Health-Related Quality-of-Life Outcomes of Very Preterm or Very Low Birth Weight Adults: Evidence From an Individual Participant Data Meta-Analysis

Socioeconomic outcomes in very preterm/very low birth weight adults: individual participant data meta-analysis

BACKGROUND

Very preterm (VPT; <32 weeks) or very low birth weight (VLBW; <1500 g) birth is associated with socioeconomic disadvantages in adulthood; however, the predictors of these outcomes remain underexplored. This study examined socioeconomic disparities and identified neonatal and sociodemographic risk factors among VPT/VLBW individuals.

METHODS

A one-stage individual participant data meta-analysis was conducted using 11 birth cohorts from eight countries, comprising 1695 VPT/VLBW and 1620 term-born adults aged 18-30 years.

RESULTS

VPT/VLBW adults had lower odds of higher educational attainment (0.40[0.26-0.59]), remaining in education (0.63[0.47-0.84]) or paid work (0.76[0.59-0.97]), and higher odds of receiving social benefits (3.93[2.63-5.68]) than term-borns. Disparities in education and social benefits persisted after adjusting for age, sex, and maternal education, even among those without neurosensory impairments (NSI). Among VPT/VLBW adults, NSI significantly impacted all socioeconomic outcomes, increasing the odds of receiving social benefits 6.7-fold. Additional risk factors included medical complications, lower gestational age and birth weight, lower maternal education, younger maternal age, and non-white ethnicity.

CONCLUSIONS

NSI is the strongest risk factor for adulthood socioeconomic challenges in the VPT/VLBW population. Mitigating these disparities may require improved neonatal care to reduce NSI prevalence and targeted social and educational support for VPT/VLBW individuals.

IMPACT

Very preterm or very low birth weight (VPT/VLBW) birth is associated with socioeconomic disadvantages in adulthood, including lower educational attainment, lower employment rates, and a higher need for social benefits compared with individuals born at term. Neurosensory impairments are strongly associated with adverse socioeconomic outcomes among VPT/VLBW adults, while lower gestational age, lower birth weight, and sociodemographic disadvantages serve as additional risk factors. Early interventions in the NICU that reduce medical complications, along with enhanced educational support throughout childhood, may help mitigate long-term socioeconomic disparities for individuals born VPT/VLBW.

Optimising neonatal services for very preterm births between 27+0 and 31+6 weeks gestation in England: the OPTI-PREM mixed-methods study

Aim

To investigate, for preterm babies born between 27+0 and 31+6 weeks gestation in England, optimal place of birth and early care.

Design

Mixed methods.

Setting

National Health Service neonatal care, England.

Methods

To investigate whether birth and early care in neonatal intensive care units (tertiary units) compared to local neonatal units (non-tertiary units) influenced gestation-specific survival and other major outcomes, we analysed data from the National Neonatal Research Database, for 29,842 babies born between 27+0 and 31+6 weeks gestation and discharged from neonatal care between 1 January 2014 and 31 December 2018. We utilised an instrumental variable (maternal excess travel time between local neonatal units and neonatal intensive care units) to control for unmeasured differences. Sensitivity analyses excluded postnatal transfers within 72 hours of birth and multiple births. Outcome measures were death in neonatal care, infant mortality, necrotising enterocolitis, retinopathy of prematurity, severe brain injury, bronchopulmonary dysplasia, and receipt of breast milk at discharge. We also analysed outcomes by volume of neonatal intensive care activity. We undertook a health economic analysis using a cost-effectiveness evaluation from a National Health Service perspective and using additional lives saved as a measure of benefit, explored differences in quality of care in high compared with low-performing units and performed ethnographic qualitative research.

