Antenatal Steroid Use Research Articles

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method.

Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh. We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh. Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh. This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Delivery room resuscitation intensity and associated neonatal outcomes of 24+0–31+6 weeks’ preterm infants in China: a retrospective cross-sectional study

BackgroundThe aim of this study was to review current delivery room (DR) resuscitation intensity in Chinese tertiary neonatal intensive care units and to investigate the association between DR resuscitation intensity and short-term outcomes in preterm infants born at 24+0–31+6 weeks’ gestation age (GA).MethodsThis was a retrospective cross-sectional study. The source population was infants born at 24+0–31+6 weeks’ GA who were enrolled in the Chinese Neonatal Network 2019 cohort. Eligible infants were categorized into five groups: (1) regular care; (2) oxygen supplementation and/or continuous positive airway pressure (O2/CPAP); (3) mask ventilation; (4) endotracheal intubation; and (5) cardiopulmonary resuscitation (CPR). The association between DR resuscitation and short-term outcomes was evaluated by inverse propensity score-weighted logistic regression.ResultsOf 7939 infants included in this cohort, 2419 (30.5%) received regular care, 1994 (25.1%) received O2/CPAP, 1436 (18.1%) received mask ventilation, 1769 (22.3%) received endotracheal intubation, and 321 (4.0%) received CPR in the DR. Advanced maternal age and maternal hypertension correlated with a higher need for resuscitation, and antenatal steroid use tended to be associated with a lower need for resuscitation (P < 0.001). Severe brain impairment increased significantly with increasing amounts of resuscitation in DR after adjusting for perinatal factors. Resuscitation strategies vary widely between centers, with over 50% of preterm infants in eight centers requiring higher intensity resuscitation.ConclusionsIncreased intensity of DR interventions was associated with increased mortality and morbidities in very preterm infants in China. There is wide variation in resuscitative approaches across delivery centers, and ongoing quality improvement to standardize resuscitation practices is needed.

Effect of cue-based feeding on time to nipple feed and time to discharge in very low birth weight infants

The objective of this study is to evaluate the effectiveness of a cue-based feeding protocol in improving time to nipple feed and time to discharge in very low birth weight infants in a Level III Neonatal Intensive Care Unit. Demographic, feeding, and discharge data were recorded and compared between the two cohorts. The pre-protocol cohort included infants born from August 2013 through April 2016 and the post-protocol cohort included infants born from January 2017 through December 2019. 272 infants were included in the pre-protocol cohort and 314 infants in the post-protocol cohort. Both cohorts were statistically comparable in gestational age, gender, race, birthweight, prenatal care, antenatal steroid use, and rates of maternal diabetes. There were statistically significant differences between the pre- versus post-protocol cohorts in median post-menstrual age (PMA) in days at first nipple feed (PO) (240 vs 238, p = 0.025), PMA in days at full PO (250 vs 247, p = 0.015), and length of stay in days (55 vs 48, p = 0.0113). Comparing each year in the post-protocol cohort, for each outcome measure, a similar trend was noted in 2017 and 2018, but not in 2019. In conclusion, the cue-based feeding protocol was associated with a decrease in the time to first PO, time to full nipple feeds, and the length of stay in very-low-birthweight infants.

Fungal infection and neurodevelopmental outcomes at 18-30 months in preterm infants.

