Process and Outcome Measures for Infants Born Moderate and Late Preterm in Tertiary Canadian Neonatal Intensive Care Units.

OBJECTIVE: To describe the prevalence of and between-center variations in care practices and clinical outcomes of moderate and late preterm infants (MLPIs) admitted to tertiary Canadian neonatal intensive care units (NICUs). STUDY DESIGN: This was a retrospective cohort study including infants born at 320/7 through 366/7 weeks of gestation and admitted to 25 NICUs participating in the Canadian Neonatal Network between 2015 and 2020. Patient characteristics, process measures represented by care practices, and outcome measures represented by clinical in-hospital and discharge outcomes were reported by gestational age weeks. NICUs were compared using indirect standardization after adjustment for patient characteristics. RESULTS: Among 25 669 infants (17% of MLPIs born in Canada during the study period) included, 45% received deferred cord clamping, 7% had admission hypothermia, 47% received noninvasive respiratory support, 11% received mechanical ventilation, 8% received surfactant, 40% received antibiotics in the first 3 days, 4% did not receive feeding in the first 2 days, and 77% had vascular access. Mortality, early-onset sepsis, late-onset sepsis, or necrotizing enterocolitis occurred in <1% of the study cohort. Median (IQR) length of stay was 14 (9-21) days among infants discharged home from the admission hospital and 5 (3-9) days among infants transferred to community hospitals. Among infants discharged home, 33% were discharged on exclusive breastmilk and 75% on any breastmilk. There were significant variations between NICUs in all process and outcome measures. CONCLUSIONS: Care practices and outcomes of MLPIs varied significantly between Canadian NICUs. Standardization of process and outcome quality measures for this population will enable benchmarking and research, facilitating systemwide improvements.

Maternal Diabetes and Neurodevelopmental Outcomes of Infants Born Before 29 Weeks' Gestation.

OBJECTIVE: To compare the neurodevelopmental outcomes of infants born at <29 weeks' gestation and exposed to diabetes in pregnancy with those unexposed. STUDY DESIGN: This was a retrospective cohort study using the Canadian Neonatal Network and Canadian Neonatal Follow-Up Network databases. Infants born <29 weeks' gestation and admitted to a level 3 neonatal intensive care unit from 2009 through 2018 who had neurodevelopmental assessments at 18-24 months corrected age were eligible. The 2 primary outcomes were as follows: (1) Neurodevelopmental impairment (NDI) (≥1 of Bayley-III scores < 85 in any domain, cerebral palsy, or vision or hearing impairment); and (2) significant NDI (sNDI) (≥1 of Bayley-III scores < 70 in any domain, cerebral palsy Gross Motor Function Classification System ≥ 3, bilateral blindness, or need for hearing aids or cochlear implants). Secondary outcomes were the individual components of NDI and sNDI. Adjusted odds ratios with 95% CIs were calculated to determine outcomes between groups. RESULTS: Of 13 988 eligible infants, 55% attended neurodevelopmental follow-up assessments. Infants exposed to diabetes had increased odds of NDI compared with those unexposed (aOR 1.09 (95% CI 1.08-1.54); there was no difference in sNDI (aOR 1.07 (95% CI 0.84-1.36). Language and motor delays were more common in those exposed to maternal diabetes. CONCLUSIONS: Higher rates of NDI, language, or motor delays were present in infants born at <29 weeks' gestation exposed to diabetes in utero. Future research is needed to determine the etiology and clinical significance of these findings.

Phosphorylating Tannin in Urea System: A Simple Approach for Enhanced Methylene Blue Removal from Aqueous Media.

