Can we estimate the length of stay of very preterm multiples?

In our recent paper1 we provided estimates of length of stay for very preterm (24–31 weeks gestational age) singleton babies admitted for neonatal care in units within England. As with much neonatal research, we chose to exclude multiples (twins, triplets and higher order; in this letter referred to as ‘multiples’) from this initial work. However, as around 1 in 10 twins are born before 32 weeks, compared with around 1 in 100 singleton births,2 it is important to be able to also estimate the length of stay for these babies to aid the planning of healthcare resources and facilitate the counselling of their parents.</p

Trends in the incidence and survival of births at 22 to 26 weeks in England: A population based study

Objective: To assess recent trends in incidence and survival of births at 22-26 weeks gestation in EnglandDesign: Population based cohort studyParticipants: All births in 2006 and 2014Main outcome measure: Incidence and survival of births at 22+0-26+6 weeks gestationResults: The birth rate at 22 to 26 weeks gestation reduced by 10% over time from 49.0 per 10000 births in 2006 to 44.3 per 10000 births in 2014. The largest difference was seen at 22 weeks gestation, decreasing from 7.5 to 6.1 per 10000 births. The difference lessened with increasing gestation, with similar rates at 26 weeks (11.5 and 11.7 per 10000 births in 2006 and 2014). Extended perinatal mortality and neonatal mortality improved significantly over time. The largest improvements were seen for babies at 23 weeks with live births surviving the neonatal period increasing from 26.0% to 38.8%, and at 24 weeks increased from 51.1% to 71.3%. The reduced incidence and improved survival led to a reduction over time of 7 deaths per 10000 births, a reduction of around 8% of the extended perinatal mortality rate for all births. Regional variation across England will also be explored.Conclusions: There has been a decrease in the incidence of births at 22 to 26 weeks gestation and also improvements in neonatal mortality since 2006. This reduction in mortality will impact on service costs for both neonatal and longer term care. Up-to-date survival rates are also vital in counselling parents regarding outcomes for extremely preterm babies.</p

Assessing the deprivation gap in stillbirths and neonatal deaths by cause of death: a national population-based study

Objective To investigate socioeconomic inequalities in cause-specific stillbirth and neonatal mortality to identify key areas of focus for future intervention strategies to achieve government ambitions to reduce mortality rates. Design Retrospective cohort study. Setting England, Wales, Scotland and the UK Crown Dependencies. Participants All singleton births between 1 January 2014 and 31 December 2015 at ≥24 weeks’ gestation. Main outcome measure Cause-specific stillbirth or neonatal death (0–27 days after birth) per 10 000 births by deprivation quintile. Results Data on 5694 stillbirths (38.1 per 10 000 total births) and 2368 neonatal deaths (15.9 per 10 000 live births) were obtained from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). Women from the most deprived areas were 1.68 (95% CI 1.56 to 1.81) times more likely to experience a stillbirth and 1.67 (95% CI 1.48 to 1.87) times more likely to experience a neonatal death than those from the least deprived areas, equating to an excess of 690 stillbirths and 231 neonatal deaths per year associated with deprivation. Small for gestational age (SGA) unexplained antepartum stillbirth was the greatest contributor to excess stillbirths accounting for 33% of the deprivation gap in stillbirths. Congenital anomalies accounted for the majority (59%) of the deprivation gap in neonatal deaths, followed by preterm birth not SGA (24–27 weeks, 27%). Conclusions Cause-specific mortality rates at a national level allow identification of key areas of focus for future intervention strategies to reduce mortality. Despite a reduction in the deprivation gap for stillbirths and neonatal deaths, public health interventions should primarily focus on socioeconomic determinants of SGA stillbirth and congenital anomalies

Optimising neonatal service provision for preterm babies born between 27 and 31 weeks gestation in England (OPTIPREM), using national data, qualitative research and economic analysis: a study protocol

