late preterm infant: is it a trend or a catastrophe? michael e. speer, md professor of pediatrics...
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Late preterm infant: Is Late preterm infant: Is it a trend or a it a trend or a catastrophe?catastrophe?
Michael E. Speer, MDMichael E. Speer, MDProfessor of Pediatrics & Medical EthicsProfessor of Pediatrics & Medical Ethics
Baylor College of MedicineBaylor College of Medicine
Survival of extremely low-birth-Survival of extremely low-birth-weight infants (birth weight < 1000 weight infants (birth weight < 1000 g) increased 35% between the g) increased 35% between the 1980s and the 1990s1980s and the 1990s– 85% of infants with very low birth 85% of infants with very low birth
weight (between 500 and 1500 grams) weight (between 500 and 1500 grams) survivesurvive
Stoelhorst GMSJ, et. al.Stoelhorst GMSJ, et. al. Pediatrics. 2005 Pediatrics. 2005 Feb;115(2):396-405.Feb;115(2):396-405.
Improved SurvivalImproved Survival
Improved SurvivalImproved Survival
Mortality: 1980s Mortality: 1980s 1990s 1990s – 32 weeks’ gestation: 30% to 11%32 weeks’ gestation: 30% to 11%– <27 weeks’ gestation: 76% to <27 weeks’ gestation: 76% to
33%33%
Stoelhorst GMSJ, et. al.Stoelhorst GMSJ, et. al. Pediatrics. 2005 Feb;115(2):396-405. Pediatrics. 2005 Feb;115(2):396-405.
Increased MorbidityIncreased Morbidity Disabilities have also increased between 1980s & Disabilities have also increased between 1980s &
1990s1990s– Primarily chronic lung disease and neuro-developmental Primarily chronic lung disease and neuro-developmental
impairmentimpairment Sepsis: Sepsis: 37% to 51% 37% to 51% Periventricular leukomalacia: Periventricular leukomalacia: 2% to 7% 2% to 7% CLD: (OCLD: (O22 at 36 wks PMA): at 36 wks PMA): 32% to 43%32% to 43% Cerebral palsy: Cerebral palsy: 16% to 25% 16% to 25% Deafness Deafness 3% to 7%3% to 7% Neurodevelopment impairment* Neurodevelopment impairment* 26% to 36% 26% to 36%
(*major neurosensory abnormality and/or Bayley Mental Developmental Index (*major neurosensory abnormality and/or Bayley Mental Developmental Index score of <70)score of <70)
Stoelhorst 2005. Stoelhorst 2005. Pediatrics. 2005 Feb;115(2):396-405.Pediatrics. 2005 Feb;115(2):396-405.
Rising Rate of Rising Rate of PrematurityPrematurity
The preterm birth rate has The preterm birth rate has increased by 36% since the increased by 36% since the 1980s1980s**– > 540,000 each year at present> 540,000 each year at present– 21% increase since 1990 (10.6% to 21% increase since 1990 (10.6% to
12.8%) 12.8%) Primarily 34 to 36 weeks Primarily 34 to 36 weeks
gestation gestation – Increase of 25% since 1990 Increase of 25% since 1990
*NCHS 2006 final natality data;*NCHS 2006 final natality data; March of March of Dimes, 2009Dimes, 2009
Trends in Late Preterm Birth, Stillbirth, and Infant Mortality: US 1990-2004
Ananth CV, et al. Am J Obste Gynecol. 2008;199:329-31
12.812.712.512.312.111.911.611.811.611.411.0
0
2
4
6
8
10
12
14
