Trends in care practices, morbidity, and mortality of extremely preterm Neonates, 1993-2012

Barbara J. Stoll, Nellie I. Hansen, Edward F. Bell, Michele C. Walsh, Waldemar A. Carlo, Seetha Shankaran, Abbot R. Laptook, Pablo J. Sánchez, Krisa P. Van Meurs, Myra Wyckoff, Abhik Das, Ellen C. Hale, M. Bethany Ball, Nancy S. Newman, Kurt Schibler, Brenda B. Poindexter, Kathleen A. Kennedy, C. Michael Cotten, Kristi L. Watterberg, Carl T. D'Angio & 4 others Sara B. DeMauro, William E. Truog, Uday Devaskar, Rosemary D. Higgins

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Abstract

IMPORTANCE Extremely preterm infants contribute disproportionately to neonatal morbidity and mortality. OBJECTIVE To review 20-year trends in maternal/neonatal care, complications, and mortality among extremely preterm infants born at Neonatal Research Network centers. DESIGN, SETTING,PARTICIPANTS Prospectiveregistryof34 636infants,22 to 28 weeks'gestation, birth weight of 401 to 1500 g, and born at 26 network centers between 1993 and 2012. EXPOSURES Extremely preterm birth. MAIN OUTCOMES AND MEASURES Maternal/neonatal care, morbidities, and survival. Major morbidities, reported for infants who survived more than 12 hours, were severe necrotizing enterocolitis, infection, bronchopulmonary dysplasia, severe intracranial hemorrhage, cystic periventricular leukomalacia, and/or severe retinopathy of prematurity. Regression models assessed yearly changes and were adjusted for study center, race/ethnicity, gestational age, birth weight for gestational age, and sex. RESULTS Use of antenatal corticosteroids increased from 1993 to 2012 (24%[348 of 1431 infants]) to 87%(1674 of 1919 infants]; P <.001), as did cesarean delivery (44%[625 of 1431 births] to 64%[1227 of 1921]; P <.001). Delivery room intubation decreased from80%(1144 of 1433 infants) in 1993 to 65%(1253 of 1922) in 2012 (P <.001). After increasing in the 1990s, postnatal steroid use declined to 8%(141 of 1757 infants) in 2004 (P <.001), with no significant change thereafter. Although most infantswere ventilated, continuous positive airway pressure without ventilation increased from 7%(120of 1666 infants) in 2002 to 11% (190 of 1756 infants) in 2012 (P <.001). Despite no improvement from 1993 to 2004, rates of late-onset sepsis declined between 2005 and 2012 for infants of each gestational age (median, 26weeks [37% {109 of 296} to 27%{85 of 320}]; adjusted relative risk [RR],0.93 [95%CI,0.92-0.94]). Rates of other morbidities declined, but bronchopulmonary dysplasia increased between 2009 and 2012 for infants at 26 to 27weeks' gestation (26weeks,50%[130 of 258] to 55%[164 of 297]; P <.001). Survival increased between 2009 and 2012 for infants at 23weeks' gestation (27%[41 of 152] to 33%[50 of 150]; adjusted RR, 1.09 [95%CI, 1.05-1.14]) and 24weeks (63%[156 of 248] to 65%[174 of 269]; adjusted RR, 1.05 [95%CI, 1.03-1.07]), with smaller relative increases for infants at 25 and 27weeks' gestation, and no change for infants at 22, 26, and 28weeks' gestation. Survival without major morbidity increased approximately 2%per year for infants at 25 to 28weeks' gestation, with no change for infants at 22 to 24weeks' gestation. CONCLUSIONS AND RELEVANCE Among extremely preterm infants born at US academic centers over the last 20 years, changes in maternal and infant care practices and modest reductions in several morbidities were observed, although bronchopulmonary dysplasia increased. Survival increased most markedly for infants born at 23 and 24 weeks' gestation and survival without major morbidity increased for infants aged 25 to 28 weeks. These findings may be valuable in counseling families and developing novel interventions.