Invasive fungal infection (IFI) is associated with significant mortality and morbidity among preterm infants but there has been no population-based study of long-term neurodevelopmental outcomes. The objective of this study was to examine population-based incidence trends as well as mortality, short term in-hospital morbidity and long-term neurodevelopmental outcomes among preterm infants with IFI, non-fungal infections (NFI) and no infections in Canada. We conducted a retrospective cohort study of 8,408 infants born at <29 weeks gestational age (GA), admitted to Canadian Neonatal Network neonatal intensive care units (NICU) from April 2009 to December 2017, and followed up at 18-30 months corrected age (CA) in Canadian Neonatal Follow-Up Network clinics. We compared mortality, long term neurodevelopmental outcomes and short term in-hospital morbidity among 3 groups of infants (IFI, NFI, and no infections). The incidence of IFI was 1.3%, non-IFI 26.9% and no infections 71.7%. IFI incidence varied between 0.93% and 1.94% across the study period with no significant trend over time. Infants of higher gestational age were significantly (p < 0.01) less likely to have IFI. Among infants with IFI, NFI and no infections, the incidence of the significant neurodevelopmental impairment (sNDI) was 44.26%, 21.63% and 14.84% respectively, while mortality was 50%, 25.35% and 22.25% respectively. Even after risk adjustment for confounders (GA, Score for Neonatal Acute Physiology Version II, ruptured membranes >24 h, maternal antibiotic treatment, antenatal steroid use, cesarean section), infants with IFI had significantly higher odds of sNDI than NFI (aOR: 2.19; 95% CI: 1.23, 3.91) or no infections (aOR: 2.97; 95% CI: 1.55, 5.71), and higher odds of mortality than NFI (aOR: 1.55; 95% CI: 1.07, 2.26) or no infections (aOR: 1.45; 95% CI: 0.97, 2.17). Preterm infants with invasive fungal infections have significantly higher incidence of mortality and adverse neurodevelopmental outcomes than those with non-invasive fungal infections and no infections.

Risk Factors for Pneumothorax and Its Association with Ventilation in Neonates.

The mode of ventilation that is implicated in pneumothorax is the one at the time of its diagnosis. Although there is evidence that air leak starts many hours before it is clinically evident, there are no prior studies that have investigated the association of pneumothorax with the mode of ventilation few hours before rather than at the time of its diagnosis. A retrospective case-control study was conducted in the neonatal intensive care unit (NICU) between 2006 and 2016 where cases of neonates with pneumothorax were compared with gestational age-matched control neonates without pneumothorax. Respiratory support associated with pneumothorax was classified as the mode of ventilation 6 hours before the clinical diagnosis of pneumothorax. We investigated the factors that were different between cases and controls, and between cases of pneumothorax on bubble continuous positive airway pressure (bCPAP) and invasive mechanical ventilation (IMV). Of the 8,029 neonates admitted in the NICU during the study period, 223 (2.8%) developed pneumothorax. Among these, 127 occurred among 2,980 (4.3%) neonates on bCPAP, 38 among 809 (4.7%) neonates on IMV, and the remaining 58 among 4,240 (1.3%) neonates on room air. Those with pneumothorax were more likely to be male, have higher body weight, require respiratory support and surfactant administration, and have bronchopulmonary dysplasia (BPD). Among those who developed pneumothorax, there were differences in the gestational age, gender, and use of antenatal steroids between those who were on bCPAP as compared to those on IMV. IMV was associated with increased odds of pneumothorax as compared to those on bCPAP in a multivariable regression analysis. Cases on IMV had higher incidence of intraventricular hemorrhage, retinopathy of prematurity, BPD, and necrotizing enterocolitis, as well as longer length of stay as compared to those on bCPAP. Neonates who require any respiratory support have higher incidence of pneumothorax. Among those on respiratory support, those on IMV had higher odds of pneumothorax and worse clinical outcomes as compared to those on bCPAP. · The process of air leak leading to pneumothorax in majority of neonates starts much before it is clinically diagnosed.. · It is possible to detect the air leak early in the process by subtle changes in the signs, symptoms and changes in lung function.. · True association of the ventilation associated with pneumothorax is not at the time of diagnosis of pneumothorax but few hours before it is diagnosed.. · There is higher incidence of pneumothorax in neonates on any respiratory support.. · There is significantly higher incidence of pneumothorax among neonates on invasive ventilations as compared to noninvasive ventilation after correction for all other clinical factors..

Impact of premature rupture of membranes on clinical outcomes of extremely premature infants: A propensity score matching study.

