Exposure to the parents' speech is positively associated with preterm infant's face preference.

BACKGROUND: The parents' presence and involvement in neonatal care is a promising approach to improve preterm infants' neurodevelopmental outcomes. We examined whether exposure to the parents' speech is associated with the preterm infant's social-cognitive development. METHODS: The study included infants born before 32 gestational weeks in two neonatal units. Each infant's language environment was assessed from 16-hour recordings using Language Environment Analysis (LENA®). Parental presence was assessed with Closeness Diary for 14 days during the hospital stay. Attention to faces and non-face patterns was measured at the corrected age of seven months using an eye-tracking disengagement test. RESULTS: A total of 63 preterm infants were included. Infants were less likely to disengage their attention from faces (M = 0.55, SD = 0.26) than non-face patterns (M = 0.24, SD = 0.22), p < 0.001, d = 0.84. Exposure to the parents' speech during the neonatal period was positively correlated with the preference for faces over non-face patterns (rs = 0.34, p = 0.009) and with the preference for parents over unfamiliar faces (rs = 0.28, p = 0.034). CONCLUSION: The exposure to the parents' speech during neonatal hospital care is a potential early marker for later social development in preterm infants. IMPACT: The exposure to the parents' speech during neonatal intensive care is a potential early marker for optimal social-cognitive development in preterm infants. This is the first study to show an association between parental vocal contact during neonatal intensive care and early social development (i.e., face preference), measured at seven months of corrected age. Our findings suggest that we should pay attention to the parents' vocal contact with their child in the neonatal intensive care unit and identify need for tailored support for face-to-face and vocal contact.

Variation in follow-up for children born very preterm in Europe.

BACKGROUND: Children born very preterm (<32 weeks of gestation) face high risks of neurodevelopmental and health difficulties compared with children born at term. Follow-up after discharge from the neonatal intensive care unit is essential to ensure early detection and intervention, but data on policy approaches are sparse. METHODS: We investigated the characteristics of follow-up policy and programmes in 11 European countries from 2011 to 2022 using healthcare informant questionnaires and the published/grey literature. We further explored how one aspect of follow-up, its recommended duration, may be reflected in the percent of parents reporting that their children are receiving follow-up services at 5 years of age in these countries using data from an area-based cohort of very preterm births in 2011/12 (N = 3635). RESULTS: Between 2011/12 and 22, the number of countries with follow-up policies or programmes increased from 6 to 11. The policies and programmes were heterogeneous in eligibility criteria, duration and content. In countries that recommended longer follow-up, parent-reported follow-up rates at 5 years of age were higher, especially among the highest risk children, born <28 weeks' gestation or with birthweight <1000 g: between 42.1% and 70.1%, vs. <20% in most countries without recommendations. CONCLUSIONS: Large variations exist in follow-up policies and programmes for children born very preterm in Europe; differences in recommended duration translate into cross-country disparities in reported follow-up at 5 years of age.

Depressive symptoms in mothers of preterm infants before and during COVID-19 restrictions in neonatal intensive care units.

AIM: Little is known about the specific restriction measures used in intensive care units (NICUs) during the COVID-19 pandemic and their impact on parental well-being. Hence, this study aimed to assess the association between restriction measures and mothers' post-partum depressive symptoms. METHODS: This comparative cohort study included mothers who gave birth before 35 weeks of gestation in Estonia. The outcome measure was mothers' post-partum depressive symptoms at the time of infant discharge, evaluated using the Edinburgh Postnatal Depression Scale (EPDS). In addition to the pandemic itself, the number of restriction measures in the NICUs was analysed as a potential explanatory factor for depressive symptoms. RESULTS: The study included 55 mothers before the pandemic in 2018-2019 and 54 mothers during the COVID-19 pandemic in 2021. No significant difference was found in the median EPDS scores between the cohorts: 7.0 [interquartile range (IQR): 4.0-12.0] and 8.0 (IQR: 5.0-12.8) respectively. The number of restriction measures was not associated with mothers' EPDS scores in either unadjusted or adjusted models. CONCLUSION: The COVID-19 pandemic or the number of restriction measures used in Estonian NICUs did not associate with mothers' post = partum depressive symptoms.

