Composite neonatal morbidity indicators using hospital discharge data: A systematic review

Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures

Although the prevalence of symptoms of post-traumatic stress disorder (PTSD) in infants and young children is similar as in older age groups, and PTSD intervention is as important in this age group, research on PTSD-treatment in infants is very scarce. Eye Movement Desensitization and Reprocessing (EMDR) Storytelling is a trauma-focused treatment that is being used by clinicians for infants with PTSD-symptoms. The aim was to assess the feasibility, acceptability and initial indications of effectiveness of EMDR Storytelling for infants aged 3-24 months with PTSD-symptoms after medical procedures. We included 6 infants and administered personalized items to assess PTSD-symptoms during the baseline, intervention and follow-up phase on a day-to-day basis. Furthermore, we measured PTSD-classification and symptoms at three and four measurement points, respectively. The data was analysed visually and quantitatively. EMDR Storytelling was shown to be feasible and acceptable for all participating families. Parent- and therapist-report showed that four out of the six infants included in the current study showed a clear reduction over time in PTSD-classification, -symptoms, and daily measured PTSD-symptoms. The results concerning the other two infants were mixed. Attention should be paid to cognitive (language) as well as interactional (infant-parent) mechanisms potentially underlying the benefits of EMDR Storytelling.

Vertebroplacental ratio for prediction of perinatal outcome and operative delivery for suspected fetal compromise: prospective observational cohort study

OBJECTIVE

To investigate differences in fetal vertebroplacental ratio (VPR) depending on the occurrence of operative delivery for suspected fetal compromise (ODFC) and composite perinatal outcome (CPO) at delivery.

METHODS

This was a prospective observational cohort study conducted in the Department of Obstetrics and Gynecology at the University Hospitals of Leuven, Leuven, Belgium, between December 2022 and April 2024. Women with a term (37-42 gestational weeks) singleton pregnancy with an appropriate-for-gestational-age (AGA) fetus were recruited, before cervical dilatation reached 5 cm, for sonographic fetal weight estimation (EFW) and Doppler sonography of the umbilical artery (UA), umbilical vein (UV), middle cerebral artery (MCA) and vertebral artery (VA). The primary outcomes were differences in VPR multiples of the median (MoM) depending on the occurrence of ODFC and CPO at delivery (based on UA cord blood pH and base excess, 1-min and 5-min Apgar score, and neonatal intensive care unit admission). We explored the technical feasibility of fetal Doppler sonography in this setting and differences in Doppler findings from individual fetal vessels (UA, UV blood flow (UVF), MCA, VA) and related parameters (UVF/EFW and cerebroplacental ratio (CPR)). We also investigated whether adding individual sonographic variables to baseline clinical prediction models could improve discriminatory power (using the area under the receiver-operating-characteristics curve (AUC)) and predictive accuracy (using the Brier score) for both outcomes.

RESULTS

A total of 161 women were recruited. The mean ± SD maternal age was 32.2 ± 3.8 years and approximately half (53.4%) of the women were nulliparous. Most (88.2%) women had labor induced. The mean ± SD gestational age at delivery was 39.3 ± 1.0 weeks and the mean ± SD ultrasound-to-delivery interval was 10.4 ± 2.75 h. An adverse CPO occurred in 13.3% of cases and ODFC occurred in 17.4%. No difference in mean VPR MoM was observed between cases with normal vs adverse CPO (1.04 ± 0.26 vs 1.17 ± 0.25; P = 0.09), or between cases which underwent ODFC vs those which did not (1.06 ± 0.29 vs 1.06 ± 0.26; P = 0.97). Likewise, no differences in other Doppler variables (UA pulsatility index (PI) MoM, MCA-PI MoM, VA-PI MoM, CPR MoM) were observed for both outcomes, except for significantly higher UVF rates in the adverse CPO group (both absolute (P = 0.02) and corrected for EFW (P = 0.048)). For both outcomes, adding VPR MoM or any other sonographic variable to baseline prediction models, which consisted solely of clinical variables, did not improve predictive accuracy or discriminatory power. The baseline model AUC and Brier score values were 0.68 (95% CI, 0.57-0.79) and 0.14 for adverse CPO, and 0.72 (95% CI, 0.61-0.83) and 0.13 for ODFC, respectively.

CONCLUSIONS

Although technically feasible to measure in most women with an AGA fetus admitted for spontaneous or induced labor at term, no difference in VPR MoM was observed depending on the occurrence of ODFC or CPO at delivery. Moreover, adding VPR MoM or any other sonographic variable to a baseline clinical prediction model did not improve predictive accuracy or discriminatory power for either outcome. Hence, peripartum ultrasound for the assessment of fetal weight and placental function has limited added value for predicting adverse labor outcomes in a low-risk obstetric population. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Identifying Newborns with Hypoxic-Ischemic Encephalopathy in Hospital Discharge Data: A Validation Study

Hospital discharge databases (HDDs) are increasingly used for research on health of newborns. Linkage between a French population-based cohort of newborns with hypoxic-ischemic encephalopathy (HIE) and national HDD showed that the HIE ICD-10 code was not accurately reported. Our results suggest that HDD should not be used for research on neonatal HIE without prior validation of HIE ICD-10 codes.

The validity of hospital diagnostic and procedure codes reflecting morbidity in preterm neonates born <32 weeks gestation

OBJECTIVE

To determine the validity of diagnostic hospital billing codes for complications of prematurity in neonates <32 weeks gestation.

STUDY DESIGN

Retrospective cohort data from discharge summaries and clinical notes (n = 160) were reviewed by trained, blinded abstractors for the presence of intraventricular hemorrhage (IVH) grades 3 or 4, periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), stage 3 or higher, retinopathy of prematurity (ROP), and surgery for NEC or ROP. Data were compared to diagnostic billing codes from the neonatal electronic health record.

RESULTS

IVH, PVL, ROP and ROP surgery had strong positive predictive values (PPV > 75%) and excellent negative predictive values (NPV > 95%). The PPVs for NEC (66.7%) and NEC surgery (37.1%) were low.

CONCLUSION

Diagnostic hospital billing codes were observed to be a valid metric to evaluate preterm neonatal morbidities and surgeries except in the instance of more ambiguous diagnoses such as NEC and NEC surgery.

Growth phenotypes of very low birth weight infants for prediction of neonatal outcomes from a Brazilian cohort: comparison with INTERGROWTH

OBJECTIVE

To assess the predictive value of selected growth phenotypes for neonatal morbidity and mortality in preterm infants < 30 weeks and to compare them with INTERGROWTH-21^st (IG21).

METHOD

Retrospective analysis of data from the Brazilian Neonatal Research Network (BNRN) database for very low birth weight (VLBW) at 20 public tertiary-care university hospitals.

OUTCOME

the composite neonatal morbidity and mortality (CNMM) consisted of in-hospital death, oxygen use at 36 weeks, intraventricular hemorrhage grade 3 or 4, and Bell stage 2 or 3 necrotizing enterocolitis. Selected growth phenotypes: small-for-gestational-age (SGA) defined as being < 3^rd (SGA3) or 10^th (SGA10) percentiles of BW, and large-for-gestational-age (LGA) as being > 97^th percentile of BW. Stunting as being < 3^rd percentile of the length and wasting as being < 3^rd percentile of BMI. Single and multiple log-binomial regression models were fitted to estimate the relative risks of CNMM, comparing them to IG21.

RESULTS

4,072 infants were included. The adjusted relative risks of CNMM associated with selected growth phenotypes were (BNRN/IG21): 1.45 (0.92-2.31)/1.60 (1.27-2.02) for SGA; 0.90 (0.55-1.47)/1.05 (0.55-1.99) for LGA; 1.65 (1.08-2.51)/1.58 (1.28-1.96) for stunting; and 1.48 (1.02-2.17) for wasting. Agreement between the two references was variable. The growth phenotypes had good specificity (>95%) and positive predictive value (70-90%), with poor sensitivity and low negative predictive value.

