Effective Perinatal Intensive Care In Europe Research Articles

Variations in neonatal mortality of preterm infants with intraparenchymal haemorrhage in Europe: the EPICE cohort

ObjectiveThe aim of this study was to investigate variations in mortality before neonatal intensive care unit (NICU) discharge of infants born preterm with intraparenchymal haemorrhage (IPH) in Europe with a...

Differences for managing mother’s own milk for very preterm infants across 11 European countries

Abstract Background There is an ongoing debate about the best practices to handle mother's own milk (MOM) for infants born very preterm (VPT, ≤32 weeks of gestation), specifically to prevent the human cytomegalovirus (HCMV) transmission and bacterial contamination of expressed MOM. Thus, we aimed to compare practices for managing MOM for VPT infants in European neonatal intensive care units (NICUs). Methods Data were collected as part of the EPICE (Effective Perinatal Intensive Care in Europe) study which explored the use of evidence-based practices for the care of VPT infants in 11 European countries. Structured questionnaires were sent to the head of all participating NICUs with at least 10 VPT admissions. Of the eligible 135 NICUs, 134 replied. Results A written protocol for breastfeeding/human milk use was available in 91% of the NICUs. Overall, 34% used human bank milk for all VPT infants whose mothers did not express and 56% reported using fresh MOM without restrictions regarding minimum gestational age, birth weight or risk of HCMV transmission (country range: 0-100%). In 22% of units all VPT infants received MOM pasteurized (country range: 0-73%). HCMV serology on all mothers who express their milk was not required in 71% of units (country range: 7-100%). Among NICUs that performed HCMV serology, 3% provided untreated fresh MOM and 23.5% formula in the case of positive mothers. Systematic bacteriological analyses of MOM were not performed in 76% NICUs (country range: 29-100%) while less than 10% did it for the first milk feeding, 7% every week and 8% with another frequency. Conclusions There are large variations in managing MOM across countries, which could reflect differences in regulations or guidelines, and among the same country NICUs, revealing that different options can operate locally. This variability suggests substantial differences in attitudes about what constitutes best practices among European neonatologists. Key messages We found significant differences across and within European countries for managing MOM for VPT infants suggesting lack of strong recommendations at the international and national level. There is wide variation in what European neonatologists consider best practices. To guide practice and not jeopardise VPT infants from MOM we need strong evidence-based data.

Cohort Profile: Effective Perinatal Intensive Care in Europe (EPICE) very preterm birth cohort.

The Effective Perinatal Intensive Care in Europe (EPICE) cohort includes all births between 22 + 0 and 31 + 6 weeks of gestation in 2011/12 in 19 regions in 11 European countries. This cohort was set up to investigate the use of evidence-based interventions for prenatal and postnatal care of infants born very preterm (VPT) and to explore the associations between evidence-based care and their health and developmental outcomes. The first phase, ‘Effective perinatal intensive care in Europe’ (EPICE) focused on obstetric and neonatal care before and around the time of birth and during the neonatal hospitalization period, with follow-up at 2 years of corrected age (CA), while a second phase, ‘Screening for Health in Infants born very Preterm’ (SHIPS), assessed follow-up care provided in the first 5 years of life and neurodevelopmental outcomes at 5 years of age.

Maternal education and language development at 2 years corrected age in children born very preterm: results from a European population-based cohort study

BackgroundSocioeconomic factors influence language development in the general population, but the association remains poorly documented in children born very preterm (VPT). We assessed the impact of maternal education on language...

Specialist health care services use in a European cohort of infants born very preterm.

Children born very preterm require additional specialist care because of the health and developmental risks associated with preterm birth, but information on their health service use is sparse. We sought to describe the use of specialist services by children born very preterm in Europe. We analysed data from the multi-regional, population-based Effective Perinatal Intensive Care in Europe (EPICE) cohort of births before 32 weeks' gestation in 11 European countries. Perinatal data were abstracted from medical records and parents completed a questionnaire at 2 years corrected age (4322 children; 2026 females, 2296 males; median gestational age 29wks, interquartile range [IQR] 27-31wks; median birthweight 1230g, IQR 970-1511g). We compared parent-reported use of specialist services by country, perinatal risk (based on gestational age, small for gestational age, and neonatal morbidities), maternal education, and birthplace. Seventy-six per cent of the children had consulted at least one specialist, ranging across countries from 53.7% to 100%. Ophthalmologists (53.4%) and physiotherapists (48.0%) were most frequently consulted, but individual specialists varied greatly by country. Perinatal risk was associated with specialist use, but the gradient differed across countries. Children with more educated mothers had higher proportions of specialist use in three countries. Large variations in the use of specialist services across Europe were not explained by perinatal risk and raise questions about the strengths and limits of existing models of care. Use of specialist services by children born very preterm varied across Europe. This variation was observed for types and number of specialists consulted. Perinatal risk was associated with specialist care, but did not explain country-level differences. In some countries, mothers' educational level affected use of specialist services.

