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Hurrell A, Webster L, Sparkes J, Battersby C, Brockbank A, Clark K, Duhig KE, Gill C, Green M, Hunter RM, Seed PT, Vowles Z, Myers J, Shennan AH, Chappell LC. Repeat Placental Growth Factor-Based Testing in Women With Suspected Preterm Preeclampsia: A Stratified Analysis of the PARROT-2 Trial. Hypertension 2024. [PMID: 38708607 DOI: 10.1161/hypertensionaha.123.22411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/09/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND PlGF (placental growth factor)-based testing reduces severe maternal adverse outcomes. Repeat PlGF-based testing is not associated with improved perinatal or maternal outcomes. This planned secondary analysis aimed to determine whether there is a subgroup of women who benefit from repeat testing. METHODS Pregnant individuals with suspected preterm preeclampsia were randomized to repeat revealed PlGF-based testing, compared with usual care where testing was concealed. Perinatal and maternal outcomes were stratified by trial group, by initial PlGF-based test result, and by PlGF-based test type (PlGF or sFlt-1 [soluble fms-like tyrosine kinase-1]/PlGF ratio). RESULTS A total of 1252 pregnant individuals were included. Abnormal initial PlGF-based test identified a more severe phenotype of preeclampsia, at increased risk of adverse maternal and perinatal outcomes. Repeat testing was not significantly associated with clinical benefit in women with abnormal initial results. Of women with a normal initial result, 20% developed preeclampsia, with the majority at least 3 to 4 weeks after initial presentation. Repeat test results were more likely to change from normal to abnormal in symptomatic women (112/415; 27%) compared with asymptomatic women (163/890; 18%). A higher proportion of symptomatic women who changed from normal to abnormal were diagnosed with preeclampsia, compared with asymptomatic women. CONCLUSIONS Our results do not demonstrate evidence of the clinical benefit of repeating PlGF-based testing if the initial result is abnormal. Judicious use of repeat PlGF-based testing to stratify risk may be considered at least 2 weeks after a normal initial test result, particularly in women who have symptoms or signs of preeclampsia. REGISTRATION URL: XXX; Unique identifier: ISRCTN85912420.
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Affiliation(s)
- Alice Hurrell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Louise Webster
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Jenie Sparkes
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Chelsea and Westminster Hospital Campus, United Kingdom (C.B.)
| | - Anna Brockbank
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Katherine Clark
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Kate E Duhig
- Division of Developmental Biology and Medicine, Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, United Kingdom (K.E.D., J.M.)
| | - Carolyn Gill
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Marcus Green
- Action on Pre-Eclampsia, Evesham, United Kingdom (M.G.)
| | - Rachael M Hunter
- Institute of Epidemiology and Health Care, University College London, United Kingdom (R.M.H.)
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Zoe Vowles
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Jenny Myers
- Division of Developmental Biology and Medicine, Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, United Kingdom (K.E.D., J.M.)
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, United Kingdom (A.H., L.W., J.S., A.B., C.G., P.T.S., K.C., Z.V., A.H.S., L.C.C.)
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van Hasselt TJ, Gale C, Battersby C, Davis PJ, Draper E, Seaton SE. Paediatric intensive care admissions of preterm children born <32 weeks gestation: a national retrospective cohort study using data linkage. Arch Dis Child Fetal Neonatal Ed 2024; 109:265-271. [PMID: 37923384 DOI: 10.1136/archdischild-2023-325970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Survival of babies born very preterm (<32 weeks gestational age) has increased, although preterm-born children may have ongoing morbidity. We aimed to investigate the risk of admission to paediatric intensive care units (PICUs) of children born very preterm following discharge home from neonatal care. DESIGN Retrospective cohort study, using data linkage of National Neonatal Research Database and the Paediatric Intensive Care Audit Network datasets. SETTING All neonatal units and PICUs in England and Wales. PATIENTS Children born very preterm between 1 January 2013 and 31 December 2018 and admitted to neonatal units. MAIN OUTCOME MEASURES Admission to PICU after discharge home from neonatal care, before 2 years of age. RESULTS Of the 40 690 children discharged home from neonatal care, there were 2308 children (5.7%) with at least one admission to PICU after discharge. Of these children, there were 1901 whose first PICU admission after discharge was unplanned.The percentage of children with unplanned PICU admission varied by gestation, from 10.2% of children born <24 weeks to 3.3% born at 31 weeks.Following adjustment, unplanned PICU admission was associated with lower gestation, male sex (adjusted OR (aOR) 0.79), bronchopulmonary dysplasia (aOR 1.37), necrotising enterocolitis requiring surgery (aOR 1.39) and brain injury (aOR 1.42). For each week of increased gestation, the aOR was 0.90. CONCLUSIONS Most babies born <32 weeks and discharged home from neonatal care do not require PICU admission in the first 2 years. The odds of unplanned admissions to PICU were greater in the most preterm and those with significant neonatal morbidity.
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Affiliation(s)
- Tim J van Hasselt
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Peter J Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Elizabeth Draper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Sarah E Seaton
- Department of Population Health Sciences, University of Leicester, Leicester, UK
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Seaton SE, Battersby C, Davis PJ, Fenton AC, Anderson J, van Hasselt TJ, Draper E. Characteristics of children requiring admission to neonatal care and paediatric intensive care before the age of 2 years in England and Wales: a data linkage study. Arch Dis Child 2024; 109:387-394. [PMID: 38346868 DOI: 10.1136/archdischild-2023-325986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/13/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To quantify the characteristics of children admitted to neonatal units (NNUs) and paediatric intensive care units (PICUs) before the age of 2 years. DESIGN A data linkage study of routinely collected data. SETTING National Health Service NNUs and PICUs in England and Wales PATIENTS: Children born from 2013 to 2018. INTERVENTIONS None. MAIN OUTCOME MEASURE Admission to PICU before the age of 2 years. RESULTS A total of 384 747 babies were admitted to an NNU and 4.8% (n=18 343) were also admitted to PICU before the age of 2 years. Approximately half of all children admitted to PICU under the age of 2 years born in the same time window (n=18 343/37 549) had previously been cared for in an NNU.The main reasons for first admission to PICU were cardiac (n=7138) and respiratory conditions (n=5386). Cardiac admissions were primarily from children born at term (n=5146), while respiratory admissions were primarily from children born preterm (<37 weeks' gestational age, n=3550). A third of children admitted to PICU had more than one admission. CONCLUSIONS Healthcare professionals caring for babies and children in NNU and PICU see some of the same children in the first 2 years of life. While some children are following established care pathways (eg, staged cardiac surgery), the small proportion of children needing NNU care subsequently requiring PICU care account for a large proportion of the total PICU population. These differences may affect perceptions of risk for this group of children between NNU and PICU teams.
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Affiliation(s)
- Sarah E Seaton
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Peter J Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, Bristol, UK
| | - Alan C Fenton
- Newcastle Neonatal Service, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Tim J van Hasselt
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Elizabeth Draper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
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Rees P, Callan C, Chadda KR, Diviney J, Harnden F, Gardiner J, Battersby C, Gale C, Sutcliffe A. Childhood outcomes after low-grade intraventricular haemorrhage: A systematic review and meta-analysis. Dev Med Child Neurol 2024; 66:282-289. [PMID: 37488717 DOI: 10.1111/dmcn.15713] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 07/26/2023]
Abstract
AIM To undertake a systematic review and meta-analysis exploring school-age neurodevelopmental outcomes of children after low-grade intraventricular haemorrhage (IVH). METHOD The published and grey literature was extensively searched to identify observational comparative studies exploring neurodevelopmental outcomes after IVH grades 1 and 2. Our primary outcome was neurodevelopmental impairment after 5 years of age, which included cognitive, motor, speech and language, behavioural, hearing, or visual impairments. RESULTS This review included 12 studies and over 2036 infants born preterm with low grade IVH. Studies used 30 different neurodevelopmental tools to determine outcomes. There was conflicting evidence of the composite risk of neurodevelopmental impairment after low-grade IVH. There was evidence of an association between low-grade IVH and lower IQ at school age (-4.23, 95% confidence interval [CI] -7.53, -0.92, I2 = 0%) but impact on school performance was unclear. Studies reported an increased crude risk of cerebral palsy after low-grade IVH (odds ratio [OR] 2.92, 95% CI 1.95, 4.37, I2 = 41%). No increased risk of speech and language impairment or behavioural impairment was found. Few studies addressed hearing and visual impairment. INTERPRETATION This systematic review presents evidence that low-grade IVH is associated with specific neurodevelopmental impairments at school age, lending support to the theory that low-grade IVH is not a benign condition. WHAT THIS PAPER ADDS The functional impact of low-grade intraventricular haemorrhage (IVH) at school age is unknown. Low-grade IVH is associated with a lower IQ at school age. The risk of cerebral palsy is increased after low-grade IVH. Low-grade IVH is not associated with speech and language impairment.
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Affiliation(s)
- Philippa Rees
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, UK
| | - Caitriona Callan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karan R Chadda
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Diviney
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - Fergus Harnden
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Julian Gardiner
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Alastair Sutcliffe
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, UK
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van Blankenstein E, Sodiwala T, Lanoue J, Modi N, Uthaya SN, Battersby C. Two-year neurodevelopmental data for preterm infants born over an 11-year period in England and Wales, 2008-2018: a retrospective study using the National Neonatal Research Database. Arch Dis Child Fetal Neonatal Ed 2024; 109:143-150. [PMID: 37788897 PMCID: PMC10894848 DOI: 10.1136/archdischild-2023-325746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/16/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE United Kingdom guidelines recommend all infants born <30 weeks' gestation receive neurodevelopmental follow-up at 2 years corrected age. In this study, we describe completeness and results of 2-year neurodevelopmental records in the National Neonatal Research Database (NNRD). DESIGN This retrospective cohort study uses data from the NNRD, which holds data on all neonatal admissions in England and Wales, including 2year follow-up status. PATIENTS We included all preterm infants born <30 weeks' gestation between 1 January 2008 and 31 December 2018 in England and Wales, who survived to discharge from neonatal care. MAIN OUTCOME MEASURES Presence of a 2-year neurodevelopmental assessment record in the NNRD, use of standardised assessment tools, results of functional 2-year neurodevelopmental assessments (visual, auditory, neuromotor, communication, overall development). RESULTS Of the 41 505 infants included, 24 125 (58%) had a 2-year neurodevelopmental assessment recorded. This improved over time, from 32% to 71% for births in 2008 and 2018, respectively.Of those with available data: 0.4% were blind; 1% had a hearing impairment not correctable with aids; 13% had <5 meaningful words, vocalisations or signs; 8% could not walk without assistance and 9% had severe (≥12 months) developmental delay. CONCLUSIONS The proportion of infants admitted to neonatal units in England and Wales with a 2-year neurodevelopmental record has improved over time. Rates of follow-up data from recent years are comparable to those of bespoke observational studies. With continual improvement in data completeness, the potential for use of NNRD as a source of longer-term outcome data can be realised.
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Affiliation(s)
- Emily van Blankenstein
- Neonatal Medicine, Department of Primary Care and Public Health, Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Tia Sodiwala
- Neonatal Medicine, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Julia Lanoue
- Neonatal Medicine, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Neena Modi
- Neonatal Medicine, Department of Primary Care and Public Health, Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sabita N Uthaya
- Neonatal Medicine, Department of Primary Care and Public Health, Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, Department of Primary Care and Public Health, Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Hurrell A, Webster L, Sparkes J, Battersby C, Brockbank A, Clark K, Duhig KE, Gill C, Green M, Hunter RM, Seed PT, Vowles Z, Myers J, Shennan AH, Chappell LC. Repeat placental growth factor-based testing in women with suspected preterm pre-eclampsia (PARROT-2): a multicentre, parallel-group, superiority, randomised controlled trial. Lancet 2024; 403:619-631. [PMID: 38342128 DOI: 10.1016/s0140-6736(23)02357-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/30/2023] [Accepted: 10/18/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND Placental growth factor (PlGF)-based testing has high diagnostic accuracy for predicting pre-eclampsia needing delivery, significantly reducing time to diagnosis and severe maternal adverse outcomes. The clinical benefit of repeat PlGF-based testing is unclear. We aimed to determine whether repeat PlGF-based testing (using a clinical management algorithm and nationally recommended thresholds) reduces adverse perinatal outcomes in pregnant individuals with suspected preterm pre-eclampsia. METHODS In this multicentre, parallel-group, superiority, randomised controlled trial, done in 22 maternity units across England, Scotland, and Wales, we recruited women aged 18 years or older with suspected pre-eclampsia between 22 weeks and 0 days of gestation and 35 weeks and 6 days of gestation. Women were randomly assigned (1:1) to revealed repeat PlGF-based testing or concealed repeat testing with usual care. The intervention was not masked to women or partners, or clinicians or data collectors, due to the nature of the trial. The trial statistician was masked to intervention allocation. The primary outcome was a perinatal composite of stillbirth, early neonatal death, or neonatal unit admission. The primary analysis was by the intention-to-treat principle, with a per-protocol analysis restricted to women managed according to their allocation group. The trial was prospectively registered with the ISRCTN registry, ISRCTN 85912420. FINDINGS Between Dec 17, 2019, and Sept 30, 2022, 1253 pregnant women were recruited and randomly assigned treatment; one patient was excluded due to randomisation error. 625 women were allocated to revealed repeat PlGF-based testing and 627 women were allocated to usual care with concealed repeat PlGF-based testing (mean age 32·3 [SD 5·7] years; 879 [70%] white). One woman in the concealed repeat PlGF-based testing group was lost to follow-up. There was no significant difference in the primary perinatal composite outcome between the revealed repeat PlGF-based testing group (195 [31·2%]) of 625 women) compared with the concealed repeat PlGF-based testing group (174 [27·8%] of 626 women; relative risk 1·21 [95% CI 0·95-1·33]; p=0·18). The results from the per-protocol analysis were similar. There were four serious adverse events in the revealed repeat PlGF-based testing group and six in the concealed repeat PlGF-based testing group; all serious adverse events were deemed unrelated to the intervention by the site principal investigators and chief investigator. INTERPRETATION Repeat PlGF-based testing in pregnant women with suspected pre-eclampsia was not associated with improved perinatal outcomes. In a high-income setting with a low prevalence of adverse outcomes, universal, routine repeat PlGF-based testing of all individuals with suspected pre-eclampsia is not recommended. FUNDING Tommy's Charity, Jon Moulton Charitable Trust, and National Institute for Health and Care Research Guy's and St Thomas' Biomedical Research Centre.