Premature rupture of membranes (PROM) is a common cause of extremely premature infants (EPIs) and also leads to adverse preterm complications. However, the effect of PROM on EPIs remains contradictory. This study used propensity score matching (PSM) to adjust the baseline characteristics to explore the impact of PROM on clinical outcomes of extremely premature infants (EPIs). Medical data of 470 EPIs at gestational age < 28weeks who received prenatal examination in our hospital between January 1, 2015 and December 31, 2020 were analyzed retrospectively. According to the presence or absence of PROM, they were divided into a PROM group and a non-PROM group. Ten covariates including birth weight, male sex, artificial conception, cesarean delivery, 5-min Apgar score ≤ 7, oligohydramnios, gestational hypertension, preeclampsia, antenatal steroid use, and complete steroid treatment were matched 1:1 by PSM. The major complication occurrence and mortality during hospitalization were compared between the two groups by t-test, nonparametric test or test. Among the 470 infants enrolled, 157 (33.4%) were in the PROM group and 313 in the no-PROM group. After matching the ten confounding factors,276 cases were successfully enrolled. The incidence of early pulmonary hypertension (EPH) and severe retinopathy of prematurity (ROP) in the PROM group were higher than those in the no-PROM group [44.2% (61/138) vs. 29.0% (40/138); 34.8% (48/138) vs. 21.7% (30/138), x 2 = 6.886 and 5.790, both P < 0.05]. However, there was no significant difference in the in-hospital mortality and the incidence of other major complications between the two groups (all P > 0.05). PROM increased the incidence of EPH and severe ROP in EPI, but had no significant impact on in-hospital mortality, length of hospital stay, and the incidence of other complications.

Evaluation of Short-Term Outcomes of Preterm Infants in 2 Periods: Vermont Oxford Network Results of a Developing Country's Single- Center Level IIIC Neonatal Intensive Care Unit Experience.

This study aimed to compare the short-term outcomes of infants from our level IIIC neonatal intensive care unit in 2 different periods. In this cohort study, data from preterm infants (≤29 weeks and birth weight <1500 g) registered in the Vermont Oxford Network system were divided into 2 periods, the first period between January 1, 2005, and December 31, 2009, and the second between January 1, 2010, and December 31, 2019. There was no difference in the distribution of preterm infants according to their gestational age subgroups (P = .169). Although the survival rate increased significantly in the second period (48.1% vs. 64.3% (P < .001), there was no difference in terms of survival without morbidity (P = .480). The frequency of antenatal care (P < .001), antenatal maternal steroid use (P < .001), cesarean section (P = .025), and small for gestational age (P < .003) increased in the second period. Surfactant treatment in the delivery room (P < .003), neonatal intensive care unit (P < .001), and nasal continuous positive airway pressure use before intubation as a part of initial resuscitation (P < .001), nosocomial infections (P = .001), patent ductus arteriosus requiring medical treatment (P = .011), and necrotizing enterocolitis (P = .014) were significantly more common, but early neonatal sepsis (P = .002) and discharge home with only formula (P = .010) were less in the second period. Differences were noted in the prognosis and treatment choices of preterm infants in the same unit between 2 periods. The analysis of neonatal intensive care unit data, through rigorous methods, may provide opportunities for the development of quality improvement projects to improve the quality of health care in developing countries.

Preterm prelabor rupture of membranes in singletons: maternal and neonatal outcomes.

