Article Text

Download PDFPDF
Five-minute Apgar score and outcomes in neonates of 24–28 weeks’ gestation
  1. Prakesh S Shah1,2,
  2. Mikael Norman3,
  3. Franca Rusconi4,
  4. Satoshi Kusuda5,
  5. Brian Reichman6,
  6. Malcolm Battin7,
  7. Dirk Bassler8,
  8. Neena Modi9,
  9. Stellan Hakansson10,
  10. Jie Yang11,
  11. Shoo K Lee2,11,
  12. Kjell Helenius12,13,
  13. Maximo Vento14,
  14. Liisa Lehtonen12,13,
  15. Mark Adams8,
  16. Tetsuya Isayama15,
  17. Kei Lui16,
  18. Luigi Gagliardi17
  19. on behalf of International Network for Evaluating Outcomes of Neonates (iNeo) Investigators
    1. 1 Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
    2. 2 Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
    3. 3 Department of Neonatal Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
    4. 4 Unit of Epidemiology, Anna Meyer Children's University Hospital and Regional Health Agency, Florence, Italy
    5. 5 Neonatal Research Network Japan, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
    6. 6 Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel
    7. 7 Department of Neonatology, Auckland District Health Board, Auckland, New Zealand
    8. 8 Swiss Neonatal Network, Department of Neonatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
    9. 9 UK Neonatal Collaborative, Neonatal Data Analysis Unit, Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, UK
    10. 10 Department of Clinical Science/Pediatrics, Umeå University, Umeå, Sweden
    11. 11 Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
    12. 12 Department of Pediatrics and Adolescent Medicine, Turku University Hospital and University of Turku, Turku, Finland
    13. 13 Department of Clinical Medicine, University of Turku, Turku, Finland
    14. 14 Division of Neonatology, Health Research Institute La Fe, Valencia, Spain
    15. 15 Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
    16. 16 Department of Newborn Care, Royal Hospital for Women and School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia
    17. 17 Division of Neonatology and Pediatrics, Ospedale Versilia, Viareggio, Azienda USL Toscana Nord Ovest, Italy
    1. Correspondence to Dr Prakesh S Shah, Paediatrics, Sinai Health System, Toronto, ON M5G 1X5, Canada; pshah{at}


    Objectives To assess associations between 5 min Apgar score and mortality and severe neurological injury (SNI) and to report test characteristics in preterm neonates.

    Design, setting and patients Retrospective cohort study of neonates 240 to 286 weeks’ gestation born between 2007 and 2016 and admitted to neonatal units in 11 high-income countries.

    Exposure 5 min Apgar score.

    Main outcome measures In-hospital mortality and SNI defined as grade 3 or 4 periventricular/intraventricular haemorrhage or periventricular leukomalacia. Outcome rates were calculated for each Apgar score and compared after adjustment. The diagnostic characteristics and ORs for each value from 0 versus 1–10 to 0–9 versus 10, with 1-point increments were calculated.

    Results Among 92 412 included neonates, as 5 min Apgar score increased from 0 to 10, mortality decreased from 60% to 8%. However, no clear increasing or decreasing pattern was identified for SNI. There was an increase in sensitivity and decrease in specificity for both mortality and SNI associated with increasing scores. The Apgar score alone had an area under the curve of 0.64 for predicting mortality, which increased to 0.73 with the addition of gestational age.

    Conclusions In neonates of 24–28 weeks’ gestation admitted to neonatal units, higher 5 min Apgar score was associated with lower mortality in a graded manner, while the association with SNI remained relatively constant at all scores. Among survivors, low Apgar scores did not predict SNI.

    • mortality
    • neurology
    • neonatology

    Data availability statement

    No data are available.

    Statistics from

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    No data are available.

    View Full Text


    • Twitter @NeenaModi1

    • Collaborators Collaborating International Network for Evaluating Outcomes of Neonates (iNeo) Investigators and Affiliations: Australian and New Zealand Neonatal Network (

