Neonatal correlates of adverse outcomes in very low‐birthweight infants in the NICU Network

Background: The aim of the present study was to explore the relationships among neonatal morbidity, interventions and death or adverse neurodevelopmental outcomes in very low‐birthweight (VLBW) infants. Methods: Subjects were infants with birthweight ≤1500 g who were cared for in the tertiary neonatal intensive care units in Japan. Multiple logistic regression analysis was performed to examine the odds ratios (OR) and 95% confidence intervals (CI) of neonatal factors for death or cerebral palsy (CP) and death or developmental delay (developmental quotient <70 or delay judged by physicians) at 3 years of age after adjusting for biological and prenatal variables. Results: Of the 3104 subjects, 257 died and 1826 were evaluated at 3 years of age. Cystic periventricular leukomalacia (PVL; OR, 23.9; 95%CI: 11.0–51.7), gastrointestinal perforation (OR, 8.5; 95%CI: 2.8–25.4), intraventricular hemorrhage (IVH) grade 3 or 4 (OR, 3.1; 95%CI: 1.3–7.2) and sepsis (OR, 2.6; 95%CI: 1.4–4.8) were neonatal factors significantly associated with an increased risk of death or CP. Significant correlates with death or developmental delay were cystic PVL (OR, 7.9; 95%CI: 3.7–16.8), gastrointestinal perforation (OR, 6.3; 95%CI: 1.9–20.8), sepsis (OR, 2.8; 95%CI: 1.6–4.8), IVH grade 3 or 4 (OR, 2.6; 95%CI: 1.2–5.7), chronic lung disease at 36 weeks of corrected gestational age (OR, 1.6; 95%CI: 1.1–2.4) and treatment for retinopathy of prematurity (ROP; OR, 1.5; 95%CI: 1.0–2.3). Conclusion: Cystic PVL, gastrointestinal perforation, IVH and sepsis correlated with both death or CP and death or developmental delay in VLBW infants. Chronic lung disease at 36 weeks and treatment for ROP were associated with death or developmental delay, but not with death or CP.     

A national study of risk factors associated with mortality in very low birthweight infants in the Malaysian neonatal intensive care units

To determine the risk factors associated with mortality in very low birthweight (VLBW) infants admitted to the neonatal intensive care units (NIUC) in Malaysia.

Method:

A prospective observational study of outcome of all VLBW infants born between 1 January 1993 and 30 June 1993 and admitted to the NICU.

Results:

Data of 868 VLBW neonates from 18 centres in Malaysia were collected. Their mean birthweight was 1223 g (95% confidence intervals: 1208–1238 g). Thirty-seven point four per cent (325/868) of these infants died before discharge. After exclusion of all infants with congenital anomalies ( n =66, and nine of them also had incomplete records) and incomplete records ( n =82), stepwise logistic regression analysis of the remaining 720 infants showed that the risk factors that were significantly associated with increased mortality before discharge were: delivery in district hospitals, Chinese race, lower birthweight, lower gestation age, persistent pulmonary hypertension of the newborn, pulmonary airleak, necrotizing enterocolitis of stage 2 or 3, confirmed sepsis, hypotension, hypothermia, acute renal failure, intermittent positive pressure ventilation, and umbilical arterial catheterization. Factors that were significantly associated with lower risk of mortality were: use of antenatal steroid, oxygen therapy, surfactant therapy and blood transfusion.

Conclusion:

The mortality of VLBW infants admitted to the Malaysian NICU was high and was also associated with a number of preventable risk factors.     