To determine the effect of gestational age at delivery on maternal and neonatal outcomes in preterm prelabor rupture of membranes (PPROM) and assess various predictors of neonatal and infant mortality in these pregnancies. United States birth data from CDC-National Center for Health Statistics natality database for years 2004-2008 was used to identify singleton pregnancies with PPROM and delivery from 32 0/7 to 36 6/7weeks. Controls were singletons at 37-40weeks, without PPROM. Maternal and neonatal complications reported by all states were analyzed along with neonatal outcomes such as chorioamnionitis and hyaline membrane disease, reported by a subgroup of states. OR (95% CI) were calculated after adjusting for preeclampsia, diabetes, chronic hypertension, maternal race, and infant sex. There were 134,502 PPROM cases and similar number of controls. There was a significant decrease in need for prolonged ventilation, hyaline membrane disease, 5min Apgar score <7, and NICU admission with advancing gestational age. Placental abruption decreased and chorioamnionitis and cord prolapse were not different between 34 and 37weeks. We found reductions in early death, neonatal death, and infant mortality with advancing gestational age (p<0.001 for each). Gestational age at delivery was the strongest predictor for early death,neonatal death, and infant mortality in PPROM. These differences persisted after adjusting for antenatal steroid use. We provide population-based evidence showing a decrease in neonatal complications and death with advancing gestational age in PPROM. Gestational age at delivery in pregnancies with PPROM is the strongest predictor of mortality risk.

Neonatal respiratory support related to lung function abnormalities in school-age children with bronchopulmonary dysplasia.

To elucidate the relationship between abnormal lung function (LF) at school age and neonatal respiratory support in very low birth weight children with bronchopulmonary dysplasia (BPD). We retrospectively examined 78 BPD children whose LF was evaluated at 8-9 years. LF abnormalities were defined by reduced values of spirometric parameters. Adjusted odds ratios (aORs) for abnormal LF by the type and postmenstrual age (PMA) of respiratory support were calculated using logistic regression analysis after controlling perinatal factors. Overall, 24 (31%) patients had LF abnormalities. Antenatal steroid use was associated with a decreased risk of abnormal LF [aOR, 0.31; 95% CI, 0.09-0.92]. Requiring positive-pressure support at 37 weeks' PMA correlated with abnormal LF [aOR, 4.58; 95% CI, 1.15-21.90]; whereas only low-flow oxygen at any PMA did not. Requiring positive-pressure support at 37 weeks' PMA could be an indicator of abnormal LF at school age.

Revisiting the use of antenatal corticosteroids for late preterm and early term infants: An observational analytical study

Background: Guidelines from prominent policymakers on the use of antenatal steroids (ANS) in “late preterm deliveries and early term casearian deliveries” (LET) are nonuniform. This descriptive study compared LET infants born during two-time epochs: Retrospective: ANS exposed (ANSE) (when institute practice was to administer ANS to all LET mothers), and prospective – ANS unexposed (ANSU) (after the policy was revised in May 2021). Methodology: All antenatal mothers of anticipated late-preterm and early-term cesarean deliveries were being administered ANS before May 2021. Following the revision of hospital policy, this practice was discontinued. Comparative analysis for respiratory morbidity (RM) and other clinically relevant outcomes were conducted in infants born during two-time epochs (ANSE vs. ANSU) Results: Among 379 included infants, those with RMs were comparable between groups: 33 (17.5%) in ANSE; 31 (16.4%) in ANSU – Odds ratio (OR) 1.08; 95% confidence interval (CI) (0.61–1.92), P = 0.78. No difference was noted in hypoglycemia events: 23 (12.2%) in ANSE; 22 (11.6%) in ANSU, OR = 1.05 95% CI (0.56–1.96), P = 0.87. Conclusion: ANS in LET did not seem to reduce the risk of RM. It may be appropriate to audit individual unit practices and relevant outcomes before blanket recommendations are made.

Neonatal Intensive Care Quality Level-Dependent Variations in the Survival Rate of Infants with a Birth Weight of 500 g or Less in Korea: A Nationwide Cohort Study

