A Novel Integrated Clinical-Biochemical-Radiological and Sonographic Classification of Necrotizing Enterocolitis.

OBJECTIVE: To evaluate the sensitivity and specificity of clinical, laboratory, and radiological markers and the neonatologist-performed intestinal ultrasound (NP-IUS) for treatment interventions in preterm neonates who developed necrotizing enterocolitis (NEC). STUDY DESIGN: This was a case-control study of preterm neonates < 35 weeks with a diagnostic workup for NEC. The diagnostic workup included NP-IUS performed by trained neonatologists using a standard protocol, abdominal roentgenogram (AXR), and laboratory investigations. Intestinal ultrasound (IUS) performed by two neonatologists was standardized to detect 11 injury markers. AXRs were read independently by experienced pediatric radiologists. The investigators who retrospectively interpreted the IUS were blinded to the clinical and treatment outcomes. RESULTS: A total of 111 neonates were assessed. Fifty-four did not require intervention and formed the control group. Twenty cases were treated medically, 21 cases were treated with late surgery for stricture or adhesions, and 16 were treated with early surgery. The integrated model of cumulative severity of ultrasound markers, respiratory and hemodynamic instability, abdominal wall cellulitis, and C- reactive protein > 16 mg/L had an area under the curve (AUC) of 0.89 (95% confidence interval [CI]: 0.83-0.94%, p < 0.0001) for diagnosing NEC requiring surgical intervention. We also investigated the utility of Bell's classification to diagnose either the need for surgery or death, and it had an AUC of 0.74 (95% CI: 0.65-0.83%, p < 0.0001). CONCLUSION: In this cohort, a combination of specific IUS markers and clinical signs of instability, abdominal wall cellulitis, plus laboratory markers were diagnostic of NEC requiring interventions. KEY POINTS: · The diagnosis of necrotizing enterocolitis requires a combination of markers.. · The combination of specific ultrasound markers, clinical signs, and laboratory markers were diagnostic of NEC requiring intervention.. · The intestinal ultrasound performed by a trained neonatologist was the most sensitive diagnostic marker of NEC requiring surgical intervention..

Perinatal Factors Associated With Breastfeeding Trends After Preterm Birth <29 Weeks Gestation: Can We Predict Early Discontinuation?

OBJECTIVE: To determine the rates and perinatal factors associated with initiation and early discontinuation of breastfeeding among very preterm neonates. METHODS: This was a retrospective cohort study of very preterm infants (<29 weeks gestation) admitted to 2 regional Level III neonatal intensive care units (NICUs) from January 1, 2015, to December 31, 2019. A national neonatal database was used to evaluate initiation and continuation rates of breastfeeding and associated perinatal factors. Stored nutrition profiles and delivery record books were used to determine feeding volumes associated with continuation of breastfeeding to hospital discharge for a subgroup of infants at a single site. Descriptive and inferential statistics were used to present the results between groups, and logistic regression modeling was used to calculate crude and adjusted odds ratios (OR) and 95% CI. RESULTS: Of 391 eligible neonates, 84% initiated breastfeeding but only 38% continued to discharge. Interestingly, frequency of breastfeeding initiation (P < 0.001) and continuation (P < 0.001) declined over the study period. After adjustment for confounders, younger maternal age, earlier gestational age, cigarette smoking, and multiparity were significantly associated with early discontinuation of breastfeeding prior to hospital discharge. Early discontinuation of breastfeeding was also related to lower volumes of breastmilk by day 7 of life (P = 0.004). CONCLUSION: Very preterm neonates are at high risk for non-initiation and early discontinuation of breastfeeding. The early postnatal period represents a critical time to establish breastmilk volumes, and the identification of key perinatal risk factors allows for early and targeted breastfeeding support.

A new intestinal ultrasound integrated approach for the management of neonatal gut injury.

