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      Mortality and Morbidity of Infants Born Extremely Preterm at Tertiary Medical Centers in China From 2010 to 2019

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          Abstract

          This cohort study examines the association of preterm birth with risk of mortality and morbidity among infants born in China from 2010 to 2019.

          Key Points

          Question

          What are the rates of mortality and major morbidity among infants born extremely preterm in China?

          Findings

          In this multicenter cohort study across mainland China from 2010 to 2019, which included 8514 infants with gestational age less than 28 weeks, there was an improved rate of survival to discharge and an increased rate of major morbidity over the decade.

          Meaning

          These findings suggest that infants born extremely preterm are at increased risk of mortality and morbidity in China and that more active and effective treatment strategies are needed, especially for infants born at gestational age 25 to 27 weeks.

          Abstract

          Importance

          Extreme prematurity is associated with a substantial burden on health care systems worldwide. However, little is known about the prognosis of infants born extremely preterm in developing countries, such as China.

          Objective

          To describe survival and major morbidity among infants born extremely preterm in China over the past decade.

          Design, Setting, and Participants

          This retrospective cohort study was conducted from January 1, 2010, through December 31, 2019. Included individuals were infants with gestational age less than 28 weeks discharged from 1 of 68 neonatal intensive care units located in 31 provinces in China. Data were analyzed from August through October 2020.

          Exposure

          Extremely preterm birth.

          Main Outcomes and Measures

          Survival to discharge and major morbidity (ie, bronchopulmonary dysplasia, grades III-IV intraventricular hemorrhage, white matter injury, stage II-III necrotizing enterocolitis, sepsis, or severe retinopathy of prematurity) were measured.

          Results

          Among 8514 eligible infants, 5295 (62.2%) were male and 116 infants (2.0%) were small for gestational age (SGA). Overall, 5302 infants (62.3%) survived to discharge. The survival rate was 1 of 21 infants (4.8%) at 22 weeks, 13 of 71 infants (18.3%) at 23 weeks, 144 of 408 infants (35.3%) at 24 weeks, 480 of 987 infants (48.6%) at 25 weeks, 1423 of 2331 infants (61.0%) at 26 weeks, and 3241 of 4692 infants (69.1%) at 27 weeks. Survival increased from 136 of 241 infants (56.4%; 95% CI, 50.1%-62.7%) in 2010 to 1110 of 1633 infants (68.0%; 95% CI, 65.7%-70.2%) in 2019 for infants born at 24 to 27 weeks (mean difference, 11.5%; 95% CI, 4.9%-18.2%; P < .001), without a significant change for infants born at less than 24 weeks. Major morbidity was found in 5999 of 8281 infants overall, for a rate of 72.4%, which increased from 116 of 223 infants (52.0%; 95% CI, 45.4%-58.6%) to 1363 of 1656 infants (82.3%; 95% CI, 80.5%-84.1%) from 2010 to 2019 (mean difference, 30.3%; 95% CI, 23.5%-37.1%, P < .001). Regional variations in survival were identified, with an almost 2-fold increase (1.94-fold; 95% CI, 1.66-2.27; P < .001) from 188 of 474 infants (39.7%) in northwest China to 887 of 1153 infants (76.9%) in north China. Gestational age (adjusted risk ratio [aRR], 1.084; 95% CI, 1.063-1.105; P < .001), birth weight (aRR, 1.028; 95% CI, 1.020-1.036; P < .001), premature rupture of membranes (aRR, 1.025; 95% CI, 1.002-1.048; P = .03), and antenatal steroids (aRR, 1.029; 95% CI, 1.004-1.055; P = .02) were associated with improved survival, while being born SGA (aRR, 0.801; 95% CI, 0.679-0.945; P = .01), being male (aRR, 0.975; 95% CI, 0.954-0.997; P = .02), multiple birth (aRR, 0.955; 95% CI, 0.929-0.982; P = .001), having a mother with gestational diabetes (aRR, 0.946; 95% CI, 0.913-0.981; P = .002), and low Apgar score (aRR, 0.951; 95% CI, 0.925-0.977; P < .001) were found to be risk factors associated with decreased chances of survival.

