Moderately Preterm Infants Research Articles

Enhancing NICU Care and Communication: Perspectives of Moderately Preterm Infant Parents.

Moderately preterm infants (MPTI) comprise a large proportion of NICU admissions and are an understudied population. The unique experience of families with MPTIs has yet to be examined in the literature. Describing MPTI parent needs and preferences may inform interventions to improve care and outcomes for this population. Semistructured qualitative interviews were performed with English-speaking birth parents of infants born between 32 and 34 weeks gestation to describe their NICU experience and identify areas for improvement specifically surrounding care team inclusion, education, discharge, and communication. Interviews were recorded, transcribed, and analyzed using directed content analysis. Enrollment ceased when the data reached thematic saturation. Sixteen birth parents participated. Four themes emerged around parent-medical team connectedness, parental confusion, discharge readiness, and the desire for a use of a mix of in-person and electronic communication methods (e-mail, texting, apps, etc) for communication. MPTI parents valued a strong connection with the medical team; however, they described a lack of knowledge regarding the reasons for admission and ongoing management. Near discharge, parents desired more information regarding feeding, reflux, and breathing patterns. Parents preferred in-person discussions but described a role for electronic methods to improve their understanding of their infant and discharge readiness. From the MPTI parent perspective, clinicians can focus improvement efforts on communication, specifically around reasons for admission, discharge planning, and anticipatory guidance. These results may serve as a foundation for initiatives to improve the MPTI parent experience and potentially parent and MPTI outcomes.

Association of Standardized Parenteral Nutrition with Early Neonatal Growth of Moderately Preterm Infants: A Population-Based Cohort Study.

In preterm infants, early nutrient intake during the first week of life often depends on parenteral nutrition. This study aimed to evaluate the influence of standardized parenteral nutrition using three-in-one double-chamber solutions (3-in-1 STD-PN) on early neonatal growth in a cohort of moderately preterm (MP) infants. This population-based, observational cohort study included preterm infants admitted to neonatal centers in the southeast regional perinatal network in France. During the study period, 315 MP infants with gestational ages between 320/7 and 346/7 weeks who required parenteral nutrition from birth until day-of-life 3 (DoL3) were included; 178 received 3-in-1 STD-PN solution (56.5%). Multivariate regression was used to assess the factors associated with the relative body-weight difference between days 1 and 7 (RBWD DoL1-7). Infants receiving 3-in-1 STD-PN lost 36% less body weight during the first week of life, with median RBWD DoL1-7 of -2.5% vs. -3.9% in infants receiving other PN solutions (p < 0.05). They also received higher parenteral energy and protein intakes during the overall first week, with 85% (p < 0.0001) and 27% (p < 0.0001) more energy and protein on DoL 3. After adjusting for confounding factors, RBWD DoL1-7 was significantly lower in the 3-in-1 STD-NP group than in their counterparts, with beta (standard deviation) = 2.08 (0.91), p = 0.02. The use of 3-in-1 STD-PN provided better energy and protein intake and limited early weight loss in MP infants.

Equally Good Neurological, Growth, and Health Outcomes up to 6 Years of Age in Moderately Preterm Infants Who Received Exclusive vs. Fortified Breast Milk-A Longitudinal Cohort Study.

Moderately preterm infants (32-36 weeks of gestational age) have an increased risk of worse health and developmental outcomes compared to infants born at term. Optimal nutrition may alter this risk. The aim of this study was to investigate the neurological, growth, and health outcomes up to six years of age in children born moderately preterm who receive either exclusive or fortified breast milk and/or formula in the neonatal unit. In this longitudinal cohort study, data were collected for 142 children. Data were collected up to six years of age via several questionnaires containing questions about demographics, growth, child health status, health care visits, and the Five to Fifteen Questionnaire. Data on the intake of breast milk, human milk fortification, formula, and growth during hospitalization were collected from the children's medical records. No statistically significant differences in neurological outcomes, growth, or health at six years of age were found between the two groups (exclusive breast milk, n = 43 vs. fortified breast milk and/or formula, n = 99). There is a need for research in larger populations to further assess potential effects on health and developmental outcomes when comparing the use of exclusive versus fortified breast milk for moderately preterm infants during neonatal hospitalization.

