Trends in neonatal morbidity and mortality for very low birthweight infants

Prenatal exposure to elevated ambient temperature may cause bronchopulmonary dysplasia: Evidence from twin pairs across China

Exposure to high ambient temperature (TM) may affect lung development, but the association of prenatal TM exposure with bronchopulmonary dysplasia (BPD) is unclear. We explored the impact of prenatal TM exposure on BPD, and identify the critical exposure windows. Individual information of participants was collected from 21 hospitals across China. Daily TM and PM2.5 were obtained from ERA-5 reanalysis, and the Tracking Air Pollution in China, respectively. BPD was diagnosis based on the 2001 criteria set by the National Institute of Child Health and Human Development (NICHD). Generalized linear model (GLM) was used to explored the impact of TM exposure on BPD during entire pregnancy. Distributed lag non-linear model was utilized to assess the week-specific association between maternal TM exposure and BPD. The study included 8343 twin pairs, among whom 363 (4.35 %) twin pairs were classified as BPD cases. Compared with the reference TM (14.2 °C), exposures to the 75th (22.5 °C) and 95th (24.9 °C) centile of TM were associated with higher BPD risks during the entire pregnancy, with OR = 2.02 (95 % CI: 1.56-2.61) and OR = 2.27 (95 % CI: 1.17-4.40), respectively. In week-specific analyses, compared with the reference TM (14.2 °C) with minimum BPD risk in GLM during the entire pregnancy, exposures to the 75th (22.5 °C) and 95th (24.9 °C) centile of TM during the 1st to 3rd, and 17th to 23rd gestational weeks were positively associated with BPD, with the highest associations in the 20th (HR = 1.25, 95 % CI: 1.12, 1.39) and 1st (HR = 1.32, 95 % CI: 1.11, 1.58) gestational week, respectively. Moreover, effects of high TM on BPD were more pronounced in participants with pregnancy complications and rural residents. Prenatal exposure to elevated TM was associated with higher BPD risk in twins, especially during the early and middle pregnancy periods, and in participants with pregnancy complications and rural residents.

Associations of preterm birth and neonatal stress exposure with chronic pain in adulthood - Results from the Gutenberg prematurity study

Although the effect of early childhood stress on central nervous pain processing is well known, studies on the association of prematurity and chronic pain are scarce. This study used data from a single-centre retrospective cohort study followed by a prospective clinical examination and pain assessment. The study was based on data from the local birth registry. Newborns born between 1969 and 2002 who had reached adulthood were eligible .. Using a selection algorithm, a study cohort stratified by gestational age (GA) was recruited. Chronic pain conditions were assessed using questionnaire and standardized pain drawings. Data on the pre-, peri- and postnatal clinical course was assessed from medical records. Multivariable logistic regression analyses were conducted to investigate associations between prematurity and chronic pain with adjustment for age, gender, socioeconomic status, and perinatal stress factors. 427 participants born preterm and full-term were included (age 28.5 ± 8.7 years). Chronic pain conditions were similarly common between groups with different levels of prematurity (GA ≥ 37 weeks: 34.5 %, GA33-36 weeks: 37.6 %, GA32-29 weeks: 25.2 %, GA < 29 weeks: 30.4 %, p = 0.20). In multivariable analyses, no association between low GA and the presence of chronic pain was found (OR = 0.99 (CI95 %: 0.94-1.04, p = 0.63); this was also true for a subanalysis of widespread pain. While neither fetal nutritional status nor perinatal stressors were associated with pain, exposure to maternal but not paternal smoking during pregnancy was associated with increased risk to develop pain (OR = 2.77 (CI95 %: 1.31-5.88, p = 0.008) in adults born preterm and full-term. This study suggests that prematurity by itself does not increase the risk of chronic pain later in life, but provides preliminary evidence for maternal smoking during pregnancy as risk factor.

Perinatal risk factors and outcomes of pulmonary air leak in very-low-birth-weight preterm infants: A multicenter registry study in Taiwan

BACKGROUND

Pulmonary air leak may cause serious complications and mortality in neonates, especially preterm infants. Its incidence and perinatal risk factors in preterm infants might differ from those in term infants. We investigated the incidence, perinatal risk factors and morbidities associated with pulmonary air leak in very-low-birth-weight (VLBW) preterm infants in Taiwan.

METHODS

Data from 2011 to 2015 from the nationwide multihospital registry of the Taiwan Premature Infant Follow-up Network were analyzed. Preterm infants with pulmonary air leak, including pneumothorax and pneumomediastinum, were enrolled. Data on perinatal characteristics, the course of resuscitation in the delivery room, the management of respiratory distress syndrome (RDS), and the clinical outcomes of pulmonary air leak were collected and compared between VLBW preterm infants with and without pulmonary air leak.

RESULTS

We included 5906 VLBW preterm infants with a mean gestational age of 28.6 ± 3 weeks and mean birth weight of 1078 ± 284 g. Of them, 379 neonates (6.4%) had pulmonary air leak, with 5.4% and 1% having isolated pneumothorax and isolated pneumomediastinum, respectively. Independent risk factors for pulmonary air leak in VLBW preterm infants were male sex, a 5-min Apgar score <7, and RDS treated with surfactant. VLBW preterm infants who had higher gestational age or received nasal continuous positive airway pressure (NCPAP) had a lower risk of pulmonary air leak. However, pulmonary air leak was associated with higher rates of severe retinopathy of prematurity, severe intraventricular hemorrhage, chronic lung disease, and mortality.

CONCLUSIONS

NCPAP appeared to protect against pulmonary air leak in VLBW preterm infants. Clinicians should be aware of the risk factors for pulmonary air leak in such infants and promptly initiate meticulous ventilation strategies as needed.

Acoustic noise in a small-format 3.0-T neonatal MRI system

BACKGROUND

Today, magnetic resonance imaging (MRI) is rarely used in managing the care of premature neonates. This is in large part due to the medical and logistical challenges associated with moving neonates from the neonatal intensive care unit (NICU) to the radiology department. Furthermore, acoustic noise associated with MR scanning poses safety concerns for both practitioners and neonatal patients. A small-format 3.0-T neonatal scanner was recently developed and placed within the NICU to address these logistical and acoustic challenges.

OBJECTIVE

To compare acoustic noise measurements of a small-format 3.0-T neonatal MRI scanner with conventional adult-sized 1.5-T and 3.0-T MRI scanners using identical neonatal head imaging protocols.

MATERIALS AND METHODS

Sound pressure level (SPL) measurements of a standard imaging protocol were made in a small-format neonatal 3.0-T MRI scanner as well as in adult-sized 1.5-T and 3.0-T scanners. SPL measurements were made with a Brüel & Kjær sound level meter model 2250. The statistical significance of the differences in SPL between scanners was determined using one-way ANOVA.

RESULTS

Average sound pressure level values were measured in unweighted decibels (dB) and A-weighted decibels (dBA) for all imaging sequences in the protocol. The average A-weighted SPLs for the NICU from 1.5-T and 3.0-T MRI scanners were 81.02 ± 0.28 dBA, 87.00 ± 0.85 dBA, and 94.91 ± 0.65 dBA, respectively. SPLs at the isocenter of the NICU MRI scanner were 5.98 dBA quieter than in the 1.5-T scanner (P=0.007), and 13.89 dBA quieter than in the 3.0-T scanner (P<0.001). For staff standing next to the scanner, the NICU scanner was 20.24 dBA quieter than the 1.5-T scanner (P<0.001) and 19.28 dBA quieter than the 3.0-T scanner (P<0.001).

CONCLUSION

The NICU 3.0-T MRI system is significantly quieter than conventional adult-sized MRI systems, improving safety for neonatal patients. Significant reductions in SPL were also noted inside the screen room where clinicians may be present during scanning.

Early Diagnosis of Bronchopulmonary Dysplasia with E-Nose: A Pilot Study in Preterm Infants

Bronchopulmonary dysplasia (BPD) is the most common respiratory disease in preterm and is still associated with increased mortality and morbidity. The great interest lies in identifying early biomarkers that can predict the development of BPD. This pilot study explores the potential of e-nose for the early identification of BPD risk in premature infants by analyzing volatile organic compounds (VOCs) in the exhaled breath condensate (EBC). Fourteen mechanically ventilated very preterm infants were included in this study. The clinical parameters and EBC were collected within the first 24 h of life. The discriminative ability of breath prints between preterms who did and did not develop BPD was investigated using pattern recognition, a machine learning algorithm, and standard statistical methods. We found that e-nose probes can significantly predict the outcome of "no-BPD" vs. "BPD". Specifically, a subset of probes (S18, S24, S14, and S6) were found to be significantly predictive, with an AUC of 0.87, 0.89, 0.82, 0.8, and p = 0.019, 0.009, 0.043, 0.047, respectively. The e-nose is an easy-to-use, handheld, non-invasive electronic device that quickly samples breath. Our preliminary study has shown that it has the potential for early prediction of BPD in preterms.

Spatial analysis and factors associated with low birth weight in Ghana using data from the 2017 Ghana Maternal Health Survey: spatial and multilevel analysis

OBJECTIVE

Low birth weight (LBW) is an important indicator of newborn health and can have long-term implications for a child's development. Spatial exploratory analysis provides a toolkit to gain insight into inequalities in LBW. Few studies in Ghana have explored the spatial distribution of LBW to understand the extent of the problem geographically. This study explores individual and cluster-level distributions of LBW using spatial exploration components for common determinants from nationally representative survey data.

DESIGN

We used data from the 2017 Ghana Maternal Health Survey and conducted individual-level and cluster-level analyses of LBW with place and zone of residence in both bivariate and multivariate analyses. By incorporating spatial and survey designs methodology, logistic and Poisson regression models were used to model LBW.

