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A publicação da obra é uma homenagem à memória de seu autor, Orlando da Silva Leite, e decorridos 40 anos de seu falecimento e 71 anos do momento em que foi escrita, esta obra também é uma oportunidade de o público inteirar-se mais um pouco sobre o importante brasileiro que foi Rui Barbosa, o tema do livro de Orlando. É importante ressaltar que o texto aqui publicado no formato de livro eletrônico foi escrito em 1949 como monografia, para comemorar o centenário de nascimento de Rui Barbosa. Existem muitos livros sobre esse grande brasileiro, referido como o “Plantador de Carvalho”. O texto é antigo, mas, como o carvalho, não envelheceu nesses 70 anos decorridos de sua redação.

To identify determinants of cesarean delivery (CD) and examine associations between mode of delivery (MOD) and maternal and perinatal outcomes.We conducted a retrospective analysis of a Canadian multicentre birth cohort derived from provincial data collected in 2008/2009. Maternal and perinatal characteristics and outcomes were compared between vaginal and cesarean birth and between the following MOD subgroups: spontaneous vaginal delivery (VD), assisted VD, planned cesarean delivery (CD), and intrapartum CD. Multivariate regression identified determinants of CD and the effects of MOD and previous CD on maternal and perinatal outcomes.The cohort included 264 755 births (72.1% VD and 27.9% CD) from 91 participating institutions. Determinants of CD included maternal age, parity, previous CD, chronic hypertension, diabetes, urinary tract infection or pyelonephritis, gestational hypertension, vaginal bleeding, labour induction, pre-term gestational age, low birth weight, large for gestational age, malpresentation, and male sex. CD was associated with greater risk of maternal and perinatal morbidity and mortality. Subgroup analysis demonstrated higher risk of adverse pregnancy outcomes with assisted VD and intrapartum CD than spontaneous VD. Planned CD reduced the risk of obstetric wound hematoma and perinatal mortality but increased maternal and neonatal morbidity. Previous CD increased the risk of maternal and neonatal morbidity among multiparous women.The CD rate in Canada is consistent with global trends reflecting demographic and obstetric intervention factors. The risk of adverse pregnancy outcomes with CD warrants evaluation of interventions to safely prevent nonessential cesarean birth.

Objective Surfactant delivery via a thin endotracheal catheter during spontaneous breathing; a technique called minimally invasive surfactant therapy (MIST) is an alternative to intubation and surfactant administration. Procedural details among different centers vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multiaccess suction catheters, vascular catheters, and more recently custom-built catheters for this purpose. The impact of choice of catheter on procedural success and procedural adverse effects has not been reported. Our present study compares the procedural success and adverse effects of MIST using a semirigid vascular catheter (16G Angiocath-Hobart Method) versus a flexible multiaccess catheter (MAC). Study Design This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit in Southwestern Ontario. All neonates who received surfactant via MIST between May 1, 2016 and September 30, 2020 were included in the study. Relevant baseline characteristics and data on procedural details (premedication, type of catheter, etc.) were collected. The procedural success, number of attempts, and adverse effects between neonates who received MIST via MAC and 16G Angiocath was compared by using Chi-square test or Fisher's test as appropriate. A p-value of less that 0.05 was considered significant. Results A total of 139 neonates received surfactant via MIST method during the study period. Moreover, 93 neonates received the surfactant via MAC, while 46 received it via Angiocath. The baseline demographic characteristics in the two group were similar. A higher proportion of neonates in Angiocath group received Atropine (100 vs. 76%, p = 0.002) and Fentanyl (98 vs. 36%, p The procedural success was 91% in the Angiocath group and 89% in the MAC group (p > 0.99). Multiple attempts were needed in 24% of neonates in the Angiocath group and 37% in the MAC group (p = 0.158). More episodes of desaturations were noted in the Angiocath group (89%) than the MAC group (69%; p = 0.012). Other rates of common adverse effects were similar between the two groups. On exploratory analysis fentanyl use held significant association with less success, more desaturation, apneic episodes, and need of positive pressure ventilation /intubation. Conclusion The overall procedural success of MIST is similar in both catheter groups. The proportion of neonates requiring multiple attempts was lower with the Angiocath, though difference was not statistically significant. Desaturation episodes were seen more frequently in the Angiocath group, which was related to higher use of procedural sedation in this group. Key Points

