Abstract
BACKGROUND:
Extremely preterm infants may use medical technology after discharge from neonatal intensive care. The aim of the study was to determine which inpatient morbidities have the strongest associations with technology at toddler-age follow-up.
METHODS:
Retrospective cohort analysis of 3904 extremely preterm infants born 22.0–26.6 weeks’ gestation from 2014 to 2019 who survived to 36 weeks’ postmenstrual age and had data on medical technology at 22–26 months’ corrected gestational age.
RESULTS:
18.8% of children used medical technology; 10.1% used one and 8.7% ≥ 2. Use of a gastrostomy tube was most common (12.8%), followed by pulse oximeter (8.2%), oxygen (5.9%), tracheostomy (3.9%), shunt for hydrocephalus (3.6%), ventilator/continuous positive airway pressure (2.2%), apnea monitor (1.4%), and total parenteral nutrition (0.3%). After adjusting for significant maternal and infant characteristics, Grade 2 or 3 bronchopulmonary dysplasia (BPD) was most strongly associated with medical technology (aOR (95% CI): 3.20 (2.65, 3.87)), followed by serious brain injury (SBI) 3.06 (2.55, 3.66) and surgical NEC (sNEC) 2.67 (1.84, 3.87).
CONCLUSIONS AND RELEVANCE:
In this cohort of extremely preterm infants, BPD, SBI and sNEC were most associated with medical technology use at toddler-age. These findings provide information for counseling of families and support during discharge planning.
CLINICALTRIALS.GOV ID:
Generic Database: NCT00063063.
INTRODUCTION
Families have told researchers that it is not the presence of morbidities, but rather the functional outcomes of them, that are most important after discharge.1 Children with medical complexity may use medical technology after discharge from the neonatal intensive care unit (NICU). Medical technology is defined as a piece of equipment that supports or compensates for a limitation in physiologic function that is essential to survival (i.e., devices supporting feeding, respiration) or is necessary for “other life activities and participation” (i.e., mobility devices, communication augmentation devices).2 Children with chronic use of technology to sustain vital functions are at highest risk for admission to pediatric intensive care units and prolonged stays when admitted,3,4 particularly those infants who are discharged after 28 days post term corrected age with medical technology and meet the definition of chronic critical illness.5 A child’s use of medical technology also has a significant impact on family functioning in multiple domains, including financial and caretaking responsibilities that can dramatically affect daily life.6–10
It has been well-described that certain inpatient morbidities such as bronchopulmonary dysplasia (BPD), serious brain injury (SBI), and retinopathy of prematurity (ROP) are independently associated with risk of future neurodevelopmental impairment,11–13 and the presence of multiple morbidities further increases risk of death or short and long-term disability.14–17 However, it is unknown if these same inpatient risk factors predispose extremely preterm infants to persistent medical technology use, an important and common complication of prematurity, as studies are limited. One large Canadian study of children born <29 weeks’ gestation from 2009 to 2011 did demonstrate increased use of medical technology at discharge among infants with BPD, sepsis, and surgical necrotizing enterocolitis10, and BPD and SBI18 have been associated with gastrostomy tube use in the United States. More studies in the modern epoch are needed to investigate how a broader range of morbidities could affect risk for multiple types of medical technology for our most at-risk extremely preterm infants.
Understanding which children are at highest risk for persistent medical technology use in early childhood can help inform counseling and interventions to support families. In this study, we aimed to identify the inpatient morbidities most associated with persistent need for medical technology at 22–26 months’ corrected age.
METHODS
This study was a retrospective cohort analysis of data from the National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN). Trained research coordinators prospectively collected maternal and neonatal data using previously described protocols with IRB approval.19 Follow-up assessments were performed at 22–26 months’ corrected age for infants born at 22–26 weeks’ gestation in 2014–2019 at 15 network centers. Infants with syndromes such as trisomies 13, 18, and 21 and infants with congenital malformations were excluded. Assessments included a report of current use of supportive medical equipment.
Neonatal morbidities were then examined as potential risk factors for technology use at 22–26 months’ corrected age. Medical technology at 22–26 months’ corrected age was defined as the presence of one of more of the following: gastrostomy tube, total parenteral nutrition, pulse oximeter, oxygen, tracheostomy, ventilator/CPAP, apnea monitor or intracranial shunt for hydrocephalus. If an infant had a shunt for hydrocephalus placed in the NICU, medical technology use was recorded as present at 22–26 months.
Morbidities investigated included: BPD grades 2 or 3 by Jensen criteria,20 early-onset infection (culture-proven sepsis/meningitis <72 h of age), late-onset infection (culture-proven sepsis/meningitis ≥72 h of age), necrotizing enterocolitis (NEC, Bell stages II or III), NEC requiring surgical intervention (sNEC), patent ductus arteriosus (PDA) undergoing surgery or catheterization for closure, SBI (one or more of the following: grades 3 or 4 intraventricular hemorrhage (IVH), intraparenchymal echodense lesions, cystic periventricular leukomalacia (PVL), porencephalic cysts, ventriculomegaly with or without IVH, cerebellar hemorrhage), and severe ROP (stage 3 or greater or presence of surgery for ROP/retinal detachment or anti-VEGF injection).
