Mortality and Morbidity of Infants Born Extremely Preterm at Tertiary Medical Centers in China From 2010 to 2019

Identification of serum metabolite biomarkers in premature infants with bronchopulmonary dysplasia: protocol for a multicentre prospective observational cohort study

INTRODUCTION

Bronchopulmonary dysplasia (BPD) is one of the most common and significant complications of preterm birth. It ultimately leads to a decrease in the quality of life for preterm infants and impacts their long-term health. Early prediction and timely intervention are crucial to halting the development of BPD. This study aims to identify the biomarkers that can predict the early occurrence and development of BPD by screening serum metabolites in preterm infants. This will provide strong support for the early prediction of BPD and targeted interventions in future research.

METHODS AND ANALYSIS

This is a prospective, multicentre, open-label, observational cohort study spanning 3 years. It will be conducted in six major neonatal intensive care units in Shenzhen, China, involving preterm infants born at gestational ages <32 weeks. Demographic data and treatment information will be collected prospectively. Serum samples will be collected at five distinct time points: within 24 hours after birth, at 1 week, 2 weeks, 28 days and at 36 weeks postmenstrual age. These samples will undergo analysis using liquid chromatography-tandem mass spectrometry for untargeted metabolomics studies. Participants will be categorised into BPD and non-BPD groups based on their final diagnosis, and metabolite differences between these groups will be analysed. The study aims to enrol 1500 preterm infants with gestational ages <32 weeks over 3 years. A three-step analysis strategy-discovery, validation and clinical testing-will be used to identify and validate the clinical utility of novel biomarkers. Additionally, a nested case-control study will be conducted, matching participants 1:1 with a control group sharing similar BPD risk factors.

ETHICS AND DISSEMINATION

Our protocol has been approved by the Medical Ethics Committees of all participating hospitals, including Peking University Shenzhen Hospital, Shenzhen People's Hospital, Shenzhen Baoan Women's and Children's Hospital, Longgang District Maternity and Child Healthcare Hospital, Nanshan Maternity and Child Healthcare Hospital and Shenzhen Luohu People's Hospital. We will disseminate our study results through academic conferences and peer-reviewed public journals.

TRIAL REGISTRATION NUMBER

ChiCTR2400081615.

Needs for rehabilitation in China: Estimates based on the Global Burden of Disease Study 1990-2019

BACKGROUND

As an essential part of health services, rehabilitation is of great significance to improve the health and quality of life of the whole population. Accelerating aging calls for a significant expansion of rehabilitation services in China, but rehabilitation needs remain unclear. We conducted the study to explore the rehabilitation needs in China and project the trend of rehabilitation needs from 2020 to 2034.

METHODS

The data of health conditions that might potentially benefit from rehabilitation were obtained from Global Burden of Disease (GBD) study. Estimated annual percentage changes (EAPCs) were calculated to quantify the trends of the age-standardized rates. Projections of rehabilitation needs were made until 2034 using Bayesian age-period-cohort analysis (BAPC).

RESULTS

Approximately 460 million persons (33.3% of the total population) need rehabilitation in China, contributing to 63 million years lived with disabilities (YLDs) in 2019. The number of prevalent cases that need rehabilitation increased from around 268 (95% uncertainty interval [UI]: 257-282) million in 1990 to almost 460 (95% UI: 443-479) million in 2019, representing an increase of 71.3%. The highest contribution to the need for rehabilitation was musculoskeletal disorders with about 322 (95% UI: 302-343) million persons in seven aggregate disease and injury categories, and hearing loss with over 95 (95% UI: 84-107) million people among 25 health conditions. Based on the projection results, there will be almost 636 million people (45% of the total population) needing rehabilitation services in China by 2034, representing an increase of 38.3%. The rehabilitation needs of neoplasms, cardiovascular diseases, and neurological disorders are expected to increase significantly from 2019 to 2034, with increases of 102.3%, 88.8% and 73.2%, respectively.

CONCLUSIONS

The need for rehabilitation in China substantially increased over the last 30 years. It is predicted that over two in five people will require rehabilitation by 2034, thus suggesting the need to develop rehabilitation services that meet individuals' rehabilitation needs.

Two risk assessment models for predicting white matter injury in extremely preterm infants

BACKGROUND

Extremely preterm infants (EPIs) are at high-risk of white matter injury (WMI), leading to long-term neurodevelopmental impairments. We aimed to develop nomograms for WMI.

METHODS

The study included patients from 31 provinces, spanning ten years. 6074 patients before 2018 were randomly divided into a training and internal validation group (7:3). The external validation group comprised 1492 patients from 2019. Predictors were identified using the least absolute shrinkage and selection operator (LASSO) and multivariable logistic regression and nomograms were constructed. Models' performance was evaluated using receiver operating characteristic (ROC), decision curve analysis (DCA) and calibration curves.

RESULTS

The prenatal nomogram included multiple gestation, premature rupture of membranes (PROM), chorioamnionitis, prenatal glucocorticoids, hypertensive disorder complicating pregnancy (HDCP) and Apgar 1 min, with area under the curve (AUC) of 0.805, 0.816 and 0.799 in the training, internal validation and external validation group, respectively. Days of mechanical ventilation (MV), shock, patent ductus arteriosus (PDA) ligation, intraventricular hemorrhage (IVH) grade III-IV, septicemia, hypothermia and necrotizing enterocolitis (NEC) stage II-III were identified as postpartum predictors. The AUCs were 0.791, 0.813 and 0.823 in the three groups, respectively. DCA and calibration curves showed good clinical utility and consistency.

CONCLUSION

The two nomograms provide clinicians with precise and efficient tools for prediction of WMI.

IMPACT

This study is a large-sample multicenter study, spanning 10 years. The two nomograms are convenient for identifying high-risk infants early, allowing for reducing poor prognosis.

Survival outcomes among periviable infants: a systematic review and meta-analysis comparing different income countries and time periods

Background

Periviable infants are a highly vulnerable neonatal group, and their survival rates are considerably affected by patient-, caregiver-, and institution-level factors, exhibiting wide variability across different income countries and time periods. This study aims to systematically review the literature on the survival rates of periviable infants and compare rates among countries with varied income levels and across different time periods.

Methods

Comprehensive searches were conducted across MEDLINE, Embase, CENTRAL, and Web of Science. Cohort studies reporting survival outcomes by gestational age (GA) for periviable infants born between 22 + 0 and 25 + 6 weeks of gestation were considered. Paired reviewers independently extracted data and assessed the risk of bias and quality of evidence. Data pooling was achieved using random-effects meta-analyses.

Results

Sixty-nine studies from 25 countries were included, covering 56,526 live births and 59,104 neonatal intensive care unit (NICU) admissions. Survival rates for infants born between 22 and 25 weeks of GA ranged from 7% (95% CI 5-10; 22 studies, n = 5,658; low certainty) to 68% (95% CI 63-72; 35 studies, n = 21,897; low certainty) when calculated using live births as the denominator, and from 30% (95% CI 25-36; 31 studies, n = 3,991; very low certainty) to 74% (95% CI 70-77; 48 studies, n = 17,664, very low certainty) for those admitted to NICUs. The survival rates improved over the two decades studied; however, stark contrasts were evident across countries with varying income levels.

Conclusion

Although the survival rates for periviable infants have improved over the past two decades, substantial disparities persist across different economic settings, highlighting global inequalities in perinatal health. Continued research and collaborative efforts are imperative to further improve the global survival and long-term outcomes of periviable infants, especially those in Low- and Middle-Income Countries.

Systematic review registration

PROSPERO, CRD42022376367, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022376367.

[Analysis of treatment outcomes of extremely preterm infants in a real-world single center]

OBJECTIVES

To study the treatment outcomes of extremely preterm infants.

METHODS

A retrospective analysis was performed for the clinical data of extremely preterm infants who were admitted to the neonatal intensive care unit of the Third Affiliated Hospital of Zhengzhou University from January 2016 to December 2022. The infants were divided into a non-in-hospital death group and a survival group. SPSS 29.0 was used for data analysis.

RESULTS

A total of 422 extremely preterm infants were included, of which 155 were in the non-in-hospital death group and 267 in the survival group. The gestational age, birth weight, cesarean section rate, and proportion of mothers with premature rupture of membranes >18 hours in the non-in-hospital death group were all lower than those in the survival group (P<0.05). In contrast, the proportions of Apgar score ≤3 at 1 minute, intubation, neonatal respiratory distress syndrome, early-onset sepsis, periventricular-intraventricular hemorrhage (grades III-IV), and pneumorrhagia were higher in the non-in-hospital death group compared to the survival group (P<0.05).

CONCLUSIONS

Low gestational age, low birth weight, the history of birth asphyxia, severe intracranial hemorrhage, and pneumorrhagia may be the main causes of non-in-hospital death in extremely preterm infants, and therefore, perinatal health care should be enhanced to reduce the onset of asphyxia and severe diseases.

Changes in the epidemiology of under-5 mortality in China from 2016 to 2022: an observational analysis of population-based surveillance data

BACKGROUND

Sustainable Development Goal (SDG) 3.2 aims to end preventable deaths of newborns and children younger than 5 years. China's progress towards SDG 3.2 has not been evaluated on multiple dimensions. We aimed to assess mortality rates in children younger than 5 years (hereafter referred to as under-5 mortality) and to quantify preventable child mortality and geospatial and temporal trends in child mortality in China from 2016 to 2022.

METHODS

In this observational analysis, we used data from the Chinese National Maternal and Child Health Surveillance System (MCHSS) for the period Jan 1, 2016, to Dec 31, 2022 and conducted all-cause mortality and cause-specific mortality analyses for different age groups (age 0-6 days, 7-27 days, 0-27 days, 1-5 months, 6-11 months, 12-23 months, 24-59 months, and birth to 59 months) separately at the national, residential (rural vs urban), and regional (eastern vs central vs western China) levels. All mortality rates were adjusted by age group, type of residency, region, and region-residency strata using a 3-year moving average of the under-reporting rates. National deaths were estimated using the number of livebirths from 2016 to 2022 from the Health Statistics Yearbook of China. Estimated national-level and regional-level mortality rates were weighted by the proportion of the population living in urban and rural areas from the 2010 national census. Optimal survival metrics for neonates and children younger than 5 years were calculated by cause of death in 2020-22 (termed the national optimum), on the basis of the lowest mortality observed among the six region-residency strata.

FINDINGS

In 2022, approximately 65 700 (95% CI 62 700-68 800) children younger than 5 years died in China, with 45·1% (42·7-47·4) of these deaths occurring in the neonatal period (age <28 days). China's under-5 mortality rate decreased from 10·2 deaths (9·9-10·5) per 1000 livebirths in 2016 to 6·8 deaths (6·5-7·2) per 1000 livebirths in 2022; the neonatal mortality rate decreased from 4·9 deaths (4·7-5·1) per 1000 livebirths in 2016 to 3·1 deaths (2·9-3·3) per 1000 livebirths in 2022. The relative risk of death in children younger than 5 years in rural areas compared with urban areas decreased from 2·4 (2·2-2·6) in 2016 to 1·9 (1·7-2·1) in 2022, and in the western region compared with the eastern region decreased from 3·4 (3·0-3·9) in 2016 to 2·3 (1·9-2·8) in 2022. The leading causes of under-5 mortality in 2022 were injuries (23·1% [21·1-25·1] of all-cause deaths), congenital malformations (14·8% [13·1-16·4]), preterm birth complications (14·1% [12·5-15·7]), intrapartum-related events (10·1% [8·7-11·5]), and acute respiratory infections (9·5% [8·2-10·9]). The leading cause of death in the neonatal period was preterm birth complications (12·8% [11·4-14·2] of deaths in children younger than 5 years).