      ANZNN): Kei Lui* Chair of ANZNN. Flinders Medical Centre, SA: Peter Marshall. Gold Coast University Hospital, QLD: Peter Schmidt. Blacktown District Hospital, NSW: Anjali Dhawan*. John Hunter Children’s Hospital, NSW: Larissa Korostenski and Javeed Travadi*. King Edward Memorial and Perth Children’s Hospitals, WA: Mary Sharp, Andy Gill* and Jane Pillow*. Liverpool Hospital, NSW: Jacqueline Stack. Mater Mothers' Hospital, QLD: Pita Birch and Karen Nothdurft*. Neonatal Retrieval Emergency Service Southern Queensland, QLD: Lucy Cooke*. Mercy Hospital for Women, VIC: Dan Casalaz and Jim Holberton*. Monash Medical Centre, VIC: Alice Stewart. Nepean Hospital, NSW: Lyn Downe. Paediatric Infant Perinatal Emergency Retrieval (VIC): Michael Stewart. NSW Newborn & Paediatric Emergency Transport Service: Andrew Berry. Royal Children's Hospital, VIC: Rod Hunt*. Royal Darwin Hospital, NT: Peter Morris. Royal Hobart Hospital, Tasmania: Tony De Paoli. Royal Hospital for Women, NSW: Kei Lui* and Srinivas Bolisetty. Royal North Shore Hospital, NSW: Mary Paradisis. Royal Prince Alfred Hospital, NSW: Mark Greenhalgh. Royal Brisbane and Women's Hospital, QLD: Pieter Koorts. Royal Women's Hospital, VIC: Carl Kuschel, Sue Jacobs and Lex Doyle. SAAS MedSTAR Emergency Medical Retrieval Services: John Craven. Sydney Children's Hospital, NSW: Andrew Numa. The Canberra Hospital, ACT: Hazel Carlisle. The Children's Hospital at Westmead, NSW: Nadia Badawi and Himanshu Popat. The Townsville Hospital, QLD: Guan Koh. Neonatal Emergency Transport Service of Western Australia: Jonathan Davis. Westmead Hospital, NSW: Melissa Luig. Women's & Children's Hospital, SA: Bevan Headley and Chad Andersen*. Australian College of Neonatal Nurses: Linda Ng*. National Perinatal Epidemiology and Statistics Unit, University of New South Wales: Georgina Chambers*. New Zealand: Christchurch Women's Hospital: Nicola Austin, Adrienne Lynn. University of Otago, Christchurch: Brian Darlow. Dunedin Hospital: Liza Edmonds. Middlemore Hospital: Lindsay Mildenhall. Auckland City Hospital: Mariam Buksh and Malcolm Battin*. Waikato Hospital: Jutta van den Boom. Wellington Women's Hospital: Vaughan Richardson. Whangarei Hospital: David Barker*. Neonatal Nurses College Aotearoa: Barbara Hammond*. Singapore: KK Women's and Children's Hospital, Singapore: Victor Samuel Rajadurai*. Hong Kong: Prince of Wales Hospital: Simon Lam. United Christian Hospital: Genevieve Fung. *Denotes the ANZNN Executive Committee. Canadian Neonatal Network: Prakesh S Shah, MD, MSc (Director, Canadian Neonatal Network and Site Investigator), Mount Sinai Hospital, Toronto, Ontario; Marc Beltempo, MD, (Associate Director, Canadian Neonatal Network and Site Investigator), Montreal Children’s Hospital at McGill University Health Centre, Montréal, Québec; Jaideep Kanungo, MD, Victoria General Hospital, Victoria, British Columbia; Joseph Ting, MD, British Columbia Women’s Hospital, Vancouver, British Columbia; Zenon Cieslak, MD, Royal Columbian Hospital, New Westminster, British Columbia; Rebecca Sherlock, MD, Surrey Memorial Hospital, Surrey, British Columbia; Ayman Abou Mehrem, MD, Foothills Medical Centre, Calgary, Alberta; Jennifer Toye, MD, and Khalid Aziz, MBBS, Royal Alexandra Hospital, Edmonton, Alberta; Carlos Fajardo, MD, Alberta Children’s Hospital, Calgary, Alberta; Jaya Bodani, MD, Regina General Hospital, Regina, Saskatchewan; Lannae Strueby, MD, Royal University Hospital, Saskatoon, Saskatchewan; Mary Seshia, MBChB, and Deepak Louis, MD, Winnipeg Health Sciences Centre, Winnipeg, Manitoba; Ruben Alvaro, MD, St. Boniface General Hospital, Winnipeg, Manitoba; Amit Mukerji, MD, Hamilton Health Sciences Centre, Hamilton, Ontario; Orlando Da Silva, MD, MSc, London Health Sciences Centre, London, Ontario; Mohammad Adie, MD, Windsor Regional Hospital, Windsor, Ontario; Kyong-Soon Lee, MD, MSc, Hospital