Centralisation of extremely preterm births and decreased early postnatal mortality in Sweden, 2004-2007 versus 2014-2016.

AIM: We evaluated the increased centralisation of extremely preterm (EPT) births in Sweden in relation to the changes in mortality and morbidity. METHODS: Population-based data covering Swedish live births from 22 + 0 to 26 + 6 weeks of gestation during 2004-2007 and 2014-2016 were analysed for associations between time-period, birth within (inborn) or outside (outborn) regional centres, and outcomes. RESULTS: Among 1626 liveborn infants, 703 were born in 2004-2007 and 923 in 2014-2016. Birth outside (vs. within) regional centres was associated with a higher infant mortality even after adjustment for birth cohort, gestational age, birthweight standard deviation score and infant sex (adjusted odds ratio 2.01, 95% confidence interval 1.31-3.07, p = 0.001). The higher 1-year mortality in outborn infants was mainly due to more deaths within 24 h after birth. Outborn infants had a higher incidence of intraventricular haemorrhage grade 3-4 than inborn infants (22% vs. 14% in 2004-2007, and 22% vs. 13% in 2014-2016, both p < 0.05). While survival to 1 year without major morbidity increased in inborn infants (33%-40%, p = 0.008), it remained unchanged in outborn infants (29% vs. 30%, p = 0.88). CONCLUSION: Centralisation of EPT births contributed to a lower 1-year mortality in 2014-2016 than that in 2004-2007, attributed to a decrease in deaths before 24 h among inborn infants.

Inborn Versus Outborn Delivery in Neonates With Congenital Diaphragmatic Hernia.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a morbid and potentially fatal condition that challenges providers. The aim of this study is to compare outcomes in neonates with prenatally diagnosed CDH that are inborn (delivered in the institution where definitive care for CDH is provided) versus outborn. METHODS: Prenatally diagnosed CDH cases were identified from the Congenital Diaphragmatic Hernia Study Group (CDHSG) database between 2007 and 2019. Using risk adjustment based on disease severity, we compared inborn versus outborn status using baseline risk and multivariable logistic regression models. The primary endpoint was mortality and the secondary endpoint was need for extracorporeal life support (ECLS). RESULTS: Of 4195 neonates with prenatally diagnosed CDH, 3087 (73.6%) were inborn and 1108 (26.4%) were outborn. There was no significant difference in birth weight, gestational age, or presence of additional congenital anomalies. There was no difference in mortality between inborn and outborn infants (32.6% versus 33.8%, P = 0.44) or ECLS requirement (30.9% versus 31.5%, P = 0.73). Among neonates requiring ECLS, outborn status was a risk factor for mortality (OR 1.51, 95% CI 1.13-2.01, P = 0.006). After adjusting for post-surgical defect size, which is not known prenatally, outborn status was no longer a risk factor for mortality for infants requiring ECLS. CONCLUSIONS: Risk of mortality and need for ECLS for inborn CDH patients is not different to outborn infants. Future studies should be directed to establishing whether highest risk infants are at risk for worse outcomes based on center of birth.

Association of delayed initiation of non-invasive respiratory support with pulmonary air leakage in outborn late-preterm and term neonates.