High Healthcare Use at Age 5 Years in a European Cohort of Children Born Very Preterm.

OBJECTIVES: To describe parent-reported healthcare service use at age 5 years in children born very preterm and investigate whether perinatal and social factors and the use of very preterm follow-up services are associated with high service use. STUDY DESIGN: We used data from an area-based cohort of births at <32 weeks of gestation from 11 European countries, collected from birth records and parental questionnaires at 5 years of age. Using the published literature, we defined high use of outpatient/inpatient care (≥4 sick visits to general practitioners, pediatricians, or nurses, ≥3 emergency room visits, or ≥1 overnight hospitalization) and specialist care (≥2 different specialists or ≥3 visits). We also categorized countries as having either a high or a low rate of children using very preterm follow-up services at age 5 years. RESULTS: Overall, 43% of children had high outpatient/inpatient care use and 48% had high specialist care use during the previous year. Perinatal factors were associated with high outpatient/inpatient and specialist care use, with a more significant association with specialist services. Associations with intermediate parental educational level and unemployment were stronger for outpatient/inpatient services. Living in a country with higher rates of very preterm follow-up service use was associated with lower use of outpatient/inpatient services. CONCLUSIONS: Children born very preterm had high healthcare service use at age 5 years, with different patterns for outpatient/inpatient and specialist care by perinatal and social factors. Longer follow-up of children born very preterm may improve care coordination and help avoid undesirable health service use.

Parents' ratings of post-discharge healthcare for their children born very preterm and their suggestions for improvement: a European cohort study.

BACKGROUND: Follow-up of very preterm infants is essential for reducing risks of health and developmental problems and relies on parental engagement. We investigated parents' perceptions of post-discharge healthcare for their children born very preterm in a European multi-country cohort study. METHODS: Data come from a 5-year follow-up of an area-based cohort of births <32 weeks' gestation in 19 regions from 11 European countries. Perinatal data were collected from medical records and 5-year data from parent-report questionnaires. Parents rated post-discharge care related to their children's preterm birth (poor/fair/good/excellent) and provided free-text suggestions for improvements. We analyzed sociodemographic and medical factors associated with poor/fair ratings, using inverse probability weights to adjust for attrition bias, and assessed free-text responses using thematic analysis. RESULTS: Questionnaires were returned for 3635 children (53.8% response rate). Care was rated as poor/fair for 14.2% [from 6.1% (France) to 31.6% (Denmark)]; rates were higher when children had health or developmental problems (e.g. cerebral palsy (34.4%) or epilepsy (36.9%)). From 971 responses, 4 themes and 25 subthemes concerning care improvement were identified. CONCLUSIONS: Parents' experiences provide guidance for improving very preterm children's post-discharge care; this is a priority for children with health and developmental problems as parental dissatisfaction was high. IMPACT: In a European population-based very preterm birth cohort, parents rated post-discharge healthcare as poor or fair for 14.2% of children, with a wide variation (6.1-31.6%) between countries. Dissatisfaction was reported in over one-third of cases when children had health or developmental difficulties, such as epilepsy or cerebral palsy. Parents' free-text suggestions for improving preterm-related post-discharge healthcare were similar across countries; these focused primarily on better communication with parents and better coordination of care. Parents' lived experiences are a valuable resource for understanding where care improvements are needed and should be included in future research.

The validity of the Language Environment Analysis system in two neonatal intensive care units.

AIM: To evaluate the validity of the Language Environment Analysis (LENA) system's automatic measures in two neonatal intensive care units supporting parent-infant closeness, and in two Finno-Ugric languages: Finnish and Estonian. METHODS: The sound environment of 70 very preterm infants was recorded for 16 h in the neonatal intensive care units with the LENA system roughly at the gestational age of 32 (+2) weeks. Of these, the recordings of 14 infants (20%, two 5-min samples with a high percentage of speech, totally 140 min) were analysed in detail and in two different ways. Parental closeness diaries were used to document the presence of the parents. Agreements between LENA system and human coder estimates were analysed. RESULTS: Findings showed a high variation in agreements. The highest agreements were found in female and adult word counts (r = 0.91 and 0.95). The agreements for child vocalisation count, conversational turns and silence were modest or low (r = -0.03 to 0.64). CONCLUSION: Our study provides novel information on the validity of the LENA system in the neonatal intensive care unit. Findings show that the LENA system provides valid information on adult words, but LENA estimates for child vocalisations were less valid at this early age.

