Trends in Mortality and Morbidity

Vermont Oxford Network (VON), a voluntary group of practitioners across the globe, examined the trends and changes in outcomes from 1997 to 2021 in order to drive new research areas.

Using the National Cancer Institute Joinpoint Regression Program and Bayesian Information criterion for analysis, VON studied the outcomes of mortality, late-onset sepsis, necrotizing enterocolitis, chronic lung disease, intraventricular hemorrhage, and retinopathy of prematurity. This study included 447,396 infants in 888 hospitals, weighing 401 to 1500 grams, born at 24+0 to 28+6 weeks.

Findings from this study demonstrated that improvements in trends across the outcome measures have slowed or stabilized, except for chronic lung disease, which increased in prevalence from 2012 – 2021. The authors of this study propose that the effectiveness of our medical interventions and treatments may have reached their peak.

To strive towards ongoing improvements in outcome measures, VON proposes a 3-part strategy: (1) research to develop innovative new therapies; (2) quality improvement to optimize the effectiveness of available interventions; and (3) a commitment to follow through addressing the social determinants. Through use of these strategies, VON aims to improve the long-term health and well-being of infants and their families.

Horbar, J.D., Greenberg, L.T., Buzas, J.S., Ehret, D.E.Y., Soll, R.F., Edwards, E.M. (2024) Trends in mortality and morbidities for infants born 24 to 28 weeks in the US: 1997-2021. Pediatrics. 153(1):e2023064153. https://doi.org/10.1542/peds.2023-064153

Neurological Development in Late Preterm Infants

Approximately 1.28 million singleton children born between 1998 and 2012, and free from congenital malformations, were studied in Sweden. Infants included in this study were born between 32 and 42 weeks gestational age.

Authors linked data from the Swedish Medical Birth Register with other registries, including the National Patient Registry, which documents diagnoses at discharge. Information collected included the following: neurodevelopmental outcomes, motor, speech, visual, hearing, cognitive and epileptic outcomes. Severe and major impairments included cerebral palsy, severe mental retardation, severe generalized epilepsy and severe hearing or visual impairments. Each child had a minimum follow up of 7 years. The association between gestational age and outcomes was also measured, as well as the estimated risk of developing a neurodevelopmental problem by age 16 years.

The median follow up time for each study subject was 13.1 years and 47.8/10,000 children were diagnosed with a neurodevelopmental impairment. The most frequent occurrence was cognitive impairment, followed in descending order by, hearing, visual, epileptic and motor impairments. Infants born at 32 weeks were at highest risk, with decreasing risk with advancing gestational age. However, infants born at 37-38 weeks still had an increased risk of cognitive impairment compared to their term counterparts. Infants born small for gestational age (<10th percentile) also had a higher risk than infants born >10th percentile for weight.

Findings from this study also demonstrated that parents of the preterm infants were younger, had a higher BMI, more often smoked, were diabetic, had hypertension and had a higher prevalence of psychiatric disorders.  Authors suggest preventing moderately or late preterm births can have implications for public health, and that the higher risks these families face should not be underestimated.

Mitha, A., Chen, R., Razaz, N., Johansson, S., Stephansson, O., Altman, M., Bolk, J. (2024). Neurological development in children born moderately or late preterm: National cohort study. British Medical Journal, 384, e075630.  https://doi.org/10.1136/bmj-2023-075630

Neonatal Opioid Withdrawal Outcomes

A review of literature in the last 10 years, with data collected over the last 20 years, was examined looking at pharmacologic and nonpharmacologic treatment for infants with Neonatal Opioid Withdrawal Syndrome (NOWS).

From this study, it was concluded that cognitive outcomes across infancy and childhood were affected not only by prenatal opioid exposure but also by the type of pharmacological treatment provided during NICU admission. Additionally, children with a history of NOWS were more likely to be referred for disability education, require classroom therapies, have developmental, speech and language delays and have progressively lower test scores over time.

Further areas of long term challenges include behavioral, emotional, and inattention/hyperactivity. Interestingly, a range of visual skills deficits (strabismus, ocular muscular disorders, poor visual attention) were also found to be impacted by NOWS diagnosis and the type of pharmacological treatment administered in the NICU. Infants with prenatal opioid exposure were even found to have higher rates of rehospitalization for infectious disease and higher rates of torticollis due to hypertonicity.

The authors conclude that neurodevelopmental follow-up is key to mitigating the negative effects of opioid exposure and NOWS treatments. Resources such as Early Intervention referrals, Social Work support, developmental assessments, behavioral questionnaires, parenting classes and family mental health support are all vital pieces of follow-up care for these at-risk infants and children.

Benninger, K., McAllister, J., Merhar, S. (2023). Neonatal Opioid Withdrawal Syndrome: An update on developmental outcomes. Clinics in Perinatology, 50(1), 17-29. https://doi.org/10.1016/j.clp.2022.10.007

Know Better. Do Better. Change a Life.

These articles highlight the most up-to-date research on long-term outcomes and the challenges many infants and families face after NICU discharge. We know that providing evidence-based, neuroprotective, developmental, family-integrated care can help to optimize neurodevelopmental outcomes. As an NTMNC or NTMTC professional, you are uniquely qualified to help change these outcomes. Whether you are working with your developmental committee to optimize practices for your ELBW infants, advocating for therapy orders for the new 33-week infant on your unit, or teaching the family for an infant with NOWS how to calm, soothe and bond with a Listening Touch Massage…what you do every day in the NICU matters. 

Your Friends in Neonatal Care,

The NTMC Team