for Sick Children, Toronto, Ontario; Eugene Ng, MD, Sunnybrook Health Sciences Centre, Toronto, Ontario; Brigitte Lemyre, MD, The Ottawa Hospital, Ottawa, Ontario; Thierry Daboval, MD, Children’s Hospital of Eastern Ontario, Ottawa, Ontario; Faiza Khurshid, MD, Kingston General Hospital, Kingston, Ontario; Ermelinda Pelausa, MD, Jewish General Hospital, Montréal, Québec; Keith Barrington, MBChB, Anie Lapoint, MD and Guillaume Ethier, NNP, Hôpital Sainte-Justine, Montréal, Québec; Christine Drolet, MD, and Bruno Piedboeuf, MD, Centre Hospitalier Universitaire de Québec, Sainte Foy, Québec; Martine Claveau, MSc, LLM, NNP, Montreal Children’s Hospital at McGill University Health Centre, Montréal, Québec; Marie St-Hilaire, MD, Hôpital Maisonneuve-Rosemont, Montréal, Québec; Valerie Bertelle, MD, and Edith Masse, MD, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec; Roderick Canning, MD, Moncton Hospital, Moncton, New Brunswick; Hala Makary, MD, Dr. Everett Chalmers Hospital, Fredericton, New Brunswick; Cecil Ojah, MBBS, and Luis Monterrosa, MD, Saint John Regional Hospital, Saint John, New Brunswick; Julie Emberley, MD, Janeway Children’s Health and Rehabilitation Centre, St. John’s, Newfoundland; Jehier Afifi, MB BCh, MSc, IWK Health Centre, Halifax, Nova Scotia; Andrzej Kajetanowicz, MD, Cape Breton Regional Hospital, Sydney, Nova Scotia; and Shoo K Lee, MBBS, PhD (Chairman, Canadian Neonatal Network), Mount Sinai Hospital, Toronto, Ontario. Finnish Medical Birth Register: Marjo Metsäranta, MD, Helsinki University Hospital, Helsinki; Liisa Lehtonen, MD, Turku University Hospital, Turku; Outi Tammela, MD, Tampere University Hospital, Tampere; Ulla Sankilampi, MD, Kuopio University Hospital, Kuopio; and Timo Saarela, MD, Oulu University Hospital, Oulu. Israel Neonatal Network: Iris Morag, MD, Assaf Harofeh Medical Centre, Tzrifin; Shmuel Zangen, MD, Barzilai Medical Centre, Ashkelon; Tatyana Smolkin, MD, Baruch Padeh Medical Centre, Poriya; Francis Mimouni, MD, Bikur Cholim Hospital, Jerusalem; Arieh Riskin, MD, Bnai Zion Medical Centre, Haifa; Karen Lavie-Nevo, MD, Carmel Medical Centre, Haifa; Zipora Strauss, Chaim Sheba Medical Centre, Ramat Gan; Clari Felszer, MD, Emek Medical Centre, Afula; Hussam Omari, MD, French Saint Vincent de Paul Hospital, Nazareth; Smadar Even Tov-Friedman, MD, Hadassah University Hospital-Ein Karem, Jerusalem; Smadar Even Tov-Friedman, MD, Hadassah University Hospital-Har Hazofim, Jerusalem; Amit Hochberg, MD, Hillel Yaffe Medical Centre, Hadera; Nizar Saad, MD, Holy Family (Italian) Hospital, Nazareth; Orna Flidel-Rimon, MD, Kaplan Medical Centre, Rehovot; Aryeh Simmonds, MD, Laniado Hospital, Netanya; Daniel Lubin, MD, Mayanei Hayeshua Medical Centre, Bnei Brak; Sofia Bauer, MD, Meir Medical Centre, Kfar Saba; Amir Kugelman, MD, Rambam Medical Centre; Eric Shinwell, MD, Rivka Ziv Medical Centre, Safed; Gil Klinger, MD, Schneider Children’s Medical Centre of Israel, Rabin Medical Centre (Beilinson Campus), Petah Tikva; Yousif Nijim, MD, Scottish (EMMS) Hospital, Nazareth; Alona Bin-Nun, MD, Shaare-Zedek Medical Centre, Jerusalem; Eilon Shani, MD, Soroka Medical Centre, Beersheba; Dror Mandel, MD, Sourasky Medical Centre, Tel Aviv; Vered Fleisher-Sheffer, MD,Western Galilee Medical Centre, Nahariya; Anat Oron, MD, Wolfson Medical Centre, Holon; and Lev Bakhrakh, MD, Yoseftal Hospital, Eilat. Neonatal Research Network Japan: Satoshi Hattori, MD, Sapporo City Hospital, Sapporo, Hokkaido; Masaru Shirai, MD, Asahikawa Kosei Hospital, Asahikawa, Hokkaido; Toru Ishioka, MD, Engaru Kosei Hospital, Engaru, Hokkaido; Toshihiko Mori, MD, NTT East Sappro Hospital, Sapporo, Hokkaido; Takasuke Amizuka, MD, Aomori Prefecture Central Hospital, Aomori, Aomori; Toru Huchimukai, MD, Iwate Prefecture Ohfunato Hospital, Ofunato, Iwate; Hiroshi Yoshida, MD, Tsuruoka City Shonai Hospital, Tsuruoka, Yamagata; Ayako