Early parenteral nutrition for preterm infants: perhaps more complicated than it first appears

Since its first neonatal application in an infant with small bowel atresia in 1968,1 parenteral nutrition (PN) has become a key tool in the management of preterm infants, and has...

Association of First-Week Nutrient Intake and Extrauterine Growth Restriction in Moderately Preterm Infants: A Regional Population-Based Study.

The purpose of this study was to determine the influence of first-week nutrition intake on neonatal growth in moderate preterm (MP) infants. Data on neonatal morbidity and nutrition intake on day of life 7 (DoL7) were prospectively collected from 735 MP infants (320/7–346/7 weeks gestational age (GA)). Multivariable regression was used to assess the factors associated with extrauterine growth restriction (EUGR) defined as a decrease of more than 1 standard deviation (SD) in the weight z-score during hospitalization. Mean (SD) gestational age and birth weight were 33.2 (0.8) weeks and 2005 (369) g. The mean change in the weight z-score during hospitalization was −0.64 SD. A total of 138 infants (18.8%) had EUGR. Compared to adequate growth infants, EUGR infants received 15% and 35% lower total energy and protein intake respectively (p < 0.001) at DoL7. At DoL7, each increase of 10 kcal/kg/d and 1 g/kg/d of protein was associated with reduced odds of EUGR with an odds ratio of 0.73 (95% CI, 0.66–0.82; p < 0.001) and 0.54 (0.44–0.67; p < 0.001), respectively. Insufficient energy and protein intakes on DoL7 negatively affected neonatal growth of MP infants. Nutritional support should be optimized from birth onwards to improve neonatal weight growth.

Inadequate oral feeding as a barrier to discharge in moderately preterm infants.

The objectives describe the frequency that inadequate oral feeding (IOF) is the reason why moderately preterm (MPT) infants remain hospitalized and its association with neonatal morbidities. Prospective study using the NICHD Neonatal Research Network MPT Registry. Multivariable logistic regression was used to describe associations between IOF and continued hospitalization at 36 weeks postmenstrual age (PMA). A total of 6017 MPT infants from 18 centers were included. Three-thousand three-seventy-six (56%) remained hospitalized at 36 weeks PMA, of whom 1262 (37%) remained hospitalized due to IOF. IOF was associated with RDS (OR 2.02, 1.66-2.46), PDA (OR 1.86, 1.37-2.52), sepsis (OR 2.36, 95% 1.48-3.78), NEC (OR 16.14, 7.27-35.90), and BPD (OR 3.65, 2.56-5.21) compared to infants discharged and was associated with medical NEC (OR 2.06, 1.19-3.56) and BPD (OR 0.46, 0.34-0.61) compared to infants remaining hospitalized for an alternative reason. IOF is the most common barrier to discharge in MPT infants, especially among those with neonatal morbidities.

Preterm-infant emotion regulation during the still-face interaction

Very-preterm (VPT), moderately-preterm (MPT), and full-term (FT) infants’ emotion-regulation behaviors were assessed via the Still-Face procedure at a corrected age of four months. As a developmental task during the first year of life, emotion regulation is important for social and cognitive development. Although substantial evidence indicates that VPT infants exhibit emotion-regulation difficulties, little is known about MPT infants' emotion regulation capabilities, this group also possibly being at risk. The participants included 135 parent-infant dyads: 46 VPT (gestational age 24–32 weeks), 51 MPT (gestational age 32–34 weeks), and 38 FT (gestational age 37–41 weeks). The infants’ affect, gaze-aversion, and self-comforting behaviors were coded. Preterm infants responded to parental still face in similar fashion to FT infants, displaying robust still-face and recovery effects. The preterm infants exhibited less developed emotion-regulation behaviors, however, manifested in less positive affect and more gaze aversion in the face-to-face and reunion episodes compared to FT infants. With respect to self-comforting behaviors, each group displayed a significantly different pattern of behaviors throughout the procedure, suggesting better emotion regulation skills among MPT infants compared to the VPT infants. The findings on gaze aversion and self-comforting behaviors could have implications for strategies to incorporate into intervention programs supporting development of emotion regulation skills.