Umbilical cord arterial and venous blood gas values reflect the acid-base balance status of a newborn at birth. Derangement in these values has been linked to poor neonatal outcomes in term and late preterm neonates; however, the utility of these values in preterm neonates of29 weeks' gestation is unclear.This study aimed to determine the associations of umbilical cord arterial and venous blood gas values with neonatal mortality and severe neurologic injury in extremely preterm neonates and to identify the cutoff values associated with 2.5-fold increases or decreases in the posttest probabilities of outcomes.This was a retrospective cohort study of neonates who were born at 23+0 to 28+6 weeks' gestation between January 1, 2018 and December 31, 2019, and who were admitted to neonatal units in Canada.Various cut-offs of umbilical cord blood gas values and lactate values were studied.The main outcomes were mortality before discharge from the neonatal unit and severe neurologic injury defined as grade 3 or 4 periventricular or intraventricular hemorrhage or periventricular leukomalacia. The outcome rates were calculated for various cutoff values of umbilical cord blood gas parameters and were adjusted for birthweight, gestational age, sex, and multiple births. Likelihood ratios were calculated to derive posttest probabilities.A total of 1040 and 1217 neonates had analyzable umbilical cord arterial and venous blood gas values, respectively. In the cohort, the mean (standard deviation) gestational age was 26.5 (1.5) weeks, the mean birthweight was 936 (215) g, the prevalence of mortality was 10% (105/1040), and the prevalence of severe neurologic injury was 9% (92/1016). An umbilical cord arterial pH of ≤7.1 and base excess of ≤-12 mmol/L were associated with2.5-fold higher posttest probability of mortality, and an umbilical cord arterial or venous lactate value of3 was associated with a 2.5-fold lower posttest probability of mortality. An umbilical cord arterial lactate value of3 was associated with a lower posttest probability of severe neurological injury.In preterm neonates of29 weeks' gestation, low umbilical cord arterial pH and high umbilical cord arterial base excess values were associated with a clinically important increase in the posttest probability of mortality, whereas low umbilical cord arterial or venous lactate values were associated with a decrease in the posttest probability of mortality.

Objective: To evaluate the association of a combined exposure to antenatal steroids and prophylactic indomethacin with the outcome of spontaneous intestinal perforation (SIP) among neonates born at 7 days before birth) exposures. The co-exposure was prophylactic indomethacin. The primary outcome was SIP. Multivariable logistic regression analysis was used to calculate aORs. Results: Among 4720 eligible infants, 4121 (87%) received antenatal steroids and 1045 (22.1%) received prophylactic indomethacin. Among infants exposed to antenatal steroids, those who received prophylactic indomethacin had higher odds of SIP (aOR 1.61, 95% CI 1.14-2.28) compared with no prophylactic indomethacin. Subgroup analyses revealed recent antenatal steroids exposure with prophylactic indomethacin had higher odds of SIP (aOR 1.67, 95% CI 1.15-2.43), but latent antenatal steroids exposure with prophylactic indomethacin did not (aOR 1.24, 95% CI 0.48-3.21), compared with the respective groups with no prophylactic indomethacin. Among those not exposed to antenatal steroids, mortality was lower among those who received prophylactic indomethacin (aOR 0.45, 95% CI 0.28-0.73) compared with no prophylactic indomethacin. Conclusions: In preterm neonates of

Background Surfactant delivery via a thin endotracheal catheter during spontaneous breathing, a technique called minimally invasive surfactant therapy (MIST), is an alternative to intubation and surfactant administration. There is paucity of data regarding the administration of high-volume surfactant using this technique. Methods We conducted a retrospective cohort study to review the safety, efficacy, and procedural details pertaining to the delivery of 5 mL/kg of BLES® via MIST approach. In 2016, our centre initiated a practice change allowing the use of MIST as an alternative method of surfactant delivery in infants born at ≥28 weeks and/or with a birth weight ≥ 1,000 g with respiratory distress syndrome. In this study, we identified all neonates who received surfactant via MIST between May 1, 2016 and July 30, 2018 and collected relevant procedural data. Results Since this practice change, MIST technique was attempted in 43 neonates with successful instillation of surfactant in 41 (95.3%) of the neonates. Intubation and positive pressure ventilation was avoided in 35 neonates (85.3%). No serious adverse effect was noted. Conclusions Our study reports successful use of higher volume surfactant via MIST. This should encourage other similar centres to consider this technique, in order to avoid unnecessary intubation and positive pressure ventilation.

