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Improved Survival of Periviable Infants after Alteration of the Threshold of Viability by the Neonatal Resuscitation Program 2015.

ABSTRACT: Periviable infants (PIs) born at 22-25 weeks gestational age (wGA) have a variable survival rate (49.7-86.2%) among hospitals. One factor involved in this difference may be the definition of the threshold of viability. The American Academy of Pediatrics revised the neonatal resuscitation program in late 2015 (NRP 2015) and altered the threshold of viability from 23 to 22 wGA. The impact on the survival of PIs after the guideline alteration has seldom been discussed. Since 2016, the unit of this study has implemented the renewed guideline for PIs. We retrospectively reviewed and analyzed the survival and clinical variables of PIs before and after implementation of the guideline, which included a 10-year cohort in a single center in Taiwan. There were 168 PIs enrolled between 2010 and 2019 (Epoch-I, 2010-2015; Epoch-II, 2016-2019), after excluding those with congenital anomalies and parent-decided comfort care. Compared to those in Epoch-I, the PIs in Epoch-II had significantly higher odds ratios (2.602) (95% confidence interval: 1.170-5.789; p = 0.019) for survival. Younger gestational age, small size for gestational age, cesarean delivery, low blood pH at birth, and surfactant therapeutic treatment were found to be significant risk factors associated with the survival of PIs (p < 0.05 for each). The altered threshold of viability by NRP 2015 may impact the survival of PIs. However, long-term follow-up for surviving PI is required in the future.

SUBMITTER: Chen YJ

PROVIDER: S-EPMC7824697 | biostudies-literature | 2021 Jan

REPOSITORIES: biostudies-literature

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Improved Survival of Periviable Infants after Alteration of the Threshold of Viability by the Neonatal Resuscitation Program 2015.

Chen Yen-Ju YJ Yu Wen-Hao WH Chen Li-Wen LW Huang Chao-Ching CC Kang Lin L Lin Hui-Shan HS Iwata Osuke O Kato Shin S Hussein Mohamed Hamed MH Lin Yung-Chieh YC

Children (Basel, Switzerland) 20210104 1

Periviable infants (PIs) born at 22-25 weeks gestational age (wGA) have a variable survival rate (49.7-86.2%) among hospitals. One factor involved in this difference may be the definition of the threshold of viability. The American Academy of Pediatrics revised the neonatal resuscitation program in late 2015 (NRP 2015) and altered the threshold of viability from 23 to 22 wGA. The impact on the survival of PIs after the guideline alteration has seldom been discussed. Since 2016, the unit of this ...[more]

PMID: 33406755

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Project description:BackgroundData reported during the past 5 years indicate that rates of survival have increased among infants born at the borderline of viability, but less is known about how increased rates of survival among these infants relate to early childhood neurodevelopmental outcomes.MethodsWe compared survival and neurodevelopmental outcomes among infants born at 22 to 24 weeks of gestation, as assessed at 18 to 22 months of corrected age, across three consecutive birth-year epochs (2000-2003 [epoch 1], 2004-2007 [epoch 2], and 2008-2011 [epoch 3]). The infants were born at 11 centers that participated in the National Institute of Child Health and Human Development Neonatal Research Network. The primary outcome measure was a three-level outcome - survival without neurodevelopmental impairment, survival with neurodevelopmental impairment, or death. After accounting for differences in infant characteristics, including birth center, we used multinomial generalized logit models to compare the relative risk of survival without neurodevelopmental impairment, survival with neurodevelopmental impairment, and death.ResultsData on the primary outcome were available for 4274 of 4458 infants (96%) born at the 11 centers. The percentage of infants who survived increased from 30% (424 of 1391 infants) in epoch 1 to 36% (487 of 1348 infants) in epoch 3 (P<0.001). The percentage of infants who survived without neurodevelopmental impairment increased from 16% (217 of 1391) in epoch 1 to 20% (276 of 1348) in epoch 3 (P=0.001), whereas the percentage of infants who survived with neurodevelopmental impairment did not change significantly (15% [207 of 1391] in epoch 1 and 16% [211 of 1348] in epoch 3, P=0.29). After adjustment for changes in the baseline characteristics of the infants over time, both the rate of survival with neurodevelopmental impairment (as compared with death) and the rate of survival without neurodevelopmental impairment (as compared with death) increased over time (adjusted relative risks, 1.27 [95% confidence interval {CI}, 1.01 to 1.59] and 1.59 [95% CI, 1.28 to 1.99], respectively).ConclusionsThe rate of survival without neurodevelopmental impairment increased between 2000 and 2011 in this large cohort of periviable infants. (Funded by the National Institutes of Health and others; ClinicalTrials.gov numbers, NCT00063063 and NCT00009633 .).