The frequency of non-invasive respiratory support use has increased in neonates of all gestational ages with respiratory distress (RD). However, the impact of delayed initiation of non-invasive respiratory support in outborn neonates remains poorly understood. This study aimed to identify the impact of the delayed initiation of non-invasive respiratory support in outborn, late-preterm, and term neonates. Medical records of 277 infants (gestational age of ≥ 35 weeks) who received non-invasive respiratory support as primary respiratory therapy < 24 h of age between 2016 and 2020 were retrospectively reviewed. Factors associated with respiratory adverse outcomes were investigated in 190 outborn neonates. Infants with RD were divided into two groups: mild (fraction of inspired oxygen [FiO2] ≤ 0.3) and moderate-to-severe RD (FiO2 > 0.3), depending on their initial oxygen requirements from non-invasive respiratory support. The median time for the initiation of non-invasive respiratory support at a tertiary center was 3.5 (2.2-5.0) h. Male sex, a high oxygen requirement (FiO2 > 0.3), high CO2 level, and respiratory distress syndrome were significant factors associated with adverse outcomes. Subgroup analysis revealed that in the moderate-to-severe RD group, delayed commencement of non-invasive respiratory support (≥ 3 h) was significantly associated with pulmonary air leakage (p = 0.033). CONCLUSION: Our study shows that outborn neonates with moderate-to-severe RD, who were treated with delayed non-invasive respiratory support, were associated with an increased likelihood of pulmonary air leakage. Additional prospective studies are required to establish the optimal timing and methods of non-invasive respiratory support for outborn, late-preterm, and term infants. WHAT IS KNOWN: • Non-invasive respiratory support is widely used in neonates of all gestational ages. • Little is known on the impact of delayed initiation of non-invasive respiratory support in outborn, late preterm, and term neonates. WHAT IS NEW: • Male sex, high oxygen requirement (FiO2 >0.3), high initial CO2 level, and respiratory distress syndrome significantly correlated with adverse outcomes. • Outborn late-preterm and term neonates with high oxygen requirement who were treated with delayed non-invasive respiratory support indicated an increased likelihood of pulmonary air leakage.

Long-term outcomes of children with neonatal transfer: the Japan Environment and Children's Study.

This study aimed to evaluate the association of neonatal transfer with the risk of neurodevelopmental outcomes at 3 years of age. Data were obtained from the Japan Environment and Children's Study. A general population of 103,060 pregnancies with 104,062 fetuses was enrolled in the study in 15 Regional Centers between January 2011 and March 2014. Live-born singletons at various gestational ages, including term infants, without congenital anomalies who were followed up until 3 years were included. Neurodevelopmental impairment was assessed using the Ages and Stages Questionnaire, third edition (ASQ-3) at 3 years of age. Logistic regression was used to estimate the adjusted risk and 95% confidence interval (CI) for newborns with neonatal transfer. Socioeconomic and perinatal factors were included as potential confounders in the analysis. Among 83,855 live-born singletons without congenital anomalies, 65,710 children were studied. Among them, 2780 (4.2%) were transferred in the neonatal period. After adjustment for potential confounders, the incidence of neurodevelopmental impairment (scores below the cut-off value of all 5 domains in the ASQ-3) was higher in children with neonatal transfer compared with those without neonatal transfer (communication: 6.5% vs 3.5%, OR 1.42, 95% CI 1.19-1.70; gross motor: 7.6% vs 4.0%, OR 1.26, 95% CI 1.07-1.49; fine motor: 11.3% vs 7.1%, OR 1.19, 95% CI 1.03-1.36; problem solving: 10.8% vs 6.8%, OR 1.29, 95% CI 1.12-1.48; and personal-social: 6.2% vs 2.9%, OR 1.52, 95% CI 1.26-1.83).   Conclusion: Neonatal transfer was associated with a higher risk of neurodevelopmental impairment at 3 years of age. What is Known: • Neonatal transfer after birth in preterm infants is associated with adverse short-term outcomes. • Long-term outcomes of outborn infants with neonatal transfer in the general population remain unclear. What is New: • This study suggests that neonatal transfer at birth is associated with an increased risk of neurodevelopmental impairment. • Efforts for referring high-risk pregnant women to higher level centers may reduce the incidence of neonatal transfer, leading to improved neurological outcomes in the general population.

Clinical characteristics & outcome of SARS-CoV-2 infected neonates presenting to paediatric emergency.

