A survey among healthcare professionals from seven countries reported diverse nutritional practices of late preterm infants.

AIM: To gain insight into nutritional practices and expected growth outcomes of infants born between 34 and 36 gestational weeks defined as late preterm infants (LPT). METHODS: An anonymous online survey among paediatricians and neonatologists from Bangladesh, Indonesia, Mexico, Nigeria, Malaysia, Singapore and Taiwan was conducted from March until October 2020. The questionnaire consisted of 40 questions on the nutritional management and expected growth outcomes of LPT in and after-hospital care. RESULTS: Healthcare professionals from low to high Human Development (HDI) countries (n = 322) and very high HDI countries (n = 169) participated in the survey. Human milk was the preferred feeding, resulting in an adequate growth of LPT (weight, length and occipitofrontal circumference), according to a majority of respondents (low to high HDI, 179/265, 68% vs. very high HDI, 73/143, 51%; p = 0.002). The expected growth outcome was higher after-hospital discharge. Less than half of healthcare professionals started enteral feeding during the 1st hour of life. Lactation difficulties, limited access to human milk fortifiers and donor human milk, especially among low to high HDI countries, were reported as major hurdles. CONCLUSION: Human milk is the first feeding choice for LPT. The diverse opinions on nutritional practices and expected growth outcomes among healthcare professionals indicate the necessity to develop general nutritional guidelines for LPT.

Economic assessment of neonatal intensive care.

Most of the studies on the costing of neonatal intensive care has concentrated on the costs associated with preterm infants which takes up more than half of neonatal intensive care unit (NICU) costs. The focus has been on determining the cost-effectiveness of extreme preterm infants and those at threshold of viability. While the costs of care have an inverse relationship with gestational age (GA) and the lifetime medical costs of the extreme preterm can be as high as $450,000, the total NICU expenditure are skewed towards the care of moderate and late preterm infants who form the main bulk of patients. Neonatal intensive care, has been found to be very cost-effective at $1,000 per term infant per QALY and $9,100 for extreme preterm survivor per QALY. For low and LMIC, where NICU resources are limited, the costs of NICU care is lower largely due to a patient profile of more term and preterm of greater GAs and correspondingly less intensity of care. Public health measures, neonatal resuscitation training, empowerment of nurses to do resuscitation, increasing the accessibility to essential newborn care are recommended cheaper cost-effective measures to reduce neonatal mortality in countries with high neonatal mortality rate, whilst upgraded neonatal intensive care services are needed to further reduce neonatal mortality rate once below 15 per 1,000 livebirths. Economic evaluation of neonatal intensive care should also include post discharge costs which mainly fall on the health, social and educational sectors. Strategies to reduce neonatal intensive care costs could include more widespread implementation of cost-effective methods of improving neonatal outcome and reducing neonatal morbidities, including access to antenatal care, perinatal interventions to delay preterm delivery wherever feasible, improving maternal health status and practising cost saving and effective neonatal intensive care treatment.

Cost is an important factor influencing active management of extremely preterm infants.

AIM: The attitudes of neonatologists towards the active management of extremely premature infants in a developing country like China are uncertain. METHODS: A web-based survey was sent to neonatologists from 16 provinces representing 59.6% (824.2 million) of the total population of China on October 2015 and December 2017. RESULTS: A total of 117 and 219 responses were received in 2015 and 2017, respectively. Compared to 2015, respondents in 2017 were more likely to resuscitate infants <25 weeks of gestation (86% vs. 72%; p < 0.05), but few would resuscitate infants ≤23 weeks of gestation in either epoch (10% vs. 6%). In both epochs, parents were responsible for >50% of the costs of intensive care, but in 2017, significantly fewer clinicians would cease intensive care (75% vs. 88%; p < 0.05) and more would request for economic aid (40% vs. 20%; p < 0.05) if parents could not afford to pay. Resource availability (e.g. ventilators) was not an important factor in either initiation or continuation of intensive care (~60% in both epochs). CONCLUSION: Cost is an important factor in the initiation and continuation of neonatal intensive care in a developing country like China. Such factors need to be taken into consideration when interpreting outcome data from these regions.

