Elsevier

The Journal of Pediatrics

Volume 164, Issue 6, June 2014, Pages 1303-1310.e2
The Journal of Pediatrics

Original Article
Developmental Outcomes of Very Preterm Infants with Tracheostomies

https://doi.org/10.1016/j.jpeds.2013.12.014Get rights and content

Objectives

To evaluate the neurodevelopmental outcomes of very preterm (<30 weeks) infants who underwent tracheostomy.

Study design

Retrospective cohort study from 16 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network over 10 years (2001-2011). Infants who survived to at least 36 weeks (N = 8683), including 304 infants with tracheostomies, were studied. Primary outcome was death or neurodevelopmental impairment (NDI; a composite of ≥1 of developmental delay, neurologic impairment, profound hearing loss, severe visual impairment) at a corrected age of 18-22 months. Outcomes were compared using multiple logistic regression. We assessed the impact of timing by comparing outcomes of infants who underwent tracheostomy before and after 120 days of life.

Results

Tracheostomies were associated with all neonatal morbidities examined and with most adverse neurodevelopmental outcomes. Death or NDI occurred in 83% of infants with tracheostomies and 40% of those without (OR adjusted for center 7.0, 95% CI 5.2-9.5). After adjustment for potential confounders, odds of death or NDI remained higher (OR 3.3, 95% CI 2.4-4.6), but odds of death alone were lower (OR 0.4, 95% CI 0.3-0.7) among infants with tracheostomies. Death or NDI was lower in infants who received their tracheostomies before, rather than after, 120 days of life (aOR 0.5, 95% CI 0.3-0.9).

Conclusions

Tracheostomy in preterm infants is associated with adverse developmental outcomes and cannot mitigate the significant risk associated with many complications of prematurity. These data may inform counseling about tracheostomy in this vulnerable population.

Section snippets

Methods

The NRN uses a predefined protocol to prospectively collect medical and developmental follow-up data at 18-22 months' corrected age on all infants born with birth weight of 401-1000 g (if born before January 1, 2008) or before 27 weeks' gestation (if born on or after January 1, 2008).13 The same protocol is used to collect follow-up data about children of any gestational age who are enrolled in an NRN clinical trial requiring neurodevelopmental follow-up. In the current analyses, we evaluated

Results

Over the study period (2001-2011), 10 128 children were born before 30 weeks' gestation, survived to at least 36 weeks' postmenstrual age, and were eligible for neonatal follow-up at 18-22 months' corrected age in 16 NRN centers. We excluded 1445 (14%) children because of missing data on the primary outcome, of whom 29 (2.0%) had tracheostomies. The remaining 8683 children included 304 children (3.5%) with tracheostomies (Table I). Infants who underwent tracheostomy had lower average birth

Discussion

This retrospective study of prospectively collected data cannot establish causality but merely suggest plausible associations. However, this cohort is unique in several ways. We evaluated mortality and neurodevelopmental outcomes at 18-22 months' corrected age in children who were born at <30 weeks' gestation and underwent tracheostomy placement. Prior smaller, mostly single-center studies of children with tracheostomies did not include comparison groups without tracheostomies. In contrast, our

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      Rates of NDI were high (>50% exhibited moderate to severe developmental disability) but similar between the groups.110 In a separate analysis, DeMauro et al. evaluated the association between tracheostomy and death or NDI at 18-22 months’ corrected age in a cohort of 8683 extremely preterm infants, including 304 with tracheostomies.111 The odds of death or NDI were higher among infants with tracheostomy (83% vs. 40%, adjusted OR 3.3, 95% CI 2.4-4.6).111

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    Supported by grants from the National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) for the Neonatal Research Network, including for the Generic Database Study, Candidiasis Study, Cord Clamping Study, Delivery Room CPAP Study, Early Blood Pressure pilot study, PCV-7 Study, Phototherapy Trial, Preemie aEEG pilot study, Preemie iNO Trial, and SUPPORT trial. Data collected at participating sites of the NICHD Neonatal Research Network were transmitted to RTI International, the data coordinating center for the network, which stored, managed, and analyzed the data for this study. The authors declare no conflicts of interest.

    List of members of the NICHD Neonatal Research Network is available at www.jpeds.com (Appendix).

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