INTERPRETATION

Under-5 mortality in China declined between 2016 and 2022. Disparities across regions and in urban versus rural areas narrowed over time, but they still exist. Therefore, efforts should be made to further reduce child mortality in China, including consistent investments and implementing of policies, programmes, and interventions, especially for the western rural areas.

FUNDING

None.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Identification of Neonatal Factors Predicting Pre-Discharge Mortality in Extremely Preterm or Extremely Low Birth Weight Infants: A Historical Cohort Study

BACKGROUND/OBJECTIVES

This study identified early neonatal factors predicting pre-discharge mortality among extremely preterm infants (EPIs) or extremely low birth weight infants (ELBWIs) in China, where data are scarce.

METHODS

We conducted a retrospective analysis of 211 (92 deaths) neonates born <28 weeks of gestation or with a birth weight <1000 g, admitted to University Affiliated Hospitals from 2013 to 2024 in Guangzhou, China. Data on 26 neonatal factors before the first 24 h of life and pre-discharge mortality were collected. LASSO-Cox regression was employed to screen predictive factors, followed by stepwise Cox regression to develop the final mortality prediction model. The model's performance was evaluated using the area under the curve (AUC) of the receiver operating characteristic, calibration curves, and decision curve analysis.

RESULTS

The LASSO-Cox model identified 13 predictors that showed strong predictive accuracy (AUC: 0.806/0.864 in the training/validation sets), with sensitivity and specificity rates above 70%. Among them, six predictors remained significant in the final stepwise Cox model and generated similar predictive accuracy (AUC: 0.830; 95% CI: 0.775-0.885). Besides the well-established predictors (e.g., gestational age, 5 min Apgar scores, and multiplicity), this study highlights the predictive value of the maximum FiO2. It emphasizes the significance of the early use of additional doses of surfactant and umbilical vein catheterization (UVC) in reducing mortality.

CONCLUSIONS

We identified six significant predictors for pre-discharge mortality. The findings highlighted the modifiable factors (FiO2, surfactant, and UVC) as crucial neonatal factors for predicting mortality risk in EPIs or ELBWIs, and offer valuable guidance for early clinical management.

Multicentre online registration of bronchopulmonary dysplasia in very preterm infants in China: protocol for a prospective, open, observational cohort study

INTRODUCTION

Bronchopulmonary dysplasia (BPD) in very preterm infants (VPIs) has adverse long-term outcomes and affects the quality of survival. There are no registry studies on BPD in VPIs in China. Our aim was to conduct a prospective, multicentre, open, longitudinal, observational cohort study to investigate the epidemiological characteristics, diagnosis, treatment, and short-term and long-term outcomes of BPD in a real-life setting in China and lay the grounds for establishing a nationwide registry with clinical data and biological specimens.

METHODS

This study aims to recruit a minimum of 2000 VPIs and start research in January 2024 in Shenzhen, China. We will collect clinical data from the beginning of the life of VPIs and follow them up to 3 years old. Short-term outcomes, such as the incidence of BPD, necrotising enterocolitis, retinopathy of prematurity, intraventricular haemorrhage and porencephalic ventricular leukomalacia, as well as the cost of hospitalisation, are the major variables of concern. Bayley-III Scale assessment, gross motor function and pulmonary function evaluation will be performed at the age of correction, that is, 18-24 months and 30-36 months. The follow-up outcomes include loss to follow-up, survival status, moderate-to-severe neurodevelopmental deficits and severe respiratory complications. Cord blood, peripheral blood, tracheal aspirate, faeces and urine from VPIs, as well as mother's milk, will be collected and stored at -80°C. All the data will be registered, stored and managed in a cloud-based database. This knowledge will be useful for establishing diagnostic criteria and predictive models for BPD in the Chinese population.

ETHICS AND DISSEMINATION

Our protocol has been approved by the Medical Ethics Committee of Shenzhen People's Hospital (LL-KY-2023174-02) and the local ethics committee of each participating centre. Our goal is to present our findings at national conferences and in peer-reviewed paediatric journals.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2400081615).

Analysis of variable metabolites in preterm infants with bronchopulmonary dysplasia: a systematic review and meta-analysis

Numerous studies have attempted to identify potential biomarkers for early detection of bronchopulmonary dysplasia (BPD) in preterm infants using metabolomics techniques. However, the presence of consistent evidence remains elusive. Our study aimed to conduct a systematic review and meta-analysis to identify differences in small-molecule metabolites between BPD and non-BPD preterm infants. Through meticulous screening of numerous samples, we identified promising candidates, providing valuable insights for future research. We searched PubMed, the Cochrane Library, Embase, Web of Science, China National Knowledge Internet, Wan-fang database, Chinese Science and Technique Journal Database and Chinese Biomedical Literature Database from inception until January 16, 2024. Studies were comprehensively reviewed against inclusion criteria. We included case-control studies and adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Study quality was assessed with the Newcastle-Ottawa scale. We compared the changes in metabolite levels between the BPD and non-BPD preterm infants. A meta-analysis was conducted on targeted metabolomics research data based on the strategy of standardized mean differences (MD) and 95% confidence intervals (CI).Fifteen studies (1357 participants) were included. These clinical-based metabolomics studies clarified 110 differential metabolites between BPD and non-BPD preterm infants. The meta-analysis revealed higher glutamate concentration in the BPD group compared to the non-BPD group (MD = 1, 95% CI 0.59 to 1.41, p < 0.00001). Amino acids were identified as the key metabolites distinguishing preterm infants with and without BPD, with glutamate potentially serving as a BPD predictor in this population.

Analysis of blood metabolite characteristics at birth in preterm infants with bronchopulmonary dysplasia: an observational cohort study

Background

To analyze the characteristics of blood metabolites within 24 h after birth in preterm infants with bronchopulmonary dysplasia (BPD) and to identify biomarkers for predicting the occurrence of BPD.

Methods

Dried blood spots (DBS) were collected at birth from preterm infants with gestational age (GA) of less than 32 weeks in the cohort. The infants were divided into the BPD group and non-BPD group based on whether they eventually developed BPD. Dried blood spot filter papers were prepared from venous blood collected within the first 24 h of life. Metabolites were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and analyzed using the R software package.

Results

DBS samples from 140 infants with the GA < 32 weeks were used in the study, with 4 infants who died being excluded. Among the remaining 136 preterm infants, 38 developed BPD and 98 did not. To control for GA differences, we conducted a subgroup analysis. In the GA 24+4-27+6 weeks subgroup, we observed a significant decrease in histidine levels and the ornithine/citrulline ratio in the BPD group. Additionally, the ratios of acylcarnitines C3/C0 and C5/C0 were also significantly reduced.

Conclusions

Metabolic markers in DBS within 24 h after birth are promising for predicting the occurrence of BPD in preterm infants with GA < 28 weeks.

Clinical Trial Registration

[https://www.chictr.org.cn/], identifier [ChiCTR2100048293, ChiCTR2400081615].

The emerging roles of microbiome and short-chain fatty acids in the pathogenesis of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that affects premature infants and leads to long-term pulmonary complications. The pathogenesis of BPD has not been fully elucidated yet. In recent years, the microbiome and its metabolites, especially short-chain fatty acids (SCFAs), in the gut and lungs have been demonstrated to be involved in the development and progression of the disease. This review aims to summarize the current knowledge on the potential involvement of the microbiome and SCFAs, especially the latter, in the development and progression of BPD. First, we introduce the gut-lung axis, the production and functions of SCFAs, and the role of SCFAs in lung health and diseases. We then discuss the evidence supporting the involvement of the microbiome and SCFAs in BPD. Finally, we elaborate on the potential mechanisms of the microbiome and SCFAs in BPD, including immune modulation, epigenetic regulation, enhancement of barrier function, and modulation of surfactant production and the gut microbiome. This review could advance our understanding of the microbiome and SCFAs in the pathogenesis of BPD, which also helps identify new therapeutic targets and facilitate new drug development.

A real-world study on the treatment of extremely preterm infants: a multi-center study in southwest area of Fujian Province in China

BACKGROUND

Due to regional and cultural differences, the current status of extremely preterm infants(EPIs) treatment across different areas of mainland China remains unclear. This study investigated the survival rate and incidence of major diseases among EPIs in the southwest area of Fujian province.

METHOD

This retrospective and multicenter study collected perinatal data from EPIs with gestational ages between 22-27+ 6w and born in the southwest area of Fujian province. The study population was divided into 6 groups based on gestational age at delivery. The primary outcome was the survival status at ordered hospital discharge or correct gestational age of 40 weeks, and the secondary outcome was the incidence of major diseases. The study analyzed the actual survival status of EPIs in the area.

RESULT

A total of 2004 preterm infants with gestational ages of 22-27+ 6 weeks were enrolled in this study. Among them, 1535 cases (76.6%) were born in the delivery room but did not survive, 469 cases (23.4%) were transferred to the neonatal department for treatment, 101 cases (5.0%) received partial treatment, and 368 cases (18.4%) received complete treatment. The overall all-cause mortality rate was 84.4% (1691/2004). The survival rate and survival rate without major serious disease for EPIs who received complete treatment were 85.1% (313/368) and 31.5% (116/318), respectively. The survival rates for gestational ages 22-22+ 6w, 23-23+ 6w, 24-24+ 6w, 25-25+ 6w, 26-26+ 6w, and 27-27+ 6w were 0%, 0%, 59.1% (13/22), 83% (39/47), 88.8% (87/98), and 89.7% (174/198), respectively. The survival rates without major serious disease were 0%, 0%, 9.1% (2/22), 19.1% (9/47), 27.6% (27/98), and 40.2% (78/194), respectively.

CONCLUSION

The all-cause mortality of EPIs in the southwest area of Fujian Province remains high, with a significant number of infants were given up after birth in the delivery room being the main influencing factor. The survival rate of EPIs who received complete treatment at 25-27 weeks in the NICU was similar to that in developed countries. However, the survival rate without major serious disease was significantly lower compared to high-income countries.

Value of near-infrared spectroscopy in evaluating the risk of neonatal necrotizing enterocolitis: A systematic review and meta-analysis

PURPOSE

Recently, near-infrared spectroscopy (NIRS) has been proposed for diagnosing patients with neonatal necrotizing enterocolitis (NEC). However, a consensus on the credibility of NIRS in evaluating NEC risk has not been reached. This meta-analysis aimed to evaluate the relationship between NEC and splanchnic regional tissue oxygen saturation (SrSO2) and cerebral regional tissue oxygen saturation (CrSO2) detected by NIRS to clarify the clinical value of NIRS in evaluating the risk of NEC.

METHODS

Studies using NIRS to monitor regional tissue oxygen saturation (rSO2) in neonates with NEC published in PubMed, Web of Science, Embase, and the Cochrane Library were searched from their inception to 30 July 2023. Mean difference (MD), pooled sensitivity, and pooled specificity, along with their 95 % confidence intervals (CI), were calculated, and the random-effects model was used for analysis. This study was registered with PROSPERO (no. CRD42022326783).