Specialist health care services use in a European cohort of infants born very preterm.

AIM: Children born very preterm require additional specialist care because of the health and developmental risks associated with preterm birth, but information on their health service use is sparse. We sought to describe the use of specialist services by children born very preterm in Europe. METHOD: We analysed data from the multi-regional, population-based Effective Perinatal Intensive Care in Europe (EPICE) cohort of births before 32 weeks' gestation in 11 European countries. Perinatal data were abstracted from medical records and parents completed a questionnaire at 2 years corrected age (4322 children; 2026 females, 2296 males; median gestational age 29wks, interquartile range [IQR] 27-31wks; median birthweight 1230g, IQR 970-1511g). We compared parent-reported use of specialist services by country, perinatal risk (based on gestational age, small for gestational age, and neonatal morbidities), maternal education, and birthplace. RESULTS: Seventy-six per cent of the children had consulted at least one specialist, ranging across countries from 53.7% to 100%. Ophthalmologists (53.4%) and physiotherapists (48.0%) were most frequently consulted, but individual specialists varied greatly by country. Perinatal risk was associated with specialist use, but the gradient differed across countries. Children with more educated mothers had higher proportions of specialist use in three countries. INTERPRETATION: Large variations in the use of specialist services across Europe were not explained by perinatal risk and raise questions about the strengths and limits of existing models of care. WHAT THIS PAPER ADDS: Use of specialist services by children born very preterm varied across Europe. This variation was observed for types and number of specialists consulted. Perinatal risk was associated with specialist care, but did not explain country-level differences. In some countries, mothers' educational level affected use of specialist services.

UTILIZACIÓN DE SERVICIOS DE SALUD ESPECIALIZADOS EN UN ESTUDIO DE COHORTE EUROPEO DE NIÑOS NACIDOS MUY PREMATUROS: OBJETIVO: Niños nacidos muy prematuramente requieren cuidados especializados adicionales debido a su salud y a los riesgos asociados con la prematuros, sin embargo la información sobre el uso de servicios de salud es escasa. Buscamos describir la utilización de servicios especializados por niños nacidos muy prematuramente, en Europa. MÉTODO: Analizamos datos de una cohorte de nacimientos ocurridos antes de las 32 semanas de gestación tomados del Effective Perinatal Intensive Care in Europe (EPICE), basado en la población y multirregional, en 11 países europeos. Los datos perinatales fueron extraídos de las historias clínicas y los padres completaron un cuestionario a los 2 años de edad corregida (4.322 niños; 2026 sexo femenino, 2.296 masculino; edad gestacional mediana 29 semanas, rango intercuartílico (IQR) 27-31 semanas; mediana de peso de nacimiento 1.230 gr, IQR 970-1.511 gr). Comparamos el uso de servicios especializados (según informe de los padres) por país, riesgo perinatal (basado en edad gestacional, bajo peso para edad gestacional y morbilidades neonatales), educación materna y lugar de nacimiento. RESULTADOS: En total 65% de los niños habían consultado por lo menos a un especialista, con un rango entre países de 53,7% a 100%. Los especialistas más frecuentemente consultados fueron Oftalmólogos (53,4%) y Fisioterapeutas (48%) pero los especialistas consultados por cada individuo variaron mucho según el país. El riesgo perinatal se asoció al uso de especialista, pero el gradiente varió entre los países. Niños de madres con mayor nivel educativo tuvieron mayor proporción de uso de especialistas en tres países. INTERPRETACIÓN: Las grandes variaciones en el uso de servicios especializados en Europa no fueron explicadas por el riesgo perinatal y arrojan cuestionamientos sobre las fortalezas y limitaciones de los modelos de cuidados existentes.

