Ayah Al Bizri

Background/Objectives: In Ontario, approximately 8% (11,000) of infants are born preterm (22–<37 weeks gestation) each year. Many of these infants are cared for in a Level II Neonatal Intensive Care Unit (NICU). Family Integrated Care (FICare), an innovative model of care, aims to facilitate the involvement of parents in the care of their infants in NICUs. The aim of this study was to gain a better understanding of the general and specific needs of Level II NICUs in Ontario prior to implementation of FICare. Methods: Using a cross-sectional study design, two surveys (leadership and site resources) were developed using the Consolidated Framework for Implementation Science Research’s innovation, inner setting, and outer setting constructs and distributed to Level II NICUs medical and nursing leaders. Results: The surveys were sent to 44 Level II NICUs in Ontario, of which 24 hospitals (55%) responded. Key facilitators to implementation of FICare in Level II hospitals in Ontario were leadership interest, availability of staff and parent volunteers, and existing policies to support implementation. The identified barriers were lack of financial resources for new initiatives, skepticism in FICare’s ability to save costs, need for tailored implementation due to variability in NICU characteristics, and the lack of environmental support for prolonged parental presence. Conclusions: This study has confirmed the interest of many Ontario level II NICUs in implementing FICare and variability in their readiness for implementation based on the identified facilitators and barriers.

Objective: To examine the contribution of preterm birth and size‐for‐gestational age in stillbirths using six ‘newborn types’. Design: Population‐based multi‐country analyses. Setting: Births collected through routine data systems in 13 countries. Sample: 125 419 255 total births from 22 ⁺⁰ to 44 ⁺⁶ weeks’ gestation identified from 2000 to 2020. Methods: We included 635 107 stillbirths from 22 ⁺⁰ weeks’ gestation from 13 countries. We classified all births, including stillbirths, into six ‘newborn types’ based on gestational age information (preterm, PT, +0 weeks versus term, T, ≥37 ⁺⁰ weeks) and size‐for‐gestational age defined as small (SGA, 90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH‐21st standards. Main outcome measures: Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types. Results: 635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22 ⁺⁰ weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8–118.8) followed by PT + AGA (RR 25.0, IQR, 20.0–34.3), PT + LGA (RR 25.9, IQR, 13.8–28.7) and T + SGA (RR 5.6, IQR, 5.1–6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7–1.1). At the population level, 25% of stillbirths were attributable to small‐for‐gestational‐age. Conclusions: In these high‐quality data from high/middle income countries, almost three‐quarters of stillbirths were born preterm and a fifth small‐for‐gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation‐specific risk in these populations, as well as patterns in lower‐income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Objective: We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020. Design: Population‐based, multi‐country study. Setting: National healthcare systems. Population: Liveborn infants. Methods: We used individual‐level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th–90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500–3999 g. INTERGROWTH 21st served as the reference population. Main outcome measures: Prevalence and neonatal mortality risks. Results: Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%–22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77–0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%–13.3%), with 1.2% (IQR 0.7%–2.0%) ≥4500 g and with 0.2% (IQR 0.1%–0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69–0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10–2.11) and ≥5000 g (RR 4.54, 95% CI 2.58–7.99), compared with birthweights of 2500–3999 g, with the highest risk observed in the first 7 days of life. Conclusions: In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

Background: Family involvement is vital to optimize the care of infants in the neonatal intensive care unit (NICU). Various technologies have been used to support communication with parents in the NICU. The purpose of this study was to evaluate the parent and staff experience and perception of the use of a cloud-based video-messaging service in our NICU. Methods: This study was a single center observational study conducted at Mount Sinai Hospital, Toronto, Canada. Following the implementation of a video-messaging service, parent and staff surveys were distributed to evaluate their experience and perception. Results: Parent responses were positive with respect to how the service helped them feel: closer to their infant (100%) and reassured about their infant’s care (100%). Nursing staff responses indicated that they perceived a benefit to parents (100%) and to their building a relationship with families (79%). However, they also identified time constraints (85%) and the use of the technology hardware (24%) as challenges. Conclusions: The use of an asynchronous video-messaging service was perceived as beneficial to both parents and staff in the NICU. Complaints pertained to the impact of the technology on nursing workflow and the difficulty using the hardware provided for use of the service.

Objective: To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000–2020. Design: Population‐based, multi‐country study. Setting: National data systems in 15 middle‐ and high‐income countries. Methods: We used individual‐level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm [PT] versus term [T]) and size‐for‐gestational age (small [SGA], 90th centile) according to INTERGROWTH‐21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types. Main outcome measures: Mortality of six newborn types. Results: Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range [IQR] 45.6–73.9), PT + AGA (median 34.3, IQR 23.9–37.5) and PT + LGA (median 28.3, IQR 18.4–32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5–54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2–388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7–342.8) compared with those between 2500 g and 4000 g as a reference group. Conclusion: Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co‐existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.