Neonatal candidiasis: Results of an 8 year study

Background: The aim of the present study was to evaluate the risk factors, demographic features, treatment and clinical outcome associated with candidemia in a neonatal intensive care unit (NICU) within an 8 year period. Methods: The data of infants who were diagnosed as having candidemia, were evaluated. Results: Between January 2000 and December 2007, a total of 28 candidemia episodes were identified in 28 infants. A 1.1% candidemia incidence was documented in the neonatal intensive care unit (NICU). The species most frequently causing candidemia were Candida parapsilosis (57.1%), followed by C. albicans (42.9%). The main predisposing factors for candidemia with C. parapsilosis included presence of maternal pre‐eclampsia, prematurity, prolonged mechanical ventilation, prolonged total parenteral nutrition and presence of jaundice. Retinopathy of prematurity and bronchopulmonary dysplasia were the most frequently seen underlying illnesses in infants with C. parapsilosis. In the present study, 13 infants (46.4%) had evidence of organ dissemination. The mortality rate was 42.8% in infants with candidemia. Mean leukocyte counts and mean C‐reactive protein were significantly higher in neonates who died compared with those who survived. Conclusion: Candida parapsilosis (57.1%) was the leading causative organism, followed by C. albicans (42.9%) in infants. The rate of organ dissemination in the present cases was high. The mortality rate was 42.8% in infants with candidemia.     

Another outcome of neonatal intensive care: First year mortality and hospital morbidity

Objectives: To determine first year mortality and hospital morbidity after neonatal intensive care.
Methodology: Cohort study of 6077 surviving infants inborn in one regional hospital in 1988. Nine hundred and eighty-eight received neonatal intensive care and 103 were very low birthweight (VLBW).
Results For infants who required care in the neonatal intensive care unit (NICU), the relative risk of dying before their first birthday was 3.6 (95% confidence intervals [Cl] 1.5-8.8). This increased risk was associated with low birthweight (LBW) rather than requirement for NICU care. Of all inborn survivors, 10.4% were readmitted to hospital in the first year and 2.4% more than once. The readmission rate was 20% for NICU survivors and 30% for VLBW infants. The risk of hospitalization was independently associated both with NICU admission (odds ratio 2.3, Cl 1.9-2.9) and with VLBW (OR 1.8, Cl 1.1-3.0). The NICU survivors also had multiple admissions and prolonged hospital stays.
Conclusions Both low birthweight and neonatal illness requiring intensive care are important indicators of continuing medical vulnerability over the first year of life.     

Early assessment and neurodevelopmental outcome in very low-birth-weight infants: implications for pediatric practice

To determine which assessments are useful, at what age, in order to identify handicaps in very Iow-birth-weight infants, neonatal cerebral ultrasound findings, neurological examinations and the mental scale of the Bayley Infant Scales of Development at 1 and 2 years of age were examined in relation to neurodevelopmental outcome at 3.6 years of age in a cohort of 79 high-risk very low-birth-weight infants. At 3.6 years of age, a minor handicap was found in 9 (11%) and a major handicap in 4 (5%) children. Cerebral palsy was found in 9 (11%) children at 3.6 years of age and could only be diagnosed reliably at 2 years of age. For short-term follow-up, as feedback to the neonatalogist, the positive predictive value of intraparenchymal damage, as detected by neonatal cerebral ultrasound, was greater than the positive predictive value of a definitely abnormal neurological examination at 1 year of age. Visual handicaps ( n = 4, 5%) and severe hearing deficits ( n = 1, 1 %) were all detected in the first year of life. A mental handicap was found in 7 (9%) children. It was impossible to predict mental handicaps for the individual child. Only 35% of the children with a mental delay at 2 years of age had a mental handicap at 3.6 years of age, whereas 35% had a normal cognitive outcome. Pediatricians therefore should be cautious in the interpretation of developmental tcst results in infancy. Long-term follow-up is essential for the child and its parents.     

