Intensive care for extreme prematurity - Moving beyond gestational age

Center for Clinical Research and Evidence-Based Medicine, University of Texas Medical School at Houston, Houston, TX 77030, USA.
New England Journal of Medicine (Impact Factor: 54.42). 05/2008; 358(16):1672-81. DOI: 10.1056/NEJMoa073059
Source: PubMed

ABSTRACT Decisions regarding whether to administer intensive care to extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients.
We prospectively studied a cohort of 4446 infants born at 22 to 25 weeks' gestation (determined on the basis of the best obstetrical estimate) in the Neonatal Research Network of the National Institute of Child Health and Human Development to relate risk factors assessable at or before birth to the likelihood of survival, survival without profound neurodevelopmental impairment, and survival without neurodevelopmental impairment at a corrected age of 18 to 22 months.
Among study infants, 3702 (83%) received intensive care in the form of mechanical ventilation. Among the 4192 study infants (94%) for whom outcomes were determined at 18 to 22 months, 49% died, 61% died or had profound impairment, and 73% died or had impairment. In multivariable analyses of infants who received intensive care, exposure to antenatal corticosteroids, female sex, singleton birth, and higher birth weight (per each 100-g increment) were each associated with reductions in the risk of death and the risk of death or profound or any neurodevelopmental impairment; these reductions were similar to those associated with a 1-week increase in gestational age. At the same estimated likelihood of a favorable outcome, girls were less likely than boys to receive intensive care. The outcomes for infants who underwent ventilation were better predicted with the use of the above factors than with use of gestational age alone.
The likelihood of a favorable outcome with intensive care can be better estimated by consideration of four factors in addition to gestational age: sex, exposure or nonexposure to antenatal corticosteroids, whether single or multiple birth, and birth weight. ( numbers, NCT00063063 [] and NCT00009633 [].).


Available from: Charles E Green, Apr 27, 2015
  • Zeitschrift für Geburtshilfe und Neonatologie 02/2015; 219(1):12-9. DOI:10.1055/s-0034-1395575 · 0.46 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Vulnerable children are at-risk newborns including premature infants and some children with pathologies presented by fear anomalies and deficiencies, most particularly neurological. Monitoring is based on the detection of these abnormalities and their early management. The organization of this monitoring system is based on a network of doctors, mostly pediatricians, trained regularly. The objective of this review was to assess the resources, means, and results of 10 years of follow-up. The Pays de la Loire network includes 24 maternity wards and 13 neonatal departments. Annual admissions are around 5000 newborns to approximately 45,000 annual births. Upon discharge of newborns, born prematurely at 34 weeks of gestation (WG) or less, or term infants with neurological problems, parents are asked to have their child monitored by a referring doctor. During the consultation, a reference document is filled out by the doctor and sent to the project manager for data collection and specific compensation for private practitioners. Standardized questionnaires were used such as the ASQ (Ages and Stage Questionnaire) completed by parents, the developmental quotient (DQ) with the Lézine Brunet-Revised test (BLR), the intelligence quotient (IQ) with the Wechsler Preschool and Primary Scale of Intelligence (WIPPSI III) completed by psychologists employed in the network, and a questionnaire completed by the teacher at 5 years of age. The network started on 1st March 2003, and 28th February 2013, after 10 years of inclusion, 10,800 children had been included. This population accounts for 2.4% of all annual births: 1.1% were included for prematurity less than 33 weeks and 0.25% were term-born infants. The characteristics of children are presented with gestational age, birth weight, and obstetric and neonatal pathologies. The percentage of these children followed was 80% at 2 years and 63% at 5 years. At 2 years, the results are presented according to gestational age with approximately 60% of children without disabilities at 25-26 WG, 73% at 27-28 WG, 77% at 29-30 WG, and 86% at 31-32 WG. Absorptions are diverse and vary according to the age of the child with physical therapy, psychomotor skill work, speech therapy, hearing and vision consultations, and psychology/psychiatry. Assessment tools were refined by specific analyses: the ASQ 24 months (completed by parents) was deemed valid and predictive with respect to IQ (abandoned in 2012), and the grid completed by the teacher was found to predict abnormalities in 5 years. The Pays de la Loire monitoring network has met its initial objective, namely to detect disabilities early and provide practical help to parents in a population of vulnerable children. Benefits for professionals and other children not followed in the network were observed, with an increase in pediatricians' skills. The benefits of the evaluation results are more difficult to assess with the care than neonatal care in obstetrics. The sustainability of such a network seems assured for healthcare professionals, provided that funding is maintained by the health authorities. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To estimate costs of preterm birth in singleton and multiple pregnancies. Cost analysis based on data from a prospective cohort study and three multicentre randomised controlled trials (2006-2012) in a Dutch nationwide consortium for women's health research. Women with preterm birth before 37 completed weeks were included for analysis. Direct costs were estimated from a health care perspective, from delivery until discharge or decease of the neonates. Costs and adverse perinatal outcome per pregnancy were measured. Adverse perinatal outcome comprised both perinatal mortality and a composite of neonatal morbidity defined as chronic lung disease, intraventricular haemorrhage≥grade 2, periventricular leukomalacia≥grade 1, proven sepsis or necrotising enterocolitis. Using a moving average technique covering three weeks per measurement, costs and adverse perinatal outcome per woman delivering for every week between 24 and 37 weeks are reported. Data of 2802 women were available of whom 1503 (53.6%) had a preterm birth; 501 in 1090 singleton (46%) and 1002 in 1712 multiple pregnancies (58.5%). The most frequent perinatal outcomes were perinatal mortality, chronic lung disease and sepsis. For singleton pregnancies the peak of total costs was at 25 weeks (€88,052 per delivery), compared to 27 weeks for multiple pregnancies (€169,571 per delivery). The total costs declined rapidly with increasing duration of pregnancy. Major cost drivers were length of stay on the NICU and airway treatments. The peaks seen in costs paralleled with the prevalence of adverse perinatal outcome. These data can be used to elaborate on the impact of preterm birth in case only data are available on duration of pregnancy. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    European Journal of Obstetrics & Gynecology and Reproductive Biology 03/2015; 186:34-41. DOI:10.1016/j.ejogrb.2014.12.024 · 1.63 Impact Factor