23-week Infant Research Articles

The Landscape of Resource Utilization After Resuscitation of 22-, 23-, and 24-Weeks’ Gestation Infants

ObjectiveTo compare estimated healthcare resources needed to care for 22 through 24 weeks’ gestation infants. Study designThis multicenter, retrospective cohort study included 1,505 live in-born and out-born infants 22 through 24 weeks’ gestational age at delivery from six pediatric tertiary care hospitals from 2011 through 2020. Median neonatal intensive care unit (NICU) length of stay (LOS) for each gestational age was used as a proxy for hospital resource utilization, and the number of comorbidities and medical technology use for each infant were used as estimates of future medical care needs. Data were analyzed using Kruskal-Wallis with Nemenyi’s post hoc test and Fisher’s exact test. ResultsOf the identified newborns, 22-week infants had shorter median LOS than their 23- and 24-week counterparts due to low survival rates. There was no significant difference in LOS for surviving 22-week infants compared with surviving 23-week infants. Surviving 22-week infants had similar proportions of comorbidities and medical technology use as 23-week infants. ConclusionsCompared with 23- and 24-week infants, 22-week infants did not use a disproportionate amount of hospital resources. 22-week infants should not be excluded from resuscitation based on concern for increased hospital care and medical technology requirements. As overall resuscitation efforts and survival rates increase for 22-week infants, future research will be needed to assess the evolution of these results.

Changes in perinatal management and outcomes in infants born at 23 weeks of gestational age during the last decade in Spain

Introduction The 2021-updated guidelines of the Spanish Society of Neonatology Guidelines have moved the zone of parental discretion to 23 + 0–23 + 6 weeks. The objective of this study was to describe the changes in perinatal management at this gestational age along the last decade and to determine if a more active perinatal management has contributed to improved outcomes. Methods Retrospective analysis of prospectively collected data from the 23-week infants included in the Spanish SEN 1500 neonatal network during the period 2010–2019. The main study outcomes were survival at discharge and survival without major morbidity of actively managed infants. Two periods were compared: 2010–2014 (Period 1) and 2015–2019 (Period 2). NICUs were classified into low activity NICUs (less than 50 admissions of very low birth weight infants per year) and high activity NICUs (50 or more admissions) Results A total of 381 infants were included, 182 in Period 1 and 199 in Period 2. In Period 2 an increase in the use of intrapartum magnesium sulfate (21.5% vs 39.9%, p .002), antenatal steroids (56.6% vs 69.3%, p .011) and active neonatal approach in delivery room (76.9% vs 86.9%, p .011) were observed. The clinical outcomes of the actively managed 313 infants were similar in both periods, except for less arterial hypotension in Period 2. Survival was 27.1% in Period 1 and 25% in Period 2 (p .068) and survival without major morbidity was 2.1% and 2.3% respectively (p .914). No difference was found between low and high activity NICUs. Conclusion A change to a more active intention to treat infants born at 23 weeks is taking place in Spain. But the survival rate of the actively-managed infants has remained stable around 25–30% during the study period. A multidisciplinary effort is needed to improve outcomes in this population.

Cost of neonatal intensive care for extremely preterm infants in Canada.

BackgroundNeonatal intensive care is expensive and prolonged. Extremely preterm infants are routinely supported. The costs for this practice at the age of borderline viability are of interest to clinicians and policymakers.MethodsWe analyzed data from the Canadian national administrative database on total cost and length of hospital care from a public payor perspective for 23–28-week premature infants from 2011 to 2015. We also compared total and daily costs for 23–25-week newborns. Each comparison evaluated the total cohort and infants who lived more than 3 days. We used non-parametric tests, correlation tests, and generalized linear models for cost difference analysis, adjusting for survival, length of stay, and year.ResultsWe analyzed 6,932 infants’ cost records. For all infants, median length of hospital stay was 41 days (IQR, 1–77 days). For infants who survived the first 3 days, median length of stay was 61 days (IQR, 34–90 days). The median total cost was $66,669 (IQR, $4,920–$125,550). For infants who survived the first 3 days, median total cost was $91,137 (IQR, $56,596–$188,757). For infants who survived the first 3 days, median total costs were $147,835 (IQR, $44,711–$233,847) for 23-week infants, $154,736 (IQR, $61,160–$248,290) for 24-week infants, and $130,317 (IQR, $79,737–$229,058) for 25-week infants. These amounts did not differ (P>0.7).ConclusionsTotal and daily costs of neonatal intensive care are high. Total cost was not different between surviving 23–25-week infants. These findings highlight the need for a funding strategy for the routine support of these fragile infants.

