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Objective To investigate the association between fluid and sodium status in the first 10 postnatal days and death/bronchopulmonary dysplasia (BPD) among infants born <29 weeks’ gestation. Study design Single center retrospective cohort study (2015–2018) of infants born 23–28 weeks’. Three exposure variables were evaluated over the first 10 postnatal days: cumulative fluid balance (CFB), median serum sodium concentration, and maximum percentage weight loss. Primary outcome was death and/or BPD. Multivariable logistic regression adjusting for patient covariates was used to assess the association between exposure variables and outcomes. Results Of 191 infants included, 98 (51%) had death/BPD. Only CFB differed significantly between BPD-free survivors and infants with death/BPD: 4.71 dL/kg (IQR 4.10–5.12) vs 5.11 dL/kg (IQR 4.47–6.07; p  < 0.001). In adjusted analyses, we found an association between higher CFB and higher odds of death/BPD (AOR 1.56, 95% CI 1.11–2.25). This was mainly due to the association of CFB with BPD (AOR 1.60, 95% CI 1.12–2.35), rather than with death (AOR 1.08, 95% CI 0.54–2.30). Conclusion Among preterm infants, a higher CFB in the first 10 days after delivery is associated with higher odds of death/BPD. Impact Previous studies suggest that postnatal fluid status influences survival and respiratory function in neonates. Fluid balance, serum sodium concentration, and daily weight changes are commonly used as fluid status indicators in neonates. We found that higher cumulative fluid balance in the first 10 days of life was associated with higher odds of death/bronchopulmonary dysplasia in neonates born <29 weeks. Monitoring of postnatal fluid balance may be an appropriate non-invasive strategy to favor survival without bronchopulmonary dysplasia. We developed a cumulative fluid balance chart with corresponding thresholds on each day to help design future trials and guide clinicians in fluid management.

Objective To investigate the association between change in body mass index (BMI) from birth to 36 weeks gestation (ΔBMI) and bronchopulmonary dysplasia (BPD) among infants born <30 weeks gestation. Methods This was a multicenter retrospective cohort study (2015–2018) of infants born <30 weeks gestation and alive at ≥34 weeks corrected. Main exposure was a change in BMI z score from birth to 36 weeks corrected age grouped into quartiles of change. Association between ΔBMI z scores and BPD was assessed using generalized linear mixed models. Results Among 772 included infants, 51% developed BPD. From birth to 36 weeks CGA, the weight z score of infants with BPD decreased less than for BPD-free infants, despite a greater decrease in length z score and similar caloric intake resulting in increases in BMI z score (median [IQR], 0.16 [–0.64; 1.03] vs –0.29 [–1.03; 0.49]; P  < 0.01). In the adjusted analysis, higher ΔBMI z score quartiles were associated with higher odds of BPD (Q3 vs Q2, AOR [95% CI], 2.02 [1.23; 3.31] and Q4 vs Q2, AOR [95% CI], 2.00 [1.20; 3.34]). Conclusion Among preterm infants, an increase in BMI z score from birth to 36 weeks corrected is associated with higher odds of BPD. Impact Preterm infants with evolving lung disease often experience disproportionate growth in the neonatal period. In this multicenter cohort study, increases in BMI z score from birth to 36 weeks CGA were associated with higher odds of BPD. Despite similar caloric intake, infants with BPD had a higher weight- but lower length-for-age, resulting in higher BMI z score compared to BPD-free infants. This suggests that infants with evolving BPD may require different growth and nutritional targets compared to BPD-free infants.

ObjectiveTo assess the association of NICU occupancy with probability of discharge and length of stay (LOS) among infants born <33 weeks gestational age (GA).Study designRetrospective study of 3388 infants born 23–32 weeks GA, admitted to five Level 3/4 NICUs (2014-2018) and discharged alive. Standardized ratios of observed-to-expected number of discharges were calculated for each quintile of unit occupancy. Multivariable linear regression models were used to assess the association between occupancy and LOS.ResultsAt the lowest unit occupancy quintiles (Q1 and Q2), infants were 12% and 11% less likely to be discharged compared to the expected number. At the highest unit occupancy quintile (Q5), infants were 20% more likely to be discharged. Highest occupancy (Q5) was also associated with a 4.7-day (95% CI 1.7, 7.7) reduction in LOS compared Q1.ConclusionNICU occupancy was associated with likelihood of discharge and LOS among infants born <33 weeks GA.