Objective: Recent evidence suggests that the survival of peri-viable infants with birth weight (BW) ≤500 g could be improved with better care practices in the neonatal intensive care unit (NICU). This study aimed to investigate the care quality level of NICU-dependent variations in the survival rate of infants with BW ≤500 g. Methods: To determine the quality of NICU care-dependent variations in the survival rate, 226 eligible infants of BW ≤500 g and ≥22 weeks gestation registered in the Korean Neonatal Network between 2013 and 2017 were grouped according to the survival rates of infants at 23–24 weeks gestation, reflecting the care quality level of each NICU as group I (≥50%, n = 107) and group II (<50%, n = 119). Results: The survival rate of group I infants (40.2%, 43/107) was significantly higher than that of group II infants (14.3%, 17/119). Significantly reduced deaths from birth to the age of 7 days due to cardiorespiratory causes were the primary contributors to improved survival. In multivariable Cox hazard model analyses, besides the gestational age and BW, antenatal steroid use, cesarean section, pH, and base excess at admission were associated with improved infant survival. Conclusions: The survival rate of pre-viable infants with BW ≤500 g could be improved by providing better NICU quality care practices, including better cardiorespiratory management starting from delivery room resuscitation.

Neonatal and Obstetric Provider Perceptions and Management at 22 Weeks' Gestation.

Active treatment for periviable infants may be influenced by neonatal and obstetric provider perceptions of prognosis. The two aims of this study are to (1) quantify prognostic discordance between provider and data-driven survival estimates and (2) evaluate if prognostic discordance is associated with the threshold probability of survival at which neonatal providers recommend active treatment or obstetric providers recommend antenatal corticosteroids. Provider survival estimates and threshold probabilities of survival for active treatment and antenatal steroid use were obtained from a case-based survey for an infant or pregnancy at 22 weeks' gestation that was administered at two Atlanta hospitals. Data-driven survival estimates, including ranges, were acquired through the National Institute of Child Health and Human Development Extremely Preterm Birth Outcomes Tool. Prognostic discordance was calculated as the difference between a provider and data-driven estimates and classified as pessimistic (provider estimate below data-driven estimate range), accurate (within range), or optimistic (above range). The association between prognostic discordance and the threshold probability of survival was evaluated using nonparametric tests. We had 137 neonatal respondents (51% response rate) and 57 obstetric responses (23% response rate). The overall median prognostic discordance was 1.5% (interquartile range: 17, 13) and 52 (27%) of all respondents were pessimistic, 100 (52%) were accurate, and 42 (22%) were optimistic. The survival threshold above which neonatal and obstetric providers recommended active treatment or antenatal corticosteroids was 30% (20-45%) and 10% (0-20%), respectively. Thresholds did not significantly differ among the three prognostic discordance groups (p = 0.45 for neonatal and p = 0.53 for obstetric providers). There was also no significant correlation between the magnitude of prognostic discordance and thresholds. Prognostic discordance exists among both neonatal and obstetric providers. However, this discordance is not associated with the threshold probability of survival at which providers recommend active treatment or antenatal corticosteroids at 22 weeks' gestation. · Prognostic discordance at 22 weeks' gestation exists for neonatal and obstetric providers.. · Prognostic discordance is not associated with survival thresholds for neonatal active treatment.. · Prognostic discordance is not associated with survival thresholds for the use of antenatal corticosteroids..

Respiratory support strategies in the prevention of bronchopulmonary dysplasia: A single center quality improvement initiative.

Bronchopulmonary dysplasia (BPD) continues to be a significant morbidity affecting very preterm infants, despite multiple advancements in therapies to treat respiratory distress syndrome and prevent BPD. Local quality improvement (QI) efforts have shown promise in reducing unit or system-wide rates of BPD. In preterm infants born between 23- and 32-weeks' gestation, our aim was to decrease the rate of BPD at 36 weeks corrected gestational age from 43% to 28% by January 2019. Directed by a multidisciplinary respiratory QI team, we gradually implemented the following interventions to reach our aim: (1) early initiation of non-invasive ventilation in the delivery room, (2) initiation of caffeine prior to 24 h of life, (3) administration of early selective surfactant per a well-defined guideline, (4) continuation of non-invasive ventilation until 32 and 0/7 weeks corrected gestational age (CGA), and (5) a revision of the early selective surfactant guideline. Outcome measures included rates of BPD, and process measures included compliance with the above interventions. A total of 509 infants with an average gestational age of 29 1/7 weeks and birth weight of 1,254 (SD±401) grams were included. The rate of BPD in our unit decreased from a baseline of 43% to 19% from the start of the project in October 2016 until the first quarter of 2022 (p < 0.00001). The greatest reductions in BPD rates were seen after the initiation of the guideline to extend non-invasive ventilation until 32 0/7 weeks CGA. The rate of severe BPD decreased from 22% to 9%. In preterm infants born between 23- and 32-weeks' gestation, our local QI interventions to reduce rates of BPD were associated with a reduction in rates by 56%. Increased use of antenatal steroids and higher birth weights post- vs. pre-intervention may have contributed to this successes.