USO DE SERVIÇOS DE SAÚDE ESPECIALIZADOS EM UMA COORTE EUROPÉIA DE LACTENTES NASCIDOS MUITO PREMATUROS: OBJETIVO: Crianças nascidas muito prematuras requerem cuidado especializado adicional por causa dos riscos à saúde e ao desenvolvimento associados ao nascimento premature, mas informações sobreo uso de serviços de saúde são escassas. Procuramos descrever o uso de serviços especializados por crianças nascidas muito prematuras na Europa. MÉTODO: Analisamos dados de uma coorte populacional multi-regional, do Cuidado Intensivo Neonatal Efetivo na Europa (EPICE), com lactentes nascidos antes de 32 semanas de gestação em 11 países europeus. Dados perinatais foram extraídos dos registros médicos, e os pais completaram um questionário com 2 anos de idade corrigida (4.322 crianças; 2.026 do sexo feminino, 2.296 do sexo masculino; idade gestacional mediana 29semanas, intervalo interquartile [IIQ] 27-31sem; peso ao nascimento mediano 1,230g, IIQ 970-1511g). Comparamos o uso de serviços especializados reportados pelos pais por país, risco perinatal (com base na idade gestacional, pequeno para a idade gestacional e morbidades neonatais), educação materna e local de nascimento. RESULTADOS: Setenta e seis por cento das crianças consultou pelo menos um especialista, variando entre países de 53,7 a 100%. Oftalmologistas (53,4%) e fisioterapeutas (48,0%) foram os mais frequentemente consultados, mas os especialistas individuais variaram bastante por país. O risco perinatal se associou com uso de serviços especializados, mas o gradient diferiu entre países. Crianças com mães mais educadas tinham maior proporção de uso de especialistas em três países. INTERPRETAÇÃO: Grandes variações no uso de serviços especializados na Europa não foram explicadas pelo risco perinatal, e levantam questões sobre as forças e limitações dos modelos de cuidado existentes.

Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort.

Breast milk feeding (BMF) is associated with lower neonatal morbidity in the very preterm infant (<32 weeks gestation) and breastfeeding is beneficial for maternal health. Previous studies show large variations in BMF after very preterm birth and recognize the need for targeted breastfeeding support in the neonatal intensive care units (NICU). In a European collaboration project about evidence-based practices after very preterm birth, we examined the association between maternal, obstetric, and infant clinical factors; neonatal and maternal care unit policies; and BMF at discharge from the NICU. In multivariable analyses, covariates associated with feeding at discharge were first investigated as predictors of any BMF and in further analysis as predictors of exclusive or partial BMF. Overall, 58% (3,826/6,592) of the infants received any BMF at discharge, but there were large variations between regions (range 36-80%). Primiparity, administration of antenatal corticosteroids, first enteral feed <24 hr after birth, and mother's own milk at first enteral feed were predictors positively associated with any BMF at discharge. Vaginal delivery, singleton birth, and receiving mother's own milk at first enteral feed were associated with exclusive BMF at discharge. Units with a Baby Friendly Hospital accreditation improved any BMF at discharge; units with protocols for BMF and units using donor milk had higher rates of exclusive BMF at discharge. This study suggests that there is a high potential for improving BMF through policies and support in the NICU.

Parents' presence and parent-infant closeness in 11 neonatal intensive care units in six European countries vary between and within the countries.

AIM: Little is known about the amount of physical parent-infant closeness in neonatal intensive care units (NICUs), and this study explored that issue in six European countries. METHODS: The parents of 328 preterm infants were recruited in 11 NICUs in Finland, Estonia, Sweden, Norway, Italy and Spain. They filled in daily diaries about how much time they spent in the NICU, in skin-to-skin contact (SSC) and holding their babies in the first two weeks of their hospitalisation. RESULTS: The parents' NICU presence varied from a median of 3.3 (minimum 0.7-maximum 6.7) to 22.3 (18.7-24.0) hours per day (p < 0.001), SSC varied from 0.3 (0-1.4) to 6.6 (2.2-19.5) hours per day (p < 0.001) and holding varied from 0 (0-1.5) to 3.2 (0-7.4) hours per day (p < 0.001). Longer SSC was associated with singleton babies and more highly educated mothers. Holding the baby for longer was associated with gestational age. The most important factor supporting parent-infant closeness was the opportunity to stay overnight in the NICU. Having other children and the distance from home to the hospital had no impact on parent-infant closeness. CONCLUSION: Parents spent more time in NICUs if they could stay overnight, underlining the importance that these facilities play in establishing parent-infant closeness.