RESULTS

Fourteen studies including 938 neonates (172 NEC, 766 controls) were identified. SrSO2 was significantly decreased in patients with NEC (MD: -12.52, 95 % CI: -15.95, -9.08; P < 0.00001), and this decrease was observed even before the diagnosis of NEC (MD: -13.79, 95 % CI: -17.97, -9.62; P < 0.00001). The pooled sensitivity and specificity of SrSO2 were 0.80 (95 % CI: 0.69, 0.88) and 0.90 (95 % CI: 0.61, 0.98), respectively. However, no significant difference in CrSO2 was found (MD: -4.37, 95 % CI: -10.62, 1.88; P = 0.17).

CONCLUSIONS

SrSO2, detected by NIRS, could be a valuable non-invasive method for differentiating NEC from non-NEC neonates. It could differentiate prior to NEC diagnosis.

End-organ damage from neonatal invasive fungal infection: a 14-year retrospective study from a tertiary center in China

BACKGROUND

Invasive fungal infection (IFI) has become an increasing problem in NICU neonates, and end-organ damage (EOD) from IFI is one of the leading causes of morbidity and mortality in neonates. This study was conducted to summarize clinical data on epidemiology, risk factors, causative pathogens, and clinical outcomes of IFI-associated EOD among neonates in a center in China for the sake of providing references for prevention and treatment of fungal infections in neonates in future.

METHODS

The clinical data of IFI neonates who received treatment in a tertiary NICU of China from January 2009 to December 2022 were retrospectively analyzed, including causative pathogens and the incidence of EOD. The neonates were divided into EOD group and non-EOD (NEOD) group. The general characteristics, risk factors and clinical outcomes of the two groups were compared.

RESULTS

Included in this study were 223 IFI neonates (137 male and 86 female) with a median gestational age (GA) of 30.71 (29,35) weeks and a median birth weight (BW) of 1470 (1120,2150) g. Of them, 79.4% were preterm infants and 50.2% were born at a GA of ≥ 28, <32 weeks, and 37.7% with BW of 1000-1499 g. Candida albicans (C. albicans) was the most common Candida spp. in these neonates, accounting for 41.3% of all cases, followed by C. parapsilosis (30.5%) and C. glabrata (7.2%). EOD occurred in 40 (17.9%) of the 223 cases. Fungal meningitis was the most common EOD, accounting for 13.5% of the 40 EOD cases. There was no significant difference in the premature birth rate, delivery mode, GA and BW between EOD and NEOD groups, but the proportion of male infants with EOD was higher than that without. There was no significant difference in antenatal corticosteroid use, endotracheal intubation, invasive procedures, use of antibiotics, total parenteral nutrition, blood transfusion, postnatal corticosteroid use, fungal prophylaxis and the incidence of necrotizing enterocolitis between the two groups, but the proportion of C. albicans infection cases in EOD group was higher than that in NEOD group (57.5% vs. 37.7%). Compared with NEOD group, the proportion of cured or improved infants in EOD group was significantly lower (P < 0.05), and the number of infants who died or withdrew from treatment was larger (P < 0.05).

CONCLUSIONS

Our retrospective study showed that preterm infants were prone to fungal infection, especially very preterm infants. C. albicans was the most common Candida spp. for IFI, and was a high-risk factor for EOD. EOD can occur in both full-term and premature infants, so the possibility of EOD should be considered in all infants with IFI.

National Trends in Survival and Short-Term Outcomes of Periviable Births ≤24 Weeks Gestation in the United States, 2009 to 2018

OBJECTIVE

Data from the academic medical centers in the United States showing improvements in survival of periviable infants born at 22 to 24 weeks GA may not be nationally representative since a substantial proportion of preterm infants are cared for in community hospital-based neonatal intensive care units. Our objective was to examine the national trends in survival and other short-term outcomes among preterm infants born at ≤24 weeks gestational age (GA) in the United States from 2009 to 2018.

STUDY DESIGN

This was a retrospective, repeated cross-sectional analysis of the National Inpatient Sample for preterm infants ≤24 weeks GA. The primary outcome was the trends in survival to discharge. Secondary outcomes were the trends in the composite outcome of death or one or more major morbidity (bronchopulmonary dysplasia, necrotizing enterocolitis stage ≥2, periventricular leukomalacia, severe intraventricular hemorrhage, and severe retinopathy of prematurity). The Cochran-Armitage trend test was used for trend analysis. p-Value <0.05 was considered significant.

RESULTS

Among 71,854 infants born at ≤24 weeks GA, 34,251 (47.6%) survived less than 1 day and were excluded. Almost 93% of those who survived <1 day were of ≤23 weeks GA. Among the 37,603 infants included in the study cohort, 48.1% were born at 24 weeks GA. Survival to discharge at GA ≤ 23 weeks increased from 29.6% in 2009 to 41.7% in 2018 (p < 0.001), while survival to discharge at GA 24 weeks increased from 58.3 to 65.9% (p < 0.001). There was a significant decline in the secondary outcomes among all the periviable infants who survived ≥1 day of life.

CONCLUSION

Survival to discharge among preterm infants ≤24 weeks GA significantly increased, while death or major morbidities significantly decreased from 2009 to 2018. The postdischarge survival, health care resource use, and long neurodevelopmental outcomes of these infants need further investigation.

KEY POINTS

· Survival increased significantly in infants ≤24 weeks GA in the United States from 2009 to 2018.. · Death or major morbidity in infants ≤24 weeks GA decreased significantly from 2009 to 2018.. · Death or surgical procedures including tracheostomy, VP shunt placement, and PDA surgical closure in infants <=24 weeks GA decreased significantly from 2009 to 2018..

Preterm birth: A neuroinflammatory origin for metabolic diseases?

Preterm birth and its related complications have become more and more common as neonatal medicine advances. The concept of "developmental origins of health and disease" has raised awareness of adverse perinatal events in the development of diseases later in life. To explore this concept, we propose that encephalopathy of prematurity (EoP) as a potential pro-inflammatory early life event becomes a novel risk factor for metabolic diseases in children/adolescents and adulthood. Here, we review epidemiological evidence that links preterm birth to metabolic diseases and discuss possible synergic roles of preterm birth and neuroinflammation from EoP in the development of metabolic diseases. In addition, we explore theoretical underlying mechanisms regarding developmental programming of the energy control system and HPA axis.

Preterm birth, a consequence of immune deviation mediated hyperinflammation

Preterm birth represents a multifaceted syndrome with intricacies still present in our comprehension of its etiology. In the context of a semi-allograft, the prosperity from implantation to pregnancy to delivery hinges on the establishment of a favorable maternal-fetal immune microenvironment and a successful trilogy of immune activation, immune tolerance and then immune activation transitions. The occurrence of spontaneous preterm birth could be related to abnormalities within the immune trilogy, stemming from deviation in maternal and fetal immunity. These immune deviations, characterized by insufficient immune tolerance and early immune activation, ultimately culminated in an unsustainable pregnancy. In this review, we accentuated the role of both innate and adaptive immune reason in promoting spontaneous preterm birth, reviewed the risk of preterm birth from vaginal microbiome mediated by immune changes and the potential of vaginal microbiomes and metabolites as a new predictive marker, and discuss the changes in the role of progesterone and its interaction with immune cells in a preterm birth population. Our objective was to contribute to the growing body of knowledge in the field, shedding light on the immunologic reason of spontaneous preterm birth and effective biomarkers for early prediction, providing a roadmap for forthcoming investigations.

Nutritional support during the first week for infants with bronchopulmonary dysplasia and respiratory distress: a multicenter cohort study in China

BACKGROUND

Bronchopulmonary dysplasia (BPD) is a major complication affecting the survival rate and long-term outcomes of preterm infants. A large, prospective, multicenter cohort study was conducted to evaluate early nutritional support during the first week of life for preterm infants with a gestational age < 32 weeks and to verify nutritional risk factors related to BPD development.

METHODS

A prospective multicenter cohort study of very preterm infants was conducted in 40 tertiary neonatal intensive care units across mainland China between January 1, 2020, and December 31, 2021. Preterm infants who were born at a gestational age < 32 weeks, < 72 h after birth and had a respiratory score > 4 were enrolled. Antenatal and postnatal information focusing on nutritional parameters was collected through medical systems. Statistical analyses were also performed to identify BPD risk factors.

RESULTS

The primary outcomes were BPD and severity at 36 weeks postmenstrual age. A total of 1410 preterm infants were enrolled in this study. After applying the exclusion criteria, the remaining 1286 infants were included in this analysis; 614 (47.7%) infants were in the BPD group, and 672 (52.3%) were in the non-BPD group. In multivariate logistic regression model, the following six factors were identified of BPD: birth weight (OR 0.99, 95% CI 0.99-0.99; p = 0.039), day of full enteral nutrition (OR 1.03, 95% CI 1.02-1.04; p < 0.001), parenteral protein > 3.5 g/kg/d during the first week (OR 1.65, 95% CI 1.25-2.17; p < 0.001), feeding type (formula: OR 3.48, 95% CI 2.21-5.49; p < 0.001, mixed feed: OR 1.92, 95% CI 1.36-2.70; p < 0.001; breast milk as reference), hsPDA (OR 1.98, 95% CI 1.44-2.73; p < 0.001), and EUGR ats 36 weeks (OR 1.40, 95% CI 1.02-1.91; p = 0.035).

CONCLUSIONS

A longer duration to achieve full enteral nutrition in very preterm infants was associated with increased BPD development. Breastfeeding was demonstrated to have a protective effect against BPD. Early and rapidly progressive enteral nutrition and breastfeeding should be promoted in very preterm infants.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry (No. ChiCTR2000030125 on 24/02/2020) and in www.ncrcch.org (No. ISRCTN84167642 on 25/02/2020).

A population-based cohort of drug exposures and adverse pregnancy outcomes in China (DEEP): rationale, design, and baseline characteristics

The DEEP cohort is the first population-based cohort of pregnant population in China that longitudinally documented drug uses throughout the pregnancy life course and adverse pregnancy outcomes. The main goal of the study aims to monitor and evaluate the safety of drug use through the pregnancy life course in the Chinese setting. The DEEP cohort is developed primarily based on the population-based data platforms in Xiamen, a municipal city of 5 million population in southeast China. Based on these data platforms, we developed a pregnancy database that documented health care services and outcomes in the maternal and other departments. For identifying drug uses, we developed a drug prescription database using electronic healthcare records documented in the platforms across the primary, secondary and tertiary hospitals. By linking these two databases, we developed the DEEP cohort. All the pregnant women and their offspring in Xiamen are provided with health care and followed up according to standard protocols, and the primary adverse outcomes - congenital malformations - are collected using a standardized Case Report Form. From January 2013 to December 2021, the DEEP cohort included 564,740 pregnancies among 470,137 mothers, and documented 526,276 live births, 14,090 miscarriages and 6,058 fetal deaths/stillbirths and 25,723 continuing pregnancies. In total, 13,284,982 prescriptions were documented, in which 2,096 chemicals drugs, 163 biological products, 847 Chinese patent medicines and 655 herbal medicines were prescribed. The overall incidence rate of congenital malformations was 2.0% (10,444/526,276), while there were 25,526 (4.9%) preterm births and 25,605 (4.9%) live births with low birth weight.

