Assessment of Neonatal Intensive Care Unit Practices, Morbidity, and Mortality Among Very Preterm Infants in China.

Importance: The Chinese Neonatal Network was established in 2018 and maintains a standardized national clinical database of very preterm or very low-birth-weight infants in tertiary neonatal intensive care units (NICUs) throughout China. National-level data on outcomes and care practices of very preterm infants (VPIs) in China are lacking. Objective: To assess the care practices in NICUs and outcomes among VPIs in China. Design, Setting, and Participants: A cohort study was conducted comprising 57 tertiary hospitals from 25 provinces throughout China. All infants with gestational age (GA) less than 32 weeks who were admitted to the 57 NICUs between January 1 and December 31, 2019, were included. Main Outcomes and Measures: Care practices, morbidities, and survival were the primary outcomes of the study. Major morbidities included bronchopulmonary dysplasia, severe intraventricular hemorrhage (grade ≥3) and/or periventricular leukomalacia, necrotizing enterocolitis (stage ≥2), sepsis, and severe retinopathy of prematurity (stage ≥3). Results: A total of 9552 VPIs were included, with mean (SD) GA of 29.5 (1.7) weeks and mean (SD) birth weight of 1321 (321) g; 5404 infants (56.6%) were male. Antenatal corticosteroids were used in 75.6% (6505 of 8601) of VPIs, and 54.8% (5211 of 9503)were born through cesarean delivery. In the delivery room, 12.1% of VPIs received continuous positive airway pressure and 26.7% (2378 or 8923) were intubated. Surfactant was prescribed for 52.7% of the infants, and postnatal dexamethasone was prescribed to 9.5% (636 of 6675) of the infants. A total of 85.5% (8171) of the infants received complete care, and 14.5% (1381) were discharged against medical advice. The incidences of the major morbidities were bronchopulmonary dysplasia, 29.2% (2379 of 8148); severe intraventricular hemorrhage and/or periventricular leukomalacia, 10.4% (745 of 7189); necrotizing enterocolitis, 4.9% (403 of 8171 ); sepsis, 9.4% (764 of 8171); and severe retinopathy of prematurity, 4.3% (296 of 6851) among infants who received complete care. Among VPIs with complete care, 95.4% (7792 of 8171) survived: 65.6% (155 of 236) at 25 weeks' or less GA, 89.0% (880 of 988) at 26 to 27 weeks' GA, 94.9% (2635 of 2755)at 28 to 29 weeks' GA, and 98.3% (4122 of 4192) at 30 to 31 weeks' GA. Only 57.2% (4677 of 8171) of infants survived without major morbidity: 10.5% (25 of 236) at 25 weeks' or less GA, 26.8% (48 of 179) at 26 to 27 weeks' GA, 51.1% (1409 of 2755) at 28 to 29 weeks' GA, and 69.3% (2904 of 4192) at 30 to 31 weeks' GA. Among all infants admitted, the survival rate was 87.6% (8370 of 9552)and survival without major morbidities was 51.8% (4947 of 9552). Conclusions and Relevance: The findings of this study suggest that survival and survival without major morbidity of VPIs in Chinese NICUs have improved but remain lower than in high-income countries. Comprehensive and targeted quality improvement efforts are needed to provide complete care for all VPIs, optimize obstetrical and neonatal care practices, and improve outcomes.

Trends in the incidence and management of hypoxic-ischaemic encephalopathy in the therapeutic hypothermia era: a national population study.

