Showing posts with label mortality. Show all posts
Showing posts with label mortality. Show all posts

Tuesday, July 7, 2015

Understanding Morbidity and Mortality Concerns When Multiple Gestations Are Born Extremely Preterm

By: Lewis First, MD, MS; Editor-in-Chief 
     We are certainly aware of a myriad of potential complications that can occur to an extremely preterm infant and are grateful that our neonatology colleagues are there to help as needed.  But what if a mother in your practice gives birth to twins or triplets at an extremely preterm gestational age?  What advice do you give that family when they ask if this makes things better or worse for each individual twin or triplet infant?   
     Yeo et al. (doi: 10.1542/peds.2015-0479) share with us the results of a retrospective study of more than 15,000 infants born at or less than 27 weeks gestation from 1995-2009 into the Australian and New Zealand Neonatal Network in which singletons are compared to multiple gestation births in this preterm cohort.  There is a lot of data worth paying attention to in this study, with good news and bad news for multiple gestation infants compared to singletons born extremely preterm.  The bad news is that not unexpectedly, the odds of mortality in infancy are greater for multiples than for singletons across the 15 years studied.   
     The good news is that thanks to ongoing advances in neonatal care and technology, the odds of a poor outcome over the most recent 5 years studied is no different for multiple compared to single extremely preterm births.  If you are asked to care for a family expecting twins or triplets, and want to help them better understand what the future might hold if the babies are born earlier than expected, then labor a bit over this interesting study and deliver what you have learned in a way that hopefully will reassure expectant parents of multiple gestations as much as possible.

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Thursday, December 11, 2014

Protective Factors In NICU Deaths

Good friends of mine always have a sad spell during the holiday season because their daughter, a 24-week preterm infant, died between Christmas and New Year’s Day. That was a decade ago, but they still remember Ava, who died of respiratory failure.  

Deaths of premature infants like Ava contribute to infant mortality and understanding modifiable factors contributing to these deaths in neonatal intensive care units (NICUs) might reduce the rate. This is  important because the US infant mortality rate of 6.1 infant deaths per 1000 live-births is the highest of the industrialized countries.

A new research article published this month in Pediatrics (doi:10.1542/peds.2014-2967) suggests that almost a third of NICU deaths in 46 NICUS studied might be prevented.  Dr. Jack Jacob and his coauthors collected data on 641 infants who died and found that 197 (31%) of the infants had potentially modifiable factors that might have contributed to their deaths. The researchers did a root-cause analysis using the “Pediatrix Data Warehouse” (a large national dataset) for Level 3 NICU deaths occurring between 2010 and 2012. Pediatrix is a medical group that staffs NICUs and collects data from admissions on a daily basis, using an electronic medical record.  

The researchers found that at lower gestational ages, mortality was due to extreme prematurity and complications of premature birth, such as respiratory distress syndrome, intraventricular hemorrhage, necrotizing entercolitis and sepsis. Among infants of higher gestational age, the mortality etiology was often hypoxic ischemic encephalopathy and genetic or structural anomalies.

Among the 197 infants with potentially modifiable factors, delivery at a center without appropriate level of support and limited/no prenatal care were the most common risks. Other modifiable factors including maternal smoking and a history of alcohol abuse. The authors suggested that researchers might be able to impact NICU mortality with quality improvement efforts focusing on modifiable factors.  

Lack of prenatal care, smoking and alcohol abuse are well known risks for bad pregnancy outcomes, although were not factors in my friends’ daughter’s death. This study reinforces what is already known. The issue is how to get women to change their behaviors during pregnancy, and that’s hard. The work with high-risk women has to start before the preterm infant arrives in the NICU.