CONCLUSION

The BNRN phenotypes at birth differed markedly from the IG21 standard and showed poor accuracy in predicting adverse neonatal outcomes.

Measuring severe neonatal morbidity using hospital discharge data in France

BACKGROUND

Measuring infant health at birth is key for surveillance and research in obstetrics and neonatology, but there is no international consensus on morbidity indicators. The Neonatal Adverse Outcome Indicator (NAOI) is a composite indicator, developed in Australia, which measures the burden of severe neonatal morbidity using hospital discharge data.

OBJECTIVE

To evaluate the applicability of the NAOI in France for surveillance and research.

METHODS

We constituted a cohort of live births ≥24 weeks' gestational age in Metropolitan France from 2014 to 2015 using hospital discharge, insurance claims and cause of death data. Outlier hospitals were identified using funnel plots of standardised morbidity ratios (SMR), and their coding patterns were assessed. We compared the NAOI and its component codes with published Australian and English data and estimated unadjusted and adjusted risk ratios for known risk factors for neonatal morbidity.

RESULTS

We included 1,459,123 births (511 hospitals). Twenty-eight hospitals had SMR above funnel plot control limits. Newborns with NAOI morbidities in these hospitals had lower mortality and shorter stays than in other hospitals. Amongst within-limit hospitals, NAOI prevalence was 4.8%, comparable to Australia (4.6%) and England (5.4%). Most individual components had a similar prevalence, with the exception of respiratory support, intravenous fluid procedures and infection. NAOI was lowest at 39 weeks (2.2%) with higher risks for maternal age ≥40 (relative risk [RR] 1.47, 95% confidence interval [CI] 1.42, 1.51), state medical insurance (RR 1.60, 95% CI 1.52, 1.68), male sex (RR 1.21, 95% CI 1.19, 1.23) and birthweight <3^rd percentile (RR 4.60, 95% CI 4.51, 4.69).

CONCLUSIONS

The NAOI provides valuable information on population prevalence of severe neonatal morbidity and its risk factors. Whilst the prevalence was similar in high-income countries with comparable neonatal mortality levels, ensuring valid comparisons between countries and hospitals will require further work to harmonize coding procedures, especially for infection and respiratory morbidity.

Neonatal Morbidities in Infants Born Late Preterm at 35-36 Weeks of Gestation: A Swedish Nationwide Population-based Study

OBJECTIVE

To assess risk for neonatal morbidities among infants born late preterm at 35-36 gestational weeks, early term (37-38 weeks), and late-term (41 weeks) infants, compared with full-term (39-40 weeks) infants.

STUDY DESIGN

This nationwide population-based cohort study included 1 650 450 non-malformed liveborn singleton infants born at 35-41 weeks between 1998 and 2016 in Sweden. The relative risks for low Apgar score (0-3) at 5 minutes; respiratory, metabolic, infectious, and neurologic morbidities; and severe neonatal morbidity (composite outcome) were adjusted for maternal, pregnancy, delivery, and infant characteristics.

RESULTS

Compared with infants born at 39-40 weeks, the adjusted relative risks and proportions of infants born at 35-36 weeks were higher for metabolic morbidity 7.79 (95%, 7.61 to 7.97; 33.75% vs 3.11%), respiratory morbidity 5.54 (95% CI, 5.24 to 5.85; 5.49% vs 0.75%), severe neonatal morbidity 2.42 (95% CI, 2.27 to 2.59; 3.40% versus 1.03%), infectious morbidity 1.98 (95% CI, 1.83 to 2.14; 2.53% vs 0.95%), neurologic morbidity 1.74 (95% CI, 1.48 to 2.03; 0.54% vs 0.23%), and low Apgar score 2.07 (95% CI, 1.72 to 2.51; 0.42% vs 0.12%). The risks for respiratory, severe neonatal morbidity, infectious, neurologic morbidities, and low Apgar score were highest at 35 weeks, gradually decreased until 39 weeks, and increased during 39-41 weeks.

