Survival in Very Preterm Infants: an International Comparison of 10 National Neonatal Networks

Survival in Very Preterm Infants: Kjell Helenius, MD,a,b Gunnar Sjörs, MD,c Prakesh S. Shah, MD, Msc,d, e Neena Modi, MD,f Brian Reichman, MBChB,g Naho Morisaki,An MD,International PhD,h Satoshi Kusuda, MD,i Kei Lui, MD, jComparison Brian A. Darlow, MD,k Dirk Bassler, MD, of MSc,l Stellan Håkansson, MD,c Mark Adams, MSc,l Maximo Vento, MD, PhD,m Franca Rusconi, MD,n Tetsuya Isayama, MD,e Shoo K. Lee, MBBS, 10PhD,d, e Liisa National Lehtonen, MD,a, b on behalf Neonatal of the International Network Networks for Evaluating Outcomes (iNeo) of Neonates

OBJECTIVES: abstract

To compare survival rates and age at death among very preterm infants in 10 METHODS: national and regional neonatal networks. ’ A cohort study of very preterm infants, born between 24 and 29 weeks gestation and weighing <1500 g, admitted to participating neonatal units between 2007 and 2013 in the International Network for Evaluating Outcomes of Neonates. Survival was compared by using standardized ratios (SRs) comparing survival in each network to the survival RESULTS: estimate of the whole population. Network populations differed with respect to rates of cesarean birth, exposure – to antenatal steroids and birth in nontertiary hospitals. Network SRs for survival were – highest in Japan (SR: 1.10; 99% confidence interval: 1.08 1.13) and lowest in Spain (SR: ’ – 0.88; 99% confidence interval: 0.85 0.90). The overall survival differed from 78% to 93% among networks, the difference being highest at 24 weeks gestation (range 35% 84%). – ’ Survival rates increased and differences between networks diminished with increasing gestational age (GA) (range 92% 98% at 29 weeks gestation); yet, relative differences in survival followed a similar pattern at all GAs. The median age at death varied from 4 days CONCLUSIONS: to 13 days across networks. The network ranking of survival rates for very preterm infants remained largely unchanged as GA increased; however, survival rates showed marked variations at lower GAs. The median age at death also varied among networks. These findings warrant further assessment of the representativeness of the study populations, organization of perinatal services, national guidelines, philosophy of care at extreme GAs, and resources used for decision-making.

What’s Known on This Subject: Survival rates of aDepartment of Pediatrics and Adolescent Medicine, Turku University Hospital, Kiinamyllynkatu, Turku, Finland; very preterm infants vary among regions. International bDepartment of Clinical Medicine, University of Turku, Turku, Finland; cNational Quality Registry for Neonatal collaborations have been established to compare Care, Department of Pediatrics/Neonatal Services, University Hospital of Umeå, Umeå, Sweden; dDepartment of Pediatrics, University of Toronto, Toronto, Ontario, Canada; eMaternal-Infant Care Research Centre, outcomes, but population-based comparisons have and Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; fUnited Kingdom Neonatal been difficult to accomplish. Collaborative, Neonatal Data Analysis Unit, and Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom; gGertner Institute for Epidemiology What This Study Adds: This study shows variations in and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel; hDepartment of Social Medicine, survival and age at death among very preterm infants National Center for Child Health and Development, Tokyo, Japan iMaternal and Perinatal Center, Tokyo Women’s in 10 national neonatal networks and provides insight Medical University, Tokyo, Japan; jRoyal Hospital for Women, and National Perinatal Epidemiology and Statistics into differences that affect comparisons. The findings k Unit, University of New South Wales, Randwick, Australia; Department of Pediatrics, University of Otago, warrant investigation of the organization of perinatal Christchurch, New Zealand; lDepartment of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; mHealth Research Institute La Fe, Avenida Fernando Abril Martorell, Valencia, Spain; and nTIN care in participating networks. Toscane Online, Unit of Epidemiology, Meyer Children’s University Hospital, Florence, Italy and Regional Health Agency of Tuscany, Florence, Italy To cite: Helenius K, Sjörs G, Shah PS, et al. Survival in Very Preterm Infants: An International Comparison of 10 National Neonatal Networks. Pediatrics. 2017;140(6):e20171264

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Preterm birth remains the major Population and Study Design however, a number of neonatal units cause of infant mortality1 in high- have not consented for participation income countries. Studies published in iNeo. Covariates in the last decade have shown ’ This cohort study included infants variability in survival rates and – born at 24 to 29 weeks gestation, outcomes among health care settings 2 12 weighing <1500 g at birth, and as well as within countries. ‍‍ GA was determined by the best registered in participating network Results from the Euro-Peristat – – estimate based on either early databases from 2007 to 2013 project showed that neonatal ultrasound, the timing of the last (2008 2013 for UKNC, 2009 2013 survival among very preterm infants menstrual period, or physical for TuscanNN). The criterion of 1500 g improved by 29% between 2004 examination after birth, in that order. was used because some networks and 2010 in 18 European countries, Antenatal steroid use was defined as limited their data collection to including those with high baseline maternal receipt of antenatal steroids 13 infants with a birth weight <1500 g. z survival. Such comparisons of at any time before birth. Birth weight Stillborn infants and delivery room different health care organizations scores were calculated according to deaths were not included because – worldwide can deliver important birth weight references appropriate all networks do not routinely collect 15 17 benchmarking information and for each country. ‍ ‍ Mode of data on these infants. Because potentially provide impetus for delivery was recorded as vaginal or of variability in practices and reviewing clinical practices, norms, ’ cesarean. Multiple births included philosophy of care provision at and guidelines. ≥ ’ twins and higher-order multiples. <24 weeks GA, we only included Outcomes The International Network for neonates born at 24 weeks gestation. Infants admitted for the Evaluating Outcomes of Neonates ’ (iNeo) is a nonprofit collaboration first time to neonatal care after 36 The primary outcome was survival among 10 national and regional weeks corrected GA were excluded. to discharge from the hospital for neonatal networks: the Australian Data on infant characteristics infants admitted to neonatal care. and New Zealand Neonatal Network and outcomes were extracted, as 14 Survival to transfer to a step-down (ANZNN), the Canadian Neonatal previously described. Transferred hospital was used when follow-up Network (CNN), the Finnish Medical infants were included only once. was available only until the transfer. Birth Register (FinMBR), the Israel Population coverage of networks We analyzed survival in 1-week GA Neonatal Network (INN), Neonatal deviate from national birth statistics increments. As a secondary outcome, Research Network Japan (NRNJ), ’ for various reasons. All neonatal we compared postnatal age at death the Spanish Neonatal Network units in Finland, New Zealand, and among nonsurvivors. Neonatal (SEN1500), Sweden s National Tuscany participate in their national morbidities among iNeo survivors Quality Registry for Neonatal Care 18 and regional neonatal networks; have been recently published. (SNQ), the Swiss Neonatal Network Data Management however, in Australia, apart from (SwissNeoNet), Tuscany Neonatal all tertiary neonatal units, only a Network (TuscanNN), and the United few lower-level units participate in Kingdom Neonatal Collaborative the ANZNN. In Canada, only tertiary For most networks, defined data (UKNC). The overarching aim of the neonatal units participate in the elements were either collected iNeo collaboration is to compare CNN. In Israel, all neonatal units from patient records by designated outcomes of very preterm infants, participate, but infants with a birth abstractors according to network understand reasons for variations, weight >1500 g are not included. policies or entered directly and, if possible, identify areas for In Japan and Spain, not all neonatal into a central online database improvement in care practices based 14 units participate in the national by participating units. For the on findings. networks. In Sweden, all neonatal UKNC, data were obtained from å By using the iNeo data set, the units presently participate in the the National Neonatal Research objective of this study was to SNQ; however, the Sk ne region is Database managed by the Neonatal compare gestational age (GA)-specific not included in this study because Data Analysis Unit, which contains survival rates for very preterm it joined in 2011. In Switzerland, all a predefined extract from electronic infants in all neonatal networks tertiary and large secondary (level patient records used in UK neonatal currently participating in the iNeo IIB) neonatal units participate in units. Finnish data were collected partnership and to explore variations SwissNeoNet. In the United Kingdom, from the Medical Birth Register kept in postnatal age at death among the all neonatal units in England, Wales, at the National Institute for Health very preterm population. and Scotland participate in the UKNC; and Welfare. 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Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics Statistical Analyses Results – – 99% CI: 1.08 1.13) and lower in ’ INN (SR: 0.91; 99% CI: 0.87 0.95) A total of 91835 infants born – Background characteristics of infants and SEN1500 (SR: 0.88; 99%: CI χ between 24 and 29 weeks gestation 0.85 0.90) and overlapped with the were2 compared by using the Pearson were identified in the iNeo database – 99% CI in ANZNN (SR: 1.01; 99% CI: test for categorical variables and during the study period. After – N 0.99 1.04), CNN (SR: 1.01; 99% CI: the analysis of variance F test for excluding infants with a birth weight – 0.99 1.04), FinMBR (SR: 1.01; 99% continuous variables. Standardized >1500 g ( = 3070) and infants – ’ N CI: 0.94 1.08), SNQ (SR: 1.03; 99% ratios (SRs) were computed by admitted to neonatal care after 36 – CI: 0.98 1.08), SwissNeoNet (SR: using the indirect standardization weeks corrected GA ( = 438), – 0.99; 99% CI: 0.94 1.04), TuscanNN approach. The pooled estimate of the final population consisted of – (SR: 0.95; 99% CI: 0.85 1.05), and survival for the whole population was 88327 infants. The variations in UKNC (SR: 0.99; 99% CI: 0.97 1.01) used as a standard. Each network was care provision and organization (Fig 2). Pairwise comparisons then compared with this standard, of care among the networks are among networks are presented in computed as the sum of predicted provided in Table 1, as reported Supplemental Table 5. probabilities from a multivariable by network directors. Table 2 Age at Death logistic zregression model with describes characteristics of infants

adjustment for GA (linear), birth in each participating network. weight score (linear and quadratic), The population coverage of iNeo A total of 11155 infants did not

multiple births, and sex. SR estimates networks compared with national survive to discharge. Age at death were displayed graphically to identify birth statistics ranged from 61% in was available for 10839 (97%) countries with survival rates greater Japan (NRNJ) to 100% in Sweden neonates, which is presented as a than and less than the average rate (SNQ), Switzerland (SwissNeoNet), function of postnatal age in Fig 3 and of all others with 99% confidence and Tuscany (TuscanNN). Infant Supplemental Fig 4. Median age at intervals (CIs). Because the SR characteristics (including exposure death for the entire population was 8 estimate is calculated in relation to antenatal steroids, cesarean birth, days, varying from 4 days to 13 days to all other networks combined, it and birth in a nontertiary hospital) in the FinMBR and NRNJ, respectively is not directly comparable among were markedly different among (Table 4). Among deaths, 14.6% networks. No adjustment was made Snetworks.urvival occurred before 24 hours of age for the administration of antenatal (6.9% TuscanNN, 26.8% FinMBR),

