Perinatal factors associated with early deaths of preterm infants born in Brazilian Networkon Neonatal Research centers

Almeida, Maria Fernanda Branco de; Guinsburg, Ruth; Martinez, Francisco Eulógio; Procianoy, Renato S.; Leone, Cléa Rodrigues; Marba, Sérgio Tadeu Martins; Rugolo, Lígia Maria Suppo de Souza; Luz, Jorge Hecker; Lopes, José Maria de Andrade

doi:10.2223/jped.1787

Cited by 53 publications

(47 citation statements)

References 25 publications

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“…The report of the Apgar score less than seven at 5 minutes of life in 71% of 2,548 infants who had this information available is a strong association observed in several studies, such as the Brazilian Neonatal Research Network (24) . It may express the time and degree of fetal distress or even ineffective implementation of neonatal resuscitation procedures due to the conditions of deficient infrastructure and human resources of health services, promoting death of newborns in the first 24 hours of life.…”

Section: Discussionmentioning

confidence: 66%

Asfixia perinatal associada à mortalidade neonatal precoce: estudo populacional dos óbitos evitáveis

Daripa

Caldas

Flores

et al. 2013

Rev. paul. pediatr.

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Perinatal asphyxia associated with early neonatal mortality: populational study of avoidable deathsResults: During the three years, 1.71 deaths per 1,000 live births were associated with perinatal asphyxia, which corresponded to 22% of the early neonatal deaths. From the 2,873 avoidable deaths, 761 (27%) occurred in São Paulo city; 640 (22%), in the metropolitan region of São Paulo city; and 1,472 (51%), in the countryside of the state. In the first two regions, deaths were more frequent in public hospitals, among newborns with gestational age of 36 weeks or less, and among babies weighing less than 2500g. In the countryside, mortality was more frequent in philanthropic hospitals, in term newborns and in neonates weighing over 2500g. Most of these neonates were born during daytime in their hometown and died at the same institution in which they were born within the first 24 hours after delivery. Meconium aspiration syndrome was related to 18% of the deaths.Conclusions: Perinatal asphyxia is a frequent contributor to the avoidable early neonatal death in the state with the highest gross domestic product per capita in Brazil, and it shows the need for specific interventions with regionalized focus during labor and birth care.

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Section: Discussionmentioning

confidence: 66%

Asfixia perinatal associada à mortalidade neonatal precoce: estudo populacional dos óbitos evitáveis

Daripa

Caldas

Flores

et al. 2013

Rev. paul. pediatr.

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“…12 If mortality increases three-fold when there is perinatal disagreement about proactive management, with a power of 80% and an alpha error of 5%, a sample of 110 patients would be needed to compare infant mortality within 24 h of birth between the positive agreement and disagreement groups.…”

Section: Methodsmentioning

confidence: 99%

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

et al. 2012

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Objective: To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death.Study Design: Prospective cohort of 484 infants with 23 0/7 to 26 6/7 weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of X1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life.Result: Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/ neonatal clinical conditions. Conclusion:In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day. Keywords: fetal viability; steroids; cesarean section; cardiopulmonary resuscitation; infant newborn; neonatal mortality Introduction According to the International Liaison Group on Resuscitation, in 2010, 1 for neonates at the margins of viability or those with conditions that predict a high risk of mortality or morbidity, attitudes and practice vary according to region and availability of resources. 2 A systematic review 3 shows that at p22 weeks, no scientific society recommends active treatment for the mother to protect the fetus beyond offering compassionate care. A general agreement is also evident for week 25 0/7 to 25 6/7 : antenatal steroid administration are recommended, prenatal transport and Cesarean section are indicated to protect the fetus and resuscitation is offered to all infants without fatal anomalies. However, there exists a gray area for infants between 23 and 24 weeks, which, in some countries, extends through 25 weeks. 3 The active management of gestations at the limit of viability involves three important clinical decisions: the use of antenatal steroids, delivery method and resuscitation at birth. One prospective cohort study between 1993 and 2007 followed 5476 infants with 23 to 29 weeks gestation admitted for neonatal care. The overall mortality among infants exposed to maternal steroids was lower than in infants not exposed: 19% vs 35% at 24 to 29 weeks and 79% vs 89% at 23 weeks. 4 23, 24, 25 and 26 weeks, respectively. 5 In the same study, 8% of the 125 542 live births with 22 to 31 weeks of gestation had Apgar scores <4 at 5 min, which indicates that resuscitation procedures were frequently needed among preterm infants. However, extensive cardiopulmonary resuscitation at birth