Background & objectives: Data on neonatal COVID-19 are limited to the immediate postnatal period, with a primary focus on vertical transmission in inborn infants. This study was aimed to assess the characteristics and outcome of COVID-19 in outborn neonates. Methods: All neonates admitted to the paediatric emergency from August 1 to December 31, 2020, were included in the study. SARS-CoV-2 reverse transcription- (RT)-PCR test was done on oro/nasopharyngeal specimens obtained at admission. The clinical characteristics and outcomes of SARS-CoV-2 positive and negative neonates were compared and the diagnostic accuracy of a selective testing policy was assessed. Results: A total of 1225 neonates were admitted during the study period, of whom SARS-CoV-2 RT-PCR was performed in 969. The RT-PCR test was positive in 17 (1.8%). Mean (standard deviation) gestation and birth weight of SARS-CoV-2-infected neonates were 35.5 (3.2) wk and 2274 (695) g, respectively. Most neonates (11/17) with confirmed COVID-19 reported in the first two weeks of life. Respiratory distress (14/17) was the predominant manifestation. Five (5/17, 29.4%) SARS-CoV-2 infected neonates died. Neonates with COVID-19 were at a higher risk for all-cause mortality [odds ratio (OR): 3.1; 95% confidence interval (CI): 1.1-8.9, P=0.03]; however, mortality did not differ after adjusting for lethal malformation (OR: 2.4; 95% CI: 0.7-8.7). Sensitivity, specificity, accuracy, positive and negative likelihood ratios (95% CI) of selective testing policy for SARS-CoV-2 infection at admission was 52.9 (28.5-76.1), 83.3 (80.7-85.6), 82.8 (80.3-85.1), 3.17 (1.98-5.07), and 0.56 (0.34-0.93) per cent, respectively. Interpretation & conclusions: SARS-CoV-2 positivity rate among the outborn neonates reporting to the paediatric emergency and tested for COVID-19 was observed to be low. The selective testing policy had poor diagnostic accuracy in distinguishing COVID-19 from non-COVID illness.

Higher prevalence of rotavirus infection among out-born newborns transferred to a regional neonatal intensive care unit in Korea.

BACKGROUND: Rotavirus is one of important pathogens which require infection control in nurseries and neonatal intensive care unit (NICU). METHOD: We retrospectively reviewed 1,135 out-born newborns who were transferred to a regional tertiary NICU of Chungbuk National University Hospital between January 2012 and December 2016. We assessed the clinical characteristics of newborns based on the results of rotavirus surveillance tests. The prevalence of rotavirus was evaluated according to the year, month, and season. RESULTS: Among the 1,135 infants, 213 (18.8%) had positive results in the rotavirus surveillance test. The rotavirus positive group had a significantly higher gestational age, birth weight, and Apgar score. They also had a significantly higher rate of postpartum care centers when compared to the rotavirus negative group (45.5% vs. 12.6%, P < 0.001). Notably, the prevalence of rotavirus was significantly increased from 3.2 to 33.8% when infants were hospitalized 48 h after birth (P < 0.001). During the study period, there were no significant differences in the annual, monthly, or seasonal prevalence of rotavirus infection. CONCLUSION AND DISCUSSION: These findings suggest that more active screening for rotavirus infection is necessary, especially for out-born newborns admitted to NICUs 48 h after birth or hospitalized after using postpartum care centers in Korea.

Outcomes of Infants with Very Low Birth Weight Associated with Birthplace Difference: A Retrospective Cohort Study of Births in Japan and California.

OBJECTIVE: To determine whether outcomes among infants with very low birth weight (VLBW) vary according to the birthplace (Japan or California) controlling for maternal ethnicity. STUDY DESIGN: Severe intraventricular hemorrhage (IVH) and mortality were ascertained for infants with VLBW born at 24-29 weeks of gestation during 2008-2017 and retrospectively analyzed by the country of birth for mothers and infants (Japan or California). RESULTS: Rates of severe IVH, mortality, or combined IVH/mortality were lower in the 24 095 infants born in Japan (5.1%, 5.0%, 8.8% respectively) compared with infants born in California either to 157 mothers with Japanese ethnicity (12.5%, 9.7%, 17.8%) or to a comparison group of 6173 non-Hispanic white mothers (8.4%, 8.8%, 14.6%). ORs for adverse outcomes were increased for infants born in California to mothers with Japanese ethnicity compared with infants born in Japan for severe IVH (OR, 3.31; 95% CI, 1.93-5.68), mortality (3.73; 95% CI, 2.03-6.86), and the combined outcome (3.26; 95% CI, 2.02-5.27). The odds of these outcomes also were increased for infants born in California to non-Hispanic white mothers compared with infants born in Japan. Outcomes of infants born in California did not differ by Japanese or non-Hispanic white maternal ethnicity. CONCLUSIONS: Low rates of severe IVH and mortality for infants with VLBW born in Japan were not seen in infants born in California to mothers with Japanese ethnicity. Differences in systems of regional perinatal care, social environment, and the quality of perinatal care may partially account for these differences in outcomes.