OBJECTIVE: Hypoxic-ischaemic encephalopathy (HIE) remains a leading cause of neonatal mortality and neurodisability. We aimed to determine the incidence of HIE and management patterns against national guidelines. DESIGN: Retrospective cohort study using the National Neonatal Research Database. SETTING: Neonatal units in England and Wales. PATIENTS: Infants 34-42 weeks gestational age (GA) with a recorded diagnosis of HIE. MAIN OUTCOMES: Incidence of HIE, mortality and treatment with therapeutic hypothermia (TH) were the main outcomes. Temporal changes were compared across two epochs (2011-2013 and 2014-2016). RESULTS: Among 407 462 infants admitted for neonatal care, 12 195 were diagnosed with HIE. 8166 infants ≥36 weeks GA had moderate/severe HIE, 62.1% (n=5069) underwent TH and mortality was 9.3% (n=762). Of infants with mild HIE (n=3394), 30.3% (n=1027) underwent TH and 6 died. In late preterm infants (34-35 weeks GA) with HIE (n=635, 5.2%), 33.1% (n=210) received TH and 13.1% (n=83) died. Between epochs (2011-2013 vs 2014-2016), mortality decreased for infants ≥36 weeks GA with moderate/severe HIE (17.5% vs 12.3%; OR 0.69, 95% CI 0.59 to 0.81, p<0.001). Treatment with TH increased significantly between epochs in infants with mild HIE (24.9% vs 35.8%, p<0.001) and those born late preterm (34.3% vs 46.6%, p=0.002). CONCLUSIONS: Mortality of infants ≥36 weeks GA with moderate/severe HIE has reduced over time, although many infants diagnosed with moderate/severe HIE do not undergo TH. Increasingly, mild HIE and late preterm infants with HIE are undergoing TH, where the evidence base is lacking, highlighting the need for prospective studies to evaluate safety and efficacy in these populations.

Antenatal care of mothers and morbidity and mortality disparities among preterm Saudi and non-Saudi infants less than or equal to 32 weeks' gestation.

BACKGROUND: Premature non-Saudi infants comprise a significant proportion of neonatal intensive care unit admissions in Saudi Arabia. Any differences in antenatal care of mothers and neonatal outcomes compared with premature Saudi infants are unreported. OBJECTIVE: Assess antenatal care of mothers and neonatal outcomes among premature Saudi and non-Saudi infants, and investigate possible reasons for disparities. DESIGN: Retrospective cohort study. SETTING: Tertiary care center in Riyadh. PATIENTS AND METHODS: All neonates of gestational age ≤32 weeks and birthweight <1500 g admitted from 2015 to 2019 were included. MAIN OUTCOME MEASURES: Antenatal care of mothers and rates of neonatal mortality and morbidity in premature Saudi and non-Saudi infants. SAMPLE SIZE: 755 premature infants, 437 (57.9%) Saudi, 318 (42.1%) non-Saudi. RESULTS: Saudi mothers received more antenatal steroids and were more likely to have gestational diabetes mellitus (P=.01 and .03, respectively). Non-Saudi mothers were more likely to have pregnancy-induced hypertension (P=.01). Non-Saudi infants had significantly higher rates of intraventricular hemorrhage, patent ductus arteriosus, pulmonary hemorrhage, bronchopulmonary dysplasia and necrotizing enterocolitis compared with Saudi infants (P=.03, <.001, .04, .002, and <.001, respectively). There were no significant differences in mortality rate, early-onset sepsis, and late-onset sepsis between Saudi and non-Saudi infants (P=.81, .81, and .12, respectively). CONCLUSIONS: Disparities exist in the antenatal care of Saudi and non-Saudi women and in the neonatal morbidities of their premature infants. There was no difference in the neonatal mortality rate. More quality improvement initiatives are required to reduce differences in antenatal and neonatal outcomes. LIMITATIONS: Retrospective, socioeconomic disparities not identified. CONFLICT OF INTEREST: None.

Ethnic and socioeconomic variation in cause-specific preterm infant mortality by gestational age at birth: national cohort study.