Follow-up study of 2-year-olds born at very low gestational age in Estonia.

AIM: To study very low gestational age (VLGA, <32 weeks) infants at 2 years of age and to identify the predictors of adverse outcomes. METHODS: A population-based cohort of 155 surviving VLGA infants born in Estonia in 2007 was followed up and compared with a matched full-term (FT) control group. A logistic regression model was used to test associations between risk factors and adverse outcomes. RESULTS: No impairment was found in 60% of the VLGA infants. Neurodevelopmental impairment was noted in 12% of VLGA infants, with 8% of the infants affected by cerebral palsy without independent walking, 5% with cognitive delay, 10% with language delay and 1% with hearing impairment. The differences between preterm and FT infants in terms of the mean Cognitive, Language, and Motor Composite Scores assessed using the Bayley-III scales were in excess of 0.5 SD. Somatic growth delay was a significant problem among preterm infants. The existence of severe neonatal cerebral lesions was the most significant predictor of adverse outcomes. CONCLUSION: In all domains studied, adverse conditions were more prevalent among VLGA infants than among the FT control group. Efforts to reduce neonatal morbidity in preterm infants should be a key priority for health care in Estonia.

Changes in care and short-term outcome for very preterm infants in Estonia.

AIM: To identify recent changes in short-term outcome and care for very preterm infants in Estonia. METHODS: Comparison of two population-based cohort of very preterm infants born alive at 22-31 gestational weeks. In 2007-2008, data were recorded prospectively in a neonatal register. For the cohort born in 2002-2003, the same variables were extracted retrospectively from the hospital records. Infants were followed up to discharge or death. RESULTS: The cohort of 2007-2008 contained a higher proportion of infants born by caesarean section and of infants who received antenatal corticosteroids, maternal antibiotics, or surfactant therapy than the earlier cohort. A higher proportion of infants was admitted for care in 2007-2008 (98% vs. 94%; p = 0.013). During the study period, survival until discharge increased (85% vs. 78%; p = 0.041), although the length of hospital stay was unchanged. The use of mechanical ventilation, inotropes, and postnatal antibiotics decreased. Neonatal morbidity remained unchanged, except for a decrease in severe periventricular/intraventricular haemorrhage. CONCLUSION: The outcome for very preterm infants in Estonia has improved since 2002. With proactive perinatal management and less invasive neonatal care, survival until discharge increased without concomitant increases in neonatal morbidity and the length of hospital stay.

Mode of Delivery and Incidence of Bronchopulmonary Dysplasia: Results from the Population-Based EPICE Cohort.

INTRODUCTION: Bronchopulmonary dysplasia (BPD) represents a tremendous disease burden following preterm birth. The strong association between compromised gas exchange after birth and BPD demands particular focus on the perinatal period. The mode of delivery can impact on lung fluid clearance and microbial colonization, but its impact on BPD and potential trade-off effects between death and BPD are not established. METHODS: A total of 7,435 live births (24+0 to 31+6 weeks postmenstrual age) in 19 regions of 11 European countries were included. Principal outcomes were death and BPD at 36 weeks. We estimated unadjusted and adjusted associations with mode of delivery using multilevel logistic regression to account for clustering within units and regions. Sensitivity analyses examined effects, taking into consideration regional variations in C-section rates. RESULTS: Compared to vaginal delivery, delivery by C-section was not associated with the incidence of BPD (OR 0.92, 95% CI: 0.68-1.25) or the composite outcome of death or BPD (OR 0.94, 95% CI: 0.74-1.19) after adjustment for perinatal and neonatal risk factors in the total cohort and in pregnancies for whom a vaginal delivery could be considered. Sensitivity analyses among singletons, infants in cephalic presentation, and infants of ≥26+0 weeks of gestation did not alter the results for BPD, severe BPD, and death or BPD, even in regions with a high C-section rate. CONCLUSIONS: In our population-based cohort study, the mode of delivery was not associated with the incidence of BPD. The intention to reduce BPD does not justify a C-section in pregnancies where a vaginal delivery can be considered.