SETTING

Ghana.

PARTICIPANTS

A total of 4127 women aged between 15 and 49 years were included in the individual-level analysis and 864 clusters corresponding to birth weight.

PRIMARY AND SECONDARY OUTCOME MEASURES

Individual and cluster-level distribution for LBW using spatial components for common determinants.

RESULTS

In the individual-level analysis, place and zone of residence were significantly associated with LBW in the bivariate model but not in a multivariate model. Hotspot analysis indicated the presence of LBW clusters in the middle and northern zones of Ghana. Compared with rural areas, clusters in urban areas had significantly lower LBW (p=0.017). Clusters in the northern zone were significantly associated with higher LBW (p=0.018) compared with the coastal zones.

CONCLUSION

Our findings from choropleth hotspot maps suggest LBW clusters in Ghana's northern and middle zones. Disparities between the rural and urban continuum require specific attention to bridge the healthcare system gap for Ghana's northern and middle zones.

Identifying barriers and facilitators to care for infants with bronchopulmonary dysplasia after NICU discharge: a prospective study of parents and clinical stakeholders

OBJECTIVE

Understand barriers and facilitators to follow-up care for infants with bronchopulmonary dysplasia (BPD).

METHODS

Qualitative study of parents and clinical stakeholders caring for infants with BPD. The interview guide was developed by a mother of a former 23-week preterm infant, neonatologist, pulmonologist, nurse, and qualitative researcher. Purposive sampling obtained a heterogenous sociodemographic and professional cohort. Subjects discussed their experience with BPD, barriers to care, caregiver quality of life and health education. Interviews were audio-recorded, transcribed and coded. Thematic analysis was used.

RESULTS

Eighteen parents and 20 stakeholders completed interviews. Family-level themes included pragmatic barriers like transportation being multi-faceted; and caregiving demands straining mental health. System-level themes included caregiver education needing to balance immediate caregiving activities with future health outcomes; and integrating primary care, specialty, and community supports.

CONCLUSIONS

Individual and system barriers impact follow-up for infants with BPD. This conceptual framework can be used to measure and improve care.

Does metformin prolong pregnancy in preterm pre-eclampsia? A study protocol for a South African, hospital-based double-blind, randomised, placebo-controlled trial

INTRODUCTION

Preterm pre-eclampsia is a leading cause of maternal morbidity and mortality. The Pre-eclampsia Intervention 2 (PI 2) trial suggested that metformin sustained release (XR) may prolong gestation by a week in pregnant women undergoing expectant management (7.6 days, geometric mean ratio 1.39, 95% CI 0.99 to 1.95; p=0.057). These findings should be confirmed with a larger sample size, and we need to know if such a prolongation improves neonatal outcome. Here, we describe the protocol for such a follow-up trial.

METHODS

The PI 3 trial is a phase III, intention-to-treat, double-blind, placebo-controlled randomised clinical trial to assess if metformin XR can prolong gestation and improve neonatal outcomes in women undergoing expectant management for preterm pre-eclampsia. We will recruit women who are between 26+0 and 31+6 weeks pregnant. Women will be randomised to receive either 3 g metformin XR or an identical placebo in divided daily doses. The primary outcome is prolongation of pregnancy. Secondary outcomes are neonatal birth weight and length of neonatal care admission (an indicator of neonatal health at birth). All other outcomes will be exploratory. We will record tolerability and adverse events. We plan a sample size of 500 participants to be powered for the primary and secondary outcomes.

ETHICS AND DISSEMINATION

PI 3 has ethical approval (Health Research Ethics Committee 2, Stellenbosch University, Protocol number M21/03/007, Project ID 21639, Federal Wide Assurance Number 00001372, Institutional Review Board Number IRB0005239), and is registered with the Pan African Clinical Trial Registry (PACTR202104532026017) and the South African Medicine Control Council (20211211). Data will be presented at international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

PACTR202104532026017).

The Role of Zinc in Developed Countries in Pediatric Patients: A 360-Degree View

Zinc is an important trace element for growth and health at pediatric ages. Zinc is fundamental in inflammatory pathways, oxidative balance, and immune function. Zinc exhibits anti-inflammatory properties by modulating Nuclear Factor-kappa (NF-κB) activity and reducing histamine release from basophils, leukocytes, and mast cells. Furthermore, its antioxidant activity protects against oxidative damage and chronic diseases. Finally, zinc improves the ability to trigger effective immune responses against pathogens by contributing to the maturation of lymphocytes, the production of cytokines, and the regulation of apoptosis. Given these properties, zinc can be considered an adjunctive therapy in treating and preventing respiratory, nephrological, and gastrointestinal diseases, both acute and chronic. This review aims to deepen the role and metabolism of zinc, focusing on the role of supplementation in developed countries in pediatric diseases.

The potential of patient-based nurse staffing - a queuing theory application in the neonatal intensive care setting

Faced by a severe shortage of nurses and increasing demand for care, hospitals need to optimally determine their staffing levels. Ideally, nurses should be staffed to those shifts where they generate the highest positive value for the quality of healthcare. This paper develops an approach that identifies the incremental benefit of staffing an additional nurse depending on the patient mix. Based on the reasoning that timely fulfillment of care demand is essential for the healthcare process and its quality in the critical care setting, we propose to measure the incremental benefit of staffing an additional nurse through reductions in time until care arrives (TUCA). We determine TUCA by relying on queuing theory and parametrize the model with real data collected through an observational study. The study indicates that using the TUCA concept and applying queuing theory at the care event level has the potential to improve quality of care for a given nurse capacity by efficiently trading situations of high versus low workload.

Current Evidence: Seizures in Extremely Low Gestational Age Newborns (ELGANs)

Extremely low gestational age newborns (ELGANs) are born at or below 28 weeks of gestational age. Despite improved obstetric care, the incidence of preterm birth continues to rise in advanced countries. Preterm birth remains a major cause of infant mortality, and for infants who survive, neonatal seizures are a significant predictor of later neurologic morbidity. However, little is known about risk factors for neonatal seizures in ELGANs. Understanding the association between neonatal seizures and the development of other neurologic disorders is important given the increasing prevalence of ELGANs. Identifying risk factors that contribute to the development of neonatal seizures in ELGANs may offer insights into novel mechanisms of epileptogenesis in the developing brain and improvements in the prevention or treatment of seizures in preterm infants, including ELGANs. In this literature review, we outline the limitations of epidemiologic studies of neonatal seizures in ELGANs and discuss risk factors for neonatal seizures.

Does Antenatal Progesterone Administration Modify the Risk of Neonatal Intraventricular Hemorrhage?

OBJECTIVE

Progesterone administration has been associated with improved neurological outcomes following traumatic brain injury in adults. However, studies examining the effect of progesterone on the risk of neonatal intraventricular hemorrhage (IVH) are inconsistent. We sought to determine if maternal administration of intramuscular 17-α-hydroxyprogesterone caproate (17-OHPC) is associated with decreased rates of IVH in infants born before 32-weeks gestation.

STUDY DESIGN

This is a retrospective study of liveborn singleton deliveries between 20- and 32-weeks gestation at two large academic medical centers from January 1, 2012 to August 30, 2020. Data were extracted from hospital electronic medical record data warehouses using standardized definitions and billing and diagnosis codes. We evaluated receipt of 17-OHPC in the antepartum period and diagnosis of IVH (grade I-IV, per Volpe classification) during the neonatal delivery hospitalization encounter. Bivariate and multivariate analyses were performed to examine the association between 17-OHPC and neonatal IVH adjusting for potential confounders. Odds ratio (ORs) and 95% confidence intervals (CIs) were presented.

RESULTS

Among 749 neonates born between 20- and 32-week gestation, 140 (18.7%) of their mothers had received antenatal 17-OHPC and 148 (19.8%) were diagnosed with IVH after birth. No significant association was observed between maternal 17-OHPC and neonatal IVH in unadjusted (OR 1.14, 95% CI 0.72-1.78) or adjusted analyses (adjusted odds ratio 1.14, 95% CI 0.71-1.84). Independent of exposure to 17-OHPC, as expected, infants born <28-weeks gestation or those with very low birthweight (<1,500 g) were at an increased risk of IVH (OR 2.32, 95% CI 1.55-3.48 and OR 2.19, 95% CI 1.09-4.38, respectively).

CONCLUSION

Antenatal maternal 17-OHPC administration was not associated with the risk of neonatal IVH. Further research may be warranted to determine whether timing, route of delivery, and duration of progesterone therapy impact rates of neonatal IVH.

KEY POINTS

· This study aimed to compare the frequency of intraventricular hemorrhage in preterm neonates exposed to antenatal 17-α-hydroxyprogesterone caproate to those not exposed.. · In neonates born at <32-weeks gestation, maternal use of progesterone is not associated with the risk of intraventricular hemorrhage.. · In contrast to preclinical and adult data, this study suggests that progesterone exposure is not associated with the prevention of neonatal brain injury..

Impact of Targeted Neonatal Echocardiography on Patent Ductus Arteriosus Management in a Canadian Tertiary Care Neonatal Unit: A Retrospective Cohort Study

OBJECTIVE

Comprehensive assessment of hemodynamic significance of a patent ductus arteriosus (PDA) is a common indication to perform targeted neonatal echocardiography (TNE). Impact of implementation of such an assessment on PDA management decisions remains to be reported. The objective of this study is to compare PDA-related hemodynamic information and PDA treatment decisions before and after introduction of TNE service.