Thresholds for surfactant use in preterm neonates: a network meta-analysis

ObjectiveTo perform a network meta-analysis of randomised controlled trials of different surfactant treatment strategies for respiratory distress syndrome (RDS) to assess if a certain fraction of inspired oxygen (FiO2) is...

A study on normalization of hypothyroxinemia in neonates below 34 weeks of gestation

Objectives: The aim of the study was to estimate the time required for normalization of hypothyroxinemia of prematurity in neonates below 34 weeks of gestation. Material and Methods: A retrospective study was conducted in neonates born below 34 weeks of gestation, between January 2015 and December 2016. Data were collected on free thyroxine (fT4) and thyroid-stimulating hormone (TSH) levels, tested on days 3, 14, 28, and 42. Gestational age, birth weight, use of antenatal steroids, mechanical ventilation, and various preterm morbidities, along with development at 18 months of corrected age, were comparatively analyzed in neonates with and without hypothyroxinemia. The median time for normalization of fT4 in all these variables was estimated. Results: On day 3, low fT4 was noted in 69 (37.7%) out of 183 neonates born below 34 weeks of gestation; all had normal TSH levels. Hypothyroxinemia showed statistically significant association with gestational age, birth weight, antenatal steroid use, respiratory distress syndrome, invasive ventilation, shock, sepsis, patent ductus arteriosus (PDA), anemia during stay in neonatal intensive care unit, and development at 18 months. Median time for normalization was 14 days in most of the neonates, and 28 days in those with &lt;28 weeks of gestational age, weight of &lt;1000 g and with shock, anemia, and PDA. Two infants with hypothyroxinemia received therapy with levothyroxine at 6 weeks for a short duration, as TSH was high. Conclusion: Hypothyroxinemia of prematurity takes 14–28 days to normalize based on maturity, weight, and illnesses. This study recommends serum fT4 testing at 2 weeks of life, provided congenital hypothyroidism was ruled out by 3–4 days of life, using direct blood spot card metabolic screening.

23 Assessing the effects of introducing prophylactic hydrocortisone in extremely low gestational age infants in a tertiary Canadian NICU

