of respiratory conditions may alleviate the clinical burden of EP birth over the long term.

Long-term burden of respiratory complications associated with extreme prematurity: An analysis of US Medicaid claims.

BACKGROUND: Infants born extremely premature (EP) (<28 weeks gestational age) are at high risk of complications, particularly bronchopulmonary dysplasia (BPD), which can develop into chronic lung disease (CLD). METHODS: The burden of respiratory complications in EP infants up to 2 years corrected age (CA) was evaluated using real-world data from the US Medicaid program. Data recorded between 1997 and 2018 on EP infants without major congenital malformations were collected from Medicaid records of six states. EP infants were divided into three cohorts: BPD, CLD, and without BPD or CLD. The incidence of respiratory conditions, respiratory medication use, and healthcare resource utilization were compared between the BPD cohort and CLD cohort versus the cohort without BPD or CLD, using unadjusted and adjusted generalized linear models. RESULTS: A total of 4462 EP infants were identified (17.4% of all premature infants in the database). Of these, BPD and CLD were diagnosed in 61.9% and 72.1%, respectively, and 14.5% were diagnosed with neither BPD nor CLD. Compared with infants without BPD or CLD, infants with BPD or CLD had more complications and a longer length of birth hospitalization stay. Respiratory distress syndrome was the most frequently reported complication (94.6%, 92.5%, and 82.3% of EP infants in the BPD, CLD, and without BPD or CLD cohorts, respectively). After the birth hospitalization, respiratory conditions, respiratory medication use, and incidence rates of rehospitalizations, emergency room visits, and outpatient visits were higher for infants with BPD or CLD. Rehospitalization occurred in 50.5%, 51.6%, and 27.3% of EP infants with BPD, CLD, or without BPD or CLD, respectively; most hospitalizations occurred for respiratory-related reasons. CONCLUSION: In this analysis of a large population of EP infants up to 2 years CA, respiratory conditions were prevalent after the birth hospitalization and were associated with high rates of medication and healthcare resource utilization.

Insurance coverage and respiratory morbidities in bronchopulmonary dysplasia.

INTRODUCTION: Preterm infants and young children with bronchopulmonary dysplasia (BPD) are at increased risk for acute care utilization and chronic respiratory symptoms during early life. Identifying risk factors for respiratory morbidities in the outpatient setting could decrease the burden of care. We hypothesized that public insurance coverage was associated with higher acute care usage and respiratory symptoms in preterm infants and children with BPD after initial neonatal intensive care unit (NICU) discharge. METHODS: Subjects were recruited from BPD clinics at 10 tertiary care centers in the United States between 2018 and 2021. Demographics and clinical characteristics were obtained through chart review. Surveys for clinical outcomes were administered to caregivers. RESULTS: Of the 470 subjects included in this study, 249 (53.0%) received employer-based insurance coverage and 221 (47.0%) received Medicaid as sole coverage at least once between 0 and 3 years of age. The Medicaid group was twice as likely to have sick visits (adjusted odd ratio [OR]: 2.06; p = 0.009) and emergency department visits (aOR: 2.09; p = 0.028), and three times more likely to be admitted for respiratory reasons (aOR: 3.04; p = 0.001) than those in the employer-based group. Additionally, those in the Medicaid group were more likely to have nighttime respiratory symptoms (aOR: 2.62; p = 0.004). CONCLUSIONS: Children with BPD who received Medicaid coverage were more likely to utilize acute care and have nighttime respiratory symptoms during the first 3 years of life. More comprehensive studies are needed to determine whether the use of Medicaid represents a barrier to accessing care, lower socioeconomic status, and/or a proxy for detrimental environmental exposures.

Pulmonary hypertension in infants with bronchopulmonary dysplasia: risk factors, mortality and duration of hospitalisation.