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Affiliation(s)
- Alice Hurrell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Louise Webster
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jenie Sparkes
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Anna Brockbank
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Katherine Clark
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Kate E Duhig
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Carolyn Gill
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | | | - Rachael M Hunter
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Zoe Vowles
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jenny Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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Nezafat Maldonado B, Lanoue J, Allin B, Hargreaves D, Knight M, Gale C, Battersby C. Place of birth and postnatal transfers in infants with congenital diaphragmatic hernia in England and Wales: a descriptive observational cohort study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326152. [PMID: 38316546 DOI: 10.1136/archdischild-2023-326152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/18/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE To describe clinical pathways for infants with congenital diaphragmatic hernia (CDH) and short-term outcomes. DESIGN Retrospective observational cohort study using the UK National Neonatal Research Database (NNRD). PATIENTS Babies with a diagnosis of CDH admitted to a neonatal unit in England and Wales between 2012 and 2020. MAIN OUTCOME MEASURES Clinical pathways defined by place of birth (with or without colocated neonatal and surgical facilities), transfers, clinical interventions, length of hospital stay and discharge outcome. RESULTS There were 1319 babies with a diagnosis of CDH cared for in four clinical pathways: born in maternity units with (1) colocated tertiary neonatal and surgical units ('neonatal surgical units'), 50% (660/1319); (2) designated tertiary neonatal unit and transfer to stand-alone surgical centre ('tertiary designated'), 25% (337/1319); (3) non-designated tertiary neonatal unit ('tertiary non-designated'), 7% (89/1319); or (4) non-tertiary unit ('non-tertiary'), 18% (233/1319)-the latter three needing postnatal transfers. Infant characteristics were similar for infants born in neonatal surgical and tertiary designated units. Excluding 149 infants with minimal data due to early transfer (median (IQR) 2.2 (0.4-4.5) days) to other settings, survival to neonatal discharge was 73% (851/1170), with a median (IQR) stay of 26 (16-44) days. CONCLUSIONS We found that half of the babies with CDH were born in hospitals that did not have on-site surgical services and required postnatal transfer. Similar characteristics between infants born in neonatal surgical units and tertiary designated units suggest that organisation rather than infant factors influence place of birth. Future work linking the NNRD to other datasets will enable comparisons between care pathways.
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Affiliation(s)
- Behrouz Nezafat Maldonado
- Neonatal Medicine, Faculty of Medicine, School of Public Health, Imperial College London, Chelsea and Westminster Campus, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Julia Lanoue
- Neonatal Medicine, Faculty of Medicine, School of Public Health, Imperial College London, Chelsea and Westminster Campus, London, UK
| | - Benjamin Allin
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Dougal Hargreaves
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Chris Gale
- Neonatal Medicine, Faculty of Medicine, School of Public Health, Imperial College London, Chelsea and Westminster Campus, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, Faculty of Medicine, School of Public Health, Imperial College London, Chelsea and Westminster Campus, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
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Conti‐Ramsden F, Fleminger J, Lanoue J, Chappell LC, Battersby C. The contribution of hypertensive disorders of pregnancy to late preterm and term admissions to neonatal units in the UK 2012-2020 and opportunities to avoid admission: A population-based study using the National Neonatal Research Database. BJOG 2024; 131:88-98. [PMID: 37337344 PMCID: PMC10767760 DOI: 10.1111/1471-0528.17574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To quantify maternal hypertensive disorder of pregnancy (HDP) prevalence in late preterm and term infants admitted to neonatal units (NNU) and assess opportunities to avoid admissions. DESIGN A retrospective population-based study using the National Neonatal Research Database. SETTING England and Wales. POPULATION Infants born ≥34 weeks' gestation admitted to NNU between 2012 and 2020. METHODS Outcomes in HDP infants are compared with non-HDP infants using regression models. MAIN OUTCOME MEASURES Hypertensive disorder of pregnancy, primary reason for admission, clinical diagnoses and resource use. RESULTS 16 059/136 220 (11.8%) of late preterm (34+0 to 36+6 weeks' gestation) and 14 885/284 646 (5.2%) of term (≥37 weeks' gestation) admitted infants were exposed to maternal HDP. The most common primary reasons for HDP infant admission were respiratory disease (28.3%), prematurity (22.7%) and hypoglycaemia (16.4%). HDP infants were more likely to be admitted with primary hypoglycaemia than were non-HDP infants (odds ratio [OR] 2.1, 95% confidence interval [CI] 2.0-2.2, P < 0.0001). 64.5% of HDP infants received i.v. dextrose. 35.7% received mechanical or non-invasive ventilation. 8260/30 944 (26.7%) of HDP infants received intervention for hypoglycaemia alone (i.v. dextrose) with no other major intervention (respiratory support, parenteral nutrition, central line, arterial line or blood transfusion). CONCLUSIONS The burden of maternal HDP on late preterm and term admissions to NNU is high, with hypoglycaemia and respiratory disease being the main drivers for admission. Over one in four were admitted solely for management of hypoglycaemia. Further research should determine whether maternal antihypertensive agent choice or postnatal pathways may reduce NNU admission.
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Affiliation(s)
| | - Jessica Fleminger
- Department of Women and Children's HealthKing's College LondonLondonUK
| | - Julia Lanoue
- Neonatal Medicine, School of Public Health, Faculty of MedicineImperial College LondonLondonUK
| | - Lucy C. Chappell
- Department of Women and Children's HealthKing's College LondonLondonUK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of MedicineImperial College LondonLondonUK
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Smith LK, van Blankenstein E, Fox G, Seaton SE, Martínez-Jiménez M, Petrou S, Battersby C. Effect of national guidance on survival for babies born at 22 weeks' gestation in England and Wales: population based cohort study. BMJ Med 2023; 2:e000579. [PMID: 38027415 PMCID: PMC10649719 DOI: 10.1136/bmjmed-2023-000579] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/31/2023] [Indexed: 12/01/2023]
Abstract
Objectives To explore the effect of changes in national clinical recommendations in 2019 that extended provision of survival focused care to babies born at 22 weeks' gestation in England and Wales. Design Population based cohort study. Setting England and Wales, comprising routine data for births and hospital records. Participants Babies alive at the onset of care in labour at 22 weeks+0 days to 22 weeks+6 days and at 23 weeks+0 days to 24 weeks+6 days for comparison purposes between 1 January 2018 and 31 December 2021. Main outcome measures Percentage of babies given survival focused care (active respiratory support after birth), admitted to neonatal care, and surviving to discharge in 2018-19 and 2020-21. Results For the 1001 babies alive at the onset of labour at 22 weeks' gestation, a threefold increase was noted in: survival focused care provision from 11.3% to 38.4% (risk ratio 3.41 (95% confidence interval 2.61 to 4.45)); admissions to neonatal units from 7.4% to 28.1% (3.77 (2.70 to 5.27)), and survival to discharge from neonatal care from 2.5% to 8.2% (3.29 (1.78 to 6.09)). More babies of lower birth weight and early gestational age received survival focused care in 2020-21 than 2018-19 (46% to 64% at <500g weight; 19% to 31% at 22 weeks+0 days to 22 weeks+3 days). Conclusions A change in national guidance to recommend a risk based approach was associated with a threefold increase in 22 weeks' gestation babies receiving survival focused care. The number of babies being admitted to neonatal units and those surviving to discharge increased.
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Affiliation(s)
- Lucy K Smith
- Population Health Sciences, University of Leicester, Leicester, UK
| | - Emily van Blankenstein
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Grenville Fox
- Neonatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Sarah E Seaton
- Population Health Sciences, University of Leicester, Leicester, UK
| | - Mario Martínez-Jiménez
- Department of Economics and Public Policy, Centre for Health Economics & Policy Innovation, Imperial College Business School, London, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care and Health Science, Oxford University, Oxford, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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10
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Evans K, Battersby C, Boardman JP, Boyle E, Carroll W, Dinwiddy K, Dorling J, Gallagher K, Hardy P, Johnston E, Mactier H, Marcroft C, Webbe JWH, Gale C. National priority setting partnership using a Delphi consensus process to develop neonatal research questions suitable for practice-changing randomised trials in the UK. Arch Dis Child Fetal Neonatal Ed 2023; 108:569-574. [PMID: 37094919 PMCID: PMC10646876 DOI: 10.1136/archdischild-2023-325504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The provision of neonatal care is variable and commonly lacks adequate evidence base; strategic development of methodologically robust clinical trials is needed to improve outcomes and maximise research resources. Historically, neonatal research topics have been selected by researchers; prioritisation processes involving wider stakeholder groups have generally identified research themes rather than specific questions amenable to interventional trials. OBJECTIVE To involve stakeholders including parents, healthcare professionals and researchers to identify and prioritise research questions suitable for answering in neonatal interventional trials in the UK. DESIGN Research questions were submitted by stakeholders in population, intervention, comparison, outcome format through an online platform. Questions were reviewed by a representative steering group; duplicates and previously answered questions were removed. Eligible questions were entered into a three-round online Delphi survey for prioritisation by all stakeholder groups. PARTICIPANTS One hundred and eight respondents submitted research questions for consideration; 144 participants completed round one of the Delphi survey, 106 completed all three rounds. RESULTS Two hundred and sixty-five research questions were submitted and after steering group review, 186 entered into the Delphi survey. The top five ranked research questions related to breast milk fortification, intact cord resuscitation, timing of surgical intervention in necrotising enterocolitis, therapeutic hypothermia for mild hypoxic ischaemic encephalopathy and non-invasive respiratory support. CONCLUSIONS We have identified and prioritised research questions suitable for practice-changing interventional trials in neonatal medicine in the UK at the present time. Trials targeting these uncertainties have potential to reduce research waste and improve neonatal care.
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Affiliation(s)
- Katie Evans
- School of Public Health, Faculty of Medicine, Neonatal Medicine, Imperial College London, London, UK
| | - Cheryl Battersby
- School of Public Health, Faculty of Medicine, Neonatal Medicine, Imperial College London, London, UK
| | - James P Boardman
- Neonatal Medicine, The University of Edinburgh MRC Centre for Reproductive Health, Edinburgh, UK
| | - Elaine Boyle
- Neonatal Medicine, University of Leicester, Leicester, UK
- Neonatal Clinical Studies Group, National Institute for Health and Care Research, London, UK
| | | | - Kate Dinwiddy
- British Association of Perinatal Medicine, London, UK
| | - Jon Dorling
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Katie Gallagher
- EGA Institute for Women's Health, University College London, London, UK
| | - Pollyanna Hardy
- Policy Research Unit in Maternal Health & Care, National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Emma Johnston
- Parents and Family Engagement Lead, Thames Valley and Wessex Operational Delivery Network, Thames Valley and Wessex, UK
| | - Helen Mactier
- Neonatal Medicine, University of Glasgow, Glasgow, UK
| | - Claire Marcroft
- Neonatal Physiotherapy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Chris Gale
- School of Public Health, Faculty of Medicine, Neonatal Medicine, Imperial College London, London, UK
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11
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Venkatesan T, Rees P, Gardiner J, Battersby C, Purkayastha M, Gale C, Sutcliffe AG. National Trends in Preterm Infant Mortality in the United States by Race and Socioeconomic Status, 1995-2020. JAMA Pediatr 2023; 177:1085-1095. [PMID: 37669025 PMCID: PMC10481321 DOI: 10.1001/jamapediatrics.2023.3487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 06/07/2023] [Indexed: 09/06/2023]
Abstract
Importance Inequalities in preterm infant mortality exist between population subgroups within the United States. Objective To characterize trends in preterm infant mortality by maternal race and socioeconomic status to assess how inequalities in preterm mortality rates have changed over time. Design, Setting, and Participants This was a retrospective longitudinal descriptive study using the US National Center for Health Statistics birth infant/death data set for 12 256 303 preterm infant births over 26 years, between 1995 and 2020. Data were analyzed from December 2022 to March 2023. Exposures Maternal characteristics including race, smoking status, educational attainment, antenatal care, and insurance status were used as reported on an infant's US birth certificate. Main Outcomes and Measures Preterm infant mortality rate was calculated for each year from 1995 to 2020 for all subgroups, with a trend regression coefficient calculated to describe the rate of change in preterm mortality. Results The average US preterm infant mortality rate (IMR) decreased from 33.71 (95% CI, 33.71 to 34.04) per 1000 preterm births per year between 1995-1997, to 23.32 (95% CI, 23.05 to 23.58) between 2018-2020. Black non-Hispanic infants were more likely to die following preterm births than White non-Hispanic infants (IMR, 31.09; 95% CI, 30.44 to 31.74, vs 21.81; 95% CI, 21.43 to 22.18, in 2018-2020); however, once born, extremely prematurely Black and Hispanic infants had a narrow survival advantage (IMR rate ratio, 0.87; 95% CI, 0.84 to 0.91, in 2018-2020). The rate of decrease in preterm IMR was higher in Black infants (-0.015) than in White (-0.013) and Hispanic infants (-0.010); however, the relative risk of preterm IMR among Black infants compared with White infants remained the same between 1995-1997 vs 2018-2020 (relative risk, 1.40; 95% CI, 1.38 to 1.44, vs 1.43; 95% CI, 1.39 to 1.46). The rate of decrease in preterm IMR was higher in nonsmokers compared with smokers (-0.015 vs -0.010, respectively), in those with high levels of education compared with those with intermediate or low (-0.016 vs - 0.010 or -0.011, respectively), and in those who had received adequate antenatal care compared with those who did not (-0.014 vs -0.012 for intermediate and -0.013 for inadequate antenatal care). Over time, the relative risk of preterm mortality widened within each of these subgroups. Conclusions and Relevance This study found that between 1995 and 2020, US preterm infant mortality improved among all categories of prematurity. Inequalities in preterm infant mortality based on maternal race and ethnicity have remained constant while socioeconomic disparities have widened over time.
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Affiliation(s)
- Tim Venkatesan
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Philippa Rees
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Julian Gardiner
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Department of Education, University of Oxford, Oxford, United Kingdom
| | - Cheryl Battersby
- Department of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Mitana Purkayastha
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Chris Gale
- Department of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Alastair G. Sutcliffe
- Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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12
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Ashworth D, Battersby C, Bick D, Green M, Hardy P, Leighton L, Magee LA, Maher A, McManus RJ, Moakes C, Morris RK, Nelson-Piercy C, Sparkes J, Rivero-Arias O, Webb A, Wilson H, Myers J, Chappell LC. A treatment strategy with nifedipine versus labetalol for women with pregnancy hypertension: study protocol for a randomised controlled trial (Giant PANDA). Trials 2023; 24:584. [PMID: 37700365 PMCID: PMC10496358 DOI: 10.1186/s13063-023-07582-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Approximately one in ten women have high blood pressure during pregnancy. Hypertension is associated with adverse maternal and perinatal outcomes, and as treatment improves maternal outcomes, antihypertensive treatment is recommended. Previous trials have been unable to provide a definitive answer on which antihypertensive treatment is associated with optimal maternal and neonatal outcomes and the need for robust evidence evaluating maternal and infant benefits and risks remains an important, unanswered question for research and clinical communities. METHODS The Giant PANDA study is a pragmatic, open-label, multicentre, randomised controlled trial of a treatment initiation strategy with nifedipine (calcium channel blocker), versus labetalol (mixed alpha/beta blocker) in 2300 women with pregnancy hypertension. The primary objective is to evaluate if treatment with nifedipine compared to labetalol in women with pregnancy hypertension reduces severe maternal hypertension without increasing fetal or neonatal death or neonatal unit admission. Subgroup analyses will be undertaken by hypertension type (chronic, gestational, pre-eclampsia), diabetes (yes, no), singleton (yes, no), self-reported ethnicity (Black, all other), and gestational age at randomisation categories (11 + 0 to 19 + 6, 20 + 0 to 27 + 6, 28 + 0 to 34 + 6 weeks). A cost-effectiveness analysis using an NHS perspective will be undertaken using a cost-consequence analysis up to postnatal hospital discharge and an extrapolation exercise with a lifetime horizon conditional on the results of the cost-consequence analysis. DISCUSSION This trial aims to address the uncertainty of which antihypertensive treatment is associated with optimal maternal and neonatal outcomes. The trial results are intended to provide definitive evidence to inform guidelines and linked, shared decision-making tools, thus influencing clinical practice. TRIAL REGISTRATION EudraCT number: 2020-003410-12, ISRCTN: 12,792,616 registered on 18 November 2020.