Tannin, after lignin, is one of the most abundant sources of natural aromatic biomolecules. It has been used and chemically modified during the past few decades to create novel biobased materials. This work intended to functionalize for the first time quebracho Tannin (T) through a simple phosphorylation process in a urea system. The phosphorylation of tannin was studied by Fourier transform infrared spectroscopy (FTIR), NMR, inductively coupled plasma optical emission spectroscopy (ICP-OES), and X-ray fluorescence spectrometry (XRF), while further characterization was performed by scanning electron microscopy/energy dispersive X-ray spectroscopy (SEM/EDX) and thermogravimetric analysis (TGA) to investigate the morphology, composition, structure, and thermal degradation of the phosphorylated material. Results indicated the occurrence of phosphorylation, suggesting the insertion of phosphate-containing groups into the tannin structure, revealing a high content of phosphate for modified tannin (PT). This elevated phosphorus content serves as evidence for the successful incorporation of phosphate groups through the functionalization process. The corresponding PT and T were employed as adsorbents for methylene blue (MB) removal from aqueous solutions. The results revealed that the Langmuir isotherm model effectively represents the adsorption isotherms. Additionally, the pseudo-second-order model indicates that chemisorption predominantly controls the adsorption mechanism. This finding also supports the fact that the introduced phosphate groups via the phosphorylation process significantly contributed to the improved adsorption capacity. Under neutral pH conditions and at room temperature, the material achieved an impressive adsorption capacity of 339.26 mg·g-1 in about 2 h.

Eco-friendly engineering of micro composite-based hydroxyapatite bio crystal and polyaniline for high removal of OG dye from wastewater: Adsorption mechanism and RSM@BBD optimization.

The presence of harmful substances such as dyes in water systems poses a direct threat to the quality of people's lives and other organisms living in the ecosystem. Orange G (OG) is considered a hazardous dye. The existing paper attempts to evaluate a low-cost adsorbent for the effective removal of OG dye. The developed adsorbent Polyaniline@Hydroxyapatite extracted from Cilus Gilberti fish Scale (PANI@FHAP) was elaborated through the application of the in situ chemical polymerization method to incorporate PANI on the surface of naturally extracted hydroxyapatite FHAP. The good synthesis of PANI@FHAP was evaluated through multiple techniques including X-ray diffraction (XRD), Scanning electron microscopy coupled with energy dispersive X-ray spectrometry (SEM/EDS), Fourier Transforms Infrared spectroscopy (FTIR), and thermogravimetric analysis (TGA) coupled with thermal differential analysis (DTA) analysis. The results reveal a highly ordered disposition of PANI chains on FHAP, resulting in a well-coated FHAP in the PANI matrix. Furthermore, the presence of functional groups on the surface of PANI such as amine (-NH2) and imine (=NH) groups would facilitate the removal of OG dye from contaminated water. The adsorption of OG onto PANI@FHAP was conducted in batch mode and optimized through response surface methodology coupled with box-Behnken design (RSM/BBD) to investigate the effect of time, adsorbent dose, and initial concentration. The outcomes proved that OG adsorption follows a quadratic model (R2 = 0.989). The kinetic study revealed that the adsorption of OG fits the pseudo-second-order model. On the other hand, the isotherm study declared that the Freundlich model is best suited to the description of OG adsorption. For thermodynamic study, the adsorption of OG is spontaneous in nature and exothermic. Furthermore, the regeneration-reusability study indicates that PANI@FHAP could be regenerated and reused up to five successive cycles. Based on the FTIR spectrum of PANI@FHAP after OG adsorption, the mechanism governing OG adsorption is predominantly driven by π-π interaction, electrostatic interaction, and hydrogen bonding interactions. The obtained results suppose that PANI@FHAP adsorbent can be a competitive material in large-scale applications.

Reduced and modified graphene oxide with Ag/V2O5 as a ternary composite visible light photocatalyst against dyes and pesticides.