steroids, cesarean birth, or birth in 29.7% at 1 to 6 days of age (23.8% a nontertiary hospital because these Of the 88327 included infants, 77172 NRNJ, 44.4% SwissNeoNet), 32.1% at are practice-related elements, and (87%) survived to discharge. Overall 7 to 27 days of age (21.6% FinMBR, adjustment of these variables can survival rates varied from 78% in 37.3% TuscanNN), and 23.6% after lead to biased estimates in favor of SEN1500 to 93% in NRNJ (Table 3). 28 days of age (14.4% SwissNeoNet, underperforming systems. Missing The differences in percentage points 32.7% NRNJ). Overall, the median data were not imputed. All statistical between networks with the lowest postnatal age at death for the entire ’ analyses and plots were conducted and highest survival rates were population remained stable at 8 days by using SAS version 9.3 (SAS 49% at 24 weeks gestation (INN to 9 days over the study duration. Institute Inc, Cary, NC) or R version 35%, NRNJ 84%), 32% at 25 weeks Discussion 2.2. (INN 57%, NRNJ 89%), 20% at 26 Research Ethics Approval weeks (73% SEN1500, 93% NRNJ), 12% at 27 weeks (82% SEN1500, In this large, multinational study, we 94% NRNJ), 8% at 28 weeks (89% identified significant differences in SEN1500, 97% NRNJ), and 6% at ’ All iNeo collaborators hold relevant the survival of very preterm infants, 29 weeks (92% SEN1500, 98% research ethics approvals for their particularly at 24 to 27 weeks SwissNeoNet). Survival increased data collection. Separate data sharing gestation. Survival increased and as GA increased in all networks. agreements were obtained from differences in survival between Internetwork ranking of the survival the executive committees of each networks decreased with increasing rate followed a similar pattern at all network and the iNeo Coordinating GA, whereas internetwork ranking GAs. The GA-specific survival rates Center in Toronto, Canada. Ethics of survival remained relatively are presented graphically in Fig 1. approval for the iNeo collaboration unchanged at each gestation. was obtained from the Research Estimated SRs comparing survival in The median postnatal age at death Ethics Board at Mount Sinai Hospital each network to all other networks ranged from 4 days to 13 days in Toronto, Canada. were higher in NRNJ (SR: 1.10; within networks. Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 140, number 6, December 2017 3

— — 470 300 The iNeo networks reached survival Total 410 ranging from 78% to 93% in the very preterm infant population. Other international studies have c 000 3

49 shown similar survival rates: KNC 131 ’ U 77% to 91% for infants born at 22 to 31 weeks gestation in the

b European Health Care Outcomes, – 000 690 7 Performance and Efficiency (study 24 9 ’ Eunicein 2006 Kennedy2008, Shriver83% for infants born at 24 to 28 weeks gestation in the National 000 30

9 Institute of Child Health and Human

12 – Development Neonatal Research SwissNeoNet TuscanNN Network (NICHD NRN) in 2008 2 ’ 2012, and 74% to 94% for infants

a born at 24 to 29 weeks gestation in 000 80 7

28 100% 99.7% 100% 73.5% 75.6% the Effective Perinatal Intensive Care19 in Europe (EPICE) study in 2011. The European Health Care Outcomes, e

000 90 Performance and Efficiency study can

61 50 also be used to validate our ranking order related to 3 countries because the ranking order of Sweden, Finland, 000 480

and Italy was the same in both 73 93 080

studies. Some differences have to be noted in the study designs, such as the 000 1

27 23 inclusion of delivery room deaths and limitation to tertiary hospitals in the NICHD NRN. The EPICE study also included stillborn infants 000 160 5 and delivery room deaths, but the 30 proportion of live-born infants

ticipating in the iNeo could be extracted from their data. Including nontertiary hospitals is 000 60 likely to decrease overall survival 28 28 rates, but excluding delivery room deaths is likely to overestimate survival. 000 380

56 29 No Partial Yes Yes Yes Yes Yes Yes Yes Partial Yes No Yes Yes No Yes YesInternetwork Yes differences Yes in survival Yes 92.5% 92.5% 99.1% 95.0% 61.1% 76.1% ANZNN CNN Fin MBR INN NRNJ SEN1500 SNQ

360 ’ were largest among infants born at 24 weeks gestation and decreased with increasing GA. However, networks with the lowest survival rates among 24-week infants

b continued to display low survival rates in relation to the other

d networks at almost all4 GA groups. Characteristics of the 10 National Neonatal Networks Par Similarly, Berger et al reported that 1 included in iNeo country or region database included compared with national birth statistics among Swiss university hospitals, nits from which data are Approximate no. of births per year U Tertiary neonatal units in the Delivery room deaths included in Data from step-down units Proportion of infants in network 2009 – 2013. Proportion numbers in national birth of infants born at 24 – 29 weeks ’ gestation in each network compared with corresponding statistics. Sweden, excluding the Sk å ne region. Of all infants born at <28 weeks ’ GA. 2008 – 2013. TABLE — , not applicable. a b c d e survival differences were most ’ pronounced among infants born at 23 to 25 weeks gestation, and the Downloaded from www.aappublications.org/news by guest on September 23, 2021 4 Helenius et al

[2151] [2425]

Total interunit rank remained consistent 188 (27.4) 249 (63.7) 256 (78.4) 327 (96.2) 402 (53.7)

6485 (9.5) − 0.11 (0.93) 56 24 69 47 for more mature infants. We do not have detailed data for an in-depth

c explanation of these differences, but [7] [9] 951 91

KNC [1725] [1018] in addition to variable population U 20 585 (83.0) 975 (95.3) 88 740 (53.8) applicable

5305 (26.6) coverage, they may be related to − 0.18 (0.93) 16 19 10 organizational factors, such as b regionalization, staffing, philosophy [1] [5] of care provision, willingness to 607 (86.1) 363 (51.5) 0.07 (0.97) offer palliative care, and withdrawal

of intensive20, support21 and other resources. ‍ Furthermore, it is [1] [42] well recognized that the approach 127 (4.7) 115 (16.3) Not

1401 (52.4) to active care largely explains − 0.17 (0.82) SwissNeoNet TuscanNN differences in survival7, in22 infants at extremely low GAs. We only a ’ [2] [13] included infants born at 24 to 29 3346 2775 737 2616 (83.7) 2400 (89.7) 3124 (93.4) 2675 (96.4) 705 (95.7) weeks gestation, assuming that − 0.12 (0.86) participating neonatal units would provide active care to these neonates. 695

[170] It has been suggested by researchers 226 (95.6)

6592 (64.5) 2159 (69.1) 2146 (80.2) 492 (69.8) 9903 (49.6) 8700 (85.1) 5461 (53.4) 1697 (54.3) in other studies that adopting a more − 0.08 (0.98) active approach to extremely– low GAs

also results in increased23 25 survival in [8] 431 10

[262] [556] higher-GA groups. ‍ ‍ 18 132 (76.7) 421 (99.9) 10

9901 (53.7) − 0.17 (0.99) 14 18 The nonsurvivors died later (median of 8 days) in our study

[3] compared with those in the NICHD

NRN (median26 of 3 days) from 2008 3877 (71.3) 4098 (75.3) − 0.10 (0.83) to 2011. However, it must be acknowledged that the infants in

[4] the NICHD NRN study were more [17] 1728 5441

79 (4.8) 63(1.2) 1193 (6.5) 562 (5.5) 321 (10.3) immature (median GA of 25.7 weeks27 484 (29.6) 2133 (39.2) 3809 (20.7) 3071 (30.0) 898 (28.7) 802 (30.0) 222 (31.5) 862 (52.8) 2952(54.3) 9877 (53.6) 1144 (70.1) 1537 (94.1) 1633 (94.5) 5441 (100) − 0.18 (0.91) for all live births). Mohamed et al found a significant increase in the

[9] mean age at death (from 6.6 days to 688 [96] [16] [22]

[429] 994 (85.3) 888 (94.2)

8.7 days) in very low birth weight 3706 (28.8) 7703 (59.8) 6985 (54.2) − 0.09 (0.83) 10 infants in a large, national sample in the United States between 1997 and – 29 Weeks ’ Gestation, Birth Weight <1500 g) Born Between 2007 and 2013 Admitted to Neonatal Care in iNeo Contributing Networks

[9] 2004. They also showed that infants 043 13 [11] [61]

[185] 14 ANZNN CNN FinMBR INN NRNJ SEN1500 SNQ 818 (89.3) 239 (94.3) 12 26 (0.2) 83 (0.6) 0 (0) 0 (0) 5 (0.03) 321 (3.0) 0 (0) 3 (0.1) 0 (0) 0 (0) 438 (0.5)

with a birth weight of <500 g died 778 (5.5) 717 (5.2) 95 (5.5) 0 (0) 5 (0.03) 148 (1.4) 222 (6.6) 97 (3.5) 32 (4.3) 976 (4.7) 3070 (3.3) 27.0 (1.6) 26.9 (1.6) 27.0 (1.6) 27.0 (1.6) 26.9 (1.7) 27.1 (1.6) 27.0 (1.6) 27.1 (1.6) 27.0 (1.7) 27.0 (1.6) 27.0 (1.6) 993 (251) 986 (246) 980 (259) 972 (247) 927 (256) 978 (247) 986 (256) 961 (254) 940 (257) 976 (243) 969 (251) 1229 (9.3) 1191 (9.2) 156 (9.6) 482 (8.9) 2082 (11.3) 866 (8.5) 292 (9.3) 186 (7.0) 94 (13.3) 2053 (10.3) 8631 (9.8) 0.01 (0.95) 1791 (13.5) 2234 (17.3) 11 13 earlier than others.