Sasaki, MD, Yamagata University, Yamagata, Yamagata; Junichi Shimizu, MD, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki; Toshihiko Nakamura, MD, National Nishisaitama Central Hospital, Tokorozawa, Saitama; Mami Maruyama, MD, Jichi Medical University Saitame Medical Centre, Omiya, Saitama; Hiroshi Matsumoto, MD, Asahi Central Hospital, Asahi, Chiba; Shinichi Hosokawa, MD, National International Medical Centre, Shinjuku, Tokyo; Atsuko Taki, MD, Tokyo Medical and Dental University, Bunkyo, Tokyo; Machiko Nakagawa, MD, Saint Luku Hospital, Chuo, Tokyo; Kyone Ko, MD, Sanikukai Hospital, Sumida, Tokyo; Azusa Uozumi, MD, Odawara City Hospital, Odawara, Kanagawa; Setsuko Nakata, MD, Iida City Hospital, Iida, Nagano; Akira Shimazaki, MD, National Shinshu Ueda Medical Centre, Ueda, Nagano; Tatsuya Yoda, MD, Saku General Hospital, Saku, Nagano; Osamu Numata, MD, Nagaoka Red Cross Hospital, Nagaoka, Niigata; Hiroaki Imamura, MD, Koseiren Takaoka Hospital, Takaoka, Toyama; Azusa Kobayashi, MD, Kanazawa Medical University, Kanazawa, Kanazawa; Shuko Tokuriki, MD, Fukui University, Fukui, Fukui; Yasushi Uchida, MD, National Nagara Medical Centre, Nagara, Gifu; Takahiro Arai, MD, Takayama Red Cross Hospital, Takayama, Gifu; Mitsuhiro Ito, MD, Fujieda City Hospital, Fujieda, Shizuoka; Kuniko Ieda, MD, Koritsu Tosei Hospital, Toyota, Aichi; Toshiyuki Ono, MD, Komaki City Hospital, Komaki, Aichi; Masashi Hayashi, MD, Okazaki City Hospital, Okazaki, Aichi; Kanemasa Maki, MD, Yokkaichi City Hospital, Yokkaichi, MieToru Yamakawa, MD, Japan Baptist Hospital, Kyoto, Kyoto; Masahiko Kawai, MD, Kyoto University, Kyoto, Kyoto; Noriko Fujii, MD, Fukuchiyama City Hospital, Fukuchiyama, Kyoto; Kozue Shiomi, MD, Kyoto City Hospital, Kyoto, Kyoto; Koji Nozaki, MD, Mitubishi Kyoto Hospital, Kyoto, Kyoto; Hiroshi Wada, MD, Yodogawa Christian Hospital, Osaka, Osaka; Taho Kim, MD, Osaka City Sumiyoshi Hospital, Osaka, Osaka; Yasuyuki Tokunaga, MD, Toyonaka City Hospital, Toyonaka, Osaka; Yasuyuki Tokunaga, MD, National Cerebral and Cardiovascular Centre, Suita, Osaka; Akihiro Takatera, MD, Chifune Hospital, Osaka, Osaka; Toshio Oshima, MD, Bell Land General Hospital, Sakai, Osaka; Hiroshi Sumida, MD, Rinku General Hospital, Izumisano, Osaka; Yae Michinomae, MD, Yao City Hospital, Yao, Osaka; Yoshio Kusumoto, MD, Osaka General Medical Centre, Osaka, Osaka; Seiji Yoshimoto, MD, Kobe Children's Hospital, Kobe, Hyogo; Takeshi Morisawa, MD, Kakogawa City Hospital, Kakogawa, Hyogo; Tamaki Ohashi, MD, Hyogo Prefectural Awaji Hospital, Sumoto, Hyogo; Yukihiro Takahashi, MD, Nara Prefecture Medical University, Kashiwara, Nara; Moriharu Sugimoto, MD, Tsuyama Central Hospital, Tsuyama, Okayama; Noriaki Ono, MD, Hiroshima University, Hiroshima, Hiroshima; Shinichiro Miyagawa, MD, National Kure Medical Centre, Kure, Hiroshima; Takahiko Saijo, MD, Tokushima University, Tokushima, Tokushima; Takashi Yamagami, MD, Tokushima City Hospital, Tokushima, Tokushima; Kosuke Koyano, MD, Kagawa University, Kida, Kagawa; Shoko Kobayashi, MD, Shikoku Medical Centre for Children and Adults, Zentsuji, Kagawa; Takeshi Kanda, MD, National Kyushu Medical Centre, Fukuoka, Fukuoka; Yoshihiro Sakemi, MD, National Kokura Medical Centre, Kitakyushu, Fukuoka; Mikio Aoki, MD, National Nagasaki Medical Centre, Nagasaki, Nagasaki; Koichi Iida, MD, Oita Prefectural Hospital, Oita, Oita; Mitsushi Goshi, MD, Nakatsu City Hospital, Nakatsu, Oita; and Yuko Maruyama, MD, Imakyure General Hospital, Kagoshima, Kagoshima. SEN1500 (Spanish Neonatal Network): Alejandro Avila-Alvarez, MD, and José Luis Fernandez-Trisac, MD, Complexo Hospitalario Universitario De A Coruña, A Coruña; Mª Luz Couce Pico, MD, and María José Fernández Seara, MD, Hospital Clínico Universitario de Santiago, Santiago de Compostela; Andrés Martínez Gutiérrez, MD, Complejo Hospitalario Albacete, Albacete; Carolina