Perinatal factors affecting survival of very low birthweight infants — a study from two hospitals

ABSTRACT. Three hundred and seventy-seven consecutive liveborn infants with a birthweight between 500g and 1500g born at two perinatal centres in the calendar years 1977 and 1978 and 40 outborn infants in the same weight group admitted to one of the hospitals during the same period were studied. Although the survival rates in individual 100g weight groups vary between 14.3% and 97.4%, overall survival rates for inborn and outborn infants in both hospitals were similar, ranging from 69.0% to 71.5%. Twenty-two perinatal factors were found to have a significant effect on survival, of which 15 were common to the inborn populations in both hospitals. Eight of these 22 factors were indicators of intrapartum asphyxia. Multiple regression analysis showed that whereas birthweight was the most important variable influencing outcome in one hospital, the infant's condition at birth is the most important in the other. This difference may be related to the aggressive approach to perinatal intensive care of extremely preterm infants in the latter hospital.     

The Prevalence and Outcomes of Thrombocytopenia in a Neonatal Intensive Care Unit: A Three-Year Report

Neonatal thrombocytopenia is one of the most common hematologic disorders in neonatal intensive care units (NICUs). The purpose of this study was to determine the prevalence of thrombocytopenia and whether thrombocytopenia has an effect on the occurrence of intraventricular hemorrhage (IVH) ≥ grade 2 and on mortality rate. This study was carried out retrospectively in neonates admitted to NICU of Cumhuriyet University in Sivas, Turkey, between 2009 and 2012. Among 2218 neonates evaluated, 208 (9.4%) developed thrombocytopenia. The prevalence of IVH ≥ grade 2 was more in infants with thrombocytopenia (7.2%) than in those without thrombocytopenia (4.4%), although this was not statistically significant (P = .08). In univariate analysis, IVH ≥ grade 2 was higher in cases with very severe thrombocytopenia (35.7%, n = 5) than in those with mild (2.1%, n = 2), moderate (4.7%, n = 3), and severe thrombocytopenia (15.2%, n = 5) (P = .04). Multivariate logistic regression analysis showed that birth weight <1500 g (OR 6.2, 95% CI 3.4–9.8; P = .0001), gram-negative sepsis (OR 2.5, 95% CI 1.8–4.2; P = .01), very severe thrombocytopenia (OR 1.3, 95% CI 1.1–2.1; P = .03), and platelet transfusion ≥2 (OR 7.3, 95% CI 4.1–12.1; P = .001) were significant risk factors for mortality. The results of our study suggest that outcomes of neonates with thrombocytopenia depend not only on platelet count but also on decreased gestational age or birth weight, prenatal factors, and sepsis.     

Risk factors for delayed discharge home in very-low-birthweight infants:- a population-based study

AIM: To identify risk factors for delayed discharge home in a population-based cohort of very-low-birthweight (VLBW) infants. METHODS: Demographic, pregnancy, perinatal, and neonatal data were collected in a national population-based database on VLBW infants born from 1995 through 2002. Multivariate analysis determined association with delayed discharge (discharge at a postmenstrual age >42 completed weeks). RESULTS: 882 infants with delayed discharge comprised 9.4% of survivors but accounted for 19.8% of total hospital days utilized until discharge home. Infants with delayed discharge compared to those discharged by term were born at an earlier mean gestational age, at a lower mean birthweight, and had a longer mean hospital stay. Delayed discharge was independently associated with decreasing birthweight (OR 1.25, 95% CI 1.19, 1.31), congenital anomalies (OR 4.80, 95% CI 3.66, 6.28), bronchopulmonary dysplasia (OR 5.88, 95% CI 4.60, 7.57), intraventricular hemorrhage grades 3-4 (OR 1.78, 95% CI 1.34, 2.36), sepsis (OR 1.87, 95% CI 1.54, 2.26), and surgically treated necrotizing enterocolitis (OR 20.20, 95% CI 12.85, 32.03).CONCLUSION: VLBW infants with congenital anomalies or severe complications of preterm birth are at increased risk for delayed discharge home. Early identification of these infants may enable interventions aimed at reducing the detrimental effects of prolonged hospitalization and promoting optimal transition from the hospital to the home environment.     