Results

The safe gestational age cut-off for babies to be born between 27+0 and 31+6 weeks and early care at either location was 28 weeks. We found no effect on mortality in neonatal care (mean difference -0.001; 99% confidence interval -0.011 to 0.010; p = 0.842) or in infancy (mean difference -0.002; 99% confidence interval -0.014 to 0.009; p = 0.579) (n = 18,847), including after sensitivity analyses. A significantly greater proportion of babies in local neonatal units had severe brain injury (mean difference -0.011; 99% confidence interval -0.022 to -0.001; p = 0.007) with the highest mean difference in babies born at 27 weeks (-0.040). Those transferred in the first 72 hours were more likely to have severe brain injury. For 27 weeks gestation, birth in centres with neonatal intensive care units reduced the risk of severe brain injury by 4.2% from 11.9% to 7.7%. The number needed to treat was 25 (99% confidence interval 10 to 59) indicating that 25 babies at 27 weeks would have to be delivered in a neonatal intensive care unit to prevent one severe brain injury. For babies born at 27 weeks gestation, birth in a high-volume unit (> 1600 intensive care days/year) reduced the risk of severe brain injury from 0.242 to 0.028 [99% confidence interval 0.035 to 0.542; p = 0.003; number needed to treat = 4 (99% confidence interval 2 to 29)]. Estimated annual total costs of neonatal care were £262 million. The mean (standard deviation) cost per baby varied from £75,594 (£34,874) at 27 weeks to £27,401 (£14,947) at 31 weeks. Costs were similar between neonatal intensive care units and local neonatal units for births at 27+0 to 29+6 weeks gestation, but higher for local neonatal units for those born at 30+0 to 31+6 weeks. No difference in additional lives saved were observed between the settings. These results suggested that neonatal intensive care units are likely to represent value for money for the National Health Service. However, careful interpretation of this results should be exercised due to the ethical and practical concerns around the reorganisation of neonatal care for very preterm babies from local neonatal units to neonatal intensive care units purely on the grounds of cost savings. We identified a mean reduction in length of stay (1 day; 95% confidence interval 1.029 to 1.081; p < 0.001) in higher-performing units, based on adherence to evidence- and consensus-based measures. Staff reported that decision-making to optimise capacity for babies was an important part of their work. Parents reported valuing their baby's development, homecoming, continuity of care, inclusion in decision-making, and support for their emotional and physical well-being.

Conclusions

Birth and early care for babies ≥ 28 weeks is safe in both neonatal intensive care units and local neonatal units in England. For anticipated births at 27 weeks, antenatal transfer of mothers to centres colocated with neonatal intensive care units should be supported. When these inadvertently occur in centres with local neonatal units, clinicians should risk assess decisions for postnatal transfer, taking patient care requirements, staff skills and healthcare resources into consideration and counselling parents regarding the increased risk of severe brain injury associated with transfer.

Study registration

This study is registered as Current Controlled Trials NCT02994849 and ISRCTN74230187.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/70/104) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 12. See the NIHR Funding and Awards website for further award information.

Developmental trajectories of visual orienting functions in children born very or extremely preterm

BACKGROUND AND AIMS

Preterm birth increases the risk of neurodevelopmental impairments, such as Cerebral Visual Impairment (CVI), which affects visual processing. Assessing visual functions in young children is challenging with traditional methods that often rely on verbal/motor responses. The aim of the study was to investigate the developmental trajectories of Visual Orienting Functions (VOF) in children born very preterm (<32 weeks gestational age) between 2 and 5 years corrected age (CA) using eye tracking.

METHODS

263 children born preterm underwent eye tracking at 2, 3 and 5 years CA. A subgroup of 49 children underwent all three measurements. Magnetic resonance imaging (MRI) was performed shortly after birth and evaluated for brain damage using a modified Kidokoro scoring protocol. The VOF results to high (cartoon and contrast) and intermediate (form and motion detection) salient visual stimuli of the preterm group were compared to those of term-born age-matched peers.

RESULTS

Approximately 40 % of children born preterm showed normal VOF development to high and intermediate salient stimuli. However, in another 40 % of children born preterm, an increase in delayed visual processing to high-salient stimuli was found at 5 years CA. No significant correlation was found between brain damage on MRI shortly after birth and abnormal VOF at 5 years CA.

CONCLUSION

The data suggest that routine visual screening using high-salient stimuli can identify VOF delays from 2 years CA onwards in children at risk of brain damage. Early detection of visual processing deficits can enable timely interventions and specialized care for pre-schoolers.