Selection Bias and Outcomes for Preterm Neonates.

Reported survival and neurodevelopmental outcomes at 23 weeks' gestation are based on the infants admitted to NICUs. In this study, we aim to describe the association between clinical characteristics and admission to NICU at 23, 24 and 25 weeks' gestation. Cohort data from 2 national databases enabled comparison of the clinical characteristics all Australian births and all NICU admissions during 2010-2013 at 23, 24, and 25 weeks' gestation. NICU admission occurred in 15% of all births at 23 weeks, in comparison with 49% at 24 weeks and 64% at 25 weeks. At 23 weeks, live-born infants were less likely to be admitted to NICU with birth weight <500 g compared with >500 g (13% vs 43%, P < .0001), and boys were admitted less compared with girls (33% vs 43%, P < .018). In contrast, birth weight (including birth weight <500 g) and sex had little or no impact on NICU admission at 24 and 25 weeks. Only 8% of live births were born by caesarean delivery at 23 weeks compared with 33% at 24 weeks and 48% at 25 weeks' gestation. In the Australian population, admission to the NICU is more likely to be influenced by birth weight and sex at 23 weeks' gestation when compared with 24 and 25 weeks' gestation. Survival outcomes at 23 weeks may be affected by less active perinatal care. Uncertainty exists regarding the generalizability of current data regarding survival and developmental potential of live-born 23-week infants.

Survival and Major Morbidity of Extremely Preterm Infants: A Population-Based Study.

To assess the rates of mortality and major morbidity among extremely preterm infants born in California and to examine the rates of neonatal interventions and timing of death at each gestational age. A retrospective cohort study of all California live births from 2007 through 2011 linked to vital statistics and hospital discharge records, whose best-estimated gestational age at birth was 22 through 28 weeks. Major morbidities were based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Survival beyond the first calendar day of life and procedure codes were used to assess attempted resuscitation after birth. A total of 6009 infants born at 22 through 28 weeks' gestation were included. Survival to 1 year for all live births ranged from 6% at 22 weeks to 94% at 28 weeks. Seventy-three percent of deaths occurred within the first week of life. Major morbidity was present in 80% of all infants, and multiple major morbidities were present in 66% of 22- and 23-week infants. Rates of resuscitation at 22, 23, and 24 weeks were 21%, 64%, and 93%, respectively. Survival after resuscitation was 31%, 42%, and 64% among 22-, 23-, and 24-week infants, respectively. Improved survival was associated with increased birth weight, female sex, and cesarean delivery (P < .01) for resuscitated 22-, 23-, and 24-week infants. In a population-based study of extreme prematurity, infants ≤24 weeks' gestation are at highest risk of death or major morbidity. These data can help inform recommendations and decision-making for extremely preterm births.

English

We present a novel technique for securing an endotracheal tube after using a #1 Classic laryngeal mask airway (LMA) as a conduit for intubating the trachea of a premature infant. During induction of anesthesia for inguinal hernia repair in an ex- 23-week infant, an unanticipated difficult airway was encountered. After several unsuccessful attempts of intubating via direct laryngoscopy, we placed the endotracheal tube (ETT) into the trachea using a fiberoptic bronchoscope through a #1 LMA. A pediatric stylette, with Hytape TM wrapped around the distal tip, was then used as a plunger to safely and easily remove the LMA from the mouth while maintaining the ETT in proper position. This technique is applicable in cases of a difficult neonatal airway where even a #1, the smallest LMA, is used.