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
<32 weeks 32-33 weeks 34-36 weeks
Source: National Center for Health Statistics Prepared by March of Dimes, Periantal Data Center, 2009
Percent of live births
>70% Late Preterm
Courtesy of Karla Damus
RISE IN LATE PRETERM BIRTHS RISE IN LATE PRETERM BIRTHS (34-36 wks)(34-36 wks)
Births by caesarean section by country (2000)# 1 Italy: 333 live births per 1,000 (33.3%)# 2 Australia: 217 live births per 1,000 (21.7%)# 3 USA: 211 live births per 1,000 (21.1%)# 4 Germany: 209 live births per 1,000 (20.9%)# 5 Canada: 205 live births per 1,000 (20.5%)# 6 Ireland: 204 live births per 1,000 (20.4%)# 7 New Zealand: 202 live births per 1,000 (20.2%)# 8 Austria: 172 live births per 1,000 (17.2%)# 9 France: 171 live births per 1,000 (17.1%)# 10 United Kingdom: 170 live births per 1,000 (17.0%)# 11 Belgium: 159 live births per 1,000 (15.9%)# 12 Finland: 157 live births per 1,000 (15.7%)# 13 Denmark: 145 live births per 1,000 (14.5%)# 14 Sweden: 144 live births per 1,000 (14.4%)# 15 Norway: 137 live births per 1,000 (13.7%)# 16 Netherlands: 129 live births per 1,000 (12.9%)
Weighted average: 185.3 live births per 1,000 (18.5%)
Cesarean Section Rates – Latin America (2005)
Median rate 33% (quartile range 24–43)
Elective 49%
Intrapartum 46%
Emerg. s Labour5%
Lancet. 2006;367:1819-29
World Wide Cesarean Section Rates - WHO Asia – 27.3% (2007 – 2008)*
– China 46.2%– Sri Lanka 30.6% – Viet Nam 35.6%– Thailand 34.1%
Latin America – 35% (2005)– Brazil 36% (2009)
Private clinic rate: >90%
– Ecuador 40% (2005)– Paraguay 42% (2005)
*Lancet. 2010;375:Pages 490-499
Risk of Placenta Accreta and Risk of Placenta Accreta and Hysterectomy by Number of Cesarean Hysterectomy by Number of Cesarean Deliveries Compared with the First Deliveries Compared with the First Cesarean DeliveryCesarean DeliveryCesarean Cesarean SectionSection
Accreta Accreta [n(%)][n(%)]
Odds RatioOdds Ratio Hysterectomy Hysterectomy [n(%]) [n(%])
Odds RatioOdds Ratio
FirstFirst 15 (0.2)15 (0.2) 40 (0.7)40 (0.7)
SecondSecond 49 (0.3)49 (0.3) 1.3 (.7–2.3)1.3 (.7–2.3) 67 (0.4)67 (0.4) 0.7 (0.4–0.97)0.7 (0.4–0.97)
ThirdThird 36 (0.6)36 (0.6) 2.4 (1.3–4.3)2.4 (1.3–4.3) 57 (0.9)57 (0.9) 1.4 (0.9–1.2)1.4 (0.9–1.2)
FourthFourth 31 (2.1)31 (2.1) 9.0 (4.8–16.7)9.0 (4.8–16.7) 35 (2.4)35 (2.4) 3.8 (2.4–6.0)3.8 (2.4–6.0)
FifthFifth 6 (2.3)6 (2.3) 9.8 (3.8–25.5)9.8 (3.8–25.5) 9 (3.5)9 (3.5) 5.6 (2.7–11.6)5.6 (2.7–11.6)
Six or Six or MoreMore
6 (6.7)6 (6.7) 29.8 (11.3–78.7)29.8 (11.3–78.7) 8 (9.0)8 (9.0) 15.2 (6.9–33.5)15.2 (6.9–33.5)
Obstet Gynecol 2006;107:1226–32.
Indications for Late Preterm Birth
05
101520253035404550
Medical Obstetric Anomaly Labor None Indication
%
23.2
Reddy U, et al. Pediatrics. 2009;124:234-9
14.4 15.9
1.3
48.9
Clinical IssuesClinical Issues
Risks of Elective Delivery– 13,258 Elective Cesarean Sections
Rates of adverse respiratory outcomes, mechanical ventilation, sepsis, hypoglycemia, NICU admission, and hospitalization for 5 days or more.
