Transcript Slide 1

Incidence of Early Neonatal Mortality and
Morbidity After Late Preterm and Term
Caesarian Delivery De Luca et al Pediatrics vol 123
no. 6 2009
Respiratory morbidity
Incidence of Early Neonatal Mortality and
Morbidity After Late Preterm and Term
Caesarian Delivery De Luca et al Pediatrics vol 123
no. 6 2009
Elective Cesarian vs Planned Vaginal Delivery
Getting evidence into obstetric practice;
appropriate timing of caesarian section
Nicholl and Cattell Australian Health review 2010,34,90-92
• Aim: to reduce rate of term elective CS with no medical
indication before 39 completed weeks, from 30% to 10%
of all term elective CS (both private and public) over a 6
month period in 2007
• Method: multidisciplinary project formed to investigate
the extent of the problem and work out the intervention
which was essentially pre-emptive education of all
midwifery and obstetric staff and provision of evidence
folders in key clinical areas
Getting evidence into obstetric practice;
appropriate timing of caesarian section
Nicholl and Cattell Australian Health review 2010,34,90-92
Getting evidence into obstetric practice;
appropriate timing of caesarian section
Nicholl and Cattell Australian Health review 2010,34,90-92
Prenatal Steroid Prophylaxis for Women Delivering
at Late Preterm Gestation. Pediatrics. K S Joseph et
al. November 2008
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Looked at patterns of prenatal steroid use, RDS, and deaths from RDS in all
live-born infants(USA and Nova Scotia)
3 cohorts all live-births in the USA 1989-91,1995-97, 2002-4
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Results
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Deaths from RDS decreased in each time period for 28-32 weeks, but not
33-36 weeks in the last time period
Steroid use in all preterms increased in the first time period then static (at
50% in under 32 weeks) with corresponding reduction in RDS (steroid use
in 33-36 weeks peaked at only 15% in 3rd time period)
Rates of induction and LSCS increased contributing to the documented
increase in preterm birth rates
Steroids could reduce RDS substantially at 33-34 weeks gestation
Recommend steroid prophylaxis at 33-34 weeks gestation and consider at
35-36 weeks gestation
(These are of course very low rates across the board cf. UK/Australasia)
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Early discharge Among Late Preterm and
Term Newborns and Risk of Neonatal
Morbidity Tomashek et al Semin Perinatol 30 2006
• 1004 late preterm/ 24320 term infants
• Vaginal delivery, discharge within 48 hours
• Readmission, observational stays recorded for
first 28 days of life
• Late pre- terms almost twice as likely to be
readmitted and 1.5 times more likely to require
subsequent hospital related care
• Breast feeding late pre-terms more likely to have
↑ morbidity than non breast fed
Long Term Preterm Outcomes
• McCormick. `Two possibilities
require further elucidation. The first
is that preterm delivery is as a result
of, not a precursor to conditions
resulting in significant disability.
• ………The second possibility,
especially for less severe disability
is the post-discharge environment of
the preterm infant.