d Finally, we also identified differences

d in the age at death of nonsurvivors [missing d d

th weight among the iNeo networks. The [missing data] 8101 (61.2) [missing data] 3758 (28.4)

n (%), reasons for death vary at different d d d postnatal26 ages. In the NICHD NRN

tiary hospital, n (%), study, the predominant causes th, n (%), of death were reported to be n (%), [missing data] 7064 (53.4) Population Characteristics of Infants (24 immaturity in the first 12 hours of d 2 data] [missing data] >1500 g, n (%) (%) life, followed by respiratory distress No. of neonates included in database Multiple births, n (%), Infants excluded due to bir Birth weight (g), mean (SD) Proportion of infants 24 wks ’ GA, n Admitted at >36 wks ’ gestation, n (%) Study infants, n (%) Male sex, Born in nonter Birth weight z score, mean (SD) GA (wks), mean (SD) Cesarean bir Any antenatal steroid, 2009 – 2013. P < .001. Sweden, excluding the Sk å ne region. 2008 – 2013. a b c d TABLE syndrome during the first 2 weeks to 4 weeks, necrotizing enterocolitis between 0.5 months and 2 months, Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 140, number 6, December 2017 5

119

and bronchopulmonary dysplasia (77.3) (85.6) (90.3) (93.7) (96.0) (87.4) 28 810/13 467/16 799/19 971/19 172/88

after 2 months of age. Corchia et al 8593/11 11 14 17 18 77

5532/8631 (64.1) reported that respiratory causes and intraventricular hemorrhage 975 were the predominant causes of n / N (%) Total n / N (%) (63.7) (76.7) (85.0) (89.9) (92.8) (96.0) (86.9) c death within the first 2 weeks of 353/19

KNC

17 life, and late-onset infections and U gastrointestinal causes became more prevalent after the first n / N b week. We did not have data on the (%) causes of death, and therefore, we 585/705 (83.0) TuscanNN were unable to find reasons for differences in postnatal age at death. However, we believe that these

(87.0) differences are important to know n / N (%) 2327/2675 and understand from health services and administrative perspectives. Other possible causes of differences in postnatal age at death can be (89.7) n / N (%) SwissNeoNet a related to the care and diagnostics 2803/3124 SNQ 450/509 (88.4) 384/458 (83.8)539/582 (92.6) 60/78 (76.9) 434/478 (90.8)624/672 (92.9) 107/127 (84.3) 2626/3091 551/581 (94.8)650/674 (96.4) 3289/3657 140/148 (94.6) 637/653 (97.5) 4068/4383 170/177 (96.0) 4247/4425 during pregnancy, in addition to perinatal and neonatal care. For 226 instance, a region with a restrictive (73.2) (81.8) (88.6) (92.4) (78.1) (%) pregnancy termination policy had a 1147/1568 1507/1842 1959/2210 2348/2540

7987/10 higher proportion of deaths because 312/866 (36.0) 205/292 (70.2) 107/186 (57.5) 50/94 (53.2) 1308/2053 714/1200 (59.5) 335/395 (84.8) 214/319 (67.1) 58/81 (71.6) 1815/2366 of congenital anomalies in the Models of OrganiSing Access to Intensive 421

29 Care for very preterm births study. (83.7) (89.3) (93.3) (94.4) (96.5) (97.0) (93.3) 192/18

In addition, policies and attitudes 3714/3850 3806/3925 17 regarding redirection of care can be

different30 in different countries and regions. (92.0) (94.4) (79.9) 4350/5441 INN n / N (%) NRNJ n / N (%) SEN1500 n / N Our study has several acknowledgeable strengths. We used a large, multinational, population- based cohort of very preterm infants. (88.1) (%) Data collection was standardized 1439/1633

155/197 (78.7) 381/664 (57.4)196/231 (84.8) 2155/2413 659/847 (77.8)295/329 (89.7) 2658/2850 809/947 (85.4)336/362 (92.8) 3116/3301 1063/1156 347/358 (96.9) 1270/1345 by using a common data set and providing clear definitions for 888 variables before analysis. Including (88.1) (79.0) (87.0) (91.5) (94.7) (96.9) data from 7 consecutive years 351/12

1445/1829 1777/2043 2208/2412 2559/2703 2626/2710

11 decreased the influence of random variations. All iNeo contributors

239 have well-established data gathering

vival Rates Among Infants (24 – 29 Weeks ’ Gestation, Birth Weight <1500 g) Born Between 2007 and 2013 Admitted to Neonatal Care in the iNeo Networks systems, conduct benchmarking (79.8) (87.5) (92.2) (94.8) (97.2) (89.0) 785/13 and quality-improvement activities, 1321/1655 1853/2117 2163/2346 2785/2939 2870/2953 11 ANZNN n / N (%) CNN n / N (%) FinMBR n / N 793/1229 (64.5) 736/1191 (61.8) 110/156 (70.5) 168/482 (34.9) 1743/2082 have similar antenatal health care resources, and contain nearly GA-Specific Sur

– – – – – – – universal access to antenatal 3 0/7 0/7 0/7 0/7 0/7 0/7 0/7 6/7 6/7 6/7 6/7 6/7 6/7 6/7 follow-up and public delivery 24 25 26 27 28 29 29 GA 25 GA 24 GA 26 GA 27 GA 28 GA 29 GA 24 2009 – 2013. Sweden, excluding the Sk å ne region. 2008 – 2013. TABLE a b c hospitals. Finally, survival as the primary outcome is objective and not biased by complex definitions. Downloaded from www.aappublications.org/news by guest on September 23, 2021 6 Helenius et al

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics However, we must also recognize influenced our results. It is likely participating units. Preliminary our limitations. First, varying that units not participating or not data from Japan suggest that units national coverage of births in providing data may have lower not contributing to the NRNJ have participating networks might have survival rates compared with mortality rates that are 1.1- to 1.5- ’ fold higher than NRNJ contributors for infants of <27 weeks gestation (N.M., unpublished observations). Some networks limited their data collection to infants with a birth weight of <1500 g, which led us to restrict our whole data set accordingly. This might introduce bias because some well-grown infants in the higher-GA range are excluded. However, this bias is similar in all networks,z and the results were adjusted for country- specific birth weight scores. Likewise, some networks collect data only from tertiary neonatal FIGURE 1 units, which is likely to introduce a GA-specific survival for infants (24–29 weeks’ gestation, birth weight <1500 g) born between 2007 and 2013 and admitted to neonatal care in the iNeo networks. bias because very preterm infants born in nontertiary hospitals have

FIGURE 2 SRs of survival for infants (24–29 weeks’ gestation, birth weight <1500 g) born during the study period (2007–2013) and admitted to neonatal care in each iNeo network. a SRs comparing the survival in each network to all other networks combined. Vertical bars are the estimated 99% CIs of the SRs. The dotted curves represent the 99% control limits expected under the null hypothesis of similar outcome rates (SR = 1).

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Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics FIGURE 3 Age at death among nonsurviving infants (24–29 weeks’ gestation, birth weight <1500 g) born between 2007 and 2013 and admitted to neonatal care in each iNeo network. a Truncated to 100 days.

31 higher mortality rates. These from32 the hospital. In Canada, Synnes factors have little effect19 on the issues should be considered when et al reported a 0.7% death rate variations in outcomes. interpreting the results. Ideally, between discharge from tertiary In the future, similar comparisons survival rates for each network neonatal care and 18 months to should attempt to include all should be calculated by using 24 months of age. Third, data on deliveries of live fetuses at all deliveries of live fetuses at delivery room deaths and stillbirths presentation to the hospital. presentation to the hospital as were not available; therefore, the Meanwhile, networks should the denominator, as done by the results may not be comparable to aim to increase the number of Extremely Preterm Infants12 in other groups and should be used participating neonatal units to Sweden Study Group ; however, cautiously for counseling. Fourth, achieve complete population such data are not available to data on maternal conditions (eg, coverage, enable a comprehensive all iNeo contributors. Second, in hypertensive disorders, preterm assessment of outcomes, and some networks, data were only rupture of membranes, and avoid selection biases in their available until transfer to a step- perinatal infections) and reasons for evaluations. down hospital. Nonetheless, death prematurity (spontaneous preterm Conclusions rates for very preterm infants after birth versus maternal or fetal transfer to step-down hospitals indication for preterm birth) were were low in Finland because only not available in sufficient detail to Large variations in the survival of 0.4% of the infants died after be used in the analyses. However, as very preterm infants were evident transfer but before discharge shown by the EPICE group, maternal among iNeo networks. Internetwork Downloaded from www.aappublications.org/news by guest on September 23, 2021 8 Helenius et al

316 differences in survival were largest at 24 weeks gestation, and relative All, N = 10 network ranking of the survival rate persisted across the studied GAs. N = b For nonsurvivors, the median age at 1 9 9 8 8 8 7 — 2621

KNC, death varied from 4 days to 13 days U among the networks. Our results

N warrant further assessment of the a organization of perinatal services, 4 5 3 8 18 24 — —

= 102 national guidelines, philosophy

TuscanNN, of care, and resources used for decision-making. Acknowledgments 1 5 5 6 5 6 9 6 N = 347

We acknowledge all investigators and data abstractors of the networks 4 4 8 9 5 10 16 13 participating in the iNeo consortium

SNQ, N = 311 SwissNeoNet, for their diligent work. We also thank staff at the Maternal-Infant Care Research Centre in Toronto, Ontario, 7 8 7 9 7 8

10 for organizational, statistical, and 253 1986 editorial support. Dr Shah had full SEN1500, N = access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the 23 11 14 15 12 11 21 12.5 1206 dataiNeo analysis. Group Information ANZNN:

Ross Haslam, MBBS,* 0 8 9 7 6 6 7.5 6.5 Chair of the Executive Committee;

INN, N = 1091 NRNJ, N = Peter Marshall, MBChB, Flinders Medical Centre (Bedford Park, South Australia); Peter Schmidt, 0 4 3 3 3 8 16 3.5 194 MBChB, Gold Coast University Hospital (Gold Coast, Queensland); Adam Buckmaster, MBBS, Gosford District Hospital (Gosford, New 6 7 9 11 10 10 South Wales); Paul Craven, MBChB, 9.5 11.5 and Koert de Waal, MBBS, PhD,* CNN, N = 1531 FinMBR, N = John Hunter Hospital (Newcastle, New South Wales); Karen Simmer, viving Infants (GA 24 – 29 Weeks ’ Gestation, Birth Weight <1500 g) Born Between 2007 and 2013 Admitted to Neonatal Care in Each iNeo Network

– 30) 10 (3 – 26) 4 (1 – 15) 7 (3 – 19) 13 (3 – 42)– 20) 8 (3 7 (2 – 24) 6 (2 – 16) 8 (2 – 19) 8 (2 – 28)– 26) 8 (3 MBChB, PhD, Andy Gill, MBChB,* 4 8 9 7 7 8 10 10 1450

8 (3 and Jane Pillow, MBBS, PhD,* 396 (27.3) 356 (23.3) 30 (15.5) 211 (19.3) 394 (32.7) 361 (18.2) 70 (22.5) 50 (14.4) 17 (16.7) 669 (25.5) 2554 (23.6) 499 (34.4) 478 (31.2) 70 (36.1) 343 (31.4) 287 (23.8) 627 (31.6) 97 (31.2) 154 (44.4) 40 (39.2) 627 (23.9) 3222 (29.7) 409 (28.2) 558 (36.5) 42 (21.6) 358 (32.8) 370 (30.7) 732 (36.9) 92 (29.6) 109 (31.4) 38 (37.3) 771 (29.4) 3479 (32.1) ANZN N, N = King Edward Memorial and Princess Margaret Hospitals (Subiaco, Western Australia);

n (%) 146 (10.0) 139 (9.1) 52 (26.8) 179 (16.4) 155 (12.9) 266 (13.4) 52 (16.7) 34 (9.8) 7 (6.9) 554 (21.1) 1584 (14.6) Jacqueline Stack, MBChB, Liverpool c Hospital (Liverpool, New South

≥ 28 d, n (%) ’ c Wales); Lucy Cooke, MBChB, Mater Age at Death Among Nonsur Mothers Hospital (South Brisbane, 4 2007 2008 2009 2010 2011 2012 2013 Queensland); Dan Casalaz, MBChB, Median (IQR) age at death, d No. missing Median age at death in days according to years

Age at death <1 d, Age at death 1 – 6 d, n (%)

Age at death 7 – 27 d, n (%)

Age at death

2008 – 2013. 2009 – 2013. Percentage of all nonsurvivors in each network.