          Conclusions and Relevance

          This study found that infants born extremely preterm were at increased risk of mortality and morbidity in China, with a survival rate that improved over time and a major morbidity rate that increased. These findings suggest that more active and effective treatment strategies are needed, especially for infants born at gestational age 25 to 27 weeks.

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          Most cited references47

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          Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

          Summary Background Preterm birth is the leading cause of death in children younger than 5 years worldwide. Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries. We estimated global, regional, and national rates of preterm birth in 2014, with trends over time for some selected countries. Methods We systematically searched for data on preterm birth for 194 WHO Member States from 1990 to 2014 in databases of national civil registration and vital statistics (CRVS). We also searched for population-representative surveys and research studies for countries with no or limited CRVS data. For 38 countries with high-quality data for preterm births in 2014, data are reported directly. For countries with at least three data points between 1990 and 2014, we used a linear mixed regression model to estimate preterm birth rates. We also calculated regional and global estimates of preterm birth for 2014. Findings We identified 1241 data points across 107 countries. The estimated global preterm birth rate for 2014 was 10·6% (uncertainty interval 9·0–12·0), equating to an estimated 14·84 million (12·65 million–16·73 million) live preterm births in 2014. 12· 0 million (81·1%) of these preterm births occurred in Asia and sub-Saharan Africa. Regional preterm birth rates for 2014 ranged from 13·4% (6·3–30·9) in North Africa to 8·7% (6·3–13·3) in Europe. India, China, Nigeria, Bangladesh, and Indonesia accounted for 57·9 million (41×4%) of 139·9 million livebirths and 6·6 million (44×6%) of preterm births globally in 2014. Of the 38 countries with high-quality data, preterm birth rates have increased since 2000 in 26 countries and decreased in 12 countries. Globally, we estimated that the preterm birth rate was 9×8% (8×3–10×9) in 2000, and 10×6% (9×0–12×0) in 2014. Interpretation Preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting. Funding WHO and the March of Dimes.
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            Bronchopulmonary dysplasia.

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              Trends in Care Practices, Morbidity, and Mortality of Extremely Preterm Neonates, 1993-2012.