In the second step of the analysis, relationships between these morbidities and persistent medical technology use at 22–26 months’ corrected age were adjusted for statistically significant infant and maternal characteristics based on p-values from tests of fixed effects at a 0.05 significance level. Characteristics examined included those previously used as predictors in the NICHD extremely preterm birth outcome tool model (infant sex, birthweight, plurality (single vs. multiple gestation), gestational age at birth, and exposure to antenatal corticosteroids)21 and maternal characteristics as listed in Table 1. Maternal race and ethnicity were included as they are known to be associated with differences in both treatment and outcomes for preterm infants.22
Table 1.
Maternal and Infant Characteristics by Presence of Medical Technology.
| Presence of Medical Technology | |||
|---|---|---|---|
| Yes N = 735 | No N = 3169 | ||
| Maternal characteristics | |||
| Age, median (IQR), y | 28(23, 33) | 29(24, 34)* | |
| Education, no. (%)a | * | ||
| Less than high school | 123(20.2) | 434(15.9) | |
| High school degree(diploma) | 175(28.7) | 786(28.7) | |
| Trade or technical school or some college | 196(32.1) | 818(29.9) | |
| College degree or more | 116(19) | 696(25.5) | |
| Public medical insuranceb | 444(60.7) | 1810(57.2) | |
| Hispanic or Latino ethnicity, no. (%) | 106(14.6) | 573(18.3)* | |
| Self-reported race, no. (%) | |||
| American Indian or Alaska Native | 5(0.7) | 28(0.9) | |
| Asian | 22(3) | 98(3.1) | |
| Black | 313(42.7) | 1303(41.2) | |
| Native Hawaiian or other Pacific Islander | 1(0.1) | 8(0.3) | |
| White | 371(50.6) | 1591(50.3) | |
| More than one race | 4(0.5) | 49(1.5) | |
| Unknown or not reported | 17(2.3) | 88(2.8) | |
| Multiple gestation | 183(24.9) | 811(25.6) | |
| Chorioamnionitis | 121(16.5) | 571(18) | |
| Antenatal corticosteroidsc | 681(92.7) | 2938(92.7) | |
| Prenatal magnesium sulfate | 598(81.5) | 2702(85.3)* | |
| Infant characteristics | |||
| Sex, no. (%) | Male | 384(52.2) | 1562(49.3) |
| Female | 350(47.6) | 1604(50.6) | |
| Ambiguous | 1 (0.13) | 3 (0.22) | |
| Gestational age in weeks, mean (SD) | 24.5(1.2) | 24.9(1.1)* | |
| Birth weight in grams, median (IQR) | 663(560, 780) | 760(650, 880)* | |
| Receipt of postnatal steroids, no. (%) | 392(55.6) | 853(28.3)* | |
| Receipt of postnatal indomethacin, no. (%) | 399(54.3) | 1601(50.5)* | |
| Receipt of surfactant, no. (%) | 700(95.2) | 2765(87.3)* | |
IQR interquartile range, SD standard deviation.
p-value < 0.05 of Chi-square test for difference in proportions or t-test for difference in means.
Missing data: Medical technologywas unknown for 788 infants. Data points missing/unknown in following categories: 560 in maternal education, 11 in public medical insurance, 42 in Hispanic or Latino ethnicity, 6 on self-reported race, 3 in chorioamnionitis, 1 in antenatal corticosteroids,
2 in prenatal magnesium sulfate, 180 in receipt of postnatal steroids.
Maternal education assessed at the time of delivery.
Public medical insurance may include Medicaid, a state or federally funded program, or insurance obtained through the Affordable Care Act.
Antenatal corticosteroids was defined as any antenatal corticosteroid given.
Analyses were performed using SAS Enterprise Guide 7.15 (SAS Institute Inc., Cary, NC, USA 2017) and STATA/MP 17.0 (StataCorp LLC., College Station, Texas 77845 USA 2023) from July 2023 to March 2024. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines were followed.23
RESULTS
Among 4692 eligible infants who survived to 36 weeks’ postmenstrual age (PMA), 125 died during the hospital stay, 60 children died after discharge, and 603 were lost to follow-up. 3904 children had information on medical technology at 22–26 months’ corrected age; of these, 735 used medical technology and 3169 did not (see Appendix Fig. 1).
Forty-one percent of children in the overall cohort were diagnosed with Grade 2 or 3 BPD, 25.2% had late-onset infection, 23.9% had SBI, 23.5% had severe ROP, 13.2% had PDA undergoing surgery or catheterization, 9.7% had NEC, 3.5% had surgical NEC, and 2.9% had early-onset infection. 27.6% of children had none of the listed morbidities.
Nineteen percent of children had medical technology use at 22–26 month corrected age follow-up; cohort maternal and infant characteristics by medical technology use are found in Table 1. Persistent need for medical technology was more common with certain maternal (younger age, lower educational attainment, non-Hispanic/Latino ethnicity, lower rates of prenatal magnesium sulfate) and infant (younger gestational age, lower birth weight, and higher rates of postnatal indomethacin and surfactant) characteristics.
Among the 3904 infants with data on medical technology, 10.1% (396/3904) of infants used one technology, and 8.7% (339/3904) used two or more. A gastrostomy tube was the most frequently present piece of medical equipment (12.8%, 501/3904), followed by pulse oximeter (8.2%, 318/3904), oxygen (5.9%, 232/3904), tracheostomy (3.9%, 152/3904), shunt for hydrocephalus (3.6%, 141/3904), ventilator/CPAP (2.2%, 84/3904), apnea monitor (1.4%, 56/3904) and total parenteral nutrition (0.3%, 11/3904).