OBJECTIVE: To describe ethnic and socioeconomic variation in cause-specific infant mortality of preterm babies by gestational age at birth. DESIGN: National birth cohort study. SETTING: England and Wales 2006-2012. SUBJECTS: Singleton live births at 24-36 completed weeks' gestation (n=256 142). OUTCOME MEASURES: Adjusted rate ratios for death in infancy by cause (three groups), within categories of gestational age at birth (24-27, 28-31, 32-36 weeks), by baby's ethnicity (nine groups) or area deprivation score (Index of Multiple Deprivation quintiles). RESULTS: Among 24-27 week births (5% of subjects; 47% of those who died in infancy), all minority ethnic groups had lower risk of immaturity-related death than White British, the lowest rate ratios being 0.63 (95% CI 0.49 to 0.80) for Black Caribbean, 0.74 (0.64 to 0.85) for Black African and 0.75 (0.60 to 0.94) for Indian. Among 32-36 week births, all minority groups had higher risk of death from congenital anomalies than White British, the highest rate ratios being 4.50 (3.78 to 5.37) for Pakistani, 2.89 (2.10 to 3.97) for Bangladeshi and 2.06 (1.59 to 2.68) for Black African; risks of death from congenital anomalies and combined rarer causes (infection, intrapartum conditions, SIDS and unclassified) increased with deprivation, the rate ratios comparing the most with the least deprived quintile being, respectively, 1.54 (1.22 to 1.93) and 2.05 (1.55 to 2.72). There was no evidence of socioeconomic variation in deaths from immaturity-related conditions. CONCLUSIONS: Gestation-specific preterm infant mortality shows contrasting ethnic patterns of death from immaturity-related conditions in extremely-preterm babies, and congenital anomalies in moderate/late-preterm babies. Socioeconomic variation derives from congenital anomalies and rarer causes in moderate/late-preterm babies. Future research should examine biological origins of extremely preterm birth.

Differential effects of delivery hospital on mortality and morbidity in minority premature and low birth weight neonates.

OBJECTIVE: To describe variation in mortality and morbidity effects of high-level, high-volume delivery hospital between racial/ethnic groups and insurance groups. STUDY DESIGN: Retrospective cohort including infants born at 24-32 weeks gestation or birth weights ≤2500 g in California, Missouri, and Pennsylvania between 1995 and 2009 (n = 636,764). Multivariable logistic random-effects models determined differential effects of birth hospital level/volume on mortality and morbidity through an interaction term between delivery hospital level/volume and either maternal race or insurance status. RESULT: Compared to non-Hispanic white neonates, odds of complications of prematurity were 14-25% lower for minority infants in all gestational age and birth weight cohorts delivering at high-level, high-volume centers (odds ratio (ORs) 0.75-0.86, p < 0.001-0.005). Effect size was greatest for Hispanic infants. No difference was noted by insurance status. CONCLUSIONS: Neonates of minority racial/ethnic status derive greater morbidity benefits than non-Hispanic white neonates from delivery at hospitals with high-level, high-volume neonatal intensive care units.

General Movement assessment and neurodevelopmental trajectory in extremely preterm infants with hypothyroxinaemia of prematurity (THOP).

BACKGROUND: Transient hypothyroxinaemia of prematurity (THOP) has been associated with neurodevelopmental deficits with a paucity of literature leading to variable practice. AIM: Evaluation of the relationship between free T4 (fT4) levels at 2 weeks after birth and early markers of neurodevelopmental outcome. STUDY DESIGN: A retrospective study of prospectively collected data from infants born <29 weeks' gestation, admitted to NICU between January 2012 and December 2014. The primary outcomes were the relationship between fT4 levels at 2 weeks, Prechtl General Movement Assessment (GMA) at 36 weeks and 3 months postterm age, and Bayley Scales of Infant Development (BSID-III) at 2 years postterm age. Secondary outcomes were survival free of disability and other neonatal morbidities. RESULTS: Of 122 infants, 101 infants had normal fT4 levels (No-THOP) and 21 had fT4 levels >1SD below the mean (THOP group). There was increased frequency of abnormal GMA in the No-THOP group compared with the THOP group at 36 weeks (abnormal writhing GMs: 43% vs 21%, p = 0.15) and 3 months corrected age (absent fidgety GMs: 7.6% vs 0%, p = 0.36), though not statistically significant. The neurodevelopmental outcome was worse in the No-THOP group compared with the THOP group with significantly lower mean cognitive and motor scores at 2 year of corrected age (90 ±â€¯13.8 vs 100 ±â€¯8.3, p = 0.01 and 91 ±â€¯15.2 vs 100 ±â€¯13.2, p = 0.04 respectively). CONCLUSIONS: This is the first report describing General Movements (GMs) in preterm infants with THOP. We found worse neurodevelopmental outcome in No-THOP infants reflected by significantly worse cognitive and motor outcomes at 2 years corrected age.