Project description:BackgroundEarly breast milk expression, prolonged skin-to-skin contact, rooming-in, use of test-weighing and minimizing use of pacifiers are positively associated with exclusive breastfeeding of preterm infants, whereas use of nipple shields is negatively associated.AimTo test whether a training program for neonatal nurses with a focus on these six breastfeeding-supportive clinical practices affects the rate of preterm infants exclusively breastfed at discharge to home, the postmenstrual age at establishment of exclusive breastfeeding, and maternal self-reported use of the practice in the neonatal intensive care unit, the.MethodsA quasi-experimental multi-centre intervention study from 2016-2019 including a control group of 420 preterm mother-infant dyads, an intervention with a training program for neonatal nurses and implementation of weekly breastfeeding meetings for neonatal nurses, and an intervention group of 494 preterm mother-infant dyads.ResultsSignificantly more preterm infants in the intervention group were exclusively breastfed at discharge to home (66.6%) than in the control group (58.1%) p = 0.008. There was no significant difference in postmenstrual age at establishment of exclusive breastfeeding between control and intervention group (37.5 vs.37.8 weeks, p = 0.073). Compared to the control group the number of infants continuing daily skin-to-skin contact after incubator care increased (83.2% vs. 88.3%, p = 0.035), infants using a nipple shield decreased (61.8% vs. 54.2%, p = 0.029), and the number of mothers initiating breast milk expression before six hours post-partum increased (32.6% vs. 42.4%, p = 0.007). There was a significant correlation between percentage of neonatal nurses participating in the breastfeeding training program and changes in exclusive breastfeeding rates (Pearson Correlation 0.638, p = 0.047).ConclusionExclusive breastfeeding rates in preterm infants and maternal self-reported use of breastfeeding-supportive practices increased by training neonatal nurses in the six clinical practices. It is important to include all nurses in the breastfeeding training program to ensure positive effect on exclusive breastfeeding rates.

Project description:Approximately 1 in 10 newborns will require basic resuscitation interventions at birth. Some infants progress to require more advanced measures including the provision of positive pressure ventilation, chest compressions, intubation and administration of volume/cardiac medications. Although advanced resuscitation is infrequent, it is crucial that personnel adequately trained in these techniques are available to provide such resuscitative measures. In 2000, Louis Halmalek et al. called for a "New Paradigm in Pediatric Medical Education: Teaching Neonatal Resuscitation in a Simulated Delivery Room Environment." This was one of the first articles to highlight simulation as a method of teaching newborn resuscitation. The last decades have seen an exponential growth in the area of simulation in newborn care, in particular in newborn resuscitation and stabilization. Simulation is best defined as an instructional strategy "used to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner." Simulation training has now become an important point of how we structure training and deliver improved healthcare to patients. Some of the key aspects of simulation training include feedback, deliberate practice, outcome measurement, retention of skills and curriculum integration. The term "Train to win" is often used in sporting parlance to define how great teams succeed. The major difference between sports teams is that generally their game day comes once a week, whereas in newborn resuscitation every day is potentially "game day." In this review we aim to summarize the current evidence on the use of simulation based education and training in neonatal resuscitation, with particular emphasis on the evidence supporting its effectiveness. We will also highlight recent advances in the development of simulation based medical education in the context of newborn resuscitation to ensure we "train to win."

