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Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018

Edward F Bell et al. JAMA. .

Erratum in

Abstract

Importance: Despite improvement during recent decades, extremely preterm infants continue to contribute disproportionately to neonatal mortality and childhood morbidity.

Objective: To review survival, in-hospital morbidities, care practices, and neurodevelopmental and functional outcomes at 22-26 months' corrected age for extremely preterm infants.

Design, setting, and participants: Prospective registry for extremely preterm infants born at 19 US academic centers that are part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. The study included 10 877 infants born at 22-28 weeks' gestational age between January 1, 2013, and December 31, 2018, including 2566 infants born before 27 weeks between January 1, 2013, and December 31, 2016, who completed follow-up assessments at 22-26 months' corrected age. The last assessment was completed on August 13, 2019. Outcomes were compared with a similar cohort of infants born in 2008-2012 adjusting for gestational age.

Exposures: Extremely preterm birth.

Main outcomes and measures: Survival and 12 in-hospital morbidities were assessed, including necrotizing enterocolitis, infection, intracranial hemorrhage, retinopathy of prematurity, and bronchopulmonary dysplasia. Infants were assessed at 22-26 months' corrected age for 12 health and functional outcomes, including neurodevelopment, cerebral palsy, vision, hearing, rehospitalizations, and need for assistive devices.

Results: The 10 877 infants were 49.0% female and 51.0% male; 78.3% (8495/10848) survived to discharge, an increase from 76.0% in 2008-2012 (adjusted difference, 2.0%; 95% CI, 1.0%-2.9%). Survival to discharge was 10.9% (60/549) for live-born infants at 22 weeks and 94.0% (2267/2412) at 28 weeks. Survival among actively treated infants was 30.0% (60/200) at 22 weeks and 55.8% (535/958) at 23 weeks. All in-hospital morbidities were more likely among infants born at earlier gestational ages. Overall, 8.9% (890/9956) of infants had necrotizing enterocolitis, 2.4% (238/9957) had early-onset infection, 19.9% (1911/9610) had late-onset infection, 14.3% (1386/9705) had severe intracranial hemorrhage, 12.8% (1099/8585) had severe retinopathy of prematurity, and 8.0% (666/8305) had severe bronchopulmonary dysplasia. Among 2930 surviving infants with gestational ages of 22-26 weeks eligible for follow-up, 2566 (87.6%) were examined. By 2-year follow-up, 8.4% (214/2555) of children had moderate to severe cerebral palsy, 1.5% (38/2555) had bilateral blindness, 2.5% (64/2527) required hearing aids or cochlear implants, 49.9% (1277/2561) had been rehospitalized, and 15.4% (393/2560) required mobility aids or other supportive devices. Among 2458 fully evaluated infants, 48.7% (1198/2458) had no or mild neurodevelopmental impairment at follow-up, 29.3% (709/2419) had moderate neurodevelopmental impairment, and 21.2% (512/2419) had severe neurodevelopmental impairment.

Conclusions and relevance: Among extremely preterm infants born in 2013-2018 and treated at 19 US academic medical centers, 78.3% survived to discharge, a significantly higher rate than for infants born in 2008-2012. Among infants born at less than 27 weeks' gestational age, rehospitalization and neurodevelopmental impairment were common at 2 years of age.

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Conflict of interest statement

Conflict of Interest Disclosures: Drs Bell, Hintz, Walsh, Vohr, Rysavy, Merhar, Laptook, Hibbs, and Fuller reported receiving grant(s) from the National Institutes of Health (NIH) outside the submitted work. Dr DeMauro reported receiving grants from the NIH outside the submitted work and a grant from the Thrasher Research Fund. Dr Carlo reported receiving grants from the NIH outside the submitted work and grants from the Thrasher Research Fund, the University of Virginia, the Hudson Alpha Institute for Biotechnology, the Foundation for the National Institutes of Health, and the Gates Foundation. Dr Van Meurs reported receiving grants from the NIH outside the submitted work and grants from the Thrasher Foundation and serving on a scientific advisory board for Greenwich Biosciences. Dr Patel reported serving on the data monitoring committee for a trial by Infant Bacterial Therapeutics/Premier Research. Dr Sánchez reported receiving grants from Merck and AstraZeneca (MedImmune). Dr Cotten reported receiving grants from the NIH outside the submitted work and a grant from the Robertson Foundation. No other disclosures were reported.

Figures

Figure.
Figure.. Neurodevelopmental Impairment at 22-26 Months’ Corrected Age in Children Born at 22-26 Weeks’ Gestational Age During 2013-2016
A, Neurodevelopmental impairment (NDI) among 2458 children evaluated at 22-26 months’ corrected age. Mild or no NDI was defined as a Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) cognitive composite score of 85 or higher, a Bayley-III motor composite score of 85 or higher, and Gross Motor Function Classification System (GMFCS) level 0 or 1. Moderate NDI was defined as any of a Bayley-III cognitive composite score or motor composite score of 70 to 84 or GMFCS level 2 or 3. Severe NDI was defined by any of a Bayley-III cognitive composite score or motor composite score less than 70, GMFCS level 4 or 5, bilateral blindness, or severe hearing impairment (see Table 4 footnotes b and d for more details). B, Death and NDI at 22-26 months’ corrected age among children born at 22-26 weeks’ gestational age who were actively treated at birth. Children born at 22-26 weeks’ gestational age were eligible for a follow-up assessment at 22-26 months’ corrected age. Proportions are shown for the 3500 children actively treated at birth who had died by 22-26 months’ corrected age or were seen at follow-up and evaluated for NDI. Active treatment was defined as intubation, surfactant therapy, respiratory support, chest compressions, epinephrine, volume resuscitation, blood pressure support, or parenteral nutrition (see Table 4 footnotes b and d for more details).
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