Impact of massage therapy on motor outcomes in very low‐birthweight infants: Randomized controlled pilot study

Background: The purpose of the present study was to determine the effects of massage therapy on motor development, weight gain, and hospital discharge in preterm very low‐birthweight (VLBW) newborns. Methods: Twenty‐four preterm VLBW newborns (<34 weeks and <1500 g) were enrolled in this randomized controlled pilot study. The intervention group (n = 12) received massage therapy starting at 34 weeks post‐conceptional age (15 min daily, 5 days/week for 4 weeks). The infants in the sham treatment group (n = 12) received similar duration of light still touch. Test of Infant Motor Performance (TIMP) score gain, weight gain, and post‐conceptional age at discharge were compared between the two groups after intervention using Mann–Whitney U‐test. Results: No significant between‐group difference in TIMP score gain and weight gain was identified when all subjects were analyzed. In subgroup analysis, among those with below‐average pre‐treatment TIMP score (<35), the intervention group (n = 6) achieved significantly higher TIMP score gain (P = 0.043) and earlier hospital discharge (P = 0.045) than the sham treatment group (n = 5). These same infants, however, also had significantly shorter duration of total parenteral nutrition than their counterparts in the sham treatment group (P = 0.044). Conclusions: Massage therapy might be a viable intervention to promote motor outcomes in a subgroup of VLBW newborns with poor motor performance. A larger randomized controlled trial is required to further explore the effects of massage therapy in this high‐risk group.     

Outcomes of very‐low‐birthweight infants at 3 years of age born in 2003–2004 in Japan

Background: The aim of this study was to describe and compare neurodevelopmental outcomes with birthweight (BW) groups at 250‐g intervals of very‐low‐birthweight (VLBW) infants at 3 years of age in a multicenter cohort in Japan. Methods: A total of 3104 VLBW infants born in 2003 and 2004 registered in a NICU‐network database were followed in the study. Neurodevelopmental impairment (NDI) was defined as any of the following impairments: cerebral palsy, unilateral or bilateral blindness, severe hearing impairment, or developmental delay; a developmental quotient (DQ) <70 measured using the Kyoto Scale of Psychological Development test or judged by physicians in infants without the test. Results: A total of 257 infants died and follow‐up data were obtained from 1826 infants. Of the 1826 infants, 155 (8.5%) had cerebral palsy, 25 (1.4%) had visual impairment, and 12 (0.7%) had hearing impairment. Of the 1197 infants in whom DQ was measured, 184 (15.4%) had DQ < 70. The proportion of NDI in the evaluated infants was 19.2% (n= 350), ranging from 11.9% (BW 1251–1500 g) to 42.0% (BW ≤ 500 g). Odds ratios (95%CI) of NDI or death against the group BW 1251–1500 g were 20.62 (13.29–31.97) in BW ≤ 500 g, 7.25 (5.45–9.64) in BW 501–750 g, 2.85 (2.12–3.82) in BW 751–1000 g and 1.18 (0.85–1.64) in BW 1001–1250 g. Conclusion: The increasing proportion of NDI or death, an indicator of adverse outcome, was associated with decrement in the BW of the groups. Although we have to consider a bias due to loss of follow‐up data, the incidence of NDI was similar to previous overseas cohort studies despite the higher survival proportion in our study.     

Mortality patterns among very preterm babies: a comparative analysis of two European regions in France and England