“Early” versus “late” 23-week infant outcomes

To determine whether survival is different in "early" (23(0/7)-23(3/7) weeks) vs "late" (23(4/7)-23(6/7) weeks) infants. Records of 126 consecutive liveborn infants delivered at 23(0/7) to 23(6/7) weeks' gestation from 2001-2010 were examined using the Vermont Oxford Network database. Infants born at 23 0/7 to 23 3/7 weeks were grouped into "early" and those at 23 4/7 to 23 6/7 weeks were "late." Clinical characteristics were compared between groups and multivariate analyses were used to predict survival. Seventy-two infants were early and 54 were late. Survival was 25% vs 56%, respectively (P < .001). The early group was less likely to receive steroids (43% vs 65%; P = .016) and had a lower mean birthweight (547 g vs 596 g; P < .001). No difference in other factors was seen between groups. No change in survival was observed during the study period in either group. Late 23-week infants have improved survival compared with early infants. Delaying delivery as little as 24-96 hours may improve survival for 23-week infants.

Attitudes of neonatal clinicians towards resuscitation of the extremely premature infant: an exploratory survey.

This study aims to explore the current attitudes of Australian neonatologists and nurses towards the resuscitation of extremely preterm infants. An anonymous questionnaire regarding resuscitation of infants of less than 28 weeks gestation was sent to all neonatologists and three registered nurses in each perinatal centre in Australia. One hundred and thirty-three questionnaires were sent. A return rate of 93% and 73% was obtained from neonatologists and nurses, respectively. Twenty-two per cent of neonatologists would 'occasionally' resuscitate at 22 weeks while none of the nurses would. A considerable proportion of neonatologists (23%) but only a few nurses (6%) would 'quite often' resuscitate 23-week infants. The majority of neonatologists (85%) and nurses (88%) would 'almost always' resuscitate 24 week infants. More than half of the respondents would 'occasionally' resuscitate a 400-499 g infant and most would resuscitate infants weighing more than 500 g. Clinicians were not as optimistic of long-term outcome as they were for survival. Typically, only 52% of neonatologists and 38% of nurses thought babies of 25 weeks gestation had a greater than 50% chance of survival without major handicap. Parental wishes and the presence of congenital abnormalities were major influences on decision to resuscitate. Hypothetically, most respondents, more doctors than nurses, would consider initiating resuscitation without parental consent at a median gestation of 25 weeks. The majority of Australian clinicians would resuscitate at a gestation of 24 weeks or greater or at a birth weight of over 500 g despite conservative estimates of intact survival. This survey has brought to light the importance of communication with parents prior to extreme premature birth.

Perinatal outcomes of a large cohort of extremely low gestational age infants (twenty-three to twenty-eight completed weeks of gestation)

Objectives: To determine gestational age (GA)-specific mortality rates; the effects of GA, birth weight, sex, and multiple gestation on mortality rates; short-term morbidity for infants born at 23 to 28 weeks GA; and impairment rates at a corrected chronologic age of 18 months for those born at 23 to 25 weeks GA. Methods: A data base analysis was performed with a linked obstetric and a neonatal database. GA was determined by obstetric data and confirmed by early ultrasonography (available in 88%) on all births <30 weeks GA at British Columbia's tertiary perinatal center from 1983 to 1989. Results: Of 1024 births occurring between 23 and 28 weeks GA, 911 were live born. The mortality rate decreased with increasing GA: 84% at 23 weeks; 57% at 24 weeks; 45% at 25 weeks; 37% at 26 weeks; 23% at 27 weeks; and 13% at 28 weeks GA. For each GA, mortality rate versus birth weight plots showed a decreasing mortality rate with increasing birth weight, except for infants who were large for GA. Male infants had a higher mortality rate than female infants (odds ratio, 1.8; confidence interval, 1.4 to 2.5). Twins fared worse than singletons with a decreasing effect from 24 weeks GA (odds ratio, 10.3) to no effect at 28 weeks GA. The median number of days supported by mechanical ventilation and the length of stay in the neonatal intensive care unit decreased markedly with increasing GA. Eighteen-month outcome of survivors between 23 and 25 weeks GA with 93% follow-up rate revealed an overall impairment rate of 36%, but 6 of the 9 surviving 23-week infants had major impairments. Conclusions: The GA-specific perinatal outcome results of this large cohort provide information to assist in perinatal management decision making and for counseling parents prenatally. (J P EDIATR 1994;125:952-60)