Resumo Objetivo Comparar a percepção de estudantes de enfermagem e as contribuições do ensino com simulação clínica ou aula prática convencional em laboratório de habilidades, na primeira experiência clínica hospitalar. Método Pesquisa descritiva, qualitativa, envolvendo estudantes de graduação em enfermagem de uma universidade pública do Brasil, submetidos à simulação clínica de alta fidelidade ou aula prática convencional, ocorrida entre 2015 e 2016. Para avaliação dos dados, utilizaram-se a nuvem de palavras e a análise de similitude do software IRAMUTEQ®. Resultados Participaram 54 estudantes, sendo 27 em cada grupo. As palavras mais evocadas pelo grupo simulação foram: “paciente real, não, mais e simulador”, relacionadas à capacidade de reflexão quanto ao seu conhecimento e preparo. As mais evocadas no grupo prática convencional foram: “mais, não, muito e sentir”, relacionadas com a percepção de que a aula convencional ajuda na aquisição de habilidades, contudo, é necessária maior frequência. Conclusão As duas estratégias contribuíram positivamente para a primeira experiência clínica hospitalar. Porém, a simulação proporcionou uma visão crítico-reflexiva sobre as competências, deficiências e maior autoconfiança em relação à prática convencional. Este estudo fortalece as evidências dos benefícios proporcionados pelo ensino baseado em simulação, e a importância de instituições de ensino fazerem uso adequado dessa estratégia. Resumen Objetivo Comparar la percepción de los estudiantes de enfermería y las contribuciones docentes con simulación clínica o clase práctica convencional en un laboratorio de habilidades, en la primera experiencia clínica hospitalaria. Métodos Investigación descriptiva y cualitativa con estudiantes universitarios de enfermería en una universidad pública de Brasil, sometidos a simulación clínica de alta fidelidad o clase práctica convencional, entre 2015 y 2016. Para el análisis de los datos se utilizo, una nube de palabras y el análisis de la similitud por el software IRAMUTEQ. Resultados Participaron 54 estudiantes, 27 en cada grupo. Las palabras mas evocadas por el grupo de simulación fueron: “paciente real, no, más y simulador” relacionadas con la capacidad de reflexionar sobre su conocimiento y preparación. Los más mencionados en el grupo práctica convencional fueron: “más, no, mucho y sentir”, relacionadas con la percepción de que la clase convencional ayuda en la adquisición de habilidades, sin embargo se necesita más frecuencia. Conclusion Ambas estrategias contribuyeron positivamente para la primera experiencia clínica hospitalaria. Sin embargo, la simulación proporcionó una visión crítica reflexiva de las habilidades, deficiencias y una mayor autoconfianza en comparación con la práctica convencional. Este estudio fortalece la evidencia de los beneficios proporcionados por la enseñanza basada en simulación y la importancia de que las instituciones educativas hagan uso adecuado de esta estrategia. Abstract Objective to compare the perception of nursing students and the contributions of teaching with clinical simulation or conventional practical classroom skills in the first clinical hospital experience. Method a descriptive, qualitative research involving undergraduate nursing students from a public university in Brazil, submitted to a high fidelity clinical simulation or conventional practical class, which took place between 2015 and 2016. For data evaluation, a word cloud and similarity analysis of the IRAMUTEQ® software were used. Results Altogether 54 students participated, 27 of them in each group. The words most evoked by the simulation group were: “real patient, no, more and simulator”, related to the capacity of reflection regarding their knowledge and preparation. The most evoked by the conventional practice group were: “more, no, much and feel”, related with the perception that the conventional class helps in the acquisition of skills, however, more frequency is needed. Conclusion Both strategies contributed positively to the first clinical hospital experience. However, the simulation provided a critical-reflexive view of skills, deficiencies and greater self-confidence in relation to conventional practice. This study strengthens the evidence of the benefits provided by simulation-based teaching, and the importance of teaching institutions making appropriate use of this strategy.

Resumo Objetivo: Traduzir para a língua portuguesa e adaptar transculturalmente para o Brasil o Creighton Competency Evaluation Instrument. Métodos: Pesquisa metodológica que adotou o referencial de Beaton para o processo de tradução e adaptação transcultural, que ocorreu em seis etapas: tradução, síntese das traduções, retrotradução, submissão ao comitê de especialistas, pré-teste e parecer do autor original. Participaram dois tradutores, dois retrotradutores e oito membros no comitê de especialistas. O pré-teste foi realizado com 32 participantes. Resultados: Após ajustes linguísticos, a versão final obteve concordância de 100% pelo Índice de Validade de Conteúdo. A confiabilidade (Alfa de Cronbach) foi de 0,897, considerado um ótimo resultado. O instrumento foi classificado como de fácil utilização por 84,4% dos experts. Conclusão: A tradução e a adaptação transcultural disponibiliza para a comunidade acadêmica brasileira um instrumento objetivo e prático, com possibilidade de feedback imediato aos estudantes nas avaliações durante a atividade clínica simulada. Resumen Objetivo: Traducir al idioma portugués y adaptar transculturalmente para Brasil el Creighton Competency Evaluation Instrument. Métodos: Investigación metodológica que adoptó el marco referencial de Beaton para el proceso de traducción y adaptación transcultural, realizada en seis etapas: traducción, síntesis de las traducciones, retrotraducción, presentación al comité de especialistas, prueba piloto y opinión del autor original. Participaron dos traductores, dos retrotraductores y ocho miembros del comité de especialistas. La prueba piloto fue realizada con 32 participantes. Resultados: Después de los ajustes lingüísticos, la versión final obtuvo una concordancia del 100 % mediante el Índice de Validez de Contenido. La fiabilidad (Alfa de Cronbach) fue de 0,897, considerado un excelente resultado. El instrumento fue clasificado como fácil de utilizar por el 84,4 % de los especialistas. Conclusión: La traducción y la adaptación transcultural pone a disposición de la comunidad académica brasileña un instrumento objetivo y práctico, con posibilidad de feedback inmediato a los estudiantes en las evaluaciones durante la actividad clínica simulada. Abstract Objective: To translate and adapt the Creighton Competency Evaluation Instrument for Brazil. Methods: A methodological research that adopted Beaton's framework for the process of translation and cross-cultural adaptation, which took place in six stages: translation, synthesis of translations, back-translation, submission to the expert committee, pre-test and opinion of the original author. Two translators, two back-translators and eight members of the expert committee participated. Pre-test was carried out with 32 participants. Results: After linguistic adjustments, the final version obtained 100% agreement by the Content Validity Index. Reliability (Cronbach's alpha) was 0.897, which is considered an excellent result. The instrument was classified as easy to use by 84.4% of experts. Conclusion: Translation and cross-cultural adaptation provide the Brazilian academic community with an objective and practical tool, with the possibility of immediate feedback to students in assessments during simulated clinical activities.