Vizcaíno, MD, Hospital General Universitario de Elche, Alicante; Miriam Salvador Iglesias, MD, and Honorio Sánchez Zaplana, MD, Hospital General Universitario de Alicante, Alicante; Belén Fernández Colomer, MD, and José Enrique García López, MD, Hospital Universitario Central de Asturias, Oviedo, Asturias; Rafael García Mozo, MD, and M. Teresa González Martínez, MD, Hospital Universitario de Cabueñes, Gijón, Asturias; Mª Dolores Muro Sebastián, MD, and Marta Balart Carbonell, MD, Clínica Corachán, Barcelona; Joan Badia Barnusell, MD, and Mònica Domingo Puiggròs, MD, Corporacio Parc Taulí, Sabadell, Barcelona; Josep Figueras Aloy, MD, and Francesc Botet Mussons, MD, Hospital Clínic de Barcelona, Barcelona; Israel Anquela Sanz, MD, Hospitalario De Granollers, Granollers; Gemma Ginovart Galiana, MD, H. De La Santa Creu I Sant Pau, Barcelona; W Coroleu, MD, Hospital Universitari Germans Trias I Pujol, Badalona; Martin Iriondo, MD, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona; Laura Castells Vilella, MD, Hospital General de Cataluña, Barcelona; Roser Porta, MD, Institute Dexeus, Barcelona; Xavier Demestre, MD, and Silvia Martínez Nadal, MD, Scias-Hospital Barcelona, Barcelona; Cristina de Frutos Martínez, MD, Hospital Universitario de Burgos, Burgos; María Jesús López Cuesta, MD, H. San Pedro de Alcántara, Cáceres; Dolores Esquivel Mora, MD, and Joaquín Ortiz Tardío, MD, Hospital Jerez, Cádiz; Isabel Benavente, MD, and Almudena Alonso, MD, Hospital Universitario Puerta Del Mar, Cádiz; Ramón Aguilera Olmos, MD, Hospital General de Castellón, Castellón; Miguel A. García Cabezas, MD, and Mª Dolores Martínez Jiménez, MD, Hospital General Universitario de Ciudad Real, Ciudad Real; Mª Pilar Jaraba Caballero, MD, and Mª Dolores Ordoñez Díaz, MD, Hospital Universitario Reina Sofía, Córdoba; Alberto Trujillo Fagundo, MD, and Lluis Mayol Canals, MD, Hospital Universitari de Girona Dr. Josep Trueta, Girona; Fermín García-Muñoz Rodrigo, MD, and Lourdes Urquía Martí, MD, H.M.I. Las Palmas, Las Palmas, Gran Canaria; María Fernanda Moreno Galdo, MD, and José Antonio Hurtado Suazo, MD, Hospital Universitario Virgen De Las Nieves, Granada; Eduardo Narbona López, and José Uberos Fernández, MD, Hospital Universitario San Cecilio, Granada; Miguel A Cortajarena Altuna, MD, and Oihana Muga Zuriarrain Hospital, MD, Donostia, Gipuzkoa; David Mora Navarro, MD, Hospital Juan Ramón Jiménez, Huelva; María Teresa Domínguez, MD, Hospital Costa De La Luz, Huelva; Mª Yolanda Ruiz del Prado, MD, and Inés Esteban Díez, MD, Hospital San Pedro, Logroño, La Rioja; María Teresa Palau Benavides, MD, and Santiago Lapeña, MD, Hospital de León, León, León; Teresa Prada, MD, Hospital del Bierzo, Ponferrada, León; Eduard Soler Mir, MD, Hospital Arnau De Vilanova, Lleida; Araceli Corredera Sánchez, MD, Enrique Criado Vega, MD, Náyade del Prado, MD, and Cristina Fernández, MD, Hospital Clínico San Carlos, Madrid; Lucía Cabanillas Vilaplana, MD, and Irene Cuadrado Pérez, MD, Hospital Universitario De Getafe, Madrid; Luisa López Gómez, MD, Hospital De La Zarzuela, Madrid; Laura Domingo Comeche, MD, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid; Isabel Llana Martín, MD, Hospital Madrid-Torrelodones, Madrid, Madrid; Carmen González Armengod, MD, and Carmen Muñoz Labián, MD, Hospital Universitario Puerta De Hierro, Majadahonda, Madrid; Mª José Santos Muñoz, MD, Hospital Severo Ochoa, Leganés, Madrid; Dorotea Blanco Bravo, MD, and Vicente Pérez, MD, Hospital Gregorio Marañón, Madrid; Mª Dolores Elorza Fernández, MD, Celia Díaz González, MD, and Susana Ares Segura, MD, H.U. La Paz, Madrid; Manuela López Azorín, MD, Hospital Universitario Quirónsalud Madrid, Madrid; Ana Belén Jimenez, MD, Hospital Universitario Fundación Jiménez Díaz, Madrid; Tomás Sánchez-Tamayo, MD, and Elías Tapia Moreno, MD, Hospital Carlos Haya, Málaga; María González, MD, and José Enrique Sánchez