Effect of breastfeeding on non-verbal cognitive development at 2-years of age in very preterm infants and the role of clinical and social risk: results from the EPICE cohort

Introduction There is a considerable controversy over the nature and the pathways involved in the relation between breastfeeding and cognitive development in very preterm infants. In a European cohort of very preterm infants we investigated the effect of breastfeeding on non-verbal cognitive development at 2 years of corrected age and variation by clinical and social risk. Methods Data were obtained from the EPICE (Effective Perinatal Intensive Care in Europe) population-based prospective cohort of infants born between 22 and 31 completed weeks of gestation, in 19 regions from 11 European countries, in 2011–2012. Of the 6792 infants discharged alive, 4425 children had a follow-up at 2 years of corrected age. For analysis, we included all infants with valid information on breastfeeding initiation, non-verbal cognitive development, and on clinical and social risk (n = 4032). Data on infant, obstetric and maternal characteristics and on neonatal morbidity were retrieved from medical records, using a structured form filled in by clinicians until discharge from the hospital. At 2 years of corrected age, data on child's health and development, breastfeeding and sociodemographic characteristics were collected using a structured questionnaire completed by parents. Non-verbal cognitive ability was measured applying the Parental Report of Children's Abilities (PARCA-R) except for France that used Ages and Stages Questionnaire (ASQ). We defined three risk groups based on perinatal factors: High-risk [born before 28 weeks of gestation or with a severe neonatal morbidity (severe congenital anomaly, bronchopulmonary dysplasia, intraventricular hemorrhage grade III or IV, cystic periventricular leukomalacia, retinopathy of prematurity, necrotizing enterocolitis)] (n = 1394, 34.6%); Medium-risk (birth 28–29 weeks of gestation or having growth restriction, but no morbidities) (n = 1485, 36.8%); Low-risk (birth at 30–31 weeks with no morbidities or growth restriction) (n = 1153, 28.6%). Social high-risk was defined as maternal age Results Overall, 15.8% (n = 638) of the children presented suboptimal non-verbal cognition. Never breastfed children were more likely to have suboptimal non-verbal cognition (Crude RR = 1.40, 95%CI: 1.20–1.64). Never-breastfeeding was associated with a significant increased risk in the clinical high-risk group (Crude RR = 1.52, 95%CI: 1.25–1.85), but not in the medium or low-risk groups (Crude RR = 1.05, 95%CI: 0.76–1.44, Crude RR = 1.22, 95%CI: 0.81–1.85, respectively). The stratified analysis by social risk found a significant effect in both low (Crude RR = 1.29, 95% CI: 1.08–1.54) and high-risk (Crude RR = 1.91, 95% CI: 1.29–2.83) groups. After adjustment for the region of birth, corrected age at completion of the questionnaire (months), migration status, clinical risk, and social risk, never-breastfeeding remained associated with an increased risk for suboptimal non-verbal cognition (RR = 1.27, 95% CI: 1.07–1.50). There was no interaction with clinical and social risk in adjusted models. Conclusions Breastfeeding promotes non-verbal cognitive development of very preterm children, independently of clinical and social risk. It provides evidence for specifically targeted interventions to protect, promote and support breastfeeding among these most vulnerable infants.

Variation in term birthweight across European countries affects the prevalence of small for gestational age among very preterm infants.

This study assessed the prevalence of small for gestational age (SGA) among very preterm (VPT) infants using national and European intrauterine references. We generated country-specific and common European intrauterine growth references for 11 European countries, according to Gardosi's approach and Hadlock's foetal growth model, using national data on birthweights by sex. These references were applied to the Effective Perinatal Intensive Care in Europe (EPICE) cohort, which comprised 7766 live VPT births without severe congenital anomalies under 32 weeks of gestation in 2011-2012, to estimate the prevalence of infants with SGA birthweights, namely those below the 10th percentile. The SGA prevalence was 31.8% with country-specific references and 34.0% with common European references. The European references yielded a 10-point difference in the SGA prevalence between countries with lower term birthweights (39.9%) - Portugal, Italy and France - and higher term birthweights, namely Denmark, the Netherlands, Sweden (28.9%; p < 0.001). This was not observed with country-specific references, where the respective figures were 32.4% and 33.9% (p = 0.34), respectively. One-third of VPT infants were SGA according to intrauterine references. Common European references showed significant differences in SGA prevalence between countries with high and low-term birthweights.