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Affiliation(s)
- Danielle Ashworth
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lisa Leighton
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Laura A Magee
- Institute of Women and Children's Health, King's College London, London, UK
| | - Alisha Maher
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Catherine Moakes
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Katie Morris
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Jenie Sparkes
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Oliver Rivero-Arias
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Webb
- Clinical Pharmacology, School of Cardiovascular and Metabolic Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Hannah Wilson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jenny Myers
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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13
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Harnden F, Lanoue J, Modi N, Uthaya SN, Battersby C. Data-driven approach to understanding neonatal palliative care needs in England and Wales: a population-based study 2015-2020. Arch Dis Child Fetal Neonatal Ed 2023; 108:540-544. [PMID: 36958813 DOI: 10.1136/archdischild-2022-325157] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/02/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE To quantify admissions to neonatal units in England and Wales with potential need for palliative care. DESIGN, SETTING AND PATIENTS Diagnoses and clinical attributes indicating a high likelihood of requiring palliative care were mapped to categories within the British Association of Perinatal Medicine's (BAPM) framework on palliative care. We extracted data from the National Neonatal Research Database on all babies born and admitted to neonatal units in England and Wales 2015-2020. OUTCOMES The number and proportion of babies meeting BAPM categories, their discharge outcomes and the characteristics of babies who died during neonatal care but did not fulfil any BAPM category. RESULTS 12 123/574 954 (2.1%) babies met one or more BAPM category: 6239/12 123 (51%) conformed to BAPM category 4 (postnatal conditions with high risk of severe impairment), 3796 (31%) to category 2 (antenatal/postnatal diagnosis with high risk of significant morbidity or death), 1399 (12%) to category 3 (born at margin of viability) and 288 (2%) to category 1 (antenatal/postnatal diagnosis not compatible with long-term survival); 401 babies (3%) met criteria for multiple categories. 6814/12 123 (56%) were discharged home, 2385 (20%) were discharged to other settings and 2914 (24%) died before neonatal discharge. 3000/5914 (51%) babies who died during neonatal care did not conform to any BAPM category. Of these, 2630/3000 (88%) were born preterm. CONCLUSIONS At least 2% of babies admitted to neonatal units had palliative care needs according to existing BAPM categories; most survived to discharge. Of deaths, 51% were not captured by the BAPM categories; most were extremely preterm.
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Affiliation(s)
- Fergus Harnden
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Julia Lanoue
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Neena Modi
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Sabita N Uthaya
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Cheryl Battersby
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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14
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Piyasena C, Galu S, Yoshida R, Thakkar D, O'Sullivan J, Longley C, Evans K, Sweeney S, Kendall G, Ben-Sasi K, Richards J, Harris C, Jagodzinski J, Demirjian A, Lamagni T, Le Doare K, Heath PT, Battersby C. Comparison of diagnoses of early-onset sepsis associated with use of Sepsis Risk Calculator versus NICE CG149: a prospective, population-wide cohort study in London, UK, 2020-2021. BMJ Open 2023; 13:e072708. [PMID: 37500270 PMCID: PMC10387649 DOI: 10.1136/bmjopen-2023-072708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE We sought to compare the incidence of early-onset sepsis (EOS) in infants ≥34 weeks' gestation identified >24 hours after birth, in hospitals using the Kaiser Permanente Sepsis Risk Calculator (SRC) with hospitals using the National Institute for Health and Care Excellence (NICE) guidance. DESIGN AND SETTING Prospective observational population-wide cohort study involving all 26 hospitals with neonatal units colocated with maternity services across London (10 using SRC, 16 using NICE). PARTICIPANTS All live births ≥34 weeks' gestation between September 2020 and August 2021. OUTCOME MEASURES EOS was defined as isolation of a bacterial pathogen in the blood or cerebrospinal fluid (CSF) culture from birth to 7 days of age. We evaluated the incidence of EOS identified by culture obtained >24 hours to 7 days after birth. We also evaluated the rate empiric antibiotics were commenced >24 hours to 7 days after birth, for a duration of ≥5 days, with negative blood or CSF cultures. RESULTS Of 99 683 live births, 42 952 (43%) were born in SRC hospitals and 56 731 (57%) in NICE hospitals. The overall incidence of EOS (<72 hours) was 0.64/1000 live births. The incidence of EOS identified >24 hours was 2.3/100 000 (n=1) for SRC vs 7.1/100 000 (n=4) for NICE (OR 0.5, 95% CI (0.1 to 2.7)). This corresponded to (1/20) 5% (SRC) vs (4/45) 8.9% (NICE) of EOS cases (χ=0.3, p=0.59). Empiric antibiotics were commenced >24 hours to 7 days after birth in 4.4/1000 (n=187) for SRC vs 2.9/1000 (n=158) for NICE (OR 1.5, 95% CI (1.2 to 1.9)). 3111 (7%) infants received antibiotics in the first 24 hours in SRC hospitals vs 8428 (15%) in NICE hospitals. CONCLUSION There was no significant difference in the incidence of EOS identified >24 hours after birth between SRC and NICE hospitals. SRC use was associated with 50% fewer infants receiving antibiotics in the first 24 hours of life.
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Affiliation(s)
| | - Sorana Galu
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - Rie Yoshida
- Imperial College Healthcare NHS Trust, London, UK
| | - Devangi Thakkar
- The Hillingdon University Hospitals NHS Foundation Trust, Harrow, London, UK
| | - Joanna O'Sullivan
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
| | | | - Katie Evans
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Giles Kendall
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Chris Harris
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Alicia Demirjian
- Evelina London Children's Hospital, London, UK
- United Kingdom Health Security Agency, London, UK
| | | | - Kirsty Le Doare
- Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Paul T Heath
- Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Imperial College London Faculty of Medicine, London, UK
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Nezafat Maldonado B, Singhal G, Chow L, Hargreaves D, Gale C, Battersby C. Association between birth location and short-term outcomes for babies with gastroschisis, congenital diaphragmatic hernia and oesophageal fistula: a systematic review. BMJ Paediatr Open 2023; 7:e002007. [PMID: 37474200 PMCID: PMC10357737 DOI: 10.1136/bmjpo-2023-002007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/13/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Neonatal care is commonly regionalised, meaning specialist services are only available at certain units. Consequently, infants with surgical conditions needing specialist care who are born in non-surgical centres require postnatal transfer. Best practice models advocate for colocated maternity and surgical services as the place of birth for infants with antenatally diagnosed congenital conditions to avoid postnatal transfers. We conducted a systematic review to explore the association between location of birth and short-term outcomes of babies with gastroschisis, congenital diaphragmatic hernia (CDH) and oesophageal atresia with or without tracheo-oesophageal fistula (TOF/OA). METHODS We searched MEDLINE, CINAHL, Web of Science and SCOPUS databases for studies from high income countries comparing outcomes for infants with gastroschisis, CDH or TOF/OA based on their place of delivery. Outcomes of interest included mortality, length of stay, age at first feed, comorbidities and duration of parenteral nutrition. We assessed study quality using the Newcastle-Ottawa Scale. We present a narrative synthesis of our findings. RESULTS Nineteen cohort studies compared outcomes of babies with one of gastroschisis, CDH or TOF/OA. Heterogeneity across the studies precluded meta-analysis. Eight studies carried out case-mix adjustments. Overall, we found conflicting evidence. There is limited evidence to suggest that birth in a maternity unit with a colocated surgical centre was associated with a reduction in mortality for CDH and decreased length of stay for gastroschisis. CONCLUSIONS There is little evidence to suggest that delivery in colocated maternity-surgical services may be associated with shortened length of stay and reduced mortality. Our findings are limited by significant heterogeneity, potential for bias and paucity of strong evidence. This supports the need for further research to investigate the impact of birth location on outcomes for babies with congenital surgical conditions and inform future design of neonatal care systems. PROSPERO REGISTRATION NUMBER CRD42022329090.
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Affiliation(s)
| | | | - LiYan Chow
- Neonatal Medicine Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Chris Gale
- Neonatal Medicine, Chelsea and Westminster Hospital Campus, Imperial College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, Chelsea and Westminster Hospital Campus, Imperial College London, London, UK
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16
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Patel N, Evans K, Berrington J, Szatkowski L, Costeloe K, Ojha S, Fleming P, Battersby C. How frequent is routine use of probiotics in UK neonatal units? BMJ Paediatr Open 2023; 7:e002012. [PMID: 37451704 PMCID: PMC10351264 DOI: 10.1136/bmjpo-2023-002012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/27/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE There is a lack of UK guidance regarding routine use of probiotics in preterm infants to prevent necrotising enterocolitis, late-onset sepsis and death. As practices can vary, we aimed to determine the current usage of probiotics within neonatal units in the UK. DESIGN AND SETTING Using NeoTRIPS, a trainee-led neonatal research network, an online survey was disseminated to neonatal units of all service levels within England, Scotland, Northern Ireland and Wales in 2022. Trainees were requested to complete one survey per unit regarding routine probiotic administration. RESULTS 161 of 188 (86%) neonatal units responded to the survey. 70 of 161 (44%) respondents routinely give probiotics to preterm infants. 45 of 70 (64%) use the probiotic product Lactobacillus acidophilus NCFM/Bifidobacterium bifidum Bb-06/B. infantis Bi-26 (Labinic™). 57 of 70 (81%) start probiotics in infants ≤32 weeks' gestation. 33 of 70 (47%) had microbiology departments that were aware of the use of probiotics and 64 of 70 (91%) had a guideline available. Commencing enteral feeds was a prerequisite to starting probiotics in 62 of 70 (89%) units. The majority would stop probiotics if enteral feeds were withheld (59 of 70; 84%) or if the infant was being treated for necrotising enterocolitis (69 of 70; 99%). 24 of 91 (26%) units that did not use probiotics at the time of the survey were planning to introduce them within the next 12 months. CONCLUSIONS More than 40% of all UK neonatal units that responded are now routinely administering probiotics, with variability in the product used. With increased probiotic usage in recent years, there is a need to establish whether this translates to improved clinical outcomes.
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Affiliation(s)
- Neaha Patel
- Department of Neonatology, Homerton Healthcare NHS Foundation Trust, London, UK
| | - Katie Evans
- Neonatal Medicine, School of Public Health Faculty of Medicine, Imperial College London, London, UK
| | - Janet Berrington
- Department of Neonatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lisa Szatkowski
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Kate Costeloe
- Department of Neonatology, Homerton Healthcare NHS Foundation Trust, London, UK
- Genomics and Child Health, Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - Shalini Ojha
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Paul Fleming
- Department of Neonatology, Homerton Healthcare NHS Foundation Trust, London, UK
- Genomics and Child Health, Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health Faculty of Medicine, Imperial College London, London, UK
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17
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Modi N, Ribas R, Johnson S, Lek E, Godambe S, Fukari-Irvine E, Ogundipe E, Tusor N, Das N, Udayakumaran A, Moss B, Banda V, Ougham K, Cornelius V, Arasu A, Wardle S, Battersby C, Bravery A. Pilot feasibility study of a digital technology approach to the systematic electronic capture of parent-reported data on cognitive and language development in children aged 2 years. BMJ Health Care Inform 2023; 30:e100781. [PMID: 37364923 PMCID: PMC10314588 DOI: 10.1136/bmjhci-2023-100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The assessment of language and cognition in children at risk of impaired neurodevelopment following neonatal care is a UK standard of care but there is no national, systematic approach for obtaining these data. To overcome these challenges, we developed and evaluated a digital version of a validated parent questionnaire to assess cognitive and language development at age 2 years, the Parent Report of Children's Abilities-Revised (PARCA-R). METHODS We involved clinicians and parents of babies born very preterm who received care in north-west London neonatal units. We developed a digital version of the PARCA-R questionnaire using standard software. Following informed consent, parents received automated notifications and an invitation to complete the questionnaire on a mobile phone, tablet or computer when their child approached the appropriate age window. Parents could save and print a copy of the results. We evaluated ease of use, parent acceptability, consent for data sharing through integration into a research database and making results available to the clinical team. RESULTS Clinical staff approached the parents of 41 infants; 38 completed the e-registration form and 30 signed the e-consent. The digital version of the PARCA-R was completed by the parents of 21 of 23 children who reached the appropriate age window. Clinicians and parents found the system easy to use. Only one parent declined permission to integrate data into the National Neonatal Research Database for approved secondary purposes. DISCUSSION This electronic data collection system and associated automated processes enabled efficient systematic capture of data on language and cognitive development in high-risk children, suitable for national delivery at scale.
