Abstract
(BMJ. 2019;367:1–11) The occurrence of infants born <28 weeks gestation is rare in both the United Kingdom and the United States, but such incidents carry a very high risk of death, neonatal morbidity, and long-term disability. Previous research has indicated that the best outcomes for these infants are achieved when care is given in specialized tertiary hospitals. At-risk pregnant women who present at nontertiary hospitals are often transferred to more specialized facilities either before or after delivery; a number of recent studies have focused on the outcomes of infants who were transferred postnatally, with inconclusive results. These investigators conducted their research to determine if transferred infants had a higher incidence of mortality and severe brain injury compared with nontransferred infants born in tertiary hospitals.
Highlights
About one in 20 preterm infants in high income countries are born at less than 28 weeks’ gestation (5.7% in the United Kingdom and 7% in the United States)[1 2]; these extremely preterm infants are at high risk of death and neonatal morbidity, such as periventricular and intraventricular haemorrhage[3 4] and long term disability.[5 6]
Postnatal transfer of extremely preterm infants between hospitals increased in England after the introduction of a networked model of neonatal care In the context of modern care and specialised transfer teams, the association between early postnatal transfers and neonatal outcomes is not known
Birth in a non-tertiary hospital is associated with an increased risk of death, and transfer in the first 48 hours is associated with an increased risk of severe brain injury, compared with infants born in hospitals with tertiary neonatal care who are not transferred in the first 48 hours Perinatal services should promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer odds of death before discharge but significantly higher odds of severe brain injury (2.32, 1.78 to 3.06; number needed to treat (NNT) 8) and significantly lower odds of survival without severe brain injury (0.60, 0.47 to 0.76; NNT 9)
Summary
About one in 20 preterm infants in high income countries are born at less than 28 weeks’ gestation (5.7% in the United Kingdom and 7% in the United States)[1 2]; these extremely preterm infants are at high risk of death and neonatal morbidity, such as periventricular and intraventricular haemorrhage[3 4] and long term disability.[5 6]. Historical studies show that preterm infants who underwent postnatal transfer had higher rates of adverse outcomes than infants born in tertiary hospitals,[20-22] recent studies have shown equivocal results on the association between early postnatal transfer and outcomes.[23-27]. It is unclear whether the association between postnatal transfer and adverse outcomes persists in the context of modern neonatal care and dedicated neonatal transfer services. Harms associated with postnatal transfer might relate to suboptimal stabilisation at a non-tertiary hospital, the transfer of sicker infants, or the transfer itself This is relevant to the organisation of perinatal health services because early postnatal transfers are increasingly common in the UK and other high income countries following the introduction of highly specialised neonatal transfer services.[15 28]
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