Original languageEnglish (US)
Pages (from-to)1039-1051
Number of pages13
JournalJAMA - Journal of the American Medical Association
Volume314
Issue number10
DOIs
StatePublished - Sep 8 2015

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Newborn Infant
Morbidity
Mortality
Pregnancy
Extremely Premature Infants
Bronchopulmonary Dysplasia
Gestational Age
Mothers
Birth Weight
Periventricular Leukomalacia
Delivery Rooms
Infant Care
Retinopathy of Prematurity
Necrotizing Enterocolitis
Continuous Positive Airway Pressure
Intracranial Hemorrhages
Premature Birth
Infant Mortality
Intubation
Ventilation

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Stoll, B. J., Hansen, N. I., Bell, E. F., Walsh, M. C., Carlo, W. A., Shankaran, S., ... Higgins, R. D. (2015). Trends in care practices, morbidity, and mortality of extremely preterm Neonates, 1993-2012. JAMA - Journal of the American Medical Association, 314(10), 1039-1051. https://doi.org/10.1001/jama.2015.10244

Trends in care practices, morbidity, and mortality of extremely preterm Neonates, 1993-2012. / Stoll, Barbara J.; Hansen, Nellie I.; Bell, Edward F.; Walsh, Michele C.; Carlo, Waldemar A.; Shankaran, Seetha; Laptook, Abbot R.; Sánchez, Pablo J.; Van Meurs, Krisa P.; Wyckoff, Myra; Das, Abhik; Hale, Ellen C.; Bethany Ball, M.; Newman, Nancy S.; Schibler, Kurt; Poindexter, Brenda B.; Kennedy, Kathleen A.; Michael Cotten, C.; Watterberg, Kristi L.; D'Angio, Carl T.; DeMauro, Sara B.; Truog, William E.; Devaskar, Uday; Higgins, Rosemary D.

In: JAMA - Journal of the American Medical Association, Vol. 314, No. 10, 08.09.2015, p. 1039-1051.