Water pollution by dyes and pesticides poses significant threats to our ecosystem. In this research, a visible-light ternary composite photocatalytic system was fabricated using graphene oxide (GO) by reducing with N2H4, modifying with KOH, and decorating with Ag/V2O5. The fabricated photocatalysts were characterized through FTIR, SEM, XRD, BET, PL, EDX, ESR, UV-vis spectroscopy, TGA, ESI-MS, and Raman spectroscopy. The point zero charge of the reduced and modified GO (RMGO/Ag/V2O5) was measured to be 6.7 by the pH drift method. This ternary composite was able to achieve complete removal of methyl orange (MO) and chlorpyrifos (CP) in solutions in 80 min under the optimum operation conditions (e.g., in terms of pollutant/catalyst concentrations, pH effects, and contact time). The role of active species responsible for photocatalytic activity was confirmed by scavenger analysis and ESR investigations. The potential mechanism for photocatalytic activity was studied through a fragmentation process carried out by MS analysis. Through nonlinear fitting of the experimental data, MO and CP exhibited the best fit results with the pseudo 1st-order kinetics (quantum yields of 1.07 × 10-3 and 2.16 × 10-3 molecules photon-1 and space-time yields of 1.53 × 10-5 and 2.7 × 10-5 molecules photon-1 mg-1, respectively). The structure of the nanomaterials remained mostly intact to support increased stability and reusability of the prepared photocatalysts even after 10 successive regeneration cycles.

Eco-friendly synthesis of clay-chitosan composite for efficient removal of alizarin red S dye from wastewater: A comprehensive experimental and theoretical investigation.

Alizarin Red S (ARS) is commonly utilized for dyeing in textile industry. The dye represents a refractory pollutant in the aquatic environment unless properly treated. To tackle this pollutant, the applicability of chitosan-clay composite (3C) for the ARS removal from textile wastewater was studied. Characterization studies were conducted on the synthesized adsorbent using Fourier transformation infrared (FT-IR), X-ray diffraction (XRD), and energy dispersive X-ray (EDX) techniques. Optimized parameters such as adsorbent's dosage, pH, reaction time, and initial concentrations were tested in a batch system. Additionally, density functional theory (DFT) was calculated to understand the adsorption mechanism and the role of benzene rings and oxygen atoms in the ARS as electron donors. At the same initial concentration of 30 mg/L and optimized conditions of 50 mg of dose, pH 2, and 10 min of reaction time, about 86% of ARS removal was achieved using the composite. The pseudo-second-order kinetic was applicable to model a reasonable fitness of the adsorption reaction, while the Temkin model was representative to simulate the reaction with a maximum adsorption capacity of 44.39 mg/g. This result was higher than magnetic chitosan (40.12 mg/g), or pure chitosan (42.48 mg/g). With ΔH = 27.22 kJ/mol and ΔG<0, the data implied the endothermic and spontaneous nature of the adsorption process. Overall, this implies that the clay-chitosan composite is promising to remove target dye from contaminated wastewater.

Bio-based composite from chitosan waste and clay for effective removal of Congo red dye from contaminated water: Experimental studies and theoretical insights.

Water pollution due to dyes in the textile industry is a serious environmental problem. During the finishing stage, Congo red (CR) dye, water-soluble, is released into wastewater, polluting the water body. This study explores the effectiveness of utilizing a composite composed of Safi raw clay and chitosan to remove an anionic dye from synthetic wastewater. The chitosan was extracted from crab shells. Its removal performance was compared to that of natural clay. Both the composite and raw clay were used to remove target pollutant. The effects of the chitosan load in the composite, size particles, initial dye concentration, contact time, pH, and temperature on the dye's elimination were tested in batch modes. The composite with 30% (w/w) of chitosan exhibited the highest dye removal. At pH 2, an adsorption capacity of 84.74 mg/g was achieved, indicating that the grafting of the polymer onto clay surface enhances its efficacity and stability in acidic environments. This finding was supported by characterization data obtained from X-ray diffraction (XRD), scanning electron microscopy (SEM), dispersive X-ray spectroscopy (EDX), and Fourier transform infrared (FT-IR) analyses. Under optimized conditions of 20 mg dose, pH 2, 30 min of reaction time, and 20 mg/L of dye concentration, about 92% of dye removal was achieved. The Langmuir isotherm model represents dye adsorption by the composite, while dye removal was controlled by pseudo-second-order model. Thermodynamic data of the adsorption (ΔH = +8.82 kJ/mol; ΔG <0) suggested that the dye adsorption was spontaneous and endothermic. The findings provide insights into the dye elimination by the adsorbent, indicating that the removal occurred via attractive colombic forces, as confirmed by density functional theory (DFT) analysis. Overall, the composite of natural clays and chitosan waste is a promising and innovative adsorbent for treating wastewater containing recalcitrant dyes.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Development and evaluation of a kangaroo mother care implementation model in South Ethiopia.

