Prediction of Neonatal Outcomes in Extremely Preterm Neonates

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Extremely preterm infants are at high risk of neonatal mortality or morbidities. Existing prediction models focus on mortality, specific morbidities, or composite mortality and morbidity outcomes and ignore differences in outcome severity. WHAT THIS STUDY ADDS:A simple and practical statistical model was developed that can be applied on the first day after NICU admission to predict outcome severity spanning from no morbidity to mortality. The model is highly discriminative (Cstatistic = 90%) and internally valid. abstract OBJECTIVE: To develop and validate a statistical prediction model spanning the severity range of neonatal outcomes in infants born at #30 weeks' gestation. METHODS:A national cohort of infants, born at 23 to 30 weeks' gestation and admitted to level III NICUs in Canada in 2010-2011, was identified from the Canadian Neonatal Network database. A multinomial logistic regression model was developed to predict survival without morbidities, mild morbidities, severe morbidities, or mortality, using maternal, obstetric, and infant characteristics available within the first day of NICU admission. Discrimination and calibration were assessed using a concordance C-statistic and the C g goodnessof-fit test, respectively. Internal validation was performed using a bootstrap approach. RESULTS:Of 6106 eligible infants, 2280 (37%) survived without morbidities, 1964 (32%) and 1251 (21%) survived with mild and severe morbidities, respectively, and 611 (10%) died. Predictors in the model were gestational age, small (,10th percentile) for gestational age, gender, Score for Neonatal Acute Physiology version II .20, outborn status, use of antenatal corticosteroids, and receipt of surfactant and mechanical ventilation on the first day of admission. High model discrimination was confirmed by internal bootstrap validation (bias-corrected C-statistic = 0.899, 95% confidence interval = 0.894-0.903). Predicted probabilities were consistent with the observed outcomes (C g P value = .96).CONCLUSIONS: Neonatal outcomes ranging from mortality to survival without morbidity in extremely preterm infants can be predicted on their first day in the NICU by using a multinomial model with good discrimination and calibration. The prediction model requires additional external validation. Pediatrics 2013;132:e876-e885 AUTHORS:

Maternal and Perinatal Outcomes of Pregnancies Delivered at 23 Weeks’ Gestation

“…This high rate is similar to those in other reports, which describe rates of survival without morbidity ranging from 7% to 28%. 3,4,9,14,15,24,42 Previous Canadian research has also noted rates of morbidity in survivors after admission to the NICU of 71.6% to 92.9%. 4,15,24 In the current study, morbidity included bronchopulmonary dysplasia, retinopathy of prematurity, severe brain injury, necrotizing enterocolitis, and sepsis.…”

“…5,7,10,11,14,[16][17][18]20,36,37,47 Other studies include only infants admitted to the NICU, with survival rates ranging from 0% to 66%. 4,9,[11][12][13][14][15]17,18,20,21,23,24,34 Previous Canadian studies that did not include stillbirth noted survival rates in infants admitted to the NICU of 35.2% to 41.7%. 4,15,24 The survival rate was lower in our study.…”

“…4,9,[11][12][13][14][15]17,18,20,21,23,24,34 Previous Canadian studies that did not include stillbirth noted survival rates in infants admitted to the NICU of 35.2% to 41.7%. 4,15,24 The survival rate was lower in our study. We included infants delivering at 23 weeks' gestation in participating centres, including stillbirths and neonatal deaths before admission to NICU, thus reducing selection bias.…”

“…1 Preterm birth can result in significant perinatal morbidity, both in the short term and long term, particularly in infants born at earlier gestational ages. [1][2][3][4][5] Multiple studies have evaluated perinatal outcomes of infants born in the periviable period (23 weeks' gestation). Many of these studies, however, have excluded infants that were stillborn or that died before admission to NICU.…”

“…Many of these studies, however, have excluded infants that were stillborn or that died before admission to NICU. 3,4,15,[21][22][23][24]27,34 In addition, some studies present data based on birth weight and not gestational age. 29,[40][41][42][43][44] Finally, a number of studies present data from populations that may differ from the Canadian population with respect to ethnicity and access to health care.…”