TABLE — , not applicable. a b c and Jim Holberton, MBBS,* Mercy Hospital for Women (Melbourne, Victoria); Charles Barfield, MBBS, Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 140, number 6, December 2017 9

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics Adrienne Lynn, MBBS, Brian General Hospital (Winnipeg, Nepean Hospital, Monash Medical ’ Centre (Melbourne, Victoria); Darlow, MD, Christchurch Manitoba); Amit Mukerji, MD, Lyn Downe, MBBS, Vijay Shingde, Women s Hospital (New Hamilton Health Sciences Centre MBChB (New South Wales); Michael Zealand); Roland Broadbent, (Hamilton, Ontario); Orlando Da Stewart, MBBS, MD, Newborn MBChB,* Dunedin Hospital (New Silva, MD, MSc, London Health Emergency Transport Service Zealand); Lindsay Mildenhall, Sciences Centre (London, Ontario); (Victoria); Barbara Bajuk, MPH,* MBChB, Middlemore Hospital Chuks Nwaesei, MD, Windsor Newborn and Pregnancy Services (New Zealand); Malcolm Batten, Regional Hospital (Windsor, Network (New South Wales); MBChB, Auckland City Hospital Ontario); Kyong-Soon Lee, MD, Andrew Berry, MBBS, Newborn and (New Zealand); Jutta van den MSc, Hospital for Sick Children Paediatric Emergency Transport Boom, MBBS,* North Shore (Toronto, Ontario); Michael Dunn, ’ MD, Sunnybrook Health Sciences Service (New South Wales); Rod and Waitakere Hospitals (New ’ Hunt, MBChB, Royal Children s Zealand); David Bourchier, MBChB, Centre (Toronto, Ontario); Brigitte Hospital (Parkville, Victoria); and Lee Carpenter, RN,* Waikato Lemyre, MD, Children s Hospital Hospital (New Zealand); Vaughan of Eastern Ontario and Ottawa Charles Kilburn, MBChB, Royal ’ Darwin Hospital (Darwin, Northern Richardson, MBChB, Wellington General Hospital (Ottawa, Ontario); Women s Hospital (New Zealand); Kimberly Dow, MD, Kingston Territory); Tony De Paoli, MBBS, ’ ’ General Hospital (Kingston, Royal Hobart Hospital (Hobart, Victor Samuel Rajadurai, MBBS, é Ontario); Ermelinda Pelausa, MD, Tasmania); Kei Lui, MBBS,* Royal MD,* KK Women s and Children s é Jewish General Hospital (Montr al, Hospital for Women (Sydney, New Hospital (Little India, Singapore). ô é South Wales); Mary Paradisis, Qu bec); Keith Barrington, MBChB, *denotes the ANZNN Executive é MBChB, Royal North Shore Hospital H pital Sainte-Justine (Montr al, Committee.CNN: Qu bec); Christine Drolet, MD, (Sydney, New South Wales); Ingrid é and Bruno Piedboeuf, MD, Centre Rieger, MBChB, and Shelley Reid, Prakesh S. Shah, MD, é RN,* Royal Prince Alfred Hospital MSc (director, CNN and site Hospitalier Universitaire de Qu bec (Syndey, New South Wales); David investigator), Mount Sinai (Sainte Foy, Qu bec); Martine Cartwright, MBChB, and Pieter Claveau, MSc, LLM, NNP, and Marc ’ Hospital (Toronto, Ontario); é é Koorts, MBBS, Royal Brisbane Adele Harrison, MD, MBChB, Beltempo, MD, McGill University and Women s Hospital (Brisbane, Victoria General Hospital (Victoria, Health Centre (Montr al, Qu bec); Queensland); Carl Kuschel, British Columbia); Anne Synnes, Valerie Bertelle, MD, and Edith ’ ’ Masse, MD, Centre Hospitalier MBChB, and Lex Doyle, MBBS, MDCM, MHSC, and Joseph Ting, é MD, MSc, Royal Women s Hospital Universitaire de Sherbrooke ’ MD, BC, Women s Hospital and (Melbourne, Victoria); Andrew Health Centre (Vancouver, British (Sherbrooke, Qu bec); Roderick Numa, MBChB, Sydney Children s Columbia); Zenon Cieslak, MD, Canning, MD, Moncton Hospital Hospital (Sydney, New South Royal Columbian Hospital (New (Moncton, New Brunswick); Hala Wales); Hazel Carlisle, MBChB, Westminster, British Columbia); Makary, MD, Dr Everett Chalmers Canberra Hospital (Canberra, Rebecca Sherlock, MD, Surrey Hospital (Fredericton, New Australian Capital Territory); Nadia Brunswick); Cecil Ojah, MBBS, and ’ Memorial Hospital (Surrey, Badawi, MBChB, PhD, and Robert British Columbia); Wendy Yee, Luis Monterrosa, MD, Saint John Regional Hospital (Saint John, New Halliday, MBBS, The Children s MD, Foothills Medical Centre ’ Hospital at Westmead (Sydney, (Calgary, Alberta); Khalid Aziz, Brunswick); Akhil Deshpandey, MBBS, MRCPI, Janeway Children s New South Wales); Guan Koh, MBBS, MA, MEd, and Jennifer Toye, ’ MBChB,* The Townsville Hospital MD, Royal Alexandra Hospital Health and Rehabilitation Centre ’ (Townsville, Queensland); Steven (Edmonton, Alberta); Carlos (St. John s, Newfoundland); Jehier Resnick, MBBS, Western Australia Fajardo, MD, Alberta Children s Afifi, MBBCh, MSc, IWK Health Neonatal Transport Service; Melissa Hospital (Calgary, Alberta); Zarin Centre (Halifax, Nova Scotia); Luig, MBChB, Westmead Hospital Andrzej Kajetanowicz, MD, Cape ’ Kalapesi, MD, Regina General (Sydney, New South Wales); Chad Breton Regional Hospital (Sydney, ’ Hospital (Regina, Saskatchewan); Anderson, MBChB, Women s Koravangattu Sankaran, MD, MBBS, Nova Scotia); and Shoo K. Lee, and Children s Hospital (South and Sibasis Daspal, MD, Royal MBBS, PhD (chairman, CNN), Mount Australia); Georgina Chambers, University Hospital (Saskatoon, INN:Sinai Hospital (Toronto, Ontario). MBA, PhD,* National Perinatal Saskatchewan); Mary Seshia, Epidemiology and Statistics Unit, MBChB, Winnipeg Health Sciences Brian Reichman, MBChB University of New South Wales Centre (Winnipeg, Manitoba); (director, INN), Sheba Medical (Sydney, New South Wales); Ruben Alvaro, MD, St. Boniface Center (Tel Hashomer); Eli Downloaded from www.aappublications.org/news by guest on September 23, 2021 10 Helenius et al