Objetivo: descrever o processo de criação e utilização de website para coleta de dados de pesquisas em simulação clínica. Metodologia: Trata-se de pesquisa descritiva na qual um website foi criado e utilizado para coleta de dados de duas dissertações de mestrado da área de simulação clínica. Resultados: Os sites: validação do instrumento Creighton e avaliação do debriefing virtual com estudantes de enfermagem foram publicados contendo informações sobre os passos da pesquisa, materiais, links de apoio, vídeos dos cenários de simulação e o formulário de coleta de dados. Os sites tiveram 1.093 e 415 acessos e 30 e 60 respostas, respectivamente. Conclusão: O website é útil para coleta de dados e amplia o alcance das pesquisas, servindo de repositório de material digital e podendo ser criado de acordo com as necessidades e objetivos da pesquisa.

Objective To compare length of stay (LOS) in neonatal care for babies born extremely preterm admitted to networks participating in the International Network for Evaluating Outcomes of Neonates (iNeo). Study design Data were extracted for babies admitted from 2014 to 2016 and born at 24 to 28 weeks of gestational age (n = 28 204). Median LOS was calculated for each network for babies who survived and those who died while in neonatal care. A linear regression model was used to investigate differences in LOS between networks after adjusting for gestational age, birth weight z score, sex, and multiplicity. A sensitivity analysis was conducted for babies who were discharged home directly. Results Observed median LOS for babies who survived was longest in Japan (107 days); this result persisted after adjustment (20.7 days more than reference, 95% CI 19.3-22.1). Finland had the shortest adjusted LOS (−4.8 days less than reference, 95% CI –7.3 to −2.3). For each week's increase in gestational age at birth, LOS decreased by 12.1 days (95% CI –12.3 to −11.9). Multiplicity and male sex predicted mean increases in LOS of 2.6 (95% CI 2.0-3.2) and 2.1 (95% CI 1.6-2.6) days, respectively. Conclusions We identified between-network differences in LOS of up to 3 weeks for babies born extremely preterm. Some of these may be partly explained by differences in mortality, but unexplained variations also may be related to differences in clinical care practices and healthcare systems between countries.

Resumo Objetivo: Validar construto e avaliar a confiabilidade do Instrumento Creighton para Avaliação de Competências Clínicas, versão português, Brasil. Métodos: Estudo metodológico, realizado com 30 docentes/enfermeiros que utilizavam a metodologia de simulação. Foram elaborados dois cenários com temas iguais e atuações divergentes das estudantes com o objetivo de testar a capacidade do instrumento de diferenciá-los. Os cenários foram gravados e disponibilizados para os especialistas por um website que viabilizou a coleta. Para a validação de construto, utilizou-se as técnicas de experimentação e da correlação phi. Para a confiabilidade, analisou-se a equivalência, com coeficiente Fleiss Kappa, e a consistência interna, com coeficiente Kuder-Richardson (KR20). Resultados: Ao analisar a validade, 20 dos 23 itens apresentaram resultados significativos. Na análise, os domínios apresentaram correlações, classificadas de baixa a alta. Quando comparados os cenários, as correlações foram baixas, muito baixas ou negativas. Quanto à confiabilidade, o coeficiente Fleiss Kappa encontrado foi razoável (0,282) para o cenário 1 e moderado para o cenário 2 (0,408). A consistência interna medida com o KR20 foi de 0,717 para o cenário 1 e 0,805 para o cenário 2, classificadas como moderada e alta. Conclusão: O Instrumento Creighton para Avaliação de Competências Clínicas versão português, Brasil, foi considerado válido e confiável para uso em todo o território nacional.

OBJECTIVE To compare neurodevelopmental outcomes of large and appropriate for gestational age (LGA, AGA) infants

OBJECTIVE: To assess the rate, location, risk factors, management, and outcomes of neonatal thrombosis (NT). DESIGN: A retrospective study investigating infants admitted to NICUs in Canadian Neonatal Network between January 2014 and December 2016 and diagnosed with NT. Each infant with NT was matched with an infant without NT. RESULTS: Of 39,971 infants, 587 (1.5%) were diagnosed with NT: 440 (75%) venous, 112 (19%) arterial, 29 (5%) both. NT rate was 1.4% in full-term and 1.7% in preterm infants. Venous thrombi occurred most commonly in the portal vein and arterial thrombi in the cerebral artery. Conservative management and low molecular weight heparin were the most common treatment modalities. Hospital stay was longer (p

Background Very preterm infants are at high risk of death or severe morbidity. The objective was to determine the significance of severe congenital heart defects ( CHDs ) for these risks. Methods and Results This cohort study included infants from 10 countries born from 2007–2015 at 24 to 31 weeks’ gestation with birth weights CHDs were defined by International Classification of Diseases, Ninth Revision ( ICD‐9 ) and Tenth ( ICD‐10 ) codes and categorized as those compromising systemic output, causing sustained cyanosis, or resulting in congestive heart failure. The primary outcome was in‐hospital mortality. Secondary outcomes were neonatal brain injury, necrotizing enterocolitis, bronchopulmonary dysplasia, and retinopathy of prematurity. Adjusted and propensity score–matched odds ratios ( ORs ) were calculated. Analyses were stratified by type of CHD , gestational age, and network. A total of 609 (0.77%) infants had severe CHD and 76 371 without any malformation served as controls. The mean gestational age and birth weight were 27.8 weeks and 1018 g, respectively. The mortality rate was 18.6% in infants with CHD and 8.9% in controls (propensity score–matched OR , 2.30; 95% CI , 1.61–3.27). Severe CHD was not associated with neonatal brain injury, necrotizing enterocolitis, or retinopathy of prematurity, whereas the OR for bronchopulmonary dysplasia increased. Mortality was higher in all types, with the highest propensity score–matched OR (4.96; 95% CI, 2.11–11.7) for CHD causing congestive heart failure. While mortality did not differ between groups at OR for mortality in infants with CHD increased to 10.9 (95% CI, 5.76–20.70) at 31 weeks’ gestational age. Rates of CHD and mortality differed significantly between networks. Conclusions Severe CHD is associated with significantly increased mortality in very preterm infants.