Spatio-temporal distribution and socioeconomic inequality of low birthweight rate in China from 1992 to 2021 and its predictions to 2030

This paper aims to investigate the trend, spatio-temporal distribution, and socioeconomic inequality of the low birthweight rate (LBWR) in China from 1992 to 2021 and to project the LBWR to 2030. We performed a secondary analysis of data from the China Health Statistics Yearbook. LBWR refers to the ratio of the number of infants born with a birth weight less than 2,500 grams to the number of live births in a given year. We used joinpoint regression models to estimate LBWR trends from 1992 to 2021 for the whole country and from 2002 to 2021 for the three regions (eastern, central, and western regions) and each province. The slope index of inequality (SII) and relative index of inequality (RII) were calculated for each year from 2002 to 2021 based on provincial data. LBWR increased from 2.52% (1992) to 3.70% (2021), and the average annual percentage change (AAPC) (95% confidence interval [CI]) was 1.35% (0.22%, 2.49%) in China. The overall LBWR from 2002 to 2021 was greatest in the Eastern region, but LBWR had the fastest increase in the Western region, with an AAPC (95% CI) of 3.15% (2.59%, 3.12%). There were spatio-temporal differences in the LBWR and trends between provinces. The SII and RII increased linearly from -0.15 and 0.94 to 0.53 (B = 0.035%, p < 0.001) and 1.16 (B = 0.011, p < 0.01), respectively, over the past 20 years. The results of the ARIAM model showed that the National LBWR will be increasedfrom 3.70% in 2021 to 5.28% in 2030. The LBWRs in the eastern, central and western regions in 2030 will be 4.93%, 6.02% and 5.82%, respectively. National and local governments must prioritize disadvantaged groups to mitigate the rapid prevalence of LBWR, reduce regional disparities, and improve perinatal and infant health and health equity in China.

Health-related quality of life in children and adolescents born very preterm and its correlates: a cross-sectional study

OBJECTIVE

We aimed to assess health-related quality of life (HRQOL) in a cohort of very preterm born children and adolescents (aged 5-16), and to compare it with their fullterm born siblings and the general population. We also explored correlates of HRQOL among the very preterm born.

DESIGN

Cross-sectional survey.

PATIENTS

Children born <32 weeks gestation (N=442) as well as their fullterm born siblings (N=145).

MAIN OUTCOME MEASURES

Primary outcome was KINDL total score (0 worst to 100 best), a validated multidimensional measure of HRQOL in children and adolescents.

METHODS

Linear mixed models accounted for family unit. Secondary analysis compared very preterm born children to another cohort of healthy children from the same time period. A classification tree analysis explored potential correlates of HRQOL.

RESULTS

On average, preterm children, both <28 and 28-31 weeks gestational age, had similar KINDL total score to fullterm sibling controls (-2.3, 95% CI -3.6 to -0.6), and to population controls (+1.4, 95% CI 0.2 to 2.5). Chronic non-respiratory health conditions (such as attention deficit hyperactivity disorder or heart conditions, but not including cerebral palsy), age and respiratory symptoms affecting daily life were key correlates of HRQOL among very preterm born children.

CONCLUSIONS

Very preterm birth in children and adolescents was not associated with a relevant reduction in HRQOL compared with their fullterm born peers. However, lower HRQOL was explained by other factors, such as older age, and the presence of chronic non-respiratory health conditions, but also by possibly modifiable current respiratory symptoms. The influence of respiratory symptom amelioration and its potential influence on HRQOL needs to be investigated further.

TRIAL REGISTRATION NUMBER

NCT04448717.

The Ethics and Practice of Periviability Care

Since the 1960s, the gestational age at which premature infants typically survive has decreased by approximately one week per decade [...].

Psychometric Performance of Generic Childhood Multi-Attribute Utility Instruments in Preterm and Low Birthweight Populations: A Systematic Review

BACKGROUND

Individuals born preterm (gestational age < 37 weeks) and/or at low birthweight (<2500 g) are at increased risk of health impairments from birth to adulthood. This review aimed to evaluate the psychometric performance of generic childhood-specific or childhood-compatible multi-attribute utility instruments (MAUIs) in preterm and/or low birthweight (PLB) populations.

METHODS

Searches covered seven databases, including studies that targeted childhood (aged < 18 years) and/or adult (≥18 years) PLB populations; provided psychometric evidence for generic childhood-specific or compatible MAUI(s) (any language version); and published in English. Eighteen psychometric properties were evaluated using a four-part criteria rating system. Data syntheses identified psychometric evidence gaps and summarised the psychometric assessment methods/results.