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics Heymann, MD, Assaf Harofeh Hattori, MD, Sapporo City Hospital Kanagawa); Keiji Suzuki, MD, Tokai Medical Center (Tzrifin); Shmuel (Sapporo, Hokkaido); Shohei University (Isehara, Kanagawa); Zangen, MD, Barzilai Medical Center Konishi, MD, Kushiro Red Cross Atsushi Nemoto, MD, Yamanashi Prefectural Central Hospital (Kofu, (Ashkelon); Tatyana Smolkin, Hospital (Kushiro, Hokkaido); ’ MD, Baruch Padeh Medical Center Takasuke Amizuka, MD, Aomori Yamanashi); Tomohiko Nakamura, (Poriya); Francis Mimouni, MD, Prefectural Central Hospital MD, Nagano Children s Hospital Bikur Cholim Hospital (Jerusalem); (Aomori, Aomori); Takeo Kasai, (Azumino, Nagano); Masaki Wada, David Bader, MD, Bnai Zion Medical MD, Iwate Medical University MD, Niigata University (Niigata, Center (Haifa); Avi Rothschild, (Morioka, Iwate); Ritsuko Takahasi, Niigata); Yoshihisa Nagayama, MD, Carmel Medical Center MD, Sendai Red Cross Hospital MD, Niigata City Hospital (Niigata, (Haifa); Zipora Strauss, Chaim (Sendai, Miyagi); Hirokazu Arai, Niigata); Osamu Numata, MD, Sheba Medical Center (Ramat MD, Akita Red Cross Hospital Nagaoka Red Cross Hospital Gan); Clari Felszer, MD, Emek (Akita, Akita); Maki Sato, MD, (Nagaoka, Niigata); Takeshi Medical Center (Afula); Jamalia Fukushima Medical University Futatani, MD, Toyama Prefectural Jeryes, MD, French Saint Vincent (Fukushima, Fukushima); Yayoi Central Hospital (Toyama, Toyama); de Paul Hospital (Nazareth); Miyazono, MD, Tsukuba University Yasuhisa Ueno, MD, Ishikawa Smadar Even Tov-Friedman, MD, (Tsukuba, Ibaraki); Junichi Prefectural Central Hospital Hadassah University Hospital- Shimizu, MD, Tsuchiura Kyodo (Kanazawa, Ishikawa); Kazuyuki Ein Karem (Jerusalem); Benjamin Hospital (Tsuchiura, Ibaraki); Iwai, MD, Fukui Prefectural Bar-Oz, MD, Hadassah University Hiroshi Suzumura, MD, Dokkyo Hospital (Fukui, Fukui); Yoshinori Hospital-Har Hazofim (Jerusalem); Medical University (Shimotsuga, Kono, MD, Gifu Prefectural Medical Michael Feldman, MD, Hillel Yaffe Tochigi); Yumi Kono, MD, Jichi Center (Gifu, Gifu); Shigeru Ooki, Medical Center (Hadera); Nizar Medical University (Shimotsuke, MD, Seirei Hamamatsu General ’ Saad, MD, Holy Family (Italian) Tochigi); Takahiro Inoue, MD, Hospital (Hamamatsu, Shizuoka); ’ Hospital (Nazareth); Orna Flidel- Gunma Children s Medical Center Yusuke Nakazawa, MD, Shizuoka Rimon, MD, Kaplan Medical Center (Shibukawa, Gunma); Hiroshi Prefectural Children s Hospital ’ (Rehovot); Meir Weisbrod, MD, Miyabayashi, MD, Saitama (Shizuoka, Shizuoka); Chizuko Laniado Hospital (Netanya); Daniel Children s Medical Center (Saitama, Suzuki, MD, Nagoya Red Cross First Lubin, MD, Mayanei Hayeshua Saitama); Hisanori Sobajima, Hospital (Nagoya, Aichi); Taihei Medical Center (Bnei Brak); Ita Saitama Medical University (Iruma, Tanaka, MD, Nagoya Red Cross Litmanovitz, MD, Meir Medical Saitama); Rika Ishiguro, Kawaguchi Second Hospital (Nagoya, Aichi); Center (Kfar Saba); Amir Kugelman, Municipal Medical Center Motoki Bonno, MD, Mie Central MD, Rambam Medical Center (Kawaguchi, Saitama); Hiroyuki Medical Center (Tsu, Mie); Kenji (Haifa); Eric Shinwell, MD, Rivka Ziv Sato, MD, Kameda General Hospital Nakamura, MD, Ohtsu Red Cross ’ ’ Medical Center (Safed); Gil Klinger, (Chiba, Kamogawa); Satsuki Totsu, Hospital (Otsu, Shiga); Minako MD, Schneider Children s Medical MD, Tokyo Women s Medical Kihara, MD, Kyoto Red Cross First Center of Israel, Rabin Medical University (Shinjuku, Tokyo); Hospital (Kyoto, Kyoto); Hiroyuki Center (Beilinson Campus) (Petah Nozomi Ishii, MD, Aiiku Hospital Sano, MD, Yodogawa Christian Tikva); Yousif Nijim, MD, Scottish (Minato, Tokyo); Shigeharu Hosono, Hospital (Osaka, Osaka); Atsushi (EMMS) Hospital (Nazareth); MD, Nihon University Itabashi Shiraishi, MD, Osaka Medical Center Francis Mimouni, MD, Shaare- Hospital (Itabashi, Tokyo); Mika and Research Institute for Maternal Zedek Medical Center (Jerusalem); Shiraishi, MD, Teikyo University and Child Health (Osaka, Izumi); Agneta Golan, MD, Soroka Medical (Itabashi, Tokyo); Humihiro Miura, Atsushi Ohashi, MD, Kansai Medical Center (Beersheba); Dror Mandel, MD, Showa University (Shinagawa, University Hirakata Hospital MD, Sourasky Medical Center (Tel Tokyo); Atsushi Nakao, MD, Japan (Hirakata, Osaka); Hiroyuki Ichiba, Aviv); Vered Fleisher-Sheffer, MD, Red Cross Medical Center (Shibuya, MD, Osaka City General Hospital Western Galilee Medical Center Tokyo); Hitoshi Yoda, MD, Toho (Osaka, Osaka); Kiyoaki Sumi, (Nahariya); David Kohelet, MD, University (Ota, Tokyo); Mitsumasa MD, Aizenbashi Hospital (Osaka, ’ Wolfson Medical Center (Holon); Shimizu, MD, Tokyo Metropolitan Osaka); Seiji Yoshimoto, MD, and Lev Bakhrakh, MD, Yoseftal Bokuto Hospital (Sumida, Tokyo); Kobe Children s Hospital (Kobe, NRNJ:Hospital (Eilat). Kazuo Seki, MD, Yokohama Hyogo); Yukihiro Takahashi, MD, City University Medical Center Nara Medical University (Nara, ’ Satoshi Kusuda, MD (Yokohama, Kanagawa); Yasuhumi Nara); Takahiro Okutani, MD, (director, NRNJ), Tokyo Women's Itani, MD, Kanagawa Children s Wakayama Medical University Medical University (Tokyo); Satoshi Medical Center (Yokohama, (Wakayama, Wakayama); Masumi Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 140, number 6, December 2017 11

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics ñ é í é Martinez Gimenez, MD, Hospital Miura, MD, Tottori University Santiago (A Coru a, Galicia); Andr s ó Mart nez Guti rrez, MD, Complejo General Universitario de Ciudad (Yonago, Tottori); Fumihide Kato, í Hospitalario De Albacete (Albacete, Real (Ciudad Real, Castile); Ram n MD, Shimane Prefectural Central í ú Aguilera Olmos, MD, and Ricardo Hospital (Izumo, Shimane); Shinichi Albacete); Mar a Mercedes ó ó ó Mart nez Ay car, MD, Hospital Tosca Segura, MD, Hospital General Watabe, MD, Kurashiki Central í í ª á ñ de Txagorritxu (Vitoria-Gasteiz, de Castell (Castell , Castell ); Hospital (Kurashiki, Okayama); é á ª μñ Araba); Carolina Vizca no D az, Juana M Guzm n Caba as, MD, Misao Kageyama, MD, Okayama í Medical Center (Okayama, MD, and Jos Luis Quiles Dur , MD, and M Dolores Huertas oz, MD, Hospital General Universitario Hospital Universitario Reina Sof a Okayama); Rie Fukuhara, MD, í á de Elche (Alicante, Alicante); (Cordoba, Andalusia); Alberto Hiroshima Prefectural Hospital ª Mar a Gonz lez Santacruz, MD, Trujillo, MD, Hospital Universitari (Hiroshima, Hiroshima); Michiko ó and M Anne Feret Siguile, MD, de Josep Trueta (Girona, Catalonia); Hayashitani, MD, Hiroshima City é Hospital General Universitario de Luis Fidel Molt Ripoll, MD, and Hospital (Hiroshima, Hiroshima); í á Alicante (Alicante, Alicante); Adela Jos Antonio Hurtado Suazo, MD, Keiko Hasegawa, MD, Yamaguchi ñ Rodr guez Fern ndez, MD, Hospital Hospital Universitario Virgen De Prefectural Medical Center (Hofu, é á de Cabue es (Gijon, Asturias); Las Nieves (Granada, Granada); Yamaguchi); Kosuke Koyano, MD, í ó í ó Kagawa University (Kita, Kagawa); Bel n Fern ndez Colomer, MD, Ana Elena Aldea Romero, MD, and and Enrique Garc a L pez, MD, Mar a Pangua G mez, MD, Hospital Shoko Kobayashi, MD, Shikoku á Hospital Universitario Central de Universitario de Guadalajara Medical Center for Children í and Adults (Zentsuji, Kagawa); Asturias (Oviedo, Asturias); Josep (Guadalajara, Castile); Luis Pais n Figuera Aloy, MD, and Francesc Shinosuke Akiyoshi, MD, Ehime í Grisol a, MD, Hospital Donostia Prefectural Central Hospital Botet Mussons, MD, Hospital (Donostia, Gipuzkoa); Ana Isabel Cl nic de Barcelona (Barcelona, Garrido Ocana, MD, and Eduardo (Matsuyama, Ehime); Yusei Nakata, ó é Catalonia); Israel Anquela Sanz, Garcia Soblechero, MD, Hospital MD, Kochi Health Sciences Center ª MD, Hospitalario De Granollers Juan Ram n Jim nez (Huelva, (Kochi, Kochi); Takeshi Kanda, é í MD, National Kyushu Medical (Granollers, Barcelona); Gemma Huelva); M Yolanda Ruiz del Prado, ’ ñ Ginovart Galiana, MD, and Elisenda MD, and In s Esteba D ez, MD, Center (Fukuoka, Fukuoka); Hisano á Moliner Calderon, MD, Hospital De Hospital San Pedro (Logro o, La Tadashi, MD, St Mary s Hospital í í μñ (Kurume, Fukuoka); Hiroshi Kanda, Sant Pau (Barcelona, Catalonia); Rioja); Gema E. Gonz lez-Luis, MD, Antonio Natal Pujol, MD, Hospital and Ferm n Garc a- oz Rodrigo, MD, Kurume University (Kurume, ó Fukuoka); Masaki Nakamura, Universitari Germans Trias i MD, Hospital Universitario De Pujol (Badalona, Barcelona); Canarias (San Crist bal de La Fukuoka University (Fukuoka, Á Alicia Mirada Vives, MD, Hospital Fukuoka); Naoko Matsumoto, MD, í Laguna, Santa Cruz de Tenerife); Universitari Mutua De Terrassa Emilio lvaro Iglesias, MD, and Kitakyushu City Medical Center ó (Barcelona, Catalonia); Mart n Fernando Fernandez Calvo, MD, (Kitakyushu, Fukuoka); Masayuki ó ó é Iriondo Sanz, MD, Hospital San Hospital Universitario de Le n Ochiai, MD, Kyushu University í (Fukuoka, Fukuoka); Mikihiro Juan De Deu (Barcelona, Catalonia); (Le n, Le n); Eduard Sol Mir, Aoki, MD, Nagasaki Medical Center Roser Porta, MD, and Eva Capdevila MD, and Jordi Garcia Mart , MD, Cogul, MD, I. Dexeus (Barcelona, (Omura, Nagasaki); Akihiko ñá University Hospital Arnau De Catalonia); Laura Castells Vilella, Vilanova (Lleida, Catalonia); Kawase, MD, Kumamoto City í MD, Hospital General de Catalu Hospital (Kumamoto, Kumamoto); Á é í Roberto Ortiz Movilla, MD, and Koichi Iida, MD, Oita Prefectural (Barcelona, Catalonia); Bruno Luc a Cabanillas Vilaplana, MD, í Alonso lvarez, MD, and Jos Mar a Center Hospital (Oita, Oita); Chie ü Hospital Universitario de Getafe Ishihara, MD, Kagoshima City Montero Macarro, MD, Hospital (Madrid, Madrid); Marta Garc a San á í Hospital (Kagoshima, Kagoshima); General Yag e (Burgos, Castile); Miguel, MD, Hospital Universitario ª ú ó í í and Moriyasu Kohama, MD, Ana R. Barrio Sacrist n, MD, and Montepr ncipe (Madrid, Madrid); á á í M Jes s L pez Cuesta, MD, H. Okinawa Prefectural Chubu í Isabel Llana Mart n, MD, and Mar a Hospital (Okinawa, Okinawa). San Pedro de Alc ntara (Caceres, Fern ndez D az, MD, Hospital SEN1500: á ú é Caceres); Ortiz Tard o, MD, and Universiatrio Torrelodonesm á á í í Eugenia Valls S nchez Puerta, Maximo Vento, MD, á (Madrid, Madrid); Jes s P rez PhD (director, SEN1500), Health MD, Hospital Jerez (C diz, C diz); Rodr guez, MD, and Sof a Salas, ª é á Research Institute La Fe (valencia, Isabel Benavente Fern ndez, MD, Hospital Universitario La é ª ú μñ MD, and Juan Mena Romero, MD, Paz (Madrid, Madrid); Carmen Valencia); M Jos Fern ndez Seara, á á í á MD, and Jos M Fraga Berm dez, Hospital Universitario Puerta Del oz Labian, MD, and Carmen MD, Hospital Clinico Universitario Mar (C diz, C diz); Mar a Dolores Gonz lez Armengod, MD, Hospital Downloaded from www.aappublications.org/news by guest on September 23, 2021 12 Helenius et al

