Quality improvement in maternal and reproductive health services.

As maternal mortality and morbidity rates stagnate or increase worldwide, there is an urgent need to address health system issues that impede access to high-quality care. Learning from efforts to address the value, safety, and effectiveness of reproductive and maternal health care is essential to advancing quality improvement efforts.

Using the Neonatal Intensive Care Unit Wisely: A National Survey of Clinicians Regarding Practices for Lower-Acuity Care.

OBJECTIVE: The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity. STUDY DESIGN: We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network. RESULTS: Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios. CONCLUSIONS: A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location.

High inter-rater reliability between physicians and nurses utilising modified Downes' scores in preterm respiratory distress.

AIM: To assess the inter-rater reliability of modified Downes' scores assigned by physicians and nurses in the Ethiopian Neonatal Network and to calculate the concordance of score-based treatment for preterm infants with respiratory distress. METHODS: We included preterm infants admitted from June 2020 to July 2021 to four tertiary neonatal intensive care units (NICUs) of the Ethiopian Neonatal Network that presented with respiratory distress. We calculated the kappa statistic to determine the nurse and physician correlation for each component of the modified Downes' score and total score on admission and evaluated the concordance of scores above and below the treatment threshold of 4. RESULTS: Of the 1151 eligible infants admitted, 817 infants (71%) had scores reported concurrently and independently by nurse and physician. The kappa statistic for modified Downes' score components ranged from 0.88 to 0.92 and was 0.89 for the total score. There was 98% concordance for score-based treatment. CONCLUSION: Incorporation of the modified Downes' score on admission for preterm infants with respiratory distress was feasible in tertiary NICUs in Ethiopia. The kappa statistics showed near-perfect agreement between nurse and physician assessments, translating to a very high degree of concordance in score-based treatment recommendations. These results highlight an opportunity for task-shifting assessments and empowering nurses.

Improving Outcomes through a Neonatal Abstinence Syndrome Collaborative in Maryland.

OBJECTIVES: A statewide Maryland Perinatal Neonatal Quality Collaborative, facilitated by the Maryland Patient Safety Center (MPSC), identified the three specific, measurable, attainable, relevant, and time-limited (SMART) aims to improve outcomes of neonatal abstinence syndrome (NAS) care as follows: (1) to reduce hospital length of stay (LOS), (2) to reduce interhospital transfers, and (3) to reduce 30-day readmission rates of infants with NAS. STUDY DESIGN: The Maryland collaborative developed a bundle of best practices for care of infants with NAS. MPSC partnered with Vermont Oxford Network (VON) to utilize the VON NAS toolkit and provided its standardized NAS educational curriculum to address the three objectives for participating birthing hospitals. Efforts began in quarter 4 (Q4) of 2016 and continued for 2 years. Thirty-one of Maryland's 32 delivery hospitals (97%) participated in the 2-year collaborative. Additionally, one specialty pediatric hospital with an NAS unit participated in the group learnings. Participating facilities implemented components of the MPSC NAS bundle and provided their staff caring for infants with NAS and their mothers access to the VON standardized educational curriculum. MPSC partnered with VON to conduct two audits of implementation of policies and procedures in Q1 of 2016 and Q3 of 2018. The Maryland Department of Health supplied quarterly aggregate hospital information on LOS, interhospital transfers, and 30-day readmissions of infants with a discharge diagnosis of the International Classification of Disease, 10th Revision (ICD-10), P96.1. RESULTS: Among term infants with NAS with total hospital stay greater than 5 days, we observed a nonsignificant reduction in both mean and median LOS of 1.5 days. In this same group, the rate of interhospital transfers fell significantly from 20.1% in 2016 to 13.8 and 11.0% in 2017 and 2018, respectively. CONCLUSION: The best practice bundle created by the Maryland collaborative was associated with a reduction in the percentage of infants with NAS who required interhospital transfer, thereby reducing family disruption. KEY POINTS: · A state NAS collaborative engaged 97% of delivery hospitals in education and standardization of care.. · The collaborative witnessed a 1.5-day decrease in length of stay, similar to that observed in other state collaboratives.. · The unique outcome of our collaborative was a 50% decrease in the rate of interhospital transfer..

