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Published on: January 27, 2023
Outcomes of Extremely Premature Infants Comparing Patent Ductus Arteriosus Management Approaches
Gabriel Altit1, Sahar Saeed2, Marc Beltempo3
1Division of Neonatology, McGill University Health Center, Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
Insights
A strict nonintervention policy for premature infants did not affect death or bronchopulmonary dysplasia (BPD) rates in those born at 26 weeks or later. However, this conservative approach significantly increased death or BPD in extremely premature infants born before 26 weeks.
Area of Science:
- Neonatalogy
- Pediatric Critical Care
- Public Health Policy
Background:
- Bronchopulmonary dysplasia (BPD) and mortality remain significant challenges in extremely premature infants.
- The optimal management strategy for very premature infants, particularly regarding intervention versus nonintervention, is debated.
- Previous studies have yielded mixed results on the impact of noninterventionist approaches in neonatal care.
Purpose of the Study:
- To evaluate the impact of a policy change towards a strict nonintervention approach on the rates of death and BPD in premature infants.
- To compare outcomes between infants born <26 weeks and those born 26-29 weeks of gestational age under different management strategies.
- To assess the effectiveness of a conservative management policy compared to standard medical treatment.
Main Methods:
- A quasi-experimental study design using a difference-in-differences approach was employed.
- Two comparable neonatal intensive care units were selected; one continued standard care (control), while the other adopted a strict nonintervention policy (exposed).
- Infant outcomes (death/BPD) were analyzed across two epochs (pre- and post-policy change) for infants born <26 weeks and 26-29 weeks gestational age.
Main Results:
- No significant difference in death or BPD was observed among infants born at 26-29 weeks gestational age between the two sites.
- A significant increase in the incidence of death or BPD (31% rise) was found in infants born <26 weeks gestational age at the site with the nonintervention policy.
- Control outcomes (Score for Neonatal Acute Physiology-Version II) remained stable, indicating the findings were specific to the intervention and not due to changes in patient acuity.
Conclusions:
- Adherence to a strict nonintervention policy did not adversely affect outcomes for premature infants born at 26 weeks or later.
- A conservative, noninterventionist approach was associated with a significant increase in adverse outcomes (death or BPD) for extremely premature infants born <26 weeks gestational age.
- The findings suggest that gestational age is a critical factor when considering noninterventionist policies in neonatal care.
Objective:
To evaluate the change in the proportion of deaths/bronchopulmonary dysplasia (BPD) among premature infants (born <26 and 26-29 weeks of gestational age) following a policy change to a strict nonintervention approach, compared with standard treatment.
Study Design:
We examined 1249 infants (341 born <26 weeks of gestational age) at 2 comparable sites. Site 1 (control) continued medical treatment/ligation, and site 2 (exposed) changed to a nonintervention policy in late 2013. Using the difference-in-differences approach, which accounts for time-invariant differences between sites and secular trends, we assessed changes in death or BPD separately among infants born 26-29 weeks and <26 weeks of gestational age in 2 epochs (epoch 1: 2011-2013; epoch 2: 2014-2017).
Results:
Baseline characteristics were similar across sites and epochs. Medical treatment/ligation use remained stable at site 1 but declined progressively to 0% at site 2, indicating adherence to policy. We saw no difference in death/BPD among infants born at 26-29 weeks of gestational age (12%, 95% CI -1% to 24%). However, incidence of death/BPD increased by 31% among infants born <26 weeks of gestational age (95% CI 10%-51%) in site 2, whereas there was no change in outcomes in site 1. The Score for Neonatal Acute Physiology-Version II, used as a control outcome, did not change in either site, suggesting that our findings were not due to changes in patients' severity.
Conclusions:
Adherence to a strict conservative policy did not impact death or BPD among 26 weeks but was associated with a significant rise in infants born <26 weeks.