Clinical management of gut injury has been a challenge to the clinician since the first description of necrotizing enterocolitis (NEC) about 50 years ago, and it is still poorly defined. Most of the diagnostic markers are non-specific, and there is no consensus yet on a reliable gold standard for diagnosis. This report describes our approach to integrating point of care intestinal ultrasound (IUS) as the primary radiological assessment modality with other clinical and biochemical markers. CONCLUSIONS: This is the first clinical guideline integrating point of care IUS as a routine assessment of the gut injury. This integrated algorithm improves the quality of care of the gut injury, provides a more accurate diagnosis of NEC, and differentiates other categories of gut injury. WHAT IS KNOWN: • Necrotizing enterocolitis is a poorly defined disease, and the routine assessment relying on AXR does not differentiate NEC from other categories of gut injury. WHAT IS NEW: • Integrating point of care IUS with the routine clinical assessment of gut injury enables the gut injury to be classified according to the triggering factors and severity; this helps target the appropriate management.

Noninvasive High-Frequency Oscillatory Ventilation: A Retrospective Chart Review.

OBJECTIVE: This study aimed to review the feasibility of nasal high-frequency oscillatory ventilation (NHFOV) in preventing reintubation in preterm infants. STUDY DESIGN: This is a retrospective cohort study of all premature newborn infants placed on NHFOV in a single-center neonatal intensive care unit. RESULTS: Twenty-seven patients (birth weight: 765 ± 186 g, gestational age: 28 ± 2 weeks) were commenced on NHFOV on 32 occasions. NHFOV was used immediately postextubation as the primary mode of noninvasive ventilation (NIV; prophylaxis) in 10 of 32 occasions and as "rescue" (failure of NCPAP or biphasic CPAP) in 22 of 32 occasions. Treatment with NHFOV was successful in 22 occasions (69%) while on 10 occasions (31%) reintubation was required within 72 hours. In the rescue group, there was significant reduction in the mean (standard deviation [SD]) number of apneas (0.9 ± 1.07 vs. 0.3 ± 0.29, p < 0.005), but there were no significant changes in the PCO2 level (52 [ ± 9.8] vs. 52 [ ± 8.6] mm Hg, p = 0.8), or the FiO2 requirement (0.39 ± 0.19 vs. 0.33 ± 0.10, p = 0.055) before and after commencing NHFOV, respectively. CONCLUSION: The use of NHFOV is feasible as a prophylactic or rescue mode of NIV following extubation and was associated with decrease in the number of apneas without significant changes in PCO2 or oxygen requirements. A well-designed randomized control trial is needed to determine the indications, clinical outcomes, and safety of this treatment modality. KEY POINTS: · NHFOV is a new and evolving mode of noninvasive ventilation.. · The use of NHFOV is feasible as a prophylactic or rescue mode of noninvasive ventilation.. · A well-designed randomized control is needed to evaluate the efficacy and safety of NHFOV safe..

Association of 24-Hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants.

OBJECTIVE: This study aimed to assess if 24-hour in-house neonatologist (NN) coverage is associated with delivery room (DR) resuscitation/stabilization and outcomes among inborn infants <29 weeks' gestational age (GA). STUDY DESIGN: Survey-linked cohort study of 2,476 inborn infants of 23 to 28 weeks' gestation, admitted between 2014 and 2015 to Canadian Neonatal Network Level-3 neonatal intensive care units (NICUs) with a maternity unit. Exposures were classified using survey responses based on the most senior provider offering 24-hour in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, and retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders. RESULTS: Among the 28 participating NICUs, most senior providers ensuring 24-hour in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). No NN/fellow coverage and 24-hour fellow coverage were associated with higher odds of infants receiving DR chest compressions/epinephrine compared with 24-hour NN coverage (adjusted odds ratio [aOR] = 4.72, 95% confidence interval [CI]: 2.12-10.6 and aOR = 3.33, 95% CI: 1.44-7.70, respectively). Rates of mortality/major morbidity did not differ significantly among the three groups: NN, 63% (249/395 infants); fellow, 64% (1092/1700 infants); no NN/fellow, 70% (266/381 infants). CONCLUSION: 24-hour in-house NN coverage was associated with lower rates of DR chest compressions/epinephrine. There was no difference in neonatal outcomes based on type of coverage; however, further studies are needed as ecological fallacy cannot be ruled out. KEY POINTS: · Lower rates of DR cardiopulmonary resuscitation with 24h in-house NN coverage. · The type of 24h in-house coverage was not associated with mortality and/or major morbidity.. · High-volume centers more often have 24h in-house neonatal fellow coverage.