Synergistic effects of achieving perinatal interventions on bronchopulmonary dysplasia in preterm infants

To investigate the effect of perinatal interventions on the risk of severe BPD (sBPD) and death in extremely preterm infants (EPIs) and their synergistic effects. This was a secondary analysis of the prospective cohort Chinese Neonatal Network (CHNN). Infants with a birth weight of 500 to 1250 g or 24-28 weeks completed gestational age were recruited. The impacts and the synergistic effects of six evidence-based perinatal interventions on the primary outcomes of sBPD and death were assessed by univariate and multivariable logistic regression modeling. Totally, 6568 EPIs were finally enrolled. Antenatal corticosteroid (adjusted OR, aOR, 0.74; 95%CI, 0.65-083), birth in centers with tertiary NICU (aOR, 0.64; 95%CI, 0.57-0.72), preventing intubation in the delivery room (aOR, 0.65; 95%CI, 0.58-0.73), early caffeine therapy (aOR, 0.59; 95%CI, 0.52-0.66), and early extubating (aOR, 0.42; 95%CI 0.37-0.47), were strongly associated with a lower risk of sBPD and death while early surfactant administration was associated with a lower risk of death (aOR, 0.84; 95%CI, 0.72, 0.98). Compared with achieving 0/1 perinatal interventions, achieving more than one intervention was associated with decreased rates (46.6% in 0/1 groups while 38.5%, 29.6%, 22.2%, 16.2%, and 11.7% in 2/3/4/5/6-intervention groups respectively) and reduced risks of sBPD/death with aORs of 0.76(0.60, 0.96), 0.55(0.43, 0.69), 0.38(0.30, 0.48), 0.28(0.22, 0.36), and 0.20(0.15, 0.27) in 2, 3, 4, 5, and 6 intervention groups respectively. Subgroup analyses showed consistent results.

CONCLUSION

Six perinatal interventions can effectively reduce the risk of sBPD and death in a synergistic form.

WHAT IS KNOWN

• Bronchopulmonary dysplasia (BPD) is a multifactorial chronic lung disease associated with prematurity. The effective management of BPD requires a comprehensive set of interventions. However, the extent to which these interventions can mitigate the risk of severe outcomes, such as severe BPD or mortality, or if they possess synergistic effects remains unknown.

WHAT IS NEW

• The implementation of various perinatal interventions, such as prenatal steroids, birth in centers with tertiary NICU, early non-Invasive respiratory support, surfactant administration within 2 hours after birth, early caffeine initiation within 3 days, and early extubation within 7 days after birth has shown promising results in the prevention of severe bronchopulmonary dysplasia (BPD) or mortality in extremely preterm infants. Moreover, these interventions have demonstrated synergistic effects when implemented in combination.

Survival and morbidity in very preterm infants in Shenzhen: a multi-center study

Objective

To analyze survival and morbidity among very preterm infants (VPIs) in Shenzhen and explore factors associated with survival without major morbidity.

Methods

Between January 2022 and December 2022, 797 infants were admitted to 25 neonatal intensive care units in Shenzhen with gestational age (GA) < 32 weeks, excluded discharged against medical advice, insufficient information, and congenital malformation, 742 VPIs were included. Comparison of maternal and neonate characteristics, morbidities, survival, and survival without major morbidities between groups used Mann Whitney U test and X2 test, multivariate logistic regression was used to analyze of risk factors of survival without major morbidities.

Results

The median GA was 29.86 weeks (interquartile range [IQR], 28.0-31.04), and the median birth weight was 1,250 g (IQR, 900-1,500). Of the 797 VPIs, 721 (90.46%) survived, 53.52% (38 of 71) at 25 weeks' or less GA, 86.78% (105 of 121) at 26 to 27 weeks' GA, 91.34% (211 of 230) at 28 to 29 weeks' GA, 97.86% (367 of 375) at 30 to 31 weeks' GA. The incidences of the major morbidities were moderate-to-severe bronchopulmonary dysplasia,16.52% (113 of 671); severe intraventricular hemorrhage and/or periventricular leukomalacia, 2.49% (17 of 671); severe necrotizing enterocolitis, 2.63% (18 of 671); sepsis, 2.34% (16 of 671); and severe retinopathy of prematurity, 4.55% (27 of 593), 65.79% (450 of 671) survived without major morbidities. After adjustment for GA, birth weight, and 5-min Apgar score, antenatal steroid administration (OR = 2.397), antenatal magnesium sulfate administration (OR =  1.554) were the positivity factors to survival without major morbidity of VPIs, however, surfactant therapy (OR = 0.684,), and delivery room resuscitation (OR = 0.626) that were the negativity factors.

Conclusions

The present results indicate that survival and the incidence of survival without major morbidities increased with GA. Further, antenatal administration of steroids and magnesium sulfate, surfactant therapy, and delivery room resuscitation were pronounced determinants of survival without morbidities.

Nomogram to predict risk of neonatal mortality among preterm neonates admitted with sepsis at University of Gondar Comprehensive Specialized Hospital: risk prediction model development and validation

BACKGROUND

Mortality in premature neonates is a global public health problem. In developing countries, nearly 50% of preterm births ends with death. Sepsis is one of the major causes of death in preterm neonates. Risk prediction model for mortality in preterm septic neonates helps for directing the decision making process made by clinicians.

OBJECTIVE

We aimed to develop and validate nomogram for the prediction of neonatal mortality. Nomograms are tools which assist the clinical decision making process through early estimation of risks prompting early interventions.

METHODS

A three year retrospective follow up study was conducted at University of Gondar Comprehensive Specialized Hospital and a total of 603 preterm neonates with sepsis were included. Data was collected using KoboCollect and analyzed using STATA version 16 and R version 4.2.1. Lasso regression was used to select the most potent predictors and to minimize the problem of overfitting. Nomogram was developed using multivariable binary logistic regression analysis. Model performance was evaluated using discrimination and calibration. Internal model validation was done using bootstrapping. Net benefit of the nomogram was assessed through decision curve analysis (DCA) to assess the clinical relevance of the model.

RESULT

The nomogram was developed using nine predictors: gestational age, maternal history of premature rupture of membrane, hypoglycemia, respiratory distress syndrome, perinatal asphyxia, necrotizing enterocolitis, total bilirubin, platelet count and kangaroo-mother care. The model had discriminatory power of 96.7% (95% CI: 95.6, 97.9) and P-value of 0.165 in the calibration test before and after internal validation with brier score of 0.07. Based on the net benefit analysis the nomogram was found better than treat all and treat none conditions.

CONCLUSION

The developed nomogram can be used for individualized mortality risk prediction with excellent performance, better net benefit and have been found to be useful in clinical practice with contribution in preterm neonatal mortality reduction by giving better emphasis for those at high risk.

Extremely preterm infants born outside a provincial tertiary perinatal center and transferred postnatally associated with poor outcomes: a real-world observational study

Introduction

Extremely preterm infants (EPIs) have high morbidity and mortality, and are recommended to be born in a tertiary perinatal center (inborn). However, many EPIs in central China are born in lower-level hospitals and transferred postnatally, the outcomes of which remain to be investigated.

Methods

EPIs admitted to the Department of Neonatology, Maternal and Child Health Hospital of Hubei Province from January 2013 to December 2022 were retrospectively recruited and divided into the control (inborn) and transfer groups (born in other hospitals). The neonatal and maternal characteristics, neonatal outcomes, and the treatment of survival EPIs were analyzed.

Results

A total of 174 and 109 EPIs were recruited in the control and transfer groups, respectively. EPIs in the transfer group have a higher birth weight and a lower proportion of multiple pregnancies than the control group (all P < 0.05). The proportions of antenatal steroids, magnesium sulfate, cesarean delivery, premature rupture of membranes ≥18 h, gestational diabetes, and amniotic fluid abnormalities were lower in the transfer group (all P < 0.05). Survival rates (64.22% vs. 56.32%), proportions of severe periventricular-intraventricular hemorrhage (PIVH) (11.93% vs. 11.49%), severe bronchopulmonary dysplasia (sBPD) (21.05% vs. 20%), and severe retinopathy of prematurity (ROP) (24.77% vs. 20.11%) were similar in the transfer and control groups (all P > 0.05). However, the transfer group had higher proportions of severe birth asphyxia (34.86% vs. 13.22%, P < 0.001), PIVH (42.20% vs. 29.89%, P = 0.034), and extrauterine growth retardation (EUGR) (17.43% vs. 6.32%, P = 0.003). Less surfactant utilization was found in the transfer group among survival EPIs (70.00% vs. 93.88%, P < 0.001).

Conclusion

EPIs born outside a tertiary perinatal center and transferred postnatally did not have significantly higher mortality and rates of severe complications (severe PIVH, severe ROP, and sBPD), but there may be an increased risk of severe asphyxia, PIVH and EUGR. This may be due to differences in maternal and neonatal characteristics and management. Further follow-up is needed to compare neurodevelopmental outcomes, and it is recommended to transfer the EPIs in utero to reduce the risk of poor physical and neurological development.

Differences in the attitudes towards resuscitation of extremely premature infants between neonatologists and obstetricians: a survey study in China

Objectives

Neonatologists and obstetricians are crucial decision-makers regarding the resuscitation of extremely preterm infants (EPIs). However, there is a scarcity of research regarding the differing perspectives on EPI resuscitation between these medical professionals. We aim to determine the differences and influential factors of their attitudes towards EPIs resuscitation in China.

Methods

This cross-sectional study was conducted in public hospitals of 31 provinces in Chinese mainland from June to July 2021. Influential factors of binary variables and those of ordinal variables were analyzed by modified Poisson regression models and multinomial logistic regression models due to the invalid parallel line assumption of ordinal logistic regression models.

Results

A total of 832 neonatologists and 1,478 obstetricians who were deputy chief physicians or chief physicians participated. Compared with obstetricians, neonatologists delivered a larger proportion of infants of <28-week gestational age (87.74% vs. 84.91%) and were inclined to think it inappropriate to use 28 weeks as the cutoff of gestational age for providing full care to premature infants [63.34% vs. 31.60%, adjusted prevalence ratio = 1.61 (95% CI: 1.46-1.77)], and to suggest smaller cutoffs of gestational age and birth weight for providing EPIs resuscitation. Notably, 46.49% of the neonatologists and 19.01% of the obstetricians believed infants ≤24 weeks' gestation should receive resuscitation.

Conclusions

In China, notable disparities exist in attitudes of neonatologists and obstetricians towards resuscitating EPIs. Strengthening collaboration between these two groups and revising the pertinent guidelines as soon as possible would be instrumental in elevating the resuscitation rate of EPIs.