Martínez, MD, Hospital Parque San Antonio De Málaga, Málaga; José María Lloreda García, MD, Hospital Universitario Santa Lucia De Cartagena, Murcia; Concepción Goñi Orayen, MD, Hospital Virgen Del Camino De Pamplona, Pamplona, Navarra; Javier Vilas González, MD, Complexo Hospitalario Pontevedra, Pontevedra; María Suárez Albo, MD, and Eva González Colmenero, MD, Hospital Xeral De Vigo, Pontevedra; Elena Pilar Gutiérrez González, MD, and Beatriz Vacas del Arco, MD, Hospital Universitario de Salamanca, Salamanca; Josefina Márquez Fernández, MD, and Laura Acosta Gordillo, MD, Hospital Valme, Sevilla; Mercedes Granero Asensio, MD, Hospital Virgen De La Macarena, Sevilla; Carmen Macías Díaz, MD, Hospital Universitario Virgen Del Rocío, Sevilla; Mar Albújar, MD, Hospital Universitari de Tarragona Joan XXIII, Tarragona; Pedro Fuster Jorge, MD, Hospital Universitario De Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife; Sabina Romero, MD, and Mónica Rivero Falero, MD, Hospital Universitario Nuestra Señora De Candelaria, Santa Cruz de Tenerife; Ana Belén Escobar Izquierdo, Hospital Virgen De La Salud, Toledo; Javier Estañ Capell, MD, Hospital Clinico Universitario De Valencia, Valencia; Mª Isabel Izquierdo Macián, MD, Hospital Universitari La Fe, Valencia; Mª Mar Montejo Vicente, MD, and Raquel Izquierdo Caballero, MD, Hospital Universitario Río Hortega, Valladolid; Mª Mercedes Martínez, MD, and Aintzane Euba, MD, Hospital de Txagorritxu, Vitoria-Gasteiz; Amaya Rodríguez Serna, MD, and Juan María López de Heredia Goya, MD, Hospital de Cruces, Baracaldo; Alberto Pérez Legorburu, MD, and Ana Gutiérrez Amorós, MD, Hospital Universitario de Basurto, Bilbao; Víctor Manuel Marugán Isabel, MD, and Natalio Hernández González, MD, Hospital Virgen De La Concha - Complejo Asistencial De Zamora, Zamora; Segundo Rite Gracia, MD, Hospital Miguel Servet, Zaragoza; and Mª Purificación Ventura Faci, MD, and Mª Pilar Samper Villagrasa, MD, Hospital Clínico Universitario Lozano Blesa, Zaragoza. Swedish Neonatal Quality Register: Zeljka Mustapic, MD, Södra Älvsborgs Sjukhus, Borås; Katarina Strand Brodd, MD, Mälarsjukhuset, Eskilstuna; Andreas Odlind, MD, Falu Lasarett, Falun; Per Friskopp, MD, Gällivare Sjukhus, Gällivare; Sofia Arwehed, MD, Gävle Sjukhus, Gävle; Ola Hafström, MD, SU/Östra, Göteborg; Anna Kasemo, MD, Länssjukhuset, Halmstad; Karin Nederman, MD, Helsingborgs Lasarett, Helsingborg; Thomas Hägg, MD, Hudiksvalls Sjukhus, Hudiksvall; Fredrik Ingemarsson, MD, Länssjukhuset Ryhov, Jönköping; Henrik Petersson, MD, Länssjukhuset, Kalmar; Ulrik Lindström, MD, Blekingesjukhuset, Karlskrona; Eva Albinsson, MD, Centralsjukhuset, Karlstad; Bo Selander, MD, Centralsjukhuset, Kristianstad; Thomas Abrahamsson, MD, Universitetssjukhuset, Linköping; Ingela Heimdahl, MD, Sunderby Sjukhus, Luleå; Kristbjorg Sveinsdottir, MD, Skånes Universitetssjukhus, Malmö/Lund; Erik Wejryd, MD, Vrinnevisjukhuset, Norrköping; Johanna Kusima-Löfbom, MD, Skellefteå Lasarett, Skellefteå; Maria Katarina Söderberg, MD, Kärnsjukhuset Skaraborg, Skövde; Lars Navér, MD, Karolinska Sjukhuset, Stockholm; Thomas Brune, MD, Södersjuhuset, Stockholm; Jens Bäckström, MD, Länssjukhuset, Sundsvall; Peder Helmersson, MD, Norra Älvsborgs Länssjukhus, Trollhättan; Aijaz Farooqi, MD, Norrlands Universitetssjukhus, Umeå; Erik Normann, MD, Akademiska Barnsjukhuset, Uppsala; Magnus Fredriksson, MD, Visby Lasarett, Visby; Anders Palm, MD, Västerviks Sjukhus, Västervik; Urban Rosenqvist, MD, Centrallasarettet, Västerås; Bengt Walde, MD, Centrallasarettet, Växjö; Linda Resman, MD, Lasarettet, Ystad; Miriam Pettersson, MD, Universitetssjukhuset, Örebro; Christina Ziegel, MD, Örnsköldsviks Sjukhus, Örnsköldsvik; Kari Arhimaa, MD, Östersunds Sjukhus, Östersund. Swiss Neonatal Network (SwissNeoNet):TIN Toscane online (Tuscany Neonatal Network):United Kingdom Neonatal Collaborative (UKNC):