Long term Outcome of the Late Preterm 2
Petrini J. Increased risk of Adverse Neurological
Development for Late Preterm Infants J Ped Feb 2009
Incidence of neurodevelopmental outcomes by
gestational age (3-week average incidence)
Developmental Delay/Mental
Retardation
Seizures
60
50
40
30
20
10
0
Gestational Age in Weeks
43
40
37
Any
34
31
Incidence per 1,000 children
Cerebral Palsy
Long term Outcome of the Late
Preterm 3 Moster D. Long Term Medical and Social
Consequences of Preterm Birth N Eng J M 2008 359; 262273
• All infants born alive1967-1983 without
congenital anomalies in Norway. Late preterm
infants were more likely to have
• Cerebral palsy 2.7 times (95% CI 2.2-3.3)
• Intellectual Disability 1.6 times (95% CI 1.4-1.8)
• Other Major disabilities (blindness, hearing loss,
seizures) 1.5 times ( (95%CI 1.2-1.8)
• Also schizophrenia, disorders of pschological
development, behaviour, and emotion more
common
Proportion of children with
special educational needs
MacKay et al PLoS Medicine 7(6): e1000289. doi:10.1371/journal.pmed.1000289
Prevalence, Stability, and Predictors of
Clinically significant Behavioural Problems in
LBW Children at 3, 5, and 8 years of age
Gray et al Pediatrics 2004;114;736-743
• 869/985 low birth weight infants studied as part
of larger Infant Health and Development
Program
• 19-21% of infants born at 34-37 weeks gestation
had clinically significant behavioural problems at
8years
• The rates were similar to those born in 31-34
week and 25-30 week gestation cohorts
• This is double that expected in term infants
• These rates remained stable over time
School Outcomes of Late Preterm infants: Special
Needs and Challenges for infants born at 32-36
Weeks Gestation 2 Lisa Chyl et al. J Pediatr. July 2008
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Results for late preterm infants(34-36wks)
(adjusted for sex, race, maternal education)
Lower reading scores to 1st grade (p<0.05)
Poor reading and maths scores risk  at 1st grade
(p<0.05)
Teacher evaluations for reading and maths worse (both
p<0.05)
Special education participation higher in late preterm
infants in early grades
Some catch up in later grades (3rd and 5th)
A gradient of outcome demonstrated with 32-33 wks
doing the worst.
The study results have implications for directing
resources in early childhood and early school ages
Morse S Paediatrics April 2009 Early School-age
Outcomes of Late Preterm Infants
Estimates of the cost and length of stay changes
that can be attributed to one-week increases in
gestational age for premature infants Phibbs et al. Early
Human Development(2006) 82 85-95
• Estimated potential savings per one week
increases in gestational age for pre-terms
• California cohort data -all births 1998-2000
• Mean $30,145 at 33 wks (n=4,719)
$10,535 at 34wks (n=14,541)
$6,007 at 35 wks (n=25,077)
$3,444 at 36 weeks (n=44,922)
Cardiovascular risk factors at age 30
following pre-term birth : Dalziel et al
International J of Epidemiology 2007
• Low gestational age at birth ( but not birth
weight) associated with increased adult
BP and insulin resistance
• At age 30 twice as many participants with
diagnosed hypertension in the preterm
group
• 80% of the preterm group born at >32
weeks gestation
Late preterm birth increases
hypertension in young adulthood
All Swedish births 1973-9
n = 636,552
25-37 years old
Hypertensive prescription
in year of study
23-27 weeks
28-32 weeks
33-34 weeks
35-36 weeks
37-42 weeks
≥43 weeks
unadjusted
adjusted
hypertensive prescription
OR (95% CI)
Crump et al Am J Epidemiol 2011; 173:797-803
Treatment perceptions
for level 2 and level 3 Parent’s Perceptions of Illness Severity in high
risk Newborns Stacey Brooks1, Keith Petrie1, Simon Rowley2
1 Dept of Psychological Medicine, University of Auckland
2 Nation women’s Health, ACH
Level 2
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Level 3
Mothers
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Clinicians
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Mean rating
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1
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Treatment is helpful
Treatment will improve
condition
Treatment will improve long
term effects
Treatment perception
Wilcoxon Signed Ranks Test. Based on positive ranks **p<.01;*p<0.5
Morbidities in the Late Preterm
Compared with term infants late preterm infants have
higher rates of
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Respiratory distress
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Apnoea