To develop and validate an itemized costing algorithm for in-patient neonatal intensive care unit (NICU) costs for infants born prematurely that can be used for quality improvement and health economic analyses.We sourced patient resource use data from the Canadian Neonatal Network database, with records from infants admitted to 30 tertiary NICUs in Canada. We sourced unit cost inputs from Ontario hospitals, schedules of benefits, and administrative sources. Costing estimates were generated by matching patient resource use data to the appropriate unit costs. All cost estimates were in 2017 Canadian dollars and assigned from the perspective of a provincial public payer. Results were validated using previous estimates of inpatient NICU costs and hospital case-cost estimates.We assigned costs to 27 742 infants born prematurely admitted from 2015 to 2017. Mean (SD) gestational age and birth weight of the cohort were 31.8 (3.5) weeks and 1843 (739) g, respectively. The median (IQR) cost of hospitalization before NICU discharge was estimated as $20 184 ($9739-51 314) for all infants; $11 810 ($6410-19 800) for infants born at gestational age of 33-36 weeks; $30 572 ($16 597-$51 857) at gestational age of 29-32 weeks; and $100 440 ($56 858-$159 3867) at gestational age of29 weeks. Cost estimates correlated with length of stay (r = 0.97) and gestational age (r = -0.65). The estimates were consistent with provincial resource estimates and previous estimates from Canada.NICU costs for infants with preterm birth increase as gestation decreases and length of stay increases. Our cost estimates are easily accessible, transparent, and congruent with previous cost estimates.

Infants with restricted growth for age are frequently exposed to insufficient placental circulation and are more likely to develop postnatal complications. Delayed cord clamping at birth for these infants requires further exploration.This study aimed to compare the short-term neonatal outcomes of delayed cord clamping with that of early cord clamping in small for gestational age preterm infants and to explore whether the effects of delayed cord clamping in small for gestational age preterm infants are different from that in non-small for gestational age preterm infants.We conducted a national retrospective cohort study, including infants born at33 weeks' gestation and admitted to the Canadian Neonatal Network units between January 2015 and December 2017. Small for gestational age infants (birthweight of10th percentile for gestational age and sex) who received delayed cord clamping ≥30 seconds were compared with those who received early cord clamping. In addition, non-small for gestational age infants who received delayed cord clamping were compared with those who received early cord clamping. The main study outcomes included composite outcome of mortality or major morbidity, neonatal morbidity rate, mortality rate, peak serum bilirubin, and number of blood transfusions. Multivariable logistic and linear regression models with a generalized estimation equation approach were used to account for the clustering of infants within centers.Overall, 9722 infants met the inclusion criteria. Of those infants, 1027 (10.6%) were small for gestational age. The median (interquartile range) gestational age was 31 weeks (range, 28-32 weeks). After adjusting for potential confounders, delayed cord clamping in small for gestational age infants was associated with a reduction in the composite outcome of mortality or major morbidity (adjusted odds ratio, 0.60; 95% confidence interval, 0.42-0.86) compared with early cord clamping. There was no difference between the 2 groups in peak serum bilirubin. Many associated benefits of delayed cord clamping in small for gestational age infants were similar to those in non-small for gestational age infants.Delayed cord clamping in small for gestational age preterm infants was associated with decreased odds of mortality or major morbidity. Many of the benefits of delayed cord clamping in the small for gestational age preterm infants were similar to those identified in the non-small for gestational age preterm infants.

Objective To study the outcomes of extremely preterm infants of hypertensive mothers who smoke. Study Design This retrospective cohort study included infants born between 2003 and 2012 at weeks' gestation and admitted to neonatal intensive care units participating in the Canadian Neonatal Network. Infants were divided into four mutually exclusive groups. Infants of hypertensive mothers who smoked; infants of hypertensive, non-smoking mothers; infants of normotensive mothers who smoked; and infants of normotensive, non-smoking mothers. Using infants of normotensive, non-smoking mothers as the reference group, neonatal outcomes were compared between the groups. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated using univariate and multivariate regression analysis. Results Of the 12,307 eligible infants, 172 had hypertensive mothers who smoked, 1689 had hypertensive non-smoking mothers, 1535 had normotensive mothers who smoked, and 8911 had normotensive non-smoking mothers. Compared to infants of normotensive non-smoking mothers, infants of hypertensive mothers, regardless of smoking status, had higher odds of developing bronchopulmonary dysplasia (AORs of smokers 1.62; 95% CI 1.12-2.35 and of non-smokers 1.43; 95% CI 1.24-1.64). There was no difference in the odds of mortality and retinopathy of prematurity stage ≥3 between the groups. Infants of hypertensive, non-smoking mothers had decreased odds of intraventricular hemorrhage >grade 2 and higher odds of necrotizing enterocolitis. There was decreased odds of hypertension if the mother was a smoker (AOR 0.71; 95% CI 0.59-0.85). Conclusion Maternal hypertension is associated with increased rates of bronchopulmonary dysplasia, irrespective of smoking status.

