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Innovations in Pediatrics Winter 2016 - Download PDF

Research shows improving outcomes for some of the tiniest newborns

MIchele Walsh, MD, MS EPi Michele Walsh, MD, MS Epi

Neonatologists have spent the last two decades refining and improving the quality of care for infants born extremely premature. Now, new research suggests these efforts are making a small yet measurable difference, especially for infants born at 23 and 24 weeks.

“It’s been a slow and steady increase,” says Michele Walsh, MD, MS Epi, Interim Chair and Chief, Division of Neonatology, UH Rainbow Babies & Children’s Hospital, Interim Chair and Professor, Department of Pediatrics, Case Western Reserve University School of Medicine. “Over the last 20 years, we’ve seen about a 9 percent improvement in survival at 23 weeks, and a 4 percent improvement in survival at 24 weeks. It’s small, but it’s real.”

Dr. Walsh and fellow members of the National Institute of Health’s (NIH) Neonatal Research Network recently released outcomes data for infants born between 22 and 28 weeks gestation between 1993 and 2012, publishing their findings in the Journal of the American Medical Association. UH Rainbow Babies and Children’s Hospital was a founding member of the Neonatal Research Network, under the leadership of former neonatology Division Chief and Principal Investigator Avroy Fanaroff, MD. The hospital has maintained continuous membership in the consortium since 1986, one of only two centers to do so. Dr. Walsh has participated in the network since 1992.

For Dr. Walsh, the new data highlight the synergistic effect of multiple neonatal interventions.

“It’s not any one intervention,” she says. “It’s the increasing sophistication of the high-risk OBs and neonatologists in taking care of the tiny babies. It’s making sure that the moms get antenatal steroids before delivery. It’s avoiding injury to their lungs and improving their nutrition by using human milk. The more human milk they receive, the more protected they are from severe infections, both in the bloodstream and in the intestines.”

Although the improvements in survival are real, Dr. Walsh says, challenges remain in other areas. “The developmental outcomes for the tiniest ones – the 23- and 24-weekers – are still not what we would want,” she says. “Half of them have a significant learning disability or mental retardation.”

Dr. Walsh says she hopes the new findings will be used to inform the conversations neonatologists have with parents, especially for those who have infants born in the “gray zone” of 23 or 24 weeks.

“At 25 and 26 weeks, interventions have high rates of survival, with very little disability,” she says. “At 22 weeks, most centers offer full resuscitation only in exceptional circumstances. The 23- and 24-weekers are more ‘gray.’ In that gray zone, we feel it’s really important to respect the family’s wishes.  We assist the family in this agonizing decision.”

For her part, Dr. Walsh is continuing research into other neonatal interventions. She is co-principal investigator on the Neonatal Research Network’s clinical trial of hydrocortisone for the prevention of bronchopulmonary dysplasia. But she’s also working the other side of equation: prevention.

“With existing technologies, we think we’re at the lowest limit for how a baby can survive outside the womb,” she says. “The next big area of research is new and better methods of preventing preterm birth. Once a treatment has been shown to be beneficial, how can we make sure that everyone who needs that treatment gets it at the right time, in the right dose?”

Through the Ohio Perinatal Quality Collaborative, Dr. Walsh and colleagues are working to get one such proven treatment – progesterone -- to pregnant women at risk of preterm birth.

“Progesterone is effective in decreasing premature birth if we can get it to the moms early enough, between 16 and 20 weeks,” she says. “If you’ve had a previous preemie and you get - progesterone - the chances of having a second preemie decrease. The data shows that very strongly.”

She and her Rainbow colleagues are also exploring ways to reduce the thorny problem of infant mortality in greater Cleveland.

“It’s very complicated, but it has a lot to do with racial disparities,” Dr. Walsh says. “African-American babies still have 2.5 times the mortality of white infants. Prematurity is the biggest contributor to that, but sleep practices, poor maternal health, including diabetes, obesity and hypertension also contribute. There’s also increasing attention being paid to the social determinants of health. Institutional racism, chronic stress, poverty and all of the environmental factors that go along with that are thought to account for about two-thirds of the disparities in infant mortality.”

Although the problem is daunting, Dr. Walsh says she and her neonatology team are committed to meeting the challenge.

“Ultimately, we need to find ways to have healthy moms who’ve made a choice to get pregnant, seek prenatal care and achieve the best health outcomes for themselves and their babies,” she says.

For more information on UH Rainbow’s role in the Neonatal Research Network or Ohio Perinatal Quality Collaborative, contact Dr. Walsh at Peds.Innovations@UHhospitals.org.

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