STUDY DESIGN

This was a retrospective cohort study at a tertiary level neonatal intensive care unit in Southwestern Ontario. We investigated two time periods: Epoch-1 (non-TNE 2013-2016) versus Epoch-2 (TNE 2018-2021). We included neonates < 32 weeks with PDA. Data on baseline clinical characteristics, PDA-related echocardiographic parameters, PDA treatment details, and relevant long-term outcomes were collected. Primary outcome was defined as PDA treatment rates and need for multiple courses. Secondary outcomes included availability of PDA hemodynamic data and neonatal mortality/morbidity (PDA-related) RESULTS:  A total of 275 neonates were included. A total of 162 were assessed by conventional echocardiography in Epoch-1, whereas 113 were assessed by TNE in Epoch-2. Baseline clinical characteristics were similar. Epoch-2 had more echocardiographic assessments per patient of 2.7 (±1.8) versus 1.9 (± 1.3), p < 0.001 in Epoch1. The mean postnatal age at first echocardiographic assessment was higher in Epoch-2 (12.7 days [ ± 14.6]) than in Epoch-1 (7.9 days [ ± 10.4]), p < 0.001. Comprehensive hemodynamic assessment of PDA-related echocardiographic parameters such as PDA size, shunt pattern, effect on systemic circulation, and pulmonary circulation were higher in Epoch-2. Overall, PDA treatment rates were comparable in the two time periods. The use of multiple courses of treatment was higher in Epoch-1 than in Epoch-2 (47.8 vs. 31.7%, p = 0.047). In Epoch-1, neonates received PDA treatment earlier than in Epoch-2.

CONCLUSION

With the implementation of the TNE service, increased echocardiographic evaluations per patient were completed with availability of more comprehensive hemodynamic information about PDA. PDA treatment rates were similar in the two epochs, but need for multiple courses were less in TNE era.

KEY POINTS

· TNE allows comprehensive hemodynamic assessment of PDA.. · Implementation of dedicated TNE service led to increased use of echocardiography to assess PDA.. · Standardized hemodynamic assessment of PDA may allow improved individualization of treatment need..

Temporal Trends in Severe Brain Injury and Associated Outcomes in Very Preterm Infants

INTRODUCTION

Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited.

METHODS

Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born <32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed.

RESULTS

Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71).

CONCLUSION

Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants.

Abdominal Ultrasound Scanning for NEC in Babies at the Threshold of Viability: A Single Centre Experience

AIM

Neonatal units are caring for increasing numbers of babies born <24 weeks gestation. These babies are vulnerable to developing necrotising enterocolitis (NEC). Their presentation is often atypical, both clinically and radiologically. Optimal diagnostic strategies are not yet known. We report our experience of abdominal ultrasound scanning (AUSS) to clarify its role.

METHODS

All babies in a single neonatal surgical centre born <24 weeks gestation undergoing AUSS for suspected NEC from January 2015 to January 2023 were included. We compared abdominal ultrasound findings with plain radiographs and correlated these to intraoperative findings.

RESULTS

Thirty-nine babies born <24 weeks gestation were diagnosed with NEC during the study period, and of these seventeen had an AUSS and formed the study cohort. Twelve underwent laparotomy at which NEC was confirmed, and the remaining five were managed non-operatively. Abdominal radiograph findings were: Paucity of gas (12), gaseous dilatation (2), paucity of gas with proximal dilatation (1), pneumatosis (1), and lucencies over the liver (1). In twelve cases who underwent surgery, AUSS findings were (more than one possible): Complex ascites (6), inflamed bowel (4), aperistaltic bowel (3), mass/collection (4), pneumatosis (1). All had NEC confirmed at laparotomy. In five cases who did not progress to surgery, findings were: Simple free fluid (2), pneumatosis (2), inflamed bowel (1), aperistaltic bowel (1). None of these cases subsequently underwent surgery or died of complications of NEC.

CONCLUSION

AUSS is a useful imaging modality for NEC in babies born <24 weeks gestation. It can reliably identify babies who would benefit from surgery.

LEVEL OF EVIDENCE: 4

TYPE OF STUDY

Retrospective cohort study.

Advanced Diagnostics of Respiratory Distress Syndrome in Premature Infants Treated with Surfactant and Budesonide through Computer-Assisted Chest X-ray Analysis

This research addresses the respiratory distress syndrome (RDS) in preterm newborns caused by insufficient surfactant synthesis, which can lead to serious complications, including pneumothorax, pulmonary hypertension, and pulmonary hemorrhage, increasing the risk of a fatal outcome. By analyzing chest radiographs and blood gases, we specifically focus on the significant contributions of these parameters to the diagnosis and analysis of the recovery of patients with RDS. The study involved 32 preterm newborns, and the analysis of gas parameters before and after the administration of surfactants and inhalation corticosteroid therapy revealed statistically significant changes in values of parameters such as FiO2, pH, pCO2, HCO3, and BE (Sig. < 0.05), while the pO2 parameter showed a potential change (Sig. = 0.061). Parallel to this, the research emphasizes the development of a lung segmentation algorithm implemented in the MATLAB programming environment. The key steps of the algorithm include preprocessing, segmentation, and visualization for a more detailed understanding of the recovery dynamics after RDS. These algorithms have achieved promising results, with a global accuracy of 0.93 ± 0.06, precision of 0.81 ± 0.16, and an F-score of 0.82 ± 0.14. These results highlight the potential application of algorithms in the analysis and monitoring of recovery in newborns with RDS, also underscoring the need for further development of software solutions in medicine, particularly in neonatology, to enhance the diagnosis and treatment of preterm newborns with respiratory distress syndrome.

Necrotizing enterocolitis: current understanding of the prevention and management

Necrotizing enterocolitis (NEC) is one of the diseases in neonates, with a high morbidity and mortality rate, especially in preterm infants. This review aimed to briefly introduce the latest epidemiology, susceptibility factors, and clinical diagnosis and presentation of NEC. We also organized new prevention strategies by risk factors according to different pathogeneses and then discussed new treatment methods based on Bell's staging and complications, and the classification of mild to high severity based on clinical and imaging manifestations. Such a generalization will help clinicians and researchers to gain a deeper understanding of the disease and to conduct more targeted classification, grading prevention, and exploration. We focused on prevention and treatment of the early and suspected stages of NEC, including the discovery of novel biomarkers and drugs to control disease progression. At the same time, we discussed its clinical application, future development, and shortcomings.

Maternal risk factors for preterm birth in Taiwan, a nationwide population-based cohort study

BACKGROUND

The rate of preterm birth is increasing globally. It causes significant short-term and long-term health care burdens. A comprehensive recognition of the risk factors related to preterm births is important in the prevention of preterm birth. Our study is to investigate the incidence and maternal risk factors of preterm birth from a nationwide population-based perspective.

METHODS

This is a retrospective cohort study. All live births from 2004 to 2014 in Taiwan enrolled. The main data source was Taiwan's Birth Certificate Application (BCA) database. The BCA database was linked with the National Health Insurance Research Database (NHIRD) to establish any links between information on newborns and maternal underlying disease.

RESULTS

A total of 1,385,979 births were included in the analysis. The incidence of preterm birth increased gradually in Taiwan from 8.85% in 2004 to 10.73% in 2014. Maternal age, socioeconomic status, maternal allergy and autoimmune diseases, gynecological diseases, and pregnancy-related complications were significant risk factors for preterm birth.

CONCLUSION

The overall incidence of preterm births has gradually increased in Taiwan. Maternal age, socioeconomic status, certain underlying diseases, and pregnancy-related complications were risk factors for preterm birth.

Impact of preterm birth on the onset of panic disorder in later life - Results from the Gutenberg Prematurity Study (GPS)

BACKGROUND

The present study aimed to investigate whether prematurity and perinatal stress exert long-term effects on the onset of panic disorder in later life.

METHODS

From 40,189 adults born in Germany between 1969 and 2002, a study cohort (n = 427) stratified by gestational age (GA) (extremely preterm: GA < 29 weeks; very preterm: GA 29-32 weeks; moderately preterm: GA 33-36 weeks; and full-term GA ≥ 37 weeks) was selected (age 28.5 ± 8.7 years). Multivariable logistic regression analyses were conducted to investigate associations between gestational age at birth and panic disorder adjusting for age, gender, socioeconomic status, and perinatal factors.

RESULTS

The prevalence of panic disorder was roughly equal in moderate to very preterm and full-term birth groups at 1.9%-3.8%. However, this rate significantly increased to 14.3% in the extreme preterm category (GA <2 9: 14.3 %, p = 0.002). In multivariable analyses, female gender and GA were independently associated with panic disorder. Adjusting for age, gender and socioeconomic status, panic disorder was associated with lower GA at birth (OR = 1.12 per week (CI95%: 1.01-1.26, p = 0.037). Whereas adjustment for nutrition status or indicators of perinatal stress had no effect, correction for the length of postnatal ICU-stay eliminated the association between preterm birth and later panic disorder.

LIMITATIONS

Limitations include the small number of cases and the reliance on questionnaires to assess mental status.

CONCLUSIONS

Prematurity likely increases the risk of panic disorder later in life, and the subsequent postnatal ICU-stay appears to be of critical importance. However, due to strong collinearity and other associated factors with preterm births, it remains unclear which is the primary determinant.

