Outcomes of singleton small for gestational age preterm infants exposed to maternal hypertension: a retrospective cohort study.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are a major cause of small for gestational age (SGA). Preterm SGA infants have higher rates of adverse outcomes than appropriate for gestational age infants. However, the outcomes are not well established in the setting of HDP. METHODS: Retrospective population-based study using the Canadian Neonatal Network database from January 1, 2010 to December 31, 2016 of SGA infants <33 weeks gestation. Using multivariable models, we determined the adjusted odds ratios (AORs) with 95% confidence intervals (CI) for mortality, bronchopulmonary dysplasia (BPD), severe intraventricular hemorrhage (IVH), severe retinopathy of prematurity, necrotizing enterocolitis, late-onset sepsis, and patent ductus arteriosus (PDA) in infants of HDP mothers and compared them to infants of non-HDP mothers. RESULTS: Of the 2081 eligible SGA infants, 1317 (63%) were born to HDP mothers and had lower odds of mortality (AOR 0.57, 95% CI 0.39-0.83) and BPD (AOR 0.69, 95% CI 0.53-0.90). Sub-group analysis demonstrated decreased mortality in 26-28 and 29-32 weeks gestation groups, decreased BPD in 29-32 weeks gestation group, and decreased PDA in <26 weeks gestation group. CONCLUSION: Preterm SGA infants of HDP mothers have lower odds of mortality and BPD compared to infants of non-HDP mothers.

Sustained quality improvement in outcomes of preterm neonates with a gestational age less than 29 weeks: results from the Evidence-based Practice for Improving Quality Phase 3 1.

Quality improvement initiatives in neonatology have yielded positive results; however, few programs have demonstrated sustainability. We evaluated an ongoing, national quality improvement initiative (Evidence-based Practice for Improving Quality Phase 3 (EPIQ-3)) on outcomes of preterm neonates with a gestational age (GA) of 220-286 weeks (i.e., from 22 weeks and 0 days of gestation to 28 weeks and 6 days of gestation). Data from 7459 neonates admitted to 25 Canadian centers between 2013 and 2017 were studied. Trends in mortality and major morbidities were evaluated. The number of neonates with a GA of 220-236 weeks increased from 90 in 2013 to 139 in 2017 without a significant change in any other GA categories. In the entire cohort, the odds of composite outcome of mortality or any major morbidity (adjusted odds ratio (AOR) 0.72, 95% confidence interval (CI) 0.61-0.84) and of necrotizing enterocolitis (AOR 0.66, 95% CI 0.49-0.89) were lower in 2017 than in 2013. When calculated per year, the odds of composite outcome (AOR 0.93, 95% CI 0.89-0.97) and odds of necrotizing enterocolitis (AOR 0.89, 95% CI 0.82-0.96) decreased significantly. Among the subgroup of neonates with a GA of 260-286 weeks, the odds of composite outcome (AOR 0.63, 95% CI 0.51-0.79), necrotizing enterocolitis (AOR 0.44, 95% CI 0.26-0.73), and nosocomial infection (AOR 0.64, 95% CI 0.49-0.84) were reduced. The collaborative, multidisciplinary, nationwide EPIQ-3 program improved outcomes of preterm neonates, and the improvement was sustainable over 5 years.

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.

Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units.

AIM: To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs). METHODS: A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice. RESULTS: In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes. CONCLUSION: There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies.

Association between Peripherally Inserted Central Venous Catheter Insertion Site and Complication Rates in Preterm Infants.

Objective To examine whether there is an association between peripherally inserted central venous catheter (PICC) insertion site and complication rates among preterm infants. Design We performed a retrospective analysis of the first PICCs placed in preterm infants in a tertiary neonatal intensive care unit between January 2006 and December 2010. The PICC-related complications resulting in catheter removal were compared based on site of insertion. Results Of the 827 PICCs, 593 (72%) were inserted in upper extremity. Lower extremity PICC group infants had higher illness severity (SNAP-II) score and more likely to be inserted later as compared with the upper extremity group. There was no significant difference in the total PICC-related complications between upper and lower extremity PICCs (31.3 vs. 26%; p > 0.05). Logistic regression analysis after adjusting for gestational age, day of line insertion, and SNAP-II score revealed that upper extremity PICCs were associated with increased risk of line infiltration (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 1.36-4.29) but not the total PICC complication (aOR, 1.29; 95% CI, 0.91-1.83). Conclusion There is no difference in total PICC-related complication between upper and lower extremity PICCs; however, the PICC-related mechanical complications vary depending on the site of insertion in preterm infants.