OBJECTIVES: Pulmonary hypertension (PH) is a complication of bronchopulmonary dysplasia (BPD) and associated with increased mortality and morbidity. Our aim was to identify, in infants with BPD, the effect of PH on health-care utilisation and health related cost of care. METHODS: An electronic data recording system was used to identify infants ≤32 weeks of gestation who developed BPD. PH was classified as early (≤28 days after birth) or late (>28 days after birth). RESULTS: In the study period, 182 infants developed BPD; 22 (12.1%) developed late PH. Development of late PH was associated with a lower gestational age [24.6 (23.9-26.9) weeks, p=0.001] and a greater need for positive pressure ventilation on day 28 after birth (100%) compared to infants without late PH (51.9%) (odds ratio (OR) 19.5, 95% CI: 2.6-148), p<0.001. Late PH was associated with increased mortality (36.4%) compared those who did not develop late PH (1.9%) after adjusting for gestational age and ventilation duration (OR: 26.9, 95% CI: 3.8-189.4), p<0.001. In infants who survived to discharge, late PH development was associated with a prolonged duration of stay [147 (118-189) days] compared to the infants that did not develop late PH [109 (85-149) days] (p=0.03 after adjusting for gestational age). Infants who had late PH had a higher cost of stay compared to infants with BPD who did not develop late PH (median £113,494 vs. £78,677, p=0.016 after adjusting for gestational age). CONCLUSIONS: Development of late PH was associated with increased mortality, a prolonged duration of stay and higher healthcare cost.

Cost-saving effect of early less invasive surfactant administration versus continuous positive airway pressure therapy alone for preterm infants with respiratory distress syndrome.

OBJECTIVES: Early rescue surfactant therapy using less invasive surfactant administration (LISA) can reduce the need for mechanical ventilation and avoid complications in preterm infants with respiratory distress syndrome. The purpose of this study was to estimate the budget impact of LISA compared with management based on continuous positive airway pressure (CPAP) alone and rescue surfactant therapy in case of CPAP failure. METHODS: A budget impact model was built comparing LISA with CPAP alone in order to estimate the potential resource consumption and budget impact from the perspective of the National Health Service in England. A literature review was conducted to populate the model. Deterministic and probabilistic sensitivity analyses were conducted to characterise the existing uncertainty and to explore the contribution of individual model parameters to the overall budget impact. RESULTS: Early rescue with LISA is expected to reduce resource consumption and costs compared with conservative therapy based on CPAP alone for preterm infants born at 25-32 weeks gestation. Savings are higher for preterm infants of 25-28 weeks (expected budget impact -£5146 per case, 95% credible interval (CrI) -£22 403 to £13, probability of being cost saving 97.4%) than for preterm infants of 29-32 weeks (-£176, 95% CrI -£4279 to £339, probability of being cost saving 85%). The impact of bronchopulmonary dysplasia (BPD) and intraventricular haemorrhage on resource consumption and the expected reduction in the incidence of BPD with LISA are the most influential parameters on the budget. CONCLUSIONS: Early rescue with LISA used in preterm infants with respiratory distress syndrome and fraction of inspired oxygen ≥0.3 is expected to be cost saving compared with management based on CPAP alone, particularly in those born at 25-28 weeks gestation.

Respiratory morbidity, healthcare resource use, and cost burden associated with extremely preterm birth in The Netherlands.

BACKGROUND: Extremely preterm (EP) infants have high rates of respiratory morbidity and correspondingly high healthcare resource utilization. OBJECTIVES: Data from the PHARMO Perinatal Research Network were analyzed to quantify the burden of EP birth in the Netherlands. METHODS: A retrospective analysis included infants <28 weeks gestational age with a birth record in the Perinatal Registry (1999-2015) and data in the PHARMO Database Network. Outcomes of interest included select comorbidities, hospital readmissions, and costs of hospitalization and medication up to 1- and 2-years corrected age. Outcomes were stratified by birth period (1999-2005, 2000-2009, 2010-2015) and by diagnosis of bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD). RESULTS: The cohort included 168 EP infants (37 born 1999-2005, 51 born 2006-2009, 80 born 2010-2015). Median (Q1-Q3) birth weights decreased by birth period from 970 (840-1,035) g in 1999-2005 to 853 (695-983) g in 2010-2015. Overall, BPD and CLD were reported during the birth hospitalization in 40% and 29% of infants, respectively; rates of BPD increased and rates of CLD decreased by birth period. Eighty-four percent of EP infants had an additional comorbidity. Mean (standard deviation) costs of birth hospitalization were €110,600 (€73,000) for 1999-2005, €119,350 (€60,650) for 2006-2009, and €138,800 (€130,100) for 2010-2015. Birth hospitalization and total costs for up to 1- and 2-years corrected age were higher for infants with BPD and/or CLD than for those without either complication. CONCLUSION: Healthcare resource utilization and costs for EP infants, especially for those with respiratory morbidities, increased between 1999 and 2015. Future cost-effectiveness analyses are essential to determine the economic impact of this change and underscore the need for new therapeutic interventions to decrease clinical sequelae in this vulnerable population.

