331 - Infant Mortality due to Pulmonary Hemorrhage in the Perinatal Period: A longitudinal Study of Changing Trends in the United States, 1999-2020.

Poster Number: 331
Publication Number: 331.1685

Background: Pulmonary hemorrhage (PHEM) occurs in 2-9% of preterm infants admitted to the NICU. It has a high mortality rate (50-80%) and significant morbidity in survivors (Ahmad et al., 2019). Data regarding the incidence and trends of PHEM-related mortality in the United States are currently lacking.

Objective: To assess temporal trends, demographics, and interstate variations in the infant mortality rate associated with pulmonary hemorrhage (PHEM-IMR) over the past two decades.

Design/Methods: Using the CDC-WONDER birth/infant death linked database from 1999 to 2020, we analyzed temporal trends of infant deaths attributed to PHEM, utilizing the ICD-10 code: P26 -Pulmonary hemorrhage originating in the perinatal period. IMR data was presented per 100,000 live births, with Poisson-modeled 95% confidence intervals (CI). Trends and annual percentage changes (APCs) were determined using Joinpoint regression 4.9.1.0 (National Cancer Institute, USA). We conducted bivariate analysis to examine IMR based on gender, race, and ethnicity with statistical significance set at p<.05.

Results: Between 1999 and 2020, out of 88,125,233 births, 3,927 (0.005%) infants died due to PHEM. Majority (84%) of these fatalities occurred within the first week of life. Male infants constituted 61% of deaths and Black infants showed higher mortality, while Asian infants exhibited lower mortality compared to White infants [Table 1]. The incidence of PHEM-IMR demonstrated a consistent decline, decreasing from 6.8 (95% CI: 6.0, 7.6) in 1999 to 3.4 (95% CI: 2.8, 4.0) per 100,000 live births in 2020. The median incidence of PHEM-IMR across states was 4.3 (IQR: 3.1, 5.5) per 100,000 live births [Figure 1]. An eight-fold variation in PHEM mortality incidence was observed among different states in the United States. Significant reduction occurred between 1999 and 2003, (APC of 13.0 [95% CI: -19.5, -5.9]; p=.001) followed by a gradual decline in mortality [Figure 2].

Conclusion(s): Over the last two decades, the incidence of PHEM mortality has notably declined, aligning with the improved survival among preterm infants across the United States. However, considerable variation exists across the states and by race. We speculate that the sharp inflection point in PHEM-IMR coincides with increasing adoption of porcine surfactant for RDS and a change in management of PDA, both of which are well-recognized risk factors for PHEM. Additionally, escalated antenatal steroid utilization, gentle ventilation and the broader implementation of QI initiatives concerning surfactant therapy may have collectively contributed to a reduction in PHEM-related mortality.