Inotrope use among extremely preterm infants in Canadian neonatal intensive care units: variation and outcomes.

OBJECTIVE: To compare neonatal outcomes between infants who received inotropes and those who did not, and identify variation in inotrope use. STUDY DESIGN: Retrospective review of data from neonates < 29 weeks gestation collected by the Canadian Neonatal Network during 2003 to 2010. After controlling for confounders and maternal/infant characteristics, rates of mortality and major morbidity were compared between those who received inotropes on days 1 and 3 of admission and those who did not. Rate of inotrope use was compared between sites. RESULTS: Inotropes were administered to 772 (10%) of the 7,913 neonates. Infants who received inotropes had significantly higher illness severity, surfactant use, and need for mechanical ventilation. Inotrope use was also associated with significantly higher rates of mortality (adjusted odds ratio [AOR] = 2.05 [1.64, 2.57]), retinopathy of prematurity (AOR = 2.04 [1.54, 2.71]), intraventricular hemorrhage (AOR = 1.59 [1.29, 1.93]), bronchopulmonary dysplasia (AOR = 1.38 [1.11, 1.72]), and necrotizing enterocolitis (AOR = 2.06 [1.59, 2.67]). Rates of inotrope use varied significantly between participating sites (0-36%; AOR = 0 [0, 0.1]-7.7 [2.9, 21]). CONCLUSION: Risk of mortality and major morbidities were significantly higher in neonates who received inotropes. Inotrope use varied significantly among Canadian neonatal intensive care units.

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.

Does primary surgical closure of the patent ductus arteriosus in infants <1500 g or ≤32 weeks' gestation reduce the incidence of necrotizing enterocolitis?

BACKGROUND: The hemodynamic perturbation related to patent ductus arteriosus (PDA) is associated with a higher risk of necrotizing enterocolitis (NEC). OBJECTIVE: To determine whether primary surgical closure, as compared with treatment with indomethacin or exposure to prophylactic indomethacin, reduces the incidence of NEC in preterm infants <1500 g and/or ≤32 weeks' gestation with clinically and echocardiogram-identified PDA. METHODS: The literature was reviewed using the methodology for systematic reviews for the Consensus of Science adapted from the American Heart Association's International Liaison Committee on Resuscitation. RESULTS: Ten studies were reviewed. The incidence of NEC was not lower in infants who underwent primary surgery for closure of the PDA compared with infants treated with indomethacin or infants exposed to prophylactic indomethacin (level of evidence 2). CONCLUSION: Primary surgical closure of the PDA cannot be recommended as an intervention to decrease the incidence of NEC in infants <1500 g and/or ≤32 weeks' gestation. BACKGROUND: The hemodynamic perturbation related to patent ductus arteriosus (PDA) is associated with a higher risk of necrotizing enterocolitis (NEC). OBJECTIVE: To determine whether primary surgical closure, as compared with treatment with indomethacin or exposure to prophylactic indomethacin, reduces the incidence of NEC in preterm infants <1500 g and/or ≤32 weeks' gestation with clinically and echocardiogram-identified PDA. METHODS: The literature was reviewed using the methodology for systematic reviews for the Consensus of Science adapted from the American Heart Association's International Liaison Committee on Resuscitation. RESULTS: Ten studies were reviewed. The incidence of NEC was not lower in infants who underwent primary surgery for closure of the PDA compared with infants treated with indomethacin or infants exposed to prophylactic indomethacin (level of evidence 2). CONCLUSION: Primary surgical closure of the PDA cannot be recommended as an intervention to decrease the incidence of NEC in infants <1500 g and/or ≤32 weeks' gestation.