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Hypothermia
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Hypoglycaemia
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Feeding –nasogastric tubes, iv infusions
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Sepsis evaluations
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Jaundice, kernicterus
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Hospital re-admissions
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SIDS(2 times rate)
Long term issues –development and behaviour
- diabetes
-heart disease, hypertension
Mortality
Neonatal and 5 year outcomes after birth at
30-34 weeks of gestation; Marret et al: Obstet
Gynecol 2007;110;72-80
• Regional study, large cohort (EPIPAGE study)
born 1997 (2018 /2467of 30-34 weeks GA
infants followed up, 1461 to 5 years)Medical and
neuropsych assessment at 5 years
• All adverse neonatal outcomes decreased with
increasing gestational age
• Cerebral palsy in -6.3% at 30 weeks
- 3.7% at 33 weeks
-0.7% at 34 weeks
• 25% at 33 or 34 weeks had mild to severe
cognitive impairment (> 2x general pop)
School Outcomes of Late Preterm infants: Special
Needs and Challenges for infants born at 32-36
Weeks Gestation 1 Lisa Chyl et al. J Pediatr. July 2008
• Data from the Early childhood Longitudinal
Study-Kindergarten cohort
• 2 cohorts out of 970 preterm infants (32-33wks,
34-36wks compared with 13,671 term controls
• Test scores, teacher evaluations, and special
education enrolments from kindergarten
compared
• Testing hypothesis that infants born in USA at
32-36 weeks gestation without significant
neonatal complications had higher rates of
learning difficulties than term classmates
Cardiovascular risk factors at age 30
following pre-term birth : Dalziel et al
International J of Epidemiology 2007
• 458/988 30 year olds from RCT of
antenatal steroids (Liggins and Howie
1972)
• 147 born at term, 311 born preterm
• Aim to look at influence of gestational age
and fetal growth (birth weight z scores) on
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systemic BP
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fasting cholesterol, TG, cortisol
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insulin, glucose following oral GTT
Long term Outcome of the Late
Preterm 2 Petrini J. Increased risk of Adverse
Neurological Development for Late Preterm Infants J Ped
Feb 2009
• Californian retrospective study using hospital
databases
• Decreasing gestational age associated with
increasing risk of cerebral palsy, developmental
delay and mental retardation
• Late preterm 3 times more likely to have
cerebral palsy. Modest increased risk of
intellectual disability and developmental delay
OR 1.25 (1.01-1.54)
Reproduction by gestational age at birth in women and men
born in 1967-1976
Swamy et al, JAMA 2008;299(12):1429
Long term Outcome of the Late
Preterm 1 Morse S Paediatrics April 2009 Early
School-age Outcomes of Late Preterm Infants
• Born in Florida 1996-7 at 34-41
weeks.(n=15,2661)
• Exclusion of babies who stayed more than 3
days, multiples, cong abnormalities and
transfers ( ie a ‘healthy’ population)
• Late preterms compared to terms had  risk of
developmental delay or disability
• 4.3% versus 3% -early childhood
• 4.5% vs 3.9% -prekindergarten at 3yrs
• 7.4% vs 6.6% -pre -school at 5yrs
Infants need to actively maintain a FRC.
Compliance decreases with increasing gestational
age
Cardiovascular risk factors at age 30
following pre-term birth : Dalziel et al
International J of Epidemiology 2007
• Conclusion: Adults born moderately
preterm have increased BP and insulin
resistance. Preterm birth rather than poor
fetal growth is the major determinant of
this.
Short Term Outcomes of Infants Born
at 35 and 36 Weeks Gestation: We
Need to Ask More Questions. Escobar et al.
Semin Perinatol 30:28-33 2006
Reviewed existing published data quantifying short
term hospital outcomes of 35-36 weeks
gestation (death, resp distress requiring support,
re-hospitalisation)
At 35-36 weeks infants8% supplemental oxygen (3x term rate)
Mortality 0.8%
Re-hospitalisation rates higher ( only
significant at 36 weeks)
Feeding Problems of Late Preterms
 Suck – ineffective
 Latch – difficult
 May benefit from nipple shield
 Does not open mouth wide with stimulus
 Abnormal tongue movements
 Can’t attain grasp
 Low suck frequency
 Can’t sustain negative pressure
 Insufficient suckling to initiate milk ejection response
 Doesn’t nurse long enough to provide sufficient flow to constitute
a complete feed.