              Extremely preterm infants contribute disproportionately to neonatal morbidity and mortality.
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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                11 May 2021
                May 2021
                11 May 2021
                : 4
                : 5
                : e219382
                Affiliations
                [1 ]Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
                [2 ]Department of Neonatology, Affiliated Bayi Children’s Hospital, Seventh Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
                [3 ]Department of Neonatology, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, China
                [4 ]Department of Neonatology, Hunan Children’s Hospital, Changsha, China
                [5 ]Department of Neonatology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
                [6 ]Department of Neonatology, Nanjing Maternity and Child Health Care Hospital, Women’s Hospital of Nanjing Medical University, Nanjing, China
                [7 ]Department of Neonatology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
                [8 ]Department of Neonatology, First Hospital of Jilin University, Changchun, China
                [9 ]Department of Neonatology, Xiangya Hospital, Central South University, Changsha, China
                [10 ]Department of Neonatology, Gansu Provincial Maternity and Child Care Hospital, Lanzhou, China
                [11 ]Department of Neonatology, Children’s Hospital of Nanjing Medical University, Nanjing, China
                [12 ]Department of Neonatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
                [13 ]Department of Neonatology, Peking University Third Hospital, Beijing, China
                [14 ]Department of Neonatology, Affiliated Hospital of Qingdao University, Qingdao, China
                [15 ]Department of Neonatology, Children’s Hospital of Chongqing Medical University, Chongqing, China
                Author notes
                Article Information
                Accepted for Publication: March 17, 2021.
                Published: May 11, 2021. doi:10.1001/jamanetworkopen.2021.9382
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Zhu Z et al. JAMA Network Open.
                Corresponding Author: Chao Chen, MD, PhD, Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, 399 Wanyuan Rd, Shanghai 201102, China ( chaochen@ 123456fudan.edu.cn ).
                Author Contributions: Dr Zhu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Zhu and Yuan contributed equally to this work.
                Concept and design: Zhu, Yuan, Yang, Gao, Yue, Bao, C. Chen.
                Acquisition, analysis, or interpretation of data: Zhu, Yuan, Wang, Li, S. Chen, S. Han, Liu, Wu, Shi, R. Cheng, X. Cheng, T. Han, Jiang, C. Chen.
                Drafting of the manuscript: Zhu, Li, Yang, S. Chen, S. Han, Yue, Shi.
                Critical revision of the manuscript for important intellectual content: Zhu, Yuan, Wang, Gao, S. Han, Liu, Wu, R. Cheng, X. Cheng, T. Han, Jiang, Bao, C. Chen.
                Statistical analysis: Zhu, Shi.
                Administrative, technical, or material support: Zhu, Yuan, Wang, Li, Yang, Gao, Liu, Wu, Yue, R. Cheng, X. Cheng, T. Han, Bao, C. Chen.
                Supervision: Gao, Bao, C. Chen.
                Conflict of Interest Disclosures: None reported.
                Additional Contributions: Data were provided by team members from participating hospitals: Jiangxi Provincial Children's Hospital, Nanchang, China; Quanzhou Women's and Children's Hospital, Quanzhou, China; Liaocheng People's Hospital, Liaocheng, China; Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China; Shandong Provincial Hospital, Jinan, China; Xiamen Maternal and Child Health Hospital, Xiamen, China; Guiyang Maternal and Child Health Hospital, Guiyang, China; Jiujiang Maternity and Child Health Care Hospital, Jiujiang, China; First Affiliated Hospital of Anhui Medical University, Hefei, China; Zhengzhou Children's Hospital, Zhengzhou, China; Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, China; Chongqing Health Center for Women and Children, Chongqing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China; Jiangsu Women and Children Health Hospital, Nanjing, China; Boai Hospital of Zhongshan, Zhongshan, China; Northwest Women and Children's Hospital affiliated to Xi'an Jiaotong University, Xi'an, China; Dalian Maternal and Child Health Care Hospital, Dalian, China; Affiliated Hospital of Guilin Medical University, Guilin, China; Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China; First Affiliated Hospital of Harbin Medical University, Harbin, China; Anhui Provincial Children's Hospital, Hefei, China; Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Baogang Third Hospital of Hongci Group, Baotou, China; Affiliated Hospital of Southwest Medical University, Luzhou, China; First Affiliated Hospital of Nanchang University, Nanchang, China; The Affiliated Hospital of Inner Mongolia Medical University, Huhehot, China; Wuhan Children's Hospital, Wuhan, China; Maternal and Child Health Hospital of Guilin, Guilin, China; First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China; People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China; Hainan Women and Children's Medical Center, Haikou, China; Children's Hospital of Kaifeng City, Kaifeng, China; Qilu Hospital of Shandong University, Jinan, China; Hunan Provincial Maternal and Child Health Care Hospital, Changsha, China; Chengdu Women's and Children's Central Hospital, Chengdu, China; Kunming Children's Hospital, Kunming, China; Fourth Hospital of Hebei Medical University, Shijiazhuang, China; Binhaiwan Central Hospital of Dongguan, Dongguan, China; Baoji Maternity and Child Health Hospital, Baoji, China; Sichuan Provincial Hospital for Women and Children, Chengdu, China; Affiliated Hospital of Zunyi Medical University, Guizhou, China; Jinhua Municipal Central Hospital, Jinhua, China; General Hospital of Ningxia Medical University, Yinchuan, China; Bozhou People's Hospital, Bozhou, China; Tianjin First Central Hospital, Tianjin, China; Affiliated Taihe Hospital of Hubei University of Medicine, Shiyan, China; Yichang Central People's Hospital, Yichang, China; HanDan Central Hospital, Handan, China; Changzhi Maternal and Child Health Care Hospital, Changzhi, China; Qinghai Red Cross Hospital, Xining, China; Qinghai Women and Children's Hospital, Qinghai, China; Tibet Autonomous Region People's Hospital, Tibet, China. Data were provided voluntarily by team members from participating hospitals.
                Article
                zoi210294
                10.1001/jamanetworkopen.2021.9382
                8114138
                33974055
                e2d2773e-9883-4c4a-bd74-0777bc7e46e6
                Copyright 2021 Zhu Z et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 8 January 2021
                : 17 March 2021
                Categories
                Research
                Original Investigation
                Online Only
                Pediatrics

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