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.

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.

Golden hour management practices for infants <32 weeks gestational age in Canada.

OBJECTIVES: To determine 'Golden Hour' resuscitation and stabilization practices for infants <32 weeks gestational age in Canadian neonatal intensive care units (NICUs). METHODS: A survey was distributed to investigators of the Evidence-based Practice for Improving Quality study within the Canadian Neonatal Network in June 2014. The questionnaire was designed to obtain information on antenatal counselling, resuscitation environment, resuscitation and management practices, including respiratory and nutritional practices in the first hour of life. Responses to these categories were stratified into gestational age groupings: 230/7-236/7, 240/7-256/7, 260/7-276/7 and 280/7-316/7 weeks. Findings were summarized using descriptive statistics. RESULTS: Investigators from 14 of the 23 (61%) NICUs responded. Antenatal counselling was provided to >75% of expectant parents by Staff Neonatologists and Neonatal Fellows. Most NICUs (78%) provided resuscitation in a room adjacent to the high-risk delivery room or the NICU, while few (36%) resuscitated in the delivery room only. Twelve (86%) NICUs practiced delayed cord clamping while two practiced milking of the cord (14%) and 100% used thermal wrap for infants <28 weeks' gestation. All, with the exception of three NICUs used fraction of inspired oxygen ≤0.3 for initial resuscitation and 12/14 (86%) centres applied continuous positive airway pressure for spontaneously breathing infants <256/7 weeks' gestation. CONCLUSIONS: Participating Canadian NICUs reported that they generally follow Neonatal Resuscitation Program recommendations for stabilization of preterm infants; however, considerable variation exists in the application of evidence-based interventions. Our findings can be used to inform quality improvement initiatives to improve clinical outcomes for this vulnerable population.

Antibiotic exposure and development of necrotizing enterocolitis in very preterm neonates.

OBJECTIVE: To examine the association between the duration of antibiotic exposure and development of stage 2 or 3 necrotizing enterocolitis (NEC) in very preterm neonates. STUDY DESIGN: A retrospective case-control study was conducted from Canadian Neonatal Network data for preterm neonates born before 29 weeks' gestation and admitted 2010 through 2013. Efforts were made to match each NEC case to two controls for gestational age, birth weight (±100 g) and sex. RESULTS: A total of 224 cases and 447 controls were identified. The incidence of antenatal steroid administration, the number of days nil-per-os and the number of antibiotic days prior to onset of NEC were significantly different in neonates with NEC. A multiple regression analysis revealed that the duration of antibiotic use was higher among NEC cases compared to controls (P<0.01). Empiric antibiotic treatment of 5 or more days was associated with significantly increased odds of NEC as compared with antibiotic exposure of 0 to 4 days (adjusted odds ratio: 2.02; 95% CI 1.55, 3.13). CONCLUSION: Empiric antibiotic exposure for 5 or more days in preterm neonates born before 29 weeks' gestation was associated with an increased risk of NEC.

The Impact of Integrated Evaluation of Hemodynamics on Management of Preterm Infants with Late-Onset Compromised Systemic Circulation.

Objectives To study the impact of integrated evaluation of hemodynamics (IEH), using targeted neonatal echocardiography (TNE), cerebral regional tissue oxygenation (crRTO), and fractional oxygen extraction (FOE), using near-infrared spectroscopy (NIRS) on the management of infants with late-onset compromised systemic circulation (LCSC), and evaluation of the hemodynamic characteristics. Study Design Retrospective cohort study comparing infants with LCSC who underwent IEH (April 2014 to May 2016) with an earlier EPOCH who did not undergo IEH (January 2012 to March 2014). The primary outcome was the time to recovery. Results Total 43 infants were included; 18 infants underwent IEH with a median (IQR) 2 (1-3) assessments per infant. The time to recovery was shorter in IEH group with a median (IQR) 28 hours (15-62) compared with non-IEH group 96 hours (30-160). Autoregulation was compromised in 50%, and systemic vascular resistance (SVR) was low in 67%. Conclusion IEH was associated with shorter time to recovery in infants with LCSC.

Association of a quality improvement program with neonatal outcomes in extremely preterm infants: a prospective cohort study.