Neonatal Morbidities among Moderately Preterm Infants with and without Exposure to Antenatal Corticosteroids.

We aimed to compare the rates of "surfactant treated respiratory disease" and other neonatal morbidities among moderately preterm (MPT) infants exposed to no, partial, or a complete course of antenatal corticosteroids (ANS). This observational cohort study evaluated MPT infants (290/7-336/7 weeks' gestational age), born between January 2012 and November 2013 and enrolled in the "MPT Registry" of the National Institute of Child Health and Human Development Neonatal Research Network. Data were available for 5,886 infants, including 676 with no exposure, 1225 with partial, and 3,985 with a complete course of ANS. Among no, partial, and complete ANS groups, respectively, there were significant differences in rates of delivery room resuscitation (4.1, 1.4, and 1.2%), surfactant-treated respiratory disease (26.5, 26.3, and 20%), and severe intracranial hemorrhage (3, 2, and 0.8%). Complete ANS course was associated with lower surfactant-treated respiratory disease, compared with partial ANS (odds ratio [OR] 0.62; 95% confidence interval [CI] 0.52-0.74), and no ANS groups (OR 0.52; 95% CI 0.41-0.66) on adjusted analysis. In MPT infants, ANS exposure is associated with lower delivery room resuscitation, surfactant-treated respiratory disease, and severe intracranial hemorrhage; with the lowest frequency of morbidities associated with a complete course.

Delivery Room Resuscitation and Short-Term Outcomes in Moderately Preterm Infants

To describe the frequency and extent of delivery room resuscitation and evaluate the association of delivery room resuscitation with neonatal outcomes in moderately preterm (MPT) infants. This was an observational cohort study of MPT infants delivered at 290/7 to 336/7 weeks' gestational age (GA) enrolled in the Neonatal Research Network MPT registry. Infants were categorized into 5 groups based on the highest level of delivery room intervention: routine care, oxygen and/or continuous positive airway pressure, bag and mask ventilation, endotracheal intubation, and cardiopulmonary resuscitation including chest compressions and/or epinephrine use. The association of antepartum and intrapartum risk factors and discharge outcomes with the intensity of resuscitation was evaluated. Of 7014 included infants, 1684 (24.0%) received routine care and no additional resuscitation, 2279 (32.5%) received oxygen or continuous positive airway pressure, 1831 (26.1%) received bag and mask ventilation, 1034 (14.7%) underwent endotracheal intubation, and 186 (2.7%) received cardiopulmonary resuscitation. Among the antepartum and intrapartum factors, increasing GA, any exposure to antenatal steroids and prolonged rupture of membranes decreased the likelihood of receipt of all levels of resuscitation. Infants who were small for GA (SGA) had increased risk of delivery room resuscitation. Among the neonatal outcomes, respiratory support at 28 days, days to full oral feeds and length of stay were significantly associated with the intensity of delivery room resuscitation. Higher intensity of resuscitation was associated with increased risk of mortality. The majority of MPT infants receive some level of delivery room resuscitation. Increased intensity of delivery room interventions was associated with prolonged respiratory and nutritional support, increased mortality, and a longer length of stay.