RESULTS

A total of 42 studies were included, generating 178 criteria rating outputs across four MAUIs: 17D, CHSCS-PS, HUI2, and HUI3. Moreover, 64.0% of outputs concerned the HUI3 MAUI, and 38.2% related to known-group validity. There was no evidence for five psychometric properties. Only 6.7% of outputs concerned reliability and proxy-child agreement. No MAUI outperformed others across all properties. The frequently applied HUI2 and HUI3 lacked content validity evidence.

CONCLUSIONS

This psychometric evidence catalogue should inform the selection of MAUI(s) suited to the specific aims of applications targeting PLB populations. Further psychometric research is warranted to address the gaps in psychometric evidence.

Sex differences in the effects of prematurity and/or low birthweight on neurodevelopmental outcomes: systematic review and meta-analyses

BACKGROUND

Premature birth and/or low birthweight have long-lasting effects on cognition. The purpose of the present systematic review is to examine whether the effects of prematurity and/or low birth weight on neurodevelopmental outcomes differ between males and females.

METHODS

Web of Science, Scopus, and Ovid MEDLINE were searched for studies of humans born premature and/or of low birthweight, where neurodevelopmental phenotypes were measured at 1 year of age or older. Studies must have reported outcomes in such a way that it was possible to assess whether effects were greater in one sex than the other. Risk of bias was assessed using both the Newcastle-Ottawa scale and the National Institutes of Health Quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

Seventy-five studies were included for descriptive synthesis, although only 24 presented data in a way that could be extracted for meta-analyses. Meta-analyses found that severe and moderate prematurity/low birthweight impaired cognitive function, and severe prematurity/low birthweight also increased internalizing problem scores. Moderate, but not severe, prematurity/low birthweight significantly increased externalizing problem scores. In no case did effects of prematurity/low birthweight differ between males and females. Heterogeneity among studies was generally high and significant, although age at assessment was not a significant moderator of effect. Descriptive synthesis did not identify an obvious excess or deficiency of male-biased or female-biased effects for any trait category. Individual study quality was generally good, and we found no evidence of publication bias.

CONCLUSIONS

We found no evidence that the sexes differ in their susceptibility to the effects of severe or moderate prematurity/low birthweight on cognitive function, internalizing traits or externalizing traits. Result heterogeneity tended to be high, but this reflects that one sex is not consistently more affected than the other. Frequently stated generalizations that one sex is more susceptible to prenatal adversity should be re-evaluated.

Comparative evaluation of the health utilities index mark 3 and the short form 6D: evidence from an individual participant data meta-analysis of very preterm and very low birthweight adults

BACKGROUND

The most appropriate preference-based health-related quality of life (HRQoL) instruments for trials or research studies that ascertain the consequences of individuals born very preterm and/or low birthweight (VP/VLBW) are not known. Agreement between the HUI3 and SF-6D multi-attribute utility measures have not been previously investigated for VP/VLBW and normal birthweight or term-born controls. This study examined the agreement between the outputs of the HUI3 and SF-6D measures among adults born VP/VLBW and normal birthweight or term born controls.

METHODS

We used two prospective cohorts of individuals born VP/VLBW and controls contributing to the 'Research on European Children and Adults Born Preterm' (RECAP) consortium which assessed HRQoL using two preference-based measures. The combined dataset of individual participant data (IPD) included 407 adult VP/VLBW survivors and 367 controls, ranging in age from 18 to 26 years. Bland-Altman plots, intra-class correlation coefficients, and generalized linear mixed models in a one-step approach were used to examine agreement between the measures.

RESULTS

There was significant discordance between the HUI3 and SF-6D multi-attribute utility measures in the VP/VLBW sample, controls, and in the combined samples. Agreement between the HUI3 and SF-6D multi-attribute utility measures was weaker in controls compared with VP/VLBW individuals.

CONCLUSIONS AND RELEVANCE

The HUI3 and SF-6D each provide unique information on different aspects of health status across the groups. The HUI3 better captures preterm-related changes to HRQoL in adulthood compared to SF-6D. Studies focused on measuring physical or cognitive aspects of health will likely benefit from using the HUI3 instead of the SF-6D, regardless of gestational age at birth and birthweight status.