Grade 2 or 3 BPD was the morbidity most strongly associated with medical technology use (OR (95% CI): 3.74 (3.15, 4.44)), followed by SBI (OR (95% CI) 3.17 (2.67, 3.75)) and sNEC (OR (95% CI): 3.10 (2.19, 4.40)). These findings were similar after adjusting for significant maternal and infant characteristics in multiple variable models (aOR (95% CI): 3.20 (2.65, 3.87), 3.06 (2.55, 3.66), and 2.67 (1.84, 3.87)) (Table 2). This analysis allowed for infants to have concurrent morbidities (i.e., infant may have both BPD and SBI). When the analysis was repeated for isolated morbidities, with smaller numbers (1059 infants had BPD alone, 410 SBI alone, and 31 sNEC alone), adjusted ORs were as follows for BPD, SBI and sNEC (aOR (95% CI)): 3.88 (3.02, 5.00), 4.48 (3.30, 6.08), and 4.02 (1.68, 9.61).
Table 2.
Associations of Individual Morbidities with Medical Technology Use.
| Neonatal Morbidity | Outcome Present n (%) | Odds Ratio (95% CI) | Adjusteda Odds Ratio (95% CI) |
|---|---|---|---|
| Bronchopulmonary dysplasia (grade 2 or 3 by Jensen criteria) | 494/728(67.9) | 3.74 (3.15, 4.44) | 3.20 (2.65, 3.87) |
| Serious brain injuryb | 318/734(43.3) | 3.17 (2.67, 3.75) | 3.06 (2.55, 3.66) |
| Surgical necrotizing enterocolitis | 56/734(7.6) | 3.10 (2.19, 4.40) | 2.67 (1.84, 3.87) |
| Late-onset neonatal infection (sepsis, meningitis) | 278/735(37.8) | 2.12 (1.78, 2.51) | 1.75 (1.46, 2.09) |
| Severe retinopathy of prematurityc | 273/723(37.8) | 2.32 (1.95, 2.76) | 1.70 (1.41, 2.06) |
| Necrotizing enterocolitis (stage 2 or 3) | 106/734(14.4) | 1.79 (1.41, 2.27) | 1.57 (1.22, 2.02) |
| Patent ductus arteriosus undergoing surgery or catheterization for closure | 131/735(17.8) | 1.57 (1.27, 1.95) | 1.39 (1.10, 1.75) |
| Early-onset neonatal infection (sepsis, meningitis) | 27/735(3.7) | 1.38 (0.89, 2.15) | 1.30 (0.81, 2.07) |
Adjusted for maternal and infant characteristics significantly associated with medical technology use. The random-effect term for center indicated moderate but statistically insignificant variations in the rate of medical technology use across centers. Analysis allowed for concurrent morbidities.
Presence of one or more of the following: grades 3 or 4 intraventricular hemorrhage (IVH), intraparenchymal echodense lesions, cystic periventricular leukomalacia (PVL), porencephalic cysts, ventriculomegaly with or without IVH, cerebellar hemorrhage.
Stage 3 or greater or presence of surgery for ROP, retinal detachment or anti-VEGF injection.
Depending on the morbidity, the type of medical equipment varied (i.e., SBI has intracranial shunt as the second most common type, see Table 3).
Table 3.
Medical Technology Types by Neonatal Morbidity*.
| Neonatal Morbidity | Apnea Monitor n (%) | Oxygen n (%) | Ventilator n (%) | Gastrostomy n (%) | Tracheostomy n (%) | Pulse oximeter n (%) | Intracranial shunt n (%) | Total Parenteral Nutrition n (%) |
|---|---|---|---|---|---|---|---|---|
| Bronchopulmonary dysplasia | 45/494 (9.1) | 186/494(37.7) | 75/494(15.2) | 367/494(74.3) | 144/494(29.1) | 259/494(52.4) | 78/494(15.8) | 9/494(1.8) |
| Serious brain injury | 20/318 (6.3) | 76/318 (23.9) | 37/318(11.6) | 187/318(58.9) | 46/318(14.5) | 106/318 (33.3) | 139/318(43.7) | 2/318(0.6) |
| Surgical necrotizing enterocolitis | 2/56 (3.6) | 18/56(32.1) | 8/56(14.3) | 43/56 (76.8) | 12/56(21.4) | 21/56(37.5) | 11/56 (19.6) | 9/56 (16.1) |
Among infants with medical technology use.
Six percent of children with no neonatal morbidities used medical technology at 22–26 months’ corrected age (Table 4).
Table 4.
Types of medical technology used by children without neonatal morbidities.
| Apnea Monitor n (%) | Oxygen n (%) | Ventilator n (%) | Gastrostomy n (%) | Tracheostomy n (%) | Pulse oximeter n (%) | Intracranial shunt n (%) | Total Parenteral Nutrition n (%) | |
|---|---|---|---|---|---|---|---|---|
| No major neonatal morbiditiesa | 4 (0.4) | 18 (1.7) | 3 (0.3) | 43 (4.0) | 4 (0.4) | 24 (2.2) | 1 (0.1) | 0(0) |
None of following morbidities: bronchopulmonary dysplasia (grade 2 or 3 by Jensen criteria), serious brain injury, necrotizing enterocolitis (stage 2 or greater including surgical), early or late-onset neonatal infection (sepsis, meningitis), severe retinopathy of prematurity, patent ductus arteriosus undergoing surgery or catheterization for closure.