Research output: Contribution to journalArticle

Stoll, BJ, Hansen, NI, Bell, EF, Walsh, MC, Carlo, WA, Shankaran, S, Laptook, AR, Sánchez, PJ, Van Meurs, KP, Wyckoff, M, Das, A, Hale, EC, Bethany Ball, M, Newman, NS, Schibler, K, Poindexter, BB, Kennedy, KA, Michael Cotten, C, Watterberg, KL, D'Angio, CT, DeMauro, SB, Truog, WE, Devaskar, U & Higgins, RD 2015, 'Trends in care practices, morbidity, and mortality of extremely preterm Neonates, 1993-2012', JAMA - Journal of the American Medical Association, vol. 314, no. 10, pp. 1039-1051. https://doi.org/10.1001/jama.2015.10244
Stoll, Barbara J. ; Hansen, Nellie I. ; Bell, Edward F. ; Walsh, Michele C. ; Carlo, Waldemar A. ; Shankaran, Seetha ; Laptook, Abbot R. ; Sánchez, Pablo J. ; Van Meurs, Krisa P. ; Wyckoff, Myra ; Das, Abhik ; Hale, Ellen C. ; Bethany Ball, M. ; Newman, Nancy S. ; Schibler, Kurt ; Poindexter, Brenda B. ; Kennedy, Kathleen A. ; Michael Cotten, C. ; Watterberg, Kristi L. ; D'Angio, Carl T. ; DeMauro, Sara B. ; Truog, William E. ; Devaskar, Uday ; Higgins, Rosemary D. / Trends in care practices, morbidity, and mortality of extremely preterm Neonates, 1993-2012. In: JAMA - Journal of the American Medical Association. 2015 ; Vol. 314, No. 10. pp. 1039-1051.
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abstract = "IMPORTANCE Extremely preterm infants contribute disproportionately to neonatal morbidity and mortality. OBJECTIVE To review 20-year trends in maternal/neonatal care, complications, and mortality among extremely preterm infants born at Neonatal Research Network centers. DESIGN, SETTING,PARTICIPANTS Prospectiveregistryof34 636infants,22 to 28 weeks'gestation, birth weight of 401 to 1500 g, and born at 26 network centers between 1993 and 2012. EXPOSURES Extremely preterm birth. MAIN OUTCOMES AND MEASURES Maternal/neonatal care, morbidities, and survival. Major morbidities, reported for infants who survived more than 12 hours, were severe necrotizing enterocolitis, infection, bronchopulmonary dysplasia, severe intracranial hemorrhage, cystic periventricular leukomalacia, and/or severe retinopathy of prematurity. Regression models assessed yearly changes and were adjusted for study center, race/ethnicity, gestational age, birth weight for gestational age, and sex. RESULTS Use of antenatal corticosteroids increased from 1993 to 2012 (24{\%}[348 of 1431 infants]) to 87{\%}(1674 of 1919 infants]; P <.001), as did cesarean delivery (44{\%}[625 of 1431 births] to 64{\%}[1227 of 1921]; P <.001). Delivery room intubation decreased from80{\%}(1144 of 1433 infants) in 1993 to 65{\%}(1253 of 1922) in 2012 (P <.001). After increasing in the 1990s, postnatal steroid use declined to 8{\%}(141 of 1757 infants) in 2004 (P <.001), with no significant change thereafter. Although most infantswere ventilated, continuous positive airway pressure without ventilation increased from 7{\%}(120of 1666 infants) in 2002 to 11{\%} (190 of 1756 infants) in 2012 (P <.001). Despite no improvement from 1993 to 2004, rates of late-onset sepsis declined between 2005 and 2012 for infants of each gestational age (median, 26weeks [37{\%} {109 of 296} to 27{\%}{85 of 320}]; adjusted relative risk [RR],0.93 [95{\%}CI,0.92-0.94]). Rates of other morbidities declined, but bronchopulmonary dysplasia increased between 2009 and 2012 for infants at 26 to 27weeks' gestation (26weeks,50{\%}[130 of 258] to 55{\%}[164 of 297]; P <.001). Survival increased between 2009 and 2012 for infants at 23weeks' gestation (27{\%}[41 of 152] to 33{\%}[50 of 150]; adjusted RR, 1.09 [95{\%}CI, 1.05-1.14]) and 24weeks (63{\%}[156 of 248] to 65{\%}[174 of 269]; adjusted RR, 1.05 [95{\%}CI, 1.03-1.07]), with smaller relative increases for infants at 25 and 27weeks' gestation, and no change for infants at 22, 26, and 28weeks' gestation. Survival without major morbidity increased approximately 2{\%}per year for infants at 25 to 28weeks' gestation, with no change for infants at 22 to 24weeks' gestation. CONCLUSIONS AND RELEVANCE Among extremely preterm infants born at US academic centers over the last 20 years, changes in maternal and infant care practices and modest reductions in several morbidities were observed, although bronchopulmonary dysplasia increased. Survival increased most markedly for infants born at 23 and 24 weeks' gestation and survival without major morbidity increased for infants aged 25 to 28 weeks. These findings may be valuable in counseling families and developing novel interventions.",
author = "Stoll, {Barbara J.} and Hansen, {Nellie I.} and Bell, {Edward F.} and Walsh, {Michele C.} and Carlo, {Waldemar A.} and Seetha Shankaran and Laptook, {Abbot R.} and S{\'a}nchez, {Pablo J.} and {Van Meurs}, {Krisa P.} and Myra Wyckoff and Abhik Das and Hale, {Ellen C.} and {Bethany Ball}, M. and Newman, {Nancy S.} and Kurt Schibler and Poindexter, {Brenda B.} and Kennedy, {Kathleen A.} and {Michael Cotten}, C. and Watterberg, {Kristi L.} and D'Angio, {Carl T.} and DeMauro, {Sara B.} and Truog, {William E.} and Uday Devaskar and Higgins, {Rosemary D.}",
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TY - JOUR

T1 - Trends in care practices, morbidity, and mortality of extremely preterm Neonates, 1993-2012

AU - Stoll, Barbara J.