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics ä Ö (Ystad); Andreas Ohlin, MD, Universitario Puerta De Hierro Katarina Strand Brodd, MD, Ö ö Universitetssjukhuset ( rebro); (Majadahonda, Madrid); Laura M larsjukhuset (Eskilstuna); Ö ö Domingo Comeche, MD, Hospital Andreas Odlind, MD, Falu Rein Florell, MD, rnsk ldsviks á ä ä ö Universitario de Fuenlabrada Lasarett (Falun); Lars Alberg, Sjukhus ( rnsk ldsvik); and á ä Ö Ö (Feunlabrada, Madrid); Tom s MD, G llivare Sjukhus (G llivare); Agneta Smedsaas-L fvenberg, MD, í í ä ö S nchez Tamayo, MD, and Manuel Sofia Arwehed, MD, G vle SwissNeoNet:stersunds Sjukhus ( stersund). á á é Á Ö ö Garc a del R o, MD, Hospital Carlos Sjukhus (G vle); Eva Engstr m, é ä Mark Adams, MsC Haya (M laga, M laga); Jos ngel MD, SU/ stra (G teborg); Anna í (coordinator, SwissNeoNet); Alonso Gallego, MD, and Jos Kasemo, MD, L nssjukhuset í Philipp Meyer, MD, and Claudia Mar a Lloreda Garcia, MD, Hospital (Halmstad); Charlotte Ekelund, ’ á Å Anderegg, MD, Cantonal Hospital, Santa Mar a De Rosell (Caragena, MD, Helsingborgs Lasarett ’ Children s Clinic (Aarau); Sven Murcia); Javier Vilas Gonz lez, MD, (Helsingborg); Lars hman, Schulzke, MD, University Children s Complexo Hospitalario Pontevedra MD, Hudiksvalls Sjukhus ä Hospital (Basel); Mathias Nelle, (Pontevedra, Pontevedra); (Hudiksvall); Fredrik Ingemarsson, ö ö Ö MD, University Hospital (Berne); Ocampo, MD, and Nieves Balado MD, L nssjukhuset Ryhov ä í á ä Bendicht Wagner, MD, University Insunza, MD, Hospital Xeral (Vigo, (J nk ping); Laura sterdahl, MD, ’ é Hospital (Berne); Walter B r, MD, Pontevedra); Pilar Garc a Gonz lez, L nssjukhuset (Kalmar); Pernilla Children s Hospital (Chur); Gr goire MD, Hospital Universitario de Thurn, MD, Blekingesjukhuset Kaczala, MD, Cantonal Hospital Salamanca (Salamanca, Castile); (Karlskrona); Eva Albinsson, MD, ó (Fribourg); Riccardo E. Pfister, Mercedes Granero Asencio, MD, Centralsjukhuset (Karlstad); Bo ç MD, Geneva University Hospital and Antonia L pez Sanz, MD, Selander, MD, Centralsjukhuset í (Geneva); Jean-Fran ois Tolsa, MD, Hospital Virgen De La Macarena (Kristianstad); Fredrik Lundberg, í ö and Matthias Roth, MD, University (Sevilla, Seville); Carmen Mac as MD, Universitetssjukhuset ’ é å Hospital (CHUV) (Lausanne); D az, MD, and Araceli Ferrari (Link ping); Ingela Heimdahl, í ö å Thomas M. Berger, MD, Children s Cort s, MD, Hospital Universitario MD, Sunderby sjukhus (Lule ); ö Hospital (Lucerne); Bernhard Virgen Del Roc o (Sevilla, Seville); Ola Hafstr m, MD, Sk nes Laubscher, MD, Cantonal Hospital Pedro Amadeo Fuster Jorge, MD, Universitetssjukhus (Malm /Lund); ó ö (Neuchatel); Andreas Malzacher, Hospital Universitario de Canarias Erik Wejryd, MD, Vrinnevisjukhuset ’ ó ö å MD, Cantonal Hospital (St. Gallen); (San Crist bal de La Laguna, Santa (Norrk ping); Johanna Kuusima- å John P. Micallef, MD, Children s Cruz de Tenerife); Santiago L pez L fbom, MD, Skellefte Lasarett í ä Hospital (St. Gallen); Lukas Hegi, Mendoza, MD, and Sabina Romero (Skellefte ); Ellen-Elisabeth ñ ö MD, Cantonal Hospital (Winterthur); Ram rez, MD, Hospital Universitario Lund, MD, K rnsjukhuset é å Dirk Bassler, MD, and Romaine Nuestra Se ora De Candelaria Skaraborg (Sk vde); Annelie ª ú å Arlettaz, MD, University Hospital (Santa Cruz de Tenerife, Santa Cruz Thor n, MD, Sollefte Sjukhus ’ Zurich (Zurich); and Vera Bernet, de Tenerife); M del Mar Alb jar (Sollefte ); Boubou Hallberg, MD, ö MD, University Children s Hospital Font, MD, Hospital Universitari Joan Karolinska Sjukhuset (Stockholm); ö (Zurich).UKNC: Eva Berggren Brostr m, MD, XXIII (Tarragona, Tarragona); Alicia ö S dersjuhuset, (Stockholm); Santanu Bag, MBChB, de Ureta Huertas, MD, and Antonio ö Arroyos Plana, MD, Hospital Virgen Torbj rn Hertzberg, MD, Bedford Hospital (Bedford, ñ ä De La Salud (Toledo, Toledo); Sophiahemmet (Stockholm); Bj rn Bedfordshire); Jonathan Kefas, Stjernstedt, MD, L nssjukhuset MBChB, Lister Hospital (Stevenage, Javier Esta Capell, MD, Hospital Ä ä Clinico Universitario De Valencia (Sundsvall); Johan Robinson, MD, Hertfordshire); Oliver Rackham, é ä (Valencia, Valencia); Vicente Norra lvsborgs L nssjukhus MBChB, Arrowe Park Hospital Roqu s, MD, and F Morcillo, (Trollh ttan); Aijaz Farooqi, MD, (Wirral, Merseyside); Arumugavelu í å MD, Hospital Universitari La Fe Norrlands Universitetssjukhus Thirumurgan, MBChB, Leighton í ñ (Valencia, Valencia); Sara Mar n, (Ume ); Erik Normann, MD, Hospital (Crewe, Cheshire); í ’ MD, and Mar a Fernanda Oma a, Akademiska Barnsjukhuset Bill Yoxall, MBChB, Liverpool (Uppsala); Magnus Fredriksson, Women s Hospital (Liverpool, MD, Hospital Universiatario R o ä MD, Visby Lasarett (Visby); Merseyside); Tim McBride, Hortega (Valladolid, Castile and ä Å Leon); and Gabriel Saitua Iturriaga, Anders Palm, MD, V sterviks MBChB, Ormskirk District General Sjukhus (V stervik); sa Hospital (Ormskirk, Lancashire); MD, Hospital de Basurto (Bilbao, ä å ö Hedblom, MD, Centrallasarettet Delyth Webb, MBChB, Warrington SNQ:Vizcaya, Bizkaia). ö ä ö (V ster s); Kenneth Sj berg, MD, Hospital (Warrington, Cheshire); Ä å ö Jiri Kofron, MD, S dra Centrallasarettet (V xj ); Leif Laweh Amegavie, MBChB, Whiston lvsborgs Sjukhus (Bor s); Thorbj rnsson, MD, Lasarettet Hospital (Prescot, Merseyside); Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 140, number 6, December 2017 13