Early developmental trajectories of preterm infants

Background and objectivesPreterm infants are at risk for neuro-developmental impairments and atypical developmental trajectories. The aims of this study were to delineate early developmental trajectories of preterm and full-term infants. MethodsThe cognitive, language, and motor development of 149 infants – 19 extremely preterm (EPT), 34 very preterm (VPT), 57 moderately preterm (MPT), and 39 full-term (FT) – was evaluated using Mullen Scales at 1, 4, 8, 12, and 18 months. Mixed models were applied to examine group differences. Gender, maternal education, and neurobehavior were included as predictors of developmental trajectories. ResultsThe EPT and VPT infants achieved significantly lower scores than the FT infants in all domains, with a significantly increasing gap over time. The MPT infants' trajectories were more favorable than those of the EPT and VPT infants yet lower than the FT infants on the Visual Reception, Gross, and Fine Motor subscales. Male gender and lower maternal education were associated with lower scores that declined over time. Abnormal neonatal neurobehavior was associated lower Mullen scores and with less stability in scores over time. ConclusionsThe EPT and VPT infants were found to have disadvantages across all domains. The MPT infants revealed more favorable developmental trajectories yet displayed vulnerability compared to the FT infants. Gender, maternal education, and neonatal neurobehavior are important in predicting the developmental outcomes of preterm infants.

Survival, Hospitalization, and Acute-Care Costs of Very and Moderate Preterm Infants in the First 6 Years of Life: A Population-Based Study

To investigate survival, hospitalization, and acute-care costs of very (28-31 weeks' gestation) and moderate preterm (32-33 weeks' gestation) infants in the first 6 years of life and compare outcomes with the more widely studied extremely preterm infants (24-27 weeks' gestation) and to full term (low risk) infants (39-40 weeks' gestation). Birth data from all women residing in New South Wales, Australia, with gestational ages between 24-33 and 39-40 weeks in 2001-2011 were linked probabilistically to hospitalization and mortality data. Study outcomes were evaluated with the use of descriptive and multivariable analyses at birth (N = 559,532), discharge (N = 540,240), and at 1 (N = 487,447) and 6 years of age (N = 230,498). Mortality was greatest among extremely preterm infants (eg, 31.2% within 6 years) and decreased with increasing gestational age. Likewise, hospitalization within the first year of life increased with decreasing gestational age (aOR 5.5 [95% CI 4.7-6.4], 3.7 [3.4-4.0], and 2.6 [2.5-2.8] for birth at 24-27, 28-31, and 32-33 weeks' gestation, relative to 39-40 weeks' gestation). Hospitalization remained significantly increased with preterm birth at each year of age up to 6 years (aORs 1.3-1.6 at 6 years). Cumulative costs were significantly greater with preterm birth within the first year of life, and also between 1 and 6 years of age. The risks of adverse health outcomes were significantly greater in very and moderately preterm infants relative to full term infants but lower than extremely preterm infants. Crucially, preterm birth was associated with prolonged increased odds of hospitalization (up to age 6 years), contributing to greater resource use.

Cerebral Palsy Among Children Born Moderately and Late Preterm

OBJECTIVE: To compare the incidence of and risk factors for cerebral palsy (CP) in moderately preterm (MP) (32+0–33+6 weeks) and late preterm (LP) (34+0–36+6 weeks) infants with those in very preterm (VP) ( METHODS: The national register study included all live-born infants in Finland from 1991 to 2008. Infants who died before the age of 1 year, had any major congenital anomaly, or had missing data were excluded. A total of 1 018 302 infants were included in the analysis and they were analyzed in 4 subgroups (VP, MP, LP, and term) and 3 time periods (1991–1995, 1996–2001, and 2002–2008). RESULTS: By the age of 7 years, 2242 children with CP were diagnosed (0.2%). CP incidence was 8.7% in the VP, 2.4% in the MP, 0.6% in the LP, and 0.1% in the term group. The risk of CP was highest in the study period 1991–1995 in all groups. Factors predictive of an increased CP risk in the MP and LP groups included resuscitation at birth (odds ratio 1.60; 95% CI 1.01–2.53 and 1.78; 1.09–2.90), antibiotic treatment during the first hospitalization (1.63; 1.08–2.45 and 1.67; 1.13–2.44), 1-minute Apgar score CONCLUSIONS: The incidence of CP is higher in LP and MP infants compared with term infants. There is a nonlinear decrease in incidence over time and with increasing gestational age.

Cerebral palsy among children born moderately and late preterm.

