Research Article: Evidence-Based Neonatal Unit Practices and Determinants of Postnatal Corticosteroid-Use in Preterm Births below 30 Weeks GA in Europe. A Population-Based Cohort Study

Date Published: January 23, 2017

Publisher: Public Library of Science

Author(s): Alexandra Nuytten, Hélène Behal, Alain Duhamel, Pierre-Henri Jarreau, Jan Mazela, David Milligan, Ludwig Gortner, Aurélie Piedvache, Jennifer Zeitlin, Patrick Truffert, Umberto Simeoni.

http://doi.org/10.1371/journal.pone.0170234

Abstract

Postnatal corticosteroids (PNC) were widely used to treat and prevent bronchopulmonary dysplasia in preterm infants until studies showed increased risk of cerebral palsy and neurodevelopmental impairment. We aimed to describe PNC use in Europe and evaluate the determinants of their use, including neonatal characteristics and adherence to evidence-based practices in neonatal intensive care units (NICUs).

3917/4096 (95,6%) infants born between 24 and 29 weeks gestational age in 19 regions of 11 European countries of the EPICE cohort we included. We examined neonatal characteristics associated with PNC use. The cohort was divided by tertiles of probability of PNC use determined by logistic regression analysis. We also evaluated the impact of the neonatal unit’s reported adherence to European recommendations for respiratory management and a stated policy of reduced PNC use.

PNC were prescribed for 545/3917 (13.9%) infants (regional range 3.1–49.4%) and for 29.7% of infants in the highest risk tertile (regional range 5.4–72.4%). After adjustment, independent predictors of PNC use were a low gestational age, small for gestational age, male sex, mechanical ventilation, use of non-steroidal anti-inflammatory drugs to treat persistent ductus arteriosus and region. A stated NICU policy reduced PNC use (odds ratio 0.29 [95% CI 0.17; 0.50]).

PNC are frequently used in Europe, but with wide regional variation that was unexplained by neonatal characteristics. Even for infants at highest risk for PNC use, some regions only rarely prescribed PNC. A stated policy of reduced PNC use was associated with observed practice and is recommended.

Partial Text

Bronchopulmonary dysplasia (BPD) is a chronic lung disease frequently associated with very preterm birth [1,2] and defined as the need for oxygen at 36 weeks gestational age (GA) [3]. Inflammatory mechanisms in BPD have been described [4]. Therefore, postnatal corticosteroids (PNC) have been used to wean infants off ventilators [5]. In the 1990s, up to 25% of very preterm infants received dexamethasone [6].

Our study showed that PNC are still used in Europe, with wide variations across regions. The main neonatal characteristics associated with PNC use were low GA, SGA, male sex, receiving mechanical ventilation, and PDA treatment with NSAIDs. However, these characteristics did not explain the wide variation in PNC prescription between regions, which persisted for infants with the most severe respiratory condition (highest risk tertile). NICUs with a PNC restricted use policy showed significantly lower PNC use.

European practices in PNC use for BPD are heterogeneous. Neonatal factors associated with PNC prescription reflected in part disease severity but did not explain the variation in PNC use. Our results suggest that a stated policy of restrictive PNC use could reduce non-evidence–based practices for individual patients. Other potential determinants such as knowledge concerning adverse effects, use of preventive respiratory strategies and saturation targets should be considered.

 

Source:

http://doi.org/10.1371/journal.pone.0170234