Abstract Background Bronchopulmonary dysplasia (BPD) is a common complication of preterm birth. A large trial and a meta-analysis support the early use of physiologic doses of hydrocortisone to reduce the incidence of death or moderate/severe BPD. In 2019, this practice was introduced for all preterm infants &amp;lt;28 weeks gestational age (GA) at our university-affiliated tertiary care NICU. Objectives To determine the effect of prophylactic hydrocortisone on the incidence of survival with mild or no BPD in neonates born &amp;lt;28 weeks GA. Secondary objectives were to compare safety outcomes related to prophylactic hydrocortisone use: late onset sepsis, gastrointestinal perforation, severe intraventricular hemorrhage (IVH) and use of postnatal dexamethasone. Design/Methods We performed a retrospective cohort study of infants born &amp;lt;28 weeks GA admitted to our NICU during 2 epochs, before and after the implementation of prophylactic hydrocortisone. The primary objective was evaluated using logistic regression adjusted for GA. Safety outcomes were compared using chi-square or Fisher’s exact test. Results Epoch 1 included 76 infants and epoch 2 included 71 infants, of whom 63 (88.7%) received prophylactic hydrocortisone. Infants in the two epochs were similar in terms of median (IQR) GA 26.5 (25.0, 27.2) vs 26.7 (25.1, 27.1) weeks GA, mean (SD) weight at admission (882g +/- 212 vs 841g +/- 176), APGAR at 5 minutes, use of antenatal steroids and/or surfactant, and need for intubation at delivery (all p&amp;gt;0.5). Three infants were transferred to another hospital and their BPD status could not be determined. Adjusting for GA, there was a statistically non-significant signal for increased survival with mild or no BPD in epoch 2 (adjusted odds ratio 1.68, 95% CI 0.80, 3.59, p= 0.17) compared to epoch 1. The two epochs had similar incidence of late onset sepsis, gastrointestinal perforation and need for postnatal dexamethasone, however, in epoch 2, fewer infants developed grade 3/4 IVH on head ultrasound within the first two weeks of life (7/71, 9.9%) compared to epoch 1 (21/76, 27.6%, p= 0.01). Conclusion Prophylactic hydrocortisone may be associated with increased survival with mild or no BPD. Safety outcomes in both epochs were similar, but with a significantly decreased incidence of grade 3/4 IVH in the prophylactic hydrocortisone group. Larger cohort studies are required before a clear recommendation for prophylactic hydrocortisone can be made.

16 RAM cannula versus Infant Flow Driver systems for post-extubation non-invasive ventilation support in extremely preterm infants - A retrospective cohort study

Abstract Background Non-invasive ventilation (NIV) delivered by RAM cannula is being used for post-extubation support of preterm infants in some centers for its potential benefits of ease of setup and less nasal trauma. Objectives To assess characteristics and clinical outcomes for infants extubated to NIV support delivered via RAM cannula, as compared to those extubated to Vyaire Infant Flow Driver (IFD) systems. Design/Methods Retrospective cohort study. All infants born at 25 to 27 + 6 weeks of gestation during a 3-year period (2016-2018) and admitted to a regional Level-3 NICU, were eligible if: 1) they were ventilated for RDS within 48 hours of birth, and 2) extubated to NIV support using RAM cannula or IFD systems (using Viasys or FabianTM devices). Primary outcome was the failure of the primary mode of NIV support within the first 72 hours post-extubation (defined as need for reintubation or change of initial NIV mode to prevent reintubation). We adjusted for antenatal steroid use and delivery route. Data was stratified for gestational age (GA) &amp;lt;26 wks/&amp;gt;=26 wks. Sensitivity analysis were performed on additional parameters, e.g., inborn status, duration of initial ventilation restricted to &amp;lt;4 days. Logistic and linear regression models were built for the categorical and continuous outcomes. Results 150 infants were enrolled, RAM cannula (n = 62) and IFD devices (n = 88). The majority of patients in both groups were on conventional ventilation, received one dose of surfactant, and were on FiO2 &amp;lt;0.3 prior to extubation. RAM cannula group had significantly longer duration of intubation prior to first extubation (median duration 99 hrs vs 19 hrs). There was no difference in the primary outcome between the groups [(RAM 51.6% and IFD 45.5%; adjOR 1.25(95% CIs: 0.65 – 2.4)]. However, RAM cannula group had higher rates of reintubation within &amp;lt;=7 days after extubation (89.5% vs 68.5%; adjOR 3.87(95% CIs: 1.18, 12.73), p-value=0.026] and higher incidence of IVH [62.9% vs 38.6%; 2.77(95% CIs: 1.39, 5.53), p-value 0.004], with lesser infants weaned to room air prior to discharge [58.1% vs 76.1.6%; adjOR 0.42(95% CIs: 0.21, 0.85), p-value 0.016]. In the stratified analyses by GA, these differences were noted to be restricted to those born at &amp;gt;=26 weeks, with an additional risk for increased BPD36 (adjORs 2.76 (95% CIs: 1.16, 6.57), p-value 0.022] associated with the RAM cannula use in this stratum. Conclusion Post-extubation NIV support via RAM cannula, as compared to IFD systems, was associated with higher rates of reintubation in &amp;lt;=7 days, IVH, with a greater number of infants discharged home on supplemental oxygen.