Preterm Infant Outcomes after Randomization to Initial Resuscitation with FiO2 0.21 or 1.0.

OBJECTIVE: To determine rates of death or neurodevelopmental impairment (NDI) at 2 years corrected age (primary outcome) in children <32 weeks' gestation randomized to initial resuscitation with a fraction of inspired oxygen (FiO2) value of 0.21 or 1.0. STUDY DESIGN: Blinded assessments were conducted at 2-3 years corrected age with the Bayley Scales of Infant and Toddler Development, Third Edition or the Ages and Stages Questionnaire by intention to treat. RESULTS: Of the 290 children enrolled, 40 could not be contacted and 10 failed to attend appointments. Among the 240 children for whom outcomes at age 2 years were available, 1 child had a lethal congenital anomaly, 1 child had consent for follow-up withdrawn, and 23 children died. The primary outcome, which was available in 238 (82%) of those randomized, occurred in 47 of the 117 (40%) children assigned to initial FiO2 0.21 and in 38 of the 121 (31%) assigned to initial FiO2 1.0 (OR, 1.47; 95% CI, 0.86-2.5; P = .16). No difference in NDI was found in 215 survivors randomized to FiO2 0.21 vs 1.0 (OR, 1.26; 95% CI, 0.70-2.28; P = .11). In post hoc exploratory analyses in the whole cohort, children with a 5-minute blood oxygen saturation (SpO2) <80% were more likely to die or to have NDI (OR, 1.85; 95% CI, 1.07-3.2; P = .03). CONCLUSIONS: Initial resuscitation of infants <32 weeks' gestation with initial FiO2 0.21 had no significant effect on death or NDI compared with initial FiO2 1.0. Further evaluation of optimum initial FiO2, including SpO2 targeting, in a large randomized controlled trial is needed. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Network Registry ACTRN 12610001059055 and the National Malaysian Research Registry NMRR-07-685-957.

Targeted Oxygen in the Resuscitation of Preterm Infants, a Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: Lower concentrations of oxygen (O2) (≤30%) are recommended for preterm resuscitation to avoid oxidative injury and cerebral ischemia. Effects on long-term outcomes are uncertain. We aimed to determine the effects of using room air (RA) or 100% O2 on the combined risk of death and disability at 2 years in infants <32 weeks' gestation. METHODS: A randomized, unmasked study designed to determine major disability and death at 2 years in infants <32 weeks' gestation after delivery room resuscitation was initiated with either RA or 100% O2 and which were adjusted to target pulse oximetry of 65% to 95% at 5 minutes and 85% to 95% until NICU admission. RESULTS: Of 6291 eligible patients, 292 were recruited and 287 (mean gestation: 28.9 weeks) were included in the analysis (RA: n = 144; 100% O2: n = 143). Recruitment ceased in June 2014, per the recommendations of the Data and Safety Monitoring Committee owing to loss of equipoise for the use of 100% O2. In non-prespecified analyses, infants <28 weeks who received RA resuscitation had higher hospital mortality (RA: 10 of 46 [22%]; than those given 100% O2: 3 of 54 [6%]; risk ratio: 3.9 [95% confidence interval: 1.1-13.4]; P = .01). Respiratory failure was the most common cause of death (n = 13). CONCLUSIONS: Using RA to initiate resuscitation was associated with an increased risk of death in infants <28 weeks' gestation. This study was not a prespecified analysis, and it was underpowered to address this post hoc hypothesis reliably. Additional data are needed.

The burden of hypoxic-ischaemic encephalopathy in Malaysian neonatal intensive care units.