Persistent medical technology use at 22–26 months’ corrected age was associated with a longer neonatal hospitalization; 28.8% of extremely preterm infants in this cohort (1053/3642) were still in the hospital/not discharged by 44 weeks’ corrected age. The majority of the infants discharged >44 weeks’ corrected age, or 66.4% (416/1053), had later medical technology use. Children discharged ≤44 weeks’ corrected age were much less likely to use medical technology later with a frequency of 33.7% (211/2589) (Fig. 1).
Fig. 1. Discharge timing and percentage of medical technology use at 22–26 months’ corrected age.
Discharge ≤44 weeks’ corrected age 
Discharge >44 weeks’ corrected age.
DISCUSSION
In this large multicenter cohort of extremely preterm infants, we report that BPD, SBI and surgical NEC had the largest risk for persistent medical technology use at 22–26 months’ corrected age. These data provide an important link from neonatal morbidities to long-term outcomes of importance to families.
Presence of medical technology, an important aspect of chronic critical illness, has a significant impact on child health and family functioning in multiple domains. Children with medical technology are more likely to be re-hospitalized, require more outpatient services, and have neurodevelopmental delay.10 Families have detailed extensive caretaking responsibilities related to home medical technology use that are “relentless,” and dramatically affect daily life,6–8 resulting in the role of an “intense parent.”24 This results from a parent’s need to take on additional roles of case manager, advocate, expert, and home nurse, to name a few, in order to ensure their child gets the care they need.9 Home medical technology can also have significant financial implications; parents have described challenges with both paying for and obtaining coverage for home health care and nursing support due to incredibly complex systems.25
Despite the significant impacts of persistent medical technology use on children and families, medical technology has been an underrecognized and underreported result of neonatal care. Parents of preterm children with BPD in outpatient NICU follow-up rank medical technology as the third most important outcome, after “more vulnerable to other problems” and “trouble with breathing,” with other aspects of neurodevelopmental impairment far lower in importance score.26 In another investigation of pulmonary-oriented outcomes, parents after discharge in follow-up care prioritize not the neonatal diagnosis of BPD but rather the limitations of home oxygen, tracheostomy, and other devices such as gastrostomy.1 The data presented here represent an important step in linking neonatal morbidities to long-term medical technology outcomes of importance to families.
The neonatal hospitalization offers an opportunity to help prepare for a child’s future and life at home. Because the morbidities presented here are easily identified prior to discharge, they can be used to help inform counseling for families at highest risk of persistent medical technology needs. Most parents of children going home with home ventilation say at discharge they worry most about medical management. However, parents report that they quickly adapt to this at home but soon feel most unprepared for the extensive changes to family life, financial strain, and changes to their home27 secondary to the technology itself. Neonatal fellows, when conducting home visits to children they had discharged, have noted this same gap in discharge preparation as related to medicalization of the home and the relevance of social context to discharge planning.28 Families of children with high-risk morbidities, who might use not only technology at discharge, but long-term, would likely benefit from question prompt lists at discharge to help with discussions of the “Big Picture” and what life can/could look like at home.29 Providers engaging in these discussions should be mindful, however, that family comprehension may be overwhelmed by excessive information,30 and to have these conversations when families are both involved and receptive to them.
NICU teams can foster connections between families of children with high-risk morbidities or those with medical technology use at discharge with peer mentors to facilitate the transition home.31 Identification of children with high-risk morbidities can also be useful to allocate social supports, such as home visits and direct focus for post-discharge interventions in the setting of a particular social and physical context.32
In addition to connecting morbidities with medical technology use, measuring medical technology needs as an independent, important outcome both at discharge and throughout follow-up is critical to improving our understanding of the consequences of extremely premature birth and of trials that aim to reduce the impact of these morbidities. Incorporating medical technology as an outcome of interest would align with many calls to underscore the importance of the parental perspective in clinical trials.33
Knowledge that a variety of commonly experienced individual neonatal morbidities in the modern era are associated with toddler-age medical technology use, in addition to death or neurodevelopmental impairment, can change both neonatal counseling and perception of these inpatient complications. More qualitative work on the parent perspective of how to best discuss NICU morbidities and their associations with important post-discharge outcomes, like medical technology use, is needed to complement these findings.
LIMITATIONS
This study has several limitations. First, although this NRN cohort is large and diverse in terms of sociodemographic characteristics and geography, it is limited to those who received care at a select number of U.S. medical centers and includes only infants born <27 weeks’ gestation. Future cohorts investigating the persistent use of medical technology in infants born later, such as at term gestational age at birth, are needed. Second, complete medical technology outcomes were missing for 17% of the overall cohort. Third, we only present data here on medical technology needs at 22–26 months’ corrected age rather than discharge (technology initiated before or after discharge). However, unlike medical technology use at discharge from the NICU that may facilitate an earlier discharge and/or have more substantial variation by center, medical technology use at 22–26 months’ corrected age measures a more impactful and longitudinal presence. Future studies can investigate differences in the qualitative family experience amongst children who are discharged with medical technology versus those who have it initiated later after discharge as well. Lastly, while we focused on the definition of medical technology that is “essential to survival” per one section of the Millar et al. Delphi definition,2 there are other types of advanced medical therapies and technologies that impact child and family wellbeing, including the use of adaptive devices to facilitate mobility or communication; longer term follow-up is needed to capture more data about these important variables.