Parent-infant closeness after preterm birth and depressive symptoms: A longitudinal study.

Background: Preterm birth increases the risk for postpartum depression in both mothers and fathers, calling for strategies to alleviate and prevent depressive symptoms in parents of preterm infants. The aim of this study was to assess the association between early parent-infant closeness and later depressive symptoms among parents of preterm infants. We hypothesized that longer duration of closeness associate with fewer depressive symptoms in both parents. Methods: This prospective cohort study included 23 neonatal intensive care units (NICUs) from 15 countries in 2018 to 2020. Each unit recruited families with preterm infants aiming to 30 families. The total duration of parents' presence in the NICU, and separately parent-infant skin-to-skin contact and holding, were measured using a Closeness Diary up to 14  days. The Edinburgh Postnatal Depression Scale (EPDS) was used at discharge and at 4  months corrected age of the infant. Results: The study included 684 mothers and 574 fathers. The median presence was 469  min (Q1 258 and Q3 1,087) per 24   h for the mothers and 259   min (Q1 100 and Q3 540) for the fathers; mean EPDS scores were 9.2 (SD 5.0) and 6.3 (SD 4.4) at discharge and 6.6 (4.7) and 4.3 (4.2) at 4  months, respectively. Parents' presence and depressive symptoms varied greatly between the units. Parents' presence as the total measure, or skin-to-skin contact and holding separately, did not associate with depressive symptoms in either mothers or fathers at either time point (adjusted). Conclusion: No association was found between the duration of parent-infant closeness in the neonatal unit and parents' depressive symptoms. The beneficial effects of family-centered care on parents' depression seem to be mediated by other elements than parent-infant physical closeness. More research is needed to identify the critical elements which are needed to alleviate parents' depression after NICU stay.

Language skills at corrected age 2;0 are poorer in extremely and very preterm boys but not girls compared with their full-term peers.

PURPOSE: To date, there are contradictory findings concerning if, at which age, and to what extent children's language development is affected by prematurity at birth. The objective was to compare language skills of extremely preterm (EPT) and very preterm (VPT) girls and boys at 24 months corrected for gestational age (GA) at birth with those of full-term (FT) girls and boys, and to explore the effect of perinatal and demographic factors. METHOD: Parents of 138 preterm (PT) children born <32 weeks' gestation (48 EPT with GA below 28 weeks, 90 VPT with GA 28-31 weeks) and of 150 FT controls completed the short Estonian version of the MacArthur-Bates Communicative Development Inventory: Words and Sentences (ECDI-II SF). Language skills of PT children were also assessed with the Bayley-III Language Scale (BSID-III), and compared with data from 152 FT controls. RESULTS: Mean scores of all language measurements were significantly lower in boys (not girls) from both PT groups compared to FT girls and boys, while no significant differences were found between PT groups. Across groups, girls obtained significantly better language scores than boys. In PT children, being a girl, and attending day care at corrected age (CA) 2;0 years, predicted a larger expressive vocabulary (measured by the ECDI-II SF). Bayley language composite scores (sum of expressive and receptive language) were higher in PT girls than in boys, and the scores were negatively affected by the number of severe neonatal morbidities. CONCLUSIONS: The findings highlight the importance of systematic language-focused assessments (using parents and trained examiners) of EPT and VPT boys, as well as the need to support their development.

Parents' presence and participation in medical rounds in 11 European neonatal units.

