Stillbirths: Contribution of preterm birth and size-for-gestational age for 125.4 million total births from nationwide records in 13 countries, 2000-2020

OBJECTIVE

To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'.

DESIGN

Population-based multi-country analyses.

SETTING

Births collected through routine data systems in 13 countries.

SAMPLE

125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020.

METHODS

We included 635 107 stillbirths from 22+0  weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0  weeks versus term, T, ≥37+0  weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards.

MAIN OUTCOME MEASURES

Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types.

RESULTS

635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0  weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age.

CONCLUSIONS

In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Neonatal mortality risk of large-for-gestational-age and macrosomic live births in 15 countries, including 115.6 million nationwide linked records, 2000-2020

OBJECTIVE

We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020.

DESIGN

Population-based, multi-country study.

SETTING

National healthcare systems.

POPULATION

Liveborn infants.

METHODS

We used individual-level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th-90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500-3999 g. INTERGROWTH 21st served as the reference population.

MAIN OUTCOME MEASURES

Prevalence and neonatal mortality risks.

RESULTS

Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%-22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77-0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%-13.3%), with 1.2% (IQR 0.7%-2.0%) ≥4500 g and with 0.2% (IQR 0.1%-0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69-0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10-2.11) and ≥5000 g (RR 4.54, 95% CI 2.58-7.99), compared with birthweights of 2500-3999 g, with the highest risk observed in the first 7 days of life.

CONCLUSIONS

In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

Building Connections with Families: Implementation of a Video-Messaging Service in the Neonatal Intensive Care Unit

BACKGROUND

Family involvement is vital to optimize the care of infants in the neonatal intensive care unit (NICU). Various technologies have been used to support communication with parents in the NICU. The purpose of this study was to evaluate the parent and staff experience and perception of the use of a cloud-based video-messaging service in our NICU.

METHODS

This study was a single center observational study conducted at Mount Sinai Hospital, Toronto, Canada. Following the implementation of a video-messaging service, parent and staff surveys were distributed to evaluate their experience and perception.

RESULTS

Parent responses were positive with respect to how the service helped them feel: closer to their infant (100%) and reassured about their infant's care (100%). Nursing staff responses indicated that they perceived a benefit to parents (100%) and to their building a relationship with families (79%). However, they also identified time constraints (85%) and the use of the technology hardware (24%) as challenges.

CONCLUSIONS

The use of an asynchronous video-messaging service was perceived as beneficial to both parents and staff in the NICU. Complaints pertained to the impact of the technology on nursing workflow and the difficulty using the hardware provided for use of the service.

A Quality improvement initiative to reduce central line-associated bloodstream infections in a neonatal intensive care unit in a low-and-middle-income country

BACKGROUND

Premature and sick neonates in the neonatal intensive care unit (NICU) are in need of central lines placing them at high risk of contracting a central line-associated bloodstream infection (CLABSI). CLABSI extends length of stay to 10-14 days post negative cultures and increases morbidity, use of multiple antibiotics, mortality and hospital cost. To reduce CLABSI rate at the American University of Beirut Medical Center NICU, the National Collaborative Perinatal Neonatal Network developed a quality improvement project to reduce CLABSI rate by 50% over a 1-year period and to sustain reduced CLABSI rate.

METHODS

Central line insertion and maintenance bundles were implemented for all infants admitted to the NICU necessitating central lines placement. Bundles included hand washing, wearing protective material and sterile drapes during central lines insertion and maintenance.

RESULTS

CLABSI rate decreased by 76% from 4.82 (6 infections; 1244 catheter days) to 1.09 (2 infection; 1830 catheter days) per 1000 CL days after 1 year. Following the bundles' success in reducing CLABSI rate, they were incorporated permanently to NICU standard procedure and bundle checklists were added to the medical sheets. CLABSI rate was maintained at 1.15 per 1000 CL days during the second year. It then decreased to 0.66 per 1000 CL days in the third year before reaching zero in the fourth year. In total, zero CLABSI rate was sustained for 23 consecutive months.