CONCLUSIONS
Among extremely preterm infants who survived to 36 weeks’ PMA, BPD, SBI, and sNEC were most associated with persistent medical technology use at 22–26 months’ corrected age. These findings provide additional information for counseling and support of families during discharge planning.
Supplementary Material
Supplementary information The online version contains supplementary material available at https://doi.org/10.1038/s41390-025-04671-0.
IMPACT:
In this cohort of extremely preterm infants <27 weeks’ gestation at birth, nearly 1 in 5 children used medical technology at 22–26 months’ corrected age.
The inpatient morbidities of bronchopulmonary dysplasia, serious brain injury, and surgical necrotizing enterocolitis were most associated with persistent medical technology use.
These findings provide important information for counseling families of children with these morbidities during the hospital stay and call for increased support of these families after discharge.
ACKNOWLEDGEMENTS
We would like to thank Scott A. McDonald from RTI International for his statistical expertise. The National Institutes of Health, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Center for Research Resources (NCRR), and the National Center for Advancing Translational Sciences (NCATS) provided grant support for the Neonatal Research Network’s Generic Database and Follow-up through cooperative agreements. While NICHD staff had input into the study design, conduct, analysis, and manuscript drafting, the comments and views of the authors do not necessarily represent the views of NICHD, the National Institutes of Health, the Department of Health and Human Services, or the U.S. Government. Participating NRN sites collected data and transmitted it to RTI International, the data coordinating center (DCC) for the network, which stored, managed and analyzed the data for this study. On behalf of the NRN, RTI International had full access to all of the data in the study, and with the NRN Center Principal Investigators, takes responsibility for the integrity of the data and accuracy of the data analysis. We are indebted to our medical and nursing colleagues and the infants and their parents who agreed to take part in this study. The following investigators, in addition to those listed as authors, participated in this study: NRN Steering Committee Chair: Richard A. Polin, MD, Division of Neonatology, College of Physicians and Surgeons, Columbia University, (2011–2023). Alpert Medical School of Brown University and Women & Infants Hospital of Rhode Island (UG1 HD27904) – Abbot R. Laptook, MD; Martin Keszler, MD; Betty R. Vohr, MD; Angelita M. Hensman, PhD RNC-NIC; Elisa Vieira, BSN RN; Lucille St. Pierre, BS; Barbara Alksninis, RNC PNP; Andrea Knoll; Mary L. Keszler, MD; Teresa M. Leach, MEd CAES; Elisabeth C. McGowan, MD; Victoria E. Watson, MS CAS. Case Western Reserve University, Rainbow Babies & Children’s Hospital (UG1 HD21364) – Anna Maria Hibbs, MD MSCE; Nancy S. Newman, RN; Deanne E. Wilson-Costello, MD; Bonnie S. Siner, RN; Elizabeth Roth, PhD. Children’s Mercy Hospital (UG1 HD68284) – William E. Truog, MD; Eugenia K. Pallotto, MD MSCE; Howard W. Kilbride MD; Cheri Gauldin, RN BS CCRC; Anne Holmes RN MSN MBA-HCM CCRC; Kathy Johnson RN, CCRC; Allison Scott, RNC-NIC BSN CCRC; Prabhu S. Parimi, MD; Lisa Gaetano, RN MSN. Cincinnati Children’s Hospital Medical Center, University Hospital, and Good Samaritan Hospital (UG1 HD27853, UL1 TR77) – Stephanie L. Merhar, MD MS; Brenda B. Poindexter, MD MS; Kurt Schibler, MD; Tanya E. Cahill, MD; Jae Kim, MD, PhD; Cathy Grisby, BSN CCRC; Kristin Kirker, CRC; Sandra Wuertz, RN BSN CLC; Juanita Dudley, RN BSN; Julia Thompson, RN BSN; Lisa Henkes, RN BSN; Sara Stacey, BA; Devan Hayes, BS, Courtney Robinson SLP, Greg Muthig, BA, David Russell, JD, Teresa Gratton, PA, Traci Beiersdorfer, RN BSN. Duke University School of Medicine, University Hospital, University of North Carolina, Duke Regional