Neonatal Outcome and Treatment Perspectives of Preterm Infants at the Border of Viability

Live births and deaths of neonates born to adolescent mothers: analysis of trends and associations from a population study in a region of a middle-income country

BACKGROUND

Adolescent pregnancy is associated with adverse outcomes, and although there has been a global decline in the incidence of teenage pregnancies and neonatal deaths, the absolute number remains significant. This study aimed to evaluate temporal trends in live births and neonatal deaths from adolescent mothers, as well as to identify the effect of adolescent pregnancy on neonatal death.

METHODS

This is a population-based study of all live births from mothers residing in Sao Paulo state, Brazil, between 2004 and 2020. The Prais-Winsten model was used to analyze annual trends for live births from adolescent mothers, neonatal mortality rates, and the percentage of neonatal deaths within specific demographic groups. The Kaplan-Meier survival curve evaluated the time to neonatal death. A Poisson regression model was utilized to identify maternal and neonatal characteristics associated with the risk of neonatal death.

RESULTS

The present study encompassed a total of 9,870,181 live births, with 14.4% occurring to adolescent mothers. There were 75,504 neonatal deaths, with 14,159 (18.8%) of those occurring in the neonates born to adolescent mothers. The annual percentage change in live births to adolescent mothers decreased by -3.03% (95%CI: -4.12% to -1.93%). The neonatal mortality rates showed a declining trend within both adolescent and non-adolescent mothers. Infants born to adolescent mothers had a higher probability of neonatal death and an earlier age of death when compared to non-adolescent mothers' infants. Poisson multiple regression analysis indicated an elevated risk of neonatal death for seven tested variables (adolescent mothers, inadequate prenatal care, multiple gestation, non-hospital delivery, low birth weight, male sex and congenital anomalies) and a reduction on risk of death for neonates born from cesarean section.

CONCLUSIONS

The study showed a reduction in live births to adolescent mothers and neonatal deaths among adolescent mothers from 2004 to 2020 in the state of Sao Paulo. Was also shown a risk association between been born to adolescent mothers and neonatal death.

[Relationship between volume and structural characteristics and the quality of outcomes of perinatal centers for infants at the border of viability]

INTRODUCTION

This study investigates the relationship between volume, structural characteristics and quality of outcome, specifically for infants at the border of viability.

METHODS

Using administrative data of the largest provider of statutory healthcare insurance in Germany between 2010-2015, infants with an admission weight (AW) between 250-1249 g treated initially in perinatal centers were included. For infants at the border of viability (250-499 g AW), the endpoints mortality and mortality or morbidity were analyzed. For comparison, infants with 500-749 g and 750-1249 g AW were analyzed. The impact of categorized volume (in quartiles) and structural characteristics (university hospital and in-house pediatric surgery) were examined in separate regressions. Odds ratios (ORs) and potentially avoidable deaths or severe morbidity were calculated.

RESULTS

Infants with 250-499 g AW were significantly more likely to survive if initially treated in perinatal centers with an estimated volume of 62 cases (250-1249 g AW) per year (OR: 0.43; 95%-CI: 0.20-0.96) or in university perinatal centers with in-house pediatric surgery (OR: 0.48; 95%-CI: 0.24-0.93). There was also a positive impact of volume and structural characteristics for infants with 500-749 g and 750-1249 g AW.

CONCLUSION

In addition to volume, structural characteristics also have a positive impact on the quality of outcomes. Additional requirements of structural characteristics for perinatal centers as well as a higher minimum volume may have a relevant positive impact on the outcome.

Thermoregulation, incubator humidity, and skincare practices in appropriate for gestational age ultra-low birth weight infants: need for more evidence

BACKGROUND

Although not universal, active care is being offered to infants weighing < 500 g at birth, referred to as ultra-low birth weight (ULBW) infants appropriate for gestational age. These infants have the greatest risk of dying or developing major morbidities. ULBW infants face challenges related to fluid and heat loss as well as skin injury in the initial days of life from extreme anatomical and physiological immaturity of the skin. Although there is an emerging literature on the outcomes of ULBW infants, there is a paucity of evidence to inform practice guidelines for delivering optimal care to this cohort of infants.

DATA SOURCES

A comprehensive review of the literature was performed using the PubMed and Embase databases. Searched keywords included "thermoregulation or body temperature regulation", "incubator humidity", "skin care", "infant, extremely low birth weight" and "ultra-low birth weight infants".

RESULTS

Evidences for thermoregulation, incubator humidity, and skincare practices are available for preterm infants weighing < 1500 g at birth but not specifically for ULBW infants. Studies on thermoregulation, incubator humidity, or skincare practices had a small sample size and did not include a sub-group analysis for ULBW infants. Current practice recommendations in ULBW infants are adopted from research in very and/or extremely low birth weight infants.

CONCLUSIONS

This narrative review focuses on challenges in thermoregulation, incubator humidity, and skincare practices in ULBW infants, highlights current research gaps and suggests potential developments for informing practices for improving health outcomes in ULBW infants. Video abstract (MP4 1,49,115 kb).

[A cross-sectional survey of delivery room transitional care management for very/extremely preterm infants in 24 hospitals in Shenzhen City]

OBJECTIVES

To investigate the current status of delivery room transitional care management for very/extremely preterm infants in Shenzhen City.