Addressing a broken drug pipeline for preterm birth: why early preterm birth is an orphan disease

Preterm birth remains one of the most urgent unresolved medical problems in obstetrics, yet only 2 therapeutics for preventing preterm birth have ever been approved by the United States Food and Drug Administration, and neither remains on the market. The recent withdrawal of 17-hydroxyprogesterone caproate (17-OHPC, Makena) marks a new but familiar era for obstetrics with no Food and Drug Administration-approved pharmaceuticals to address preterm birth. The lack of pharmaceuticals reflects a broad and ineffective pipeline hindered by extensive regulatory hurdles, soaring costs of performing drug research, and concerns regarding adverse effects among a particularly vulnerable population. The pharmaceutical industry has historically limited investments in research for diseases with similarly small markets, such as cystic fibrosis, given their rarity and diminished projected financial return. The Orphan Drug Act, however, incentivizes drug development for "orphan diseases", defined as affecting <200,000 people in the United States annually. Although the total number of preterm births in the United States exceeds this threshold annually, the early subset of preterm birth (<34 weeks' gestation) would qualify, which is predominantly caused by inflammation and infection. The scientific rationale for classifying preterm birth into early and late subsets is strong given that their etiologies differ, and therapeutics that may be efficacious for one subset may not work for the other. For example, antiinflammatory therapeutics would be expected to be highly effective for early but not late preterm birth. A robust therapeutic pipeline of antiinflammatory drugs already exists, which could be used to target spontaneous early preterm birth, in combination with antibiotics shown to sterilize the amniotic cavity. New applications for therapeutics targeting spontaneous early preterm birth could categorize as orphan disease drugs, which could revitalize the preterm birth therapeutic pipeline. Herein, we describe why drugs targeting early preterm birth should qualify for orphan status, which may increase pharmaceutical interest for this vitally important obstetrical condition.

Changes in neonatal morbidity, neonatal care practices, and length of hospital stay of surviving infants born very preterm in the Netherlands in the 1980s and in the 2000s: a comparison analysis with identical characteristics definitions

BACKGROUND

This study evaluates changes in the neonatal morbidity, the neonatal care practices, and the length of hospital stay of surviving very preterm (VP) infants born in the Netherlands in the 1980s and in the 2000s; a period over which historical improvements were introduced into neonatal care. We, herein, also study whether these changes in neonatal morbidity, neonatal care practices and length of hospital stay are associated with sociodemographic, prenatal, and infant characteristics.

METHODS

Two community-based cohorts from 1983 (POPS) and 2002-03 (LOLLIPOP) have provided the perinatal data for our study. The analysis enrolled 1,228 participants born VP (before the 32nd week of gestation) and surviving to 2 years of age without any severe congenital malformation. A rigorous harmonisation protocol ensured a precise comparison of the cohorts by using identical definitions of the perinatal characteristics.

RESULTS

In 2003, mothers were older when giving birth, had higher multiple birth rates, and significantly more parents had received higher education. In 2003, less VP infants had severe intraventricular haemorrhage and sepsis and relatively more received continuous positive airway pressure, mechanical ventilation and caffeine therapy than in 1983. Antenatal corticosteroids and surfactant therapy were provided only in 2003. The length of the stay in the neonatal intensive care unit and in hospital had decreased in 2003 by 22 and 11 days, respectively. Differences persisted after adjustment for sociodemographic, prenatal, and infant characteristics.

CONCLUSIONS

Neonatal morbidities of the surviving VP infants in this study have not increased, and exhibit improvements for various characteristics in two cohorts born 20 years apart with comparable gestational age and birth weight. Our data suggest that the improvements found are associated with more advanced therapeutic approaches and new national protocols in place, and less so with sociodemographic changes. This analysis provides a basis for further comparative analyses of the health and the development of VP children, particularly with regard to long-term outcomes.

The Association Between Maternal Short Stature and Neonatal Intensive Care Unit Admission: A Longitudinal Study in Sabah

BACKGROUND

The rising number of newborns requiring neonatal intensive care unit (NICU) care poses immediate threats to their health and places emotional and financial burdens on families and healthcare systems. This study investigates the direct effect of maternal short stature on NICU admission in Sabah, Malaysia.

METHODS

A longitudinal study at Hospital Wanita Dan Kanak-Kanak Sabah (HWKKS) from 2018 to 2022 included 254 Malaysian women with singleton pregnancies and neonates born after the 37th week, excluding significant disorders, smoking/alcohol use, fetal death, and malformations. Birth weight, gestational age, and neonatal condition were recorded. The association between maternal height, low birth weight (LBW), and NICU admission was analyzed.

RESULTS

LBW prevalence was 15.35%, with an average participant height of 147.37 cm. Maternal stature was significantly associated with LBW, with the shortest quartile (Q1) having the highest risk. LBW was significantly associated with NICU admission, with LBW newborns at a sixfold higher risk. Maternal height was also significantly associated with NICU admission, with Q1 having the highest risk. The receiver operating characteristic (ROC) curve suggested combining Q1 and Q2 for the best prediction of NICU admission, indicating that shorter mothers face a higher risk of neonates requiring NICU care.

CONCLUSION

Maternal short stature could be a valuable predictor of LBW and NICU admission risk. It may be a screening tool to assess these risks in healthcare settings. However, further research is needed to explore this association's underlying mechanisms and potential interventions.

Cross-sectional association between red blood cell distribution width and regional cerebral tissue oxygen saturation in preterm infants in the first 14 days after birth

Background

Hypoxia can threaten the metabolic functions of different systems in immature neonates, particularly the central nervous system. The red blood cell distribution width (RDW) has recently been reported as a prognostic factor in neurologic diseases. Herein, we examined the correlation between RDW and regional cerebral tissue oxygen saturation (rcSO2).

Methods

This cross-sectional study included 110 preterm infants born at a gestational age (GA) of <32 weeks, or with a birth weight (BW) of <1,500 g at our institution between January and June 2,022. The rcSO2 was monitored using near-infrared spectroscopy, and RDW was extracted from the complete blood count during the first 14 days after birth. RDW and rcSO2 measurements were analyzed using a cross-sectional research method.

Results

We divided the study population into two groups, with a mean rcSO2 value over the first 14 days. Fifty-three preterm had rcSO2 ≥ 55% and 57% < 55%. The 14-days-mean in the study population showing an association of lower rcSO2 values with higher RDW values. Significantly higher RDW values were observed in the low rcSO2 group compared with those in the high rcSO2 group. Threshold effect analysis showed that rcSO2 decreased with RDW values ≥18% (β, -0.03; 95% CI, -0.04 and -0.02; p ≥ 0.0001). After adjusting for potential confounders, an RDW of ≥18% was determined as the predictive cutoff value for preterm infants with low rcSO2 (Model I: OR, 3.31; 95% CI, 1.36-8.06; p = 0.009; and Model II: OR, 3.31; 95% CI, 1.28-8.53; p = 0.013).

Conclusions

An RDW of ≥18% in the first 14 days is associated with rcSO2 of <55% in preterm infants.

Surfactant therapy guided by tests for lung maturity in preterm infants at risk of respiratory distress syndrome

BACKGROUND

Administration of various exogenous surfactant preparations has been shown to decrease lung injury and pneumothorax and improve survival in very preterm infants with respiratory distress syndrome (RDS). There is no consensus on the threshold for surfactant administration, to allow timely intervention and avoid over-treatment, also considering the invasiveness of the procedure and its cost. Rapid tests for lung maturity, which include the click test, lamellar body counts and stable microbubble test, might guide the identification of those infants needing surfactant administration.

OBJECTIVES

To assess the effects of surfactant treatment guided by rapid tests for surfactant deficiency in preterm infants at risk for or having RDS. Comparison 1: In preterm infants at risk for RDS, does surfactant treatment guided by rapid tests for surfactant deficiency compared to prophylactic surfactant administration to all high-risk infants minimize the need for surfactant treatment and prevent bronchopulmonary dysplasia and mortality? Comparison 2: In preterm infants who require early respiratory support, does surfactant treatment guided by rapid tests for surfactant deficiency compared to surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria minimize the need for surfactant treatment and prevent bronchopulmonary dysplasia and mortality?

SEARCH METHODS

We searched in October 2022 CENTRAL, PubMed, Embase and three additional trial registries. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs evaluating rapid tests after birth for surfactant deficiency in infants at high risk of RDS or requiring respiratory support. We specified two comparisons: 1)surfactant treatment guided by rapid tests for surfactant deficiency versus prophylactic surfactant administration to all high-risk infants in extremely preterm (less than 28 weeks' gestation) and very preterm (28 to 32 weeks' gestation); 2)surfactant treatment guided by rapid tests for surfactant deficiency versus surfactant therapy provided to preterm infants (less than 37 weeks' gestation) with RDS diagnosed on clinical and radiologic criteria.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD), with their 95% confidence intervals (CIs) for dichotomous data. Our primary outcomes were: neonatal mortality, mortality prior to hospital discharge, bronchopulmonary dysplasia and the composite outcome bronchopulmonary dysplasia or mortality. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included three RCTs enrolling 562 newborn infants in this review. No studies compared surfactant treatment guided by rapid tests for surfactant deficiency versus prophylactic surfactant administration to all high-risk infants. Comparing surfactant therapy guided by rapid tests for surfactant deficiency versus surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported neonatal mortality. Compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria, the evidence is very uncertain about the effect of surfactant treatment guided by rapid tests for surfactant deficiency on mortality prior to hospital discharge: RR 1.25, 95% CI 0.65 to 2.41, RD 0.01, 95% CI -0.03 to 0.05, 562 participants, 3 studies; I² for RR and RD = 75% and 43%, respectively; very low-certainty evidence. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in bronchopulmonary dysplasia: RR 0.90, 95% CI 0.61 to 1.32, RD -0.02, 95% CI -0.08 to 0.04, 562 participants, 3 studies; I² for RR and RD = 0%; low-certainty evidence. No studies reported the composite outcome bronchopulmonary dysplasia or mortality. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in surfactant utilization (RR 0.97, 95% CI 0.85 to 1.11, RD -0.02, 95% CI -0.10 to 0.06, 562 participants, 3 studies, I² for RR and RD = 63% and 65%, respectively, low-certainty evidence), and any pneumothorax (RR 0.53, 95% CI 0.15 to 1.92, RD -0.01, 95% CI -0.04 to 0.01, 506 participants, 2 studies, I² for RR and RD = 0%, low-certainty evidence) compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported moderate to severe neurodevelopmental impairment. We identified two large ongoing RCTs.