 Behavioural states less defined
 Tires easily
 Quiet or active alert
 Crying, deep sleep
 Light or active sleep,drowsy
Breast feeding rates in the late
preterm Merewood, A, Brooks, D, Bauchner, H, et al. Maternal
birthplace and breastfeeding initiation among term and preterm infants:
a statewide assessment for Massachusetts. Pediatrics 2006;
118:e1048.
• Singleton breastfeeding initiation rates
• -63% 24-31wks
• -70% 32-37wks
• -77% term
• Decreasing rates with decreasing
prematurity
Decreased expiratory flow in
infants who were healthy late
preterms
Colin et al Pediatrics 2010; 126: 115-128
Cost of the late preterm
The Cost of Prematurity: Quantification by Gestational Age and Birth
Weight.
Gilbert et al Obstet Gynecol Sept 2003
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Increasing length of stay and cost..
At 34 wks LOS 5.9 days, cost $7200
At 35 wks LOS 3.9 days, cost $4200
At 36 wks LOS 2.8 days cost $2600
This trend continues with increasing gestation so
that at 38 weeks, LOS is 1.8 days and cost is
$1100
•  Frequency of complications
• Medical outcomes a hidden cost
• Hospital readmission rates 2-3 fold higher than
full term
Background
• Clinician’s perceptions of illness structured
around NICU education, NICU experience, peer
network of other health professionals -are likely
to be more objective than lay perceptions
• There is likely mismatch between parent and
physician perception of illness severity
• In adults it has been shown that illness severity
perception may have significant effect on
adjustment and recovery from a health condition
Implications
• Clinicians should be aware that parents’ views of
their infants’ illness are likely to be significantly
more negative than their own assessments. This
may lead to miscommunications.
• This is more likely with the less sick level 2
infants
• Currently more clinician time is spent talking with
parents of the sicker level 3 infants
• This study suggests that clinicians consider
increasing communication with parents of the
less sick infants
Perinatal Outcomes Associated with Preterm Birth at 33 to
36 Weeks’ Gestation: A Population-Based Cohort Study :
Khasu et al Pediatrics 2009; 123
• British Columbia Perinatal Database Registry
accessed
• All singleton births from 33-40 weeks gestation
1999-2002
• Mortality and morbidity data compared between
33-36 wks(n=6,381) and term(n=88,867) groups
• Stilbirth, perinatal, neonatal, and infant mortality
rates significantly higher in the late preterm
group
• Late preterms had significantly higher incidence
of respiratory morbidity and infection
Risk factors for the Development of RDS
and TTN in Newborn Infants –Dani et al. Eur
Resp J;199; 14; 155-159
Illness perceptions of level 2 and level 3 mothers
Parent’s Perceptions of Illness Severity in high risk Newborns Stacey Brooks1,
Keith Petrie1, Simon Rowley2
1 Dept of Psychological Medicine, University of Auckland
2 Nation women’s Health, ACH
Mann Whitney U test **p<.01; * p<.05
Parent’s Perceptions of Illness
Severity in high risk Newborns
Stacey Brooks1, Keith Petrie1, Simon
Rowley2
1 Dept of Psychological Medicine, University of Auckland
2 Nation women’s Health, ACH
Re-admission of the late Preterm
• Rates 2-3 times higher than term infants
• 3-5 times more likely to be be admitted in
1st 15 days after discharge from maternity
• Causes include jaundice, feeding
difficulties, poor weight gain, dehydration,
and apnoea
• For late readmissions bronchiolitis and
gastroenteritis are most common
Kernicterus in Late Preterm Infants Cared for as
Term Healthy Infants. Bhutani, Semin Perinatol 2006;
30:89-97
Perinatal Outcomes Associated with Preterm Birth at 33 to
36 Weeks’ Gestation: A Population-Based Cohort Study :
Khasu et al Pediatrics 2009; 123