      Mark Adams, PhD (Network coordinator), University Hospital Zurich; Philipp Meyer, MD, and Rachel Kusche, MD, Cantonal Hospital, Children's Clinic, Aarau; Sven Schulzke, MD, University Children's Hospital, Basel; Mathias Nelle, MD, University Hospital, Berne; Bendicht Wagner, MD, University Hospital, Berne; Thomas Riedel, MD, Children's Hospital, Chur; Grégoire Kaczala, MD, Cantonal Hospital, Fribourg; Riccardo E Pfister, MD, University Hospital (HUG), Geneva; Jean-François Tolsa, MD, and Matthias Roth, MD, University Hospital (CHUV), Lausanne; Martin Stocker, MD, Children's Hospital, Lucerne; Bernhard Laubscher, MD, Cantonal Hospital, Neuchatel; Andreas Malzacher, MD, Cantonal Hospital, St. Gallen; John P Micallef, MD, Children's Hospital, St. Gallen; Lukas Hegi, MD, Cantonal Hospital, Winterthur; and Dirk Bassler, MD, and Romaine Arlettaz, MD, University Hospital (USZ), Zurich; Vera Bernet, MD, University Children's Hospital, Zurich. Carlo Dani, MD, Careggi University Hospital, Florence, Italy; Patrizio Fiorini, MD, Anna Meyer Children’s University Hospital, Florence, Italy; Paolo Ghirri, MD, University Hospital of Pisa, Pisa, Italy; and Barbara Tomasini, MD, University Hospital of Siena, Siena, Italy.