Microorganisms Profile and Antimicrobial Resistance Pattern in Outborn Neonates in Northern India: A Hospital-Based Observational Study.

BACKGROUND: Neonates born somewhere else (outborn) and treated in a referral centre have different microbiological profile. We report the microorganism's profile and antimicrobial resistance (AMR) in blood culture proven sepsis in outborn neonates. METHODS: Culture positive neonatal sepsis from a neonatal unit of a referral institute catering to outborn neonates was studied over an 18 months duration. Data from the hospital information system were used to analyse the culture positivity rates, the spectrum of the microorganisms isolated and AMR pattern. RESULTS: Out of 5258 admitted neonates, 3687 blood samples were sent for suspect sepsis. The blood cultures were positive in 537 (14.6%) samples from 514 neonates. Gram-positive cocci (GPC) were the most common [240 (45%)] followed by gram-negative bacilli (GNB) [233 (43.4%)] and fungi [64 (11.9%)]. Coagulase negative staphylococcus (CONS) contributed to two-thirds of GPC followed by Klebsiella [93 (17.3%)] and Acinetobacter species [52 (9.7%)]. In 403 (75%) neonates, organisms grew in the samples sent at or within 24 h of admission. The case fatality rate was significantly higher in those with culture positive sepsis. The resistance to meropenem and imipenem was documented in 57.1% and 49.7%, respectively and 48% of the GNB was multidrug resistant. CONCLUSIONS: CONS followed by Klebsiella species were the most common organisms isolated. Three-fourths of the neonates had organisms grown at or within 24 h from admission. More than half of the GNB were multidrug resistant. The case fatality rate was significantly higher in those with culture positive sepsis.

Sepsis is the third most common cause of neonatal mortality globally. Outborn neonates differ in their microorganisms' profile and antimicrobial resistance (AMR) pattern in comparison to inborn neonates. In this study, we report the microorganisms profile and their AMR pattern in blood culture proven sepsis in a large cohort of outborn (extramural) neonates admitted to the index institute. We have also presented the state-wise profile and have compared their AMR pattern. Out of the 5258 admitted neonates, 3687 blood samples were sent for culture for suspect sepsis. The blood cultures were positive in 537 (14.6%) samples from 514 neonates. Coagulase-negative staphylococcus (CONS) followed by Klebsiella species were the most common organisms isolated from this large cohort of outborn neonates. More than 75% of the neonates grew the organisms within 24 h from admission indicating that many of them harboured the organisms at admission. Case fatality rate was significantly higher in those neonates with culture positive sepsis in comparison to culture negative sepsis. Close to 50% of the gram-negative bacilli isolates were multidrug resistant and half of them were extensively drug resistant. A significant between-state difference in organism profile and their AMR patterns were observed.

Evaluation of Risk Factors Affecting Outcome in Outborn Surgical Neonates.

BACKGROUND: Mortality in surgical neonates contributes to neonatal mortality rates. The study was conceptualized to study clinical and nonclinical factors affecting mortality in surgical neonates so that timely intervention could result in improved survival of the neonates. MATERIALS AND METHODS: The study was initiated after approval from the institutional ethics committee and included 120 surgical neonates over a period of 18 months after obtaining consent from the parents/caregivers. Predesigned pro forma was used to record the details of antenatal care received, place of birth, travel history, maternal education and gestational age, and clinical condition at the time of admission. Values of biochemical tests such as serum electrolytes, serum creatinine, and arterial blood gasses were recorded. The need of inotrope support, blood or blood product transfusion, and postoperative ventilator support and intensive care unit (ICU) care was recorded. The results of the two groups, i.e., survivals and mortality, were compared. Outcome was recorded as mortality at 30 days or earlier. RESULTS: Irrespective of the surgical condition, the survival rate was significantly better in those babies who weighed more than 2.5 kg at the time of admission, had capillary refill time of <3 s, had serum ionized calcium levels more than 1 mmol/L, and did not require inotropes, blood or blood product transfusion, and postoperative ICU care and ventilator support. The place of birth, educational status of the mother, gestational age, and distance traveled for care had no statistically significant effect on survival. CONCLUSION: There is a statistically significant correlation between the survival of the babies who weighed more than 2.5 kg and are more physiologically preserved at the time of admission. Mortality rates can be decreased by timely interventions to reduce the need of inotropes, blood or blood products, and ICU care and ventilator support during their postoperative recovery.

