Effect of antenatal and postnatal corticosteroid therapy on weight gain and head circumference growth in the nursery.

OBJECTIVE: To assess the effect of antenatal and postnatal corticosteroids on head circumference growth and weight gain from birth to discharge. METHODS: We conducted a retrospective analysis of nonanomalous newborns admitted to the neonatal intensive care unit from 23 to 34 6/7 weeks of gestation. Independent variables included maternal age, race, nulliparity, poor prenatal care, multiple gestation, obstetric complications, alcohol, tocolytic drugs, smoking, illicit drugs, gestational age at birth, presentation, method of delivery, 5-minute Apgar score < 7, surfactant use, severe intracranial hemorrhage, and length of stay. RESULTS: Antenatal and postnatal corticosteroids were given in 62% and 14% of the newborns, respectively, and 10% of newborns received both. The mean (+/-SD) weight gain and head circumference growth in the nursery was 440 +/- 582 g (n = 14,217) and 2.54 +/- 3.42 cm (n = 12,808), respectively. After multivariable analysis, use of antenatal corticosteroids did not affect weight gain (3.6 +/- 4.6 g) and head circumference growth (0.05 +/- 0.04 cm) compared with no exposure to perinatal corticosteroids, but postnatal corticosteroids were associated with significant reductions in weight gain and head circumference growth (-120 +/- 12.2 g and -0.53 +/- 0.11 cm, respectively). CONCLUSIONS: Antenatal corticosteroid therapy did not affect weight gain or head circumference growth in the nursery, even when used in conjunction with postnatal corticosteroid therapy.

Site of care influences breastmilk feedings at NICU discharge.

OBJECTIVE: To determine if site of care influences rates of breastmilk use in neonatal intensive care units (NICUs). STUDY DESIGN: Subjects included all admissions to 124 NICUs between 1/1/1999 and 12/31/2000 who were subsequently discharged home. We reviewed discharge feeding data collected during the routine provision of care, and used stepwise logistic regression analysis to identify which factors were independently associated with a neonate being discharged on some breastmilk versus none. RESULTS: We studied 42,891 neonates; 21,327 (49.7%) were sent home receiving some breastmilk and 21,564 (50.3%) were not. The significant variables associated with being discharged on breastmilk were more mature gestational age, white race, maternal age, parents being married, and site of care. Site of care remained significant even when adjusted for other variables. CONCLUSION: Neonates admitted to NICUs are often discharged on feedings that do not include breastmilk. Beyond previously identified risk factors, site of care significantly influences this occurrence.

Necrotizing enterocolitis among neonates in the United States.

BACKGROUND: Prior studies have identified individual risk factors that are associated with necrotizing enterocolitis (NEC); however, the small sample sizes of these previous studies have not allowed the analysis of potential interaction between multiple variables and NEC. Our purpose was to describe the incidence and risk factors for NEC in premature neonates admitted for intensive care. METHODS: We identified neonates as having NEC if they met accepted diagnostic criterion for necrotizing enterocolitis. Using a national database, we assessed the association between NEC and a battery of risk factors previously reported in peer-reviewed literature. RESULTS: There were 15,072 neonates that met inclusion criteria; 14,682 did not have NEC, while 390 (2.6%) met criterion for NEC. Multivariate analysis showed that low birth weight was the most important risk factor for NEC. Other factors that were associated with an increased risk of NEC were exposure to antenatal glucocorticoids, vaginal delivery, need for mechanical ventilator support, exposure to both glucocorticoids and indomethacin during the first week of life, absence of an umbilical arterial catheter, and low Apgar score at 5 minutes. Length of hospital stay and mortality were higher in neonates with NEC than in neonates without NEC. CONCLUSIONS: NEC remains an important cause of morbidity and mortality in prematurely born neonates. In contrast to previous studies, we found that exposure to antenatal glucocorticoids was associated with an increased risk for NEC independent of birth weight.

Extrauterine growth restriction remains a serious problem in prematurely born neonates.