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.

Association of Antenatal Steroid Exposure at 21 to 22 Weeks of Gestation With Neonatal Survival and Survival Without Morbidities

The provision of antenatal corticosteroids to pregnant patients at gestational age (GA) 22 6/7 weeks or less remains controversial and lacks support from randomized clinical trials. To compare rates of survival and survival without major morbidities among infants born at GA 22 0/7 to 23 6/7 weeks after exposure to antenatal steroids at 22 6/7 weeks' gestation or less vs no exposure to antenatal steroids. This cohort study enrolled infants born at GA 22 0/7 to 23 6/7 weeks between January 1, 2016, and December 31, 2019, at centers in the National Institute of Child Health and Human Development Neonatal Research Network. Infants who did not receive intensive care and infants with antenatal steroid exposure after GA 22 6/7 weeks were excluded. Infants were classified as having no, partial, or complete exposure to antenatal steroids. The primary outcome was survival to discharge. The main secondary outcome was survival without major neonatal morbidity. The associations of differential exposures to antenatal steroids with outcomes were evaluated using logistic regression, adjusting for GA, sex, race, maternal education, small for GA status, mode of delivery, multiple birth, prolonged rupture of membranes, year of birth, and Neonatal Research Network center. A total of 431 infants (mean [SD] GA, 22.6 [0.5] weeks; 232 [53.8%] boys) were included, with 110 infants (25.5%) receiving no antenatal steroids, 80 infants (18.6%) receiving partial antenatal steroids, and 241 infants (55.9%) receiving complete antenatal steroids. Seventeen infants were exposed to antenatal steroids at GA 21 weeks. Among infants exposed to complete antenatal steroids, 130 (53.9%) survived to discharge, compared with 30 infants (37.5%) with partial antenatal steroid exposure and 239 infants (35.5%) with no antenatal steroids. Infants born after complete antenatal steroid exposure, compared with those without antenatal steroid exposure, were more likely to survive to discharge (adjusted odds ratio [aOR], 1.95 [95% CI, 1.07-3.56]) and to survive without major morbidity (aOR, 2.74 [95% CI, 1.19-6.30]). In this retrospective cohort study, among infants born between GA 22 0/7 and 23 6/7 weeks who received intensive care, exposure to a complete course of antenatal steroids at GA 22 6/7 weeks or less was independently associated with greater odds of survival and survival without major morbidity. These data suggest that the use of antenatal steroids in patients at GA 22 6/7 weeks or less could be beneficial when active treatment is considered.

Admission temperature of very low birth weight infants and outcomes at three years old

The lower body temperature of preterm newborns at admission to neonatal intensive care units (NICUs) is inversely associated with their morbidities and mortalities before discharge. This retrospective cohort study aimed to determine whether admission rectal temperature in very low birth weight infants (VLBWIs) is independently associated with a composite outcome of death or moderate-to-severe neurodevelopmental impairments as defined by a performance developmental quotient of < 70 at three years of age. VLBWIs admitted to the NICU between April 2010 and March 2016 were assesed. Developmental assessment was completed in 216 newborns. Nine and two infants died before and after discharge, respectively. A higher admission temperature was associated with a lower incidence of death or moderate-to-severe neurodevelopmental impairments with adjustment for gestational age, sex, antenatal steroid use, Apgar score, severe intraventricular hemorrhage, and severe bronchopulmonary dysplasia (odds ratio [OR] 0.424; 95% confidence interval [CI] 0.250–0.717; p = 0.001). The admission temperature remained as an independent variable of adverse outcome at three years of age even when the study cohort was limited to surviving infants (OR 0.448; 95% CI 0.259–0.774; p = 0.004). Further studies are needed to assess whether avoiding low body temperature at admission results in better long-term neurodevelopmental outcomes in VLBWIs.