BACKGROUND: We previously demonstrated improvement in bronchopulmonary dysplasia and nosocomial infection among preterm infants at 12 neonatal units using the Evidence-based Practice for Improving Quality (EPIQ). In the current study, we assessed the association of Canada-wide implementation of EPIQ with mortality and morbidity among preterm infants less than 29 weeks gestational age. METHODS: This prospective cohort study included 6026 infants admitted to 25 Canadian units between 2008 and 2012 (baseline year, n = 1422; year 1, n = 1611; year 2, n = 1508; year 3, n = 1485). Following a 1-year baseline period and 6 months of training and planning, EPIQ was implemented over 3 years. Our primary outcome was a composite of neonatal mortality and any of bronchopulmonary dysplasia, severe neurologic injury, severe retinopathy of prematurity, necrotizing enterocolitis and nosocomial infection. We compared outcomes for baseline and year 3 using multivariable analyses. RESULTS: In adjusted analyses comparing baseline with year 3, the composite outcome (70% v. 65%; adjusted odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51 to 0.79), severe retinopathy (17% v. 13%; OR 0.60, 95% CI 0.45 to 0.79), necrotizing enterocolitis (10% v. 8%; OR 0.73, 95% CI 0.52 to 0.98) and nosocomial infections (32% v. 24%; OR 0.63, 95% CI 0.48 to 0.82) were significantly reduced. The composite outcome was lower among infants born at 26 to 28 weeks gestation (62% v. 52%; OR 0.62, 95% CI 0.49 to 0.78) but not among infants born at less than 26 weeks gestational age (90% v. 88%; OR 0.73, 95% CI 0.44 to 1.20). INTERPRETATION: EPIQ methodology was generalizable within Canada and was associated with significantly lower likelihood of the composite outcome, severe retinopathy, necrotizing enterocolitis and nosocomial infections. Infants born at 26 to 28 weeks gestational age benefited the most.

Grade 7 school performance of children born preterm: a retrospective Canadian Cohort study.

IMPORTANCE: Data on the middle school outcomes of preterm children are limited and have methodologic issues. OBJECTIVE: To study the association between preterm birth and grade 7 school performance. METHODS: A retrospective population-based cohort study of children born in Manitoba, Canada between 1994 and 2006 using their grade 7 school performance data. A secondary sibling cohort was created comprising children born preterm and their full-term siblings. Primary exposure was preterm birth categorized as <28, 28-33 and 34-36 weeks gestation. The two co-primary grade 7 outcome measures were: not meeting the mathematics competencies, and not meeting the student engagement competencies. Multivariable logistic regression models tested the association between preterm birth and both co-primary outcomes; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. RESULTS: 7653 preterm (gestational age median [IQR]: 35 weeks [34,36]) and 110,313 term (40 [39,40]) were included. 43% of < 28 weeks, 18% of 28-33 weeks and 17% of 34-36 weeks had the mathematics co-primary outcome compared to 13% of term children. The corresponding % for the student engagement outcome were 42%, 24%, 24% and 24% respectively. Preterm birth was associated with the mathematics (<28 weeks: 5.48, 3.89-7.70; 28-33 weeks: 1.47, 1.27-1.70; 34-36 weeks: 1.26, 1.16-1.35) and student engagement outcomes (<28 weeks: 2.49, 1.76-3.51; 28-33 weeks: 1.21, 1.06-1.39; 34-36 weeks: 1.09, 1.01-1.16). However, there was no difference in outcomes among the sibling cohort. CONCLUSIONS AND RELEVANCE: Children born preterm had lower grade 7 performance compared to children born term in this population-based cohort. Screening and supports for them in their middle school years are warranted.

Association between congenital anomalies and area-level deprivation among infants in neonatal intensive care units.