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“…Variability in mortality rate by center has been observed in several populations and networks. [2][3][4][5][6][7] Two factors may contribute to these center differences: (1) the inherent risk of the patient population served by a center and (2) the patient care delivered at the center. Existing models to predict neonatal mortality at birth are based on individual patient characteristics surrounding birth.…”

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confidence: 99%

Individual and Center-Level Factors Affecting Mortality Among Extremely Low Birth Weight Infants

Alleman

Bell

et al. 2013

Pediatrics

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WHAT'S KNOWN ON THIS SUBJECT: Significant variation in the mortality of preterm infants has been observed among NICUs. Factors explaining this variation have been difficult to identify.WHAT THIS STUDY ADDS: Sizable center differences in mortality exist, even among similarly sized NICUs in academic centers. Patient characteristics and center treatment rates explain some of the center effect, especially for the youngest infants, but a significant portion of these differences remains unexplained. abstract OBJECTIVE: To examine factors affecting center differences in mortality for extremely low birth weight (ELBW) infants. METHODS:We analyzed data for 5418 ELBW infants born at 16 Neonatal Research Network centers during [2006][2007][2008][2009]. The primary outcomes of early mortality (#12 hours after birth) and in-hospital mortality were assessed by using multilevel hierarchical models. Models were developed to investigate associations of center rates of selected interventions with mortality while adjusting for patient-level risk factors. These analyses were performed for all gestational ages (GAs) and separately for GAs ,25 weeks and $25 weeks. RESULTS:Early and in-hospital mortality rates among centers were 5% to 36% and 11% to 53% for all GAs, 13% to 73% and 28% to 90% for GAs ,25 weeks, and 1% to 11% and 7% to 26% for GAs $25 weeks, respectively. Center intervention rates significantly predicted both early and in-hospital mortality for infants ,25 weeks. For infants $25 weeks, intervention rates did not predict mortality. The variance in mortality among centers was significant for all GAs and outcomes. Center use of interventions and patient risk factors explained some but not all of the center variation in mortality rates. CONCLUSIONS:Center intervention rates explain a portion of the center variation in mortality, especially for infants born at ,25 weeks' GA. This finding suggests that deaths may be prevented by standardizing care for very early GA infants. However, differences in patient characteristics and center intervention rates do not account for all of the observed variability in mortality; and for infants with GA $25 weeks these differences account for only a small part of the variation in mortality. Pediatrics 2013;132:e175-e184 Mr Alleman participated in the conception and design of the study including the analysis plan and in the interpretation of the data and wrote the first and subsequent drafts of the manuscript and helped to revise it critically for important intellectual content; Dr Bell conceived and helped to design the study including the analysis plan, participated in the interpretation of the data, and revised the manuscript critically for important intellectual content; Dr Li helped to design the analysis plan and was responsible for the data management and analysis, performed the analysis with guidance from Mr Alleman and Dr Bell and with advice from Drs Das and Wallace, and helped to revise the manuscript critically for important intellectual content; Both patient factors (eg, gestatio...

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Perinatal factors associated with early deaths of preterm infants born in Brazilian Networkon Neonatal Research centers

Cited by 53 publications

References 25 publications

Asfixia perinatal associada à mortalidade neonatal precoce: estudo populacional dos óbitos evitáveis

Asfixia perinatal associada à mortalidade neonatal precoce: estudo populacional dos óbitos evitáveis

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

Individual and Center-Level Factors Affecting Mortality Among Extremely Low Birth Weight Infants

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