Mortality in the Great Maghreb (1990-2015): causes of death and trends.

OBJECTIVES: To describe trends of gross and specific mortality rates for all five countries of the Great Maghreb and to identify the typology and the main causes of death during the period 1990-2015. METHODS: This is an observational and descriptive study of causes of death in the Great Maghreb (Tunisia, Algeria, Morocco, Mauritania and Libya) using the database Global Burden of Diseases (GBD) of the Institute for Health Metrics and Evaluation (IHME). Causes of death were categorized according to the IHME into three categories: "Communicable Diseases", "Non Communicable Diseases" and "Trauma". These following tracer years (1995, 2005, 2015) were considered in the study of global and specific causes of death by country, disease group, sex and age group. RESULTS: During the period 1990-2015, the general trend in gross mortality rates was going down, reaching in 2015 rates that varied from 547/100 000 inhabitants in Tunisia to 437/100 000 inhabitants in Algeria. The trend in specific mortality from Communicable Diseases has been declining, particularly in Mauritania. Among the "Top 10" list of causes of death, four to eight were "Non Communicable Diseases" including ischemic heart disease, which was ranked first in the Maghreb except Mauritania. For children under 5 years old, prematurity was the leading cause of death in the five Maghreb countries in 2015. CONCLUSION: This analysis of causes of death in the Great Maghreb confirmed the similarity of the epidemiological transition and health priorities. Hence the urgency of developing common North African strategies for monitoring, training and intervention in public health.

Very Preterm Infants with Technological Dependence at Home: Impact on Resource Use and Family.

OBJECTIVE: To examine the impact of medical complexity among very preterm infants on health care resource use, family, and neurodevelopmental outcomes at 18 months' corrected age. METHODS: This observational cohort study of Canadian infants born < 29 weeks' gestational age in 2009-2011 compared infants with and those without medical complexity defined as discharged home with assistive medical technology. Health care resource use and family outcomes were collected. Children were assessed for cerebral palsy, deafness, blindness, and developmental delay at 18 months. Logistic regression analysis was performed for group comparisons. RESULTS: Overall, 466/2,337 infants (20%) needed assistive medical technology at home including oxygen (79%), gavage feeding (21%), gastrostomy or ileostomy (20%), CPAP (5%), and tracheostomy (3%). Children with medical complexity were more likely to be re-hospitalized (OR 3.6, 95% CI 3.0-4.5) and to require ≥2 outpatient services (OR 4.4, 95% CI 3.5-5.6). Employment of both parents at 18 months was also less frequent in those with medical complexity compared to those without medical complexity (52 vs. 60%, p < 0.01). Thirty percent of children with medical complexity had significant neurodevelopmental impairment compared to 13% of those without medical complexity (p < 0.01). Lower gestational age, lower birth weight, bronchopulmonary dysplasia, sepsis, and surgical necrotizing enterocolitis were associated with a risk of medical complexity. CONCLUSION: Medical complexity is common following very preterm birth and has a significant impact on health care use as well as family employment and is more often associated with neurodevelopmental disabilities. Efforts should be deployed to facilitate care coordination upon hospital discharge and to support families of preterm children with medical complexity.