AU - Hansen, Nellie I.

AU - Bell, Edward F.

AU - Walsh, Michele C.

AU - Carlo, Waldemar A.

AU - Shankaran, Seetha

AU - Laptook, Abbot R.

AU - Sánchez, Pablo J.

AU - Van Meurs, Krisa P.

AU - Wyckoff, Myra

AU - Das, Abhik

AU - Hale, Ellen C.

AU - Bethany Ball, M.

AU - Newman, Nancy S.

AU - Schibler, Kurt

AU - Poindexter, Brenda B.

AU - Kennedy, Kathleen A.

AU - Michael Cotten, C.

AU - Watterberg, Kristi L.

AU - D'Angio, Carl T.

AU - DeMauro, Sara B.

AU - Truog, William E.

AU - Devaskar, Uday

AU - Higgins, Rosemary D.

PY - 2015/9/8

Y1 - 2015/9/8

N2 - IMPORTANCE Extremely preterm infants contribute disproportionately to neonatal morbidity and mortality. OBJECTIVE To review 20-year trends in maternal/neonatal care, complications, and mortality among extremely preterm infants born at Neonatal Research Network centers. DESIGN, SETTING,PARTICIPANTS Prospectiveregistryof34 636infants,22 to 28 weeks'gestation, birth weight of 401 to 1500 g, and born at 26 network centers between 1993 and 2012. EXPOSURES Extremely preterm birth. MAIN OUTCOMES AND MEASURES Maternal/neonatal care, morbidities, and survival. Major morbidities, reported for infants who survived more than 12 hours, were severe necrotizing enterocolitis, infection, bronchopulmonary dysplasia, severe intracranial hemorrhage, cystic periventricular leukomalacia, and/or severe retinopathy of prematurity. Regression models assessed yearly changes and were adjusted for study center, race/ethnicity, gestational age, birth weight for gestational age, and sex. RESULTS Use of antenatal corticosteroids increased from 1993 to 2012 (24%[348 of 1431 infants]) to 87%(1674 of 1919 infants]; P <.001), as did cesarean delivery (44%[625 of 1431 births] to 64%[1227 of 1921]; P <.001). Delivery room intubation decreased from80%(1144 of 1433 infants) in 1993 to 65%(1253 of 1922) in 2012 (P <.001). After increasing in the 1990s, postnatal steroid use declined to 8%(141 of 1757 infants) in 2004 (P <.001), with no significant change thereafter. Although most infantswere ventilated, continuous positive airway pressure without ventilation increased from 7%(120of 1666 infants) in 2002 to 11% (190 of 1756 infants) in 2012 (P <.001). Despite no improvement from 1993 to 2004, rates of late-onset sepsis declined between 2005 and 2012 for infants of each gestational age (median, 26weeks [37% {109 of 296} to 27%{85 of 320}]; adjusted relative risk [RR],0.93 [95%CI,0.92-0.94]). Rates of other morbidities declined, but bronchopulmonary dysplasia increased between 2009 and 2012 for infants at 26 to 27weeks' gestation (26weeks,50%[130 of 258] to 55%[164 of 297]; P <.001). Survival increased between 2009 and 2012 for infants at 23weeks' gestation (27%[41 of 152] to 33%[50 of 150]; adjusted RR, 1.09 [95%CI, 1.05-1.14]) and 24weeks (63%[156 of 248] to 65%[174 of 269]; adjusted RR, 1.05 [95%CI, 1.03-1.07]), with smaller relative increases for infants at 25 and 27weeks' gestation, and no change for infants at 22, 26, and 28weeks' gestation. Survival without major morbidity increased approximately 2%per year for infants at 25 to 28weeks' gestation, with no change for infants at 22 to 24weeks' gestation. CONCLUSIONS AND RELEVANCE Among extremely preterm infants born at US academic centers over the last 20 years, changes in maternal and infant care practices and modest reductions in several morbidities were observed, although bronchopulmonary dysplasia increased. Survival increased most markedly for infants born at 23 and 24 weeks' gestation and survival without major morbidity increased for infants aged 25 to 28 weeks. These findings may be valuable in counseling families and developing novel interventions.

