Understanding the adverse impact of centralised care on neonatal outcomes

Shipley, Lara (2021) Understanding the adverse impact of centralised care on neonatal outcomes. PhD thesis, University of Nottingham.

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Centralisation of neonatal intensive care has led to a reduction in mortality, but this has not translated into significant improvements in neurodisability. Understanding the factors contributing to adverse neurological outcomes in infants, especially those transported due to centralised care, could aid the reduction of long-term morbidity in these infants. Centralised care can also risk maternal-infant separation and result in a greater risk of additional stress on the parents of these infants. The aims of my thesis were to: 1) explore the current trends of in-utero transfer (IUT) and early postnatal transportation (PNT) in extremely preterm infants within the UK, 2) evaluate the relationship between early PNT of high-risk infants and severe intraventricular haemorrhage (IVH), 3) quantify the potential stressors for families of extremely preterm infants who undergo centralised care, 4) determine the UK prevalence and treatment of infants with hypoxic-ischaemic encephalopathy (HIE), and 5) explore the effects of whole body vibration (WBV), as experienced during neonatal transportation, on the developing brain.

The prevalence of early PNT has increased over time, which is likely a reflection of a reduction in IUTs and an increase in inter-hospital transfers due to a lack of cot capacity. Early PNT of extremely preterm infants is associated with an increased risk of severe IVH in the first week of life. Centralised intensive care may also have a negative impact on their parents due to the substantial time and distance their baby spends away from their booking hospital. This burden could be further exacerbated as almost half of infants who die are away from their booking hospital and therefore potentially their parents’ support network.

HIE is the leading cause of brain injury in the UK and there is an increasing number of infants being managed with therapeutic hypothermia (TH) outside of evidence-based guidance. Almost half of these infants with HIE are born in non-cooling centres without immediate access to TH. Birth in a non-cooling centre is associated with reduced risk of survival without seizures, driven mainly by an increase in seizures.

The transportation pathway exposes both preterm infants and those with HIE to excessive WBV. In a new animal model, short-term WBV exposure results in neuroinflammation, cellular stress and apoptosis in the cortex of the developing brain. The effect of this insult appears to be both more profound in the immature brain and to be dose dependent, potentially indicating a role in the excess brain injury observed in PNT high-risk infants.

In conclusion, centralised neonatal care is associated with a recent increase in early PNT of high-risk infants and adverse neurological outcomes. This could, in part, be a consequence of exposure to excessive WBV during PNT. The additional stress related factors generated by this care pathway could contribute to poor mental health in the parents of these infants. Understanding the factors contributing to these adverse outcomes may help prevent harm and ultimately reduce the hidden burden associated with centralised care on high-risk infants and their families.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Sharkey, Don
Farr, Tracey
Dorling, Jon
Keywords: preterm; neonate; intraventricular haemorrhage; hypoxic ischaemic encephalopathy; transport
Subjects: W Medicine and related subjects (NLM Classification) > WS Pediatrics
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 64483
Depositing User: Shipley, Lara
Date Deposited: 31 Jul 2021 04:40
Last Modified: 31 Jul 2021 04:40
URI: http://eprints.nottingham.ac.uk/id/eprint/64483

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