To compare the incidence of and risk factors for cerebral palsy (CP) in moderately preterm (MP) (32(+0)-33(+6) weeks) and late preterm (LP) (34(+0)-36(+6) weeks) infants with those in very preterm (VP) (<32(+0) weeks) and term infants (≥37 weeks). The national register study included all live-born infants in Finland from 1991 to 2008. Infants who died before the age of 1 year, had any major congenital anomaly, or had missing data were excluded. A total of 1 018 302 infants were included in the analysis and they were analyzed in 4 subgroups (VP, MP, LP, and term) and 3 time periods (1991-1995, 1996-2001, and 2002-2008). By the age of 7 years, 2242 children with CP were diagnosed (0.2%). CP incidence was 8.7% in the VP, 2.4% in the MP, 0.6% in the LP, and 0.1% in the term group. The risk of CP was highest in the study period 1991-1995 in all groups. Factors predictive of an increased CP risk in the MP and LP groups included resuscitation at birth (odds ratio 1.60; 95% CI 1.01-2.53 and 1.78; 1.09-2.90), antibiotic treatment during the first hospitalization (1.63; 1.08-2.45 and 1.67; 1.13-2.44), 1-minute Apgar score <7 (1.70; 1.15-2.52 and 1.80; 1.21-2.67) and intracranial hemorrhage (7.18; 3.60-14.3 and 12.8; 5.58-29.2). The incidence of CP is higher in LP and MP infants compared with term infants. There is a nonlinear decrease in incidence over time and with increasing gestational age.

Cerebral Palsy Among Children Born Moderately and Late Preterm

OBJECTIVE: To compare the incidence of and risk factors for cerebral palsy (CP) in moderately preterm (MP) (32+0–33+6 weeks) and late preterm (LP) (34+0–36+6 weeks) infants with those in very preterm (VP) ( METHODS: The national register study included all live-born infants in Finland from 1991 to 2008. Infants who died before the age of 1 year, had any major congenital anomaly, or had missing data were excluded. A total of 1 018 302 infants were included in the analysis and they were analyzed in 4 subgroups (VP, MP, LP, and term) and 3 time periods (1991–1995, 1996–2001, and 2002–2008). RESULTS: By the age of 7 years, 2242 children with CP were diagnosed (0.2%). CP incidence was 8.7% in the VP, 2.4% in the MP, 0.6% in the LP, and 0.1% in the term group. The risk of CP was highest in the study period 1991–1995 in all groups. Factors predictive of an increased CP risk in the MP and LP groups included resuscitation at birth (odds ratio 1.60; 95% CI 1.01–2.53 and 1.78; 1.09–2.90), antibiotic treatment during the first hospitalization (1.63; 1.08–2.45 and 1.67; 1.13–2.44), 1-minute Apgar score CONCLUSIONS: The incidence of CP is higher in LP and MP infants compared with term infants. There is a nonlinear decrease in incidence over time and with increasing gestational age.

The economic burden of prematurity in Canada

BackgroundPreterm birth is a major risk factor for morbidity and mortality among infants worldwide, and imposes considerable burden on health, education and social services, as well as on families and caregivers. Morbidity and mortality resulting from preterm birth is highest among early (< 28 weeks gestational age) and moderate (28–32 weeks) preterm infants, relative to late preterm infants (33–36 weeks). However, substantial societal burden is associated with late prematurity due to the larger number of late preterm infants relative to early and moderate preterm infants.MethodsThe aim in this study was to characterize the burden of premature birth in Canada for early, moderate, and late premature infants, including resource utilization, direct medical costs, parental out-of-pocket costs, education costs, and mortality, using a validated and published decision model from the UK, and adapting it to a Canadian setting based on analysis of administrative, population-based data from Québec.ResultsTwo-year survival was estimated at 56.0% for early preterm infants, 92.8% for moderate preterm infants, and 98.4% for late preterm infants. Per infant resource utilization consistently decreased with age. For moderately preterm infants, hospital days ranged from 1.6 at age two to 0.09 at age ten. Cost per infant over the first ten years of life was estimated to be $67,467 for early preterm infants, $52,796 for moderate preterm infants, and $10,010 for late preterm infants. Based on population sizes this corresponds to total national costs of $123.3 million for early preterm infants, $255.6 million for moderate preterm infants, $208.2 million for late preterm infants, and $587.1 million for all infants.ConclusionPremature birth results in significant infant morbidity, mortality, healthcare utilization and costs in Canada. A comprehensive decision-model based on analysis of a Canadian population-based administrative data source suggested that the greatest national-level burden is associated with moderate preterm infants due to both a large cost per infant and population size while the highest individual-level burden is in early preterm infants and the largest total population size is in late preterm infants. Although the highest medical costs are incurred during the neonatal period, greater resource utilization and costs extend into childhood.