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

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.

Early treatment versus expectative management of patent ductus arteriosus in preterm infants: a multicentre, randomised, non-inferiority trial in Europe (BeNeDuctus trial).

BACKGROUND: Much controversy exists about the optimal management of a patent ductus arteriosus (PDA) in preterm infants, especially in those born at a gestational age (GA) less than 28 weeks. No causal relationship has been proven between a (haemodynamically significant) PDA and neonatal complications related to pulmonary hyperperfusion and/or systemic hypoperfusion. Although studies show conflicting results, a common understanding is that medical or surgical treatment of a PDA does not seem to reduce the risk of major neonatal morbidities and mortality. As the PDA might have closed spontaneously, treated children are potentially exposed to iatrogenic adverse effects. A conservative approach is gaining interest worldwide, although convincing evidence to support its use is lacking. METHODS: This multicentre, randomised, non-inferiority trial is conducted in neonatal intensive care units. The study population consists of preterm infants (GA < 28 weeks) with an echocardiographic-confirmed PDA with a transductal diameter > 1.5 mm. Early treatment (between 24 and 72 h postnatal age) with the cyclooxygenase inhibitor (COXi) ibuprofen (IBU) is compared with an expectative management (no intervention intended to close a PDA). The primary outcome is the composite of mortality, and/or necrotising enterocolitis (NEC) Bell stage ≥ IIa, and/or bronchopulmonary dysplasia (BPD) defined as the need for supplemental oxygen, all at a postmenstrual age (PMA) of 36 weeks. Secondary outcome parameters are short term sequelae of cardiovascular failure, comorbidity and adverse events assessed during hospitalization and long-term neurodevelopmental outcome assessed at a corrected age of 2 years. Consequences regarding health economics are evaluated by cost effectiveness analysis and budget impact analysis. DISCUSSION: As a conservative approach is gaining interest, we investigate whether in preterm infants, born at a GA less than 28 weeks, with a PDA an expectative management is non-inferior to early treatment with IBU regarding to the composite outcome of mortality and/or NEC and/or BPD at a PMA of 36 weeks. TRIAL REGISTRATION: This trial is registered with the Dutch Trial Register NTR5479 (registered on 19 October 2015), the registry sponsored by the United States National Library of Medicine Clinicaltrials.gov NCT02884219 (registered May 2016) and the European Clinical Trials Database EudraCT 2017-001376-28 .

A care bundle including antenatal corticosteroids reduces preterm infant mortality in Tanzania a low resource country.

BACKGROUND: Preterm neonatal mortality (NM) has remained high and unchanged for many years in Tanzania, a resource-limited country. Major causes of mortality include birth asphyxia, respiratory insufficiency and infections. Antenatal corticosteroids (ACS) have been shown to significantly reduce mortality in developed countries. There is inconsistent use of ACS in Tanzania. OBJECTIVE: To determine whether implementation of a care bundle that includes ACS, maternal antibiotics (MA), neonatal antibiotics (NA) and avoidance of moderate hypothermia (temperature < 36°C) targeting infants of estimated gestational age (EGA) 28 to 34 6/7 weeks would reduce NM (< 7 days) by 35%. METHODS: A Pre (September 2014 to May 2015) and Post (June 2015 to June 2017) Implementation strategy was used and introduced at three University-affiliated and one District Hospital. Dexamethasone, as the ACS, was added to the national formulary in May 2015, facilitating its free use down to the district level. FINDINGS: NM was reduced 26% from 166 to 122/1000 livebirths (P = 0.005) and fresh stillbirths (FSB) 33% from 162/1000 to 111/1000 (p = 0.0002) Pre versus Post Implementation. Medications including combinations increased significantly at all sites (p<0.0001). By logistic regression, combinations of ACS, maternal and NA (odds ratio (OR) 0.33), ACS and NA (OR 0.30) versus no treatment were significantly associated with reduced NM. NM significantly decreased per 250g birthweight increase (OR 0.59), and per one week increase in EGA (OR 0.87). Moderate hypothermia declined pre versus post implementation (p<0.0001) and was two-fold more common in infants who died versus survivors. INTERPRETATION: A low-cost care bundle, ~$6 per patient, was associated with a significant reduction in NM and FSB rates. The former presumably by reducing respiratory morbidity with ACS and minimizing infections with antibiotics. If these findings can be replicated in other resource-limited settings, the potential for further reduction of <5 year mortality rates becomes enormous.