Hospital, and WakeMed Health & Hospitals (UG1 HD40492, UL1 TR1117) – C. Michael Cotten, MD MHS; Ronald N. Goldberg, MD; William F. Malcolm, MD; Patricia L. Ashley, MD; Deesha Mago-Shah, MD; Mollie Warren, MD; Joanne Propst, RN JD; Kimberley A. Fisher, PhD FNP-BC IBCLC; Matthew M. Laughon, MD MPH; Carl L. Bose, MD; Janice Bernhardt, MS RN; Gennie Bose, RN; Janice Wereszczak, CPNP-AC/PC; Andrea Trembath, MD MPH; Jennifer Talbert, MS RN; Stephen D. Kicklighter, MD; Ryan Moore, MD; Alexandra Bentley, MD; Laura Edwards, MD; Ginger Rhodes-Ryan, ARNP MSN, NNP-BC; Donna White, RN-BC BSN. Emory University, Children’s Healthcare of Atlanta, Grady Memorial Hospital, and Emory University Hospital Midtown (UG1 HD27851, UL1 TR454) – Ravi M. Patel, MD MSc; David P. Carlton, MD; Brenda B. Poindexter, MD MS; Nathalie L. Maitre, MD PhD; Ira Adams-Chapman, MD (deceased); Yvonne Loggins, RN; Diane Bottcher, RN; Sheena L. Carter, PhD; Salathiel Kendrick-Allwood, MD; Maureen Mulligan LaRossa, RN; Judith Laursen, RN; Colleen Mackie, RRT; Amy Sanders, PsyD; Gloria Smikle, PNP; Lynn Wineski, NNP. Eunice Kennedy Shriver National Institute of Child Health and Human Development – Michele C. Walsh, MD MS; Andrew A. Bremer, MD PhD; Rosemary D. Higgins, MD; Stephanie Wilson Archer, MA. Indiana University, University Hospital, Methodist Hospital, Riley Hospital for Children, and Wishard Health Services (UG1 HD27856, UL1 TR6) – Gregory M. Sokol, MD; Brenda B. Poindexter, MD MS; Lu Ann Papile, MD; Heidi Harmon, MD MS; Dianne E. Herron, RN CCRC; Abbey C. Hines, PsyD; Carolyn Lytle, MD MPH; Lucy Smiley, CCRC; Leslie Dawn Wilson, BSN CCRC; Donna Watkins, MSN NNP-BC; Susan Gunn, NNP-BC CCRC; Jeff Joyce, CCRC (deceased). McGovern Medical School at The University of Texas Health Science Center at Houston, Children’s Memorial Hermann Hospital, and Memorial Hermann Southwest Hospital (U10 HD21373, UG1 HD87229) – Jon E. Tyson, MD MPH; Amir M. Khan, MD; Kathleen A. Kennedy, MD MPH; Barbara J. Stoll, MD; Ricardo A. Mosquera, MD MS; Andrea F. Duncan, MD MS; Nora I. Alaniz, BS; Elizabeth Allain, PhD; Julie Arldt-McAlister, MSN APRN; Fatima Boricha, MD; Allison G. Dempsey, PhD; Elizabeth Eason, MD; Carmen Garcia, RN BSN; Donna J. Hall, RN; Janice John, CPNP; Karen Martin, RN; Georgia E. McDavid, RN; Shannon L. McKee, EdS; Kimberly Rennie, PhD; Tina Reddy, MD; Debasree Sana Boral, BS IMG; Daniel K. Sperry, RN; Emily Stephens, BSN RNC-NIC; Michelle White, BSN RNC-NIC; Sharon L. Wright, MT (ASCP), Dinorah Zanger, PhD. Nationwide Children’s Hospital, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Perinatal Research, The Ohio State University College of Medicine, The Ohio State University Wexner Medical Center, and Riverside Methodist Hospital (UG1 HD68278) – Pablo J. Sánchez, MD; Leif D. Nelin, MD; Jonathan L. Slaughter, MD MPH; Sudarshan R. Jadcherla, MD; Nathalie L. Maitre, MD PhD; Christopher Timan, MD; Omid Fathi, MD; Keith O. Yeates, MD PhD; Patricia Luzader, RN; Julie Gutentag, RN BSN; Jennifer L. Grothause, BA RN BSN; Melanie Stein, RRT BBS; Rox Ann Sullivan, RN BSN; Cole D. Hague, BA MS; Helen Carey, PT DHSc PCS; Michelle Chao, BS; Stephanie Burkhardt, BS MPH; Margaret Sullivan, BS; Lina Yossef-Salameh, MD; Mary Ann Nelin, MD; Erna Clark, BA; Julie C. Shadd, BSN RD; Courtney Park, RN BSN; Courtney Cira, BS; Erin Fearns; Kristi Small, BS; Sarah A. Keim, PhD MA MS; Christine A. Fortney, RN PhD; Aubrey Fowler, BS, Jacqueline McCool; Lindsay Pietruszewski, PT DPT; Jessica Purnell, BS CCRC; Kyrstin Warnimont, BS; Laura Marzec, MD; Bethany Miller, RN BSN; Demi R. Beckford, MHS; Hallie Baugher, BS MSN; Julia Newton, MPH; Katelyn Levengood, PT DPT; Nancy Batterson, OT/L; Brittany DeSantis, BS. RTI International (UG1 HD36790) – Carla M. Bann, PhD; Jeanette O’Donnell Auman, BS; Margaret M. Crawford, BS; Jenna Gabrio, BS MPH; Jamie E. Newman, PhD MPH; Lindsay Parlberg, BS; Carolyn M. Petrie Huitema, MS; Kristin M. Zaterka-Baxter, RN BSN; David