Comprehensive Analysis of Risk Factors for Bronchopulmonary Dysplasia in Preterm Infants in Taiwan: A Four-Year Study

Bronchopulmonary dysplasia (BPD) is a major respiratory condition mainly affecting premature infants. Although its occurrence is global, risk factors may differ regionally. This study, involving 3111 infants with birth weight ≤ 1500 gm or gestational age (GA) < 30 weeks, aimed to identify risk factors for BPD and BPD/mortality in Taiwan using data from the Taiwan Neonatal Network. The BPD criteria were based on the National Institute of Child Health and Human Development standards. Average GA was 27.5 weeks, with 23.7% classified as small for GA (SGA). Multivariate analysis highlighted low GA, low birth weight, and other perinatal factors as significant risk indicators for BPD. For moderate-to-severe BPD, additional risk factors included male gender and SGA, endotracheal intubation (ETT) or cardiopulmonary cerebral resuscitation (CPCR) in initial resuscitation. In the moderate-to-severe BPD/death group, SGA and ETT or CPCR in initial resuscitation remained the only additional risk factors. The study pinpoints male gender, SGA and ETT or CPCR as key risk factors for moderate-to-severe BPD/death in low-birth-weight infants in Taiwan, offering a basis for focused interventions and further research.

Status of the neonatal follow-up system in China: survey and analysis

BACKGROUND

There is little information about neonatal follow-up programs (NFUPs) in China. This study aimed to conduct a survey of hospitals participating in the Chinese Neonatal Network (CHNN) to determine the status of NFUPs, including resources available, criteria for enrollment, neurodevelopmental assessments, and duration of follow-up.

METHODS

We conducted a descriptive study using an online survey of all 72 hospitals participating in CHNN in 2020. The survey included 15 questions that were developed based on the current literature and investigators' knowledge about follow-up practices in China.

RESULTS

Sixty-four (89%) of the 72 hospitals responded to the survey, with an even distribution of children's (31%), maternity (33%) and general (36%) hospitals. All but one (98%) hospital had NFUPs, with 44 (70%) being established after 2010. Eligibility criteria for follow-up were variable, but common criteria included very preterm infants < 32 weeks or < 2000 g birth weight (100%), small for gestational age (97%), hypoxic ischemic encephalopathy (98%) and postsurgery (90%). The average follow-up rate was 70% (range: 7.5%-100%). Only 12% of hospitals followed up with patients for more than 24 months. There was significant variation in neurodevelopmental assessments, follow-up schedule, composition of staff, and clinic facilities and resources. None of the staff had received formal training, and only four hospitals had sent staff to foreign hospitals as observers.

CONCLUSIONS

There is significant variation in eligibility criteria, duration of follow-up, types of assessments, staffing, training and facilities available. Coordination and standardization are urgently needed.

A nomogram for predicting death for infants born at a gestational age of <28 weeks: a population-based analysis in 18 neonatal intensive care units in northern China

Background

In China, the number of preterm infants is the second largest globally. Compared with those in developed countries, the mortality rate and proportion of treatment abandonment for extremely preterm infants (EPIs) are higher in China. It would be valuable to conduct a multicenter study and develop predictive models for the mortality risk. This study aimed to identify a predictive model among EPIs who received complete care in northern China in recent years.

Methods

This study included EPIs admitted to eighteen neonatal intensive care units (NICUs) within 72 hours of birth for receiving complete care in northern China between January 1, 2015, and December 31, 2018. Infants were randomly assigned into a training dataset and validation dataset with a ratio of 7:3. Univariate Cox regression analysis and multiple regression analysis were used to select the predictive factors and to construct the best-fitting model for predicting in-hospital mortality. A nomogram was plotted and the discrimination ability was tested by an area under the receiver operating characteristic curve (AUROC). The calibration ability was tested by a calibration curve along with the Hosmer-Lemeshow (HL) test. In addition, the clinical effectiveness was examined by decision curve analysis (DCA).

Results

A total of 568 EPIs were included and divided into the training dataset and validation dataset. Seven variables [birth weight (BW), being inborn, chest compression in the delivery room (DR), severe respiratory distress syndrome, pulmonary hemorrhage, invasive mechanical ventilation, and shock] were selected to establish a predictive nomogram. The AUROC values for the training and validation datasets were 0.863 [95% confidence interval (CI): 0.813-0.914] and 0.886 (95% CI: 0.827-0.945), respectively. The calibration plots and HL test indicated satisfactory accuracy. The DCA demonstrated that positive net benefits were shown when the threshold was >0.6.

Conclusions

A nomogram based on seven risk factors is developed in this study and might help clinicians identify EPIs with risk of poor prognoses early.

Immune regulation by activation markers at feto-maternal interface in infection-associated spontaneous preterm birth

BACKGROUND

Spontaneous preterm birth (sPTB) is a global health concern. Studies reveal infections are majorly responsible for sPTB and immune activation markers play a role in regulation of maternal immune responses against pathogens during sPTB.

AIM

To study the mRNA expression and correlation of activation markers (CD66a, ICAM1, ITGB1, TIM3, CD25, CD95) and associated cytokines (IL-1β and IL-17)/prostaglandin receptors (EP2 and IP) in the placenta of Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum-infected sPTB women.

METHODS

Placental samples were collected from 160 sPTB and 160 term birth women. PCR was used for the detection of C. trachomatis, M. hominis, U. urealyticum. The mRNA expression of activation markers, cytokines and prostaglandin receptors was evaluated by real-time qPCR.

RESULTS

The fold-change expression of CD66a, ICAM1, TIM3, CD25 and CD95 was 2.89, 5.5, 4.95, 6.44 and 6.95-fold (p < 0.001), respectively; while for cytokines- IL-1β and IL-17 was 5.41 and 4.71-fold (p < 0.001), respectively and for prostaglandin receptors- EP2 and IP was 5.5 and 5-fold (p < 0.001) upregulated, respectively in infected sPTB women. Significant positive correlation was obtained among ICAM-1 and IL-1β/EP2/IL-17, TIM3 and IP/IL-17. Significant negative correlation was obtained between CD66a and EP2/IL-17, CD25 and IL-1β/EP2, CD95 and IL-1β/EP2 in infected sPTB women.

CONCLUSIONS

CD66a, ICAM1 and TIM3 may play role in inflammation and have potential for the clinical beginning of preterm labour during infection while CD25 and CD95 are possibly involved in immunotolerance at feto-maternal interface during C. trachomatis, M. hominis and U. urealyticum infection.

Modified lung ultrasound score for bronchopulmonary dysplasia predicts late respiratory outcomes in preterm infants

OBJECTIVE

Lung ultrasound (LUS) is a useful and radiation-free diagnostic tool for predicting bronchopulmonary dysplasia, which is a risk factor for late respiratory disease. However, data on the relationship of LUS with late respiratory disease was scarce. This study aims to determine whether LUS is associated with late respiratory disease during early childhood.

METHODS

This prospective cohort study enrolled preterm infants born before 32 weeks of gestation. LUS was performed at 36 weeks' postmenstrual age. The predictive values of a modified lung ultrasound (mLUS) score based on eight standard sections were assessed to predict late respiratory disease, defined as a physician diagnosis of bronchopulmonary dysplasia deterioration, asthma, reactive airway disease, bronchiolitis, pneumonia, or respiratory-related hospitalization during the first 2 years of life.

RESULTS

A total of 94 infants completed follow-up, of whom 74.5% met the late respiratory disease criteria. The mLUS scores were significantly associated with late respiratory disease (adjusted odds ratio: 1.23, CI: 1.10-1.38, p < 0.001). The mLUS scores also well predicted late respiratory disease (AUC = 0.820, 95% CI: 0.733-0.907). These scores were superior to the classic lung ultrasound score (p = 0.02) and as accurate as the modified NICHD-defined bronchopulmonary dysplasia classification (p = 0.91). A mLUS score ≥14 was the optimal cutoff point for predicting late respiratory disease.

CONCLUSION

The modified lung ultrasound score correlates significantly with late respiratory disease and well predicts it in preterm infants during the first 2 years of life.

Clinical characteristics and long-term neurodevelopmental outcomes of leukomalacia in preterm infants and term infants: a cohort study

BACKGROUND

Leukomalacia is a serious form of neonatal brain injury that often leads to neurodevelopmental impairment, and studies on neonatal leukomalacia and its long-term outcomes are lacking. The aim of this study was to analyze the clinical manifestations, imaging features, and long-term neurodevelopmental outcomes in preterm infants and term infants with leukomalacia.

METHODS

Newborns diagnosed with leukomalacia by head magnetic resonance imaging (MRI) and who were admitted to intensive care units from January 2015 to June 2020 were enrolled. All infants were followed up to June 2022 (2-7 years old), and their neurodevelopmental outcomes were evaluated. The clinical data and long- term outcomes of preterm infants and term infants was analyzed by Chi-square tests.

RESULTS

A total of 218 surviving infants with leukomalacia including 114 preterm infants and 104 term infants completed the follow-up. The major typesof leukomalacia on MRI were periventricular leukomalacia in the preterm group and subcortical cystic leukomalacia in the term group, respectively (χ2 = 55.166; p < 0.001). When followed up to 2-7 years old, the incidence of neurodevelopmental impairment in the preterm group and term group was not significantly different (χ2 = 0.917; p = 0.338). However, the incidence of cerebral palsy (CP) in the preterm group was significantly higher (χ2 = 4.896; p = 0.027), while the incidence of intellectual disability (ID) (χ2 = 9.445; p = 0.002), epilepsy (EP) (χ2 = 23.049; p < 0.001), and CP combined with ID andEP (χ2 = 4.122; p = 0.042) was significantly lower than that in the term group.

CONCLUSIONS

Periventricular leukomalacia mainly occurred in preterm infants while subcortical cystic leukomalacia was commonly seen in term infants. Although the long-term neurodevelopmental outcomes of leukomalacia were both poor, preterm infants were more prone to CP, while term infants were more prone to ID, EP, and the combination of CP with ID and EP.

Determinants of microbial colonization in the premature gut

Abnormal microbial colonization in the gut at an early stage of life affects growth, development, and health, resulting in short- and long-term adverse effects. Microbial colonization patterns of preterm infants differ from those of full-term infants in that preterm babies and their mothers have more complicated prenatal and postnatal medical conditions. Maternal complications, antibiotic exposure, delivery mode, feeding type, and the use of probiotics may significantly shape the gut microbiota of preterm infants at an early stage of life; however, these influences subside with age. Although some factors and processes are difficult to intervene in or avoid, understanding the potential factors and determinants will help in developing timely strategies for a healthy gut microbiota in preterm infants. This review discusses potential determinants of gut microbial colonization in preterm infants and their underlying mechanisms.

Characteristics of home oxygen therapy for preterm infants with bronchopulmonary dysplasia in China: results of a multicenter cohort study

BACKGROUND

Home oxygen therapy (HOT) is indicated upon discharge in some preterm infants with severe bronchopulmonary dysplasia (BPD). There is a lack of evidence-based consensus on the indication for HOT among these infants. Because wide variation in the institutional use of HOT exists, little is known about the role of regional social-economic level in the wide variation of HOT.

METHODS

This was a secondary analysis of Chinese Neonatal Network (CHNN) data from January 1, 2019 to December 31, 2019. Infants at gestational ages < 32 weeks, with a birth weight < 1500 g, and with moderate or severe BPD who survived to discharge from tertiary hospitals located in 25 provinces were included in this study. Infants with major congenital anomalies and those who were discharged against medical advice were excluded.