AUTHORS' CONCLUSIONS

No studies compared surfactant treatment guided by rapid tests for surfactant deficiency to prophylactic surfactant administration to all high-risk infants. Low to very low-certainty evidence from three studies is available on surfactant therapy guided by rapid tests for surfactant deficiency versus surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria. No studies reported neonatal mortality, the composite outcome 'bronchopulmonary dysplasia or mortality', or neurodevelopmental outcomes. Compared with surfactant therapy provided to infants with RDS diagnosed on clinical and radiologic criteria, the evidence is very uncertain about the effect of surfactant treatment guided by rapid tests for surfactant deficiency on mortality prior to hospital discharge. Surfactant treatment guided by rapid tests for surfactant deficiency may result in little to no difference in bronchopulmonary dysplasia, surfactant utilization and any pneumothorax. The findings of the two large ongoing trials identified in this review are likely to have an important impact on establishing the effects of surfactant treatment guided by rapid tests for surfactant deficiency in preterm infants.

Doxapram versus placebo in preterm newborns: a study protocol for an international double blinded multicentre randomized controlled trial (DOXA-trial)

BACKGROUND

Apnoea of prematurity (AOP) is one of the most common diagnoses among preterm infants. AOP often leads to hypoxemia and bradycardia which are associated with an increased risk of death or disability. In addition to caffeine therapy and non-invasive respiratory support, doxapram might be used to reduce hypoxemic episodes and the need for invasive mechanical ventilation in preterm infants, thereby possibly improving their long-term outcome. However, high-quality trials on doxapram are lacking. The DOXA-trial therefore aims to investigate the safety and efficacy of doxapram compared to placebo in reducing the composite outcome of death or severe disability at 18 to 24 months corrected age.

METHODS

The DOXA-trial is a double blinded, multicentre, randomized, placebo-controlled trial conducted in the Netherlands, Belgium and Canada. A total of 396 preterm infants with a gestational age below 29 weeks, suffering from AOP unresponsive to non-invasive respiratory support and caffeine will be randomized to receive doxapram therapy or placebo. The primary outcome is death or severe disability, defined as cognitive delay, cerebral palsy, severe hearing loss, or bilateral blindness, at 18-24 months corrected age. Secondary outcomes are short-term neonatal morbidity, including duration of mechanical ventilation, bronchopulmonary dysplasia and necrotising enterocolitis, hospital mortality, adverse effects, pharmacokinetics and cost-effectiveness. Analysis will be on an intention-to-treat principle.

DISCUSSION

Doxapram has the potential to improve neonatal outcomes by improving respiration, but the safety concerns need to be weighed against the potential risks of invasive mechanical ventilation. It is unknown if the use of doxapram improves the long-term outcome. This forms the clinical equipoise of the current trial. This international, multicentre trial will provide the needed high-quality evidence on the efficacy and safety of doxapram in the treatment of AOP in preterm infants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04430790 and EUDRACT 2019-003666-41. Prospectively registered on respectively June and January 2020.

Identifying Barriers and Facilitators to Care for Infants with Bronchopulmonary Dysplasia After NICU Discharge: A Prospective Study of Parents and Clinical Stakeholders

Objective

Understand barriers and facilitators to follow-up care for infants with bronchopulmonary dysplasia (BPD).

Methods

Qualitative study of parents and clinical stakeholders caring for infants with BPD. The interview guide was developed by a mother of a former 23-week preterm infant, neonatologist, pulmonologist, nurse, and qualitative researcher. Purposive sampling obtained a heterogenous sociodemographic and professional cohort. Subjects discussed their experience with BPD, barriers to care, caregiver quality of life and health education. Interviews were audio-recorded, transcribed and coded. Thematic analysis was used.

Results

Eighteen parents and 20 stakeholders completed interviews. Family-level themes included pragmatic barriers like transportation being multi-faceted; and caregiving demands straining mental health. System-level themes included caregiver education needing to balance process needs with future trajectories; and integration of primary care, specialty care, and community supports.

Conclusions

Individual and system barriers impact follow-up for infants with BPD. This conceptual framework can be used to measure and improve care.

The Most Valuable Predictive Factors for Bronchopulmonary Dysplasia in Very Preterm Infants

INTRODUCTION

It is urgent to make a rapid screening of infants at the highest risk for bronchopulmonary dysplasia (BPD) via some succinct postnatal biomarkers, such as Ureaplasma Urealyticum (UU) infection and chest radiograph images.

METHODS

A retrospective study was performed. Moderate to severe BPD or death was set as the main outcome. The association between putative variables and the main outcome were assessed by bivariate analyses and logistic regression.

RESULTS

A total of 134 infants were enrolled. Bivariate analyses showed the gestational age, birth weight, appearances of diffuse opacities or grid shadows/interstitial opacities or mass opacities or cystic lucencies on chest radiographic images, a ductal diameter ≥1.5 mm and whether UU infection was associated with BPD. After adjustment by logistic regression, the risk of BPD with gestational age, sex and specific chest-radiographic manifestations remained significant.

CONCLUSIONS

Chest radiograph images (appearance of diffuse opacities or grid shadows/interstitial opacities or mass opacities or cystic lucencies) could provide a quick prediction of developing BPD in clinical practice, in addition to gestational age and sex. UU infection was not an independent risk factor for BPD.

Phthalate exposure in the neonatal intensive care unit is associated with development of bronchopulmonary dysplasia

OBJECTIVE

Bronchopulmonary dysplasia (BPD) is a serious yet common morbidity of preterm birth. Although prior work suggests a possible role for phthalate exposure in the development of BPD, no study has rigorously evaluated this. Our objective was to determine whether hospital-based phthalate exposure is associated with the development of BPD and to identify developmental windows sensitive to exposure.

STUDY DESIGN

This is a prospective multicenter cohort study of 360 preterm infants born at 23-33 weeks gestation participating in the Developmental Impact of NICU Exposures (DINE) cohort. 939 urine specimens collected during the NICU stay were analyzed for biomarkers of phthalate exposure by liquid chromatography with tandem mass spectrometry. The modified Shennan definition was used to diagnose bronchopulmonary dysplasia. Reverse distributed-lag modeling identified developmental windows sensitive to specific phthalate exposure, controlling for relevant covariates including sex and respiratory support.

RESULTS

Thirty-five percent of participants were diagnosed with BPD. Exposure to specific phthalate mixtures at susceptible points in preterm infant development are associated with later diagnosis of BPD in models adjusted for use of respiratory support. The weighted influence of specific phthalate metabolites in the mixtures varied by sex. Metabolites of di(2-ethylhexyl) phthalate, a phthalate previously linked to neonatal respiratory support equipment, drove this association, particularly among female infants, at 26- to 30-weeks post-menstrual age.

CONCLUSIONS

This is the largest and only multi-site study of NICU-based phthalate exposure and clinical impact yet reported. In well-constructed models accounting for infant sex and respiratory support, we found a significant positive association between ultimate diagnosis of BPD and prior exposure to phthalate mixtures with DEHP predominance at 26- to 30-weeks PMA or 34-36-weeks PMA. This information is critically important as it identifies a previously unrecognized and modifiable contributing factor to BPD.

Decreased Expression of KLF4 Leading to Functional Deficit in Pediatric Patients with Intestinal Failure and Potential Therapeutic Strategy Using Decanoic Acid

Pediatric intestinal failure (IF) is the reduction in gut function to below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. The overall goal in treating IF is to achieve intestinal adaptation; however, the underlying mechanisms have not been fully understood. In this study, by performing single-cell RNA sequencing in pediatric IF patients, we found that decreased Kruppel-Like Factor 4 (KLF4) may serve as the hub gene responsible for the functional deficit in mature enterocytes in IF patients, leading to the downregulation of solute carrier (SLC) family transporters (e.g., SLC7A9) and, consequently, nutrient malabsorption. We also found that inducible KLF4 was highly sensitive to the loss of certain enteral nutrients: in a rodent model of total parenteral nutrition mimicking the deprivation of enteral nutrition, the expression of KLF4 dramatically decreased only at the tip of the villus and not at the bottom of crypts. By using IF patient-derived intestinal organoids and Caco-2 cells as in vitro models, we demonstrated that the supplementation of decanoic acid (DA) could significantly induce the expression of KLF4 along with SLC6A4 and SLC7A9, suggesting that DA may function as a potential therapeutic strategy to promote cell maturation and functional improvement. In summary, this study provides new insights into the mechanism of intestinal adaptation depending on KLF4, and proposed potential strategies for nutritional management using DA.

Air quality and respiratory health in children

Air pollution is a leading modifiable risk factor for various cardio-respiratory outcomes globally, both for children and for adults. Children are particularly susceptible to the adverse effects of air pollution due to various physiological and behavioural factors. Children are at a higher risk of outcomes such as acute respiratory infections, asthma and decreased lung function due to air pollution exposure; the risk varies in different geographical regions, depending on the source of air pollution, duration of exposures and concentration. Prenatal exposure to air pollution may also contribute to adverse respiratory outcomes later in life.

Over-reaching with causality language in neurodevelopmental infant research: A methodological literature review

BACKGROUND

A methodological review of 78 empirical articles focusing on the neurodevelopmental outcomes of at-risk infants was conducted.

AIMS

To examine ways language and terminology are used to describe methods, present results, and/or state conclusions in studies published during 1994-2005, a decade reflecting major advances in neurodevelopmental research and in medical intervention. More specifically, to investigate to what extent the design of the study and the language in the results section aligned in regard to causality.