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Affiliation(s)
- Neena Modi
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Ricardo Ribas
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Samantha Johnson
- Department of Population Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Elizabeth Lek
- Neonatal Medicine, Hillingdon Hospital, Uxbridge, UK
| | - Sunit Godambe
- Department of Neonatology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Enitan Ogundipe
- Department of Neonatology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nora Tusor
- Department of Neonatology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nayan Das
- Imperial College Clinical Trials Unit (ICTU), Imperial College London, London, UK
| | | | - Becky Moss
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | - Victor Banda
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Kayleigh Ougham
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Victoria Cornelius
- Imperial College Clinical Trials Unit (ICTU), Imperial College London, London, UK
| | - Anusha Arasu
- British Association of Neonatal Neurodevelopmental Follow-up, Department of Neonatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Steve Wardle
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Cheryl Battersby
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | - Amanda Bravery
- Imperial College Clinical Trials Unit (ICTU), Imperial College London, London, UK
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18
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Rees P, Callan C, Chadda K, Vaal M, Diviney J, Sabti S, Harnden F, Gardiner J, Battersby C, Gale C, Sutcliffe A. School-age outcomes of children after perinatal brain injury: a systematic review and meta-analysis. BMJ Paediatr Open 2023; 7:e001810. [PMID: 37270200 PMCID: PMC10255042 DOI: 10.1136/bmjpo-2022-001810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/14/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Over 3000 children suffer a perinatal brain injury in England every year according to national surveillance. The childhood outcomes of infants with perinatal brain injury are however unknown. METHODS A systematic review and meta-analyses were undertaken of studies published between 2000 and September 2021 exploring school-aged neurodevelopmental outcomes of children after perinatal brain injury compared with those without perinatal brain injury. The primary outcome was neurodevelopmental impairment, which included cognitive, motor, speech and language, behavioural, hearing or visual impairment after 5 years of age. RESULTS This review included 42 studies. Preterm infants with intraventricular haemorrhage (IVH) grades 3-4 were found to have a threefold greater risk of moderate-to-severe neurodevelopmental impairment at school age OR 3.69 (95% CI 1.7 to 7.98) compared with preterm infants without IVH. Infants with perinatal stroke had an increased incidence of hemiplegia 61% (95% CI 39.2% to 82.9%) and an increased risk of cognitive impairment (difference in full scale IQ -24.2 (95% CI -30.73 to -17.67) . Perinatal stroke was also associated with poorer academic performance; and lower mean receptive -20.88 (95% CI -36.66 to -5.11) and expressive language scores -20.25 (95% CI -34.36 to -6.13) on the Clinical Evaluation of Language Fundamentals (CELF) assessment. Studies reported an increased risk of persisting neurodevelopmental impairment at school age after neonatal meningitis. Cognitive impairment and special educational needs were highlighted after moderate-to-severe hypoxic-ischaemic encephalopathy. However, there were limited comparative studies providing school-aged outcome data across neurodevelopmental domains and few provided adjusted data. Findings were further limited by the heterogeneity of studies. CONCLUSIONS Longitudinal population studies exploring childhood outcomes after perinatal brain injury are urgently needed to better enable clinicians to prepare affected families, and to facilitate targeted developmental support to help affected children reach their full potential.
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Affiliation(s)
- Philippa Rees
- Population Policy and Practice, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Caitriona Callan
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karan Chadda
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Meriel Vaal
- Population Policy and Practice, University College London Great Ormond Street Institute of Child Health, London, UK
| | - James Diviney
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Fergus Harnden
- Neonatal Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Julian Gardiner
- Population Policy and Practice, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Alastair Sutcliffe
- Population Policy and Practice, University College London Great Ormond Street Institute of Child Health, London, UK
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Abstract
OBJECTIVES To identify the association between maternal SARS-CoV-2 infection in pregnancy and individual neonatal morbidities and outcomes, particularly longer-term outcomes such as neurodevelopment. DESIGN Systematic review of outcomes of neonates born to pregnant women diagnosed with a SARS-CoV-2 infection at any stage during pregnancy, including asymptomatic women. DATA SOURCES MEDLINE, Embase, Global Health, WHOLIS and LILACS databases, last searched on 28 July 2021. ELIGIBILITY CRITERIA Case-control and cohort studies published after 1 January 2020, including preprint articles were included. Study outcomes included neonatal mortality and morbidity, preterm birth, caesarean delivery, small for gestational age, admission to neonatal intensive care unit, level of respiratory support required, diagnosis of culture-positive sepsis, evidence of brain injury, necrotising enterocolitis, visual or hearing impairment, neurodevelopmental outcomes and feeding method. These were selected according to a core outcome set. DATA EXTRACTION AND SYNTHESIS Data were extracted into Microsoft Excel by two researchers, with statistical analysis completed using IBM SPSS (Version 27). Risk of bias was assessed using a modified Newcastle-Ottawa Scale. RESULTS The search returned 3234 papers, from which 204 were included with a total of 45 646 infants born to mothers with SARS-CoV-2 infection during pregnancy across 36 countries. We found limited evidence of an increased risk of some neonatal morbidities, including respiratory disease. There was minimal evidence from low-income settings (1 study) and for neonatal outcomes following first trimester infection (17 studies). Neonatal mortality was very rare. Preterm birth, neonatal unit admission and small for gestational age status were more common in infants born following maternal SARS-CoV-2 infection in pregnancy in most larger studies. CONCLUSIONS There are limited data on neonatal morbidity and mortality following maternal SARS-CoV-2 infection, particularly from low-income countries and following early pregnancy infections. Large, representative studies addressing these outcomes are needed to understand the consequences for babies born to women with SARS-CoV-2. PROSPERO REGISTRATION NUMBER CRD42021249818.
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Affiliation(s)
- Sarah Sturrock
- Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Shohaib Ali
- School of Public Health, Imperial College London Faculty of Medicine, London, UK
| | - Chris Gale
- School of Public Health, Imperial College London Faculty of Medicine, London, UK
| | - Cheryl Battersby
- School of Public Health, Imperial College London Faculty of Medicine, London, UK
| | - Kirsty Le Doare
- Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
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20
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Sawtell M, van Blankenstein E, Bilal T, Hall T, Juniper L, Kotsoni J, Lee J, Modi N, Battersby C. Views of parents, adults born preterm and professionals on linkage of real-world data of preterm babies. Arch Dis Child Fetal Neonatal Ed 2023; 108:194-199. [PMID: 36261144 DOI: 10.1136/archdischild-2022-324272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/26/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To explore views of parents of preterm babies, adults born preterm and professionals, on the linkage of real-world health and education data for research on improving future outcomes of babies born preterm. DESIGN Three-stage mixed-methods participatory design involving focus groups, a national survey and interviews. Survey participants who expressed uncertainty or negative views were sampled purposively for invitation to interview. Mixed methods were used for data analysis. SETTING AND PARTICIPANTS All data collection was online. Participants were: focus groups-17 parents; survey-499 parents, 44 adults born preterm (total 543); interviews-6 parents, 1 adult born preterm, 3 clinicians, 2 teachers. RESULTS Three key themes were identified: (1) Data linkage and opt-out consent make sense for improving future outcomes. We found clear demand for better information on long-term outcomes and strong support for data linkage with opt-out consent as a means of achieving this. (2) Information requirements-what, how and when. There was support for providing information in different formats and discussing linkage near to, or following discharge from, the neonatal unit, but not sooner. (3) Looking to the future; the rights of young people. We identified a desire for individuals born preterm to be consulted in the future on the use of their data. CONCLUSION With appropriate information provision, at the right time, parents, adults born preterm and professionals are supportive of data linkage for research, including where temporary identifiers and opt-out consent are used. Resources are being co-produced to improve communication about routine data linkage.
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Affiliation(s)
- Mary Sawtell
- Social Research Unit, University College London Institute of Education, London, UK
| | | | | | | | | | | | | | - Neena Modi
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Cheryl Battersby
- Department of Primary Care and Public Health, Imperial College London, London, UK
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21
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Lammons WB, Moss B, Bignell C, Gale C, MacBride A, Ribas R, Battersby C, Modi N. Involving multiple stakeholders in assessing and reviewing a novel data visualisation tool for a national neonatal data asset. BMJ Health Care Inform 2023; 30:e100694. [PMID: 36720494 PMCID: PMC9890751 DOI: 10.1136/bmjhci-2022-100694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/07/2023] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES We involved public and professional stakeholders to assess a novel data interrogation tool, the Neonatal Health Intelligence Tool, for a National Data Asset, the National Neonatal Research Database. METHODS We recruited parents, preterm adults, data managers, clinicians, network managers and researchers (trialists and epidemiologists) for consultations demonstrating a prototype tool and semi-structured discussion. A thematic analysis of consultations is reported by stakeholder group. RESULTS We held nine on-line consultations (March-December 2021), with 24 stakeholders: parents (n=8), preterm adults (n=2), data managers (n=3), clinicians (n=3), network managers (n=2), triallists (n=3) and epidemiologists (n=3). We identified four themes from parents/preterm adults: struggling to consume information, Dads and data, bring data to life and yearning for predictions; five themes from data managers/clinicians/network managers: benchmarking, clinical outcomes, transfers and activity, the impact of socioeconomic background and ethnicity, and timeliness of updates and widening availability; and one theme from researchers: interrogating the data. DISCUSSION Other patient and public involvement (PPI) studies have reported that data tools generate concerns; our stakeholders had none. They were unanimously supportive and enthusiastic, citing visualisation as the tool's greatest strength. Stakeholders had no criticisms; instead, they recognised the tool's potential and wanted more features. Parents saw the tool as an opportunity to inform themselves without burdening clinicians, while clinicians welcomed an aid to explaining potential outcomes to parents. CONCLUSION All stakeholder groups recognised the need for the tool, praising its content and format. PPI consultations with all key groups, and their synthesis, illustrated desire for additional uses from it.
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Affiliation(s)
- William Bishop Lammons
- Department of Applied Health Research, UCL, London, UK
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | - Becky Moss
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | - Charlie Bignell
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | - Chris Gale
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | | | - Ricardo Ribas
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | - Cheryl Battersby
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
| | - Neena Modi
- Section of Neonatal Medicine, School of Primary Care and Public Health, Imperial College London, London, UK
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22
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Rees P, Callan C, Chadda KR, Vaal M, Diviney J, Sabti S, Harnden F, Gardiner J, Battersby C, Gale C, Sutcliffe A. Preterm Brain Injury and Neurodevelopmental Outcomes: A Meta-analysis. Pediatrics 2022; 150:e2022057442. [PMID: 36330752 PMCID: PMC9724175 DOI: 10.1542/peds.2022-057442] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/06/2022] Open
Abstract
CONTEXT Preterm brain injuries are common; neurodevelopmental outcomes following contemporary neonatal care are continually evolving. OBJECTIVE To systematically review and meta-analyze neurodevelopmental outcomes among preterm infants after intraventricular hemorrhage (IVH) and white matter injury (WMI). DATA SOURCES Published and grey literature were searched across 10 databases between 2000 and 2021. STUDY SELECTION Observational studies reporting 3-year neurodevelopmental outcomes for preterm infants with IVH or WMI compared with preterm infants without injury. DATA EXTRACTION Study characteristics, population characteristics, and outcome data were extracted. RESULTS Thirty eight studies were included. There was an increased adjusted risk of moderate-severe neurodevelopmental impairment after IVH grade 1 to 2 (adjusted odds ratio 1.35 [95% confidence interval 1.05-1.75]) and IVH grade 3 to 4 (adjusted odds ratio 4.26 [3.25-5.59]). Children with IVH grade 1 to 2 had higher risks of cerebral palsy (odds ratio [OR] 1.76 [1.39-2.24]), cognitive (OR 1.79 [1.09-2.95]), hearing (OR 1.83 [1.03-3.24]), and visual impairment (OR 1.77 [1.08-2.9]). Children with IVH grade 3 to 4 had markedly higher risks of cerebral palsy (OR 4.98 [4.13-6.00]), motor (OR 2.7 [1.52-4.8]), cognitive (OR 2.3 [1.67-3.15]), hearing (OR 2.44 [1.42-4.2]), and visual impairment (OR 5.42 [2.77-10.58]). Children with WMI had much higher risks of cerebral palsy (OR 14.91 [7.3-30.46]), motor (OR 5.3 [3-9.36]), and cognitive impairment (OR 3.48 [2.18-5.53]). LIMITATIONS Heterogeneity of outcome data. CONCLUSIONS Mild IVH, severe IVH, and WMI are associated with adverse neurodevelopmental outcomes. Utilization of core outcome sets and availability of open-access study data would improve our understanding of the nuances of these outcomes.
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Affiliation(s)
- Philippa Rees
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
| | - Caitriona Callan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Karan R. Chadda
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Meriel Vaal
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
| | - James Diviney
- Paediatric ICU, Great Ormond Street Hospital, London, United Kingdom
| | | | - Fergus Harnden
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Julian Gardiner
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
| | | | | | - Alastair Sutcliffe
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
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23
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Yao S, Uthaya S, Gale C, Modi N, Battersby C. Postnatal corticosteroid use for prevention or treatment of bronchopulmonary dysplasia in England and Wales 2012-2019: a retrospective population cohort study. BMJ Open 2022; 12:e063835. [PMID: 36396314 PMCID: PMC9676997 DOI: 10.1136/bmjopen-2022-063835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/12/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Describe the population of babies who do and do not receive postnatal corticosteroids for prevention or treatment of bronchopulmonary dysplasia (BPD). DESIGN Retrospective cohort study using data held in the National Neonatal Research Database. SETTING National Health Service neonatal units in England and Wales. PATIENTS Babies born less than 32 weeks gestation and admitted to neonatal units from 1 January 2012 to 31 December 2019. MAIN OUTCOMES Proportion of babies given postnatal corticosteroid; type of corticosteroid; age at initiation and duration, trends over time. SECONDARY OUTCOMES Survival to discharge, treatment for retinopathy of prematurity, BPD, brain injury, severe necrotising enterocolitis, gastrointestinal perforation. RESULTS 8% (4713/62019) of babies born <32 weeks and 26% (3525/13527) born <27 weeks received postnatal corticosteroids for BPD. Dexamethasone was predominantly used 5.3% (3309/62019), followed by late hydrocortisone 1.5%, inhaled budesonide 1.5%. prednisolone 0.8%, early hydrocortisone 0.3% and methylprednisolone 0.05%. Dexamethasone use increased over time (2012: 4.5 vs 2019: 5.8%, p=0.04). Median postnatal age of initiation of corticosteroid course was around 3 weeks for late hydrocortisone, 4 weeks for dexamethasone, 6 weeks for inhaled budesonide, 12 weeks for prednisolone and 16 weeks for methylprednisolone. Babies who received postnatal corticosteroids were born more prematurely, had a higher incidence of comorbidities and a longer length of stay. CONCLUSIONS In England and Wales, around 1 in 12 babies born less than 32 weeks and 1 in 4 born less than 27 weeks receive postnatal corticosteroids to prevent or treat BPD. Given the lack of convincing evidence of efficacy, challenges of recruiting to and length of time taken to conduct randomised controlled trial, our data highlight the need to monitor long-term outcomes in children who received neonatal postnatal corticosteroids.