      Anita Mittal, MBChB, Bedford Hospital, Bedford, Bedfordshire; Jonathan Kefas, MBChB, Lister Hospital, Stevenage, Hertfordshire; Anand Kamalanathan, MBChB, Arrowe Park Hospital, Wirral, Merseyside; Michael Grosdenier, MBChB, Leighton Hospital, Crewe, Cheshire; Christopher Dewhurst, MBChB, Liverpool Women's Hospital, Liverpool, Merseyside; Andreea Bontea, MBChB, Ormskirk District General Hospital, Ormskirk, Lancashire; Delyth Webb, MBChB, Warrington Hospital, Warrington, Cheshire; Ross Garr, MBChB, Whiston Hospital, Prescot, Merseyside; Ahmed Hassan, MBChB, Broomfield Hospital, Chelmsford, Essex; Priyadarshan Ambadkar, MBChB, James Paget Hospital, Gorleston, Norfolk; Mark Dyke, MBChB, Norfolk & Norwich University Hospital, Norwich, Norfolk; Katharine McDevitt, MBChB, Peterborough City Hospital, Peterborough, Cambridgeshire; Glynis Rewitzky, MBChB, Queen Elizabeth Hospital, King's Lynn, Birmingham, West Midlands; Angela D'Amore, MBChB, Rosie Maternity Hospital, Addenbrookes, Cambridge, Cambridgeshire; P Kamath, MBChB, North Manchester General Hospital, Manchester, Greater Manchester; Paul Settle, MBChB, Royal Bolton Hospital, Bolton, Lancashire; Natasha Maddock, MBChB, Royal Oldham Hospital, Manchester, Greater Manchester; Ngozi Edi-Osagie, MBChB, St Mary's Hospital, Manchester, Greater Manchester; Christos Zipitis, MBChB, The Royal Albert Edward Infirmary, Wrightington, Greater Manchester; Carrie Heal, MBChB, Stepping Hill Hospital, Stockport, Cheshire; Jacqeline Birch, MBChB, Tameside General Hospital, Ashton-under-Lyne, Lancashire; Abdul Hasib, MBChB, Darent Valley Hospital, Dartford, Kent; Aung Soe, MBChB, Medway Maritime Hospital, Gillingham, Kent; Bushra Abdul-Malik, MBChB, Queen Elizabeth The Queen Mother Hospital, Margate, Kent; Hamudi Kisat, MBChB, Tunbridge Wells Hospital, Tunbridge Wells, Kent; Vimal Vasu, MBChB, William Harvey Hospital, Ashford, Kent; Savi Sivashankar, MBChB, Lancashire Women & Newborn Centre, Burnley, Lancashire; Richa Gupta, MBChB, Royal Preston Hospital, Preston, Lancashire; Chris Rawlingson, MBChB, Victoria Hospital, Blackpool, Blackpool, Lancashire; Tim Wickham, MBChB, Barnet Hospital, Barnet, Hertfordshire; Marice Theron, MBChB, The Royal Free Hospital, Hampstead, London; Giles Kendall, MBChB, University College Hospital, Fitzrovia, London; Aashish Gupta, MBChB, Basildon Hospital, Basildon, Essex; Narendra Aladangady, MBChB, Homerton Hospital, Hackney, London; Imdad Ali, MBChB, Newham General Hospital, Newham, London; Neeraj Jain, MBChB, North Middlesex University Hospital, Edmonton, London; Khalid Mannan, MBChB, Queen's Hospital, Romford, Essex; Vadivelam Murthy, MBChB, The Royal London Hospital, Whitechapel, London; Caroline Sullivan, MBChB, Whipps Cross University Hospital, Whipps Cross, London; Shu-Ling Chuang, MBChB, Chelsea & Westminster Hospital, Chelsea, London; Tristan Bate, MBChB, Hillingdon Hospital, Hillingdon, London; Lidia Tyszcuzk, MBChB, Queen Charlotte's Hospital, East Acton, London; Lidia Tyszcuzk, MBChB, St Mary's Hospital, Westminister, London; Geraint Lee, MBChB, Guy's & St Thomas’ Hospital, Lambeth, London; Ozioma Obi, MBChB, University Hospital Lewisham, Lewisham, London; John Chang, MBChB, Croydon University Hospital, Croydon, Surrey; Vinay Pai, MBChB, Kingston Hospital, Kingston, London; Charlotte Huddy, MBChB, St George's Hospital, Wandsworth, London; Salim Yasin, MBChB, St. Helier Hospital, Merton, London; Richard Nicholl, MBChB, Northwick Park Hospital, Brent, London; Poornima Pandey, MBChB, Kettering General Hospital, Kettering, Northhamptonshire; Jonathan Cusack, MBChB, Leicester General Hospital, Leicester, Leicestershire; Venkatesh Kairamkonda, MBChB, Leicester Royal Infirmary, Leicester, Leicestershire; Dominic Muogbo, MBChB, Queen's Hospital, Burton On Trent, Burton-on-Trent, Staffordshire; Liza Harry, MBChB, Alexandra Hospital, Redditch, Worcestershire; Pinki Surana, MBChB, Birmingham Heartlands Hospital, Birmingham, West Midlands; Penny Broggio, MBChB, City Hospital, Birmingham, West Midlands; Pinki Surana, MBChB, Good Hope Hospital, Birmingham, West Midlands; Liza Harry, MBChB, Worcestershire Royal Hospital, Worcester, Worcestershire; Tilly Pillay, MBChB, New Cross Hospital, Wolverhampton, West Midlands; Sanjeev Deshpande, MBChB, Princess Royal Hospital, Shrewsbury, Shropshire; Mahadevan, MBChB, Russells Hall Hospital, Dudley, West Midlands; Alison Moore, MBChB, Royal Stoke University Hospital, Hartshill, Staffordshire; Porus Bastani, MBChB, The Jessop Wing, Sheffield, South Yorkshire; Mehdi Garbash, MBChB, Darlington Memorial Hospital, Darlington, County Durham; Mithilesh Lal, MBChB, James Cook University Hospital, Middlesborough, North Yorkshire; Majd Abu-Harb, MBChB, Sunderland Royal Hospital, Sunderland, Tyne and Wear; Mehdi Garbash, MBChB, University Hospital of North Durham, Durham, Durham; Alex Allwood, MBChB, Derriford Hospital, Plymouth, Devon; Michael Selter, MBChB, North Devon District Hospital, Barnstaple, Devon; Paul Munyard, MBChB, Royal Cornwall Hospital, Truro, Cornwall; David Bartle, MBChB, Royal Devon & Exeter Hospital, Exeter, Devon; Siba Paul, MBChB, Torbay Hospital, Torquay, Devon; Graham Whincup, MBChB, Conquest Hospital, St.Leonards-on-sea, East Sussex; Sanghavi Rekha, MBChB, Frimley Park Hospital, Frimley, Surrey; Philip Amess, MBChB, Princess Royal Hospital, Telford, Shropshire; Ben Obi, MBChB, Royal Surrey County Hospital, Guildford, Surrey; Philip Amess, MBChB, Royal Sussex County Hospital, Brighton, East Sussex; Peter Reynolds, MBChB, St Peter's Hospital, Chertsey, Surrey; Indranil Misra, MBChB, Milton Keynes Foundation Trust Hospital, Milton Keynes, Buckinghamshire; Peter De Halpert, MBChB, Royal Berkshire Hospital, Reading, Berkshire; Sanjay Salgia, MBChB, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire; Rekha Sanghavi, MBChB, Wexham Park Hospital, Slough, Berkshire; Nicola Paul, MBChB, Basingstoke & North Hampshire Hospital, Basingstoke, Hampshire; Abby Deketelaere, MBChB, Dorset County Hospital, Dorchester, Dorset; Minesh Khashu, MBChB, Poole Hospital NHS Foundation Trust, Poole, Dorset; Mark Johnson, MBChB, Princess Anne Hospital, Southampton, Hampshire; Charlotte Groves, MBChB, Queen Alexandra Hospital, Portsmouth, Hampshire; Jim Baird, MBChB, Salisbury District Hospital, Salisbury, Wiltshire; Nick Brennan, MBChB, St Richard's Hospital, Chichester, West Sussex; Katia Vamvakiti, MBChB, Worthing Hospital, Worthing, West Sussex; John McIntyre, MBChB, Royal Derby Hospital, Derby, Derbyshire; Jennifer Holman, MBChB, Gloucestershire Royal Hospital, Gloucester, Gloucestershire; Stephen Jones, MBChB, Royal United Hospital, Avon, Somerset; Alison Pike, MBChB, Southmead Hospital, Westbury-on-Trym, Bristol; Pamela Cairns, MBChB, St Michael's Hospital, Bristol, Bristol; Megan Eaton, MBChB, Yeovil District Hospital, Yeovil, Somerset; Karin Schwarz, MBChB, Calderdale Royal Hospital, Halifax, West Yorkshire; David Gibson, MBChB, Pinderfields General Hospital, Dewsbury, West Yorkshire; Lawrence Miall, MBChB, Leeds Neonatal Service, Leeds, Yorkshire; David Gibson, MBChB, Pinderfields General Hospital, Wakefield, West Yorkshire; and Krishnamurthy, MBChB, Walsall Manor Hospital, Walsall, West Midlands.

    • Contributors PSS conceptualised and designed the study, acquired data, guided the data analyses, interpreted data and drafted and revised the manuscript. JY designed the protocol, conducted the data analyses and drafted and revised the manuscript. MN, FR, SK, BR, MB, DB, NM, SH, SKL, KH, MV, LL, MA, TI, KL and LG participated in designing the study, acquiring the data and interpreting the results and reviewed the manuscript critically for important intellectual content. PSS acted as guarantor.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

    Linked Articles

    • Fantoms
      Ben J Stenson