C. Leblond, BS; Anna Mazur, BA; Annie M. Bayard, BS; Amanda Lewis. Stanford University, El Camino Hospital, and Lucile Packard Children’s Hospital (UG1 HD27880, UL1 TR93) – Krisa P. Van Meurs, MD; David K. Stevenson, MD; M. Bethany Ball, BS CCRC; Valerie Y. Chock, MD MS Epi; Marian M. Adams, MD; Alexis S. Davis, MD MS Epi; Dona Bahmani, CRC; Barbara Recine, MA; Lilia Rutkowska, MA; Barbara Bentley, PsychD MSEd; Maria Elena DeAnda, PhD; Anne M. DeBattista, RN PNP PhD; Beth Earhart, PhD; Lynne C. Huffman, MD; Casey E. Krueger, PhD; Ryan E. Lucash, PhD; Melinda S. Proud, RCP; Elizabeth N. Reichert, MA CCRC; Heather Taylor, PhD; Hali E. Weiss, MD; R. Jordan Williams, MD. Tufts Medical Center (U10 HD53119) – Ivan D. Frantz III, MD; John M. Fiascone, MD; Brenda L. MacKinnon, RNC; Anne Furey, MPH; Ellen Nylen, RN BSN; Paige T. Church, MD. University of Alabama at Birmingham Health System and Children’s Hospital of Alabama (UG1 HD34216) – Namasivayam Ambalavanan, MD; Myriam Peralta-Carcelen, MD MPH; Fred J. Biasini, PhD; Monica V. Collins, RN BSN MaEd; Shirley S. Cosby, RN BSN; Kristy A. Domnanovich, PhD; Chantel J. Jno-Finn, PT DPT; Morissa Ladinsky, MD; Tara E. McNair, RN BSN; Vivien A. Phillips, RN BSN; Kimberlly Stringer, MD MPH; Sally Whitley, MA OTR-L FAOTA; Sheree York Chapman, PT DPT PCS. University of California - Los Angeles, Mattel Children’s Hospital, Santa Monica Hospital, Los Robles Hospital and Medical Center, and Olive View Medical Center (UG1 HD68270) – Uday Devaskar, MD; Meena Garg, MD; Isabell B. Purdy, PhD CPNP; Teresa Chanlaw, MPH; Rachel Geller, RN BSN. University of Iowa, Mercy Medical Center, and Sanford Health (UG1 HD53109, UL1 TR442) – Edward F. Bell, MD; Tarah T. Colaizy, MD MPH; Jane E. Brumbaugh, MD; Heidi M. Harmon, MD; Michelle L. Baack, MD; Karen J. Johnson, RN BSN; Mendi L. Schmelzel, RN MSN; Jacky R. Walker, RN; Claire A. Goeke, RN; Diane L. Eastman, RN CPNP MA; Michelle L. Baack, MD; Laurie A. Hogden, MD; Megan M. Henning, RN; Chelsey Elenkiwich, BSN RN; Megan Broadbent, RN BSN; Sarah Van Muyden, RN BSN; Dan L. Ellsbury, MD; Tracy L. Tud, RN. University of New Mexico Health Sciences Center (UG1 HD53089, UL1 TR41) – Janell Fuller, MD; Kristi L. Watterberg, MD; Robin K. Ohls, MD; Conra Backstrom Lacy, RN; Carol Hartenberger, BSN MPH; Sandra Sundquist Beauman, MSN RNC-NIC; Mary Ruffner Hanson, RN BSN; Jean R. Lowe, PhD; Elizabeth Kuan, RN BSN. University of Pennsylvania, Hospital of the University of Pennsylvania, Pennsylvania Hospital, Children’s Hospital of Philadelphia, and Virtua Voorhees Hospital (UG1 HD68244) – Eric C. Eichenwald, MD; Haresh Kirpalani, MB MSc; Karen M. Puopolo, MD PhD; Andrea F. Duncan, MD MSClinRes; Soraya Abbasi, MD; Aasma S. Chaudhary, BS RRT; Dara M. Cucinotta, RN; Judy C. Bernbaum, MD; Marsha Gerdes, PhD; Sarvin Ghavam, MD; Hallam Hurt, MD; Jonathan Snyder, RN BSN, Kristina Ziolkowski, CMA(AAMA) CCRP. University of Rochester Medical Center, Golisano Children’s Hospital, and the University of Buffalo Women’s and Children’s Hospital of Buffalo (UG1 HD68263, UL1 TR42) – Carl T. D’Angio, MD; Ronnie Guillet, MD PhD; Satyan Lakshminrusimha, MD; Gary J. Myers, MD; Anne Marie Reynolds, MD; Holly I.M. Wadkins; Michael G. Sacilowski, BS; Rosemary L. Jensen; Joan Merzbach, LMSW; William Zorn, PhD; Osman Farooq, MD; Stephanie Guilford, BS; Kelley Yost, PhD; Mary Rowan, RN; Diane Prinzing; Ann Marie Scorsone, MS CCRC; Michelle Hartley-McAndrew, MD; Kyle Binion, BS; Constance Orme; Premini Sabaratnam, MPH; Alison Kent, BMBS FRACP MD; Brenna Cavanaugh, PsyD BCBA-D; Rachel Jones; Elizabeth Boylin, BA; Daisy Rochez, BS MHA; Emily Li, BA; Jennifer Kachelmeyer, BS; Kimberly G. McKee, BS; Kelly R. Coleman, PsyD; Deanna Maffett, RN; Julieanne Hunn, BS; Melissa Bowman, RN; Ashley Williams, MS Ed; Cait Fallone, MA. University of Texas Southwestern Medical Center, Parkland Health & Hospital System, and Children’s Medical Center Dallas (UG1 HD40689) – Luc P. Brion, MD; Roy J. Heyne, MD; Diana