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Affiliation(s)
- Sijia Yao
- Neonatal Medicine, Imperial College London, London, UK
| | - Sabita Uthaya
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Neena Modi
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
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24
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Evans K, Battersby C, Boardman JP, Boyle EM, Carroll WD, Dinwiddy K, Dorling J, Gallagher K, Hardy P, Johnston E, Mactier H, Marcroft C, Webbe J, Gale C. National priority setting partnership using a Delphi consensus process to develop neonatal research questions suitable for practice-changing randomised trials in the United Kingdom. BMJ Open 2022; 12:e061330. [PMID: 36171048 PMCID: PMC9528679 DOI: 10.1136/bmjopen-2022-061330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Methodologically robust clinical trials are required to improve neonatal care and reduce unwanted variations in practice. Previous neonatal research prioritisation processes have identified important research themes rather than specific research questions amenable to clinical trials. Practice-changing trials require well-defined research questions, commonly organised using the Population, Intervention, Comparison, Outcome (PICO) structure. By narrowing the scope of research priorities to those which can be answered in clinical trials and by involving a wide range of different stakeholders, we aim to provide a robust and transparent process to identify and prioritise research questions answerable within the National Healthcare System to inform future practice-changing clinical trials. METHODS AND ANALYSIS A steering group comprising parents, doctors, nurses, allied health professionals, researchers and representatives from key organisations (Neonatal Society, British Association of Perinatal Medicine, Neonatal Nurses Association and Royal College of Paediatrics and Child Health) was identified to oversee this project. We will invite submissions of research questions formatted using the PICO structure from the following stakeholder groups using an online questionnaire: parents, patients, healthcare professionals and academic researchers. Unanswered, non-duplicate research questions will be entered into a three-round eDelphi survey of all stakeholder groups. Research questions will be ranked by mean aggregate scores. ETHICS AND DISSEMINATION The final list of prioritised research questions will be disseminated through traditional academic channels, directly to key stakeholder groups through representative organisations and on social media. The outcome of the project will be shared with key research organisations such as the National Institute for Health Research. Research ethics committee approval is not required.
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Affiliation(s)
- Katie Evans
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - James P Boardman
- MRC Centre for Reproductive Health, The University of Edinburgh, Edinburgh, UK
| | - Elaine M Boyle
- Neonatal Medicine, Department of Health Sciences, University of Leicester, Leicester, UK
| | - William D Carroll
- Department of Paediatric Respiratory Medicine, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Kate Dinwiddy
- Chief Executive of British Association of Perinatal Medicine, London, UK
| | - Jon Dorling
- Neonatal Medicine, University Hospital Southampton, Southampton, UK
| | - Katie Gallagher
- Child and Adolescent Health, University College London, EGA Institute for Women's Health, London, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Emma Johnston
- Parents and Families Engagement Lead, Thames Valley and Wessex Operational Deliveries Network, Thames Valley and Wessex, UK
| | - Helen Mactier
- Neonatal Medicine, University of Glasgow, Glasgow, UK
| | - Claire Marcroft
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - James Webbe
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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25
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Hurrell A, Sparkes J, Duhig K, Seed PT, Myers J, Battersby C, Clark K, Green M, Hunter RM, Shennan AH, Chappell LC, Webster L. Placental growth fActor Repeat sampling for Reduction of adverse perinatal Outcomes in women with suspecTed pre-eclampsia: study protocol for a randomised controlled trial (PARROT-2). Trials 2022; 23:722. [PMID: 36056408 PMCID: PMC9437393 DOI: 10.1186/s13063-022-06652-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background Pre-eclampsia is a complex pregnancy disorder, characterised by new or worsening hypertension associated with multi-organ dysfunction. Adverse outcomes include eclampsia, liver rupture, stroke, pulmonary oedema, and acute kidney injury in the mother, and stillbirth, foetal growth restriction, and iatrogenic preterm delivery for the foetus. Angiogenic biomarkers, including placental growth factor (PlGF) and soluble fms-like tyrosine kinase 1 (sFlt-1), have been identified as valuable biomarkers for preterm pre-eclampsia, accelerating diagnosis and reducing maternal adverse outcomes by risk stratification, with enhanced surveillance for high-risk women. PlGF-based testing for suspected preterm pre-eclampsia has been incorporated into national guidance. The role of repeat PlGF-based testing and its effect on maternal and perinatal adverse outcomes have yet to be evaluated. Methods The PARROT-2 trial is a multi-centre randomised controlled trial of repeat revealed PlGF-based testing compared to repeat concealed testing, in women presenting with suspected pre-eclampsia between 22+0 and 35+6 weeks’ gestation. The primary objective is to establish whether repeat PlGF-based testing decreases a composite of perinatal severe adverse outcomes (stillbirth, early neonatal death, or neonatal unit admission). All women prior to enrolment in the trial will have an initial revealed PlGF-based test. Repeat PlGF-based tests will be performed weekly or two-weekly, depending on the initial PlGF-based test result, with results randomised to revealed or concealed. Discussion National guidance recommends that all women presenting with suspected preterm pre-eclampsia should have a single PlGF-based test when disease is first suspected, to help rule out pre-eclampsia. Clinical and cost-effectiveness of repeat PlGF-based testing has yet to be investigated. This trial aims to address whether repeat PlGF-based testing reduces severe maternal and perinatal adverse outcomes and whether repeat testing is cost-effective. Trial registration ISRCTN 85912420. Registered on 25 November 2019 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06652-8.
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Affiliation(s)
- Alice Hurrell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Jenie Sparkes
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Kate Duhig
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jenny Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Chelsea and Westminster Hospital Campus, 369 Fulham Road, London, SW10 9NH, UK
| | - Katherine Clark
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | | | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Louise Webster
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
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Webbe J, Battersby C, Longford N, Oughham K, Uthaya S, Modi N, Gale C. Use of parenteral nutrition in the first postnatal week in England and Wales: an observational study using real-world data. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001543. [PMID: 36053624 PMCID: PMC9422803 DOI: 10.1136/bmjpo-2022-001543] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Parenteral nutrition (PN) is used to provide supplemental support to neonates while enteral feeding is being established. PN is a high-cost intervention with beneficial and harmful effects. Internationally, there is substantial variation in how PN is used, and there are limited contemporary data describing use across Great Britain. OBJECTIVE To describe PN use in the first postnatal week in infants born and admitted to neonatal care in England, Scotland and Wales. METHOD Data describing neonates admitted to National Health Service neonatal units between 1 January 2012 and 31 December 2017, extracted from routinely recorded data held the National Neonatal Research Database (NNRD); the denominator was live births, from Office for National Statistics. RESULTS Over the study period 62 145 neonates were given PN in the first postnatal week (1.4% of all live births); use was higher in more preterm neonates (76% of livebirths at <28 weeks, 0.2% of term livebirths) and in neonates with lower birth weight. 15% (9181/62145) of neonates given PN in the first postnatal week were born at term. There was geographic variation in PN administration: the proportion of live births given PN within neonatal regional networks ranged from 1.0% (95% CIs 1.0 to 1.0) to 2.8% (95% CI 2.7 to 2.9). CONCLUSIONS AND RELEVANCE Significant variation exists in neonatal PN use; it is unlikely this reflects optimal use of an expensive intervention. Research is needed to identify which babies will benefit most and which are at risk of harm from early PN. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT03767634; registration date: 6 December 2018.
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Affiliation(s)
- James Webbe
- Neonatal Medicine, Imperial College London, London, UK
| | | | | | - Kayleigh Oughham
- Neonatal Data Analysis Unit, Imperial College London, Faculty of Medicine, London, UK
| | - Sabita Uthaya
- Neonatal Medicine, Imperial College London, London, UK
| | - Neena Modi
- Neonatal Medicine, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, Imperial College London, London, UK
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Moore HL, Battersby C, Piyasena C, Demirjian A, Lamagni T. Assessing variation in neonatal sepsis screening across England. Arch Dis Child Fetal Neonatal Ed 2022:archdischild-2022-324380. [PMID: 35790345 DOI: 10.1136/archdischild-2022-324380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Hannah L Moore
- UK Field Epidemiology Training Program, UK Health Security Agency, Leeds, UK
| | | | | | - Alicia Demirjian
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK.,Neonatal Medicine, Evelina London Children's Hospital, London, UK
| | - Theresa Lamagni
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK
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Ducey J, Kennedy AM, Linsell L, Woolfall K, Hall NJ, Gale C, Battersby C, Penman G, Knight M, Lansdale N. Timing of neonatal stoma closure: a survey of health professional perspectives and current practice. Arch Dis Child Fetal Neonatal Ed 2022; 107:448-450. [PMID: 34413091 PMCID: PMC9209674 DOI: 10.1136/archdischild-2021-322040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/09/2021] [Indexed: 12/03/2022]
Abstract
Optimal timing for neonatal stoma closure remains unclear. In this study, we aimed to establish current practice and illustrate multidisciplinary perspectives on timing of stoma closure using an online survey sent to all 27 UK neonatal surgical units, as part of a research programme to determine the feasibility of a clinical trial comparing 'early' and 'late' stoma closure. 166 responses from all 27 units demonstrated concordance of opinion in target time for closure (6 weeks most commonly stated across scenarios), although there was a high variability in practice. A sizeable proportion (41%) of respondents use weight, rather than time, to determine when to close a neonatal stoma. Thematic analysis of free text responses identified nine key themes influencing decision-making; most related to nutrition, growth and stoma complications. These data provide an overview of current practice that is critical to informing an acceptable trial design.
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Affiliation(s)
- Jonathan Ducey
- Department of Paediatric and Neonatal Surgery, Royal Manchester Children's Hospital, Manchester, UK
| | - Ann M Kennedy
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Chris Gale
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Cheryl Battersby
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Gareth Penman
- Newborn Intensive Care Unit, St Mary’s Hospital, Manchester, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nick Lansdale
- Department of Paediatric and Neonatal Surgery, Royal Manchester Children's Hospital, Manchester, UK .,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Dallera G, Skopec M, Battersby C, Barlow J, Harris M. Review of a frugal cooling mattress to induce therapeutic hypothermia for treatment of hypoxic-ischaemic encephalopathy in the UK NHS. Global Health 2022; 18:43. [PMID: 35449006 PMCID: PMC9027044 DOI: 10.1186/s12992-022-00833-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Hypoxic ischaemic encephalopathy (HIE) is a major cause of neonatal mortality and disability in the United Kingdom (UK) and has significant human and financial costs. Therapeutic hypothermia (TH), which consists of cooling down the newborn’s body temperature, is the current standard of treatment for moderate or severe cases of HIE. Timely initiation of treatment is critical to reduce risk of mortality and disability associated with HIE. Very expensive servo-controlled devices are currently used in high-income settings to induce TH, whereas low-income settings rely on the use of low-tech devices such as water bottles, ice packs or fans. Cooling mattresses made with phase change materials (PCMs) were recently developed as a safe, efficient, and affordable alternative to induce TH in low-income settings. This frugal innovation has the potential to become a reverse innovation for the National Health Service (NHS) by providing a simple, efficient, and cost-saving solution to initiate TH in geographically remote areas of the UK where cooling equipment might not be readily available, ensuring timely initiation of treatment while waiting for neonatal transport to the nearest cooling centre. The adoption of PCM cooling mattresses by the NHS may reduce geographical disparity in the availability of treatment for HIE in the UK, and it could benefit from improvements in coordination across all levels of neonatal care given challenges currently experienced by the NHS in terms of constraints on funding and shortage of staff. Trials evaluating the effectiveness and safety of PCM cooling mattresses in the NHS context are needed in support of the adoption of this frugal innovation. These findings may be relevant to other high-income settings that experience challenges with the provision of TH in geographically remote areas. The use of promising frugal innovations such as PCM cooling mattresses in high-income settings may also contribute to challenge the dominant narrative that often favours innovation from North America and Western Europe, and consequently fight bias against research and development from low-income settings, promoting a more equitable global innovation landscape.
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Affiliation(s)
- Giulia Dallera
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Mark Skopec
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Cheryl Battersby
- Department of Primary Care and Public Health, Imperial College London, London, UK.,Consultant Neonatologist, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - James Barlow
- Imperial College Business School, Imperial College London, London, UK
| | - Matthew Harris
- Department of Primary Care and Public Health, Imperial College London, London, UK.
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Webbe JWH, Longford N, Battersby C, Oughham K, Uthaya SN, Modi N, Gale C. Outcomes in relation to early parenteral nutrition use in preterm neonates born between 30 and 33 weeks' gestation: a propensity score matched observational study. Arch Dis Child Fetal Neonatal Ed 2022; 107:131-136. [PMID: 34548324 DOI: 10.1136/archdischild-2021-321643] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 08/06/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate whether in preterm neonates parenteral nutrition use in the first 7 postnatal days, compared with no parenteral nutrition use, is associated with differences in survival and other important morbidities. Randomised trials in critically ill older children show that harms, such as nosocomial infection, outweigh benefits of early parenteral nutrition administration; there is a paucity of similar data in neonates. DESIGN Retrospective cohort study using propensity matching including 35 maternal, infant and organisational factors to minimise bias and confounding. SETTING National, population-level clinical data obtained for all National Health Service neonatal units in England and Wales. PATIENTS Preterm neonates born between 30+0 and 32+6 weeks+days. INTERVENTIONS The exposure was parenteral nutrition administered in the first 7 days of postnatal life; the comparator was no parenteral nutrition. MAIN OUTCOME MEASURES The primary outcome was survival to discharge from neonatal care. Secondary outcomes comprised the neonatal core outcome set. RESULTS 16 292 neonates were compared in propensity score matched analyses. Compared with matched neonates not given parenteral nutrition in the first postnatal week, neonates who received parenteral nutrition had higher survival at discharge (absolute rate increase 0.91%; 95% CI 0.53% to 1.30%), but higher rates of necrotising enterocolitis (absolute rate increase 4.6%), bronchopulmonary dysplasia (absolute rate increase 3.9%), late-onset sepsis (absolute rate increase 1.5%) and need for surgical procedures (absolute rate increase 0.92%). CONCLUSIONS In neonates born between 30+0 and 32+6 weeks' gestation, those given parenteral nutrition in the first postnatal week had a higher rate of survival but higher rates of important neonatal morbidities. Clinician equipoise in this area should be resolved by prospective randomised trials. TRIAL REGISTRATION NUMBER NCT03767634.
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Affiliation(s)
| | | | | | | | | | - Neena Modi
- Neonatal Medicine, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, Imperial College London, London, UK
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Greenbury SF, Angelini ED, Ougham K, Battersby C, Gale C, Uthaya S, Modi N. Post-natal growth of very preterm neonates - Authors' reply. Lancet Child Adolesc Health 2022; 6:e11. [PMID: 35182488 DOI: 10.1016/s2352-4642(22)00025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/12/2022] [Indexed: 02/09/2023]
Affiliation(s)
- Sam F Greenbury
- National Institute for Health Research Imperial Biomedical Research Centre, Institute for Translational Medicine and Therapeutics Data Science Group, Imperial College London, London SW10 9NH, UK
| | - Elsa D Angelini
- National Institute for Health Research Imperial Biomedical Research Centre, Institute for Translational Medicine and Therapeutics Data Science Group, Imperial College London, London SW10 9NH, UK
| | - Kayleigh Ougham
- School of Public Health, Faculty of Medicine, Imperial College London, London SW10 9NH, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Cheryl Battersby
- School of Public Health, Faculty of Medicine, Imperial College London, London SW10 9NH, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Christopher Gale
- School of Public Health, Faculty of Medicine, Imperial College London, London SW10 9NH, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Sabita Uthaya
- School of Public Health, Faculty of Medicine, Imperial College London, London SW10 9NH, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Neena Modi
- School of Public Health, Faculty of Medicine, Imperial College London, London SW10 9NH, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK.
