Trends in Care Practices, Morbidity, and Mortality of Extremely Preterm Neonates, 1993-2012.
Trends in Care Practices, Morbidity, and Mortality of Extremely Preterm Neonates, 1993-2012.
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DOI：
10.1001/jama.2015.10244
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发表时间：
2015-09-08
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影响因子：
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通讯作者：
Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network
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文献类型：
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作者：
Stoll BJ;Hansen NI;Bell EF;Walsh MC;Carlo WA;Shankaran S;Laptook AR;Sánchez PJ;Van Meurs KP;Wyckoff M;Das A;Hale EC;Ball MB;Newman NS;Schibler K;Poindexter BB;Kennedy KA;Cotten CM;Watterberg KL;D'Angio CT;DeMauro SB;Truog WE;Devaskar U;Higgins RD;Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network
极早产儿对新生儿发病率和死亡率的贡献不成比例。回顾新生儿研究网络中心出生的极早产儿的孕产妇/新生儿护理、并发症和死亡率的20年趋势。1993-2012年在26个网络中心出生的34，636名胎龄（GA）为22-28周、出生体重为401-1500 g的婴儿的前瞻性登记研究。极度早产。产妇/新生儿护理、发病率和存活率。存活超过12小时的婴儿报告的主要发病率为：重度坏死性小肠结肠炎、感染、支气管肺发育不良、重度颅内出血、囊性脑室周围白质软化和/或重度早产儿视网膜病变。回归模型评估了每年的变化，调整了研究中心、人种/种族、GA、GA的出生体重和性别。从1993年到2012年，产前皮质类固醇的使用增加（348/1431 [24%]到1674/1919 [87%]，p<0.001），剖腹产也是如此（625/1431 [44%]到1227/1921 [64%]，p<0.001）。产房插管从1993年的1144/1433（80%）下降到2012年的1253/1922（65%）（p<0.001）。在1990年代增加之后，产后类固醇使用在2004年下降到141/1757（8%）（p<0.001），此后没有显著变化。尽管大多数婴儿进行了通气，但无通气的持续气道正压通气从2002年的120/1666（7%）增加到2012年的190/1756（11%）（p<0.001）。尽管从1993年到2004年没有改善，但在2005年到2012年期间，每种GA的婴儿迟发性脓毒症的发生率都有所下降（中位GA 26周，109/296 [37%]到85/320 [27%]，校正的相对风险[aRR]：0.93 [95%CI，0.92-0.94]）。2009年至2012年，26-27周婴儿的其他疾病发生率下降，但支气管肺发育不良增加（26周，130/258 [50%]至164/297 [55%]，p<0.001）。2009年至2012年，23周婴儿的存活率有所增加（41/152 [27%]至50/150 [33%]，aRR：1.09 [95% CI，1.05-1.14]）和24周（156/248 [63%]至174/269 [65%]，aRR：1.05 [95% CI，1.03-1.07]），25和27周婴儿的相对增加较小，22、26和28周婴儿无变化。对于25-28周的婴儿，无重大发病率的存活率每年增加约2%，而对于22-24周的婴儿没有变化。在过去20年中，在美国学术中心出生的极早产儿中，观察到母婴护理实践的变化和几种发病率的适度降低，尽管支气管肺发育不良增加。23周和24周出生的婴儿存活率增加最明显，25-28周出生的婴儿无重大发病率的存活率增加。这些发现可能对辅导家庭和开发新的干预措施有价值。
Extremely preterm infants contribute disproportionately to neonatal morbidity and mortality. To review 20-year trends in maternal/neonatal care, complications, and mortality among extremely preterm infants born at Neonatal Research Network centers. Prospective registry of 34,636 infants 22–28 weeks’ gestational age (GA) and 401–1500 gram birthweight born at 26 Network centers, 1993–2012. Extremely preterm birth. Maternal/neonatal care, morbidities, and survival. Major morbidities, reported for infants who survived more than 12 hours, were: severe necrotizing enterocolitis, infection, bronchopulmonary dysplasia, severe intracranial hemorrhage, cystic periventricular leukomalacia, and/or severe retinopathy of prematurity. Regression models assessed yearly changes, adjusting for study center, race/ethnicity, GA, birthweight for GA, and sex. Use of antenatal corticosteroids increased from 1993 to 2012 (348/1431 [24%] to 1674/1919 [87%], p<0.001), as did cesarean delivery (625/1431 [44%] to 1227/1921 [64%], p<0.001). Delivery room intubation decreased from 1144/1433 (80%) in 1993 to 1253/1922 (65%) in 2012 (p<0.001). After increasing in the 1990s, postnatal steroid use declined to 141/1757 (8%) in 2004 (p<0.001), with no significant change thereafter. Although most infants were ventilated, continuous positive airway pressure without ventilation increased from 120/1666 (7%) in 2002 to 190/1756 (11%) in 2012 (p<0.001). Despite no improvement from 1993 to 2004, rates of late-onset sepsis declined between 2005 and 2012 for infants of each GA (median GA 26 weeks, 109/296 [37%] to 85/320 [27%], adjusted relative risk [aRR]: 0.93 [95% CI, 0.92–0.94]). Rates of other morbidities declined, but bronchopulmonary dysplasia increased between 2009 and 2012 for infants 26–27 weeks (26 weeks, 130/258 [50%] to 164/297 [55%], p<0.001). Survival increased between 2009 and 2012 for infants 23 weeks (41/152 [27%] to 50/150 [33%], aRR: 1.09 [95% CI, 1.05–1.14]) and 24 weeks (156/248 [63%] to 174/269 [65%], aRR: 1.05 [95% CI, 1.03–1.07]), with smaller relative increases for infants 25 and 27 weeks and no change for infants 22, 26 and 28 weeks. Survival without major morbidity increased approximately 2% per year for infants 25–28 weeks with no change for infants 22–24 weeks. Among extremely preterm infants born at US academic centers over the last 20 years, changes in maternal and infant care practices and modest reductions in several morbidities were observed, although bronchopulmonary dysplasia increased. Survival increased most markedly for infants born at 23 and 24 weeks and survival without major morbidity increased for infants 25–28 weeks. These findings may be valuable in counselling families and developing novel interventions.