RESULTS

Of 1768 preterm infants with BPD, 474 infants (26.8%) were discharged to home with oxygen. The proportion of HOT use in participating member hospitals varied from 0 to 89%, with five of 52 hospitals' observing proportions of HOT use that were significantly greater than expected, with 14 hospitals with observing proportions significantly less than expected, and with 33 hospitals with appropriate proportions. We noted a negative correlation between different performance groups of HOT and median GDP per capita (P = 0.04).

CONCLUSIONS

The use of HOT varied across China and was negatively correlated with the levels of provincial economic levels. A local HOT guideline is needed to address the wide variation in HOT use with respect to different regional economic levels in countries like China.

Determining resuscitation threshold for extremely preterm infants based on the survival rates without severe neurological injury

Background

Published guidelines on decision-making and resuscitation of extremely preterm infants primarily focus on high-income countries. For rapidly industrializing ones like China, there is a lack of population-based data for informing prenatal management and practice guidelines.

Methods

The Sino-northern Neonatal Network conducted a prospective multi-centre cohort study between 1 January 2018 and 31 December 2021. Infants with a gestational age (GA) between 22 (postnatal age in days = 0) and 28 (postnatal age in days = 6) admitted to 40 tertiary NICUs in northern China were included and evaluated for death or severe neurological injury before discharge.

Results

For all extremely preterm infants (n = 5838), the proportion of admission to the neonatal was 4.1% at 22-24 weeks, 27.2% at 25-26 weeks, and 75.2% at 27 and 28 weeks. Among 2228 infants admitted to the NICU, 216 (11.1%) were still elected for withdrawal of care (WIC) due to non-medical factors. Survival rates without severe neurological injury were 6.7% for infants at 22-23 weeks, 28.0% at 24 weeks, 56.7% at 24 weeks, 61.7% at 25 weeks, 79.9% at 26 weeks, and 84.5% at 27 and 28 weeks. Compared with traditional criterion at 28 weeks, the relative risk for death or severe neurological injury were 1.53 (95% confidence interval (CI) = 1.26-1.86) at 27 weeks, 2.32 (95% CI = 1.73-3.11) at 26 weeks, 3.62 (95% CI = 2.43-5.40) at 25 weeks, and 8.91 (95% CI = 4.69-16.96) at 24 weeks. The NICUs with higher proportion of WIC also had a higher rate of death or severe neurological injury after maximal intensive care (MIC).

Conclusions

Compared to the traditional threshold of 28 weeks, more infants received MIC after 25 weeks, leading to significant increases in survival rates without severe neurological injury. Therefore, the resuscitation threshold should be gradually adjusted from 28 to 25 weeks based on reliable capacity.

Registration

China Clinical Trials Registry. ID: ChiCTR1900025234.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Acceptability of COVID-19 vaccination in Chinese children aged 3-7 years with bronchopulmonary dysplasia

OBJECTIVES

To describe the status of coronavirus disease 2019 (COVID-19) vaccination with inactivated vaccines BBIBP-CorV and CoronaVac in Chinese children aged 3-7 years with bronchopulmonary dysplasia (BPD), and explore factors influencing vaccination and reasons for nonvaccination.

METHODS

This cross-sectional study involving parents of 397 BPD children aged 3-7 years was conducted through WeChat or follow-up telephone interviews using a standardized questionnaire form. Factors influencing COVID-19 vaccination were explored by using modified Poisson regression models.

RESULTS

The overall COVID-19 vaccination rate was 69.0% (95% confidence interval: 64.3%-73.4%). COVID-19 vaccination was less likely to be accepted in children whose mothers had a relatively high educational background (university and above), who lived in urban areas and had a low birth weight (<1 kg), a history of hospitalization for lung diseases in the past 12 months, and intellectual disability. Conversely, kindergarten students and children from families with an annual income of >300,000 CNY (≈ $\approx $ 41,400 USD) were more likely to accept vaccination. Adverse reactions occurred in 13/274 children (4.7%) within 10 days after vaccination. With respect to reasons of not accepting COVID-19 vaccination, 95 parents (77.2%) worried about the adverse reactions, and 17 parents (13.8%) refused vaccination on the excuse of not being convenient to go to the vaccination station or not knowing where to get the vaccines.

CONCLUSIONS

The COVID-19 vaccination rate in BPD children aged 3-7 years needs to be further improved in China. Continuous efforts are required to monitor postvaccination adverse reactions in BPD children, and make vaccination more convenient and accessible.

The likelihood of a healthy live birth after frozen embryo transfer with endometrium prepared by natural ovulation regimen vs programmed regimen: a propensity-score matching study

BACKGROUND

The number of frozen embryo transfer cycles is increasing, but the optimal method of endometrial preparation for frozen embryo transfer remains controversial. Few studies have investigated the healthy live birth outcome after the natural ovulation regimen vs the programmed regimen.

OBJECTIVE

This study aimed to explore whether the likelihood of a healthy live birth after frozen embryo transfer differs between the natural ovulation regimen and the programmed regimen.

STUDY DESIGN

We conducted a retrospective cohort study including 7824 ovulatory women who underwent the first frozen embryo transfer cycle of single-blastocyst transfer with endometrial preparation by natural ovulation regimen vs programmed regimen, between June 2017 and June 2021. Propensity score matching was used to control for confounding variables in a 1:1 ratio. The primary outcome was healthy live birth, defined as birth of a live, singleton infant born at term, with an appropriate birthweight for gestational age.

RESULTS

The natural ovulation regimen resulted in a higher probability of achieving healthy live birth compared with the programmed regimen (35.8% vs 30.6%; P<.0001). In addition, a higher rate of singleton live birth was observed after the natural ovulation regimen relative to the programmed regimen (49.6% vs 45.7%; P=.003). Women with the natural ovulation regimen were also less likely to experience clinical pregnancy loss (16.0% vs 19.7%; P=.005) and hypertensive disorders of pregnancy (3.9% vs 6.0%; P=.004) compared with women with the programmed regimen. Singletons born after the programmed regimen had greater mean birthweight (3441.50±539.97 vs 3394.96±503.87; P=.020) and higher risk of being large for gestational age (23.3% vs 18.7%; P=.003) than those conceived after the natural ovulation regimen.

CONCLUSION

The natural ovulation regimen may be superior to the programmed regimen with regard to higher likelihood of healthy live birth and lower risk of pregnancy loss and maternal hypertensive disorders of pregnancy.

Regional distribution of the MTHFR C677T polymorphism in Chinese females

Objective: For analyzing the distribution characteristics of MTHFR C677T polymorphism in Chinese females in order to provide information for reducing birth defects and formulating public health policies to prevent congenital malformations. Methods: Literature search in the last 6 years on "MTHFR C677T," "polymorphism" and "methylene tetrahydrofolate reductase." The included literature provides the MTHFR C677T frequency in healthy females in the corresponding regions. The data were grouped by the national administrative region as a unit to obtain the distribution information of the MTHFR C677T and alleles in the female population in every province, municipality or autonomous region. This was done for analyzing the overall distribution of the MTHFR C677T allele and the geographical distribution of pregnancy complications. Results: A total of 126 studies were included, covering five autonomous areas, four municipalities directly under the Central Government, as well as 22 provinces (except Taiwan Province) in China. MTHFR C677T polymorphism data of 27 groups of Chinese Han women and 31 groups of other Chinese females were obtained, and the chi-square test revealed notable inter-group differences (p = 0.000). The TT genotype and T allele of MTHFR C677T accounted for 18.2% (4.7%-38.3%) and 40.3% (19.7%-61.4%) of the Chinese female population, respectively, with a significant north-south difference. Chinese females had a consistent frequency of the T allele with the geographical distribution of pregnancy complications such as recurrent abortion and preeclampsia. Conclusion: With a obvious geographical gradient, the MTHFR C677T polymorphism distribution in Chinese females is consistent with the geographical distribution of multiple pregnancy complications, and the risk assessment for it might be included in primary prevention for birth defects.

Neighborhood Incarceration Rates and Adverse Birth Outcomes in New York City, 2010-2014

Importance

The US has high rates of adverse birth outcomes, with substantial racial disparities augmented by stress and neighborhood disadvantage. Black people are more likely to live in neighborhoods with high rates of incarceration, which is a source of both stress and neighborhood disadvantage and, thus, may contribute to adverse birth outcomes.

Objective

To determine whether neighborhoods with high incarceration rates also have higher rates of adverse birth outcomes compared with neighborhoods with lower rates.

Design, Setting, and Participants

This cross-sectional study used publicly available data from the New York City Department of Health (2010-2014). Censored Poisson regression, with the US Census tract as the unit of analysis, was used to examine the association of neighborhood incarceration rate and birth outcomes. Multivariable models included percentage of births aggregated to the Census tract by maternal factors (age, parity, singleton vs multiple birth, insurance, and race) and neighborhood factors (poverty, education, and violent crime). Analyses were performed between May 2021 and October 2022.

Exposure

Neighborhood incarceration rate, categorized into quintiles.

Main Outcomes and Measures

The primary outcome was the incidence rate ratio (IRR) of preterm birth and low birth weight. Secondary outcomes were IRRs of very preterm birth, extremely preterm birth, and very low birth weight. Hypotheses were formulated before data collection.

Results

Among 2061 Census tracts with 562 339 births, incarceration rates varied from 0 to 4545 people incarcerated per 100 000, and high-incarceration neighborhoods had more residents of Black race (54.00% vs 1.90%), living in poverty (32.30% vs 10.00%), and without a general educational development equivalent (28.00% vs 12.00%) compared with low-incarceration neighborhoods. In fully adjusted models, high-incarceration neighborhoods had a 13% higher IRR of preterm birth (IRR, 1.13; 95% CI, 1.08-1.18), 45% higher IRR of very preterm birth (IRR, 1.45; 95% CI, 1.24-1.71), 125% higher IRR of extremely preterm birth (IRR, 2.25; 95% CI, 1.59-3.18), 10% higher IRR of low birth weight (IRR, 1.10; 95% CI, 1.05-1.16), and 52% higher IRR of very low birth weight compared with low-incarceration neighborhoods (IRR, 1.52; 95% CI, 1.28-1.81).

Conclusions and Relevance

Neighborhood incarceration rate was positively associated with adverse birth outcomes, particularly those associated with infant mortality. Black people were significantly more likely to live in high-incarceration neighborhoods, suggesting that mass incarceration may contribute to racial disparities in birth outcomes.

Impact of premature rupture of membranes on clinical outcomes of extremely premature infants: A propensity score matching study

Background

Premature rupture of membranes (PROM) is a common cause of extremely premature infants (EPIs) and also leads to adverse preterm complications. However, the effect of PROM on EPIs remains contradictory. This study used propensity score matching (PSM) to adjust the baseline characteristics to explore the impact of PROM on clinical outcomes of extremely premature infants (EPIs).

Methods

Medical data of 470 EPIs at gestational age < 28weeks who received prenatal examination in our hospital between January 1, 2015 and December 31, 2020 were analyzed retrospectively. According to the presence or absence of PROM, they were divided into a PROM group and a non-PROM group. Ten covariates including birth weight, male sex, artificial conception, cesarean delivery, 5-min Apgar score ≤ 7, oligohydramnios, gestational hypertension, preeclampsia, antenatal steroid use, and complete steroid treatment were matched 1:1 by PSM. The major complication occurrence and mortality during hospitalization were compared between the two groups by t-test, nonparametric test or x 2 test.