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics Ahmed Hassan, MBChB, Broomfield MBChB, The Royal Free Hospital MBChB, Alexandra Hospital Hospital (Chelmsford, Essex); (Hampstead, London); Sara Watkin, (Redditch, Worcestershire); Phil Priyadarshan Ambadkar, MBChB, MBChB, University College Hospital Simmons, MBChB, Birmingham James Paget Hospital (Gorleston, (Fitzrovia, London); Aashish Heartlands Hospital (Birmingham, Norfolk); Mark Dyke, MBChB, Gupta, MBChB, Basildon Hospital West Midlands); Julie Nycyk, Norfolk and Norwich University (Basildon, Essex); Narendra MBChB, City Hospital (Birmingham, Hospital (Norwich, Norfolk); Seif Aladangady, MBChB, Homerton West Midlands); Phil Simmons, Babiker, MBChB, Peterborough Hospital (Hackney, London); Imdad MBChB, Good Hope Hospital City Hospital (Peterborough, Ali, MBChB, Newham General (Birmingham, West Midlands); Cambridgeshire); Susan Rubin, Hospital (Newham, London); Lesley Andrew Gallagher, MBChB, ’ MBChB, Queen Elizabeth Hospital, Alsford, MBChB, North Middlesex Worcestershire Royal Hospital University Hospital (Edmonton, (Worcester, Worcestershire); King s Lynn (Birmingham, West ’ Midlands); Amanda Ogilvy-Stuart, London); Khalid Mannan, MBChB, Chrisantha Halahakoon, MBChB, Rosie Maternity Hospital Queen s Hospital (Romford, Essex); MBChB, New Cross Hospital (Addenbrookes, Cambridge, Ebel Rainer, MBChB, The Royal (Wolverhampton, West Midlands); Cambridgeshire); Nagesh Panasa, London Hospital (Whitechapel, Sanjeev Deshpande, MBChB, Royal MBChB, North Manchester General London); Nicholas Wilson, MBChB, Shrewsbury Hospital (Shrewsbury, Hospital (Manchester, Greater Whipps Cross University Hospital Shropshire); Anand Mohite, MBChB, Manchester); Paul Settle, MBChB, (Whipps Cross, London); Mark Russells Hall Hospital (Dudley, Royal Bolton Hospital (Bolton, Thomas, MBChB, Chelsea and West Midlands); Kate Palmer, Lancashire); Jonathan Moise, Westminster Hospital (Chelsea, MBChB, University Hospital of MBChB, Royal Oldham Hospital London); Ramnik Mathur, MBChB, North Staffordshire (Hartshill, ’ (Manchester, Greater Manchester); Ealing Hospital (Southall, London); Staffordshire); Alan Gibson, Ngozi Edi-Osagie, MBChB, St Mary s Michele Cruwys, MBChB, Hillingdon MBChB, Jessop Hospital (Sheffield, Hospital (Hillingdon, London); South Yorkshire); Mehdi Garbash, Hospital (Manchester, Greater ’ Manchester); Christos Zipitis, Sunit Godambe, MBChB, Queen MBChB, Darlington Memorial Charlotte s Hospital (East Acton, Hospital (Darlington, County MBChB, The Robert Albert Edward ’ Infirmary (Wrightington, Greater London); Sunit Godambe, MBChB, Durham); Mithilesh Lal, MBChB, St Mary s Hospital (Westminster, James Cook University Hospital Manchester); Carrie Heal, MBChB, ’ ’ Stepping Hill Hospital (Stockport, London); Timothy Watts, MBChB, (Middlesborough, North Yorkshire); Cheshire); Jacqeline Birch, MBChB, Guy s and St Thomas Hospital Majd Abu-Harb, MBChB, Sunderland Tameside General Hospital (Ashton- (Lambeth, London); Jauro Kuna, Royal Hospital (Sunderland, Tyne and Wear); Mehdi Garbash, MBChB, under-Lyne, Lancashire); Abdul MBChB, University Hospital ó í Hasib, MBChB, Darent Valley Lewisham (Lewisham, London); University Hospital of North Hospital (Dartford, Kent); Aung Soe, John Chang, MBChB, Croydon Durham (Durham, Durham); R is n MBChB, Medway Maritime Hospital University Hospital (Croydon, McKeon-Carter, MBChB, Derriford (Gillingham, Kent); Niraj Kumar, Surrey); Jon Filkin, MBChB, Hospital (Plymouth, Devon); Kingston Hospital (Kingston, Michael Selter, MBChB, North MBChB, Queen Elizabeth The Queen ’ Mother Hospital (Margate, Kent); London); Charlotte Huddy, MBChB, Devon District Hospital (Barnstaple, Hamudi Kisat, MBChB, Tunbridge St George s Hospital (Wandsworth, Devon); Paul Munyard, MBChB, Wells Hospital (Tunbridge Wells, London); Ruth Shephard, MBChB, Royal Cornwall Hospital (Truro, Kent); Vimal Vasu, MBChB, William St. Helier Hospital (Merton, Cornwall); Vaughan Lewis, MBChB, Harvey Hospital (Ashford, Kent); London); Krzystof Zieba, MBChB, Royal Devon and Exeter Hospital Meera Lama, MBChB, Lancashire Northwick Park Hospital (Brent, (Exeter, Devon); Mala Raman, Women & Newborn Centre London); Patti Rao, MBChB, MBChB, Torbay Hospital (Torquay, (Burnley, Lancashire); Richa Gupta, Kettering General Hospital Devon); Graham Whincup, MBChB, MBChB, Royal Preston Hospital (Kettering, Northhamptonshire); Conquest Hospital (St. Leonards- (Preston, Lancashire); Chris Andrew Currie, MBChB, Leicester on-Sea, East Sussex); Abdus Mallik, Rawlingson, MBChB, Blackpool General Hospital (Leicester, MBChB, Frimley Park Hospital Victoria Hospital (Blackpool, Leicestershire); Andrew Currie, (Frimley, Surrey); Philip Amess, MBChB, Leicester Royal Infirmary MBChB, Princess Royal Hospital Lancashire); Tim Wickham, ’ MBChB, Barnet Hospital (Barnet, (Leicester, Leicestershire); Azhar (Telford, Shropshire); Charles Hertfordshire); Karin Schwarz, Manzoor, MBChB, Queen s Hospital, Godden, MBChB, Royal Surrey MBChB, Chase Farm Hospital Burton-on-Trent (Burton-on-Trent, County Hospital (Guildford, Surrey); (Enfield, Middlesex); Van Sommen, Staffordshire); Munir Ahmed, Philip Amess, MBChB, Royal Sussex Downloaded from www.aappublications.org/news by guest on September 23, 2021 14 Helenius et al

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics Abbreviations County’ Hospital (Brighton, East Glourcestershire); Stephen Jones, Sussex); Peter Reynolds, MBChB, St MBChB, Royal United Hospital Peter s Hospital (Chertsey, Surrey); (Avon, Somerset); Paul Mannix, ANZNN: Australian and New Indranil Misra, MBChB, Milton MBChB, Southmead Hospital ’ Zealand Neonatal Keynes Foundation Trust Hospital (Westbury-on-Trym, Bristol); David Network (Milton Keynes, Buckinghamshire); Harding, MBChB, St Michael s CI: confidence interval Naveen Shettihalli, MBChB, Oxford Hospital (Bristol, Bristol); Megan CNN: Canadian Neonatal University Hospitals, Horton Eaton, MBChB, Yeovil District Network Hospital (Oxford, Oxfordshire); Hospital (Yeovil, Somerset); Karin EPICE: Effective Perinatal Peter De Halpert, MBChB, Royal Schwarz, MBChB, Calderdale Royal Intensive Care in Europe Berkshire Hospital (Reading, Hospital (Halifax, West Yorkshire); FinMBR: Finnish Medical Birth Berkshire); Sanjay Salgia, MBChB, David Gibson, MBChB, Dewsbury Register Stoke Mandeville Hospital and District Hospital (Dewsbury, GA: gestational age (Aylesbury, Buckinghamshire); West Yorkshire); Lawrence Miall, iNeo: International Network for Rekha Sanghavi, MBChB, Wexham MBChB, Leeds Neonatal Service Evaluating Outcomes of Park Hospital (Slough, Berkshire); (Leeds, Yorkshire); and David NeonatesEunice Kennedy Ruth Wigfield, MBChB, Basingstoke Gibson, MBChB, Pinderfields INN: Israel NeoShrivernatal Network and North Hampshire Hospital General Hospital (Wakefield, West NICHD NRN: FinMBR: (Basingstoke, Hampshire); Abby Yorkshire). National Deketelaere, MBChB, Dorset County Sture Andersson, MD, Institute of Child Hospital (Dorchester, Dorset); Helsinki University Hospital Health and Human Minesh Khashu, MBChB, Poole (Helsinki); Liisa Lehtonen, MD, Development Hospital NHS Foundation Trust Turku University Hospital (Turku); Neonatal Research (Poole, Dorset); Michael Hall, Outi Tammela, MD, Tampere Network MBChB, Princess Anne Hospital University Hospital (Tampere); NRNJ: Neonatal Research (Southampton, Hampshire); Ulla Sankilampi, MD, Kuopio Network Japan Charlotte Groves, MBChB, Queen University Hospital (Kuopio); and SEN1500: Spanish Neonatal Alexandra Hospital (Portsmouth, ’ Timo Saarela, MD, Oulu University Network Hampshire); Nick Brown, MBChB, HospitalTuscanNN: (Oulu). SNQ: Sweden s National Salisbury District Hospital ’ Quality Registry for Carlo Dani, MD, Careggi (Salisbury, Wiltshire); Nick Neonatal Care University Hospital (Florence); Brennan, MBChB, St Richard s ’ SR: standardized ratio Patrizio Fiorini, MD, Anna Meyer Hospital (Chichester, West Sussex); SwissNeoNet: Swiss Neonatal Children s University Hospital Katia Vamvakiti, MBChB, Worthing Network (Florence); Antonio Boldrini, Hospital (Worthing, West Sussex); TuscanNN: Tuscany Neonatal MD, University Hospital of Pisa Mal Ratnayaka, MBChB, Royal Derby Network (Pisa); and Barbara Tomasini, MD, Hospital (Derby, Derbyshire); Simon UKNC: United Kingdom Neonatal University Hospital of Siena Pirie, MBChB, Gloucestershire Collaborative Royal Hospital (Gloucester, (Siena). Dr Helenius conceptualized and designed the study, acquired, analyzed, and interpreted data, drafted the manuscript, and performed statistical analyses; Dr Shah conceptualized and designed the study, acquired, analyzed, and interpreted data, reviewed and revised the manuscript for important intellectual content, provided administrative, technical, and material support, performed statistical analyses and supervised the study; Drs Lehtonen and Sjörs conceptualized and designed the study, acquired, analyzed, and interpreted data, reviewed and revised the manuscript for important intellectual content, performed statistical analyses, and supervised the study; Drs Modi, Reichman, Morisaki, Kusuda, Lui, Darlow, Bassler, Håkansson, Vento, Rusconi, Isayama, and Lee and Mr Adams acquired, analyzed, and interpreted data and reviewed and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2017-1264 Accepted for publication Aug 16, 2017 Address correspondence to Kjell Helenius, MD, Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Kiinamyllynkatu 4-8, 20521 Turku, Finland. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics FUNDING: Funding for International Network for Evaluating Outcomes of Neonates has been provided by a Canadian Institutes of Health Research Chair in Reproductive and Child Health Services and Policy Research (APR-126340) held by P.S.S. The Australian and New Zealand Neonatal Network is predominantly funded by membership contributions from participating centers. The Canadian Neonatal Network is funded by financial support from the Canadian Institutes of Health Research (FRN87518, PBN150642) and individual participating centers. The Finnish Medical Birth Register is governmentally funded and kept by the National Institute for Health and Welfare (THL). The Israel Neonatal Network very low birth weight infant database is partially funded by the Israel Center for Disease Control and the Ministry of Health. The Neonatal Research Network Japan is partly funded by a Health and Labour Sciences Research grant from the Ministry of Health, Labour and Welfare of Japan. Spanish Neonatal Network is supported by funds from the Spanish Neonatal Society. The National Quality Registry for Neonatal Care is funded by the Swedish Government (Ministry of Health and Social Affairs) and the body of regional health care providers (county councils). Swiss Neonatal Network is partially funded by participating units in the form of membership fees. The Tuscany Neonatal Network is funded by the Tuscany Region. The United Kingdom Neonatal Collaborative receives no core funding. The funding bodies played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. COMPANION PAPER: A companion to this article can be found online at www.pediatrics. org/cgi/doi/10.1542/peds.2017-2808.