CONCLUSION

Reducing CLABSI rate is necessary to improving newborn quality of care and outcome. Our bundles were successful in drastically reducing and sustaining a low CLABSI rate. It was even successful in achieving a zero CLABSI unit for 2 years.

Neonatal mortality risk for vulnerable newborn types in 15 countries using 125.5 million nationwide birth outcome records, 2000-2020

OBJECTIVE

To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000-2020.

DESIGN

Population-based, multi-country study.

SETTING

National data systems in 15 middle- and high-income countries.

METHODS

We used individual-level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm [PT] versus term [T]) and size-for-gestational age (small [SGA], <10th centile, appropriate [AGA], 10th-90th centile or large [LGA], >90th centile) according to INTERGROWTH-21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types.

MAIN OUTCOME MEASURES

Mortality of six newborn types.

RESULTS

Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range [IQR] 45.6-73.9), PT + AGA (median 34.3, IQR 23.9-37.5) and PT + LGA (median 28.3, IQR 18.4-32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5-54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2-388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7-342.8) compared with those between 2500 g and 4000 g as a reference group.

CONCLUSION

Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co-existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.

Vulnerable newborn types: Analysis of population-based registries for 165 million births in 23 countries, 2000-2021

OBJECTIVE

To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021.

DESIGN

Population-based, multi-country analysis.

SETTING

National data systems in 23 middle- and high-income countries.

POPULATION

Liveborn infants.

METHODS

Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, <10th centile), appropriate (10th-90th centiles), or large (LGA, >90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types.

MAIN OUTCOME MEASURES

Prevalence of six newborn types.

RESULTS

We analysed 165 017 419 live births and the median prevalence of small types was 11.7% - highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries.

CONCLUSIONS

The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries.

Ultrasound guided central line insertion in neonates: Pain score results from a prospective study

BACKGROUND

Central lines can be placed through different techniques, either peripherally or centrally. Although they have the same aim, decision to use one of these modalities depends on the patient outcomes. The aim is to compare pain scores between ultrasound-guided central line insertion and peripherally inserted catheter in neonates in a prospective randomized single center study.

METHODS

A randomized controlled trial was conducted in neonates requiring central venous access for any of the following reasons: total parenteral nutrition (TPN), antibiotics treatment for at least 7 days and having poor or difficult venous access. The study compared pain difference, in neonates, that were randomized between peripherally and ultra-sound guided centrally placed central lines using the validated pain score N - PASS.

RESULTS

61 neonates were enrolled in the study. US-guided CICC was associated with less pain as reported by the statistically significant lower pain score difference (p-value <0.001) than the standard PICC. Additionally, the US-guided CICC had a higher rate of successful first attempt (p = 0.012), lower overall number of attempts (p < 0.001), and shorter procedure duration (p < 0.001) as compared to standard PICC.

CONCLUSION

US-guided CICC is a less painful technique than PICC line insertion associated with higher rate of successful first attempt, lower overall number of attempts and shorter procedure duration.

Assessing the Risk of Having Small for Gestational Age Newborns Among Lebanese Underweight and Normal Pre-pregnancy Weight Women