Outcomes for Ectopia Cordis.

OBJECTIVES: To utilize a large multicenter neonatal cohort to describe survival and clinical outcomes of very low birth weight (VLBW) or preterm infants with ectopia cordis. STUDY DESIGN: Data were prospectively collected on 2 211 262 infants (born 2000-2017) from 845 US centers. Both VLBW (401-1500 g or 22-29 weeks of gestation) and non-VLBW (>1500 g and >29 weeks) infants had diagnoses or anatomic descriptors consistent with ectopia cordis and/or pentalogy of Cantrell. The primary outcome was neonatal survival, defined as hospital discharge or initial length of stay of ≥12 months. RESULTS: In total, 180 infants had ectopia cordis, 135 (76%) with findings of pentalogy of Cantrell. VLBW infants comprised 52% of the population. VLBW mortality was 96% with 79% dying within 12 hours, compared with 59% and 36%, respectively, for non-VLBW. One-third of VLBW infants received life support compared with 65% of non-VLBW. Surgery was reported for 34% of VLBW and 68% of non-VLBW infants. Congenital heart disease was reported in 8% of VLBW and 36% of non-VLBW, with conotruncal abnormalities most common. Survival exceeded 50% for infants >2500 g and >37 weeks of gestation. CONCLUSIONS: Survival of VLBW infants with ectopia cordis was poor and substantially worse compared with non-VLBW, with notable discrepancies in resuscitative efforts and surgical interventions. Although gestational age and weight strongly influence current survival, more detailed information regarding the severity of cardiac and noncardiac abnormalities is required to fully determine prognosis and inform counseling.

The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families.

Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.

In-Hospital Outcomes in Large for Gestational Age Infants at 22-29 Weeks of Gestation.

OBJECTIVE: To estimate the risks of mortality and morbidities in large for gestational age (LGA) infants relative to appropriate for gestational age infants born at 22-29 weeks of gestation. STUDY DESIGN: Data on 156 587 infants were collected between 2006 and 2014 in 852 US centers participating in the Vermont Oxford Network. We defined LGA as sex-specific birth weight above the 90th centile for gestational age measured in days. Generalized additive models with smoothing splines on gestational age by LGA status were fitted on mortality and morbidity outcomes to estimate adjusted relative risks and their 95% CIs. RESULTS: Compared with appropriate for gestational age infants, being born LGA was associated with decreased risks of mortality, respiratory distress syndrome, patent ductus arteriosus, necrotizing enterocolitis, late-onset sepsis, severe retinopathy of prematurity, and chronic lung disease. Early onset sepsis and severe intraventricular hemorrhage were increased among LGA infants, but these risks were not homogeneous across the gestational age range. CONCLUSIONS: Being born LGA was associated with lower risks for all the examined outcomes except for early onset sepsis and severe intraventricular hemorrhage.

Neonatal and fetal growth charts to identify preterm infants <30 weeks gestation at risk of adverse outcomes.

BACKGROUND: It is unclear whether a neonatal or a fetal growth standard is a better predictor of adverse in-hospital newborn infant outcomes. OBJECTIVE: We aimed to evaluate and compare the power of birthweight for gestational age to predict adverse neonatal outcomes using neonatal and fetal growth charts. Gestational age-specific birthweight was examined either as a percentile score or as a binary indicator for birthweight <10th percentile (small for gestational age) with the use of 3 fetal growth charts (National Institute of Child Health and Human Development, World Health Organization, and Intergrowth-21st) and 1 neonatal sex-specific birthweight chart. STUDY DESIGN: Inborn singleton infants from 2006-2014 with gestational age between 22 and 29 weeks and who were enrolled at 1 of the 852 US centers that were participating in the Vermont Oxford Network were studied. Outcomes included death, necrotizing enterocolitis, severe intraventricular hemorrhage, severe retinopathy of prematurity, and chronic lung disease. Receiver operating characteristic curve analysis was used to assess the predictive power of birthweight for gestational age, either as a score or as a small-for-gestational-age indicator, with the use of the 4 charts. We also examined the relative risks of the outcomes by comparing small-for-gestational-age and non-small-for-gestational-age infants with the use of the 4 charts. RESULTS: The percentage of small-for-gestational-age newborn infants ranged from 25.9-29.7% when with used the fetal growth charts. In contrast, the percentage was 10% when we used the neonatal charts. The areas under the receiver operating characteristic curves were similar across the 4 classification methods and were all <0.60, which suggests a poor predictive power. Small-for-gestational-age status, as classified by the neonatal chart, showed stronger associations with death, necrotizing enterocolitis, severe retinopathy of prematurity, and chronic lung disease, compared with those associations that were based on the other classification methods. CONCLUSION: Neither the neonatal nor the fetal growth charts are predictive of adverse infant in-hospital outcomes. In contrast to fetal charts, the use of the neonatal charts results in stronger associations between small-for-gestational-age and adverse outcomes.

Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study.

OBJECTIVE: To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis. STUDY DESIGN: Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS). RESULTS: Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome. CONCLUSIONS: Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.

Potentially Better Practices for Follow Through in Neonatal Intensive Care Units.

OBJECTIVE: To ascertain how NICU teams are undertaking action to follow through, involving teams, families, and communities as partners to address health-related social needs of infants and families. METHODS: Nineteen potentially better practices (PBPs) for follow through first published in 2020 were reported and analyzed as a sum, overall, and by safety-net hospital status, hospital ownership, and NICU type, among US NICUs that finalized Vermont Oxford Network data collection in 2023. RESULTS: One hundred percent of 758 eligible hospitals completed the annual membership survey, of which 57.5% reported screening for social risks. Almost all NICUs offered social work, lactation support, and translation services, but only 16% included a lawyer or paralegal on the team. Overall, 90.2% helped families offset financial costs while their infants were in the hospital, either with direct services or vouchers. At discharge, 94.0% of NICUs connected families with appropriate community organizations and services, 52.9% provided telemedicine after discharge, and 11.7% conducted home visits. The median number of PBPs at each hospital was 10 (25th percentile: 8, 75th percentile: 12). The number of PBPs reported differed by hospital control or ownership and level of NICU care. There were no differences by safety-net hospital status. CONCLUSIONS: Despite concerns about time and resources, a diverse set of US NICUs reported adopting potentially better practices for follow through. However, the marked variation among NICUs and the lower rates at for-profit and lower-level NICUs suggest there is substantial opportunity for improvement.

Does faster weight trajectory lead to improved neurodevelopmental outcomes in ELBW infants with bronchopulmonary dysplasia?

OBJECTIVE: Examine the relationship between weight trajectory and 2-year neurodevelopmental outcomes for extremely low birthweight (ELBW) infants with BPD. STUDY DESIGN: Secondary analysis of infants born from 2010 to 2019. The predictor was BPD severity and the outcome was neurodevelopmental impairment, defined as any Bayley Scales of Infant Development (BSID) III score <70 at 24 months' corrected age. Repeated measures logistic regression was performed. RESULTS: In total, 5042 infants were included. Faster weight trajectory was significantly associated with a decreased probability of having at least one BSID III score <70 for infants with grade 1-2 BPD (p < 0.0001) and an increased probability of at least one BSID III score <70 for infants with grade 3 BPD (p < 0.009). There was no significant association between weight trajectory and BSID III score <70 for infants with grade 0 BPD. CONCLUSION: The association between postnatal weight trajectory and neurodevelopmental outcome in this study differs by BPD severity.

Transfer Patterns Among Infants Born at 28 to 34 Weeks' Gestation.