Association of Short Antenatal Corticosteroid Administration-to-Birth Intervals With Survival and Morbidity Among Very Preterm Infants

Administration-to-birth intervals of antenatal corticosteroids (ANS) vary. The significance of this variation is unclear. Specifically, to our knowledge, the shortest effective administration-to-birth interval is unknown. To explore the associations between ANS administration-to-birth interval and survival and morbidity among very preterm infants. The Effective Perinatal Intensive Care in Europe (EPICE) study, a population-based prospective cohort study, gathered data from 19 regions in 11 European countries in 2011 and 2012 on 4594 singleton infants with gestational ages between 24 and 31 weeks, without severe anomalies and unexposed to repeated courses of ANS. Data were analyzed November 2016. Time from first injection of ANS to delivery in hours and days. Three outcomes were studied: in-hospital mortality; a composite of mortality or severe neonatal morbidity, defined as an intraventricular hemorrhage grade of 3 or greater, cystic periventricular leukomalacia, surgical necrotizing enterocolitis, or stage 3 or greater retinopathy of prematurity; and severe neonatal brain injury, defined as an intraventricular hemorrhage grade of 3 or greater or cystic periventricular leukomalacia. Of the 4594 infants included in the cohort, 2496 infants (54.3%) were boys, and the mean (SD) gestational age was 28.5 (2.2) weeks and mean (SD) birth weight was 1213 (400) g. Mortality for the 662 infants (14.4%) unexposed to ANS was 20.6% (136 of 661). Administration of ANS was associated with an immediate and rapid decline in mortality, reaching a plateau with more than 50% risk reduction after an administration-to-birth interval of 18 to 36 hours. A similar pattern for timing was seen for the composite mortality or morbidity outcome, whereas a significant risk reduction of severe neonatal brain injury was associated with longer administration-to-birth intervals (greater than 48 hours). For all outcomes, the risk reduction associated with ANS was transient, with increasing mortality and risk for severe neonatal brain injury associated with administration-to-birth intervals exceeding 1 week. Under the assumption of a causal relationship between timing of ANS and mortality, a simulation of ANS administered 3 hours before delivery to infants who did not receive ANS showed that their estimated decline in mortality would be 26%. Antenatal corticosteroids may be effective even if given only hours before delivery. Therefore, the infants of pregnant women at risk of imminent preterm delivery may benefit from its use.

Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort

Objectives To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they...

PS-044 Neonatal Unit Admission Volume Impacts In-hospital Mortality For Very Preterm Infants In Europe: Results From The Epice Cohort

Background and aims Studies have shown that very preterm infants (VPTI) have higher survival when they are born in a maternity unit associated with a high volume neonatal unit. We sought to analyse the impact of nursery volume on in-hospital mortality in Europe. Methods Data come from the EPICE (Effective Perinatal Intensive Care in Europe) project, a population-based study of VPTI born in 19 European regions over 12 months in 2012–2013. We included all live births between 24 and 31 weeks of gestation without severe congenital anomalies (n = 7383) born in 350 maternity units. Volume was defined as the number of observed admissions to the neonatal unit associated with the delivery hospital. Our outcome was death before discharge home. We assessed the impact of volume, analysed as a continuous variable, using multi-level logistic regression and considering case-mix (gestational age, sex, small for gestational age, multiple pregnancy, maternal age and parity). Results 8% of VPTI were born in maternity units with less than 10 neonatal admissions, 8% in units with 10 to 29 admissions, 11% in units with 30 to 49 admissions, 42% in units with 50 to 99 admissions and 31% in units with ≥100 admissions. After adjustment, we found a significant linear association between volume and in-hospital mortality, with an odds ratio of 0.95 (0.91–0.98) for 20 additional admissions. Conclusions VPTI born in maternity units associated with high volume neonatal units had better survival. Delivery in matenity units with larger neonatal units may contribute to improved outcomes in this population.