INTRODUCTION: This study aimed to determine the incidence of hypoxic-ischaemic encephalopathy (HIE) and predictors of HIE mortality in Malaysian neonatal intensive care units (NICUs). METHODS: This was a retrospective study of data from 37 NICUs in the Malaysian National Neonatal Registry in 2012. All newborns with gestational age ≥ 36 weeks, without major congenital malformations and fulfilling the criteria of HIE were included. RESULTS: There were 285,454 live births in these hospitals. HIE was reported in 919 newborns and 768 of them were inborn, with a HIE incidence of 2.59 per 1,000 live births/hospital (95% confidence interval [CI] 2.03, 3.14). A total of 144 (15.7%) affected newborns died. Logistic regression analysis showed that the significant predictors of death were: chest compression at birth (adjusted odds ratio [OR] 2.27, 95% CI 1.27, 4.05; p = 0.003), being outborn (adjusted OR 2.65, 95% CI 1.36, 5.13; p = 0.004), meconium aspiration syndrome (MAS) (adjusted OR 2.16, 95% CI 1.05, 4.47; p = 0.038), persistent pulmonary hypertension of the newborn (PPHN) (adjusted OR 4.39, 95% CI 1.85, 10.43; p = 0.001), sepsis (adjusted OR 4.46, 95% CI 1.38, 14.40; p = 0.013), pneumothorax (adjusted OR 4.77, 95% CI 1.76, 12.95; p = 0.002) and severe HIE (adjusted OR 42.41, 95% CI 18.55, 96.96; p < 0.0001). CONCLUSION: The incidence of HIE in Malaysian NICUs was similar to that reported in developed countries. Affected newborns with severe grade of HIE, chest compression at birth, MAS, PPHN, sepsis or pneumothorax, and those who were outborn were more likely to die before discharge.

Impact and Challenges of Early Continuous Positive Airway Pressure Therapy for Very Low Birth Weight Neonates in a Developing Country.

BACKGROUND: Early nasal continuous positive airway pressure (EnCPAP) therapy after birth for very low birth weight (VLBW; <1,500 g) neonates has been reported to be beneficial in developed countries. Its benefits in developing countries, such as Malaysia, are unknown. OBJECTIVES: This study aimed to determine EnCPAP rates in 36 neonatal intensive care units of the Malaysian National Neonatal Registry (MNNR) in 2013, to compare the outcomes of VLBW neonates with and without EnCPAP, and to determine whether the availability of CPAP facilities and unit policies played a significant role in EnCPAP rates. METHODS: First, a retrospective cohort study was conducted of VLBW neonates born in the hospitals participating in the study without major congenital abnormalities in the MNNR. This was followed by a questionnaire survey of these hospitals focussed on CPAP facilities and unit policies. RESULTS: Of the 2,823 neonates, 963 (34.1%) received EnCPAP. Amongst EnCPAP neonates significantly fewer deaths were recorded (10.9 vs. 21.7%; p < 0.001), less bronchopulmonary dysplasia was observed (BPD; 8.0 vs. 11.7%; p = 0.002) and fewer mechanical ventilation days were necessary (p < 0.001) than in non-EnCPAP neonates. Logistic regression analysis showed that EnCPAP was significantly associated with a lower mortality (adjusted OR 0.623; 95% CI 0.472, 0.824; p = 0.001) and BPD among survivors (adjusted OR 0.585; 95% CI 0.427, 0.802; p = 0.001). The median EnCPAP rate of the 36 hospitals was 28.4% (IQR 14.3-38.7). Hospitals with CPAP facilities in the delivery suites (p = 0.001) and during transport (p = 0.001) and a policy for EnCPAP (p = 0.036) had significantly higher EnCPAP rates. CONCLUSION: EnCPAP reduced mortality and BPD in Malaysian VLBW neonates. Resource-strapped developing countries should prioritise the use of this low-cost therapy.

Factors associated with inter-institutional variations in sepsis rates of very-low-birth-weight infants in 34 Malaysian neonatal intensive care units.