METHODS

A process of search and selection of studies published in pediatric journals was conducted through Google Scholar. Criteria of inclusion and exclusion, following PRISMA, were used. Selected studies reported neurodevelopmental outcomes of infants and young children considered at-risk, and were further categorized accordingly to their study designs. Language use in regard to whether the presentation and interpretation of results may convey causal relationships between birth risk factors and neurodevelopmental outcomes was examined following two analytical steps.

RESULTS

Forty out of 78 studies, (51.28 %) used causality-implying language (e.g., effect, predict, influence) notwithstanding that the study design was non-causal.

CONCLUSIONS

Anticipating the next generation of neurodevelopmental-outcomes research, a framework that aims to raise awareness of the importance of language use and the impact of causality-related terms often used in longitudinal studies is proposed. The objective is to avoid ambiguities and misunderstandings around causal or non-causal connections between birth risk factors and developmental outcomes across diverse audiences, including early intervention practitioners working directly with infants and their families.

Evaluation of the impact of continuous Kangaroo Mother Care (KMC) initiated immediately after birth compared to KMC initiated after stabilization in newborns with birth weight 1.0 to < 1.8 kg on neurodevelopmental outcomes: Protocol for a follow-up study

BACKGROUND

Preterm birth or low birth weight is the single largest cause of death in newborns, however this mortality can be reduced through newborn care interventions, including Kangaroo Mother Care (KMC). Previously, a multi-country randomized controlled trial, coordinated by the World Health Organization (WHO), reported a significant survival advantage with initiation of continuous KMC immediately after birth compared with initiation of continuous KMC a few days after birth when the baby is considered clinically stable. Whether the survival advantage would lead to higher rates of neurodevelopmental morbidities, or the immediate KMC will also have a beneficial effect on cognitive development also, has not been investigated. We therefore propose to test the hypothesis that low-birth-weight infants exposed to immediate KMC will have lower rates of neurodevelopmental impairment in comparison to traditional KMC-treated infants, by prospectively following up infants already enrolled in the immediate KMC trial for the first 2 years of life, and assessing their growth and neurodevelopment.

METHODS

This prospective cohort study will enroll surviving neonates from the main WHO immediate KMC trial. The main trial as well as this follow-up study are being conducted in five low- and middle-income countries in South Asia and sub-Saharan Africa. The estimated sample size for comparison of the risk of neurodevelopmental impairment is a total of 2200 children. The primary outcome will include rates of cerebral palsy, hearing impairment, vision impairment, mental and motor development, and epilepsy and will be assessed by the age of 3 years. The analysis will be by intention to treat.

DISCUSSION

Immediate KMC can potentially reduce low-birth-weight-associated complications such as respiratory disease, hypothermia, hypoglycemia, and infection that can result in impaired neurocognitive development. Neuroprotection may also be mediated by improved physiological stabilization that may lead to better maturation of neural pathways, reduced risk of hypoxia, positive parental impact, improved sleep cycles, and improved stress responses. The present study will help in evaluating the overall impact of KMC by investigating the long-term effect on neurodevelopmental impairment in the survivors.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2019/11/021899. Registered on 06 November 2019. Trials registration of parent trial: ACTRN12618001880235; Clinical Trials Registry-India: CTRI/2018/08/015369.

Adverse Perinatal Outcomes among Adolescent Pregnant Women Living with HIV: A Propensity-Score-Matched Study

HIV infection and adolescent pregnancy are known to increase the risk of adverse perinatal outcomes. However, data are limited concerning the outcomes of pregnancies among adolescent girls living with HIV. This retrospective propensity-score matched study aimed to compare adverse perinatal outcomes in adolescent pregnant women living with HIV (APW-HIV-positive) with HIV-negative adolescent pregnant women (APW-HIV-negative) and adult pregnant women with HIV (PW-HIV). APW-HIV-positive were propensity-score matched with APW-HIV-negative and PW-HIV. The primary endpoint was a composite endpoint of adverse perinatal outcomes, comprising preterm birth and low birth weight. There were 15 APW-HIV-positive and 45 women in each control group. The APW-HIV-positive were aged 16 (13-17) years and had had HIV for 15.5 (4-17) years, with 86.7% having perinatally acquired HIV. The APW-HIV-positive had higher rates of perinatally acquired HIV infection (86.7 vs. 24.4%, p < 0.001), a longer HIV infection time (p = 0.021), and longer exposure to antiretroviral therapy (p = 0.034) compared with the PW-HIV controls. The APW-HIV-positive had an almost five-fold increased risk of adverse perinatal outcomes compared with healthy controls (42.9% vs. 13.3%, p = 0.026; OR 4.9, 95% CI 1.2-19.1). The APW-HIV-positive and APW-HIV-negative groups had similar perinatal outcomes.

Clinical NEC prevention practices drive different microbiome profiles and functional responses in the preterm intestine

Preterm infants with very low birthweight are at serious risk for necrotizing enterocolitis. To functionally analyse the principles of three successful preventive NEC regimens, we characterize fecal samples of 55 infants (<1500 g, n = 383, female = 22) longitudinally (two weeks) with respect to gut microbiome profiles (bacteria, archaea, fungi, viruses; targeted 16S rRNA gene sequencing and shotgun metagenomics), microbial function, virulence factors, antibiotic resistances and metabolic profiles, including human milk oligosaccharides (HMOs) and short-chain fatty acids (German Registry of Clinical Trials, No.: DRKS00009290). Regimens including probiotic Bifidobacterium longum subsp. infantis NCDO 2203 supplementation affect microbiome development globally, pointing toward the genomic potential to convert HMOs. Engraftment of NCDO 2203 is associated with a substantial reduction of microbiome-associated antibiotic resistance as compared to regimens using probiotic Lactobacillus rhamnosus LCR 35 or no supplementation. Crucially, the beneficial effects of Bifidobacterium longum subsp. infantis NCDO 2203 supplementation depends on simultaneous feeding with HMOs. We demonstrate that preventive regimens have the highest impact on development and maturation of the gastrointestinal microbiome, enabling the establishment of a resilient microbial ecosystem that reduces pathogenic threats in at-risk preterm infants.

Developmental trajectory of extracellular vesicle characteristics from the lungs of preterm infants

Extracellular vesicles (EVs) are secreted lipid-enclosed particles that have emerged as potential biomarkers and therapeutic agents in lung disease, including bronchopulmonary dysplasia (BPD), a leading complication of preterm birth. Many unanswered questions remain about the content and cargo of EVs in premature infants and their role in lung development. To characterize EVs during human lung development, tracheal aspirates were collected from premature neonates between 22 and 35 wk gestational age and analyzed via nanoparticle tracking analysis, electron microscopy, and bead-based flow cytometry. EVs were detectable across late canalicular through saccular stages of lung development, demonstrating larger sizes earlier in gestation. EVs contained an abundance of the EV-enriched tetraspanins CD9, CD63, and CD81, as well as epithelial cell and immune cell markers. Increases in select surface proteins (CD24 and CD14) on EVs were associated with gestational age and with the risk of BPD. Finally, query of expression data obtained from epithelial cells in a single-cell atlas of murine lung development found that epithelial EV marker expression also changes with developmental time. Together, these data demonstrate an association between EV profile and lung development and provide a foundation for future functional classification of EVs, with the goal of determining their role in cell signaling during development and harnessing their potential as a new therapeutic target in BPD.

Hyperoxia impairs intraflagellar transport and causes dysregulated metabolism with resultant decreased cilia length

Supplemental oxygen is a lifesaving measure in infants born premature to facilitate oxygenation. Unfortunately, it may lead to alveolar simplification and loss of proximal airway epithelial cilia. Little is known about the mechanism by which hyperoxia causes ciliary dysfunction in the proximal respiratory tract. We hypothesized that hyperoxia causes intraflagellar transport (IFT) dysfunction with resultant decreased cilia length. Differentiated basal human airway epithelial cells (HAEC) were exposed to hyperoxia or air for up to 48 h. Neonatal mice (<12 h old) were exposed to hyperoxia for 72 h and recovered in room air until postnatal day (PND) 60. Cilia length was measured from scanning electron microscopy images using a MATLAB-derived program. Proteomics and metabolomics were carried out in cells after hyperoxia. After hyperoxia, there was a significant time-dependent reduction in cilia length after hyperoxia in HAEC. Proteomic analysis showed decreased abundance of multiple proteins related to IFT including dynein motor proteins. In neonatal mice exposed to hyperoxia, there was a significant decrease in acetylated α tubulin at PND10 followed by recovery to normal levels at PND60. In HAEC, hyperoxia decreased the abundance of multiple proteins associated with complex I of the electron transport chain. In HAEC, hyperoxia increased levels of malate, fumarate, and citrate, and reduced the ATP/ADP ratio at 24 h with a subsequent increase at 36 h. Exposure to hyperoxia reduced cilia length, and this was associated with aberrant IFT protein expression and dysregulated metabolism. This suggests that hyperoxic exposure leads to aberrant IFT protein expression in the respiratory epithelium resulting in shortened cilia.

Protective technologies of modern methods of respiratory support in neonatal practice

The article  presents  an analysis of literature data  on modern  protective regimens  for invasive respiratory support  in premature newborns  with respiratory distress  syndrome. We have considered positive and negative  aspects of the used methods  of invasive ventilation of the lungs, which are currently widely used as a method  of respiratory therapy  in obstetric hospitals  at any level, even in the category  of children  with extremely and very low birth weight. Modern  protective mechanical ventilation provides for 2 main directions for reducing ventilator-induced lung damage: a decrease in tidal volume (Vt) and the principle  of tolerable  (permissive) hypercapnia. The use of the technique of permissive hypercapnia and regimens with a target volume can reduce the likelihood of ventilator-induced lung injury in newborns. Despite the limited indications for mechanical ventilation in modern neonatology and the widespread use of non-invasive ventilation, for patients who really need mechanical ventilation, the use of volume-targeted regimens offers the best chance of reducing  ventilation complications.