AB - IMPORTANCE Extremely preterm infants contribute disproportionately to neonatal morbidity and mortality. OBJECTIVE To review 20-year trends in maternal/neonatal care, complications, and mortality among extremely preterm infants born at Neonatal Research Network centers. DESIGN, SETTING,PARTICIPANTS Prospectiveregistryof34 636infants,22 to 28 weeks'gestation, birth weight of 401 to 1500 g, and born at 26 network centers between 1993 and 2012. EXPOSURES Extremely preterm birth. MAIN OUTCOMES AND MEASURES Maternal/neonatal care, morbidities, and survival. Major morbidities, reported for infants who survived more than 12 hours, were severe necrotizing enterocolitis, infection, bronchopulmonary dysplasia, severe intracranial hemorrhage, cystic periventricular leukomalacia, and/or severe retinopathy of prematurity. Regression models assessed yearly changes and were adjusted for study center, race/ethnicity, gestational age, birth weight for gestational age, and sex. RESULTS Use of antenatal corticosteroids increased from 1993 to 2012 (24%[348 of 1431 infants]) to 87%(1674 of 1919 infants]; P <.001), as did cesarean delivery (44%[625 of 1431 births] to 64%[1227 of 1921]; P <.001). Delivery room intubation decreased from80%(1144 of 1433 infants) in 1993 to 65%(1253 of 1922) in 2012 (P <.001). After increasing in the 1990s, postnatal steroid use declined to 8%(141 of 1757 infants) in 2004 (P <.001), with no significant change thereafter. Although most infantswere ventilated, continuous positive airway pressure without ventilation increased from 7%(120of 1666 infants) in 2002 to 11% (190 of 1756 infants) in 2012 (P <.001). Despite no improvement from 1993 to 2004, rates of late-onset sepsis declined between 2005 and 2012 for infants of each gestational age (median, 26weeks [37% {109 of 296} to 27%{85 of 320}]; adjusted relative risk [RR],0.93 [95%CI,0.92-0.94]). Rates of other morbidities declined, but bronchopulmonary dysplasia increased between 2009 and 2012 for infants at 26 to 27weeks' gestation (26weeks,50%[130 of 258] to 55%[164 of 297]; P <.001). Survival increased between 2009 and 2012 for infants at 23weeks' gestation (27%[41 of 152] to 33%[50 of 150]; adjusted RR, 1.09 [95%CI, 1.05-1.14]) and 24weeks (63%[156 of 248] to 65%[174 of 269]; adjusted RR, 1.05 [95%CI, 1.03-1.07]), with smaller relative increases for infants at 25 and 27weeks' gestation, and no change for infants at 22, 26, and 28weeks' gestation. Survival without major morbidity increased approximately 2%per year for infants at 25 to 28weeks' gestation, with no change for infants at 22 to 24weeks' gestation. CONCLUSIONS AND RELEVANCE Among extremely preterm infants born at US academic centers over the last 20 years, changes in maternal and infant care practices and modest reductions in several morbidities were observed, although bronchopulmonary dysplasia increased. Survival increased most markedly for infants born at 23 and 24 weeks' gestation and survival without major morbidity increased for infants aged 25 to 28 weeks. These findings may be valuable in counseling families and developing novel interventions.

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