Despite evidence suggesting that parent involvement was beneficial for infant and parent outcomes, the Family Integrated Care (FICare) programme was one of the first pragmatic approaches to enable parents to become primary caregivers in the neonatal intensive care unit (NICU). We aimed to analyse the effect of FICare on infant and parent outcomes, safety, and resource use.In this multicentre, cluster-randomised controlled trial, we stratified 26 tertiary NICUs from Canada, Australia, and New Zealand by country and size, and assigned them, using a computer-generated random allocation sequence, to provide FICare or standard NICU care. Eligible infants were born at 33 weeks' gestation or earlier, and had no or low-level respiratory support; parents gave written informed consent for enrolment. To be eligible, parents in the FICare group had to commit to be present for at least 6 h a day, attend educational sessions, and actively care for their infant. The primary outcome, analysed at the individual level, was infant weight gain at day 21 after enrolment. Secondary outcomes were weight gain velocity, high frequency breastfeeding (≥6 times a day) at hospital discharge, parental stress and anxiety at enrolment and day 21, NICU mortality and major neonatal morbidities, safety, and resource use (including duration of oxygen therapy and hospital stay). This trial is registered with ClinicalTrials.gov, number NCT01852695.From Oct 1, 2012, 26 sites were randomly assigned to provide FICare (n=14) or standard care (n=12). One site assigned to FICare discontinued because of poor site enrolment. Parents and infants were enrolled between April 1, 2013, and Aug 31, 2015, with 895 infants being eligible in the FICare group and 891 in the standard care group. At day 21, weight gain was greater in the FICare group than in the standard care group (mean change in Z scores -0·071 [SD 0·42] vs -0·155 [0·42]; p0·0002). Average daily weight gain was significantly higher in infants receiving FICare than those receiving standard care (mean daily weight gain 26·7 g [SD 9·4] vs 24·8 g [9·5]; p0·0001). The high-frequency exclusive breastmilk feeding rate at discharge was higher for infants in the FICare group (279 [70%] of 396) than those in the standard care group (394 [63%] of 624; p=0·016). At day 21, parents in the FICare group had lower mean stress scores than did parents in the standard care group (2·3 [SD 0·8] vs 2·5 [0·8]; p0·00043), and lower mean anxiety scores (70·8 [20·1] vs 74·2 [19·9]; p=0·0045). There were no significant differences between groups in the rates of the secondary outcomes of mortality, major morbidity, duration of oxygen therapy, and duration of hospital stay. Although the safety assessment was not completed, there were no adverse events.FICare improved infant weight gain, decreased parent stress and anxiety, and increased high-frequency exclusive breastmilk feeding at discharge, which together suggest that FICare is an important advancement in neonatal care. Further research is required to examine if these results translate into better long-term outcomes for families.Canadian Institutes of Health Research Partnerships for Health System Improvement, and Ontario Ministry of Health and Long-Term Care.

To examine rates and determinants of mother's own milk (MOM) feeding at hospital discharge in a cohort of infants born very preterm within the Canadian Neonatal Network (CNN).This was a population-based cohort study of infants born at33 weeks of gestation and admitted to neonatal intensive care units (NICUs) participating in the CNN between January 1, 2015, and December 31, 2018. We examined the rates and determinants of MOM use at discharge home among the participating NICUs. We used multivariable logistic regression analysis to identify independent determinants of MOM feeding.Among the 6404 infants born very preterm and discharged home during the study period, 4457 (70%) received MOM or MOM supplemented with formula. Rates of MOM feeding at discharge varied from 49% to 87% across NICUs. Determinants associated with MOM feeding at discharge were gestational age 29-32 weeks compared with26 weeks (aOR 1.56, 95% CI 1.25-1.93), primipara mothers (aOR 2.12, 95% CI 1.86-2.42), maternal diabetes (aOR 0.79, 95% CI 0.66-0.93), and maternal smoking (aOR 0.27, 95% CI 0.19-0.38). Receipt of MOM by day 3 of age was the major predictor of breast milk feeding at discharge (aOR 3.61, 95% CI 3.17-4.12).Approximately two-thirds of infants born very preterm received MOM at hospital discharge, and rates varied across NICUs. Supporting mothers to provide breast milk in the first 3 days after birth may be associated with improved MOM feeding rates at discharge.