Oxygen Toxicity to the Immature Lung-Part II: The Unmet Clinical Need for Causal Therapy.

Oxygen toxicity continues to be one of the inevitable injuries to the immature lung. Reactive oxygen species (ROS) production is the initial step leading to lung injury and, subsequently, the development of bronchopulmonary dysplasia (BPD). Today, BPD remains the most important disease burden following preterm delivery and results in life-long restrictions in lung function and further important health sequelae. Despite the tremendous progress in the pathomechanistic understanding derived from preclinical models, the clinical needs for preventive or curative therapies remain unmet. This review summarizes the clinical progress on guiding oxygen delivery to the preterm infant and elaborates future directions of research that need to take into account both hyperoxia and hypoxia as ROS sources and BPD drivers. Many strategies have been tested within clinical trials based on the mechanistic understanding of ROS actions, but most have failed to prove efficacy. The majority of these studies were tested in an era before the latest modes of non-invasive respiratory support and surfactant application were introduced or were not appropriately powered. A comprehensive re-evaluation of enzymatic, antioxidant, and anti-inflammatory therapies to prevent ROS injury is therefore indispensable. Strategies will only succeed if they are applied in a timely and vigorous manner and with the appropriate outcome measures.

Specificity of International Classification of Diseases codes for bronchopulmonary dysplasia: an investigation using electronic health record data and a large insurance database.

OBJECTIVE: International Classification of Diseases (ICD) codes in electronic health records (EHRs) are increasingly used for health services research, in spite of unknown diagnostic accuracy. The accuracy of ICD codes to identify bronchopulmonary dysplasia (BPD) is unknown. STUDY DESIGN: Retrospective cohort study in a single-center NICU (n = 166) to evaluate sensitivity and specificity of ICD-10 codes for the diagnosis of BPD. Analysis of large insurance claims database (n = 7887) to determine date of assignment of the code. RESULTS: The sensitivity of any BPD-related ICD codes ranged from 0.82 to 0.95, while the specificity ranged from 0.25 to 0.36. In a large national insurance database, the most common date of ICD-9 or ICD-10 code assignment was the day of birth, which is inconsistent with the clinical definition. CONCLUSIONS: ICD codes registered for BPD are unlikely to accurately reflect the current clinical definition and should be interpreted with caution.

Multimodal longitudinal respiratory function assessment in very low birth weight 7-year-old children.

PURPOSE: Preterm birth is associated with adverse pulmonary outcomes. We aimed to evaluate respiratory morbidities and lung function of very low birth weight (VLBW) Polish children followed up at the age of 7 years old, and to compare with electrical impedance segmentography (EIS) results recorded at 4 years of age. MATERIALS AND METHODS: VLBW children were compared with term controls using impulse oscillometry and spirometry. Perinatal data and current respiratory morbidities were analyzed and pulmonary function test results were compared with previous EIS results. RESULTS: We included 40 VLBW children and 30 controls in the analysis. Elevated total airway resistance and forced expiratory volume in the first second below the lower limit of normal were more prevalent in VLBW children compared with term controls (15 vs 0%; 18 vs 0%). A positive bronchodilator response was more common in VLBW children (R5 Hz: 46 vs 13.3%; R5-20 â€‹Hz: 65 vs 36.7%). Children with bronchopulmonary dysplasia (BPD) had higher total airway resistance (R5 Hz/R5 Hz pred: 1.35 vs 0.95; p â€‹< â€‹0.001), large airway resistance (R20 Hz/R20 Hz pred: 0.89 vs 0.66; p â€‹= â€‹0.001), small airway resistance (R5-20 â€‹Hz: 0.57 vs 0.34 â€‹kPa â€‹L-1 â€‹s-1; p â€‹= â€‹0.009), than controls. Strong correlation between BDR in EIS and R5 Hz/R5 Hz pred was observed in children with BPD (r â€‹= â€‹0.7). CONCLUSION: VLBW school-aged children with BPD presented with substantial respiratory morbidity and persistent reduction of lung function, affecting small and large airways and lung parenchyma. EIS may be an alternative tool for lung function assessment in children with BPD.