OBJECTIVE: To examine the relationship between area-level material deprivation and the risk of congenital anomalies in infants admitted to neonatal intensive care units (NICUs) across Canada. STUDY DESIGN: The Canadian Neonatal Network database was used to identify admitted infants who had congenital anomalies between 2005 and 2009. The association between congenital anomalies and material deprivation quintile was assessed using logistic regression analysis. RESULTS: Of 55,961 infants admitted to participating NICUs during the study period, 6002 (10.7%) had major, 6244 (11.2%) had minor, and 43,715 (78.1%) had no anomalies. There were higher odds of major anomalies (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.03 to 1.24) but not minor anomalies (OR 1.01, 95% CI 0.93 to 1.11) in the highest-deprivation areas as compared with the lowest-deprivation area of maternal residence. Analyses of groups of major anomalies revealed higher odds for chromosomal (OR 1.48, 95% CI 1.05 to 2.10) and multiple-systems (OR 1.40, 95% CI 1.14 to 1.71) anomalies in the highest-deprivation areas compared with the lowest-deprivation areas. CONCLUSION: There are socioeconomic inequalities in the risk of major congenital anomalies, especially chromosomal and multiple-systems anomalies, in the NICU population with the highest rates in the most socioeconomically deprived areas.

Grade 3 school performance among children born preterm: a population-based cohort study.

OBJECTIVE: To study the association between prematurity and grade 3 school performance in a contemporary cohort of children. METHODS: Population-based retrospective cohort study in Manitoba, Canada. Children born between 1999 and 2011 who had their grade 3 school performance data available were eligible. Preterm birth (<37 weeks) was the exposure of interest assessed using multivariable logistic regression models. Our primary outcomes were 'needs ongoing help' or 'outside the range' in at least two of each of the (1) four numeracy and (2) three reading competencies. RESULTS: Of the 186 956 eligible children, 101 436 children (7187 preterm (gestational age, median (IQR) 35 weeks (34, 36)) and 94 249 term (40 weeks (39,40)) were included. Overall, 19% of preterm and 14% of term children had the numeracy outcome (adjusted OR (aOR) 1.38; 95% CI 1.29 to 1.47, p<0.001), while 19% and 13% had the reading outcome (aOR 1.38; 1.29 to 1.48, p<0.001). These differences showed a gestational age gradient. Gestational age (for numeracy, <28 weeks aOR 4.93 (3.45 to 7.03), 28-33 weeks 1.72 (1.50 to 1.98), 34-36 weeks 1.24 (1.15 to 1.34); for reading, <28 weeks 3.51 (2.40 to 5.14), 28-33 weeks 1.72 (1.49 to 1.98), 34-36 weeks 1.24 (1.17-1.37)), male sex, small for gestational age and maternal medical and sociodemographic factors were associated with the numeracy and reading outcomes in this cohort. CONCLUSIONS AND RELEVANCE: Children born preterm had poorer performance in grade 3 numeracy and reading proficiencies than children born full term. All children born preterm, not just those born extremely preterm, should be screened for reading and numeracy performance in school and strategies implemented to address any deficits.

Treatment of patent ductus arteriosus and neonatal mortality/morbidities: adjustment for treatment selection bias.

OBJECTIVE: To examine the association between treatment for patent ductus arteriosus (PDA) and neonatal outcomes in preterm infants, after adjustment for treatment selection bias. STUDY DESIGN: Secondary analyses were conducted using data collected by the Canadian Neonatal Network for neonates born at a gestational age ≤ 32 weeks and admitted to neonatal intensive care units in Canada between 2004 and 2008. Infants who had PDA and survived beyond 72 hours were included in multivariable logistic regression analyses that compared mortality or any severe neonatal morbidity (intraventricular hemorrhage grades ≥ 3, retinopathy of prematurity stages ≥ 3, bronchopulmonary dysplasia, or necrotizing enterocolitis stages ≥ 2) between treatment groups (conservative management, indomethacin only, surgical ligation only, or both indomethacin and ligation). Propensity scores (PS) were estimated for each pair of treatment comparisons, and used in PS-adjusted and PS-matched analyses. RESULTS: Among 3556 eligible infants with a diagnosis of PDA, 577 (16%) were conservatively managed, 2026 (57%) received indomethacin only, 327 (9%) underwent ligation only, and 626 (18%) were treated with both indomethacin and ligation. All multivariable and PS-based analyses detected significantly higher mortality/morbidities for surgically ligated infants, irrespective of prior indomethacin treatment (OR ranged from 1.25-2.35) compared with infants managed conservatively or those who received only indomethacin. No significant differences were detected between infants treated with only indomethacin and those managed conservatively. CONCLUSIONS: Surgical ligation of PDA in preterm neonates was associated with increased neonatal mortality/morbidity in all analyses adjusted for measured confounders that attempt to account for treatment selection bias.