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Uthaya S, Longford N, Battersby C, Oughham K, Lanoue J, Modi N. Early versus later initiation of parenteral nutrition for very preterm infants: a propensity score-matched observational study. Arch Dis Child Fetal Neonatal Ed 2022; 107:137-142. [PMID: 34795009 PMCID: PMC8867269 DOI: 10.1136/archdischild-2021-322383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/08/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the impact of timing of initiation of parenteral nutrition (PN) after birth in very preterm infants. DESIGN Propensity-matched analysis of data from the UK National Neonatal Research Database. PATIENTS 65 033 babies <31 weeks gestation admitted to neonatal units in England and Wales between 2008 and 2019. INTERVENTIONS PN initiated in the first 2 days (early) versus after the second postnatal day (late). Babies who died in the first 2 days without receiving PN were analysed as 'late'. MAIN OUTCOME MEASURES The main outcome measure was morbidity-free survival to discharge. The secondary outcomes were survival to discharge, growth and other core neonatal outcomes. FINDINGS No difference was found in the primary outcome (absolute rate difference (ARD) between early and late 0.50%, 95% CI -0.45 to 1.45, p=0.29). The early group had higher rates of survival to discharge (ARD 3.3%, 95% CI 2.7 to 3.8, p<0.001), late-onset sepsis (ARD 0.84%, 95% CI 0.48 to 1.2, p<0.001), bronchopulmonary dysplasia (ARD 1.24%, 95% CI 0.30 to 2.17, p=0.01), treated retinopathy of prematurity (ARD 0.50%, 95% CI 0.17 to 0.84, p<0.001), surgical procedures (ARD 0.80%, 95% CI 0.20 to 1.40, p=0.01) and greater drop in weight z-score between birth and discharge (absolute difference 0.019, 95% CI 0.003 to 0.035, p=0.02). Of 4.9% of babies who died in the first 2 days, 3.4% were in the late group and not exposed to PN. CONCLUSIONS Residual confounding and survival bias cannot be excluded and justify the need for a randomised controlled trial powered to detect differences in important functional outcomes.
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Affiliation(s)
- Sabita Uthaya
- Department of Neonatal Medicine, Imperial College London, London, UK
| | - Nicholas Longford
- Department of Neonatal Medicine, Imperial College London, London, UK
| | - Cheryl Battersby
- Department of Neonatal Medicine, Imperial College London, London, UK
| | - Kayleigh Oughham
- Department of Neonatal Medicine, Imperial College London, London, UK
| | - Julia Lanoue
- Department of Neonatal Medicine, Imperial College London, London, UK
| | - Neena Modi
- Department of Neonatal Medicine, Imperial College London, London, UK
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33
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Ashworth D, Battersby C, Green M, Hardy P, McManus RJ, Cluver C, Chappell LC. Which antihypertensive treatment is better for mild to moderate hypertension in pregnancy? BMJ 2022; 376:e066333. [PMID: 35042721 DOI: 10.1136/bmj-2021-066333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | | | - Marcus Green
- Action on Pre-eclampsia (APEC), Evesham WR11 4EU, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, UK
| | | | - Catherine Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
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Gale C, Jeyakumaran D, Longford N, Battersby C, Ojha S, Oughham K, Dorling J. Administration of parenteral nutrition during therapeutic hypothermia: a population level observational study using routinely collected data held in the National Neonatal Research Database. Arch Dis Child Fetal Neonatal Ed 2021; 106:608-613. [PMID: 33952628 PMCID: PMC8543212 DOI: 10.1136/archdischild-2020-321299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/08/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Parenteral nutrition is commonly administered during therapeutic hypothermia. Randomised trials in critically ill children indicate that parenteral nutrition may be harmful. OBJECTIVE To examine the association between parenteral nutrition during therapeutic hypothermia and clinically important outcomes. DESIGN Retrospective, population-based cohort study using the National Neonatal Research Database; propensity scores were used to create matched groups for comparison. SETTING National Health Service neonatal units in England, Scotland and Wales. PARTICIPANTS 6030 term and near-term babies, born 1/1/2010 and 31/12/2017, who received therapeutic hypothermia; 2480 babies in the matched analysis. EXPOSURE We compared babies that received any parenteral nutrition during therapeutic hypothermia with babies that did not. MAIN OUTCOME MEASURES Primary outcome: blood culture confirmed late-onset infection; secondary outcomes: treatment for late onset infection, necrotising enterocolitis, survival, length of stay, measures of breast feeding, hypoglycaemia, central line days, time to full enteral feeds, discharge weight. RESULTS 1475/6030 babies (25%) received parenteral nutrition. In comparative matched analyses, the rate of culture positive late onset infection was higher in babies that received parenteral nutrition (0.3% vs 0.9%; difference 0.6; 95% CI 0.1, 1.2; p=0.03), but treatment for presumed infection was not (difference 0.8%, 95% CI -2.1 to 3.6, p=0.61). Survival was higher in babies that received parenteral nutrition (93.1% vs 90.0%; rate difference 3.1, 95% CI 1.5, 4.7; p<0.001). CONCLUSIONS Receipt of parenteral nutrition during therapeutic hypothermia is associated with higher late-onset infection but lower mortality. This finding may be explained by residual confounding. Research should address the risks and benefits of parenteral nutrition in this population.
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Affiliation(s)
- Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Dusha Jeyakumaran
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Nicholas Longford
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Shalini Ojha
- School of Medicine, University of Nottingham, Derby, UK,Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Kayleigh Oughham
- Neonatal Data Analysis Unit, Imperial College London Faculty of Medicine, London, UK
| | - Jon Dorling
- Division of Neonatal—Perinatal Medicine, Dalhousie University—Faculty of Medicine, Halifax, Nova Scotia, Canada
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Greenbury SF, Longford N, Ougham K, Angelini ED, Battersby C, Uthaya S, Modi N. Changes in neonatal admissions, care processes and outcomes in England and Wales during the COVID-19 pandemic: a whole population cohort study. BMJ Open 2021; 11:e054410. [PMID: 34598993 PMCID: PMC8488283 DOI: 10.1136/bmjopen-2021-054410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The COVID-19 pandemic instigated multiple societal and healthcare interventions with potential to affect perinatal practice. We evaluated population-level changes in preterm and full-term admissions to neonatal units, care processes and outcomes. DESIGN Observational cohort study using the UK National Neonatal Research Database. SETTING England and Wales. PARTICIPANTS Admissions to National Health Service neonatal units from 2012 to 2020. MAIN OUTCOME MEASURES Admissions by gestational age, ethnicity and Index of Multiple Deprivation, and key care processes and outcomes. METHODS We calculated differences in numbers and rates between April and June 2020 (spring), the first 3 months of national lockdown (COVID-19 period), and December 2019-February 2020 (winter), prior to introduction of mitigation measures, and compared them with the corresponding differences in the previous 7 years. We considered the COVID-19 period highly unusual if the spring-winter difference was smaller or larger than all previous corresponding differences, and calculated the level of confidence in this conclusion. RESULTS Marked fluctuations occurred in all measures over the 8 years with several highly unusual changes during the COVID-19 period. Total admissions fell, having risen over all previous years (COVID-19 difference: -1492; previous 7-year difference range: +100, +1617; p<0.001); full-term black admissions rose (+66; -64, +35; p<0.001) whereas Asian (-137; -14, +101; p<0.001) and white (-319; -235, +643: p<0.001) admissions fell. Transfers to higher and lower designation neonatal units increased (+129; -4, +88; p<0.001) and decreased (-47; -25, +12; p<0.001), respectively. Total preterm admissions decreased (-350; -26, +479; p<0.001). The fall in extremely preterm admissions was most marked in the two lowest socioeconomic quintiles. CONCLUSIONS Our findings indicate substantial changes occurred in care pathways and clinical thresholds, with disproportionate effects on black ethnic groups, during the immediate COVID-19 period, and raise the intriguing possibility that non-healthcare interventions may reduce extremely preterm births.
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Affiliation(s)
- Sam F Greenbury
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Institute for Translational Medicine and Therapeutics Data Science Group, Imperial College London, London, UK
| | - Nicholas Longford
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Kayleigh Ougham
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Elsa D Angelini
- Institute for Translational Medicine and Therapeutics Data Science Group, Imperial College London, London, UK
| | - Cheryl Battersby
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Sabita Uthaya
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Neena Modi
- Section of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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36
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Greenbury SF, Angelini ED, Ougham K, Battersby C, Gale C, Uthaya S, Modi N. Birthweight and patterns of postnatal weight gain in very and extremely preterm babies in England and Wales, 2008-19: a cohort study. Lancet Child Adolesc Health 2021; 5:719-728. [PMID: 34450109 DOI: 10.1016/s2352-4642(21)00232-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intrauterine and postnatal weight are widely regarded as biomarkers of fetal and neonatal wellbeing, but optimal weight gain following preterm birth is unknown. We aimed to describe changes over time in birthweight and postnatal weight gain in very and extremely preterm babies, in relation to major morbidity and healthy survival. METHODS In this cohort study, we used whole-population data from the UK National Neonatal Research Database for infants below 32 weeks gestation admitted to neonatal units in England and Wales between Jan 1, 2008, and Dec 31, 2019. We used non-linear Gaussian process to estimate monthly trends, and Bayesian multilevel regression to estimate unadjusted and adjusted coefficients. We evaluated birthweight; weight change from birth to 14 days; weight at 36 weeks postmenstrual age; associated Z scores; and longitudinal weights for babies surviving to 36 weeks postmenstrual age with and without major morbidities. We adjusted birthweight for antenatal, perinatal, and demographic variables. We additionally adjusted change in weight at 14 days and weight at 36 weeks postmenstrual age, and their Z scores, for postnatal variables. FINDINGS The cohort comprised 90 817 infants. Over the 12-year period, mean differences adjusted for antenatal, perinatal, demographic, and postnatal variables were 0 g (95% compatibility interval -7 to 7) for birthweight (-0·01 [-0·05 to 0·03] for change in associated Z score); 39 g (26 to 51) for change in weight from birth to 14 days (0·14 [0·08 to 0·19] for change in associated Z score); and 105 g (81 to 128) for weight at 36 weeks postmenstrual age (0·27 [0·21 to 0·33] for change in associated Z score). Greater weight at 36 weeks postmenstrual age was robust to additional adjustment for enteral nutritional intake. In babies surviving without major morbidity, weight velocity in all gestational age groups stabilised at around 34 weeks postmenstrual age at 16-25 g per day along parallel percentile lines. INTERPRETATION The birthweight of very and extremely preterm babies has remained stable over 12 years. Early postnatal weight loss has decreased, and subsequent weight gain has increased, but weight at 36 weeks postmenstrual age is consistently below birth percentile. In babies without major morbidity, weight velocity follows a consistent trajectory, offering opportunity to construct novel preterm growth curves despite lack of knowledge of optimal postnatal weight gain. FUNDING UK Medical Research Council.
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Affiliation(s)
- Sam F Greenbury
- National Institute for Health Research Imperial Biomedical Research Centre, Institute for Translational Medicine and Therapeutics Data Science Group, Imperial College London, London, UK
| | - Elsa D Angelini
- National Institute for Health Research Imperial Biomedical Research Centre, Institute for Translational Medicine and Therapeutics Data Science Group, Imperial College London, London, UK
| | - Kayleigh Ougham
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Cheryl Battersby
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Christopher Gale
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Sabita Uthaya
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK
| | - Neena Modi
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK; Section of Neonatal Medicine, Chelsea and Westminster Hospital, London, UK.
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Hage L, Jeyakumaran D, Dorling J, Ojha S, Sharkey D, Longford N, Modi N, Battersby C, Gale C. Changing clinical characteristics of infants treated for hypoxic-ischaemic encephalopathy in England, Wales and Scotland: a population-based study using the National Neonatal Research Database. Arch Dis Child Fetal Neonatal Ed 2021; 106:501-508. [PMID: 33541916 DOI: 10.1136/archdischild-2020-319685] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/20/2020] [Accepted: 01/09/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Therapeutic hypothermia is standard of care for babies with moderate/severe hypoxic-ischaemic encephalopathy and is increasingly used for mild encephalopathy. OBJECTIVE Describe temporal trends in the clinical condition of babies diagnosed with hypoxic-ischaemic encephalopathy who received therapeutic hypothermia. DESIGN Retrospective cohort study using data held in the National Neonatal Research Database. SETTING National Health Service neonatal units in England, Wales and Scotland. PATIENTS Infants born from 1 January 2010 to 31 December 2017 with a recorded diagnosis of hypoxic-ischaemic encephalopathy who received therapeutic hypothermia for at least 3 days or died in this period. MAIN OUTCOMES Primary outcomes: recorded clinical characteristics including umbilical cord pH; Apgar score; newborn resuscitation; seizures and treatment on day 1. SECONDARY OUTCOMES recorded hypoxic-ischaemic encephalopathy grade. RESULTS 5201 babies with a diagnosis of hypoxic-ischaemic encephalopathy received therapeutic hypothermia or died; annual numbers increased over the study period. A decreasing proportion had clinical characteristics of severe hypoxia ischaemia or a diagnosis of moderate or severe hypoxic-ischaemic encephalopathy, trends were statistically significant and consistent across multiple clinical characteristics used as markers of severity. CONCLUSIONS Treatment with therapeutic hypothermia for hypoxic-ischaemic encephalopathy has increased in England, Scotland and Wales. An increasing proportion of treated infants have a diagnosis of mild hypoxic-ischaemic encephalopathy or have less severe clinical markers of hypoxia. This highlights the importance of determining the role of hypothermia in mild hypoxic-ischaemic encephalopathy. Receipt of therapeutic hypothermia is unlikely to be a useful marker for assessing changes in the incidence of brain injury over time.
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Affiliation(s)
- Lory Hage
- Department of Medicine, Imperial College London, London, UK
| | - Dusha Jeyakumaran
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Shalini Ojha
- Division of Academic Child Health, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Division of Academic Child Health, University of Nottingham, Nottingham, UK
| | - Nicholas Longford
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Neena Modi
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
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Lammons W, Moss B, Battersby C, Cornelius V, Babalis D, Modi N. Incorporating parent, former patient and clinician perspectives in the design of a national UK double-cluster, randomised controlled trial addressing uncertainties in preterm nutrition. BMJ Paediatr Open 2021; 5:e001112. [PMID: 34212120 PMCID: PMC8208018 DOI: 10.1136/bmjpo-2021-001112] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Comparative effectiveness randomised controlled trials are powerful tools to resolve uncertainties in existing treatments and care processes. We sought parent and patient perspectives on the design of a planned national, double-cluster randomised controlled trial (COLLABORATE) to resolve two longstanding uncertainties in preterm nutrition. Methods We used qualitative focus groups and interviews with parents, former patients and clinicians. We followed the Consolidated Criteria for Reporting Qualitative Research checklist and conducted framework analysis, a specific methodology within thematic analysis. Results We identified support for the trial's methodology and vision, and elicited themes illustrating parents' emotional needs in relation to clinical research. These were: relieving the pressure on mothers to breastfeed; opt-out consent as reducing parent stress; the desire for research to be a partnership between clinicians, parents and researchers; the value of presenting trial information in a collaborative tone; and in a format that allows assimilation by parents at their own pace. We identified anxiety and cognitive dissonance among some clinicians in which they recognised the uncertainties that justify the trial but felt unable to participate because of their strongly held views. Conclusions The early involvement of parents and former patients identified the centrality of parents' emotional needs in the design of comparative effectiveness research. These insights have been incorporated into trial enrolment processes and information provided to participants. Specific outputs were a two-sided leaflet providing very brief as well as more detailed information, and use of language that parents perceive as inclusive and participatory. Further work is warranted to support clinicians to address personal biases that inhibit trial participation.