Predictive values of clinical data,molecular biomarkers, and echocardiographic measurements in preterm infants with bronchopulmonary dysplasia

Objective

We aimed to use molecular biomarkers and clinical data and echocardiograms that were collected during admission to predict bronchopulmonary dysplasia (BPD) in preterm infants with gestational age ≤32 weeks.

Methods

Eighty-two patients (40 with BPD, BPD group and 42 healthy as controls, non-BPD group) admitted to the Department of Neonatology of the Children's Hospital of Soochow University between October 1, 2018, and February 29, 2020, were enrolled in this study at the tertiary hospital. Basic clinical data on the perinatal period, echocardiographic measurements, and molecular biomarkers (N-terminal-pro-B-brain natriuretic peptide, NT-proBNP) were collected. We used multiple logistic regression analysis to establish an early predictive model for detecting BPD development in preterm infants of gestational age ≤32 weeks. We also used a receiver operating characteristic curve to assess the sensitivity and specificity of the model.

Results

No significant differences were found between the BPD and non-BPD groups in terms of sex, birth weight, gestational age, incidence of asphyxia, maternal age, gravidity, parity, mode of delivery, premature rupture of membranes >18 h, use of prenatal hormones, placental abruption, gestational diabetes mellitus, amniotic fluid contamination, prenatal infections, and maternal diseases. The use of caffeine, albumin, gamma globulin; ventilation; days of FiO2 ≥ 40%; oxygen inhalation time; red blood cell suspension infusion volume (ml/kg); and proportion of infants who received total enteral nutrition (120 kcal/kg.d) ≥24 d after birth were higher in the BPD group than in the non-BPD group. The levels of hemoglobin, hematocrit, and albumin in the BPD group were significantly lower than those in the non-BPD group. The total calorie intake was significantly lower in the BPD group on the 3rd, 7th, and 14th day after birth than in the non-BPD group (P < 0.05). The incidence rates of patent ductus arteriosus (PDA), pulmonary hypertension, and tricuspid regurgitation were significantly higher in the BPD group than in the non-BPD group (P < 0.05). The serum level of NT-proBNP 24 h after birth was significantly higher in the BPD group than in the non-BPD group (P < 0.05). Serum NT-proBNP levels were significantly higher in infants with severe BPD than in those with mild or moderate BPD (P < 0.05).

Conclusion

As there were various risk factors for BPD, a combining clinical data, molecular biomarkers, and echocardiogram measurements can be valuable in predicting the BPD. The tricuspid regurgitation flow rate (m/s), NT-proBNP (pg/ml), ventilator-associated pneumonia, days of FiO2 ≥ 40% (d), red blood cell suspension infusion volume (ml/kg), and proportion of infants who received total enteral nutrition (120 kcal/kg.d) ≥24 d after birth were the most practical factors considered for designing an appropriate model for predicting the risk of BPD.

Echocardiography performed by the neonatologist: the impact on the clinical management

BACKGROUND

The aim of this study was to assess whether neonatologist-performed echocardiography (NPE) changed the previously planned hemodynamic approach in critically ill newborn infants.

METHODS

This prospective cross-sectional study included the first NPE of 199 neonates. Before the exam, the clinical team was asked about the planned hemodynamic approach and the answer was classified as an intention to change or not to change the therapy. After being informed about the NPE results, the clinical management was grouped as performed as previously planned (maintained) or modified.

RESULTS

NPE modified the planned pre-exam approach in 80 cases (40.2%; 95% CI: 33.3-47.4%), and variables associated with an increased chance of this modification were exams to assess pulmonary hemodynamics (prevalent ratio (PR): 1.75; 95% CI: 1.02-3.00) and to assess systemic flow (PR: 1.68; 95% CI: 1.06-2.68) in relation to those requested for patent ductus arteriosus, pre-exam intention of changing the prescribed management (PR: 2.16; 95% CI: 1.50-3.11), use of catecholamines (PR: 1.68; 95% CI: 1.24-2.28) and birthweight (per kg) (PR: 0.81; 95% CI: 0.68-0.98).

CONCLUSION

The NPE was an important tool to direct hemodynamic management in a different approach from the previous intention of the clinical team, mainly for critically ill neonates.

IMPACT

This study shows that neonatologist-performed echocardiography guides the therapeutic planning in the NICU, mainly in the more unstable newborns, with lower birthweight and receiving catecholamines. Exams requested with the intention of modifying the current approach were more likely to change the management in a different way than planned pre-exam.

Comparison of mortality and survival without major morbidities of very preterm infants with very low birth weight from Japan and Brazil

Objective:

This study was carried out to understand the disparities in mortality and survival without major morbidities among very premature and very low birth weight infants between participating Neonatal Intensive Care Units (NICUs) from the Brazilian Network on Neonatal Research (RBPN) and the Neonatal Research Network of Japan (NRNJ).

Methods:

Secondary data analysis of surveys by the RBPN and NRNJ was performed. The surveys were conducted in 2014 and 2015 and included 187 NICUs. Primary outcome was mortality or survival without any major morbidity. Logistic regression analysis adjustment for confounding factors was used.

Results:

The study population consisted of 6,406 infants from the NRNJ and 2,319 from the RBPN. Controlling for various confounders, infants from RBPN had 9.06 times higher adjusted odds of mortality (95%CI 7.30–11.29), and lower odds of survival without major morbidities (AOR 0.36; 95%CI 0.32–0.41) compared with those from the NRNJ. Factors associated with higher odds of mortality among Brazilian NICUs included: Air Leak Syndrome (AOR 4.73; 95%CI 1.26–15.27), Necrotizing Enterocolitis (AOR 3.25; 95%CI 1.38–7.26), and Late Onset Sepsis (LOS) (AOR 4.86; 95%CI 2.25–10.97).

Conclusions:

Very premature and very low birth weight infants from Brazil had significantly higher odds for mortality and lower odds for survival without major morbidities in comparison to those from Japan. Additionally, we identified the factors that increased the odds of in-hospital neonatal death in Brazil, most of which was related to LOS.

Mental health in adults born preterm with very low birth weight at 14 and 26 years of age assessed by the Strengths and Difficulties Questionnaire

AIM

Very low birth weight (VLBW: <1500 g) is associated with risk of adverse long-term outcomes, including mental health problems. We assessed whether self-reported mental health differed between young adults born preterm with VLBW and term-born controls. We also examined changes in mental health from 14 to 26 years.

METHODS

In a prospective cohort study, 61 VLBW and 88 control participants completed the Strengths and Difficulties Questionnaire at 26 years. Group differences were analysed by linear regression with adjustment for sex and parental socioeconomic status. Longitudinal changes from 14 to 26 years were analysed using linear mixed model.

RESULTS

Mean total difficulties score was 1.9 (95% CI: 0.5 to 3.5) higher in the VLBW than in the control group. Internalising and its subscale emotional problems as well as externalising and its subscale hyperactivity/inattention symptoms were higher in the VLBW group. From 14 to 26 years, changes in emotional symptoms, peer relationship problems, externalising problems, hyperactivity/inattention, and prosocial behaviour differed between the groups.

CONCLUSION

At 26 years, VLBW participants had more self-reported mental health difficulties than controls. Emotional symptoms increased from 14 to 26 years in the VLBW group, whereas hyperactivity and inattention did not decrease with age as it did in the control group.

Growth and differentiation factor 15 (GDF15) levels predict adverse respiratory outcomes in premature neonates

Growth and differentiation factor 15 (GDF15) is a stress-responsive cytokine, and its expression increases during inflammation, hyperoxia, and senescence. Significantly, GDF15 is secreted by the placenta, and maternal levels increase throughout pregnancy. Serum GDF15 level is a promising biomarker for many lung diseases like pulmonary hypertension and pulmonary fibrosis. However, circulating GDF15 levels in preterm infants and their role as a predictor of respiratory outcomes have not been studied. We hypothesized that GDF15 levels would increase with gestational age at birth, and that postnatal GDF15 will be correlated with adverse respiratory outcomes in preterm infants. Scavenged blood samples were retrieved from 57 preterm infants at five time points, from birth until 36-weeks postmenstrual age (PMA). GDF15 levels were measured using ELISA in 114 samples. We performed two-sample t-test, correlation and linear regression, logistic regression, and mixed-effects linear models for statistical analysis, and significance was identified when p < 0.05. Contrary to our hypothesis, for every 1-week increase in gestational age at birth, the predicted GDF15 level decreased by 475.0 pg/ml (p < 0.001). Greater PMA was significantly associated with lower serum GDF15 levels (p < 0.001). Interestingly, higher GDF15 levels were associated with a longer need for mechanical ventilation (p = 0.034), prolonged respiratory support need (p < 0.001), and length of hospital stay (p = 0.006). In conclusion, in preterm infants, GDF15 levels show an inverse correlation with gestational age at birth, with higher levels in more preterm babies, and levels trend down postnatally. Furthermore, longitudinal GDF15 levels through 36 weeks PMA predict adverse respiratory outcomes in preterm infants.

Impact of concomitant necrotizing enterocolitis on mortality in very low birth weight infants with intraventricular hemorrhage

OBJECTIVE

To evaluate the impact of necrotizing enterocolitis (NEC) on mortality in very low birth weight (VLBW) infants with intraventricular hemorrhage (IVH).

STUDY DESIGN

Data were collected on VLBW infants born 2014-2018 at Vermont Oxford Network (VON) centers. NEC and IVH were categorized by severity. Adjusted risk ratios (ARR) for in-hospital mortality were calculated.

RESULTS

This study included 187 187 VLBW infants. Both medical and surgical NEC increased mortality risk compared to those without NEC. Stratification by IVH severity modified this effect (no IVH: ARR 3.04 (95%CI 2.74-3.38) for medical NEC and 4.17 (3.84-4.52) for surgical NEC; mild IVH: ARR 2.14 (1.88-2.44) for medical NEC and 2.49 (2.24-2.78) for surgical NEC; severe IVH: ARR 1.14 (1.03-1.26) for medical NEC and 1.10 (1.02-1.18) for surgical NEC).

CONCLUSION

The relative impact of NEC on mortality decreased as IVH severity increased. Given the frequent coexistence of NEC and IVH, these data inform multidisciplinary management of these complex patients.

Latent class analysis to characterize neonatal risk for neurodevelopmental differences

BACKGROUND

Neonatal risk factors, such as preterm birth and low birth weight, have been robustly linked to neurodevelopmental deficits, yet it is still unclear why some infants born preterm and/or low birth weight experience neurodevelopmental difficulties while others do not. The current study investigated this heterogeneity in neurodevelopmental abilities by examining additional neonatal morbidities as risk factors, utilizing latent class analysis to classify neonates into groups based on similar neonatal risk factors, and including neonates from the full spectrum of gestational age.

METHODS

Neonates who received neonatal care at an academic public hospital during an almost 10-year period (n = 19,951) were included in the latent class analysis, and 21 neonatal indicators of health were used. Neonatal class, sex, and the interaction between neonatal class and sex were used to examine differences in neurodevelopment at 18 months of age in a typically developing population.

RESULTS

The best fitting model included five infant classes: healthy, hypoxic, critically ill, minorly ill, and complicated delivery. Scores on the parent-rated neurodevelopmental measure differed by class such that infants in the critically ill, minorly ill, and complicated delivery classes had lower scores. There was no main effect of sex on the neurodevelopmental measure scores, but the interaction between sex and neonatal class was significant for three out of five neurodevelopmental domains.

CONCLUSIONS

The current study extends the understanding of risk factors in neurodevelopment by including several neonatal medical conditions that are often overlooked and by using a person-centered, as opposed to variable-centered, approach. Future work should continue to examine risk factors, such as maternal health during pregnancy and medical interventions for newborns, in relation to neonatal risks and neurodevelopment by using a person-centered approach.

Risk factors for length of NICU stay of newborns: A systematic review

Background

The improvement in survival of preterm infants is accompanied by an increase in neonatal intensive care unit (NICU) admissions. Prolonged length of stay in the NICU (LOS-NICU) increases the incidence of neonatal complications and even mortality and places a significant economic burden on families and strain on healthcare systems. This review aims to identify risk factors influencing LOS-NICU of newborns and to provide a basis for interventions to shorten LOS-NICU and avoid prolonged LOS-NICU.

Methods

A systematic literature search was conducted in PubMed, Web of Science, Embase, and Cochrane library for studies that were published in English from January 1994 to October 2022. The PRISMA guidelines were followed in all phases of this systematic review. The Quality in Prognostic Studies (QUIPS) tool was used to assess methodological quality.

Results

Twenty-three studies were included, 5 of which were of high quality and 18 of moderate quality, with no low-quality literature. The studies reported 58 possible risk factors in six broad categories (inherent factors; antenatal treatment and maternal factors; diseases and adverse conditions of the newborn; treatment of the newborn; clinical scores and laboratory indicators; organizational factors).

Conclusions

We identified several of the most critical risk factors affecting LOS-NICU, including birth weight, gestational age, sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, and retinopathy of prematurity. As only a few high-quality studies are available at present, well-designed and more extensive prospective studies investigating the risk factors affecting LOS-NICU are still needed in the future.

Analysis of risk factors of early intraventricular hemorrhage in very-low-birth-weight premature infants: a single center retrospective study

BACKGROUND

This study aimed to determine the risk factors of early intraventricular hemorrhage (IVH) in very-low-birth-weight (VLBW) premature infants in China to guide early interventions and improve the survival and quality of life of these infants.

METHODS

Data on 421 VLBW premature infants admitted to the neonatal intensive care unit of Tianjin Central Hospital of Gynecology Obstetrics between July 2017 and July 2019 were retrospectively evaluated. Data on head ultrasound results, maternal pregnancy complications, and perinatal conditions were reviewed to evaluate the association between maternal and neonatal factors and the development and severity of IVH.

RESULTS

Univariate analysis showed that the incidence of early IVH was significantly higher in neonates with early gestational age, delivered after spontaneous labor, low birth weight, 5-minute Apgar score ≤ 7, invasive mechanical ventilation, and early onset sepsis (χ² = 11.087, 16.868, 4.779, 11.170, 6.655, and 6.260, respectively; P < 0.05), but it was significantly lower in the presence of gestational hypertension (χ² = 4.373, P = 0.037). In addition, severe IVH was significantly associated with early gestational age, low birth weight, 5-minute Apgar score ≤ 7, and neonatal sepsis (χ² = 11.599, 8.263, 11.172, and 7.749, respectively; P < 0.05). Logistic regression analysis showed that antenatal glucocorticoid use was associated with significantly reduced incidence of severe IVH (OR = 0.095, 95% CI = 0.012-0.739, P = 0.024).

CONCLUSION

Appropriate mode of delivery may effectively reduce the incidence of IVH in VLBW premature infants. The antenatal glucocorticoid use may also protect against severe IVH. The focus on steroid prophylaxis, mode of delivery and prevention of perinatal asphyxia should be stressed in China.

Delayed-interval delivery in multiple gestation pregnancies: neonatal mortality, morbidity, and development

OBJECTIVE

Delayed-interval delivery (DID) is the delivery of the first fetus in a multiple gestation pregnancy without prompt delivery of the remaining fetus(es). We aimed to assess infant outcomes of DID.

STUDY DESIGN

We performed a retrospective cohort study of infants born 22-28 weeks' gestation or weighing 401-1500 g. DID was defined as a passage of >24 h between the birth of firstborn and retained infants. Rates of mortality, morbidity, and developmental outcomes were compared within DID multiples, to other multiples not born by DID, and all infants in the Generic Database and follow-up datasets (excluding DID-born).

RESULTS

DID-born multiples were younger and smaller than other multiples. Retained infants had no significantly different rates of mortality and morbidities compared to their firstborn counterparts, apart from less bronchopulmonary dysplasia.

CONCLUSIONS

DID showed no evidence of harm and a potential benefit of decreased bronchopulmonary dysplasia mediated by increased gestational age and birthweight.

Contributions of the NICHD neonatal research network's generic database to documenting and advancing the outcomes of extremely preterm infants

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) maintains a database of extremely preterm infants known as the Generic Database (GDB). Begun in 1987, this database now includes more than 91,000 infants, most of whom are extremely preterm (<29 weeks gestation). The GDB has been the backbone of the NRN, providing high quality, prospectively collected data to study the changing epidemiology of extreme prematurity and its outcomes over time. In addition, GDB data have been used to generate hypotheses for prospective studies and to develop new clinical trials by providing information about the numbers and characteristics of available subjects and the expected event rates for conditions and complications to be studied. Since its inception, the GDB has been the basis of more than 200 publications in peer-reviewed journals, many of which have had a significant impact on the field of neonatology.

The critical importance of follow-up to school age: Contributions of the NICHD Neonatal Research Network

Follow-up studies are essential for understanding outcomes and informing the care of infants with high risk for medical and developmental consequences because of extreme prematurity or perinatal illness. Studies that extend to school age often identify sequelae that go unrecognized in neonatal or short-term follow-up studies. Many critical neurocognitive, behavioral, functional, and health outcomes are best assessed beginning at school age. The Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN) has performed comprehensive school age evaluations of several key trial cohorts. This manuscript summarizes the important contributions of school age follow-up studies in the NRN, both historically and in ongoing research. We describe in detail the clinical questions that have been answered by the completed studies and new questions about the outcomes of high-risk infants that must be addressed by ongoing and future studies.

The impact of kangaroo mother care on work of breathing and oxygen saturation in very low birth weight infants with respiratory insufficiency

BACKGROUND: Kangaroo mother care (KMC) is defined as prolonged skin to skin care between a mother and infant with the infant lying in prone position on mom’s chest. KMC decreases morbidity and mortality and promotes physiologic stability. The aim of this study is to measure work of breathing (WOB) during KMC in very low birth weight (VLBW) infants on non-invasive respiratory support. METHODS: A prospective observational pilot study was conducted comparing WOB indices during standard care (SC) and KMC. Respiratory inductive plethysmography (RIP) measured WOB indices non-invasively: phase angle and labored breathing index. VLBW infants who were stable on non-invasive respiratory support were randomized to receive RIP measurements during KMC or during SC first. Summary statistics and mixed linear models were used to compare WOB and vital signs. RESULTS: A total of 32 infants were consented for the study, data collection and analysis was completed on 28 infants. There were no significant differences in mean phase angle during KMC or SC (73.5±4.6 SE deg vs 66.8±3.9 SE deg, p = 0.25). No differences in WOB and vital signs were detected. Controlling for respiratory support or randomization/first location did not change the results. CONCLUSION: In this pilot cohort, infants demonstrated no differences in work of breathing indices or oxygen saturation during KMC or SC while receiving non-invasive respiratory support. KMC appears to be safe and well tolerated with no worsened WOB. Larger studies should be performed to confirm our findings.