Results

Among the 470 infants enrolled, 157 (33.4%) were in the PROM group and 313 in the no-PROM group. After matching the ten confounding factors,276 cases were successfully enrolled. The incidence of early pulmonary hypertension (EPH) and severe retinopathy of prematurity (ROP) in the PROM group were higher than those in the no-PROM group [44.2% (61/138) vs. 29.0% (40/138); 34.8% (48/138) vs. 21.7% (30/138), x ² = 6.886 and 5.790, both P < 0.05]. However, there was no significant difference in the in-hospital mortality and the incidence of other major complications between the two groups (all P > 0.05).

Conclusions

PROM increased the incidence of EPH and severe ROP in EPI, but had no significant impact on in-hospital mortality, length of hospital stay, and the incidence of other complications.

Analysis of risk factors related to extremely and very preterm birth: a retrospective study

Background:

Preterm birth is one of the main causes of perinatal morbidity and mortality and imposes a heavy burden on families and society. The aim of this study was to identify risk factors and analyze birth conditions and complications of newborns born at < 32 gestational weeks for extremely preterm (EP) and very preterm (VP) birth in the clinic to further extend the gestational period.

Methods:

We performed a retrospective cohort study and collected data from 1598 pregnant women and 1660 premature newborns (excluding 229 premature babies who died due to severe illness and abandonment) admitted to the Obstetrics and Gynecology Hospital Affiliated with Nanjing Medical University in China from 2016 to 2020. We compared women’s and newborns’ characteristics by t-tests and Chi-square tests for continuous and categorical variables, respectively. Multivariable logistic regression was performed to estimate the effects of risk factors on EP and VP birth.

Results:

We identified 3 independent risk factors for EP birth: cervical incompetency (P < 0.001); multiple pregnancy (P < 0.01), primipara (P < 0.001). Additionally, we identified 4 independent risk factors for VP birth: gestational diabetes mellitus (GDM) (P < 0.05), preterm premature rupture of membrane (PPROM) (P < 0.01), fetal intrauterine distress (P < 0.001), and hypertensive disorder complicating pregnancy (HDCP) (P < 0.001). In addition, pairwise comparisons revealed statistically significant differences in the incidence rates of neonatal pneumonia, bronchopulmonary dysplasia (BPD) and sepsis between the 28–28 + 6 and 29–29 + 6 weeks of gestation groups (P < 0.05). Compared with 28–28 + 6 weeks of gestation, neonatal complications were significantly more common at < 26 weeks of gestation (P < 0.05). The incidence rates of neonatal intracranial hemorrhage(NICH), patent ductus arteriosus(PDA), patent foramen ovale(PFO), pneumonia, BPD and sepsis were significantly higher in the 26–26 + 6 and 27–27 + 6 gestational weeks than in the 28–28 + 6 gestational weeks (P < 0.05).

Conclusion:

PPROM, is the most common risk factor for EP and VP birth, and cervical insufficiency, multiple pregnancy, and primipara are independent risk factors for EP birth. Therefore, during pregnancy, attention should be devoted to the risk factors for PPROM, and reproductive tract infection should be actively prevented to reduce the occurrence of PPROM. Identifying the risk factors for cervical insufficiency, actively intervening before pregnancy, and cervical cervix ligation may be considered to reduce the occurrence of EP labor. For iatrogenic preterm birth, the advantages and disadvantages should be carefully weighed, and the gestational period should be extended beyond 28 weeks to enhance the safety of the mother and child and to improve the outcomes of preterm birth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05119-7.

The Male to Female Ratio in Treatment-Warranted Retinopathy of Prematurity: A Systematic Review and Meta-analysis

Importance

Literature and anecdotal evidence suggest a relationship between male sex and retinopathy of prematurity (ROP). It is not known whether a difference, if present, is sex-related pathophysiologic predisposition or sex difference in meeting ROP screening criteria.

Objective

To evaluate the association of sex with the development of treatment-warranted ROP.

Data Sources

PubMed, Embase, and Web of Science databases were searched from 2000 to 2022. The search strategy used keywords including retinopathy of prematurity or ROP or retrolental fibroplasia and treatment or anti-VEGF or bevacizumab or ranibizumab or aflibercept or conbercept or laser or cryotherapy and gender or sex or male or female and medical subject headings terms.

Study Selection

All studies reporting on treatment with anti-vascular endothelial growth factor, laser photocoagulation, and/or cryotherapy for ROP were identified. Studies reporting sex distribution in the treatment group were included in the meta-analysis. Exclusion criteria included case reports, case series of fewer than 10 treated patients, systematic reviews, conference abstracts, letters to the editor, animal studies, and non-English records.

Data Extraction and Synthesis

Two reviewers independently screened and extracted the data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The proportions of treated male and female infants were combined using random-effects meta-analysis.

Main Outcomes and Measures

Numbers and percentages of male and female infants treated for ROP.

Results

Of 11 368 identified studies, 316 met inclusion criteria, yielding a total of 31 026 treated patients. A higher percentage of male infants were treated for ROP (55% [95% CI, 0.54%-0.55%]), with low heterogeneity between studies (I2 = 34%; P < .001). Thirty-eight studies reported sex distribution in the screened population (170 053 patients; 92 612 [53%] male vs 77 441 [47%] female). There was no significant difference in the odds of receiving treatment between screened male and female infants (pooled odds ratio, 1.04 [95% CI, 0.91-1.18]; P = .67).

Conclusions and Relevance

More male infants are treated for ROP than female infants. This could be due to a known relative pathophysiological fragility of preterm male infants in addition to a difference in ROP screening rates, with more male infants meeting the criteria than female infants. These findings have implications for future studies and may prompt more careful clinical monitoring of male neonates.

Obstetricians' Attitudes Toward the Treatment of Extremely Preterm Infants in China

IMPORTANCE

Extremely preterm infants (EPIs) are at high risk of mortality and disability, and whether obstetricians are active in treating EPIs is directly related to whether EPIs can get an opportunity to enter the neonatal intensive care unit (NICU) for treatment. A greater understanding of the attitudes of obstetricians toward the treatment of EPIs is needed to improve treatment of this population and optimize pediatric health policies and services.

OBJECTIVE

To clarify the attitudes of obstetricians toward the treatment of EPIs in China.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, online, questionnaire-based survey was conducted among obstetricians from various provinces and cities in China through the wenjuanxing application (a survey platform) between June and July 2021. The questionnaire included characteristics of the participants, their experiences in delivering EPIs, their attitudes toward EPI resuscitation, and their opinions about the cutoff for providing full care to preterm infants in China. Possible factors associated with their attitudes toward the cutoff for providing full care to preterm infants were analyzed by logistic regression. Data analysis was performed from August 2021 to January 2022.

MAIN OUTCOMES AND MEASURES

The attitudes of obstetricians toward the resuscitation and treatment of EPIs, and the current cutoff for providing full care to premature infants.

RESULTS

A total of 2817 valid questionnaires were recovered from 30 provinces and cities in mainland China. Of the 2817 obstetricians (mean [SD] age, 41.76 [8.50] years) investigated, 156 (5.5%) were male, 2661 (94.5%) were female, 1339 (47.5%) were deputy chief physicians or chief physicians, 1662 (59.0%) were from tertiary hospitals, and 2048 (72.7%) had experience in delivering EPIs. The proportion of obstetricians who supported resuscitation of preterm infants was 19.1% (539 respondents) at a gestational age 24 weeks, 24.1% (679 respondents) at 25 weeks, 54.8% (1543 respondents) at 26 weeks, and 100.0% (2817 respondents) at 27 weeks. A total of 1326 obstetricians (47.1%) reported that it was common or very common for EPIs to be withdrawn from resuscitation and not to be admitted to the NICU for treatment. Regarding the treatment of EPIs with higher possibility of survival, 1621 obstetricians (57.5%) maintained that appropriate information should be communicated but their parents' wishes should be respected. Most obstetricians (2051 respondents [72.8%]) maintained that 28 weeks was the cutoff for providing full care to preterm infants in China; 766 respondents (27.2%) thought of it as inappropriate, suggesting the cutoff should be less than 28 weeks. Logistic regression analysis showed that these differences were significantly associated with the professional titles of the obstetricians, geographical regions, hospital levels and types, whether they had any experience in delivering EPIs, and the total number of EPIs born yearly in their units.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, most Chinese obstetricians maintained a conservative attitude toward the treatment of EPIs. It was very common for EPIs to be withdrawn from treatment without entering the NICU directly after birth. Most obstetricians maintained that 28 weeks' gestational age should be the cutoff for providing full care to premature infants.

CircRNA, lncRNA, and mRNA profiles of umbilical cord blood exosomes from preterm newborns showing bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) represents a multifactorial chronic pulmonary pathology and a major factor causing premature illness and death. The therapeutic role of exosomes in BPD has been feverishly investigated. Meanwhile, the potential roles of exosomal circRNAs, lncRNAs, and mRNAs in umbilical cord blood (UCB) serum have not been studied. This study aimed to detect the expression profiles of circRNAs, lncRNAs, and mRNAs in UCB-derived exosomes of infants with BPD. Microarray analysis was performed to compare the RNA profiles of UCB-derived exosomes of a preterm newborn with (BPD group) and without (non-BPD, NBPD group) BPD. Then, circRNA/lncRNA-miRNA-mRNA co-expression networks were built to determine their association with BPD. In addition, cell counting kit-8 (CCK-8) assay was used to evaluate the proliferation of lipopolysaccharide (LPS)-induced human bronchial epithelial cells (BEAS-2B cells) and human umbilical vein endothelial cells (HUVECs). The levels of tumor necrosis factor (TNF)-α and interleukin (IL)-1β in LPS-induced BEAS-2B cells and HUVECs were assessed through Western blot analysis. Then, quantitative reverse transcription-polymerase chain reaction assay was used to evaluate the expression levels of four differentially expressed circRNAs (hsa_circ_0086913, hsa_circ_0049170, hsa_circ_0087059, and hsa_circ_0065188) and two lncRNAs (small nucleolar RNA host gene 20 (SNHG20) and LINC00582) detected in LPS-induced BEAS-2B cells or HUVECs. A total of 317 circRNAs, 104 lncRNAs, and 135 mRNAs showed significant differential expression in UCB-derived exosomes of preterm infants with BPD compared with those with NBPD. Gene Ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were conducted to examine differentially expressed exosomal circRNAs, lncRNAs, and mRNAs. The results showed that the GO terms and KEGG pathways mostly involving differentially expressed exosomal RNAs were closely associated with endothelial or epithelial cell development. In vitro, CCK-8 and Western blot assays revealed that LPS remarkably inhibited the viability and promoted inflammatory responses (TNF-α and IL-1β) of BEAS-2B cells or HUVECs. The expression levels of circRNAs hsa_circ_0049170 and hsa_circ_0087059 were upregulated in LPS-induced BEAS-2B cells; the expression level of hsa_circ_0086913 was upregulated and that of hsa_circ_0065188 was downregulated in LPS-induced HUVECs. Moreover, the expression level of lncRNA SNHG20 was upregulated and that of LINC00582 was downregulated in LPS-induced BEAS-2B cells. Further, 455 circRNA/lncRNA-miRNA-mRNA interaction networks were predicted, including hsa_circ_0086913/hsa-miR-103a-3p/transmembrane 4 L six family member 1 (TM4SF1) and lncRNA-SNHG20/hsa-miR-6720-5p/spermine synthase (SMS) networks, which may take part in BPD.