HISTORIQUE: La perturbation hémodynamique liée à la persistance du canal artériel (PCA) s'associe à un risque plus élevé d'entérocolite nécrosante (ECN). OBJECTIF: Déterminer si la fermeture chirurgicale primaire par rapport au traitement à l'indométhacine ou à l'exposition à une prophylaxie à l'indométhacine réduit l'incidence d'ECN chez les prématurés de moins de 1 500 g ou d'un maximum de 32 semaines d'âge gestationnel ayant une PCA diagnostiquée sur le plan clinique et par échocardiogramme. MÉTHODOLOGIE: Les chercheurs ont analysé les publications au moyen de la méthodologie des analyses systématiques pour le Consensus of Science adaptées du comité de liaison internationale sur la réanimation de l'American Heart Association. RÉSULTATS: Les chercheurs ont analysé dix études. L'incidence d'ECN n'était pas plus faible chez les nourrissons qui avaient subi une chirurgie primaire pour fermer une PCA que chez les nourrissons traités à l'indométhacine ou exposés à une prophylaxie à l'indométhacine (qualité des preuves 2). CONCLUSION: La fermeture chirurgicale primaire de la PCA ne peut être recommandée pour réduire l'incidence d'ECN chez les nourrissons de moins de 1 500 g ou d'un maximum de 32 semaines d'âge gestationnel.

Elective cesarean delivery, neonatal intensive care unit admission, and neonatal respiratory distress.

OBJECTIVE: To evaluate the relationship among gestational age at elective cesarean delivery, neonatal intensive care unit (NICU) admission, and whether the presence of pre-cesarean delivery labor or ruptured membranes affected the incidence of neonatal respiratory distress. METHODS: A chart review was performed of all elective caesarean deliveries (documented planned in advance) during 1 year, 2004-2005, in the Calgary Health Region; resulting in liveborn infants at or after 36 weeks of gestation and birth weight equal to or greater than 2,500 g. The primary outcomes are relative risk of NICU admission or respiratory distress. RESULTS: A total of 1,193 paired maternal and infant charts were reviewed. Admission rate to the NICU was 156 of 1,195 (13.1%). The most common admitting diagnosis was respiratory distress, 126 of 156 (80%). Male gender was a significant risk factor for admission to the NICU or respiratory distress (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.27-2.60, and OR 1.98, 95% CI 1.33-2.95, respectively). Elective cesarean delivery beyond 270 days of gestational age (38(4/7) weeks) significantly reduced the risk for NICU admission or respiratory distress (OR 0.62, 95% CI 0.43-0.89, and OR 0.50, 95% CI 0.34-0.74, respectively). The presence of spontaneous contractions or rupture of membranes before elective cesarean delivery did not reduce the risk of NICU admission or respiratory distress (OR 1.05, 95% CI 0.69-1.62, and OR 0.96, 95% CI 0.60-1.55, respectively). CONCLUSION: Admission to NICU and development of respiratory distress were associated with gestational age at time of elective cesarean delivery and male gender. Awaiting the onset of labor or ruptured membranes did not appear to reduce the risk of NICU admission or neonatal respiratory distress.

Room air resuscitation of the depressed newborn: a systematic review and meta-analysis.

UNLABELLED: Understanding of the potential dangers of hyperoxia in the newborn is growing. Several studies have examined the use of room air for the resuscitation of newborns. OBJECTIVE: To assess the effects of room air resuscitation versus 100% oxygen resuscitation on mortality at 1 week and 1 month in asphyxiated newborn infants. STUDY DESIGN: Systematic review and meta-analysis of seven randomized and quasi-randomised controlled trials comparing room air and 100% oxygen resuscitation of newborn infants. RESULTS: Compared to the 100% oxygen resuscitation group, neonates in the room air resuscitation group had a lower mortality both in the first week of life (odds ratio 0.70, 95% CI 0.50, 0.98) and at 1 month and beyond (odds ratio 0.63, 95% CI 0.42, 0.94). The incidence of severe hypoxic ischemic encephalopathy (Stage II and Stage III) was similar between the two groups. CONCLUSION: This meta-analysis supports the hypothesis that room air is superior to 100% oxygen as the initial choice for resuscitating clinically depressed newborns as it may result in a lower mortality rate. However, adequately powered studies of long-term neurodevelopmental outcomes are not yet available.

What information do parents want from the antenatal consultation?