AIM: To develop a model for increasing the coverage of kangaroo mother care (KMC), which involved ≥8 h of skin-to-skin contact per day and exclusive breastfeeding, for small babies with birth weight < 2000 g in South Ethiopia. METHODS: A mixed methods study was conducted between June 2017 and January 2019 at four hospitals and their catchment areas. Iterative cycles of implementation, program learning and evaluation were used to optimise KMC implementation models. The study explored the community-facility continuum of care and assessed the proportion of neonates with a birth weight less than 2000 g receiving effective KMC. RESULTS: Three KMC implementation models were tested with Model 2 being the final version. This model included enhanced identification of home births, improved referral linkages, immediate skin-to-skin care initiation in facilities and early contact after discharge. These improvements resulted in 86% coverage of effective facility-based KMC initiation for eligible babies. The coverage was 81.5% at discharge and 57.5% 7 days after discharge. The mean age of babies at KMC initiation was 8.2 days (SD = 5.7). CONCLUSION: The study found that the KMC implementation model was feasible and can lead to substantial population-level KMC coverage for small babies.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Part 2: Evidence Evaluation and Guidelines Development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

The 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.

Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Gestational Age-Dependent Variations in Effects of Prophylactic Indomethacin on Brain Injury and Intestinal Injury.

OBJECTIVE: To evaluate the impact of prophylactic indomethacin on early death (<10 days after birth) or severe neurologic injury and on early death or spontaneous intestinal perforation by completed weeks of gestational age in neonates born <29 weeks of gestation. STUDY DESIGN: This was a multicenter, retrospective cohort study of neonates (n = 12 515) born at 236/7 weeks of gestational age, admitted to neonatal intensive care units participating in the Canadian Neonatal Network who received prophylactic indomethacin started within the first 12 hours after birth. Univariate and multivariate analysis compared the composite outcomes of early death or severe neurologic injury and early death or spontaneous intestinal perforation. RESULTS: Of 12 515 eligible neonates, 1435 (11.5%) were exposed to prophylactic indomethacin; recipients were of lower gestational age and birth weight and had greater severity of illness (Score of Neonatal Acute Physiology with Perinatal Extension) on admission compared with nonrecipients. After we adjusted for confounders, prophylactic indomethacin was associated with reduced odds of early death or severe neurologic injury and early death or spontaneous intestinal perforation in neonates born at 23-24 weeks of gestational age. However, prophylactic indomethacin was associated with increased odds of early mortality or spontaneous intestinal perforation for neonates born at 26-28 weeks of gestational age. CONCLUSIONS: Prophylactic indomethacin use was associated with benefit in neonates born at 23-24 weeks of gestational age, but with harm at 26-28 weeks of gestational age. Given the observation of significantly improved survival, a randomized controlled trial is needed to investigate the effect of prophylactic indomethacin in babies born at 23-25 weeks of gestational age.

Barriers for kangaroo mother care (KMC) acceptance, and practices in southern Ethiopia: a model for scaling up uptake and adherence using qualitative study.

BACKGROUND: Globally, approximately 15 million babies are born preterm every year. Complications of prematurity are the leading cause of under-five mortality. There is overwhelming evidence from low, middle, and high-income countries supporting kangaroo mother care (KMC) as an effective strategy to prevent mortality in both preterm and low birth weight (LBW) babies. However, implementation and scale-up of KMC remains a challenge, especially in lowincome countries such as Ethiopia. This formative research study, part of a broader KMC implementation project in Southern Ethiopia, aimed to identify the barriers to KMC implementation and to devise a refined model to deliver KMC across the facility to community continuum. METHODS: A formative research study was conducted in Southern Ethiopia using a qualitative explorative approach that involved both health service providers and community members. Twenty-fourin-depth interviewsand 14 focus group discussions were carried out with 144study participants. The study applied a grounded theory approach to identify,examine, analyse and extract emerging themes, and subsequently develop a model for KMC implementation. RESULTS: Barriers to KMC practice included gaps in KMC knowledge, attitude and practices among parents of preterm and LBW babies;socioeconomic, cultural and structural factors; thecommunity's beliefs and valueswith respect to preterm and LBW babies;health professionals' acceptance of KMC as well as their motivation to implement practices; and shortage of supplies in health facilities. CONCLUSIONS: Our study suggests a comprehensive approach with systematic interventions and support at maternal, family, community, facility and health care provider levels. We propose an implementation model that addresses this community to facility continuum.