Objective To provide comprehensive, contemporary information on the actuarial survival of infants born at 22-25 weeks of gestation in Canada. Study design In a retrospective cohort study, we included data from preterm infants of 22-25 weeks of gestation admitted to neonatal intensive care units participating in the Canadian Neonatal Network between 2010 and 2017. Infants with major congenital anomalies were excluded. We calculated gestational age using in vitro fertilization date, antenatal ultrasound dating, last menstrual period, obstetrical estimate, or neonatal estimate (in that order). Infants were followed until either discharge or death. Each day of gestational age was considered a category except for births at 22 weeks, where the first 4 days were grouped into one category and the last 3 days were grouped into another category. For each day of life, an actuarial survival rate was obtained by calculating how many infants survived to discharge out of those who had survived up to that day. Results Of 4335 included infants, 85, 679, 1504, and 2067 were born at 22, 23, 24, and 25 weeks of gestation, respectively. Survival increased from 32% at 22 weeks to 83% at 254−6/7 weeks. Graphs of actuarial survival developed for the first 6 weeks after birth in male and female children indicated a steep increase in survival during the first 7-10 days postnatally. Conclusions Survival increased steadily with postnatal survival and was dependent on gestational age in days and sex of the child.

Objective To evaluate the impact of prophylactic indomethacin on early death ( Study design This was a multicenter, retrospective cohort study of neonates (n = 12 515) born at 236/7 weeks of gestational age, admitted to neonatal intensive care units participating in the Canadian Neonatal Network who received prophylactic indomethacin started within the first 12 hours after birth. Univariate and multivariate analysis compared the composite outcomes of early death or severe neurologic injury and early death or spontaneous intestinal perforation. Results Of 12 515 eligible neonates, 1435 (11.5%) were exposed to prophylactic indomethacin; recipients were of lower gestational age and birth weight and had greater severity of illness (Score of Neonatal Acute Physiology with Perinatal Extension) on admission compared with nonrecipients. After we adjusted for confounders, prophylactic indomethacin was associated with reduced odds of early death or severe neurologic injury and early death or spontaneous intestinal perforation in neonates born at 23-24 weeks of gestational age. However, prophylactic indomethacin was associated with increased odds of early mortality or spontaneous intestinal perforation for neonates born at 26-28 weeks of gestational age. Conclusions Prophylactic indomethacin use was associated with benefit in neonates born at 23-24 weeks of gestational age, but with harm at 26-28 weeks of gestational age. Given the observation of significantly improved survival, a randomized controlled trial is needed to investigate the effect of prophylactic indomethacin in babies born at 23-25 weeks of gestational age.

Background One of the controversies in the management of twin gestations relates to mode of delivery, especially when the second twin is in a nonvertex presentation (Vertex/nonVertex pairs) and birth is imminent at extremely low gestation. Objective We hypothesized that, for Vertex/nonVertex twins born before 28 weeks’ gestation, cesarean delivery would be associated with a lower risk of adverse neonatal outcomes than trial of vaginal delivery. Our aim was to test this hypothesis by comparing the neonatal outcomes of Vertex/nonVertex twins born before 28 weeks’ gestation by mode of delivery using a large national cohort. Study Design This work is a retrospective cohort study of all twin infants born at 240/7 to 276/7 weeks’ gestation and admitted to level III neonatal intensive care units participating in the Canadian Neonatal Network (2010–2017). Exposure is defined a trial of vaginal delivery for Vertex/nonVertex twins. Nonexposed (control) groups are defined as cases where both twins were delivered by cesarean delivery, either in vertex or nonvertex presentation (control group 1) or owing to the nonvertex presentation of the first twin (control group 2). Outcome measures are defined as a composite of neonatal death, severe neurologic injury, or birth trauma. Results A total of 1082 twin infants (541 twin pairs) met the inclusion criteria: 220 Vertex/nonVertex pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had cesarean delivery for both twins (control group 1); 170 pairs with the first twin in nonvertex presentation, all of which were born by cesarean delivery (control group 2); and 151 pairs with both twins in vertex presentation (vertex or nonvertex). In the study group, the rate of urgent cesarean delivery for the second twin was 30%. The rate of the primary outcome in the study group was 42%, which was not significantly different compared with control group 1 (37%; adjusted relative risk, 0.93; 95% confidence interval, 0.71–1.22) or control group 2 (34%; adjusted relative risk, 1.20; 95% confidence interval, 0.92–1.58). The findings remained similar when outcomes were analyzed separately for the first and second twins. Conclusion For preterm Vertex/nonVertex twins born at

Background: Mothers of preterm infants often are at risk of expressing an inadequate amount of milk for their infants and the use of galactogogues is often considered. Domperidone is a widely used galactogogue with little information available to guide clinicians regarding initiation, timing, and duration of treatment. Research aim: The primary objective of this study was to determine whether administration of domperidone within the first 21 days after delivery would lead to a higher proportion of mothers achieving a 50% increase in the volume of milk at the end of 14 days of treatment compared with mothers receiving placebo. Methods: Eligible mothers were randomized to one of two treatment arms: Group A—domperidone 10 mg orally three times daily for 28 days; or Group B—placebo 10 mg orally three times daily for 14 days followed by domperidone 10 mg orally three times daily for 14 days. Results: A total of 90 mothers of infants ≤ 29 weeks gestation were randomized. Mean milk volumes at entry were similar for both groups. More mothers achieved a 50% increase in milk volume after 14 days in Group A (77.8%) compared with Group B (57.8%), odds ratio = 2.56, 95% confidence interval [1.02, 6.25], p = .04. Conclusion: A greater number of mothers experienced a 50% or more increase in human milk volume, but the absolute increase in milk volume was modest.