OBJECTIVE: To explore the differences in outcome of very preterm pregnancies between two geographically defined populations in Europe with similar socioeconomic characteristics and healthcare provision but different organisational arrangements for perinatal care. DESIGN: Prospective cohort study. SETTING: Nord Pas-de-Calais (NPC), France, and Trent, UK. PARTICIPANTS: All pregnancy outcomes 22(+0) to 32(+6) weeks' gestational age for resident mothers. OUTCOME MEASURES: Mortality patterns (antepartum death, intrapartum death, labour ward death and neonatal unit death) among very preterm babies were analysed by region. Multinomial logistic regression was used to model regional differences for a variety of pregnancy outcomes and to adjust for regional differences in the organisation of perinatal care. RESULTS: Delivery of very preterm infants was significantly higher in Trent compared with NPC (1.9% v 1.5% of all births, respectively (p<0.001)). Stillbirth rate was significantly higher in NPC than in Trent (23.0%, 95% CI 20.0% to 26.5% v 14.4%, 95% CI 12.3% to 16.6%, respectively (p<0.001)) and survival to discharge was higher in Trent than in NPC (74.6%, 95% CI 71.9% to 77.1% v 66.7%, 95% CI 63.3% to 69.9%, respectively (p<0.001)). Probability of intrapartum and labour ward death in NPC was more than five times higher than Trent (relative risk 5.3, 95% CI 2.2 to 13.1 (p<0.001)). CONCLUSION: The high rate of very preterm deliveries and the larger proportion of these infants recorded as live born in Trent appear to be the cause of the excess neonatal mortality seen in the routine statistics. Information about very preterm babies (not usually included in routine statistics) is vital to avoid inappropriate interpretation of international perinatal and infant data. This study highlights the importance of including deaths before transfer to neonatal care and emphasises the need to include the outcome of all pregnancies in a population in any comparative analysis.     

Simplified PRISM III score and outcome in the pediatric intensive care unit

BACKGROUND: To evaluate the association of the PRISM III (pediatric risk of mortality) score with the infant outcome in the pediatric intensive care unit (PICU), and to determine if this score could be simplified. METHODS: A prospective cohort study was carried out with 170 infants who were consecutively admitted to the PICU. The PRISM III score with 17 physiologic variables was performed during the first 8 h of admission to the unit. Statistical analysis was done with logistic regression, odds ratios (OR) with 95% confidence intervals (95% CI), and receiver operating curve. The Alfa value was set at 0.05. RESULTS: There were 42 deaths (24.7%). The two main causes of death were septic shock (28.6%) and head trauma (16.7%). The PRISM III score had a sensitivity of 0.71, and a specificity of 0.64 as a mortality predictor. Out of the 17 physiologic variables only four of them were significant: abnormal pupillary reflexes OR 9.9 (95% CI, 3.5-28.4), acidosis OR 3.1 (95% CI, 2.0-4.9), blood urea nitrogen concentration OR 1.03 (95% CI, 1.01-1.04), and white blood cell count OR 1.02 (95% CI, 1.01-1.03). The whole logistic regression model had a coefficient of determination R(2) = 0.219, P < 0.001. CONCLUSIONS: In this setting, the PRISM III score had good sensitivity and specificity to predict mortality. This score could be simplified using only the four variables that were significant in this study. This modified PRISM III score could reduce the cost of patient care especially in developing countries PICU.     

Changing survival and impairment rates at 18–24 months in outborn very low-birth-weight infants: 1984–1987 versus 1980–1983

Outcomes at 18–24 months corrected age of very low-birth-weight infants admitted to our Neonatal Intensive Care Unit in 1984–1987 (period 2) were compared with the outcomes of infants admitted in 1980–1983 (period 1) (total 1357 infants). In the 500–750–g birth-weight subgroup, the survival rate increased from 32 to 54% ( p = 0.002). Rates of moderate and severe impairment at 18–24 months (neurosensory deficit, or Bayley corrected mental developmental index <68) in this subgroup decreased from 41 to 15% ( p = 0.005), and in those without severe impairment, mean mental Bayley scores in periods 1 and 2 were 84 ± 18 and 90 ± 16, respectively (p = 0.20). Analysis after exclusion of small-for-gestational-age infants gave similar results. In the small-for-gestational-age infants of birth weight 500–750 g, the survival rate increased but the impairment rate was unchanged between periods. It is concluded that outcomes improved in 1984–1987 compared with 1980–1983 only for infants with birth weight of 500–750 g.