2019 American Heart Association Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2019 focused update to the American Heart Association neonatal resuscitation guidelines is based on 2 evidence reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. The International Liaison Committee on Resuscitation Expert Systematic Reviewer and content experts performed comprehensive reviews of the scientific literature on the appropriate initial oxygen concentration for use during neonatal resuscitation in 2 groups: term and late-preterm newborns (≥35 weeks of gestation) and preterm newborns (<35 weeks of gestation). This article summarizes those evidence reviews and presents recommendations. The recommendations for neonatal resuscitation are as follows: In term and late-preterm newborns (≥35 weeks of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. One hundred percent oxygen should not be used to initiate resuscitation because it is associated with excess mortality. In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen and to base subsequent oxygen titration on oxygen saturation targets. These guidelines require no change in the Neonatal Resuscitation Algorithm-2015 Update.

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Outcomes and care practices for preterm infants born at less than 33 weeks' gestation: a quality-improvement study.

BACKGROUND: Preterm birth is the leading cause of morbidity and mortality in children younger than 5 years. We report the changes in neonatal outcomes and care practices among very preterm infants in Canada over 14 years within a national, collaborative, continuous quality-improvement program. METHODS: We retrospectively studied infants born at 23-32 weeks' gestation who were admitted to tertiary neonatal intensive care units that participated in the Evidence-based Practice for Improving Quality program in the Canadian Neonatal Network from 2004 to 2017. The primary outcome was survival without major morbidity during the initial hospital admission. We quantified changes using process-control charts in 6-month intervals to identify special-cause variations, adjusted regression models for yearly changes, and interrupted time series analyses. RESULTS: The final study population included 50 831 infants. As a result of practice changes, survival without major morbidity increased significantly (56.6% [669/1183] to 70.9% [1424/2009]; adjusted odds ratio [OR] 1.08, 95% confidence interval [CI] 1.06-1.10, per year) across all gestational ages. Survival of infants born at 23-25 weeks' gestation increased (70.8% [97/137] to 74.5% [219/294]; adjusted OR 1.03, 95% CI 1.02-1.05, per year). Changes in care practices included increased use of antenatal steroids (83.6% [904/1081] to 88.1% [1747/1983]), increased rates of normothermia at admission (44.8% [520/1160] to 67.5% [1316/1951]) and reduced use of pulmonary surfactant (52.8% [625/1183] to 42.7% [857/2009]). INTERPRETATION: Network-wide quality-improvement activities that include better implementation of optimal care practices can yield sustained improvement in survival without morbidity in very preterm infants.

Effectiveness of Alberta Family Integrated Care on infant length of stay in level II neonatal intensive care units: a cluster randomized controlled trial.