Prevalence of chronic respiratory morbidity, length of stay, inpatient readmissions, and costs among extremely preterm infants with bronchopulmonary dysplasia.

Objective: To evaluate the prevalence of chronic respiratory morbidity (CRM) in preterm infants (born ≤28 weeks gestational age (GA)) and compare healthcare resource utilization and costs among infants with/without CRM, and with/without bronchopulmonary dysplasia (BPD).Methods: Commercial claims data from the Truven MarketScan database were retrospectively analyzed. Included infants were born ≤28 weeks GA and admitted to a neonatal intensive care unit (January 2009-June 2016). Continuous insurance eligibility was required from birth through 1 year (CRM/no CRM cohorts) or ≥3 months (BPD/no BPD cohorts) CA or death.Results: CRM analysis included 1782 infants; 29.0% had CRM. BPD analysis included 2805 infants; 61.1% had BPD. The mean birth hospital length of stay was longer in infants with CRM versus those with no CRM (p < 0.0001). In infants with CRM or BPD, hospital readmission rates were significantly increased versus those without (both p < 0.0001). Total health care costs were significantly higher in infants with CRM (p = 0.0488) and BPD (p < 0.0001) versus those without. After birth hospitalization, outpatient visits and hospital readmissions accounted for most of the costs for the CRM and BPD cohorts.Conclusion: CRM and BPD following extremely preterm birth impose a significant health care burden.

Readmissions among NICU graduates: Who, when and why?

Readmission amongst previous neonatal intensive care unit (NICU) graduates, especially for preterm infants, is common and remains a significant risk for these infants beyond the neonatal period. This review explores risk factors for readmissions, common reasons for requiring rehospitalization and explores opportunities for improving the transition from discharge to home with the ultimate goal of reducing readmissions for these high risk infants.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status.

OBJECTIVE: To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge. STUDY DESIGN: This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37 weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5 days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors. RESULTS: Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5 years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits. CONCLUSIONS: Among immigrant mothers, non-English primary language, >5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Home Oxygen Use and 1-Year Readmission among Infants Born Preterm with Bronchopulmonary Dysplasia Discharged from Children's Hospital Neonatal Intensive Care Units.

OBJECTIVE: To determine associations between home oxygen use and 1-year readmissions for preterm infants with bronchopulmonary dysplasia (BPD) discharged from regional neonatal intensive care units. STUDY DESIGN: We performed a secondary analysis of the Children's Hospitals Neonatal Database, with readmission data via the Pediatric Hospital Information System and demographics using ZIP-code-linked census data. We included infants born <32 weeks of gestation with BPD, excluding those with anomalies and tracheostomies. Our primary outcome was readmission by 1 year corrected age; secondary outcomes included readmission duration, mortality, and readmission diagnosis-related group codes. A staged multivariable logistic regression was adjusted for center, clinical, and social risk factors; at each stage we included variables associated at P < .1 in bivariable analysis with home oxygen use or readmission. RESULTS: Home oxygen was used in 1906 of 3574 infants (53%) in 22 neonatal intensive care units. Readmission occurred in 34%. Earlier gestational age, male sex, gastrostomy tube, surgical necrotizing enterocolitis, lower median income, nonprivate insurance, and shorter hospital-to-home distance were associated with readmission. Home oxygen was not associated with odds of readmission (OR, 1.2; 95% CI, 0.98-1.56), readmission duration, or mortality. Readmissions for infants with home oxygen were more often coded as BPD (16% vs 4%); readmissions for infants on room air were more often gastrointestinal (29% vs 22%; P < .001). Clinical risk factors explained 72% of center variance in readmission. CONCLUSIONS: Home oxygen use is not associated with readmission for infants with BPD in regional neonatal intensive care units. Center variation in home oxygen use does not impact readmission risk. Nonrespiratory problems are important contributors to readmission risk for infants with BPD.