Assessment of sickness severity of illness in neonates: review of various neonatal illness scoring systems.

Sickness severity scores are widely used for neonates admitted to neonatal intensive care units to predict severity of illness and risk of mortality and long-term outcome. These scores are also used frequently for quality assessment among various neonatal intensive care unit and hospital. Accurate and reliable measures of severity of illness are required for unbiased and reliable comparisons especially for benchmarking or comparative quality improvement care studies. These scores also serve to control for population differences when performing studies such as clinical trials, outcome evaluations, and evaluation of resource utilisation. Although presently there are multiple scores designed for neonates' sickness assessment but none of the score is ideal. Each score has its own advantages and disadvantages. We did literature search for identifying all neonatal sickness severity score and in this review article, we discuss these scores along with their merits and demerits.

Racial and Ethnic Disparities in Preterm Infant Mortality and Severe Morbidity: A Population-Based Study.

BACKGROUND: Disparities exist in the rates of preterm birth and infant mortality across different racial/ethnic groups. However, only a few studies have examined the impact of race/ethnicity on the outcomes of premature infants. OBJECTIVE: To report the rates of mortality and severe neonatal morbidity among multiple gestational age (GA) groups stratified by race/ethnicity. METHODS: A retrospective cohort study utilizing linked birth certificate, hospital discharge, readmission, and death records up to 1 year of life. Live-born infants ≤36 weeks born in the period 2007-2012 were included. Maternal self-identified race/ethnicity, as recorded on the birth certificate, was used. ICD-9 diagnostic and procedure codes captured neonatal morbidities (intraventricular hemorrhage, retinopathy of prematurity, periventricular leukomalacia, bronchopulmonary dysplasia, and necrotizing enterocolitis). Multiple logistic regression was performed to evaluate the impact of race/ethnicity on mortality and morbidity, adjusting for GA, birth weight, sex, and multiple gestation. RESULTS: Our cohort totaled 245,242 preterm infants; 26% were white, 46% Hispanic, 8% black, and 12% Asian. At 22-25 weeks, black infants were less likely to die than white infants (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.62-0.94). However, black infants born at 32-34 weeks (OR 1.64; 95% CI 1.15-2.32) or 35-36 weeks (OR 1.57; 95% CI 1.00-2.24) were more likely to die. Hispanic infants born at 35-36 weeks were less likely to die than white infants (OR 0.66; 95% CI 0.50-0.87). Racial disparities at different GAs were also detected for severe morbidities. CONCLUSIONS: The impact of race/ethnicity on mortality and severe morbidity varied across GA categories in preterm infants. Disparities persisted even after adjusting for important potential confounders.

Survival, Hospitalization, and Acute-Care Costs of Very and Moderate Preterm Infants in the First 6 Years of Life: A Population-Based Study.