BACKGROUND: Parents of infants in neonatal intensive care units (NICUs) are often unintentionally marginalized in pursuit of optimal clinical care. Family Integrated Care (FICare) was developed to support families as part of their infants' care team in level III NICUs. We adapted the model for level II NICUs in Alberta, Canada, and evaluated whether the new Alberta FICare™ model decreased hospital length of stay (LOS) in preterm infants without concomitant increases in readmissions and emergency department visits. METHODS: In this pragmatic cluster randomized controlled trial conducted between December 15, 2015 and July 28, 2018, 10 level II NICUs were randomized to provide Alberta FICare™ (n = 5) or standard care (n = 5). Alberta FICare™ is a psychoeducational intervention with 3 components: Relational Communication, Parent Education, and Parent Support. We enrolled mothers and their singleton or twin infants born between 32 0/7 and 34 6/7 weeks gestation. The primary outcome was infant hospital LOS. We used a linear regression model to conduct weighted site-level analysis comparing adjusted mean LOS between groups, accounting for site geographic area (urban/regional) and infant risk factors. Secondary outcomes included proportions of infants with readmissions and emergency department visits to 2 months corrected age, type of feeding at discharge, and maternal psychosocial distress and parenting self-efficacy at discharge. RESULTS: We enrolled 654 mothers and 765 infants (543 singletons/111 twin cases). Intention to treat analysis included 353 infants/308 mothers in the Alberta FICare™ group and 365 infants/306 mothers in the standard care group. The unadjusted difference between groups in infant hospital LOS (1.96 days) was not statistically significant. Accounting for site geographic area and infant risk factors, infant hospital LOS was 2.55 days shorter (95% CI, - 4.44 to - 0.66) in the Alberta FICare™ group than standard care group, P = .02. Secondary outcomes were not significantly different between groups. CONCLUSIONS: Alberta FICare™ is effective in reducing preterm infant LOS in level II NICUs, without concomitant increases in readmissions or emergency department visits. A small number of sites in a single jurisdiction and select group infants limit generalizability of findings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02879799 , retrospectively registered August 26, 2016.

Does breastfeeding self-efficacy theory apply to mothers of moderate and late preterm infants? A qualitative exploration.

BACKGROUND: Breastmilk feeding reduces morbidities and improves outcomes related to prematurity. However, breastmilk feeding rates in preterm infants are substantially lower than those in term infants. Breastfeeding self-efficacy theory is a social change theory, which is predictive of exclusive breastmilk feeding at 2 months postpartum in mothers of full-term infants. However, this theory has not been well explored in mothers of moderate and late preterm infants. AIMS AND OBJECTIVES: To explore maternal experiences with feeding moderate (320/7 - 336/7  weeks' gestational age) and late preterm infants (340/7 - 366/7  weeks' GA) in neonatal intensive care units and assess applicability of breastfeeding self-efficacy theory. METHODS: We conducted a qualitative descriptive exploration of maternal experiences with infant feeding in neonatal intensive care units. Using purposive, maximum variation sampling, we selected mothers of preterm infants born at 320/7 - 346/7  weeks, who experienced high mean differences in their BSE scores between admission and discharge. Fourteen mothers participated in semi-structured telephone interviews. Data were examined using thematic analysis. To explore and describe breastfeeding self-efficacy within the context of neonatal intensive care units, we super-imposed the four sources of information from breastfeeding self-efficacy theory onto the defined themes. RESULTS: Three main themes emerged: (a) institutional influences, (b) relationship with the pump and (c) establishing breastfeeding, with an emphasis on the importance of direct breastfeeding at discharge. Overlaying the four sources of information from breastfeeding self-efficacy highlighted the presence of three sources of information: verbal persuasion, performance accomplishment and physiologic/affective responses. Vicarious experience was not identified in maternal experiences with infant feeding. CONCLUSION: Our findings indicate that breastfeeding self-efficacy is an applicable theory for mothers of preterm infants. RELEVANCE TO CLINICAL PRACTICE: Healthcare providers need to be aware of the influence that institutional culture and policies may have on maternal breastfeeding self-efficacy and breastfeeding outcomes.

'What's in a name?'-The effective promotion of brain health in preterm babies.

The achievement of optimal brain health in very preterm babies is a challenge for modern neonatology. There has been limited success in this area of concern despite improvements in other neonatal outcomes. The barriers to progress are (a) the language and definitions that clinicians and scientists use to describe outcomes, (b) our representation of causation, and (c) the rigour with which we apply quality improvement science. Quality improvement science requires clear, relevant, and discriminating language to explain aims, drivers, processes, outcomes, interventions, and definitions. To date, clinical guidelines and research publications have not addressed prevailing flaws in language, causation, and definition. The persisting flaws have restricted identification of quality improvement opportunities and limited the impact of quality improvement efforts. Our community of neonatal caregivers and researchers needs a new and comprehensive approach to language, causation, and implementation science in order to address brain health in very preterm babies.