BACKGROUND: Although postnatal transfer patterns among high-risk (eg, extremely preterm or surgical) infants have been described, transfer patterns among lower-risk populations are unknown. The objective was to examine transfer frequency, indication, timing, and trajectory among very and moderate preterm infants. METHODS: Observational study of the US Vermont Oxford Network all NICU admissions database from 2016 to 2021 of inborn infants 280/7 to 346/7 weeks. Infants' first transfer was assessed by gestational age, age at transfer, reason for transfer, and transfer trajectory. RESULTS: Across 467 hospitals, 294 229 infants were eligible, of whom 12 552 (4.3%) had an initial disposition of transfer. The proportion of infants transferred decreased with increasing gestational age (9.6% [n = 1415] at 28 weeks vs 2.4% [n = 2646] at 34 weeks) as did the median age at time of transfer (47 days [interquartile range 30-73] at 28 weeks vs 8 days [interquartile range 3-16] at 34 weeks). The median post menstrual age at transfer was 34 or 35 weeks across all gestational ages. The most common reason for transfer was growth or discharge planning (45.0%) followed by medical and diagnostic services (30.2%), though this varied by gestation. In this cohort, 42.7% of transfers were to a higher-level unit, 10.2% to a same-level unit, and 46.7% to a lower-level unit, with indication reflecting access to specific services. CONCLUSIONS: Over 4% of very and moderate preterm infants are transferred. In this population, the median age of transfer is later and does not reflect immediate care needs after birth, but rather the provision of risk-appropriate care.

Quality Improvement Interventions to Prevent Intraventricular Hemorrhage: A Systematic Review.

OBJECTIVES: Quality improvement may reduce the incidence and severity of intraventricular hemorrhage in preterm infants. We evaluated quality improvement interventions (QIIs) that sought to prevent or reduce the severity of intraventricular hemorrhage. METHODS: PubMed, CINAHL, Embase, and citations of selected articles were searched. QIIs that had reducing incidence or severity of intraventricular hemorrhage in preterm infants as the primary outcome. Paired reviewers independently extracted data from selected studies. RESULTS: Eighteen quality improvement interventions involving 5906 infants were included. Clinical interventions in antenatal care, the delivery room, and the NICU were used in the QIIs. Four of 10 QIIs reporting data on intraventricular hemorrhage (IVH) and 9 of 14 QIIs reporting data on severe IVH saw improvements. The median Quality Improvement Minimum Quality Criteria Set score was 11 of 16. Clinical intervention heterogeneity and incomplete information on quality improvement methods challenged the identification of the main reason for the observed changes. Publication bias may result in the inclusion of more favorable findings. CONCLUSIONS: QIIs demonstrated reductions in the incidence and severity of intraventricular hemorrhage in preterm infants in some but not all settings. Which specific interventions and quality improvement methods were responsible for those reductions and why they were successful in some settings but not others are not clear. This systematic review can assist teams in identifying potentially better practices for reducing IVH, but improvements in reporting and assessing QIIs are needed if systematic reviews are to realize their potential for guiding evidence-based practice.

Association between type of feeding at hospital discharge and nutritional status of Brazilian very preterm infants: a multicenter study.

OBJECTIVES: To examine trends over time in diet and size of very preterm infants, and associations of diet with size at hospital discharge/transfer. METHODS: The authors studied 4062 surviving very preterm infants born < 32 weeks' gestational age and < 1500 g between January 2012 and December 2020 from 12 Brazilian Neonatal Intensive Care Units. Diet type at discharge/transfer was classified as exclusive human milk, exclusive formula, or mixed. Outcomes were weight and head circumference at hospital discharge and the change in each from birth to discharge. The authors used linear regression to estimate adjusted associations of diet type with infant size, overall, and stratified by fetal growth category (small vs. appropriate for gestational age). The authors also examined trends in diet and infant size at discharge over the years. RESULTS: Infants' mean gestational age at birth was 29.3 weeks, and the mean birth weight was 1136 g. Diet at discharge/transfer was exclusive human milk for 22 %, mixed for 62 %, and exclusive formula for 16 %. Infant size in weight and head circumference were substantially below the growth chart reference for all diets. Infants fed human milk and mixed diets were lighter and had smaller heads at discharge/transfer than infants fed formula only (weight z: -2.0, -1.8, and -1.5; head z: -1.3, -1.2 and -1.1 for exclusive human milk, mixed and exclusive formula respectively). CONCLUSION: Results suggest high human milk use but gaps in nutrient delivery among hospitalized Brazilian very preterm infants, with little evidence of improvement over time.

Association between neurodevelopmental outcomes and concomitant presence of NEC and IVH in extremely low birth weight infants.