ObjectiveIn a healthcare system with finite resources, hospital organisational factors may contribute to patient outcomes. We aimed to assess the association of nurse staffing and neonatal intensive care unit (NICU) occupancy with outcomes of preterm infants born <33 weeks’ gestation.DesignRetrospective cohort study.SettingFour level III NICUs.PatientsInfants born 23–32 weeks’ gestation 2015–2018.Main outcome measuresNursing provision ratios (nursing hours worked/recommended nursing hours based on patient acuity categories) and unit occupancy rates were averaged for the first shift, 24 hours and 7 days of admission of each infant. Primary outcome was mortality/morbidity (bronchopulmonary dysplasia, severe neurological injury, retinopathy of prematurity, necrotising enterocolitis and nosocomial infection). ORs for association of exposure with outcomes were estimated using generalised linear mixed models adjusted for confounders.ResultsAmong 1870 included infants, 823 (44%) had mortality/morbidity. Median nursing provision ratio was 1.03 (IQR 0.89–1.22) and median unit occupancy was 89% (IQR 82–94). In the first 24 hours of admission, higher nursing provision ratio was associated with lower odds of mortality/morbidity (OR 0.93, 95% CI 0.89 to 0.98), and higher unit occupancy was associated with higher odds of mortality/morbidity (OR 1.19, 95% CI 1.04 to 1.36). In causal mediation analysis, nursing provision ratios mediated 47% of the association between occupancy and outcomes.ConclusionsNICU occupancy is associated with mortality/morbidity among very preterm infants and may reflect lack of adequate resources in periods of high activity. Interventions aimed at reducing occupancy and maintaining adequate resources need to be considered as strategies to improve patient outcomes.

Many infants in Canada are born with low vitamin D stores, putting them at risk of developing complications such as rickets, if untreated. Newborns are not routinely screened for vitamin D status. Identifying those at high risk may facilitate targeted education to parents regarding supplementation for infants. However, a screening tool is not available. The objective was to develop and test the validity of a screening survey tool to identify term-born neonates at high risk for vitamin D deficiency (25-hydroxyvitamin D (25(OH)D) < 30 nmol/L). Healthy mother-infant pairs (n = 1112) were recruited at the Lakeshore General Hospital, Montreal, from March 2016 to March 2019. Parental demographic and lifestyle factors were surveyed. Newborn blood samples, collected < 36 h after birth, were tested for serum 25(OH)D (Liaison, Diasorin Inc.). Content validity was based on 21 known risk factors. Logistic regression models were used to identify key variables associated with risk of low neonatal vitamin D concentrations. Receiver operating characteristic (ROC) curves were used to demonstrate sensitivity and specificity of the screening tool against known vitamin D status. Mothers (age 32.4 ± 4.5 y) were mostly white (58%) and 57% had a pre-pregnancy body mass index (BMI) in the healthy range (18.5–24.9 kg/m2). Mean neonatal serum 25(OH)D concentration was 44.5 ± 19.9 nmol/L, with 23% (95% CI 0.20, 0.25) below 30 nmol/L. Six out of the 21 existing risk factors assessed were most predictive of neonatal low vitamin D status (P < 0.05). These risk factors (maternal age at delivery < 26.0 y, pre-pregnancy BMI < 18.5 or ≥ 25 kg/m2, non-white skin color, prenatal supplement intake < 2–3 times/wk before or during pregnancy and delivery in October through April) are easily assessable from hospital charts. Regression coefficients for each risk factor were transformed into integer scores. The average of the total scores was taken as the cut-off score for neonates at high risk for vitamin D deficiency. The screening tool had a sensitivity of 68.8% and specificity of 70.0%. Area under the ROC curve was 0.712 (95% CI 0.679, 0.745; P < 0.0001). This screening survey tool consisting of 6 easily assessable questions was moderately successful in identifying neonates at high risk for vitamin D deficiency; however, further research is needed to refine and validate this screening tool in other populations before it can be used in clinical practice.