BACKGROUND: Poor growth is a common problem in premature neonates and may be associated with neurodevelopmental delay. OBJECTIVE: To evaluate the incidence of extrauterine growth restriction (growth values < or =10th percentile of intrauterine growth expectation based on estimated postmenstrual age in premature (23-34 weeks' estimated gestational age) neonates at the time they are discharged from the hospital. DESIGN/METHODS: Using a database formed from a computer-assisted tool that generates clinical progress notes and discharge summaries on neonatal intensive care unit admissions, we reviewed data on neonates discharged from 124 neonatal intensive care units between January 1, 1997, and December 31, 2000. We evaluated neonates who were born between 23 and 34 weeks' estimated gestational age without congenital anomalies and who were cared for at and discharged from the same hospital. For each patient, we compared the discharge growth values to the expected values based on our intrauterine growth data and postmenstrual age on the day of discharge. We defined extrauterine growth restriction as having a measured growth value (weight, length or head circumference) that was < or =10th percentile of the predicted value. In each specific birth weight and estimated gestational age group, we counted the number of neonates < or =10th percentile for each growth parameter and calculated the percentage of patients who had values < or =10th percentile at discharge. Using logistic regression, we evaluated the factors associated with extrauterine growth restriction for weight, length, and head circumference. RESULTS: Our sample included 24 371 premature neonates. Data on discharge weight, length, and head circumference was available on 23 970, 17 203, and 20 885 neonates, respectively. The incidence of extrauterine growth restriction was common (28%, 34%, and 16% for weight, length, and head circumference, respectively). For each growth parameter, the incidence of extrauterine growth restriction increased with decreasing estimated gestational age and birth weight. Factors independently associated with extrauterine growth restriction were male gender, need for assisted ventilation on day 1 of life, a history of necrotizing enterocolitis, need for respiratory support at 28 days of age, and exposure to steroids during the hospital course. CONCLUSIONS: Extrauterine growth restriction remains a serious problem in premature neonates especially for neonates who are small, immature, and critically ill.

Improving growth of very low birth weight infants in the first 28 days.

OBJECTIVE: To increase weight gain in the first 28 days after birth for very low birth weight (VLBW) infants by isolating and sharing meaningful process differences between high- and low-weight-gain centers within a neonatal network. DESIGN/METHODS: We identified weight gain as an important target for improvement in 1999 for our national group practice of neonatologists. Site-specific average weight gain during the first 28 days was the primary outcome measure. Our target population was defined as inborn infants who survived and remained in the hospital of birth, whose birth weights were between 401 and 1500 g (VLBW), and who were >22 weeks' estimated gestational age. A team of 6 neonatologists and 1 nurse met, reviewed processes that might influence growth, and developed a structured observation guide for site visits. Weight gain data were obtained from an existing administrative database for the period January 1, 1997, through June 30, 1999. Centers were ranked and divided into upper, middle, and lower thirds. Seven team members visited 1 high- and 1 low-weight-gain center without being informed of the center's performance. Following the site visits, the team isolated 16 meaningful differences between high- and low-weight-gain sites. Meaningful differences were defined as processes observed in all or virtually all (for this project, 6 or 7 of 7 centers) of the high and none or virtually none (for this project, 0 or 1 of 7) of the low centers. The meaningful differences were distributed to our medical directors in August 2000 along with their site-specific weight-gain performance. To document the impact of sharing this material, we compared weight gain in a baseline period of January 1 through December 31, 1999 and a posteducational intervention period of January 1 through September 30, 2001. RESULTS: Compared with neonates admitted to our national neonatal practice in 1999, neonates admitted in 2001 were similar in birth weight, gestational age at birth, exposure to antenatal steroids, and male gender. Average daily weight gain during the first 28 days increased from 10.4 +/- 6 g for neonates cared for in 1999 to 12.5 +/- 6 g for neonates cared for in 2001. Thirty-nine of 51 (76%) units noted improvements, 4 were unchanged and 8 noted a decrease in average weight gain. Despite similar average lengths of stay, the average discharge weight for neonates sent home increased from 2.15 +/- 0.5 kg for 1999 to 2.29 +/- 0.5 kg for 2001. There were no differences in frequencies of mortality or major morbidities, including severe intraventricular hemorrhage, retinopathy, or necrotizing enterocolitis, between the 2 time periods. An increase in the use of continuous positive airway pressure was noted in the post implementation period. CONCLUSIONS: Variation in common processes can alter clinical outcomes. Although temporal trends in weight gain may be, in part, responsible for this trend, it appears that isolation and implementation of meaningful differences in processes can augment our desire to rapidly improve clinical outcomes.