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Published on: February 18, 2012
Effects of a small-baby protocol on early and long-term outcomes in extremely preterm infants: A quality improvement
Sage N Saxton1, John Evered2, Karlee McCoy3
1Oregon Health & Science University, Portland, OR, USA.
Insights
Small baby protocols (SBPs) significantly improved outcomes for extremely preterm infants, reducing mortality and improving long-term neurological survival. This approach offers a promising strategy for enhanced infant care.
Area of Science:
- Neonatalogy
- Pediatric Critical Care
- Developmental Pediatrics
Background:
- Extremely preterm (EPT) infants (≤28 weeks gestation) face significant risks for adverse outcomes.
- Optimal management strategies for EPT infants are still under investigation.
- Small baby protocols (SBPs) are proposed to improve outcomes in this vulnerable population.
Purpose of the Study:
- To evaluate the effectiveness of a Small Baby Protocol (SBP) in improving outcomes for extremely preterm infants.
- To compare the outcomes of EPT infants managed with an SBP to a historical control (HC) group.
- To assess long-term neurodevelopmental outcomes up to 13 years of age.
Main Methods:
- A historical control (HC) group of EPT infants (23-28 weeks GA, 2006-2007) was compared to a SBP group (2007-2008).
- The SBP included antenatal steroids, delayed cord clamping, respiratory/hemodynamic minimalism, prophylactic indomethacin, early caffeine, and controlled sensory environment.
- Survivors were followed until 13 years of age for mortality and neurodevelopmental outcomes.
Main Results:
- The SBP group showed significantly reduced rates of severe IVH-PVH (9% vs. 40%), mortality (17% vs. 46%), and acute pulmonary hemorrhage (6% vs. 23%).
- SBP compliance was excellent, with decreased use of inotropes, hydrocortisone, sodium bicarbonate, intubation, mechanical ventilation, and fluid boluses.
- At 10-13 years, SBP survivors had higher rates of normal neurologic survival (51% vs. 23%) and better cognitive function (Vineland score >85 in 44% vs. 11%).
Conclusions:
- Implementation of a Small Baby Protocol (SBP) is associated with improved short-term and long-term outcomes for extremely preterm infants.
- SBPs contribute to enhanced neurodevelopmental outcomes and reduced morbidities in EPT survivors.
- The findings support the adoption of SBPs as an optimal strategy for managing extremely preterm infants.
Background:
Extremely preterm (EPT) infants (≤28 weeks) remain at risk for poor outcomes. Small baby protocols (SBPs) may improve outcomes, but optimal strategies are unknown.
Methods:
This study evaluated whether EPT infants managed using an SBP would have better outcomes compared to a historical control (HC) group. The study compared a HC group of EPT infants 23 0/7 weeks to 28 0/7 weeks GA (2006-2007), to a similar SBP group (2007-2008). Survivors were followed until 13 years of life. The SBP emphasized antenatal steroids, delayed cord clamping, respiratory and hemodynamic minimalism, prophylactic indomethacin, early empiric caffeine, and control of sound and light.
Results:
There were 35 HC subjects and 35 SBP subjects. The SBP group had less severe IVH-PVH (9 % vs. 40 %, risk ratio 0.7, 95 % CI 0.5-0.9, P = 0.002) mortality (17 % vs. 46 %, risk ratio 0.6, 95 % CI 0.5-0.9, P = 0.004), and acute pulmonary hemorrhage (6 % vs. 23 %, risk ratio 0.8, 95 % CI 0.7-1.0, P = 0.04). Compliance with the SBP protocol was excellent. For the SBP group in the first 72 h, no subjects received inotropes, hydrocortisone, or sodium bicarbonate. Intubation, mechanical ventilation, fluid boluses, sedation, red blood cell transfusions, and insulin use decreased. At 10-13 years, more SBP subjects had survived without NDI (51 % vs. 23 %, risk ratio = 1.6, 95 % CI = 1.1-2.4, P = 0.01). More SBP subjects also survived without NDI and with a Vineland Adaptive Behavior Composite score > 85 (44 % vs. 11 %, risk ratio = 2.0, 95 % CI = 1.2-3.2, P ≤0.001). The SBP group had less visual impairment.
Conclusion:
An SBP was associated with improved outcomes, including normal neurologic survival after 10 years.