Neonatal outcomes of small for gestational age preterm infants in Canada.

To compare the effect of small for gestational age (SGA) on mortality, major morbidity and resource utilization among singleton very preterm infants (<33 weeks gestation) admitted to neonatal intensive care units (NICUs) across Canada. Infants admitted to participating NICUs from 2003 to 2008 were divided into SGA (defined as birth weight <10th percentile for gestational age and sex) and non-small gestational age (non-SGA) groups. The risk-adjusted effects of SGA on neonatal outcomes and resource utilization were examined using multivariable analyses. SGA infants (n = 1249 from a cohort of 11,909) had a higher odds of mortality (adjusted odds ratio [AOR] 2.46; 95% confidence interval [CI], 1.93-3.14), necrotizing enterocolitis (AOR 1.57; 95% CI, 1.22-2.03), bronchopulmonary dysplasia (AOR 1.78; 95% CI, 1.48-2.13), and severe retinopathy of prematurity (AOR 2.34; 95% CI, 1.71-3.19). These infants also had lower odds of survival free of major morbidity (AOR 0.50; 95% CI, 0.43-0.58) and respiratory distress syndrome (AOR 0.79; 95% CI, 0.68-0.93). In addition, SGA infants had a more prolonged stay in the NICU, and longer use of ventilation continuous positive airway pressure, and supplemental oxygen (p < 0.01 for all). SGA infants had a higher risk of mortality, major morbidities, and higher resource utilization compared with non-SGA infants.

Antenatal breastfeeding promotion amongst pregnancies at high-risk for newborn admission to the NICU: A cross-sectional study.

Objectives: To determine the prevalence and factors associated with antenatal promotion of breastfeeding in high-risk pregnancies. Study design: This was a cross-sectional study of trends in breastfeeding promotion during antenatal consultation of pregnancies at high-risk for newborn admission to the neonatal intensive care unit (NICU) between January 2017 and December 2020. Eligible high-risk pregnant patients undergoing antenatal consultation in a tertiary-level fetal assessment unit were identified using an electronic clinic repository. Consult letters and fetal assessment reports were reviewed to determine baseline demographics, pregnancy history, fetal findings, and communication about breastfeeding. Descriptive and inferential statistics were used to present findings and compare outcomes between groups. Results: 316 pregnancies were included for final analysis. The mean maternal age was 28.7 years (SD 6.2) and 65 % were multiparas. Median gestational age at time of antenatal consult was 32 weeks [IQR 29-34]. The main indication for consultation was fetal anomalies (72.8%), namely cardiac defects (21.2 %). There was a significant improvement in prevalence of antenatal discussions about breastfeeding over the study period, from 48.8 % early in the study period compared to 73.7 % in the past year (p = 0.036). However, amongst consults where breastfeeding was discussed, almost one-quarter (23.8 %) of patients indicated that they were not planning on breastfeeding postnatally. Conclusion: There has been a significant improvement in promoting breastfeeding antenatally amongst high-risk pregnancies. However, no follow-up or supports were offered to one-quarter of patients who indicated no intention of breastfeeding or using donor milk postnatally. Ongoing work is required to further advance breastfeeding promotion antenatally, increase parental supports and education, and optimize breastfeeding rates postnatally for improving outcomes of this high-risk group.

School Readiness Among Children Born Preterm in Manitoba, Canada.