Increased by a factor of 1.8 to 4.2 for births at 37 weeks
Increased by a factor of 1.3 to 2.1 for births at 38 weeks.
Tita A, et al. NEJM. 2009;360:111-120
Clinical IssuesClinical Issues
http://www.femalepatient.com/html/arc/sig/PatS/articles/http://www.femalepatient.com/html/arc/sig/PatS/articles/034_09_041.asp034_09_041.asp
Khashu, M. et al. Pediatrics 2009;123:109-113
Mortality Higher in Preterm (33-36 wk) versus Term (37-40 wk)
Mortality: Late Mortality: Late Preterm vs Term Preterm vs Term Infant: 1995-2002Infant: 1995-2002
Mortality/1000 live births
Late PT Term Ratio
Overall (0 – 364 days)
7.9 2.4 3x
Early neonatal (0 – 6 days)
2.8 0.5 6x
Late neonatal (7 – 27 days)
1.4 0.4 3x
Post neonatal (28-364 days)
3.7 1.6 2x
Tomashak KM. J Pediatr 2007; 151;450
Shapiro-Mendoza, C. K. et al. Pediatrics 2008;121:e223-e232
Proportion with newborn morbidity during birth hospitalization according
to gestational age
Clinical outcomes in near-term and full-term infants
(% of patients studied)
Wang, M. L. et al. Pediatrics 2004;114:372-376
Early Respiratory Morbidity Early Respiratory Morbidity in Late Preterm Infantsin Late Preterm Infants
34 35 36 37 39
TTN (%) 2.4 1.6 1.1 0.7 0.4
Ventilator (%)
3.3 1.7 0.8 0.5 0.3
Weeks of Gestation
McIntire & Leveno. Obstet. Gynecol. 2008;111:35-41
Early Respiratory MorbidityEarly Respiratory Morbidity
GA (wk) Oxygen > 1 hour
Assisted Ventilation
38-40 Reference Reference
37 2.04 (1.61-2.59) 2.35 (1.84-3.02)
36 4.95 (3.95-6.21) 5.24 (4.11-6.68)
35 8.76 (6.77-11.4) 0.04 (6.88-11.9)
34 18.67 (14-24.9) 19.8 (14.7-26.6)
Odds Odds RatiosRatios
Escobar GJ. Semin Perinatal. 2006;30:28-33
Early & Late Nutritional Early & Late Nutritional MorbidityMorbidity
Inadequate caloric intake:Inadequate caloric intake: – Poor suck/swallow coordinationPoor suck/swallow coordination– FatigueFatigue
Feeding intoleranceFeeding intolerance– Delayed stoolingDelayed stooling– Feeding residualsFeeding residuals
Exaggerated physiologic jaundiceExaggerated physiologic jaundice DehydrationDehydration HypernatremiaHypernatremia Increased need for parenteral nutritionIncreased need for parenteral nutrition Failure to thriveFailure to thrive
Breastfeeding IssuesBreastfeeding Issues
Decreased milk Decreased milk productionproduction
Poor latchPoor latch Poor sucking Poor sucking
efforteffort Poor coordinationPoor coordination Potential Potential
alteration in alteration in bondingbonding
Wang, M. L. et al. Pediatrics 2004;114:372-376
Neonatal gestational age versus length of hospital stay
Primary Reason Documented for Discharge Delay of Near-Term and Full-Term Neonates
Primary Reason for Delay of Discharge
Near Term
Full Term Comment
Jaundice 8/49 (16.3%)
1/36 (0.03%)
P = .072; 95% CI: 0.083–311.1; OR: 6.71
Respiratory distress 8/26 (30.8%)
2/4 (50%)
P = .58; 95% CI: 0.03–7.36; OR: 0.46
Poor feeding 22/29 (75.9%)
2/7 (28.6%)
P = .029; 95% CI: 0.94–93.4; OR: 7
Neonates (total) with discharge delay
5050 77
Wang, M. L. et al. Pediatrics 2004;114:372-376
GA at Presentation to ED: GA at Presentation to ED: 20032003
80.2
17.7
1.60
10
20
30
40
50
60
70
80
90
% GA
TermLate PretermEarly Preterm
Jain S. Clinics in Perinatology. 2006;33:935-945
Lung MaturationLung Maturation
PulmonaryPulmonary– Persistent airway obstruction Persistent airway obstruction
demonstrated in healthy premature demonstrated in healthy premature infants (infants (36 wk GA) compared with 36 wk GA) compared with infants born at term:infants born at term: 6–10 weeks after birth6–10 weeks after birth: : FEF in healthy FEF in healthy
30–34 wk GA infants (30–34 wk GA infants (PP<0.001)<0.001)11
At age 1At age 1: : V VmaxmaxFRC in healthy 29–36 wk FRC in healthy 29–36 wk GA infants (GA infants (PP<0.05)<0.05)22
1.1. Friedrich L, et al.Friedrich L, et al. Am J Resp Crit Care Med. 2006;173:442-447. 22.2. Hoo A-F, et al.Hoo A-F, et al. J Pediatr. J Pediatr. 2002;141:652-658.2002;141:652-658.