Introduction It has been established that underweight women with low gestational weight gain (GWG) are at a higher risk of having Small for Gestational Age (SGA) newborns. However, the association remains poorly studied in Middle Eastern societies exhibiting different ethnic groups, genetic predisposing factors along with differences in nutritional food intake during pregnancy. The aim of this study is to assess the risk of having a SGA newborn among underweight and normal weight BMI women while studying the role of GWG in this association. Methods This is a retrospective cross-sectional study of 62,351 singleton pregnancies from the National Collaborative Perinatal Neonatal Network between 2001 and 2009 from 27 hospitals across Lebanon. Women who had underweight and normal pre-pregnancy BMI were included. Results A total of 8.6% newborns were SGA and 6.6% of women were underweight. Among women with normal and underweight pre-pregnancy BMI, 8.6 and 12.4% had SGA births respectively. Overall, the adjusted OR of having SGA newborns was significantly higher among underweight women (OR = 1.448; 95%CI = 1.287-1.630) compared to normal pre-pregnancy BMI. Below normal weight gain significantly increased the odds of SGA for both normal and underweight pre-pregnancy BMI women, with adjusted ORs of 1.535 (95% CI = 1.418-1.661) and 1.970 (95%CI = 1.515-2.560) respectively. Discussion Higher risks of SGA newborns in underweight and normal BMI women with low GWG were observed. In addition, normal weight gain couldn't protect underweight women of having risk for SGA newborns. Hence, all pregnant women should be encouraged to maintain healthy BMI before pregnancy and attain adequate GWG.

Ultrasound-guided Central Line Insertion and Standard Peripherally Inserted Catheter Placement in Preterm Infants: Comparing Results from Prospective Study in a Single-center

Background:

Among preterm infants, the peripherally inserted central catheter (PICC) is the standard line for central venous access; however, its placement exposes them to hypothermia and pain. Ultrasound (US)-guided central line insertion may be less morbid than standard PICC line.

Aims:

To determine the ease, success rate, and morbidity associated with US-guided central line insertion in the internal jugular vein (IJV) by comparing it to the standard PICC line placement.

Materials and Methods:

This is a single-center nonrandomized prospective study evaluating preterm infants between October 2013 and June 2014. Patients were allocated into two groups: The standard group (control group) who underwent blind PICC line insertion and the intervention group who underwent a percutaneous US-guided central line insertion in the IJV. The epicutaneo-cava-catheter was used in both groups.

Results:

Fifty neonates were enrolled on study. A statistically difference in favor of US-IJV insertion was noted concerning the rate of successful first attempt (P < 0.001), insertion (P = 0.001), and procedure duration (P < 0.001) and number of trials (P < 0.001) compared to PICC. No difference in complications (P = 1.000) was noted.

Conclusion:

US guided catheterization of the IJV technique is faster than PICC line insertion with higher rates of successful first attempt and insertion, less procedure duration and fewer number of trials compared to PICC line insertion. There were no differences in complications.

Association of Pre-Pregnancy Body Mass Index and Gestational Weight Gain with Preterm Births and Fetal Size: an Observational Study from Lebanon

BACKGROUND

Pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) are reported to impact the preterm birth (PTB) rate and newborn size. Most studies have been conducted in developed countries, although PTB and adverse pregnancy outcomes are more frequent in the developing world. The aim of this study is to elucidate the association of pre-pregnancy BMI and GWG on the occurrence of PTB and sub-optimal fetal size in Lebanon.

METHODS

This is a retrospective cohort study using a hospital-based register covering 35% of births in Lebanon between 2001 and 2012. Data were collected on 170 428 pregnancies from 32 hospitals using medical records and interviews.

RESULTS

After adjusting for confounders, underweight women had increased odds of having very preterm [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.16, 2.14], preterm (OR 1.42, 95% CI 1.28, 1.58), and small for gestational age (SGA) (OR 1.50, 95% CI 1.37, 1.63) neonates. When BMI was analysed with GWG, only SGA remained significant in underweight women with low GWG. For all BMI groups, low GWG was protective against large for gestational age (LGA) and high GWG increased the odds of LGA. GWG, both low (OR 1.25, 95% CI 1.15, 1.35) and high (OR 1.43, 95% CI 1.32, 1.55) increased the risk of PTB in normal weight women. The same result was obtained for overweight women.

CONCLUSIONS

High GWG increased the risk of LGA for all groups and PTB in normal weight and overweight women, whereas low GWG increased the risk of SGA and PTB. Given that there are not many studies from middle income/developing countries on patterns of weight gain during pregnancy, findings from this study may help with pre-conception counselling with emphasis on the importance of an optimal pre-pregnancy BMI and appropriate weight gain during pregnancy.