INTRODUCTION: This study aimed to determine whether patient loads, infant status on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis rates in very-low-birth-weight (VLBW) infants in the Malaysian National Neonatal Registry (MNNR). METHODS: This was a retrospective study of 3,880 VLBW (≤ 1,500 g) infants admitted to 34 neonatal intensive care units (NICUs) in the MNNR. Sepsis was diagnosed in symptomatic infants with positive blood culture. RESULTS: Sepsis developed in 623 (16.1%) infants; 61 (9.8%) had early-onset sepsis (EOS) and 562 (90.2%) had late-onset sepsis (LOS). The median EOS rate of all NICUs was 1.0% (interquartile range [IQR] 0%, 2.0%). Compared with NICUs reporting no EOS (n = 14), NICUs reporting EOS (n = 20) had significantly higher patient loads (total live births, admissions, VLBW infants, outborns); more mothers with a history of abortions, and antenatal steroids and intrapartum antibiotic use; more infants requiring resuscitation procedures at birth; higher rates of surfactant therapy, pneumonia and insertion of central venous catheters. The median LOS rate of all NICUs was 14.5% (IQR 7.8%, 19.2%). Compared with NICUs with LOS rates below the first quartile (n = 8), those above the third quartile (n = 8) used less intrapartum antibiotics, and had significantly bigger and more mature infants, more outborns, as well as a higher number of sick infants requiring ventilator support and total parenteral nutrition. CONCLUSION: Patient loads, resuscitation at birth, status of infants on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis.

The assessment of the readiness of five countries to implement child maltreatment prevention programs on a large scale.

This study aimed to systematically assess the readiness of five countries - Brazil, the Former Yugoslav Republic of Macedonia, Malaysia, Saudi Arabia, and South Africa - to implement evidence-based child maltreatment prevention programs on a large scale. To this end, it applied a recently developed method called Readiness Assessment for the Prevention of Child Maltreatment based on two parallel 100-item instruments. The first measures the knowledge, attitudes, and beliefs concerning child maltreatment prevention of key informants; the second, completed by child maltreatment prevention experts using all available data in the country, produces a more objective assessment readiness. The instruments cover all of the main aspects of readiness including, for instance, availability of scientific data on the problem, legislation and policies, will to address the problem, and material resources. Key informant scores ranged from 31.2 (Brazil) to 45.8/100 (the Former Yugoslav Republic of Macedonia) and expert scores, from 35.2 (Brazil) to 56/100 (Malaysia). Major gaps identified in almost all countries included a lack of professionals with the skills, knowledge, and expertise to implement evidence-based child maltreatment programs and of institutions to train them; inadequate funding, infrastructure, and equipment; extreme rarity of outcome evaluations of prevention programs; and lack of national prevalence surveys of child maltreatment. In sum, the five countries are in a low to moderate state of readiness to implement evidence-based child maltreatment prevention programs on a large scale. Such an assessment of readiness - the first of its kind - allows gaps to be identified and then addressed to increase the likelihood of program success.

Admission hypothermia among VLBW infants in Malaysian NICUs.

This study aimed to determine the prevalence of admission hypothermia (AH) among very-low-birth-weight (≤1500 g) infants in 32 Malaysian neonatal intensive care units (NICUs). This was a retrospective analysis of prospectively collected data of all very-low-birth-weight infants admitted and a questionnaire survey of the practice of AH prevention. Of the 3768 (99.8%) infants with admission temperature recorded, 64.8% (n = 2440) were hypothermic: 40.3% (n = 983) mildly (36.0-36.4°C), 58.5% (n = 1428) moderately (32.0-35.9°C) and 1.2% (n = 29) severely (<32.0°C). Mean ambient temperature of these NICUs was 22.8°C (SD = 2.7, n = 28) in labour rooms and 20.1°C (SD = 1.6, n = 30) in operation theatres. None of the NICUs practised complete care bundle against AH at birth (i.e. use of pre-warmed radiant warmer and cling wrap, ambient temperature of at least 25°C and use of pre-warmed transport incubator). Care bundle against neonatal hypothermia should be actively promoted in Malaysian labour rooms and operation theatres.