METHODS

A cross-sectional survey was conducted in November 2022, involving 24 tertiary hospitals participating in the Shenzhen Neonatal Data Network. The survey assessed the implementation of transitional care management in the delivery room, including prenatal preparation, delivery room resuscitation, and post-resuscitation management in the neonatal intensive care unit. Very/extremely preterm infants were divided into four groups based on gestational age: <26 weeks, 26-28+6 weeks, 29-30+6 weeks, and 31-31+6 weeks. Descriptive analysis was performed on the results.

RESULTS

A total of 140 very/extremely preterm infants were included, with 10 cases in the <26 weeks group, 45 cases in the 26-28+6 weeks group, 49 cases in the 29-30+6 weeks group, and 36 cases in the 31-31+6 weeks group. Among these infants, 99 (70.7%) received prenatal counseling, predominantly provided by obstetricians (79.8%). The main personnel involved in resuscitation during delivery were midwives (96.4%) and neonatal resident physicians (62.1%). Delayed cord clamping was performed in 52 cases (37.1%), with an average delay time of (45±17) seconds. Postnatal radiant warmer was used in 137 cases (97.9%) for thermoregulation. Positive pressure ventilation was required in 110 cases (78.6%), with 67 cases (60.9%) using T-piece resuscitators and 42 cases (38.2%) using a blended oxygen device. Blood oxygen saturation was monitored during resuscitation in 119 cases (85.0%). The median time from initiating transitional care measures to closing the incubator door was 87 minutes.

CONCLUSIONS

The implementation of delivery room transitional care management for very/extremely preterm infants in the hospitals participating in the Shenzhen Neonatal Data Network shows varying degrees of deviation from the corresponding expert consensus in China. It is necessary to bridge the gap through continuous quality improvement and multicenter collaboration to improve the quality of the transitional care management and outcomes in very/extremely preterm infants.

Nutrition and Growth of Preterm Neonates during Hospitalization: Impact on Childhood Outcomes

The Special Issue has been completed with the publication of 13 review and research articles [...].

Adults born prematurely prefer a periviability guideline that considers multiple prognostic factors beyond gestational age

AIM

The aim of the study was to explore the perspectives of adults born prematurely on guidelines for management at extreme premature birth and personalisation at the limit of viability.

METHODS

We conducted four 2-h online focus group interviews in the Netherlands.

RESULTS

Twenty-three participants born prematurely were included in this study, ranging in age from 19 to 56 years and representing a variety of health outcomes. Participants shared their perspectives on different types of guidelines for managing extremely premature birth. They agreed that a guideline was necessary to prevent arbitrary treatment decisions and to avoid physician bias. All participants favoured a guideline that is based upon multiple prognostic factors beyond gestational age. They emphasised the importance of discretion, regardless of the type of guideline used. Discussions centred mainly on the heterogeneity of value judgements about outcomes after extreme premature birth. Participants defined personalisation as 'not just looking at numbers and statistics'. They associated personalisation mainly with information provision and decision-making. Participants stressed the importance of involving families in decision-making and taking their care needs seriously.

CONCLUSION

Adults born prematurely prefer a periviability guideline that considers multiple prognostic factors and allows for discretion.

Resuscitation in the “Periviable” Period—Commentary of Opposing Views

The periviable period is defined as delivery between 20 0/7 weeks and 25 6/7 weeks of gestation. It has long been considered a “gray area,” as there are still no clear guidelines on initial resuscitation and subsequent treatment of the newborn. This lack of guidance compounds the uncertainty in decision-making in low- and middle-income countries with limited resources. The decision to treat or not has far-reaching economic, social, cultural, and sometimes even religious implications for the parents and family. This review explores the perspectives of parents, caregivers, and policymakers in detail to utilize the existing evidence better. We present arguments for and against resuscitation in the periviable period, discussing concerns surrounding neurodevelopmental outcomes, cost, parental concerns, nonuniformity of evidence, and ethical considerations. A large survival gap exists between developed and developing countries, and the infrastructure and clinical care network in low- and middle-income country are not strong enough to provide adequate support for these infants and their families. Antenatal factors, socioeconomic and cultural issues, center capacity, and resuscitation capacity of birthing centers should be considered when making decisions. The neonatologists are expected to be impartial, provide information, and not advise based on their beliefs and outlook; while preserving the autonomy of parents. The only way forward is for parents and caregivers to work together to develop a logical and ethical approach that can be accepted as national and institutional policies.

Ethical Dilemmas in Neonatal Care at the Limit of Viability

Advances in neonatal care have pushed the limit of viability to incrementally lower gestations over the last decades. However, surviving extremely premature neonates are prone to long-term neurodevelopmental handicaps. This makes ethics a crucial dimension of periviable birth management. At 22 weeks, survival ranges from 1 to 15%, and profound disabilities in survivors are common. Consequently, there is no beneficence-based obligation to offer any aggressive perinatal management. At 23 weeks, survival ranges from 8 to 54%, and survival without severe handicap ranges from 7 to 23%. If fetal indication for cesarean delivery appears, the procedure may be offered when neonatal resuscitation is planned. At a gestational age ≥24 weeks, up to 51% neonates are expected to survive the neonatal period. Survival without profound neurologic disability ranges from 12 to 38%. Beneficence-based obligation to intervene is reasonable at these gestations. Nevertheless, autonomy of parents should also be respected, and parental consent should be sought prior to any intervention. Optimal counselling of parents involves harmonized cooperation of obstetric and neonatal care providers. Every fetus/neonate and every pregnant woman are different and have the right to be considered individually when treatment decisions are being made.