[The support of the paediatric nurse in the paediatric emergency rapid response unit]. / L'accompagnement de l'infirmière puéricultrice en Smur pédiatrique.

When a newborn baby is in need of rapid care outside the hospital where the mother has given birth, the nursery nurses work specifically to support the baby during the separation from its parents. They intervene before, during and after the separation of mother and child, particularly during the transfer of the baby to the mobile paediatric emergency and resuscitation unit.

Presence of neonatal intensive care services at birth hospital and early intervention enrollment in infants ≤1500 g.

Objectives To determine whether the receipt of therapeutic services of very-low-birth-weight (VLBW; ≤1500 g) neonates inadvertently delivered at community Level 2 and 3 neonatal intensive care units (NICUs) compared with those born at a well-baby nursery (WBN; Level 1) differed. Methods This is a retrospective study of neonates who were born at Level 1 (WBN), 2, 3, and 4 NICUs and discharged from a Level 4 hospital (n = 529). All infants were evaluated at the Regional Neonatal Follow-up Program at 12 ± 1 months corrected gestational age (CA) and assessed for use of therapeutic services including: early intervention (EI), occupational therapy (OT), physical therapy (PT), speech therapy (ST), and special education (SE). Results Compared to infants born at community Level 2 and 3 NICU hospitals, those outborn at a community Level 1 WBN had significantly higher utilization of EI (90% vs. 62%) and PT (83% vs. 61%) at 12 months CA. This association persisted when controlling for covariates. Infants who required EI had significantly lower Bayley-III cognitive scores at 3 years of age. Conclusion VLBW infants outborn at WBN (Level 1) hospitals required more outpatient therapeutic services than those born at hospitals with NICU facilities. These results suggest that delivering at the appropriate community hospital level of care might be advantageous for long-term outcomes.

Predictors of mortality in outborns with neonatal sepsis: A prospective observational study.

BACKGROUND: Neonatal sepsis-related mortalities are the outcome of a complex interaction of maternal-foetal colonisation, transplacental immunity and physical and cellular defence mechanisms of neonates. OBJECTIVE: The objective of this study was to evaluate the risk factors of mortality in outborn neonatal sepsis. MATERIALS AND METHODS: A 1-year prospective observational study was undertaken at a tertiary care centre. All referred neonates with maternal and neonatal risk factors of sepsis were enrolled. Blood culture, sepsis screen and other relevant investigations were performed. RESULTS: The mortality rate of neonatal sepsis among outborns was 38.24%. The common presentations of these neonates were respiratory distress, lethargy and hypothermia. On univariate analysis, significant risk factors for mortality included male sex (P = 0.05), weight on admission <1500 g (P < 0.001), hypothermia (P = 0.003), respiratory distress (P = 0.04), cyanosis (P = 0.001), convulsions (P = 0.02), prolonged capillary refill time (P < 0.001), thrombocytopenia (P < 0.001), abnormal radiological finding (P = 0.01), cerebrospinal fluid cellularity (P = 0.002) and positive C-reactive protein (P < 0.001). Maternal factors such as hypertension in pregnancy (P = 0.001) and antepartum haemorrhage (P = 0.03) were associated with statistically significant mortality. Gestational age (odds ratio [OR]: 0.49, confidence interval [CI]: 0.26-0.90, P = 0.02), weight on admission (OR: 1.57, CI: 1.08-2.27, P = 0.01), age at admission (OR: 0.89, CI: 0.78-0.99, P = 0.04), distance travelled with neonate (OR: 1.01, CI: 1.00-1.01, P = 0.003), duration of hospital stay (OR: 0.69, CI: 0.63-0.74, P < 0.001), hypothermia (OR: 1.87, CI: 1.01-3.42, P = 0.04), convulsion (OR: 2.88, CI: 1.33-6.20, P = 0.007), cyanosis (OR: 2.39, CI: 1.07-5.35, P = 0.03) and prolonged capillary refill time (OR: 3.34, CI: 1.78-6.24, P < 0.001) were the independent predictors of mortality in neonatal sepsis. CONCLUSION: Gestational age; birth weight; long distance travelled with neonate and presentation with hypothermia, cyanosis, convulsions and prolonged capillary refill time were the independent risk factors for mortality in neonatal sepsis among outborns.

Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth.

OBJECTIVE: To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs). STUDY DESIGN: Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18-21 months of age, corrected for prematurity. RESULTS: Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology-II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3-2.2), death or overall NDI (aOR 1.6, 95% CI 1.2-2.2), death (aOR 2.1, 95% CI 1.5-3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1-3.3). CONCLUSIONS: The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.

Survival prediction of high-risk outborn neonates with congenital diaphragmatic hernia from capillary blood gases.

BACKGROUND: The extent of lung hypoplasia in neonates with congenital diaphragmatic hernia (CDH) can be assessed from gas exchange. We examined the role of preductal capillary blood gases in prognosticating outcome in patients with CDH. METHODS: We retrospectively reviewed demographic data, disease characteristics, and preductal capillary blood gases on admission and within 24 h following admission for 44 high-risk outborn neonates. All neonates were intubated after delivery due to acute respiratory distress, and were emergently transferred via ground ambulance to our unit between 1/2000 and 12/2014. The main outcome measure was survival to hospital discharge and explanatory variables of interest were preductal capillary blood gases obtained on admission and during the first 24 h following admission. RESULTS: Higher ratio of preductal partial pressure of oxygen to fraction of inspired oxygen (PcO2/FIO2) on admission predicted survival (AUC = 0.69, P = 0.04). However, some neonates substantially improve PcO2/FIO2 following initiation of treatment. Among neonates who survived at least 24 h, the highest preductal PcO2/FIO2 achieved in the initial 24 h was the strongest predictor of survival (AUC = 0.87, P = 0.002). Nonsurvivors had a mean admission preductal PcCO2 higher than survivors (91 ± 31 vs. 70 ± 25 mmHg, P = 0.02), and their PcCO2 remained high during the first 24 h of treatment. CONCLUSION: The inability to achieve adequate gas exchange within 24 h of initiation of intensive care treatment is an ominous sign in high-risk outborn neonates with CDH. We suggest that improvement of oxygenation during the first 24 h, along with other relevant clinical signs, should be used when making decisions regarding treatment options in these critically ill neonates.

Outcome of outborn infants at the borderline of viability in Western Australia: A retrospective cohort study.

AIM: Preterm infants have a high risk of morbidity and mortality, which increases with decreasing gestational age. Inborn infants (infants born in tertiary perinatal centres) have higher survival and lower morbidity than outborn infants. We aimed to compare short-term and 1-year developmental outcomes of outborn infants at the borderline of viability (≥23 to ≤25 + 6 weeks gestation) with a similar cohort of inborn infants in the sole tertiary perinatal centre in Western Australia from 2001 to 2011. METHODS: This was a retrospective cohort study. Outborn infants ≥23 to ≤25 + 6 weeks gestation who survived to be transported to the Neonatal Intensive Care Unit (NICU) in the perinatal centre were contemporaneously matched to the next inborn infant of comparable gestation and birth weight. We compared mortality, morbidity (including intraventricular haemorrhage, necrotising enterocolitis and chronic lung disease) and Griffiths General Quotient scores at 1-year corrected age. RESULTS: There were 54 outborn and 519 inborn births in the gestational age range during the study period. Thirty-five (65%) outborn infants were transported to the NICU. Of the outborn infants, 21/54 (39%) survived to discharge compared with 375/519 (72%) inborn infants. For the 35 outborn infants transported to NICU, 14 (40%) died, compared with 6/35 (17%) of inborn infants. There were no differences in short-term and developmental outcomes in surviving infants. CONCLUSIONS: Outborn extremely preterm infants <26 weeks gestation have higher mortality than inborn counterparts. However, those transported to a tertiary NICU have similar morbidity and developmental outcomes.

Identification of the Best Predictive Model for Mortality in Outborn Neonates-Retrospective Cohort Study.