Clinical Outcomes and Cost of the Moderately Preterm Infant

The purpose of this study is to define the incidence of admission and morbidities and the economic impact of moderately preterm infants in the neonatal intensive care unit (NICU). A retrospective descriptive study. All infants born between 32 to 34 weeks' gestational age (GA) (n=4932) followed by ParadigmHealth, a care management company, from January 2001 through June 2004 were evaluated. Infants with major congenital anomalies were excluded. This sample represented 453 NICUs in 24 states in the United States. Retrospective data analysis. Infants born between 32 and 34 weeks' GA were studied (n=4932). This subset of patients in the NICU was compared to the entire population in the database (n=19,923) for incidence and cost comparison. Infants were followed for 2 weeks after hospital discharge. Demographics, feeding characteristics, respiratory needs, complications, discharge needs, and patient costs. The 4932 infants admitted to the NICU with gestational ages of 32 to 34 weeks represented 24.8% of the 19,923 admissions during this time period. This cohort experienced low mortality (0.5%) and had an average length of stay (LOS) of 17.6 days. The average cost per case was $31,000, representing 21.6% of total NICU costs. Fifty-four percent of infants experienced respiratory compromise, requiring ventilation, continuous positive airway pressure, or oxygen during their hospital course. Fifty-six percent required intravenous nutrition, and 19% of these patients were discharged home with ongoing medical needs and the use of durable medical equipment. Although morbidities with long-term consequences were rare, there is a significant burden on the infant, family, and healthcare team for patients 32 to 34 weeks' GA. It is important to understand the characteristics of this group of infants and explore ways of optimizing care to minimize this burden.

Neonatal Intensive Care Unit Census Influences Discharge of Moderately Preterm Infants

The timely discharge of moderately premature infants has important economic implications. The decision to discharge should occur independent of unit census. We evaluated the impact of unit census on the decision to discharge moderately preterm infants. In a prospective multicenter cohort study, we enrolled 850 infants born between 30 and 34 weeks' gestation at 10 NICUs in Massachusetts and California. We divided the daily census from each hospital into quintiles and tested whether discharges were evenly distributed among them. Using logistic regression, we analyzed predictors of discharge within census quintiles associated with a greater- or less-than-expected likelihood of discharge. We then explored parental satisfaction and postdischarge resource consumption in relation to discharge during census periods that were associated with high proportions of discharge. There was a significant correlation between unit census and likelihood of discharge. When unit census was in the lowest quintile, patients were 20% less likely to be discharged when compared with all of the other quintiles of unit census. In the lowest quintile of unit census, patient/nurse ratio was the only variable associated with discharge. When census was in the highest quintile, patients were 32% more likely to be discharged when compared with all of the other quintiles of unit census. For patients in this quintile, a higher patient/nurse ratio increased the likelihood of discharge. Conversely, infants with prolonged lengths of stay, an increasing Score for Neonatal Acute Physiology II, and minor congenital anomalies were less likely to be discharged. Infants discharged at high unit census did not differ from their peers in terms of parental satisfaction, emergency department visits, home nurse visits, or rehospitalization rates. Discharges are closely correlated with unit census. Providers incorporate demand and case mix into their discharge decisions.