FEF: forced expiratory flow; VmaxFRC: maximal expiratory flow at functional residual capacity.
4.48.0
12.19.4 8.2
56.3
0
10
20
30
40
50
60
Boyce TG, et al. J Pediatr. 2000;137:865-870.
28 wks GA
Low-risk**29 to <33 wks GA
33 to <36 wks GA
RS
V-r
ela
ted
Ho
sp
ita
liza
tio
ns
pe
r 1
00
Ch
ild
ren
<6
Mo
nth
s o
f A
ge
BPD CHD
*Retrospective study of enrollees in Tennessee Medicaid, July 1989-June 1993.**Low-risk defined as all other children born at term.
Risk of Infection: RSVRisk of Infection: RSV
56.3
12.19.4 8.2 8.
04.4
Infection
Changes in brain volume and Changes in brain volume and maturation with increasing maturation with increasing gestational agegestational age
Kapelloou, O et al. PLOS Med 2006;3:e265
NeurodevelopmentalNeurodevelopmental
Early School-Age Early School-Age OutcomeOutcome
AgAgee
%%
Late Late PreterPreter
mmN=7152N=7152
% % TermTermN=152N=152
,661,661
Unadjusted RRUnadjusted RR
[95% CI][95% CI]Adjusted RRAdjusted RR
[95% CI][95% CI]
Developmental delay/disability
0–3 4.24 2.96 1.43 (1.36–1.51) 1.36 (1.29–1.43)
Disability in prekindergarten 3 4.46 3.89 1.15 (1.09–1.20) 1.13 (1.08–1.19)
Disability in prekindergarten 4 7.40 6.60 1.12 (1.08–1.16) 1.10 (1.05–1.14)
Not ready to start school 4 5.09 4.40 1.16 (1.11–1.21) 1.04 (1.00–1.09)
Exceptional student education
5 13.30 11.9 1.13 (1.09–1.16) 1.10 (1.07–1.13)
Retention in kindergarten 5 7.96 6.17 1.29 (1.24–1.34) 1.11 (1.07–1.15)
Suspension in kindergarten 5 1.80 1.22 1.48 (1.37–1.60) 1.19 (1.10–1.29)Morse SB et al. Pediatrics. 2009;123:e622-e629
0
0.5
1
1.5
2
2.5
CP* MR+ Work^ OMD#
34-36 6/ 7 wk
=/ > 37 wk
Disabilities Related to GA at Birth (Adults)
%
*RR: 2.7(2.2 – 3.3)
+RR: 1.6(1.4 – 1.8)
^RR: 1.4(1.3 – 1.5)
#RR: 1.5(1.2 – 1.8)
* Cerebral Palsy
+ Mental Retardation
^ Disability Affecting Work
# Other Major Disability
Moster D et al. NEJM. 2008; 359:262-273