Neural tube defects in Malaysia: data from the Malaysian National Neonatal Registry.

UNLABELLED: This study aimed to determine the prevalence and early outcome of neural tube defects (NTDs) in Malaysia. This prospective study included all neonates with NTDs (spina bifida, anencephaly, encephalocoele) born in 2009 in 32 Malaysian hospitals in the Malaysian National Neonatal Network. The prevalence of NTDs was 0.42 per 1000 live births, being highest among the indigenous people of Sarawak (1.09 per 1000 live births) and lowest among Malaysians of Chinese descent (0.09 per 1000 live births). The most common type of NTDs was anencephaly (0.19 per 1000 live births), followed by spina bifida (0.11 per 1000 live births) and encephalocoele (0.07 per 1000 live births). Majority of the infants with anencephaly (94.5%, n = 51), 45.8% (n = 11) with encephalocoele and 9.5% (n = 4) with spina bifida died. The median duration of hospital stay was 4 (range: 0-161) days. CONCLUSION: NTDs were common in Malaysia. Mortality was high. Long-term monitoring of NTD prevalence following folic fortification of food is recommended.

Risk factors associated with outcomes of very low birthweight infants in four Asian countries.

AIM: The study aims to determine the risk factors associated with mortality and necrotising enterocolitis (NEC) among very low birthweight infants in 95 neonatal intensive care units in the Asian Network on Maternal and Newborn Health. METHODS: This is a cross-sectional study using an international collaborative database of 17,595 very low birthweight infants admitted within 28 days of birth between 2003 and 2006 in four Asian countries. Information on the mortality and morbidity of neonates admitted to the neonatal intensive care units was recorded. Factors associated with the death and diseases of infants were estimated using multilevel multivariate logistic regression. Random effects were included to account for the clustering of the observations. RESULTS: Overall discharge mortality was 15% and it was significantly different by countries and units. The mortality rate was found to be significantly higher in neonates with pulmonary haemorrhage (odds ratio 1.83, 95% confidence interval 1.63-2.04) and air leak syndrome (odds ratio 1.51, 95% confidence interval 1.30-1.72). The incidence of NEC was 4.3% and was strongly associated with other morbidities. Multivariate logistic regression showed that patent ductus arteriosus was the most significant risk factor associated with NEC. CONCLUSIONS: Our analysis has highlighted the great potential that multi-country, collaborative datasets have in terms of epidemiologic research when it comes to identifying issues in perinatal health that are common throughout Asia, and in relation to particular issues pertaining to specific countries and neonatal units. Establishing collaborative networks, conducting analyses of common datasets and further epidemiologic research are now essential measures to improve newborn health in Asia.

Risk factors associated with necrotising enterocolitis in very low birth weight infants in Malaysian neonatal intensive care units.