OBJECTIVE: To explore whether the information content, process and social interaction of the antenatal consultation satisfies the informational needs of women admitted to hospital in preterm and threatened preterm labour. METHODS: Fifty women with pregnancies of gestational ages of between 25 and 32 weeks were admitted to a tertiary care perinatal referral centre and provided with an antenatal consultation about the medical risks and treatments relative to their potentially premature infant. Within 48 h following the consultation, patients were asked to respond to a questionnaire to assess their recall of the information provided, their information expectations and their anxiety level. RESULTS: The majority of respondents (92%) thought that the antenatal consultation increased their knowledge and understanding of what might happen if their infant was born preterm. Although the mean state anxiety score was high, 78% agreed that the consultation relieved some of their worry and anxiety about their baby. In rank order, respondents wanted information about chances of survival, likely medical problems and the risk for disability, followed by medical treatments and breastfeeding. They consistently recalled receiving information about chances of survival, likely medical problems and medical treatments. CONCLUSION: Following the antenatal consultation, respondents were generally satisfied with the information provided but remained highly anxious. Recall of the discussion about disability was inconsistent. They reported needing an opportunity to express their feelings, and to talk about their baby and their anticipated interaction with their baby. Recognizing these aspects can help to improve physician-patient communication.

Communicating with parents of high-risk infants in neonatal intensive care.

Good communication between parents and staff about the likely outcome of high-risk infants is essential to ensure parents' full involvement in decision-making. The present paper discusses the literature on this topic to explore the best practices for professionals communicating with parents of high-risk infants.

Effect of a Quality Improvement Project to Use Exclusive Mother's Own Milk on Rate of Necrotizing Enterocolitis in Preterm Infants.

OBJECTIVE: Mother's own milk (MOM) remains the key strategy to prevent necrotizing enterocolitis (NEC) in preterm infants. We developed and implemented quality improvement (QI) initiatives to improve rate of using MOM in preterm infants of <32 weeks of gestation. The objective was to evaluate the impact of this QI project on NEC incidence in this population. STUDY DESIGN: In November 2009, we established a QI multidisciplinary team that reviewed literature and practices of other institutions to promote exclusive use of MOM in preterm infants of <32 weeks of gestation. The team developed practice changes that were implemented in February 2010. We tracked use of MOM and occurrence of NEC stage ≥ 2 from January 2009 until March 2012 when donor human milk was introduced. The subjects were divided into three groups: baseline (year 2009; n = 189), intervention phase (year 2010; n = 202), and sustain phase (January 2011-March 2012; n = 254). Clinical outcomes of the baseline and sustain phases were compared. RESULTS: Exclusive use of MOM improved significantly from 60.8% to 73.6% at time of first feed (p = 0.004) without any delay in feed introduction (median [interquartile range], 40 [26, 75.5] hours versus 43.5 [24, 69] hours; p = 0.96). There was a nonsignificant increase in exclusive use of MOM at time of full feed (from 79.5% to 85.2%; p = 0.11); however; use of any MOM increased significantly from 80.4% to 91.3% (p < 0.001) at discharge. Time to reach full feed and length of stay remained similar between the baseline and sustain periods. On regression analysis, risk of NEC decreased significantly in the sustain period (odds ratio = 0.32; 95% confidence interval, 0.11-0.93). CONCLUSIONS: QI initiatives were effective in increasing use of exclusive MOM at time of first feed and of any MOM at time of discharge and in reducing NEC incidence in our neonatal intensive care unit.

Intrapartum magnesium sulfate and need for intensive delivery room resuscitation.

OBJECTIVE: To evaluate the association of intrapartum magnesium sulfate for fetal neuroprotection (MgSO4-FN) with the delivery room resuscitation and neonatal outcomes of preterm infants in an era of minimisation of invasive mechanical ventilation. DESIGN: Retrospective cohort study. SETTING: Neonatal intensive care units in the Canadian Neonatal Network. PATIENTS AND INTERVENTION: Preterm infants (23(0) to 31(6) weeks gestational age) born in 2011 or 2012. Resuscitation requirements and neonatal outcomes were compared between infants exposed and unexposed to intrapartum MgSO4-FN. MAIN OUTCOME MEASURES: The primary outcome was a composite outcome of 'intensive resuscitation', defined as the need for intubation and ventilation or chest compressions or epinephrine administration in the delivery room. Secondary outcomes included mortality and major neonatal morbidities. RESULTS: Of 6015 eligible infants, 1387 (23.1%) were exposed to intrapartum MgSO4-FN. Significantly fewer MgSO4-FN infants (41.0% vs 44.6%, p=0.02) required intensive resuscitation. However, after adjustment for confounders, this difference was no longer significant (adjusted OR (AOR) 0.88; 95% CI 0.66 to 1.17). Infants exposed to MgSO4-FN had decreased odds of death (AOR 0.61; 95% CI 0.40 to 0.94), but there was no difference in neonatal morbidities compared with the unexposed infants. CONCLUSIONS: Intrapartum MgSO4 for fetal neuroprotection was not associated with an increased need for intensive delivery room resuscitation in this cohort of preterm infants.