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Affiliation(s)
- William Lammons
- Section of Neonatal Medicine, Imperial College London, London, UK
| | - Becky Moss
- Section of Neonatal Medicine, Imperial College London, London, UK
| | | | | | - Daphne Babalis
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Neena Modi
- Section of Neonatal Medicine, Imperial College London, London, UK
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Gale C, Jeyakumaran D, Battersby C, Ougham K, Ojha S, Culshaw L, Selby E, Dorling J, Longford N. Nutritional management in newborn babies receiving therapeutic hypothermia: two retrospective observational studies using propensity score matching. Health Technol Assess 2021; 25:1-106. [PMID: 34096500 PMCID: PMC8215569 DOI: 10.3310/hta25360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Therapeutic hypothermia is standard of care for babies with moderate to severe hypoxic-ischaemic encephalopathy. There is limited evidence to inform provision of nutrition during hypothermia. OBJECTIVES To assess the association during therapeutic hypothermia between (1) enteral feeding and outcomes, such as necrotising enterocolitis and (2) parenteral nutrition and outcomes, such as late-onset bloodstream infection. DESIGN A retrospective cohort study using data held in the National Neonatal Research Database and applying propensity score methodology to form matched groups for analysis. SETTING NHS neonatal units in England, Wales and Scotland. PARTICIPANTS Babies born at ≥ 36 gestational weeks between 1 January 2010 and 31 December 2017 who received therapeutic hypothermia for 72 hours or who died during treatment. INTERVENTIONS Enteral feeding analysis - babies who were enterally fed during therapeutic hypothermia (intervention) compared with babies who received no enteral feeds during therapeutic hypothermia (control). Parenteral nutrition analysis - babies who received parenteral nutrition during therapeutic hypothermia (intervention) compared with babies who received no parenteral nutrition during therapeutic hypothermia (control). OUTCOME MEASURES Primary outcomes were severe and pragmatically defined necrotising enterocolitis (enteral feeding analysis) and late-onset bloodstream infection (parenteral nutrition analysis). Secondary outcomes were survival at neonatal discharge, length of neonatal stay, breastfeeding at discharge, onset of breastfeeding, time to first maternal breast milk, hypoglycaemia, number of days with a central line in situ, duration of parenteral nutrition, time to full enteral feeds and growth. RESULTS A total of 6030 babies received therapeutic hypothermia. Thirty-one per cent of babies received enteral feeds and 25% received parenteral nutrition. Seven babies (0.1%) were diagnosed with severe necrotising enterocolitis, and further comparative analyses were not conducted on this outcome. A total of 3236 babies were included in the matched enteral feeding analysis. Pragmatically defined necrotising enterocolitis was rare in both groups (0.5% vs. 1.1%) and was lower in babies who were fed during hypothermia (rate difference -0.5%, 95% confidence interval -1.0% to -0.1%; p = 0.03). Higher survival to discharge (96.0% vs. 90.8%, rate difference 5.2%, 95% confidence interval 3.9% to 6.6%; p < 0.001) and higher breastfeeding at discharge (54.6% vs. 46.7%, rate difference 8.0%, 95% confidence interval 5.1% to 10.8%; p < 0.001) rates were observed in enterally fed babies who also had a shorter neonatal stay (mean difference -2.2 days, 95% confidence interval -3.0 to -1.2 days). A total of 2480 babies were included in the matched parenteral nutrition analysis. Higher levels of late-onset bloodstream infection were seen in babies who received parenteral nutrition (0.3% vs. 0.9%, rate difference 0.6%, 95% confidence interval 0.1% to 1.2%; p = 0.03). Survival was lower in babies who did not receive parenteral nutrition (90.0% vs. 93.1%, rate difference 3.1%, 95% confidence interval 1.5% to 4.7%; p < 0.001). LIMITATIONS Propensity score methodology can address imbalances in observed confounders only. Residual confounding by unmeasured or poorly recorded variables cannot be ruled out. We did not analyse by type or volume of enteral or parenteral nutrition. CONCLUSIONS Necrotising enterocolitis is rare in babies receiving therapeutic hypothermia, and the introduction of enteral feeding is associated with a lower risk of pragmatically defined necrotising enterocolitis and other beneficial outcomes, including rates of higher survival and breastfeeding at discharge. Receipt of parenteral nutrition during therapeutic hypothermia is associated with a higher rate of late-onset infection but lower mortality. These results support introduction of enteral feeding during therapeutic hypothermia. FUTURE WORK Randomised trials to assess parenteral nutrition during therapeutic hypothermia. TRIAL REGISTRATION Current Controlled Trials ISRCTN474042962. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Dusha Jeyakumaran
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Kayleigh Ougham
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Shalini Ojha
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | | | - Nicholas Longford
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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Da Costa K, Watson S, Perks H, Battersby C. 219 Documentation of Scrotal Examination in Male Children with Abdominal Pain. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Abdominal pain is a common presentation in all age groups with 7-10% of emergency department admissions.
Method
This registered audit looks at male children (aged <16), admitted with abdominal pain during this period. Approximately 2,877 children under the age of sixteen were admitted, 1,582 males. This equates to 55% of children admitted within 3 months. Manual note analysis from ED records identified 53 males <16 years of age with abdominal pain for inspection of documentation.
Results
45% of inspected notes had documented genital and scrotal examination, none of which had a documented consent. In addition, 21% had a documented chaperone for the intimate examination. None of the cases had BOTH consent and presence of chaperone documented.
Conclusions
A common presentation in children lacks significant elements of documentation. This is noted in multiple specialties. Potentially overlooked aspects of examination can lead to missed or delayed identification of time sensitive diagnosis namely testicular torsion, with possible substantial legal, professional, and financial consequences.
To improve the quality of documentation, education at junior doctor level has been carried out, with further analysis to take place and with the view to incorporate the three elements of an intimate examination: consent, chaperone, and findings.
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Affiliation(s)
- K Da Costa
- Wrexham Maelor Hospital, Wrexham, United Kingdom
| | - S Watson
- Wrexham Maelor Hospital, Wrexham, United Kingdom
| | - H Perks
- Wrexham Maelor Hospital, Wrexham, United Kingdom
| | - C Battersby
- Wrexham Maelor Hospital, Wrexham, United Kingdom
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Kimpton JA, Verma A, Thakkar D, Teoh S, Verma A, Piyasena C, Battersby C. Comparison of NICE Guideline CG149 and the Sepsis Risk Calculator for the Management of Early-Onset Sepsis on the Postnatal Ward. Neonatology 2021; 118:562-568. [PMID: 34518475 DOI: 10.1159/000518059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/09/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The NICE guideline CG149 has increased the number of well infants receiving antibiotics for suspected early-onset sepsis (EOS). The Kaiser Permanente sepsis risk calculator (SRC) has safely and dramatically reduced investigations and antibiotics for suspected EOS in the USA. This study evaluates the current management of suspected EOS against the NICE guideline CG149 and the SRC. METHODS This study is a prospective, multicentre, observational study across 13 neonatal units in London. Infants were born between June and August 2019 at ≥34 weeks gestation and commenced on antibiotics for suspected EOS and cared for on postnatal/transitional care wards. Data were prospectively recorded: risk factors, clinical indicators, investigations, and results. Outcome measures included the following: (1) incidence of EOS and (2) proportion of infants recommended for antibiotics by NICE versus theoretical application of SRC. RESULTS 1,066/8,856 (12%) infants on postnatal/transitional care wards received antibiotics, 7 of whom had a positive blood culture (group B Streptococcus = 6 and Escherichia coli = 1), making the EOS incidence 0.8/1,000 infants. Six hundred one infants had data for SRC analysis, which recommended "antibiotics" or "blood culture" for 130/601 (21.6%) infants using an EOS incidence of 0.5/1,000 versus 527/601 (87.7%) if NICE was applied. CONCLUSIONS Currently, 12.0% of infants on postnatal/transitional care wards receive antibiotics for suspected EOS. The SRC could dramatically reduce antibiotic use, but further prospective studies are required to evaluate safety of SRC implementation.
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Affiliation(s)
| | - Amit Verma
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Sophia Teoh
- Croydon University Hospital, Croydon, United Kingdom
| | - Aarti Verma
- Southend University Hospital NHS Foundation Trust, London, United Kingdom
| | - Chinthika Piyasena
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Cheryl Battersby
- Imperial College London, London, United Kingdom.,Chelsea and Westminster Hospital, London, United Kingdom
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Subhedar NV, Jawad S, Oughham K, Gale C, Battersby C. Increase in the use of inhaled nitric oxide in neonatal intensive care units in England: a retrospective population study. BMJ Paediatr Open 2021; 5:e000897. [PMID: 33705500 PMCID: PMC7903123 DOI: 10.1136/bmjpo-2020-000897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To describe temporal changes in inhaled nitric oxide (iNO) use in English neonatal units between 2010 and 2015. DESIGN Retrospective analysis using data extracted from the National Neonatal Research Database. SETTING All National Health Service neonatal units in England. PATIENTS Infants of all gestational ages born 2010-2015 admitted to a neonatal unit and received intensive care. MAIN OUTCOME MEASURES Proportion of infants who received iNO; age at initiation and duration of iNO use. RESULTS 4.9% (6346/129 883) of infants received iNO; 31% (1959/6346) were born <29 weeks, 18% (1152/6346) 29-33 weeks and 51% (3235/6346)>34 weeks of gestation. Between epoch 1 (2010-2011) and epoch 3 (2014-2015), there was (1) an increase in the proportion of infants receiving iNO: <29 weeks (4.9% vs 15.9%); 29-33 weeks (1.1% vs 4.8%); >34 weeks (4.5% vs 5.0%), (2) increase in postnatal age at iNO initiation: <29 weeks 10 days vs 18 days; 29-33 weeks 2 days vs 10 days, (iii) reduction in iNO duration: <29 weeks (3 days vs 2 days); 29-33 weeks (2 days vs 1 day). CONCLUSIONS Between 2010 and 2015, there was an increase in the use of iNO among infants admitted to English neonatal units. This was most notable among the most premature infants with an almost fourfold increase. Given the cost of iNO therapy, limited evidence of efficacy in preterm infants and potential for harm, we suggest that exposure to iNO should be limited, ideally to infants included in research studies (either observational or randomised placebo-controlled trial) or within a protocolised pathway. Development of consensus guidelines may also help standardise practice.
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Affiliation(s)
- Nimish V Subhedar
- Neonatal Intensive care Unit, Liverpool Women's Hospital, Liverpool, UK
| | - Sena Jawad
- Neonatal Data Analysis Unit, Imperial College London, London, UK
| | - Kayleigh Oughham
- Neonatal Data Analysis Unit, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, Imperial College London Faculty of Medicine, London, UK
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Yeo KT, Oei JL, De Luca D, Schmölzer GM, Guaran R, Palasanthiran P, Kumar K, Buonocore G, Cheong J, Owen LS, Kusuda S, James J, Lim G, Sharma A, Uthaya S, Gale C, Whittaker E, Battersby C, Modi N, Norman M, Naver L, Giannoni E, Diambomba Y, Shah PS, Gagliardi L, Harrison M, Pillay S, Alburaey A, Yuan Y, Zhang H. Review of guidelines and recommendations from 17 countries highlights the challenges that clinicians face caring for neonates born to mothers with COVID-19. Acta Paediatr 2020; 109:2192-2207. [PMID: 32716579 DOI: 10.1111/apa.15495] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/14/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
AIM This review examined how applicable national and regional clinical practice guidelines and recommendations for managing neonates born to mothers with COVID-19 mothers were to the evolving pandemic. METHODS A systematic search and review identified 20 guidelines and recommendations that had been published by May 25, 2020. We analysed documents from 17 countries: Australia, Brazil, Canada, China, France, India, Italy, Japan, Saudi Arabia, Singapore, South Africa, South Korea, Spain, Sweden, Switzerland, the UK and the United States. RESULTS The documents were based on expert consensus with limited evidence and were of variable, low methodological rigour. Most did not provide recommendations for delivery methods or managing symptomatic infants. None provided recommendations for post-discharge assimilation of potentially infected infants into the community. The majority encouraged keeping mothers and infants together, subject to infection control measures, but one-third recommended separation. Although breastfeeding or using breastmilk was widely encouraged, two countries specifically prohibited this. CONCLUSION The guidelines and recommendations for managing infants affected by COVID-19 were of low, variable quality and may be unsustainable. It is important that transmission risks are not increased when new information is incorporated into clinical recommendations. Practice guidelines should emphasise the extent of uncertainty and clearly define gaps in the evidence.
