Search

Background: The antibiotic use rate (AUR) has emerged as a potential metric for neonatal antibiotic use, but reported center-level AURs are limited by differences in case mix. The objective of this study was to identify patient characteristics associated with AUR among a large cohort of preterm infants., Methods: Retrospective observational study using the Optum Neonatal Database, including infants born from January 1, 2010 through November 30, 2016 with gestational age 23-34 weeks admitted to neonatal units across the United States. Exposures were patient-level characteristics including length of stay, gestational age, sex, race/ethnicity, bacterial sepsis, necrotizing enterocolitis, and survival status. The primary outcome was AUR, defined as days with ≥ 1 systemic antibiotic administered divided by length of stay. Descriptive statistics, univariable comparative analyses, and generalized linear models were utilized., Results: Of 17 910 eligible infants, 17 836 infants (99.6%) from 1090 centers were included. Median gestation was 32.9 (interquartile range [IQR], 30.3-34) weeks. Median length of stay was 25 (IQR, 15-46) days and varied by gestation. Overall median AUR was 0.13 (IQR, 0-0.26) and decreased over time. Gestational age, sex, and race/ethnicity were independently associated with AUR (P < .01). AUR and gestational age had an unexpected inverse parabolic relationship, which persisted when only surviving infants without bacterial sepsis or necrotizing enterocolitis were analyzed., Conclusions: Neonatal AURs are influenced by patient-level characteristics besides infection and survival status, including gestational age, sex, and race/ethnicity. Neonatal antibiotic use metrics that account for patient-level characteristics as well as morbidity case mix may allow for more accurate comparisons and better inform neonatal antibiotic stewardship efforts., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Compare rates of hypoxaemia during transpyloric and gastric feedings in very preterm infants with severe bronchopulmonary dysplasia., Design: N-of-1 multiple crossover trials with individual patient and pooled data analyses., Setting: Level IV intensive care nursery., Patients: Infants receiving positive airway pressure between 36 and 55 weeks postmenstrual age were enrolled between December 2014-July 2016., Intervention: N-of-1 trial consisting of two blocks, each with a 4-day gastric and 4-day transpyloric feeding period assigned in random order., Main Outcome Measures: The primary outcome was the frequency of daily intermittent hypoxaemic events (SpO 2 ≤80% lasting 10-180 s). Secondary outcomes included the daily proportion of time with an SpO 2 ≤80% and mean daily fraction of inspired oxygen., Results: Of 15 infants, 13 completed the trial and 2 stopped early for transient worsening in respiratory status during gastric feedings. In the intention-to-treat analyses, transpyloric feedings resulted in increased rates of intermittent hypoxaemia in five infants, greater time per day in hypoxaemia in three infants and more supplemental oxygen use in three infants. One infant received more supplemental oxygen during gastric feedings. The remaining study outcomes were similar between the feeding routes in all other infants. Pooling all data, transpyloric feedings resulted in a higher frequency of intermittent hypoxaemic events (median 7.5/day (IQR 1-23.5) vs 3/day (1-11); adjusted incidence rate ratio 1.8, 95% CI 1.3 to 2.5) and a greater proportion of daily hypoxaemia time (median 0.8% (IQR 0.1-2.3) vs 0.4% (0.07-1.8); adjusted mean difference 1.6, 95% CI 1.1 to 2.5)., Conclusions: Transpyloric compared with gastric feedings modestly increased rates of hypoxaemia among study participants., Trial Registration Number: NCT02142621., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Current diagnostic criteria for bronchopulmonary dysplasia rely heavily on the level and duration of oxygen therapy, do not reflect contemporary neonatal care, and do not adequately predict childhood morbidity. Objectives: To determine which of 18 prespecified, revised definitions of bronchopulmonary dysplasia that variably define disease severity according to the level of respiratory support and supplemental oxygen administered at 36 weeks' postmenstrual age best predicts death or serious respiratory morbidity through 18-26 months' corrected age. Methods: We assessed infants born at less than 32 weeks of gestation between 2011 and 2015 at 18 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Measurements and Main Results: Of 2,677 infants, 683 (26%) died or developed serious respiratory morbidity. The diagnostic criteria that best predicted this outcome defined bronchopulmonary dysplasia according to treatment with the following support at 36 weeks' postmenstrual age, regardless of prior or current oxygen therapy: no bronchopulmonary dysplasia, no support ( n  = 773); grade 1, nasal cannula ≤2 L/min ( n  = 1,038); grade 2, nasal cannula >2 L/min or noninvasive positive airway pressure ( n  = 617); and grade 3, invasive mechanical ventilation ( n  = 249). These criteria correctly predicted death or serious respiratory morbidity in 81% of study infants. Rates of this outcome increased stepwise from 10% among infants without bronchopulmonary dysplasia to 77% among those with grade 3 disease. A similar gradient (33-79%) was observed for death or neurodevelopmental impairment. Conclusions: The definition of bronchopulmonary dysplasia that best predicted early childhood morbidity categorized disease severity according to the mode of respiratory support administered at 36 weeks' postmenstrual age, regardless of supplemental oxygen use.