BACKGROUND: Transportation of sick newborns is a major predictor of outcome. Prompt identification of the sickest newborns allows adequate intervention and outcome optimization. An optimal scoring system has not yet been identified. AIM: To identify a rapid, accurate, and easy-to-perform score predictive for neonatal mortality in outborn neonates. MATERIAL AND METHODS: All neonates admitted by transfer in a level III regional neonatal unit between 1 January 2015 and 31 December 2021 were included. Infants with congenital critical abnormalities were excluded (N = 15). Gestational age (GA), birth weight (BW), Apgar score, place of birth, time between delivery and admission (AT), early onset sepsis, and sick neonatal score (SNS) were collected from medical records and tested for their association with mortality, including in subgroups (preterm vs. term infants); GA, BW, and AT were used to develop MSNS-AT score, to improve mortality prediction. The main outcome was all-cause mortality prediction. Univariable and multivariable analysis, including Cox regression, were performed, and odds ratio and hazard ratios were calculated were appropriate. RESULTS: 418 infants were included; 217/403 infants were born prematurely (53.8%), and 20 died (4.96%). Compared with the survivors, the non-survivors had lower GA, BW, and SNS scores (p < 0.05); only the SNS scores remained lower in the subgroup analysis. Time to admission was associated with an increased mortality rate in the whole group and preterm infants (p < 0.05). In multiple Cox regression models, a cut-off value of MSNS-AT score ≤ 10 was more precise in predicting mortality as compared with SNS (AUC 0.735 vs. 0.775) in the entire group and in the preterm infants group (AUC 0.885 vs. 0.810). CONCLUSIONS: The new MSNS-AT score significantly improved mortality prediction at admission in the whole study group and in preterm infants as compared with the SNS score, suggesting that, besides GA and BW, AT may be decisive for the outcome of outborn preterm infants.

Neonatal AKI profile using KDIGO guidelines: A cohort study in tertiary care hospital ICU of Lahore, Pakistan.

Background and objective: Acute kidney injury (AKI) was observed in sick neonates and was associated with poor outcomes. Our cohort represents the neonatal characteristics of those diagnosed with AKI using Kidney Disease: Improved Global Outcome (KDIGO) guidelines. Methodology: A cohort study was conducted in the NICU of FMH from June 2019 to May 2021. Data were collected on a proforma. All continuous variables were not normally distributed and expressed as the median and interquartile range. Categorical variables were analyzed by proportional differences with the Pearson chi-square test or Fisher's exact tests. A multinomial logistic regression model was used to explore the independent risk factors for AKI. Time to the event (death) and the cohort's survival curves were plotted using the Cox proportional hazard model. Results: AKI occurred in 473 (37.6%) neonates. The risk factors of AKI were outborn birth [adjusted odds ratio (AOR): 3.987, 95% confidence interval (CI): 2.564-6.200, p: 0.000], birth asphyxia (AOR: 3.567, 95% CI: 2.093-6.080, p: 0.000), inotropic agent (AOR: 2.060, 95% CI: 1.436-2.957, p: 0.000), antenatal steroids (AOR: 1.721, 95% CI: 1.213-2.443, p: 0.002), central lines (AOR: 1.630, 95% CI: 1.155-2.298, p: 0.005) and intraventricular hemorrhage (IVH)/intracranial hemorrhage/disseminated intravascular coagulopathy (AOR: 1.580, 95% CI: 1.119-2.231, p: 0.009). AKI significantly increases the duration of stay and mortality rates by 16.5% vs. 3.9% in neonates with normal renal function (p < 0.001). Conclusion: About one-third of critically sick neonates had AKI. Significant risk factors for AKI were outborn birth, asphyxia inotropic agents, necrotizing enterocolitis, antenatal steroids central lines, and IVH. AKI is associated with an increased length of stay and increased mortality.

Impact of Outborn/Inborn Birth Status of Infants Born at <29 Weeks of Gestation on Neurodevelopmental Impairment: A Nationwide Cohort Study in Korea.