INTRODUCTION: This study aimed to identify the risk factors associated with necrotising enterocolitis (NEC) in very low birth weight (VLBW; weight < 1,501 g) infants in Malaysian neonatal intensive care units (NICUs). METHODS: This was a retrospective study based on data collected in a standardised format for all VLBW infants born in 2007 (n = 3,601) and admitted to 31 NICUs in Malaysian public hospitals. A diagnosis of NEC was made based on clinical, radiological and/or histopathological evidence of stage II or III, according to Bell's criteria. Logistic regression analysis was performed to determine the significant risk factors associated with NEC. RESULTS: 222 (6.2%) infants developed NEC (stage II, n = 197; stage III, n = 25). 69 (31.3%) infants died (stage II, n = 58; stage III, n = 11). The significant risk factors associated with NEC were: maternal age (adjusted odds ratio [OR] 1.024, 95% confidence interval [CI] 1.003-1.046; p = 0.027), intrapartum antibiotics (OR 0.639, 95% CI 0.421-0.971; p = 0.036), birth weight (OR 0.999, 95% CI 0.998-0.999; p < 0.001), surfactant therapy (OR 1.590, 95% CI 1.170-2.161; p = 0.003), congenital pneumonia (OR 2.00, 95% CI 1.405-2.848; p < 0.001) and indomethacin therapy for the closure of patent ductus arteriosus (PDA) (OR 1.821, 95% CI 1.349-2.431; p = 0.001). CONCLUSION: Increasing maternal age, decreasing birth weight, surfactant therapy, congenital pneumonia and indomethacin therapy for the closure of PDA were associated with an increased risk of NEC in Malaysian VLBW infants. Infants that received intrapartum antibiotics were associated with a reduced risk of developing NEC.

Risk factors associated with pneumothorax in Malaysian neonatal intensive care units.

AIMS: This study aimed to determine the risk factors associated with the development of pneumothorax among infants admitted to the Malaysian neonatal intensive care units (NICUs). METHODS: Twenty-nine of forty NICUs in Malaysian public hospitals participated in the 2006 Malaysian National Neonatal Registry (MNNR). Data of infants from this registry with and without pneumothorax were analysed. A diagnosis of pneumothorax was made in the presence of extra-pleural air detected by chest radiograph or needle aspiration. RESULTS: There were 10,387 infants admitted to these NICUs who met the MNNR inclusion criteria and were included in this study. Pneumothorax developed in 505 (4.9%) of them. Pneumothorax was most common (7.3%) among the extremely low birthweight infants (birthweight equal or less than 1000 g) and the extremely preterm infants of gestation equal or less than 26 weeks (6.8%). Logistic regression analysis showed that the significant risk factors associated with increased risk of development of pneumothorax were: meconium aspiration syndrome (adjusted odds ratio (OR) = 2.1, 95% confidence intervals (CI): 1.7, 2.7), intermittent mandatory ventilation (adjusted OR = 1.5, 95% CI: 1.2, 2.0), high-frequency oscillatory ventilation (adjusted OR = 3.9, 95% CI: 3.0, 5.2) and confirmed sepsis (adjusted OR = 1.6, 95% CI: 1.3, 2.1). Infants on nasal continuous positive airway pressure (nCPAP) therapy were associated with significantly lower risk of pneumothorax (adjusted OR = 0.5, 95% CI: 0.4, 0.6). CONCLUSION: Meconium aspiration syndrome, mechanical ventilation and sepsis were associated with increased risk and the use of nCPAP with decreased risk of pneumothorax in Malaysian NICUs.

Cost-effectiveness analysis of Malaysian neonatal intensive care units.

OBJECTIVE: To perform a cost-effective analysis on the care of infants between 1000 and 1500 g birthweight (the study group), where outcomes are measured as survival to 1 year of age. METHODOLOGY: This was a multicenter observational study to determine the outcome, cost and cost-effectiveness of neonatal intensive care provided by Ministry of Health (MOH) Pediatric services. A total of 333 patients enrolled were eligible for analysis according to the inclusion and exclusion criteria of this study. RESULTS: Overall survival probability of the study group infants at 1 year of age was 78%. Survival at 1-year of age was 77% for infants with birth weight 1000 to 1249 g, 79% for 1250 to 1499 g. Survival at 1 year of age for the sample group was 53% for 22 to 27 weeks gestation, 80% for 28 to 36 weeks. The average cost-effectiveness ratio (CER) of neonatal intensive care for the study group infants was US$3979 [corrected] per survivor at 1 year of age (95% confidence interval US$3411, 5160). CONCLUSION: There was variability in the outcome and cost-effectiveness between the neonatal units, which need to be further assessed. However, neonatal intensive care services provided for the study group infants were cost-effective compared to that in developed countries.