Variations in incidence of necrotizing enterocolitis in Canadian neonatal intensive care units.

OBJECTIVES: Necrotizing enterocolitis (NEC) is the most common acquired intestinal disease of neonates. Previous reports on incidence have generally examined small cohorts of extremely low-birth-weight infants and have not examined risk-adjusted variations among neonatal intensive care units (NICUs). The authors examined risk-adjusted variations in the incidence of NEC in a large group of Canadian NICUs and explored possible therapy-related risks. METHODS: The authors obtained data on 18,234 infants admitted to 17 tertiary level Canadian NICUs from January 1996 to October 1997. They used multivariate logistic regression analysis to examine the inter-NICU variation in incidence of NEC, with adjustment for population risk factors and admission illness severity, and explored therapy-related variables. RESULTS: The incidence of NEC was 6.6% (n = 238) among 3,628 infants with birth weight < or = 1,500 g (VLBW), and 0.7% (n = 98) among 14,606 infants with birth weight > 1,500 g (HBW). Multivariate logistic regression analysis showed that for VLBW infants, NEC was associated with lower gestational age and treatment for hypotension and patent ductus arteriosus. Among HBW infants, NEC was associated with lower gestational age, presence of congenital anomalies (cardiovascular, digestive, musculoskeletal, multiple systems) and need for assisted ventilation. There was no significant variation in the risk-adjusted incidence of NEC among NICUs, with the exception of one NICU reporting no cases of NEC. CONCLUSIONS: Risk factors for NEC were different in VLBW and HBW infants. There was no significant variation in the risk-adjusted incidence of NEC among Canadian NICUs, with one possible exception.

The benefit of preterm birth at tertiary care centers is related to gestational age.

OBJECTIVE: The purpose of this study was to examine the relationship between gestational age and outcomes of outborn versus inborn preterm infants. STUDY DESIGN: Multivariable logistic regression analysis was used to examine gestational age-specific, risk-adjusted outcomes of 2962 singleton infants who were born at <32 weeks of gestation who were admitted to 17 Canadian neonatal intensive care units from 1996 through 1997. RESULTS: The risk-adjusted incidence was significantly (P <.05) higher among outborn versus inborn infants for mortality rates (odds ratio, 2.2) and > or =grade 3 intraventricular hemorrhage (odds ratio, 2.1) at < or =26 weeks of gestation and for chronic lung disease (odds ratio, 1.7) at 27 to 29 weeks of gestation. Outcomes of outborn and inborn infants at 30 to 31 weeks of gestation were not significantly different. CONCLUSION: The short-term benefit of preterm birth at tertiary centers is related inversely to gestational age and may not extend beyond 29 weeks of gestation.

Variations in antenatal corticosteroid therapy: a persistent problem despite 30 years of evidence.

OBJECTIVE: To document current use of antenatal corticosteroid therapy in a large cohort of Canadian preterm infants admitted to neonatal intensive care units, and to assess the impact of variations in use on neonatal outcomes. METHODS: The study subjects included 11,440 infants less than 38 weeks' gestation who were admitted to 17 Canadian Neonatal Network intensive care units from January 1996 to October 1997. Data analyses were conducted separately for infants less than 24 weeks' gestation, 24-34 weeks' gestation, and over 34 weeks' gestation. Logistic regression analysis was used to model the examined relationships, controlling for patient characteristics. RESULTS: The incidence of antenatal corticosteroid treatment was 42% for infants less than 24 weeks' gestation, 59% for infants 24-34 weeks' gestation, and 10% for infants over 34 weeks' gestation. Antenatal corticosteroid treatment was associated with reduced risk for neonatal mortality and respiratory distress syndrome, but not for infants over 34 weeks' gestation. Significant institutional variations in antenatal corticosteroid use were present among both inborn and outborn infants. Increased antenatal corticosteroid treatment for infants 24-34 weeks' gestation can potentially reduce the number of neonatal deaths by 41 cases (10%) and respiratory distress syndrome by 90 cases (3%) among participating hospitals. CONCLUSION: Wide institutional differences persist in the incidence of antenatal corticosteroid treatment for women expected to give birth preterm. Increased use of antenatal corticosteroids for preterm deliveries can reduce neonatal mortality in Canada by up to 10%.

A prospective clinical audit of neonatal resuscitation practices in Canada.

PURPOSE: This is a prospective audit to determine the frequency of resuscitation interventions in the clinical setting and to compare self-reports of clinical performance with the existing Neonatal Resuscitation Program (NRP) and Canadian National Guidelines for Neonatal Resuscitation. SUBJECTS: Fifty-six level I, II, and III hospitals in Canada participated. Any infant requiring resuscitation, as defined by the need for at least positive pressure ventilation (PPV), was eligible for inclusion (n = 783 resuscitations). DESIGN AND METHODS: A prospective self-report audit was chosen and data were collected over a 6-month period in 1998. The audit focused on the use of PPV, intubation, chest compressions, free-flow oxygen, or medications during the resuscitation. The infant's temperature at the end of resuscitation was also noted. The data were analyzed with descriptive statistics. The composition of the resuscitation team and their NRP certification status were recorded. PRINCIPAL RESULTS: The need for resuscitation was not anticipated in 76% of the cases (596 of 783). Errors in the sequencing of care, such as delays in initiating PPV, provision of chest compressions before or without establishing an airway and ventilatory support, and administering naloxone before PPV, were reported. Resuscitations attended by a team of NRP certified providers had improved sequencing when compared with those in which only some individual providers were certified. Chest compressions were provided in 8% of the cases (65 of 783). Medications were used in 14% (113/783) of all cases. Providers in level I hospitals performed chest compressions more frequently than those in level II and III settings. At the end of the resuscitation, 27% of the infants were hypothermic (142 of 520), and 25% were hyperthermic (128 of 520). Overall, 52% were out of the normal neutral range. CONCLUSIONS: Clear differences between the NRP guidelines and actual clinical practice were shown. A high rate of unanticipated resuscitations, delivery room medications, and chest compressions was described. Postresuscitation hypothermia or hyperthermia were common. Improved sequencing was noted when the entire resuscitation team was NRP certified. Certification in NRP does not assure competency, nor does it ensure compliance with established standards of care.