Background The current resuscitation guidelines for neonates recommend considering stopping resuscitation efforts if the heart rate remains undetectable after 10 min of adequate resuscitation. However, this recommendation does not take into account the gestational age (GA) of the neonates. We determined the outcomes of neonates with a 10-min Apgar score of zero (Apgar10 = 0) with respect to their GA. Methods In a retrospective matched cohort study, we studied neonates admitted to the Canadian Neonatal Network NICUs between 2010 and 2016 with an Apgar10 = 0. The neonates were divided into 3 subgroups according to their GA: (1) ≥36 weeks’, (2) 320/7–356/7 weeks’, and (3) Results 177 neonates had Apgar10 = 0. Survival to discharge was significantly different between GA groups [≥36 weeks’ 61% vs. 320/7–356/7 weeks’ 58% vs. Conclusion Neonates with Apgar10 = 0 had different outcomes depending on their GA. Less than half of neonates born at

To assess associations between neonatal intensive care unit (NICU)-level patent ductus arteriosus (PDA) treatment rates (pharmacologic or surgical) and neonatal outcomes.This cohort study included infants born at 24-28 weeks of gestation and birth weight1500 g in 2007-2015 in NICUs caring for ≥100 eligible infants in 6 countries. The ratio of observed/expected (O/E) PDA treatment rates was derived for each NICU by estimating the expected rate using a logistic regression model adjusted for potential confounders and network. The primary composite outcome was death or severe neurologic injury (grades III-IV intraventricular hemorrhage or periventricular leukomalacia). The associations between the NICU-level O/E PDA treatment ratio and neonatal outcomes were assessed using linear regression analyses including a quadratic effect (a square term) of the O/E PDA treatment ratio.From 139 NICUs, 39 096 infants were included. The overall PDA treatment rate was 45% in the cohort (13%-77% by NICU) and the O/E PDA treatment ratio ranged from 0.30 to 2.14. The relationship between the O/E PDA treatment ratio and primary composite outcome was U-shaped, with the nadir at a ratio of 1.13 and a significant quadratic effect (P.001). U-shaped relationships were also identified with death, severe neurologic injury, and necrotizing enterocolitis.Both low and high PDA treatment rates were associated with death or severe neurologic injury, whereas a moderate approach was associated with optimal outcomes.

To compare mortality and neurodevelopmental outcomes of extremely low gestational age neonates who received delivery room extensive cardiopulmonary resuscitation (DR-CPR) to those who did not require DR-CPR.Preterm neonates born at29 weeks' gestational age between January 2010 and September 2011 and assessed at Canadian Neonatal Follow-Up Network centers were studied. Neonates who received DR-CPR were compared to those who did not require DR-CPR using univariate and multivariable analyses. The primary outcome was a composite of mortality or any neurodevelopmental impairment at 18 to 24 months corrected age defined as the presence of any one or more of the following: cerebral palsy; Bayley-III cognitive, language, or motor composite scores85 on any one of the components; sensorineural/mixed hearing loss or unilateral or bilateral visual impairment. Secondary outcomes were the individual components of the composite outcomes.Of the 2760 neonates born, 173 were excluded and remaining 2587 eligible neonates were included in our study. Of these 2068 had outcome data (80%) of whom 190 (9.2%) received DR-CPR. DR-CPR was independently associated with mortality or neurodevelopmental impairment (adjusted odds ratio [aOR] 1.76; 95% CI 1.21-2.55) and mortality alone (aOR1.94; 95% CI 1.33-2.83). DR-CPR was also associated with increased odds of motor impairment (aOR 2.03; 95% CI 1.28-3.23).In extremely low gestational age neonates, DR-CPR was associated with higher odds of the composite outcome of mortality or neurodevelopmental impairment, mortality alone, and lower motor scores at 18 to 24 months' corrected age.

To determine if the reported reduction in hospital-acquired infections is due to reduced central line-associated blood stream infections (CLABSI) or non-CLABSIs.A retrospective cohort study design was used to describe the change in organism pattern and incidence of hospital-acquired infections (CLABSIs and non-CLABSIs) in neonates33 weeks of gestation admitted to tertiary neonatal intensive care units in the Canadian Neonatal Network between January 1, 2010, and December 31, 2016. Hospital-acquired infection was diagnosed when a pathogenic organism was isolated from blood or cerebrospinal fluid in a neonate with suspected sepsis. CLABSI was diagnosed when a central venous catheter was present at the time or removed in the 2 days before a hospital-acquired infection diagnosis. Cochran-Armitage and Mann-Kendall trend tests and linear regression models were used for statistical analyses.Of 28 144 eligible neonates from 30 Canadian Neonatal Network neonatal intensive care units, 3306 (11.7%) developed hospital-acquired infections. There was a significant decrease in the rate of hospital-acquired infections (14.2% in 2010 and 9.2% in 2016; P .01), and the rate of both CLABSIs and non-CLABSIs (P .01) over the study period concomitant with a significant decrease in the duration of central line use (P = .01). The rates of meningitis also decreased during the study period (1.2% in 2010 and 0.9% in 2016; P .01). Infections owing to gram-positive cocci significantly decreased, but infections owing to gram-negative organisms remained unchanged.Although there was a significant decrease in CLABSIs and non-CLABSIs, hospital-acquired infections in preterm neonates remained high. Infections owing to gram-negative organisms remained unchanged and are a target for future preventative efforts.