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Affiliation(s)
- Kee Thai Yeo
- KK Women’s & Children’s Hospital Singapore Singapore
- Duke‐NUS Medical School Singapore Singapore
| | - Ju Lee Oei
- School of Women's and Children's Health University of New South Wales Australia
- Royal Hospital for Women Randwick NSW Australia
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care “A. Béclère” Medical Center Paris Saclay University HospitalsAPHP Paris France
- Physiopathology and Therapeutic Innovation Unit‐INSERM U999 South Paris‐Saclay Paris France
| | | | | | | | | | | | - Jeanie Cheong
- Clinical Sciences Murdoch Children’s Research Institute Parkville VIC Australia
- Department of Obstetrics and Gynaecology University of Melbourne Parkville VIC Australia
- Royal Women’s Hospital Melbourne VIC Australia
| | - Louise S. Owen
- Clinical Sciences Murdoch Children’s Research Institute Parkville VIC Australia
- Department of Obstetrics and Gynaecology University of Melbourne Parkville VIC Australia
- Royal Women’s Hospital Melbourne VIC Australia
| | | | | | - Gina Lim
- Ulsan University Hospital Ulsan South Korea
| | | | - Sabita Uthaya
- Imperial College London and Chelsea and Westminster NHS Foundation Trust London UK
- Imperial College Healthcare NHS Trust London UK
| | - Christopher Gale
- Imperial College London and Chelsea and Westminster NHS Foundation Trust London UK
- Imperial College Healthcare NHS Trust London UK
| | - Elizabeth Whittaker
- Imperial College Healthcare NHS Trust London UK
- Imperial College London London UK
| | - Cheryl Battersby
- Imperial College London and Chelsea and Westminster NHS Foundation Trust London UK
- Imperial College Healthcare NHS Trust London UK
| | - Neena Modi
- Imperial College London and Chelsea and Westminster NHS Foundation Trust London UK
- Imperial College Healthcare NHS Trust London UK
| | - Mikael Norman
- Karolinska University Hospital and Karolinska Institutet Stockholm Sweden
| | - Lars Naver
- Karolinska University Hospital and Karolinska Institutet Stockholm Sweden
| | - Eric Giannoni
- Department Mother‐Woman‐Child Clinic of Neonatology Lausanne University Hospital and University of Lausanne Lausanne Switzerland
| | | | | | - Luigi Gagliardi
- Ospedale VersiliaLido di CamaioreAUSL Toscana Nord Ovest Pisa Italy
| | | | | | | | - Yuan Yuan
- Guangzhou Women and Children's Medical Center Guangzhou China
| | - Huayan Zhang
- Children’s Hospital of Philadelphia Philadelphia PA USA
- Guangzhou Women and Children's Medical Center Guangzhou China
- University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
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Johnson SM, Vasu V, Marseille C, Hill C, Janvier L, Toussaint P, Battersby C. Validation of transcutaneous bilirubinometry during phototherapy for detection and monitoring of neonatal jaundice in a low-income setting. Paediatr Int Child Health 2020; 40:25-29. [PMID: 30973082 DOI: 10.1080/20469047.2019.1598126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Severe neonatal jaundice (SNJ) and the associated long-term health sequelae are a significant problem in low-income countries (LIC) where measurement of total serum bilirubin (TSB) is often unavailable. Transcutaneous bilirubinometry (TcB) provides the opportunity for non-invasive, point-of-care monitoring. Few studies have evaluated its agreement with TSB levels during phototherapy in LIC.Aim: To determine agreement between TcB and TSB during phototherapy in a Haitian newborn population and to establish whether TcB can be safely used to guide treatment during phototherapy when TSB is unavailable.Methods: A single-centre prospective study (February to May 2017) in Cap Haïtien, northern Haiti was undertaken. Newborns <7 days of age with clinically detected jaundice were eligible for inclusion. A TcB device (JM-103) was used to screen for newborn jaundice along with a parallel TSB. A strip of black tape was placed across the sternum during phototherapy and uncovered for subsequent TcB measurements. Decisions about phototherapy treatment were based upon UK National Institute of Clinical Excellence (NICE) threshold criteria. Paired TSB and TcB measurements were compared using Bland-Altman methods.Results: The final analysis included 70 parallel TSB/TcB measurements from 35 infants within the first 5 days of life. Nineteen (54.3%) were male and 12 (34.3%) were <35 weeks. Thirty-two (91.4%) were receiving phototherapy. There was good agreement between TSB and TcB. Compared with TSB, TcB tended to over-estimate bilirubin (mean difference 11.1 µmol/L, 95% CI -10.2-32.5 µmol/L). However, at higher bilirubin levels (>250 µmol/L), TcB tended to under-estimate bilirubin compared with TSB and the difference increased.Conclusion: In an LIC setting in which serum bilirubin testing is not commonly available, TcB demonstrates good agreement with TSB and can be safely used to guide jaundice treatment during phototherapy but can lead to over-treatment at lower bilirubin levels and are more inaccurate at higher levels. For TcB levels >250 µmol, confirmation with serum bilirubin should be performed, if available, to avoid under-estimation.Abbreviations: LIC: low income countries; LMIC: low and middle income countries; TcB: transcutaneous bilirubinometry; TSB: transcutaneous serum biliubin.
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Affiliation(s)
- S M Johnson
- Department of Paediatrics, Queen Elizabeth Hospital, Woolwich, UK
| | - V Vasu
- Neonatal Unit, East Kent Hospitals University NHS Foundation Trust, Ashford, UK
| | - C Marseille
- Neonatal Unit, Hospital Convention Baptiste d'Haiti, Cap Haïtien, Haiti
| | - C Hill
- Neonatal Unit, Hospital Convention Baptiste d'Haiti, Cap Haïtien, Haiti
| | - L Janvier
- Neonatal Unit, Hospital Convention Baptiste d'Haiti, Cap Haïtien, Haiti
| | - P Toussaint
- Neonatal Unit, Hospital Convention Baptiste d'Haiti, Cap Haïtien, Haiti
| | - C Battersby
- Section of Neonatal Medicine, Imperial College London, London, UK
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Modi N, Ashby D, Battersby C, Brocklehurst P, Chivers Z, Costeloe K, Draper ES, Foster V, Kemp J, Majeed A, Murray J, Petrou S, Rogers K, Santhakumaran S, Saxena S, Statnikov Y, Wong H, Young A. Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme. Programme Grants Appl Res 2019. [DOI: 10.3310/pgfar07060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background
Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.
Objectives
(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.
Design
Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.
Setting
NHS neonatal units.
Participants
Neonatal clinical teams; parents of babies admitted to NHS neonatal units.
Interventions
In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.
Data sources
Data were extracted from the EPR of admissions to NHS neonatal units.
Main outcome measures
We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).
Results
We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.
Limitations
We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.
Conclusions
We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.
Future work
We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.
Study registration
This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).
Funding
The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).
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Affiliation(s)
- Neena Modi
- Department of Medicine, Imperial College London, London, UK
| | - Deborah Ashby
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Kate Costeloe
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | | | - Victoria Foster
- Department of Social Sciences, Edge Hill University, Ormskirk, UK
| | - Jacquie Kemp
- National Programme of Care, NHS England, London, UK
| | - Azeem Majeed
- School of Public Health, Imperial College London, London, UK
| | | | - Stavros Petrou
- Division of Health Sciences, University of Warwick, Coventry, UK
| | - Katherine Rogers
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
| | | | - Hilary Wong
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Alys Young
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
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Ojha S, Dorling J, Battersby C, Longford N, Gale C. Optimising nutrition during therapeutic hypothermia. Arch Dis Child Fetal Neonatal Ed 2019; 104:F230-F231. [PMID: 30322974 PMCID: PMC6764248 DOI: 10.1136/archdischild-2018-315393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/16/2018] [Accepted: 09/20/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Shalini Ojha
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Faculty of Medicine, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Cheryl Battersby
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK
| | - Nicholas Longford
- Neonatal Data Analysis Unit, Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK
| | - Chris Gale
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK
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47
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Walsh C, Battersby C, Suggett N, Slade D. Lessons from cadaveric dissection in AWR. Hernia 2019; 23:175-176. [DOI: 10.1007/s10029-018-1793-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 06/09/2018] [Indexed: 10/28/2022]
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Battersby C, Longford N, Patel M, Selby E, Ojha S, Dorling J, Gale C. Study protocol: optimising newborn nutrition during and after neonatal therapeutic hypothermia in the United Kingdom: observational study of routinely collected data using propensity matching. BMJ Open 2018; 8:e026739. [PMID: 30355795 PMCID: PMC6224768 DOI: 10.1136/bmjopen-2018-026739] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Therapeutic hypothermia is standard of care for infants born ≥36 weeks gestation with hypoxic ischaemic encephalopathy (HIE); consensus on optimum nutrition during therapeutic hypothermia is lacking. This results in variation in enteral feeding and parenteral nutrition (PN) for these infants. In this study, we aim to determine the optimum enteral nutrition and PN strategy for newborns with HIE during therapeutic hypothermia. METHODS AND ANALYSIS We will undertake a retrospective cohort study using routinely recorded electronic patient data held on the United Kingdom (UK) National Neonatal Research Database (NNRD). We will extract data from infants born ≥36 weeks gestational age between 1 January 2008 and 31 December 2016, who received therapeutic hypothermia for at least 72 hours or died during therapeutic hypothermia, in neonatal units in England, Wales and Scotland. We will form matched groups in order to perform two comparisons examining: (1) the risk of NEC between infants enterally fed and infants not enterally fed, during therapeutic hypothermia; (2) the risk of late-onset blood stream infections between infants who received intravenous dextrose without any PN and infants who received PN, during therapeutic hypothermia. The following secondary outcomes will also be examined: survival, length of stay, breast feeding at discharge, hypoglycaemia, time to full enteral feeds and growth. Comparison groups will be matched on demographic, maternal, infant and organisational factors using propensity score matching. ETHICS AND DISSEMINATION In this study, we will use deidentifed data held in the NNRD, an established national population database; parents can opt out of their baby's data being held in the NNRD. This study holds study-specific Research Ethics Committee approval (East Midlands Leicester Central, 17/EM/0307). These results will help inform optimum nutritional management in infants with HIE receiving therapeutic hypothermia; results will be disseminated through conferences, scientific publications and parent-centred information produced in partnership with parents. TRIAL REGISTRATION NUMBER NCT03278847; pre-results, ISRCTN47404296; pre-results.
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Affiliation(s)
- Cheryl Battersby
- Neonatal Data Analysis Unit, Department of Medicine, Section of Neonatal Medicine, Imperial College London, London, UK
| | - Nick Longford
- Neonatal Data Analysis Unit, Department of Medicine, Section of Neonatal Medicine, Imperial College London, London, UK
| | - Mehali Patel
- Bliss: for babies born premature or sick, London, UK
| | - Ella Selby
- Bliss: for babies born premature or sick, London, UK
| | - Shalini Ojha
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Faculty of Medicine, Dalhousie University, IWK Health Centre, Nova Scotia, Canada
| | - Chris Gale
- Neonatal Data Analysis Unit, Department of Medicine, Section of Neonatal Medicine, Imperial College London, London, UK
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Battersby C, Statnikov Y, Santhakumaran S, Gray D, Modi N, Costeloe K. The United Kingdom National Neonatal Research Database: A validation study. PLoS One 2018; 13:e0201815. [PMID: 30114277 PMCID: PMC6095506 DOI: 10.1371/journal.pone.0201815] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 07/22/2018] [Indexed: 11/18/2022] Open
Abstract
Background The National Neonatal Research Database (NNRD) is a rich repository of pre-defined clinical data extracted at regular intervals from point-of-care, clinician-entered electronic patient records on all admissions to National Health Service neonatal units in England, Wales, and Scotland. We describe population coverage for England and assess data completeness and accuracy. Methods We determined population coverage of the NNRD in 2008–2014 through comparison with data on live births in England from the Office for National Statistics. We determined the completeness of seven data items on the NNRD. We assessed the accuracy of 44 data items (16 patient characteristics, 17 processes, 11 clinical outcomes) for infants enrolled in the multi-centre randomised controlled trial, Probiotics in Preterm Study (PiPs). We compared NNRD to PiPs data, the gold standard, and calculated discordancy rates using predefined criteria, and sensitivity, specificity and positive predictive values (PPV) of binary outcomes. Results The NNRD holds complete population data for England for infants born alive from 25+0 to 31+6 (completed weeks) of gestation; and 70% and 90% for those born at 23 and 24 weeks respectively. Completeness of patient characteristics was over 90%. Data were linked for 2257 episodes of care received by 1258 of the 1310 babies recruited to PiPs. Discordancy rates were <5% for 13/16 patient characteristics (exceptions: mode of delivery 8.7%; maternal ethnicity 10.2%, Lower layer Super Output Area 16.5%); <5% for 9/16 processes (exceptions: medical treatment for Patent ductus arteriosus 6.1%, high-dependency days 10.2%, central line days 11.2%, type of first milk 22.3%; and during first 14 days, summary of types of milk 13.8%; number of days of antibiotics 9.0%; whether antacid given 5.1%); and <5% for 10/11 clinical outcomes (exception: Bronchopulmonary dysplasia, defined as oxygen dependency at 36 weeks postmenstrual age 3.3%). The specificity of NNRD data was >85% for all outcomes; sensitivity ranged from 50–100%; PPV ranged from 58.8 (95% CI 40.8–75.4%) for porencephalic cyst to 99.7 (95% CI 99.2, 99.9%) for survival to discharge. Conclusions The completeness and quality of data held in the NNRD is high, providing assurance in relation to use for multiple purposes, including national audit, health service evaluations, quality improvement, and research.
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Affiliation(s)
- Cheryl Battersby
- Neonatal Data Analysis Unit, Imperial College London, London, United Kingdom
- * E-mail:
| | | | | | - Daniel Gray
- Neonatal Data Analysis Unit, Imperial College London, London, United Kingdom
| | - Neena Modi
- Neonatal Data Analysis Unit, Imperial College London, London, United Kingdom
| | - Kate Costeloe
- Barts and the London School of Medicine and Dentistry, London, United Kingdom
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50
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Santhakumaran S, Statnikov Y, Gray D, Battersby C, Ashby D, Modi N. Survival of very preterm infants admitted to neonatal care in England 2008-2014: time trends and regional variation. Arch Dis Child Fetal Neonatal Ed 2018; 103:F208-F215. [PMID: 28883097 PMCID: PMC5916099 DOI: 10.1136/archdischild-2017-312748] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/07/2017] [Accepted: 06/12/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To analyse survival trends and regional variation for very preterm infants admitted to neonatal care. SETTING All neonatal units in England. PATIENTS Infants born at 22+0-31+6 weeks+daysgestational age (GA) over 2008-2014 and admitted to neonatal care; published data for admitted infants 22+0-25+6 weeks+days GA in 1995 and 2006, and for live births at 22+0-31+6 weeks+days GA in 2013. METHODS We obtained data from the National Neonatal Research Database. We used logistic regression to model survival probability with birth weight, GA, sex, antenatal steroid exposure and multiple birth included in the risk adjustment model and calculated annualpercentage change (APC) for trends using joinpoint regression. We evaluated survival over a 20-year period for infants <26 weeks' GA using additional published data from the EPICure studies. RESULTS We identified 50 112 eligible infants. There was an increase in survival over 2008-2014 (2008: 88.0%; 2014: 91.3%; adjusted APC 0.46% (95% CI 0.30 to 0.62) p<0.001). The greatest improvement was at 22+0-23+6 weeks (APC 6.03% (95% CI 2.47 to 3.53) p=0.002). Improvement largely occurred in London and South of England (APC: London 1.26% (95% CI 0.60 to 1.96); South of England 1.09% (95% CI 0.36 to 1.82); Midlands and East of England 0.15% (95% CI -0.56 to 0.86); and North of England 0.26% (95% CI -0.54 to 1.07)). Survival at the earliest gestations improved at a similar rate over 1995-2014 (22+0-25+6 weeks, APC 2.73% (95% CI 2.35 to 3.12), p value for change=0.25). CONCLUSIONS Continued national improvement in the survival of very preterm admissions masks important regional variation. Timely assessment of preterm survival is feasible using electronic records.
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Affiliation(s)
- Shalini Santhakumaran
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK,Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Yevgeniy Statnikov
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK,Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Daniel Gray
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK,Royal College of Paediatrics and Child Health, National Neonatal Audit Programme, London, UK
| | - Cheryl Battersby
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK,Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Deborah Ashby
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Neena Modi
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK,Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
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