M. Vasil, MSN BSN RNC-NIC; Maria M. De Leon, RN BSN; Frances Eubanks, RN BSN; E. Lara Pavageau, MD; Pollieanna Sepulveda, RN; Sally S. Adams, MS RN CPNP; Alicia Guzman; Elizabeth Heyne, MS MA PA-C, PsyD; Lizette E. Lee, RN; Rebecca McDougald, MSN APRN CPNP-PC/AC; Anna Puentez, MSN RN CPNP-PC; Azucena Vera, AS; Jillian Waterbury, DNP RN CPNP-PC; Cathy Twell Boatman, MS CIMI; Kristine Tolentino-Plata, MS PhD. University of Utah Medical Center, Intermountain Medical Center, McKay-Dee Hospital, Utah Valley Hospital, and Primary Children’s Medical Center (UG1 HD87226, UL1 TR105) – Robin K. Ohls, MD; Bradley A. Yoder, MD; Mariana Baserga, MD MSCI; Roger G. Faix, MD; Sarah Winter, MD; Stephen D. Minton, MD; Mark J. Sheffield, MD; Erick B. Gerday, MD; Laura Cole Bledsoe, RN; Kathleen Coleman, RN; Barbara L. Francom, BSN RN; Brixen A. Reich, RN MSN; Carrie A. Rau, RN BSN CCRC; Shawna Baker, RN; Jill Burnett, RNC BSN; Susan Christensen, RN; Sean D. Cunningham, PhD; Brandy Davis, RN BSN; Jennifer O. Elmont, RN BSN; Becky Hall, APRN; Erika R. Jensen, APRN; Jamie Jordan, RN BSN; Manndi C. Loertscher, BS CCRP; Trisha Marchant, RNC BSN; Earl Maxson, RN CCRN; Kandace M. McGrath, BS; Hena G. Mickelsen, BA; Galina Morshedzadeh, BSN APRN; D. Melody Parry, RN BSN; Susan T. Schaefer, RN BSN RRT; Kelly Stout, PhD; Ashley L. Stuart, PhD; Katherine Tice, RN BSN; Kimberlee Weaver-Lewis, RN MS; Kathryn D. Woodbury, RN BSN. Wayne State University, Hutzel Women’s Hospital, Children’s Hospital of Michigan (UG1 HD21385) and University of Michigan Ann Arbor – Seetha Shankaran, MD; Beena G. Sood, MD MS; Athina Pappas, MD; Girija Natarajan, MD; Sanjay Chawla, MD; Monika Bajaj, MD; Prashant Agarwal, MD; Jeanette Prentice, MD; Melissa February, MD; Lilia De Jesus, MD; Gerry Muran, RN; Rebecca Bara, RN BSN; Kirsten Childs, RN BSN; Bogdan Panaitescu, MD; Eunice Woldt, RN MSN; Mary E. Johnson, RN BSN; Laura A. Goldston, MA; Stephanie A. Wiggins, MS; Mary K. Christensen, BA RRT; Diane F. White, RN MSN; Martha Carlson, MD; John Barks, MD. Yale University, Yale-New Haven Children’s Hospital, and Bridgeport Hospital (U10 HD27871, UL1 TR142) – Richard A. Ehrenkranz, MD (deceased); Harris Jacobs, MD; Christine G. Butler, MD; Patricia Cervone, RN; Sheila Greisman, RN; Monica Konstantino, RN BSN; JoAnn Poulsen, RN; Janet Taft, RN BSN; Joanne Williams, RN BSN; Elaine Romano, MSN.
FUNDING
The National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (U10 HD27871, U10 HD53119, UG1 HD21364, UG1 HD21373, UG1 HD21385, UG1 HD27851, UG1 HD27853, UG1 HD27856, UG1 HD27880,UG1 HD27904, UG1 HD34216, UG1 HD36790, UG1 HD40492, UG1 HD40689, UG1 HD53089, UG1 HD53109, UG1 HD68244, UG1 HD68270, UG1 HD68278, UG1 HD68263, UG1 HD68284, UG1 HD87226, UG1 HD87229) and the National Center for Advancing Translational Sciences (NCATS) (UL1 TR6, UL1 TR41, UL1 TR42, UL1 TR77, UL1 TR93, UL1 TR442, UL1 TR454, UL1 TR1117) provided grant support through cooperative agreements for the Neonatal Research Network. NICHD staff provided input into the study design, conduct, analysis, and manuscript drafting; NCRR and NCATS cooperative agreements provided infrastructure support to the NRN.
Footnotes
COMPETING INTERESTS
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The institutional review board at each participating hospital approved data collection. Waiver of parental consent was granted for inpatient data collection for all but 5 hospitals. Most hospitals required parental consent for participation in the follow-up study, but 5 hospitals allowed participation under waiver.
DATA AVAILABILITY
Data reported in this paper may be requested through a data use agreement. Further details are available at https://neonatal.rti.org/index.cfm?fuseaction=DataRequest.Home.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data reported in this paper may be requested through a data use agreement. Further details are available at https://neonatal.rti.org/index.cfm?fuseaction=DataRequest.Home.