CONCLUSION

This study provided a systematic perspective on UCB-derived exosomal circRNAs and lncRNAs and laid an important foundation for further investigating the potential biological functions of exosomal circRNAs and lncRNAs in BPD.

WHAT IS KNOWN

• BPD represents a multifactorial chronic pulmonary pathology and a major factor causing premature illness and death. • The therapeutic role of exosomes in BPD has been feverishly investigated, and exosomal RNAs were ignored.

WHAT IS NEW

• The profiles of UCB-derived exosomal circRNAs, lncRNAs, and mRNAs were performed. • Several differentially expressed circRNAs and lncRNAs were identified in LPS-induced BEAS-2B cells and HUVECs.

An assessment of improved outcomes using low-cost bubble CPAP in very low birthweight neonates in a Nigerian tertiary hospital

Respiratory distress contributes to the high burden of preterm mortality globally. The aim of our study was to evaluate the use of low-cost Bubble Continuous Positive Airway Pressure devices for treating respiratory distress and their outcomes in preterm infants weighing <1500g. Data was extracted from admission records of 211 infants over two distinct 4-year periods before and after introduction of bCPAP. With survival rates of 26.7% and 61.8% in the pre and post bCPAP eras respectively, significantly improved outcomes were found.

The clinical burden of extremely preterm birth in a large medical records database in the United States: Mortality and survival associated with selected complications

BACKGROUND

Preterm birth is a leading cause of infant mortality, particularly for those born extremely prematurely (EP; <28 weeks' gestational age [GA]). Survivors are predisposed to complications such as bronchopulmonary dysplasia (BPD), chronic lung disease (CLD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP).

AIMS

To examine the epidemiology, complications, and mortality/survival among EP infants.

STUDY DESIGN

Retrospective analysis of electronic medical records from the Kaiser Permanente Northern California database.

SUBJECTS

EP infants live-born between 22 and <28 weeks' GA from 1997 to 2016.

OUTCOME MEASURES

Cumulative all-cause mortality/survival were analyzed and stratified by GA (22 to <24, 24 to <26, 26 to <28 weeks), complications (BPD/CLD, IVH, ROP), and birth period (1997 to 2003, 2004 to 2009, 2010 to 2016). Cox proportional hazard models were constructed to assess the mortality risk associated with BPD/CLD or IVH.

RESULTS

2154 EP infants were identified; of these, 916 deaths were recorded. Mortality was highest during the first 3 months (41.7 % cumulative mortality), and few were reported after 2 years (42.5 % cumulative mortality). Mortality decreased with higher GA and over more recent birth periods. BPD/CLD and IVH grade 3/4 were associated with increased mortality risk versus no complications (adjusted hazard ratios 1.41 and 1.78, respectively).

CONCLUSIONS

The risk of mortality is high during the first few months of life for EP infants, and is even higher for those with BPD and IVH. Despite an overall trend toward increased survival for EP infants, strategies targeting survival of EP infants with these complications are needed.

Effects of Antioxidants in Human Milk on Bronchopulmonary Dysplasia Prevention and Treatment: A Review

Bronchopulmonary dysplasia (BPD) is a severe chronic lung illness that affects neonates, particularly premature infants. It has far-reaching consequences for infant health and their families due to intractable short- and long-term repercussions. Premature infant survival and long-term quality of life are severely harmed by BPD, which is characterized by alveolarization arrest and hypoplasia of pulmonary microvascular cells. BPD can be caused by various factors, with oxidative stress (OS) being the most common. Premature infants frequently require breathing support, which results in a hyperoxic environment in the developing lung and obstructs lung growth. OS can damage the lungs of infants by inducing cell death, inhibiting alveolarization, inducing inflammation, and impairing pulmonary angiogenesis. Therefore, antioxidant therapy for BPD relieves OS and lung injury in preterm newborns. Many antioxidants have been found in human milk, including superoxide dismutase, glutathione peroxidase, glutathione, vitamins, melatonin, short-chain fatty acids, and phytochemicals. Human milk oligosaccharides, milk fat globule membrane, and lactoferrin, all unique to human milk, also have antioxidant properties. Hence, human milk may help prevent OS injury and improve BPD prognosis in premature infants. In this review, we explored the role of OS in the pathophysiology of BPD and related signaling pathways. Furthermore, we examined antioxidants in human milk and how they could play a role in BPD to understand whether human milk could prevent and treat BPD.

Incidence of retinopathy of prematurity treatment in extremely preterm infants in China

BACKGROUND

Retinopathy of prematurity (ROP) continues to be a major cause of visual impairment and blindness in premature infants and children.

OBJECTIVES

To investigate the incidence of severe ROP receiving treatment in extremely preterm (EP) infants in China over time. The risk factors for ROP treatment were also assessed.

METHODS

This was a multicentre retrospective study and a subanalysis of baseline data from the "Outcomes of EP infants in China 2010-2019" study. This study was conducted in 68 tertiary neonatal care centres from 31 provinces of China. Infants with a gestational age of 23⁰ -27⁶  weeks and admitted to a neonatal unit within the first 72 h of life between 2010 and 2019 were enrolled. Incidence of ROP was analysed in infants who survived to 32 weeks postmenstrual age and screened for ROP. Multivariable modified Poisson regression models were used to identify risk factors for ROP treatment.

RESULTS

Among 7295 eligible infants, 4701 (64.5%) survived to 32 weeks postmenstrual age and met ROP screening criteria. Of the 3756 infants who screened and with ROP data, 2320 (61.8%) developed ROP of any stage. The overall incidence of ROP treatment was 12.6%, decreasing from 45.5% at 23 weeks to 8.3% at 27 weeks. During the 10-year period, the incidence of ROP treatment did not change, although the incidence of any ROP increased over time. Independent risk factors associated with ROP treatment included lower gestational age, small for gestational age, multiple birth, severe intraventricular haemorrhage, patent ductus arteriosus and supplemental oxygen duration.

CONCLUSIONS

The incidence of EP infants receiving ROP treatment showed no change during this 10-year period in China. Prevention of prematurity and foetal growth restriction, judicious use of oxygen and reducing comorbidities are promising factors that may reduce the incidence of ROP needing treatment in these high-risk infants.

Implementing the Golden Hour Protocol to Improve the Clinical Outcomes in Preterm Infants

Purpose: Since premature infants are sensitive to the changes in blood glucose levels and body temperature, maintaining these parameters is important to avoid the risk of infections. The authors implemented the Golden Hour protocol (GHP) that aims to close the final incubator within one hour of birth by implementing early treatment steps for premature infants after birth, such as maintaining body temperature, securing airway, and rapidly administering glucose fluid and prophylactic antibiotics by securing breathing and rapid blood vessels. This study investigated the effect of GHP application on the short- and long-term clinical outcomes.Methods: We retrospectively analyzed the medical records between 2017 and 2018 before GHP application and between 2019 and 2020 after GHP application in preterm infants aged 24 weeks or older and those aged less than 33 weeks who were admitted to the neonatal intensive care unit.Results: Overall, 117 GHP patients and 81 patients without GHP were compared and analyzed. Peripheral vascularization time and prophylactic antibiotic administration time were shortened in the GHP-treated group (P=0.007 and P=0.008). In the short-term results, the GHP-treated group showed reduced hypothermia upon arrival at the neonatal intensive care unit (P=0.002), and the blood glucose level at 1 hour of hospitalization was higher (P=0.012). Furthermore, the incidence of neonatal necrotizing enteritis decreased (P=0.043). As a long-term result, the incidence of BPD was reduced (P=0.004).Conclusion: We confirmed that applying GHP improved short- and long-term clinical outcomes in premature infants aged <33 weeks age of gestation, and we expect to improve the treatment quality by actively using it for postnatal treatment.

Hyperoxia Induced Bronchopulmonary Dysplasia-Like Inflammation via miR34a-TNIP2-IL-1β Pathway

Lung injury induced by oxygen is a key contributor to the pathogenesis of preterm infant bronchopulmonary dysplasia (BPD). To date, there are comprehensive therapeutic strategy for this disease, but the underlying mechanism is still in progress. By using lentivirus, we constructed microRNA34a (miR34a)-overexpressing or knockdown A549 cell lines, and exposure to hyperoxia to mimic oxygen induce lung injury. In this study, we investigated 4 proinflammatory cytokines, interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), angiopoietin-1 (Ang-1), and Cyclooxygenase-2 (COX-2) in the secreted sputum of infants who received mechanical ventilation, and found that IL-1β was substantially elevated in the first week after oxygen therapy and with no significant decrease until the fourth week, while TNF-α, Ang-1, and COX-2 were increased in the first week but decreased quickly in the following weeks. In addition, in vitro assay revealed that hyperoxia significantly increased the expression of miR-34a, which positively regulated the proinflammatory cytokine IL-1β in a time- and concentration-dependent manner in A549 cells. Overexpressing or knockdown miR34 would exacerbate or inhibit production of IL-1β and its upstream NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3) inflammasome signaling pathway. Mechanically, it's found that TNFAIP3 interacting protein 2 (TNIP2), an inhibitor of nuclear factor κB (NF-κB), is a direct target of miR34a, negatively regulated activation of NLRP3 inflammasome and the production of IL-1β. Overexpressing TNIP2 ameliorated hyperoxia-induced production of IL-1β and cell apoptosis. Our findings suggest that TNIP2 may be a potential clinical marker in the diagnosis of BPD.

Prediction of necrotizing enterocolitis in very low birth weight infants by superior mesenteric artery ultrasound of postnatal day 1: A nested prospective study

BACKGROUND

Necrotizing enterocolitis (NEC) is a devastating intestinal complication that occurs mainly in very-low-birth-weight infants (VLBWI). The study's aim was to investigate the possibility of early prediction of NEC on postnatal day 1 based on superior mesenteric artery (SMA) doppler ultrasonograpy.

METHODS

A prospective, observational, nested case control study (ChiCTR1900026197) was conducted to enroll VLBWIs (birth weight <1,500 grams) between October 2019 and September 2021. Doppler ultrasound measurement was done during the first 12 h of life and before first feeding. Infants developing NEC (stage II or III) subsequently were included in NEC group and infants spare of NEC were included in control group.

RESULTS

370 VLBWIs were enrolled (30 NEC cases). Among the ultrasound parameters, S/D was significantly higher in the NEC group (OR: 2.081, 95% CI: 1.411-3.069, P = 0.000). The area under the receiver operating curve (AUROC) following the Logistic regression was 0.704 (95% CI: 0.566-0.842, P = 0.001). The sensitivity of S/D for predicting NEC was 52.2% and the specificity was 92.7%. The critical value of S/D was 6.944 and Youden index was 0.449. Preplanned subgroup analysis confirmed that NEC infants of different stages were characterized by different SMA bloodstream. Small for gestational age (SGA) might be a confounding factor affecting intestinal bloodflow. And infants with delayed initiation or slow advancement of feeding exhibited characteristic intestinal perfusion.

CONCLUSIONS

In VLBWI, early SMA ultrasound shows the potential to predict NEC. It is reasonable to speculate that SMA bloodstream is related to intestinal structural and functional integrity.