OBJECTIVES: To investigate survival, hospitalization, and acute-care costs of very (28-31 weeks' gestation) and moderate preterm (32-33 weeks' gestation) infants in the first 6 years of life and compare outcomes with the more widely studied extremely preterm infants (24-27 weeks' gestation) and to full term (low risk) infants (39-40 weeks' gestation). STUDY DESIGN: Birth data from all women residing in New South Wales, Australia, with gestational ages between 24-33 and 39-40 weeks in 2001-2011 were linked probabilistically to hospitalization and mortality data. Study outcomes were evaluated with the use of descriptive and multivariable analyses at birth (N = 559,532), discharge (N = 540,240), and at 1 (N = 487,447) and 6 years of age (N = 230,498). RESULTS: Mortality was greatest among extremely preterm infants (eg, 31.2% within 6 years) and decreased with increasing gestational age. Likewise, hospitalization within the first year of life increased with decreasing gestational age (aOR 5.5 [95% CI 4.7-6.4], 3.7 [3.4-4.0], and 2.6 [2.5-2.8] for birth at 24-27, 28-31, and 32-33 weeks' gestation, relative to 39-40 weeks' gestation). Hospitalization remained significantly increased with preterm birth at each year of age up to 6 years (aORs 1.3-1.6 at 6 years). Cumulative costs were significantly greater with preterm birth within the first year of life, and also between 1 and 6 years of age. CONCLUSIONS: The risks of adverse health outcomes were significantly greater in very and moderately preterm infants relative to full term infants but lower than extremely preterm infants. Crucially, preterm birth was associated with prolonged increased odds of hospitalization (up to age 6 years), contributing to greater resource use.

Antenatal corticosteroids: analytical decision model and economic analysis in a Brazilian cohort of preterm infants.

OBJECTIVE: To analyze the hospital costs and the effectiveness of antenatal corticosteroid (ACS) therapy in a cohort of Brazilian preterm infants. METHODS: Infants with gestational age (GA) 26 to 32 weeks, born between 2006 and 2009 in a tertiary university hospital and who survived hospitalization were included. A decision tree was built according to GA (26-27, 28-29, 30-31 and 32 weeks), assuming that each patient exposed or not to ACS may or not develop one of the clinical outcomes included in the model. The cost of each outcome was calculated by microcosting. Sensitivity analysis tested the model stability and calculated outcomes and costs per 1000 patients. RESULTS: The cost-effectiveness analysis indicated that ACS reduced USD 3413 in hospital costs per patient exposed to ACS. Its use decreased oxygen dependency at 36 weeks in 11%, advanced resuscitation in delivery room in 24%, severe peri-intraventricular hemorrhage in 12%, patent ductus arteriosus requiring surgery in 3.6% and retinopathy of prematurity in 0.3%, but increased the probability of late-onset sepsis in 2.5%. The sensitivity analysis indicated that ACS was dominant over no ACS therapy for most outcomes. CONCLUSION: The results indicate that ACS therapy decreases costs and severe neonatal outcomes of preterm infants.

Association of unit size, resource utilization and occupancy with outcomes of preterm infants.

OBJECTIVE: Assess association of NICU size, and occupancy rate and resource utilization at admission with neonatal outcome. STUDY DESIGN: Retrospective cohort study of 9978 infants born at 23-32 weeks gestation and admitted to 23 tertiary-level Canadian NICUs during 2010-2012. Adjusted odds ratios (AOR) were estimated for a composite outcome of mortality/any major morbidity with respect to NICU size, occupancy rate and intensity of resource utilization at admission. RESULTS: A total of 2889 (29%) infants developed the composite outcome, the odds of which were higher for 16-29, 30-36 and >36-bed NICUs compared with <16-bed NICUs (AOR (95% CI): 1.47 (1.25-1.73); 1.49 (1.25-1.78); 1.55 (1.29-1.87), respectively) and for NICUs with higher resource utilization at admission (AOR: 1.30 (1.08-1.56), Q4 vs Q1) but not different according to NICU occupancy. CONCLUSION: Larger NICUs and more intense resource utilization at admission are associated with higher odds of a composite adverse outcome in very preterm infants.

Characterizing the burden of invasive Pseudomonas infection on neonatal units in the UK between 2005 and 2011.