Neighbourhood socio-economic status and spontaneous premature birth in Alberta.

OBJECTIVE: To evaluate a possible association between neighbourhood socio-economic status and spontaneous premature birth in Alberta births. METHODS: The study design was a retrospective cohort of all births in Alberta for the years 2001 and 2006. The primary outcome was spontaneous preterm birth at <37 weeks gestation. Neighbourhood socio-economic status was measured by the Pampalon Material Deprivation Index for each Statistics Canada census dissemination area. Births were linked to dissemination area using maternal postal codes. RESULTS: The analysis comprised 73,585 births, in which the rate of spontaneous preterm delivery at <37 weeks was 5.3%. The rates of spontaneous preterm delivery for each neighbourhood socio-economic category ranged from 4.9% (95% CI 4.5%-5.2%) in the highest category to 6.3% (95% CI 6.0%-6.7%) in the lowest (p<0.001). After controlling for smoking, parity, maternal age and year, we found that women living in the highest socio-economic status neighbourhoods had an adjusted spontaneous preterm birth rate of 5.1% (95% CI 4.7%-5.5%) compared to 6.0% (95% CI 5.6%-6.4%) for women living in the lowest (p=0.003). CONCLUSION: This study documented a modest increase in the risk of spontaneous preterm birth with low socio-economic status. The possibility of confounding bias cannot be ruled out.

Neonatal hypercalcemia secondary to subcutaneous fat necrosis successfully treated with pamidronate: a case series and literature review.

Subcutaneous fat necrosis (SCFN) is a noninfectious panniculitis that occurs in term infants who experience significant distress in the 1st weeks of life, including hypoxic ischemic encephalopathy (HIE). Since the introduction of therapeutic hypothermia for HIE, there have been a few published case reports of SCFN, following this modality of treatment. Although, most cases of SCFN resolve spontaneously, SCFN may be associated with hypercalcemia, which may sometimes reach dangerous levels. Approaches used for the management of this potentially life-threatening condition, include hyperhydration, calciuric diuretics, corticosteroids, and in more resistant cases pamidronate, a bisphosphonate. We report our experience on the use of pamidronate in two cases of severe hypercalcemia associated with SCFN following therapeutic hypothermia for HIE. We believe that with increasing use of therapeutic hypothermia for HIE, clinicians are likely to encounter this condition more frequently.

Hospital re-admission of late preterm or term infants is not a factor influencing duration of predominant breastfeeding.

OBJECTIVE: To determine whether hospital re-admission within the first 2 months of life decreases the odds of predominant breastfeeding. DESIGN: Mothers living in two large healthcare regions of Alberta (population 1 000 000 each) were recruited to participate in this prospective matched cohort study if they delivered a singleton infant between 34 and 41 weeks' gestation and were discharged within 7 days. Re-admitted infants were matched to non-re-admitted infants by site and date of birth. Questionnaires were mailed at 2 months postpartum. Predominant breastfeeding was defined as breastfeeding for at least three feedings per day for the past 7 days. RESULTS: A total of 1798 mothers were eligible for analysis, (n=250 re-admitted, 1548 non-re-admitted). Seventy three per cent (n=1315) reported predominant breastfeeding at 2 months. Infant re-admission (adjusted OR: 1.12, 95% CI 0.8 to 1.55) and late preterm birth were not associated with discontinuation of predominant breastfeeding. The odds of predominantly breastfeeding were two times greater, if mothers' perceptions of talking about breastfeeding with a healthcare provider were positive versus negative. Whereas the odds were decreased for primiparous women (adjusted OR 0.61 95% CI 0.47 to 0.78) and not impacted for multiparous women (OR 0.60 95% CI 0.32 to 1.13) with a negative versus neutral perception of the breastfeeding talk experience. CONCLUSIONS: Hospital re-admission and late preterm birth had no significant impact on the odds of predominant breastfeeding beyond 8 weeks post partum whereas the odds were increased with a perception of a positive experience in speaking with a healthcare provider.