Ultrashort Echo-Time MRI for the Assessment of Tracheomalacia in Neonates.

BACKGROUND: Bronchoscopy is the gold standard for evaluating tracheomalacia; however, reliance on an invasive procedure limits understanding of normal airway dynamics. Self-gated ultrashort echo-time MRI (UTE MRI) can assess tracheal dynamics but has not been rigorously evaluated. METHODS: This study was a validation of UTE MRI diagnosis of tracheomalacia in neonates using bronchoscopy as the gold standard. Bronchoscopies were reviewed for the severity and location of tracheomalacia based on standardized criteria. The percent change in cross-sectional area (CSA) of the trachea between end-inspiration and end-expiration was determined by UTE MRI, and receiver-operating curves were used to determine the optimal cutoff values to predict tracheomalacia and determine positive and negative predictive values. RESULTS: Airway segments with tracheomalacia based on bronchoscopy had a more than threefold change in CSA measured from UTE MRI (54.4 ± 56.1% vs 14.8 ± 19.5%; P < .0001). UTE MRI correlated moderately with bronchoscopy for tracheomalacia severity (ρ = 0.39; P = .0001). Receiver-operating curves, however, showed very good ability of UTE MRI to identify tracheomalacia (area under the curve, 0.78). A "loose" definition (> 20% change in CSA) of tracheomalacia had good sensitivity (80%) but low specificity (64%) for identifying tracheomalacia based on UTE MRI, whereas a "strict" definition (> 40% change in CSA) was poorly sensitive (48%) but highly specific (93%). CONCLUSIONS: Self-gated UTE MRI can noninvasively assess tracheomalacia in neonates without sedation, ionizing radiation, or increased risk. This technique overcomes major limitations of other diagnostic modalities and may be suitable for longitudinal population studies of tracheal dynamics.

Short-term outcomes of extremely preterm infants at discharge: a multicenter study from Guangdong province during 2008-2017.

BACKGROUND: An increasing number of extremely preterm (EP) infants have survived worldwide. However, few data have been reported from China. This study was designed to investigate the short-term outcomes of EP infants at discharge in Guangdong province. METHODS: A total of 2051 EP infants discharged from 26 neonatal intensive care units during 2008-2017 were enrolled. The data from 2008 to 2012 were collected retrospectively, and from 2013 to 2017 were collected prospectively. Their hospitalization records were reviewed. RESULTS: During 2008-2017, the mean gestational age (GA) was 26.68 ± 1.00 weeks and the mean birth weight (BW) was 935 ± 179 g. The overall survival rate at discharge was 52.5%. There were 321 infants (15.7%) died despite active treatment, and 654 infants (31.9%) died after medical care withdrawal. The survival rates increased with advancing GA and BW (p < 0.001). The annual survival rate improved from 36.2% in 2008 to 59.3% in 2017 (p < 0.001). EP infants discharged from hospitals in Guangzhou and Shenzhen cities had a higher survival rate than in others (p < 0.001). The survival rate of EP infants discharged from general hospitals was lower than in specialist hospitals (p < 0.001). The major complications were neonatal respiratory distress syndrome, 88.0% (1804 of 2051), bronchopulmonary dysplasia, 32.3% (374 of 1158), retinopathy of prematurity (any grade), 45.1% (504 of 1117), necrotizing enterocolitis (any stage), 10.1% (160 of 1588), intraventricular hemorrhages (any grade), 37.4% (535 of 1431), and blood culture-positive nosocomial sepsis, 15.7% (250 of 1588). The multivariate logistic regression analysis indicated that improved survival of EP infants was associated with discharged from specialist hospitals, hospitals located in high-level economic development region, increasing gestational age, increasing birth weight, antenatal steroids use and a history of premature rupture of membranes. However, twins or multiple births, Apgar ≤7 at 5 min, cervical incompetence, and decision to withdraw care were associated with decreased survival. CONCLUSIONS: Our study revealed the short-term outcomes of EP infants at discharge in China. The overall survival rate was lower than the developed countries, and medical care withdrawal was a serious problem. Nonetheless, improvements in care and outcomes have been made annually.