OBJECTIVE: To quantify the association between necrotizing enterocolitis (NEC) and neurodevelopmental disability (NDI) in extremely low birth weight (ELBW) infants with intraventricular hemorrhage (IVH). STUDY DESIGN: ELBW survivors born 2011-2017 and evaluated at 16-26 months corrected age in the Vermont Oxford Network (VON) ELBW Follow-Up Project were included. Logistic regression determined the adjusted relative risk (aRR) of severe NDI in medical or surgical NEC compared to no NEC, stratified by severity of IVH. RESULTS: Follow-up evaluation occurred in 5870 ELBW survivors. Compared to no NEC, medical NEC had no impact on NDI, regardless of IVH status. Surgical NEC increased risk of NDI in patients with no IVH (aRR 1.69; 95% CI 1.36-2.09), mild IVH (aRR 1.36;0.97-1.92), and severe IVH (aRR 1.35;1.13-1.60). CONCLUSIONS: ELBW infants with surgical NEC carry increased risk of neurodevelopmental disability within each IVH severity stratum. These data describe the additive insult of surgical NEC and IVH on neurodevelopment, informing prognostic discussions and highlighting the need for preventative interventions.

Trends in Mortality and Morbidities for Infants Born 24 to 28 Weeks in the US: 1997-2021.

BACKGROUND: Mortality and morbidity for very preterm infants in the United States decreased for years. The current study describes recent changes to assess whether the pace of improvement has changed. METHODS: Vermont Oxford Network members contributed data on infants born at 24 to 28 weeks' gestation from 1997 to 2021. We modeled mortality, late-onset sepsis, necrotizing enterocolitis, chronic lung disease, severe intraventricular hemorrhage, severe retinopathy of prematurity, and death or morbidity by year of birth using segmented relative risk regression, reporting risk-adjusted annual percentage changes with 95% confidence intervals overall and by gestational age week. RESULTS: Analyses of data for 447 396 infants at 888 hospitals identified 3 time point segments for mortality, late onset sepsis, chronic lung disease, severe intraventricular hemorrhage, severe retinopathy of prematurity, and death or morbidity, and 4 for necrotizing enterocolitis. Mortality decreased from 2005 to 2021, but more slowly since 2012. Late-onset sepsis decreased from 1997 to 2021, but more slowly since 2012. Severe retinopathy of prematurity decreased from 2002 to 2021, but more slowly since 2011. Necrotizing enterocolitis, severe intraventricular hemorrhage, and death or morbidity were stable since 2015. Chronic lung disease has increased since 2012. Trends by gestational age generally mirror those for the overall cohort. CONCLUSIONS: Improvements in mortality and morbidity have slowed, stalled, or reversed in recent years. We propose a 3-part strategy to regain the pace of improvement: research; quality improvement; and follow through, practicing social as well as technical medicine to improve the health and well-being of infants and families.

Transcatheter and Surgical Ductus Arteriosus Closure in Very Low Birth Weight Infants: 2018-2022.

BACKGROUND AND OBJECTIVE: The optimal patent ductus arteriosus (PDA) closure method in very low birth weight (VLBW) infants is uncertain. In 2019, the first transcatheter occlusion device was approved in the United States for infants ≥700 g. We described survival and short-term outcomes among VLBW infants who underwent transcatheter or surgical PDA closure (2018-2022). METHODS: Vermont Oxford Network members submitted data on infants born from 401 to 1500 g or 22 to 29 weeks' gestational age. Adjusted risk ratios (aRR) for survival, length of stay (LOS), prematurity complications, and discharge support were used to compare transcatheter versus surgical closure. Subgroup analyses were conducted for infants with birth weight ≥700 g and born in 2020-2022. RESULTS: Overall, 6410 of 216 267 infants at 726 hospitals received invasive PDA treatment. Transcatheter closure increased from 29.8% in 2018 to 71.7% in 2022. VLBW infants undergoing transcatheter closure had higher survival (adjusted rate ratio [aRR] 1.03; 1.02-1.04) with similar LOS (aRR 1.00; 0.97-1.03), neonatal complications (aRR 1.00; 0.98-1.01), and receipt of discharge support (aRR 0.94; 0.89-1.01). In subgroup analyses, survival (aRR 1.02; 1.00-1.04) and discharge support (aRR 0.90; 0.81-1.01) were similar between groups, whereas selected neonatal complications (aRR 0.95; 0.93-0.98) and LOS (aRR 0.95; 0.90-0.99) were lower after transcatheter closure. CONCLUSIONS: Transcatheter PDA closure in VLBW infants was increasingly used after 2018. Selected short-term outcomes for infants receiving transcatheter closure may be more favorable, compared with surgical, and warrants further clinical investigation.