References 1. Liu L, Oza S, Hogan D, et al. Global, 1996-1997 and 1999-2000. Pediatrics. mortality rates in Europe between regional, and national causes of child 2007;119(1):29–36 2004 and 2010: results from the mortality in 2000-13, with projections Euro-Peristat project. J Epidemiol 7. Serenius F, Sjörs G, Blennow M, et al; Community Health. 2016;70(6):609 615 to inform post-2015 priorities: an EXPRESS Study Group. EXPRESS study – updated systematic analysis. Lancet. shows significant regional differences 14. Shah PS, Lee SK, Lui K, et al; 2015;385(9966):430–440 in 1-year outcome of extremely International Network for Evaluating 2. Stoll BJ, Hansen NI, Bell EF, et al; preterm infants in Sweden. Acta Outcomes of Neonates (iNeo). The Eunice Kennedy Shriver National Paediatr. 2014;103(1):27–37 International Network for Evaluating Outcomes of very low birth weight, Institute of Child Health and Human 8. Costeloe KL, Hennessy EM, Haider S, very preterm neonates (iNeo): a Development Neonatal Research Stacey F, Marlow N, Draper ES. Short protocol for collaborative comparisons Network. Trends in care practices, term outcomes after extreme preterm of international health services for morbidity, and mortality of extremely birth in England: comparison of two quality improvement in neonatal care. preterm neonates, 1993-2012. JAMA. birth cohorts in 1995 and 2006 (the BMC Pediatr. 2014;14:110 2015;314(10):1039–1051 EPICure studies). BMJ. 2012;345:e7976 15. Sankilampi U, Hannila ML, Saari A, 3. Shah PS, Sankaran K, Aziz K, et al; 9. Numerato D, Fattore G, Tediosi F, et al. Gissler M, Dunkel L. New population- Canadian Neonatal Network. Mortality and length of stay of very based references for birth weight, Outcomes of preterm infants <29 low birth weight and very preterm length, and head circumference weeks gestation over 10-year period infants: a EuroHOPE study. PLoS One. in singletons and twins from 23 in Canada: a cause for concern? 2015;10(6):e0131685 to 43 gestation weeks. Ann Med. J Perinatol. 2012;32(2):132–138 10. García-Muñoz Rodrigo F, Díez Recinos 2013;45(5–6):446–454 AL, Garc a-Alix P rez A, Figueras 4. Ber ger TM, Steurer MA, Woerner A, í é 16. Mar tin LJ, Sj rs G, Reichman B, et al; Aloy J, Vento Torres M. Changes ö Meyer-Schiffer P, Adams M; Swiss International Network for Evaluating in perinatal care and outcomes in Neonatal Network. Trends and centre- Outcomes (iNeo) of Neonates newborns at the limit of viability in to-centre variability in survival rates Investigators. Country-specific vs. Spain: the EPI-SEN study. Neonatology. of very preterm infants (<32 weeks) common birthweight-for-gestational 2015;107(2):120 129 over a 10-year-period in Switzerland. – age references to identify small for Arch Dis Child Fetal Neonatal Ed. 11. Grisaru-Granovsky S, Reichman B, gestational age infants born at 24-28 2012;97(5):F323–F328 Lerner-Geva L, et al; Israel Neonatal weeks: an international study. Paediatr 5. Ancel P-Y, Goffinet ,F Kuhn P, et al; Network. Population-based trends in Perinat Epidemiol. 2016;30(5):450–461 mortality and neonatal morbidities EPIPAGE-2 Writing Group. Survival and 17. Ber tino E, Spada E, Occhi L, et al. among singleton, very preterm, very morbidity of preterm children born Neonatal anthropometric charts: the low birth weight infants over 16 years. at 22 through 34 weeks’ gestation Italian neonatal study compared with Early Hum Dev. 2014;90(12):821 827 in France in 2011: results of the – other European studies. J Pediatr EPIPAGE-2 cohort study [published 12. Fellman V, Hellström-Westas L, Norman Gastroenterol Nutr. 2010;51(3):353–361 correction appears in JAMA Pediatr. M, et al; EXPRESS Group. One-year 18. Shah PS, Lui K, Sj rs G, et al; 2015;169(4):323]. JAMA Pediatr. ö survival of extremely preterm infants International Network for Evaluating 2015;169(3):230 238 – after active perinatal care in Sweden. Outcomes (iNeo) of Neonates. Neonatal JAMA. 2009;301(21):2225 2233 6. Tommiska V, Heinonen K, Lehtonen – outcomes of very low birth weight L, et al. No improvement in outcome 13. Zeitlin J, Mortensen L, Cuttini M, et al; and very preterm neonates: an of nationwide extremely low birth Euro-Peristat Scientific Committee. international comparison. J Pediatr. weight infant populations between Declines in stillbirth and neonatal 2016;177:144–152.e6

Downloaded from www.aappublications.org/news by guest on September 23, 2021 16 Helenius et al

Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics 19. Draper ES, Manktelow BN, Cuttini M, Arch Dis Child Fetal Neonatal Ed. J Pediatr. 2013;162(6):1125–1132, 1132. et al; EPICE Cohort. Variability in very 2009;94(6):F407–F413 e1–e4 preterm stillbirth and in-hospital 24. Zegers MJ, Hukkelhoven CWPM, 29. Papiernik E, Zeitlin J, Delmas D, mortality across Europe. Pediatrics. Uiterwaal CSPM, Kollée LAA, et al; MOSAIC Research Group. 2017;139(4):e20161990 Groenendaal F. Changing Dutch Termination of pregnancy among 20. Phibbs CS, Baker LC, Caughey AB, approach and trends in short-term very preterm births and its impact Danielsen B, Schmitt SK, Phibbs outcome of periviable preterms. on very preterm mortality: results RH. Level and volume of neonatal Arch Dis Child Fetal Neonatal Ed. from ten European population-based intensive care and mortality in very- 2016;101(5):F391–F396 cohorts in the MOSAIC study. BJOG. low-birth-weight infants. N Engl J Med. 25. Ishii N, Kono Y, Yonemoto N, Kusuda 2008;115(3):361–368 2007;356(21):2165–2175 S, Fujimura M; Neonatal Research 30. Eventov-Friedman S, Kanevsky H, Bar-Oz 21. Synnes AR, Macnab YC, Qiu Z, et al; Network, Japan. Outcomes of infants B. Neonatal end-of-life care: a single- Canadian Neonatal Network. Neonatal born at 22 and 23 weeks’ gestation. center NICU experience in Israel over intensive care unit characteristics Pediatrics. 2013;132(1): a decade. Pediatrics. 2013;131(6). affect the incidence of severe 62–71 Available at: www.pediatrics.org/cgi/ intraventricular hemorrhage. Med 26. Patel RM, Kandefer S, Walsh MC, content/full/131/6/e1889 Care. 2006;44(8):754–759 et al; Eunice Kennedy Shriver 31. Rautava L, Lehtonen L, Peltola M, et al; 22. Rysavy MA, Li L, Bell EF, et al; National Institute of Child Health PERFECT Preterm Infant Study Group. Eunice Kennedy Shriver National and Human Development Neonatal The effect of birth in secondary- or Institute of Child Health and Human Research Network. Causes and timing tertiary-level hospitals in Finland on Development Neonatal Research of death in extremely premature mortality in very preterm infants: Network. Between-hospital variation in infants from 2000 through 2011. a birth-register study. Pediatrics. treatment and outcomes in extremely N Engl J Med. 2015;372(4): 2007;119(1). Available at: www. preterm infants. N Engl J Med. 331–340 pediatrics.org/cgi/content/full/119/1/ 2015;372(19):1801–1811 27. Mohamed MA, Nada A, Aly H. Day-by-day e257 23. Fischer N, Steurer MA, Adams M, postnatal survival in very low birth 32. Synnes A, Luu TM, Moddemann D, et al; Berger TM; Swiss Neonatal Network. weight infants. Pediatrics. 2010;126(2). Canadian Neonatal Network and the Survival rates of extremely preterm Available at: www.pediatrics.org/cgi/ Canadian Neonatal Follow-Up Network. infants (gestational age <26 weeks) content/full/126/2/e360 Determinants of developmental in Switzerland: impact of the 28. Corchia C, Ferrante P, Da Frè M, outcomes in a very preterm Canadian Swiss guidelines for the care of et al. Cause-specific mortality of very cohort. Arch Dis Child Fetal Neonatal infants born at the limit of viability. preterm infants and antenatal events. Ed. 2017;102(3):F235–F234

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Helenius et al 2017 ROUGH GALLEY PROOF Survival in Very Preterm Infants: An https://doi.org/10.1542/peds.2017-1264 December 2017 International Comparison of 10 National Neonatal Networks 6 140 Pediatrics Survival in Very Preterm Infants: An International Comparison of 10 National Neonatal Networks Kjell Helenius, Gunnar Sjörs, Prakesh S. Shah, Neena Modi, Brian Reichman, Naho Morisaki, Satoshi Kusuda, Kei Lui, Brian A. Darlow, Dirk Bassler, Stellan Håkansson, Mark Adams, Maximo Vento, Franca Rusconi, Tetsuya Isayama, Shoo K. Lee, Liisa Lehtonen and on behalf of the International Network for Evaluating Outcomes (iNeo) of Neonates Pediatrics 2017;140; DOI: 10.1542/peds.2017-1264 originally published online November 21, 2017;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/140/6/e20171264 References This article cites 32 articles, 12 of which you can access for free at: http://pediatrics.aappublications.org/content/140/6/e20171264#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Fetus/Newborn Infant http://www.aappublications.org/cgi/collection/fetus:newborn_infant_ sub Neonatology http://www.aappublications.org/cgi/collection/neonatology_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 23, 2021 Survival in Very Preterm Infants: An International Comparison of 10 National Neonatal Networks Kjell Helenius, Gunnar Sjörs, Prakesh S. Shah, Neena Modi, Brian Reichman, Naho Morisaki, Satoshi Kusuda, Kei Lui, Brian A. Darlow, Dirk Bassler, Stellan Håkansson, Mark Adams, Maximo Vento, Franca Rusconi, Tetsuya Isayama, Shoo K. Lee, Liisa Lehtonen and on behalf of the International Network for Evaluating Outcomes (iNeo) of Neonates Pediatrics 2017;140; DOI: 10.1542/peds.2017-1264 originally published online November 21, 2017;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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