Project description:BackgroundClinical practice in neonatal intensive care units for nursing college students has been restricted due to the COVID-19 pandemic outbreak; thus, the gamification program has emerged as an alternative learning method. Consequently, there is a need to examine the effectiveness of such alternative learning methods to enhance the response to high-risk newborn emergencies.ObjectivesTo examine the effects (neonatal resuscitation nursing knowledge, problem-solving and clinical reasoning ability, self-confidence in practical performance, degree of anxiety, and learning motivation) of a neonatal resuscitation gamification program using immersive virtual reality based on Keller's ARCS model.DesignA non-randomized controlled simulation study with a pretest-posttest design.SettingLab and lecture rooms of two universities in South Korea, from June to November 2021.ParticipantsPrelicensure nursing students.MethodsThe virtual reality group (n = 29) underwent a neonatal resuscitation gamification program using virtual reality based on Keller's ARCS model. The simulation group (n = 28) received high-fidelity neonatal resuscitation simulations and online neonatal resuscitation program lectures. The control group (n = 26) only received online neonatal resuscitation program lectures. Changes in scores among these groups were compared using analysis of variance and analysis of covariance with SPSS for Windows version 27.0.ResultsPost intervention, neonatal resuscitation knowledge [F(2) = 3.83, p = .004] and learning motivation [F(2) = 1.79, p = .025] were significantly higher in the virtual reality and simulation groups than in the control group, whereas problem-solving ability [F(2) = 2.07, p = .038] and self-confidence [F(2) = 6.53, p < .001] were significantly higher in the virtual reality group than in the simulation and control groups. Anxiety [F(2) = 16.14, p < .001] was significantly lower in the simulation group than in the virtual reality and control groups.ConclusionsThe neonatal resuscitation gamification program using immersive virtual reality was found to be effective in increasing neonatal resuscitation knowledge, problem-solving ability, self-confidence, and learning motivation of the nursing students who participated in the trial application process.

Project description:ImportanceActive postnatal care has been associated with center differences in survival among periviable infants. Regional differences in outcomes among periviable infants in the US may be associated with differences in active postnatal care.ObjectiveTo determine if regions with higher rates of active postnatal care will have higher gestational age-specific survival rates among periviable infants.Design, setting, and participantsThis cohort study included live births from 22 to 25 weeks' gestation weighing 400 to 999 g in the US Centers for Disease Control and Prevention (CDC) WONDER 2017 to 2020 (expanded) database. Infants with congenital anomalies were excluded. Active postnatal care was defined using the CDC definition of abnormal conditions of newborn as presence of any of the following: neonatal intensive care unit (NICU) admission, surfactant, assisted ventilation, antibiotics, and seizures. Data were analyzed from August to November 2022.Main outcomes and measuresRegional gestational age-specific survival rates were compared with rates of active postnatal care in the 10 US Health and Human Services regions using Kendall τ test.ResultsWe included 41 707 periviable infants, of whom 32 674 (78%) were singletons and 19 467 (46.7%) were female. Among those studied 34 983 (83.9%) had evidence of active care, and 26 009 (62.6%) survived. Regional rates of active postnatal care were positively correlated with regional survival rates at 22 weeks' gestation (rτ[8] = 0.56; r2 = 0.31; P = .03) but the correlation was not significant at 23 weeks' gestation (rτ[8] = 0.47; r2 = 0.22; P = .07). There was no correlation between active care and survival at 24 or 25 weeks' gestation. Regional rates of both NICU admission and assisted ventilation following delivery were positively correlated with regional rates of survival at 22 weeks' gestation (both P < .05). Regional rates of antenatal corticosteroids exposure were also positively correlated with regional rates of survival at 22 weeks' gestation (rτ[8] = 0.60; r2 = 0.36; P = .02).Conclusions and relevanceIn this cohort study of 41 707 periviable infants, regional differences in rates of active postnatal care, neonatal intensive care unit admission, provision of assisted ventilation and antenatal corticosteroid exposure were moderately correlated with survival at 22 weeks' gestation. Further studies focused on individual-level factors associated with active periviable care are warranted.

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Improved Survival of Periviable Infants after Alteration of the Threshold of Viability by the Neonatal Resuscitation Program 2015.

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Improved Survival of Periviable Infants after Alteration of the Threshold of Viability by the Neonatal Resuscitation Program 2015.

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