Objective: To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021. Design: Population‐based, multi‐country analysis. Setting: National data systems in 23 middle‐ and high‐income countries. Population: Liveborn infants. Methods: Country teams with high‐quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, 90th centile) for gestational age, according to INTERGROWTH‐21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3‐year moving averages for small and large types. Main outcome measures: Prevalence of six newborn types. Results: We analysed 165 017 419 live births and the median prevalence of small types was 11.7% – highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries. Conclusions: The distribution of newborn types varies across the 23 middle‐ and high‐income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low‐ and middle‐income countries.

Introduction It has been established that underweight women with low gestational weight gain (GWG) are at a higher risk of having Small for Gestational Age (SGA) newborns. However, the association remains poorly studied in Middle Eastern societies exhibiting different ethnic groups, genetic predisposing factors along with differences in nutritional food intake during pregnancy. The aim of this study is to assess the risk of having a SGA newborn among underweight and normal weight BMI women while studying the role of GWG in this association. Methods This is a retrospective cross-sectional study of 62,351 singleton pregnancies from the National Collaborative Perinatal Neonatal Network between 2001 and 2009 from 27 hospitals across Lebanon. Women who had underweight and normal pre-pregnancy BMI were included. Results A total of 8.6% newborns were SGA and 6.6% of women were underweight. Among women with normal and underweight pre-pregnancy BMI, 8.6 and 12.4% had SGA births respectively. Overall, the adjusted OR of having SGA newborns was significantly higher among underweight women (OR = 1.448; 95%CI = 1.287-1.630) compared to normal pre-pregnancy BMI. Below normal weight gain significantly increased the odds of SGA for both normal and underweight pre-pregnancy BMI women, with adjusted ORs of 1.535 (95% CI = 1.418-1.661) and 1.970 (95%CI = 1.515-2.560) respectively. Discussion Higher risks of SGA newborns in underweight and normal BMI women with low GWG were observed. In addition, normal weight gain couldn't protect underweight women of having risk for SGA newborns. Hence, all pregnant women should be encouraged to maintain healthy BMI before pregnancy and attain adequate GWG.

Background: Among preterm infants, the peripherally inserted central catheter (PICC) is the standard line for central venous access; however, its placement exposes them to hypothermia and pain. Ultrasound (US)-guided central line insertion may be less morbid than standard PICC line. Aims: To determine the ease, success rate, and morbidity associated with US-guided central line insertion in the internal jugular vein (IJV) by comparing it to the standard PICC line placement. Materials and Methods: This is a single-center nonrandomized prospective study evaluating preterm infants between October 2013 and June 2014. Patients were allocated into two groups: The standard group (control group) who underwent blind PICC line insertion and the intervention group who underwent a percutaneous US-guided central line insertion in the IJV. The epicutaneo-cava-catheter was used in both groups. Results: Fifty neonates were enrolled on study. A statistically difference in favor of US-IJV insertion was noted concerning the rate of successful first attempt (P < 0.001), insertion (P = 0.001), and procedure duration (P < 0.001) and number of trials (P < 0.001) compared to PICC. No difference in complications (P = 1.000) was noted. Conclusion: US guided catheterization of the IJV technique is faster than PICC line insertion with higher rates of successful first attempt and insertion, less procedure duration and fewer number of trials compared to PICC line insertion. There were no differences in complications.

Background: Pre‐pregnancy body mass index (BMI) and gestational weight gain (GWG) are reported to impact the preterm birth (PTB) rate and newborn size. Most studies have been conducted in developed countries, althoughPTBand adverse pregnancy outcomes are more frequent in the developing world. The aim of this study is to elucidate the association of pre‐pregnancyBMIandGWGon the occurrence ofPTBand sub‐optimal fetal size inLebanon.Methods: This is a retrospective cohort study using a hospital‐based register covering 35% of births inLebanon between 2001 and 2012. Data were collected on 170 428 pregnancies from 32 hospitals using medical records and interviews.Results: After adjusting for confounders, underweight women had increased odds of having very preterm [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.16, 2.14], preterm (OR1.42, 95%CI1.28, 1.58), and small for gestational age (SGA) (OR1.50, 95%CI1.37, 1.63) neonates. WhenBMIwas analysed withGWG, onlySGAremained significant in underweight women with lowGWG. For allBMIgroups, lowGWGwas protective against large for gestational age (LGA) and highGWGincreased the odds ofLGA.GWG, both low (OR1.25, 95%CI1.15, 1.35) and high (OR1.43, 95%CI1.32, 1.55) increased the risk ofPTBin normal weight women. The same result was obtained for overweight women.Conclusions: HighGWGincreased the risk ofLGAfor all groups andPTBin normal weight and overweight women, whereas lowGWGincreased the risk ofSGAandPTB. Given that there are not many studies from middle income/developing countries on patterns of weight gain during pregnancy, findings from this study may help with pre‐conception counselling with emphasis on the importance of an optimal pre‐pregnancyBMIand appropriate weight gain during pregnancy.