Incidence and timing of presentation of necrotizing enterocolitis in preterm infants.

OBJECTIVES: To examine the variation in the incidence and to identify the timing of the presentation of necrotizing enterocolitis (NEC) in a cohort of preterm infants within the Canadian Neonatal Network (CNN). METHODS: This was a population-based cohort of 16 669 infants with gestational age (GA) <33 weeks, admitted to 25 NICUs participating in the CNN between January 1, 2003, and December 31(,) 2008. Variations in NEC incidence among the participating NICUs for the study period were examined. We categorized early-onset NEC as occurring at <14 days of age and late-onset NEC occurring at ≥14 days. Multivariate logistic regression analysis was performed to identify risk factors for early-onset NEC. RESULTS: The overall incidence of NEC was 5.1%, with significant variation in the risk adjusted incidence among the participating NICUs in the CNN. Early-onset NEC occurred at a mean of 7 days compared with 32 days for late-onset NEC. Early-onset NEC infants had lower incidence of respiratory distress syndrome, patent ductus treated with indomethacin, less use of postnatal steroids, and shorter duration of ventilation days. Multivariate logistic regression analysis identified that greater GA and vaginal delivery were associated with increased risk of early-onset NEC. CONCLUSIONS: Among infants <33 weeks' gestation, NEC appears to present at mean age of 7 days in more mature infants, whereas onset of NEC is delayed to 32 days of age in smaller, lower GA infants. Further studies are required to understand the etiology of this disease process.

Prediction of survival without morbidity for infants born at under 33 weeks gestational age: a user-friendly graphical tool.

OBJECTIVE: To develop models and a graphical tool for predicting survival to discharge without major morbidity for infants with a gestational age (GA) at birth of 22-32 weeks using infant information at birth. DESIGN: Retrospective cohort study. SETTING: Canadian Neonatal Network data for 2003-2008 were utilised. PATIENTS: Neonates born between 22 and 32 weeks gestation admitted to neonatal intensive care units in Canada. MAIN OUTCOME MEASURE: Survival to discharge without major morbidity defined as survival without severe neurological injury (intraventricular haemorrhage grade 3 or 4 or periventricular leukomalacia), severe retinopathy (stage 3 or higher), necrotising enterocolitis (stage 2 or 3) or chronic lung disease. RESULTS: Of the 17 148 neonates who met the eligibility criteria, 65% survived without major morbidity. Sex and GA at birth were significant predictors. Birth weight (BW) had a significant but non-linear effect on survival without major morbidity. Although maternal information characteristics such as steroid use, improved the prediction of survival without major morbidity, sex, GA at birth and BW for GA predicted survival without major morbidity almost as accurately (area under the curve: 0.84). The graphical tool based on the models showed how the GA and BW for GA interact, to enable prediction of outcomes especially for small and large for GA infants. CONCLUSION: This graphical tool provides an improved and easily interpretable method to predict survival without major morbidity for very preterm infants at the time of birth. These curves are especially useful for small and large for GA infants.

Does the use of primary continuous positive airway pressure reduce the need for intubation and mechanical ventilation in infants ≤32 weeks' gestation?

BACKGROUND: Ventilator-induced lung injury is a recognized risk factor for bronchopulmonary dysplasia. OBJECTIVE: To determine whether primary continuous positive airway pressure (CPAP), defined as CPAP without previous endotracheal intubation for any indication, can reduce the need for intubation and mechanical ventilation in infants born at ≤32 weeks' gestational age. METHODS: The literature was reviewed using the methodology for systematic reviews for the Consensus on Resuscitation Science adapted from the American Heart Association's International Liaison Committee on Resuscitation. RESULTS: Fourteen studies were reviewed. Eleven studies provided varying degrees of supportive evidence (level of evidence 3 to 4) that the use of primary CPAP can reduce the need for intubation and mechanical ventilation. CONCLUSION: The use of CPAP as a primary intervention and mode of respiratory support is an option for infants ≤32 weeks' gestation, but avoidance of intubation and mechanical ventilation is more likely in mature infants >27 weeks' gestation.