CONCLUSIONS

Infants born late preterm at 35-36 weeks of gestation are at increased risk of neonatal morbidities, although the absolute risks for severe neonatal morbidities are low. Our findings reinforce the need of preventing late preterm delivery to decrease the burden of neonatal morbidity and help professionals and families with a better risk assessment.

The risks of advancing parental age on neonatal morbidity and mortality are U- or J-shaped for both maternal and paternal ages

BACKGROUND

The biologic implications of delayed parenthood have been blamed for a major public health crisis in the United States, that includes high rates of neonatal morbidity and mortality (NMM). The objective of this study was to evaluate the risk of parent age on NMM and to provide results that can serve as a starting point for more specific mediation modeling.

METHODS

Data containing approximately 15,000,000 birth records were obtained from the United States Natality database for the years 2014 to 2018. A Bayesian modeling approach was used to estimate the both the total effect and the risk adjusted for confounding between parent ages and for mediation by chromosomal disorders including Down syndrome. Outcomes included intra-hospital death and nine measures of neonatal morbidity.

RESULTS

For paternal age, seven NMM (preterm birth, very preterm birth, low Apgar score, treatment with antibiotics, treatment with surfactant, prolonged ventilation, intra-hospital death) had U-shaped risk patterns, two NMM (small for gestational age, admission to neonatal intensive care) had J-shaped risk patterns, one NMM (seizures) was not significantly related to paternal age. For maternal age, three NMM (low Apgar score, treatment with antibiotics and intra-hospital death) had U-shaped risk patterns, four NMM (preterm delivery, very preterm delivery, admission to neonatal intensive care, treatment with surfactant) had J-shaped risk patterns, one NMM (small for gestational age) had a risk declining with age, one NMM (prolonged ventilation) had a risk increasing with age and one NMM (seizures) was not significantly related to maternal age.

CONCLUSIONS

Both advancing maternal and paternal ages had U- or J-shaped risk patterns for neonatal morbidity and mortality.

Echocardiography-Guided Management of Preterms With Patent Ductus Arteriosus Influences the Outcome: A Cohort Study

Introduction: Echocardiography (ECHO) with color flow Doppler is considered as the gold standard to identify a hemodynamic patent ductus arteriosus (hs-PDA). However, the optimal diagnostic and therapeutic management for newborns with hs-PDA is still controversial. We aimed to investigate two clinical strategies: (1) targeted treatment based on ECHO criteria and (2) treatment based on ECHO criteria in addition to clinical signs and symptoms. Materials and Methods: This is a cohort study including all neonates consecutively admitted in the Neonatal Intensive Care Unit of University La Sapienza in Rome, with gestational age <32 weeks or body birth weight <1,500 g and with a diagnosis of hs-PDA as confirmed by ECHO evaluation performed within 72 h of life. We classified the babies in two cohorts: (A) pharmacological treatment immediately after ECHO screening and (B) pharmacological therapy for PDA was administered when the relevance of a hs-PDA was associated with clinical signs of hemodynamic instability. Results: We considered as primary outcome newborns who survived without any morbidities (A: 48.1% vs. B: 22.2%, p = 0.022). In particular, we found that the rate of intraventricular hemorrhage stage ≥2 was increased in cohort B (A: 3.7% vs. B 24.4%, p = 0.020). A multivariate analysis showed that assignment to cohort A independently influences the primary outcome. Conclusions: Adopting an hs-PDA management option based on ECHO-directed therapy regardless of symptoms may reduce the morbidity and improve the survival of very low birth weight infants.