Comparing Healthcare Needs in Extremely Low Birth Weight Infants With NEC and Spontaneous Intestinal Perforation.

BACKGROUND: Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) affect 6-8% of extremely low birth weight (ELBW) infants. SIP has lower mortality than NEC, but with similar short-term morbidity in length of stay, growth failure, and supplemental oxygen requirements. Comparative long-term neurodevelopmental outcomes have not been clarified. METHODS: Data were prospectively collected from 59 North American neonatal units, regarding ELBW infants (401-1000 g or 22-27 weeks gestational age) born between 2011 and 2018 and evaluated again at 16-26 months corrected age. Outcomes were collected from infants with laparotomy-confirmed NEC, laparotomy-confirmed SIP, and those without NEC or SIP. The primary outcome was severe neurodevelopmental disability. Secondary outcomes were weight <10th percentile, medical readmission, post-discharge surgery and medical support at home. Adjusted risk ratios (ARR) were calculated. RESULTS: Of 13,673 ELBW infants, 6391 (47%) were followed including 93 of 232 (40%) with NEC and 100 of 235 (42%) with SIP. There were no statistically significant differences in adjusted risk of any outcomes when directly comparing NEC to SIP (ARR 2.35; 95% CI 0.89, 6.26). However, infants with NEC had greater risk of severe neurodevelopmental disability (ARR 1.43; 1.09-1.86), rehospitalization (ARR 1.46; 1.17-1.82), and post-discharge surgery (ARR 1.82; 1.48-2.23) compared to infants without NEC or SIP. Infants with SIP only had greater risk of post-discharge surgery (ARR 1.64; 1.34-2.00) compared to infants without NEC or SIP. CONCLUSIONS: ELBW infants with NEC had significantly increased risk of severe neurodevelopmental disability and post-discharge healthcare needs, consistent with prior literature. We now know infants with SIP also have increased healthcare needs. LEVELS OF EVIDENCE: Level II.

Predictors of Mortality in Very Low Birth Weight Neonates With Congenital Diaphragmatic Hernia.

BACKGROUND: Limited data exists regarding the mortality of very low birth weight (VLBW) neonates with congenital diaphragmatic hernia (CDH). This study aims to quantify and determine predictors of mortality in VLBW neonates with CDH. METHODS: This analysis of 829 U.S. NICUs included VLBW [birth weight ≤1500g] neonates, born 2011-2021 with and without CDH. The primary outcome was in-hospital mortality. A generalized estimating equation regression model determined the adjusted risk ratio (ARR) of mortality. RESULTS: Of 426,140 VLBW neonates, 535 had CDH. In neonates with CDH, 48.4% had an additional congenital anomaly vs 5.5% without. In-hospital mortality for neonates with CDH was 70.4% vs 12.6% without. Of those with CDH, 73.3% died by day of life 3. Of VLBW neonates with CDH, 38% were repaired. A subgroup analysis was performed on 60% of VLBW neonates who underwent delivery room intubation or mechanical ventilation, as an indicator of active treatment. Mortality in this group was 62.7% for neonates with CDH vs 16.4% without. Higher Apgars at 1 min and repair of CDH were associated with lower mortality (ARR 0.91; 95%CI 0.87,0.96 and ARR 0.28; 0.21,0.39). The presence of additional congenital anomalies was associated with higher mortality (ARR 1.14; 1.01,1.30). CONCLUSION: These benchmark data reveal that VLBW neonates with CDH have an extremely high mortality. Almost half of the cohort have an additional congenital anomaly which significantly increases the risk of death. This study may be utilized by providers and families to better understand the guarded prognosis of VLBW neonates with CDH. TYPE OF STUDY: Level II. LEVEL OF EVIDENCE: Level II.