Concern about Pseudomonas infection in neonatal units has focused on outbreaks. This study analysed cases of invasive Pseudomonas infection in 18 UK neonatal units participating in the NeonIN Neonatal Infection Surveillance Network from January 2005 to December 2011. Forty-two cases were reported. The majority (35/42, 93%) of cases were late-onset (median 14 days, range 2-262 days), the highest incidence was seen in extremely-low-birthweight infants and all cases were sporadic. One-third of cases were known to be colonized prior to invasive disease. Attributable mortality was 18%. Opportunities for preventing invasive disease due to this important pathogen should be prioritized.

Outcomes in preterm infants.

Preterm birth is defined as birth before 37 completed weeks gestation, and it is estimated that each day, across the world over 41,000 infants are born before this gestational age. The risk of adverse consequences declines with increasing gestational age. While this paper focuses on the consequences of preterm birth, the adverse consequences for infants born at 38 and 39 weeks gestation are also of a higher risk than those for infants born at 40 weeks gestation, with the neonatal mortality risk increasing again in infants born beyond the 42nd week of gestation.

[Health insurance expenses for children in the first five years of life - a cohort-based analysis]. / Ausgaben einer Krankenkasse für Kinder in den ersten fünf Lebensjahren - eine kohortenbasierte Analyse.

INTRODUCTION: The development of paediatrics is characterised by several changes in the past few years, concerning, in particular holistic treatments or preventive check-ups, but also the transfer of treatment from the inpatient to the outpatient sector. There are no reference values for assessing emerging health insurance expenses. The aim of this study was to obtain a frame of reference for the costs of the treatment for neonates, infants, and young children using the example of the expenditures of one health insurance fund. METHODS: The individual health insurance expenditures were analysed for the first five years of life of children insured with the AOK PLUS in Saxony, Germany, in 2005. Costs of hospital treatment, ambulatory care, remedies, tools, medicines and care were included. RESULTS: The costs per insured child and year amounted to approximately 1,277 Euro (N = 11,147), with the highest costs arising in the first two years. 858 Euro were spent annually for an "average" child; 5,691 Euro per year incurred for a child with special medical needs. DISCUSSION: The present cost analysis describes both the height and structure of a health insurance's spendings on children within the first five years of their life in consideration of regional medical care offers. The question of whether this analysis provides valid reference values for other health insurances or other service areas will have to be answered by other analyses.

Effect of adopting host-country nationality on perinatal mortality rates and causes among immigrants in Brussels.

OBJECTIVES: Perinatal mortality rates vary between ethnic groups but the relation with immigrant status is unclear. Previous research suggested that birth outcomes may either improve or deteriorate with duration of residence, depending on the migrant group. The objectives of this study are to describe and measure inequalities in pregnancy outcomes, perinatal mortality and causes of perinatal deaths according to current citizenship versus national origin of the mother, in Brussels. STUDY DESIGN: This is a population-based cohort study using data from linked birth and death certificates from the Belgian civil registration system. The data relate to all babies born between 1998 and 2008, whose mothers were living in Brussels, irrespective of the place of delivery. We used a logistic regression to estimate the odds ratios (ORs) for the association between mortality, causes of deaths and nationality. RESULTS: Women from Morocco, sub-Saharan Africa and Turkey experience an 80% excess in perinatal mortality (p<0.0001) compared to Belgians, but this excess of perinatal mortality is not observed for mothers with Belgian citizenship at delivery. For sub-Saharan African women, this excess is caused mainly by immaturity-related conditions and reflects a high rate of preterm deliveries, low birth weight and a low socio-economic level. Moroccan and Turkish mothers have favourable pregnancy outcomes that persist after adopting Belgian nationality, but they experience a strong excess of perinatal mortality, mainly due to congenital anomalies and asphyxia or unexplained deaths prior to the onset of labour. CONCLUSION: In Brussels, perinatal mortality varies according to nationality but those differences do not persist after adopting Belgian nationality. The explanation of this positive effect is probably due to a mix of determinants such as acculturation, use of health services or cultural contexts. Further analysis should help to better understand the results observed.