Source: Stoll BJ, Hansen NI, Bell EF, et al. Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993-2012. JAMA. 2015;314(10):1039-1051; doi:10.1001/jama.2015.10244. See AAP Grand Rounds commentary by Dr. Jonathan Mintzer (subscription required).
PICO Question: Among extremely premature newborns, how have maternal and neonatal care practices, neonatal morbidity, and neonatal mortality changed between 1993 and 2012?
Question type: Descriptive
Study design: Prospective cohort
This report mines data from the Neonatal Research Network, funded by the National Institutes of Health. It's just a descriptive study (not to demean that, it involves some very well planned statistical analysis as well as cooperation among many clinical centers), but it provides a great snapshot of progress in care of extremely premature infants over the last couple decades.
The report focuses on outcomes of over 30,000 infants with very low birth weight (401-1500 grams) and gestational age (22-28 weeks) born at, or transferred before 2 weeks of age to, one of 26 academic neonatal care centers. The study period covered the years 1993 - 2012, with results broken up into 5-year chunks. To summarize a lot of data succinctly, changes in practice included an increase in use of antenatal steroids (reaching 87% of births), continuous positive airway pressure without ventilation (11%), and cesarean delivery (64%), and decreases in delivery room intubation (to 65%) and postnatal steroid use (8%). In terms of outcomes, survival improved primarily for infants born at 23 weeks (33% at 4 months chronologic age) and 24 weeks (65%). Rates of postnatal sepsis and other morbidities declined somewhat, but bronchopulmonary dysplasia rates increased. Although the study couldn't directly tie outcomes with a specific intervention, mostly this was very good news and suggests many benefits from modern neonatal intensive care.
The glass half-empty side of this report, however, was noted in the authors' discussion: "...medical science may have reached the limits of what current technologies can provide." The article, as well as the accompanying editorial, suggests that the next breakthroughs probably await new advances in areas such as mesenchymal stem cell and other cellular therapies, neuroimaging, and neuroscience.
Left out of the discussions, however, is an important tenet of medicine, particularly so with pediatric care: preventive measures. I had to go to the last reference in the article (the National Vital Statistics Reports) to find out how we're doing in prematurity rates in the US. According to the data just released for 2014, the preterm (< 37 weeks' gestation) birth rate has declined by about 8% since 2007. For infants 27 weeks or earlier, the rates were 0.69% of all births in 2014, compared to 0.74% in 2007. Advances in prevention of preterm delivery would go a long way towards lowering neonatal morbidity and mortality. Much of the medical science to accomplish this is already known, but of course the implementation of that science is a very challenging issue.