Importance: Children born preterm may experience learning challenges at school. However, there is a paucity of data on the school readiness of these children as they prepare to begin grade 1. Objective: To examine the association between prematurity and school readiness in a population-based cohort of children. Design, Setting, and Participants: This cohort study was conducted in the province of Manitoba, Canada, and involved 2 cohorts of children in kindergarten at the time of data collection. The population-based cohort included children born between January 1, 2000, and December 31, 2011, whose school readiness was assessed in kindergarten using the Early Development Instrument (EDI) data. The sibling cohort comprised children born preterm and their closest-in-age siblings born full term. Data were analyzed between March 12 and September 28, 2021. Exposures: Preterm birth, defined as gestational age (GA) less than 37 weeks. Main Outcomes and Measures: The primary outcome was vulnerability in the EDI, defined as a score below the tenth percentile of the Canadian population norms for any 1 or more of the 5 EDI domains (physical health and well-being, social competence, emotional maturity, language and cognitive development, and communication skills and general knowledge). Logistic regression models were used to identify the factors associated with vulnerability in the EDI. P values were adjusted for multiplicity using the Simes false discovery method. Results: Of 86 829 eligible children, 63 277 were included, of whom 4352 were preterm (mean [SD] GA, 34 [2] weeks; 2315 boys [53%]) and 58 925 were full term (mean [SD] GA, 39 (1) weeks; 29 885 boys [51%]). Overall, 35% of children (1536 of 4352) born preterm were vulnerable in the EDI compared with 28% of children (16 449 of 58 925) born full term (adjusted odds ratio [AOR], 1.32; 95% CI, 1.23-1.41; P < .001]). Compared with children born full term, those born preterm had a higher percentage of vulnerability in each of the 5 EDI domains. In the population-based cohort, prematurity (34-36 weeks' GA: AOR, 1.23 [95% CI, 1.14-1.33]; <34 weeks' GA: AOR, 1.72 [95% CI, 1.48-1.99]), male sex (AOR, 2.24; 95% CI, 2.16-2.33), small for gestational age (AOR, 1.31; 95% CI, 1.23-1.40), and various maternal medical and sociodemographic factors were associated with EDI vulnerability. In the sibling cohort, EDI outcomes were similar for both children born preterm and their siblings born full term except for the communication skills and general knowledge domain (AOR, 1.39; 95% CI, 1.07-1.80) and Multiple Challenge Index (AOR, 1.43; 95% CI, 1.06-1.92), whereas male sex (AOR, 2.19; 95% CI, 1.62-2.96) and maternal age at delivery (AOR, 1.53; 95% CI, 1.38-1.70) were associated with EDI vulnerability. Conclusions and Relevance: Results of this study suggest that, in a population-based cohort, children born preterm had a lower school-readiness rate than children born full term, but this difference was not observed in the sibling cohort. Child and maternal factors were associated with lack of school readiness among this population-based cohort.

Reflections on knowledge translation in Canadian NICUs using the EPIQ method.

The Canadian Neonatal Network conducted a trial of Evidence-Based Practice for Improving Quality (EPIQ) between 2002 and 2005. Improved neonatal intensive care unit (NICU) outcomes established credibility for quality improvement. We surveyed team members and physician leaders to examine critical success factors and barriers to improvement during EPIQ. Respondents agreed that EPIQ had a high utility, was effectively implemented and was a major learning opportunity. The collaborative nature of the project was key to success. Respondents identified the need for additional training and resources in quality improvement. Better communication between clinicians and senior leaders is required to support quality improvement in NICUs.

Neonatal seizures: diagnosis and management.

The recognition of epileptic seizures in newborns is challenging as neonates exhibit a variety of paroxysmal motor phenomena, some epileptic but others not. The distinction, frequently requiring video-EEG monitoring, is crucial for management. Causes are often multi-factorial, specific to country/region, and change over time. Hypoxia-ischemia and infection are still common in both developed and developing countries. Venous and arterial strokes are being increasingly recognized. Treatable conditions, including inborn errors of metabolism, must be anticipated and considered early in the course. Etiology is the principal determinant of outcome. Management is based on uncontrolled studies and expert opinions. Information on neonatal seizures is reviewed, and suggestions for management provided. Phenobarbital remains the first anti-epileptic drug of choice, worldwide. Pharmacogenetic information and hepatic or renal dysfunction will influence doses of all drugs. The toxicity of excipients present in intravenous medicines should be kept in mind, especially when infusions are given to critically ill neonates. Therapeutic trials with pyridoxine or ideally pyridoxal phosphate, folinic acid and biotin should be considered early, if seizures are intractable. The management of electrographic seizures without clinical seizures needs critical study. When anti-epileptic drug treatment is required, maintenance should be for a short duration if seizures are of an acute symptomatic nature.