This study designed to evaluate the short- and long-term outcomes of outborn and inborn preterm infants enhancing the regional perinatal system in South Korea. It is a prospective cohort study of the Korean neonatal network database for infants born at <29 weeks of gestation between 2013 and 2015. Of 2995 eligible infants, 312 were outborn, and 976 completed the assessment of long-term outcome at 18-24 months of corrected age. The mean gestational age was significantly younger in outborn infants than in inborn infants (p = 0.004). The mean Apgar score at 5 min was higher in inborn infants (p = 0.046). More inborn preterm infants died before discharge (p < 0.001); however, most of the other short-term outcomes occurred significantly more often in outborn infants than in inborn infants. The outborn infants had higher odds of neurodevelopmental impairment (adjusted odds ratio (aOR) 2.412, 95% confidence interval (CI) 1.585-3.670), cerebral palsy (aOR 4.460, 95% CI 2.249-8.845) and developmental impairment (aOR 2.238, 95% CI 1.469-3.408). In preterm infants, the location of birth may be a key factor influencing short- and long-term outcomes. Thus, to provide adequate care and efficiently allocate medical resources to high-risk preterm infants, nationwide regional perinatal systems need to be improved and standardized.

Epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary hospital in Northern India.

AIMS AND OBJECTIVES: To study the epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary care teaching hospital in Northern India. MATERIALS AND METHODS: Neonates (n = 406) with blood culture positive sepsis were enrolled prospectively over a period of 1 year (February 2018-January 2019). Demographic details, clinical features, microbiological profile, antibiotic sensitivity pattern, treatment, and outcome were recorded. RESULTS: The mean (±SD) age at presentation was 2.4 (±0.6) days and 2/3rd were males. The mean (±SD) gestation was 35.5 (±3.4) weeks, birth weight was 2215 (±219) g, and 42.4% were preterm. The proportion of neonates with early and late onset sepsis were 69% and 31%, respectively. Predominant isolates were Gram-negative (46.5%), Gram-positive (27.6%) organisms, and yeast (25.9%). Klebsiella pneumoniae (46.5%), Acinetobacter baumannii (17.5%), and Escherichia coli (8%) were common Gram-negative; and coagulase negative Staphylococcus (CONS) (70%), Staphylococcus aureus (13.4%), and Enterococcus (12.5%) were common Gram-positive organisms. Among Gram-negative organisms, the antibiotic sensitivity pattern was ciprofloxacin 45%, cephalosporins 15-40%, aminoglycosides 20-42%, piperacillin-tazobactam 49%, carbapenems 34-51%, tetracyclines 55-70%, doxycycline 55%, chloramphenicol 42%, and colistin 98%; and among Gram-positive organisms were methicillin 30%, clindamycin 52%, vancomycin 100%, teicoplanin 98%, and linezolid 99%. The survival rate was 60.3%. The neonates with Gram-negative sepsis had higher requirement of oxygen, mechanical ventilation, and vasoactive drugs; had more complications; and lower survival (50.3% vs. 72.3%, p= .003) when compared to Gram-positive sepsis. CONCLUSIONS: Gram-negative organisms were commonest cause of neonatal sepsis, had low sensitivity to commonly used antibiotics, and associated with poor outcome.

Neonatal mortality among outborn versus inborn babies.

BACKGROUND: Most previous studies reported there were higher survival rates if low birth weight babies were born in tertiary perinatal centers (inborn) than elsewhere (outborn). The objective of this study is to examine whether the number and ratio of outborn babies decrease and the neonatal mortality differs between inborn and outborn babies. METHODS: We used the pooled data of the Taiwan Clinical Effectiveness Index for the years 2011-2016 obtained from the Joint Commission of Taiwan to study the outborn/inborn number and neonatal mortality rate. RESULTS: We found that the number of outborn babies did not decrease year by year. The ratio of outborn to total babies was lower in the groups of birth body weight 750-999 g and ≧ 2500 g than the other groups. The neonatal mortality rate in outborns was significantly higher than the inborns in the groups of birth body weight 1000-1499 g, 2000-2499 g and ≧ 2500 g (6.9 ± 2.4 vs. 3.8 ± 0.9, P = 0.009, 2.6 ± 0.6 vs. 0.6 ± 0.3, P = 0.002 and 1.52 ± 0.67 vs. 0.08 ± 0.02, P = 0.002, respectively) in medical centers. CONCLUSION: Improved maternal transport which promotes in utero transfer of patients may further improve neonatal outcome.