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Late preterm infant: Is it a trend or a catastrophe?

Late preterm infant: Is it a trend or a catastrophe?. Michael E. Speer, MD Professor of Pediatrics & Medical Ethics Baylor College of Medicine. Improved Survival. Survival of extremely low-birth-weight infants (birth weight < 1000 g) increased 35% between the 1980s and the 1990s

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Late preterm infant: Is it a trend or a catastrophe?

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  1. Late preterm infant: Is it a trend or a catastrophe? Michael E. Speer, MD Professor of Pediatrics & Medical Ethics Baylor College of Medicine

  2. Improved Survival • Survival of extremely low-birth-weight infants (birth weight < 1000 g) increased 35% between the 1980s and the 1990s • 85% of infants with very low birth weight (between 500 and 1500 grams) survive StoelhorstGMSJ, et. al.Pediatrics. 2005 Feb;115(2):396-405.

  3. Improved Survival • Mortality: 1980s 1990s • 32 weeks’ gestation: 30% to 11% • <27 weeks’ gestation: 76% to 33% Stoelhorst GMSJ, et. al. Pediatrics. 2005 Feb;115(2):396-405.

  4. Increased Morbidity • Disabilities have also increased between 1980s & 1990s • Primarily chronic lung disease and neuro-developmental impairment • Sepsis: 37% to 51% • Periventricular leukomalacia: 2% to 7% • CLD: (O2 at 36 wks PMA): 32% to 43% • Cerebral palsy: 16% to 25% • Deafness 3% to 7% • Neurodevelopment impairment* 26% to 36% (*major neurosensory abnormality and/or Bayley Mental Developmental Index score of <70) Stoelhorst 2005. Pediatrics. 2005 Feb;115(2):396-405.

  5. Rising Rate of Prematurity • The preterm birth rate has increased by 36% since the 1980s* • > 540,000 each year at present • 21% increase since 1990 (10.6% to 12.8%) • Primarily 34 to 36 weeks gestation • Increase of 25% since 1990 • *NCHS 2006 final natality data; March of Dimes, 2009

  6. Trends in Late Preterm Birth, Stillbirth, and Infant Mortality: US 1990-2004 Ananth CV, et al. Am J Obste Gynecol. 2008;199:329-31

  7.  Preterm Birth in the United States: 1996 - 2006

  8. RISE IN LATE PRETERM BIRTHS (34-36 wks) Percent of live births >70% Late Preterm Source: National Center for Health Statistics Prepared by March of Dimes, Periantal Data Center, 2009 Courtesy of Karla Damus

  9. Percentage of Births by Cesarean: 32% (2007)

  10. 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%)

  11. Cesarean Section Rates – Latin America (2005) Median rate 33% (quartile range 24–43) Elective 49% Intrapartum 46% Emerg. s Labour 5% Lancet. 2006;367:1819-29

  12. 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

  13. Rates are not necessarily current http://blog.fortiusone.com/2009/04/22/birth-in-the-usa/

  14. Risk of Placenta Accreta and Hysterectomy by Number of Cesarean Deliveries Compared with the First Cesarean Delivery Obstet Gynecol 2006;107:1226–32.

  15. Indications for Late Preterm Birth 48.9 % 23.2 15.9 14.4 1.3 Reddy U, et al. Pediatrics. 2009;124:234-9

  16. Clinical 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

  17. Clinical Issues http://www.femalepatient.com/html/arc/sig/PatS/articles/034_09_041.asp

  18. Mortality Higher in Preterm (33-36 wk) versus Term (37-40 wk) Khashu, M. et al. Pediatrics 2009;123:109-113

  19. Mortality: Late Preterm vs Term Infant: 1995-2002 Tomashak KM. J Pediatr 2007; 151;450

  20. RR of morbidity, preterm versus term Khashu, M. et al. Pediatrics 2009;123:109-113

  21. Proportion with newborn morbidity during birth hospitalization according to gestational age Shapiro-Mendoza, C. K. et al. Pediatrics 2008;121:e223-e232

  22. Clinical outcomes in near-term and full-term infants (% of patients studied) Wang, M. L. et al. Pediatrics 2004;114:372-376

  23. Early Respiratory Morbidity in Late Preterm Infants Weeks of Gestation McIntire & Leveno. Obstet. Gynecol. 2008;111:35-41

  24. Early Respiratory Morbidity Odds Ratios Escobar GJ. Semin Perinatal. 2006;30:28-33

  25. Early & Late Nutritional Morbidity • Inadequate caloric intake: • Poor suck/swallow coordination • Fatigue • Feeding intolerance • Delayed stooling • Feeding residuals • Exaggerated physiologic jaundice • Dehydration • Hypernatremia • Increased need for parenteral nutrition • Failure to thrive

  26. Breastfeeding Issues • Decreased milk production • Poor latch • Poor sucking effort • Poor coordination • Potential alteration in bonding

  27. Neonatal gestational age versus length of hospital stay Wang, M. L. et al. Pediatrics 2004;114:372-376

  28. Primary Reason Documented for Discharge Delay of Near-Term and Full-Term Neonates Wang, M. L. et al. Pediatrics 2004;114:372-376

  29. GA at Presentation to ED: 2003 Jain S. Clinics in Perinatology. 2006;33:935-945

  30. Lung Maturation • Pulmonary • Persistent airway obstruction demonstrated in healthy premature infants (36 wk GA) compared with infants born at term: • 6–10 weeks after birth:  FEF in healthy 30–34 wk GA infants (P<0.001)1 • At age 1:  VmaxFRC in healthy 29–36 wk GA infants (P<0.05)2 FEF: forced expiratory flow; VmaxFRC: maximal expiratory flow at functional residual capacity. • Friedrich L, et al.Am J Resp Crit Care Med. 2006;173:442-447. 2 • Hoo A-F, et al. J Pediatr.2002;141:652-658.

  31. Risk of Infection: RSV Infection *Retrospective study of enrolleesin Tennessee Medicaid, July 1989-June 1993. **Low-risk defined as all other children born at term. 56.3 RSV-related Hospitalizations per 100 Children <6 Months of Age 12.1 9.4 8.2 8.0 4.4 BPD CHD £28 wks GA 29 to <33 wks GA 33 to <36 wks GA Low-risk** Boyce TG, et al. J Pediatr. 2000;137:865-870.

  32. Changes in brain volume and maturation with increasing gestational age Kapelloou, O et al. PLOS Med 2006;3:e265

  33. Brain Growth During Gestation Hüppi PS, et al. Ann Neurol. 1998 Feb;43(2):224-35.

  34. Neurologic Maturation: Cerebral White Matter Hüppi PS, et al. Ann Neurol. 1998 Feb;43(2):224-35.

  35. Neurologic Maturation From Conel, 1939-59

  36. Neurodevelopmental Morse SB et al. Pediatrics. 2009;123:e622-e629

  37. Disabilities Related to GA at Birth (Adults) % * Cerebral Palsy + Mental Retardation ^ Disability Affecting Work # Other Major Disability *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) Moster D et al. NEJM. 2008; 359:262-273

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