Objective: To determine differences in severe intraventricular hemorrhage (IVH) between very-low-birth-weight (≤1500 g, VLBW) infants born to mothers with and without hypertensive disorders (HD)., Design/methods: Retrospective analysis from the Optum Neonatal Database. The primary outcome of interest was severe IVH (grade 3 or 4). Secondary outcomes included other neonatal morbidities, mortality, and length of hospitalization. Outcomes were compared between VLBW infants born to mothers with and without HD., Results: A total of 5456 infants met inclusion criteria. After multivariable regression analysis, risks of severe IVH and bronchopulmonary dysplasia (BPD) were lower ([OR 0.42, 95% CI 0.33-0.89, p = 0.01] and [OR 0.75, 95% CI 0.58-0.97, p = 0.03], respectively) and median length of hospitalization was decreased in the HD group (49 versus 61 days, p < 0.001)., Conclusions: VLBW infants born to mothers with HD have a decreased risk of severe IVH, BPD, and a shorter duration of hospitalization.

Objective: To characterise the excess risk for death, grade 3-4 intraventricular haemorrhage (IVH), bronchopulmonary dysplasia (BPD) and stage 3-5 retinopathy of prematurity independently associated with birth small for gestational age (SGA) among very preterm infants, stratified by completed weeks of gestation., Methods: Retrospective cohort study using the Optum Neonatal Database. Study infants were born <32 weeks gestation without severe congenital anomalies. SGA was defined as a birth weight <10th percentile. The excess outcome risk independently associated with SGA birth among SGA babies was assessed using adjusted risk differences (aRDs)., Results: Of 6708 infants sampled from 717 US hospitals, 743 (11.1%) were SGA. SGA compared with non-SGA infants experienced higher unadjusted rates of each study outcome except grade 3-4 IVH among survivors. The excess risk independently associated with SGA birth varied by outcome and gestational age. The highest aRD for death (0.27; 95% CI 0.13 to 0.40) occurred among infants born at 24 weeks gestation and declined as gestational age increased. In contrast, the peak aRDs for BPD among survivors (0.32; 95% CI 0.20 to 0.44) and the composites of death or BPD (0.35; 95% CI 0.24 to 0.46) and death or major morbidity (0.35; 95% CI 0.24 to 0.45) occurred at 27 weeks gestation. The risk-adjusted probability of dying or developing one or more of the evaluated morbidities among SGA infants was similar to that of non-SGA infants born approximately 2-3 weeks less mature., Conclusion: The excess risk for neonatal morbidity and mortality associated with being born SGA varies by adverse outcome and gestational age., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

We compared survival and outcomes in process of care in female versus male infants born ≤32 weeks gestational age (GA). Data were obtained from the Alere database for infants born ≤32 weeks GA. Females were compared with males for demographics, complications, and care processes. Univariate and multivariate analysis was conducted using chi-square analysis, analysis of variance, or logistic regression. Of the infants included, 6086 female and 6721 males were included. Mean GA did not differ, males were born larger than females, and females were more likely to be born SGA. Males received more surfactant, developed more CLD, received more steroids, and more often required oxygen at discharge. Females were more likely to develop a patent ductus arteriosus. After controlling for body weight, GA, and small-for-GA status, females were more likely to survive (95.4% versus 93.6%, odds ratio 1.63, P < 0.01). Male sex did not play a role in other processes of care except for weaning to a crib. Male infants born ≤32 weeks GA have a decreased rate of survival and an increased rate of respiratory morbidity in spite of higher birth weight distributions. Sex did not play a role in other processes of care., (© Thieme Medical Publishers.)

We examined if very low-birth-weight (VLBW) infants of multiple gestation pregnancies experience more complications and take longer to achieve clinical milestones compared with similar singletons. We performed a retrospective analysis of all infants less than 1500 g at birth in a large neonatal database. Singletons were compared with twins and higher-order multiples for demographic, morbidities, and process milestones including feeding, respiratory, thermoregulation, and length of stay. Multivariable regression analyses were performed to control for potential confounding variables. A total of 5507 infants were included: 3792 singletons, 1391 twins, and 324 higher-order multiples. There were no differences in Apgar scores, small for gestational age status, and incidence of necrotizing enterocolitis, severe retinopathy of prematurity, severe intraventricular hemorrhage, sepsis, bronchopulmonary dysplasia, or the need for surgery. Multiples had higher rates of apnea and patent ductus arteriosus than singletons. VLBW multiples achieved milestones at similar rates in most areas compared with singletons except for the achievement of full oral feedings. Length of stay, after controlling for confounding variables, did not differ between the groups. Compared with singletons, VLBW multiples had similar morbidity and achieved most feeding and thermoregulation milestones at similar rates., (Thieme Medical Publishers.)