BACKGROUND: Parents' involvement during hospital care is beneficial for preterm infants and their parents. Although parents are encouraged to be present in many neonatal intensive care units (NICUs), little is known about their role during medical rounds. AIMS: To study parents' presence in the NICU, the degree of parents' participation during medical rounds, and to identify underlying factors for participation. STUDY DESIGN AND SUBJECTS: A prospective study was performed in 11 neonatal units in six European countries including parents of preterm infants born before 35 gestational weeks. OUTCOME MEASURES: Parents' presence and the degree of participation (7-point Likert scale) during medical rounds were asked using a text-message question sent to the mobile phone of each parent separately. RESULTS: A total of 241 families were included in the study; mothers responded to 630 and fathers to 474 text-message questions, respectively. In studied units, mothers were present during medical rounds on 62.5% to 91% and fathers 30.8% to 77.8% of the days. The degree of mothers' and fathers' participation also varied between units (p < 0.001 and p = 0.022, respectively). In multivariate analysis, parents' presence increased by increasing gestational age (p = 0.010), fathers' education (p = 0.009), and by the policy in the unit to invite parents to medical rounds (p = 0.036). The background characteristics did not explain the degree of participation. CONCLUSION: There is significant variation between neonatal units in how they include parents in medical rounds. Only few background characteristics explained the differences suggesting that unit culture plays a major role in welcoming parents to participate.

Breastfeeding outcomes in European NICUs: impact of parental visiting policies.

OBJECTIVE: The documented benefits of maternal milk for very preterm infants have raised interest in hospital policies that promote breastfeeding. We investigated the hypothesis that more liberal parental policies are associated with increased breastfeeding at discharge from the neonatal unit. DESIGN: Prospective area-based cohort study. SETTING: Neonatal intensive care units (NICUs) in 19 regions of 11 European countries. PATIENTS: All very preterm infants discharged alive in participating regions in 2011-2012 after spending >70% of their hospital stay in the same NICU (n=4407). MAIN OUTCOME MEASURES: We assessed four feeding outcomes at hospital discharge: any and exclusive maternal milk feeding, independent of feeding method; any and exclusive direct breastfeeding, defined as sucking at the breast. We computed a neonatal unit Parental Presence Score (PPS) based on policies regarding parental visiting in the intensive care area (range 1-10, with higher values indicating more liberal policies), and we used multivariable multilevel modified Poisson regression analysis to assess the relation between unit PPS and outcomes. RESULTS: Policies regarding visiting hours, duration of visits and possibility for parents to stay during medical rounds and spend the night in unit differed within and across countries. After adjustment for potential confounders, infants cared for in units with liberal parental policies (PPS≥7) were about twofold significantly more likely to be discharged with exclusive maternal milk feeding and exclusive direct breastfeeding. CONCLUSION: Unit policies promoting parental presence and involvement in care may increase the likelihood of successful breastfeeding at discharge for very preterm infants.

Patent Ductus Arteriosus Treatment in Very Preterm Infants: A European Population-Based Cohort Study (EPICE) on Variation and Outcomes.

BACKGROUND: Spontaneous closure of patent ductus arteriosus (PDA) occurs frequently in very preterm infants and despite the lack of evidence for treatment benefits, treatment for PDA is common in neonatal medicine. OBJECTIVES: The aim of this work was to study regional variations in PDA treatment in very preterm infants (≤31 weeks of gestation), its relation to differences in perinatal characteristics, and associations with bronchopulmonary dysplasia (BPD) and survival without major neonatal morbidity. METHODS: This was a population-based cohort study in 19 regions in 11 European countries conducted during 2011 and 2012. A total of 6,896 infants with data on PDA treatment were included. The differences in infant characteristics were studied across regions using a propensity score derived from perinatal risk factors for PDA treatment. The primary outcomes were a composite of BPD or death before 36 weeks postmenstrual age, or survival without major neonatal morbidity. RESULTS: The proportion of PDA treatment varied from 10 to 39% between regions (p < 0.001), and this difference could not be explained by differences in perinatal characteristics. The regions were categorized according to a low (<15%, n = 6), medium (15-25%, n = 9), or high (>25%, n = 4) proportion of PDA treatment. Infants treated for PDA, compared to those not treated, were at higher risk of BPD or death in all regions, with an overall propensity score adjusted risk ratio of 1.33 (95% confidence interval 1.18-1.51). Survival without major neonatal morbidity was not related to PDA treatment. CONCLUSIONS: PDA treatment varies largely across Europe without associated variations in perinatal characteristics or neonatal outcomes. This finding calls for more uniform guidance for PDA diagnosis and treatment in very preterm infants.