Introduction: In England, for babies born at 23-26 weeks gestation, care in a Neonatal Intensive Care unit (NICU) as opposed to a Local Neonatal Unit (LNU) improves survival to discharge. This evidence is shaping neonatal health services. In contrast, there is no evidence to guide location of care for the next most vulnerable group (born at 27-31 weeks gestation) whose care is currently spread between 45 NICU and 84 LNU in England. This group represents 12% of preterm births in England and over a third of all neonatal unit care days. Compared to those born at 23-26 weeks gestation they account for four times more admissions and twice as many NHS bed days/year. Methods: In this mixed methods study our primary objective is to assess, for babies born at 27-31 weeks gestation and admitted to a neonatal unit in England, whether care in a NICU versus a LNU impacts on survival and key morbidities (up to age 1 year), at each gestational age in weeks. Routinely recorded data extracted from real-time, point-of-care patient management systems held in the National Neonatal Research Database, Hospital Episode Statistics and Office for National Statistics, for January 2014 to December 2018, will be analysed. Secondary objectives are to assess a)whether differences in care provided, rather than a focus on LNU/NICU designation, drives gestation-specific outcomes, b)where care is most cost-effective, c)what parents’ and clinicians' perspectives are on place of care, and how these could guide clinical decision-making. Our findings will be used to develop recommendations, in collaboration with national bodies, to inform clinical practice, commissioning and policy making. The project is supported by a parent advisory panel, and a study steering committee. Ethics and dissemination: Research ethics approval has been obtained (IRAS 212304). Dissemination will be through publication of findings and development of recommendations for care. Strengths and Limitations of this Study Strengths Scientific evidence from this study will be used to develop national recommendations for health service delivery for babies born between 27-31 weeks gestation in England. This will be guided by clinical outcomes, cost-effectiveness, parents’ and staff perspectives. Limitations As a retrospective population-based observational cohort study it is subject to selection bias in the assignment of location of birth of babies. Heterogeneity in the quality of care provided within and between LNU and NICU, is likely, and will be addressed. Formal study-driven neurodevelopmental follow up is not cost-effective in this large cohort, so routinely collected data will be used to investigate their outcomes

Evaluation of timeliness and models of transporting critically ill children for intensive care: The DEPICT mixed-methods study

Background Centralisation of paediatric intensive care has increased the need for specialist critical care transport teams to transfer sick children from general hospitals to tertiary centres. National audit data show variation in how quickly transport teams reach the patient’s bedside and in the models of care provided during transport; however, the impact of this variation on clinical outcomes and the experience of patients, families and clinicians is unknown. Objectives We aimed to understand if and how clinical outcomes and experience of children transported for intensive care are affected by timeliness of access to a transport team and different models of transport care. Methods We used a mixed-methods approach with a convergent triangulation study design. There were four study workstreams: a retrospective analysis of linked national clinical audit data (2014–16) (workstream A), a prospective questionnaire study to collect experience data from parents of transported children and qualitative analysis of interviews with patients, families and clinicians (workstream B), health economic evaluation of paediatric transport services (workstream C) and mathematical modelling evaluating the potential impact of alternative service configurations (workstream D). Results Transport data from over 9000 children were analysed in workstream A. Transport teams reached the patient bedside within 3 hours of accepting the referral in > 85% of transports, and there was no apparent association between time to bedside and 30-day mortality. Similarly, the grade of the transport team leader or stabilisation approach did not appear to affect mortality. Patient-related critical incidents were associated with higher mortality (adjusted odds ratio 3.07, 95% confidence interval 1.48 to 6.35). In workstream B, 2133 parents completed experience questionnaires pertaining to 2084 unique transports of 1998 children. Interviews were conducted with 30 parents and 48 staff. Regardless of the actual time to bedside, parent satisfaction was higher when parents were kept informed about the team’s arrival time and when their expectation matched the actual arrival time. Satisfaction was lower when parents were unsure who the team leader was or when they were not told who the team leader was. Staff confidence, rather than seniority, and the choice for parents to travel with their child in the ambulance were identified as key factors associated with a positive experience. The health economic evaluation found that team composition was variable between transport teams, but not significantly associated with cost and outcome measures. Modelling showed marginal benefit in changing current transport team locations, some benefit in reallocating existing teams and suggested where additional transport teams could be allocated in winter to cope with the expected surge in demand. Limitations Our analysis plans were limited by the impact of the pandemic. Unmeasured confounding may have affected workstream A findings. Conclusions There is no evidence that reducing the current 3-hour time-to-bedside target for transport teams will improve patient outcomes, although timeliness is an important consideration for parents and staff. Improving communication during transport and providing parents the choice to travel in the ambulance with their child are two key service changes to enhance patient/family experience. Future work More research is needed to develop suitable risk-adjustment tools for paediatric transport and to validate the short patient-related experience measure developed in this study. Trial registration This trial is registered as ClinicalTrials.gov NCT03520192.</p

Vulnerable newborn types: Analysis of population-based registries for 165 million births in 23 countries, 2000–2021

Objective: To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021. Design: Population-based, multi-country analysis. Setting: National data systems in 23 middle- and high-income countries. Population: Liveborn infants. Methods: Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm 90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types. Main outcome measures: Prevalence of six newborn types. Results: We analysed 165 017 419 live births and the median prevalence of small types was 11.7% – highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries. Conclusions: The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries