Hypoxic respiratory failure in the late preterm infant

Practice patterns in the administration of late preterm antenatal corticosteroids

BACKGROUND

Given the unpredictable nature of preterm birth and the short-term impact of antenatal corticosteroids on neonatal outcomes, optimal timing of antenatal corticosteroid administration (2–7 days from expected birth) remains challenging.

OBJECTIVE

We set out to evaluate the likelihood of delivery between 2 and 7 days after antenatal corticosteroid administration in the late preterm period and whether this differs based on the indication for corticosteroid administration.

STUDY DESIGN

Retrospective cohort of all singletons that received antenatal corticosteroids in the late preterm period (34 0/7 to 36 6/7 weeks’ gestation) and delivered within a large health system between November 2017 and March 2020. Women who received antenatal corticosteroids before the late preterm period, major fetal structural malformations, and cases with missing data were excluded. Cases were stratified on the basis of the indication for antenatal corticosteroid administration, that is, anticipated spontaneous late preterm birth or medically indicated late preterm birth. The primary outcome was delivery between 2 and 7 days after the administration of the first dose of antenatal corticosteroids. Secondary outcomes included time interval from antenatal corticosteroid administration to delivery and delivery during the first 2 days or later than 7 days after antenatal corticosteroid administration. Multivariable logistic regression was performed to evaluate factors associated with optimal timing while adjusting for potential confounders.

RESULTS

Of the 1238 patients included in the study, 656 (53%) delivered within the first day after antenatal corticosteroid administration and thus received only the first of 2 doses. Regardless of the indication for late preterm antenatal corticosteroid administration, the likelihood of delivery between 2 and 7 days later was 13.3% (165 of 1238). Moreover, it was more common (23.4% vs 5.0%; P≤.001) (Table 2) and more likely (adjusted odds ratio, 5.88; 95% confidence interval, 4.00–9.09) in women at risk of medically indicated preterm birth than in those with anticipated spontaneous preterm birth. Furthermore, women with anticipated spontaneous preterm birth had a shorter time interval from antenatal corticosteroid administration to delivery (10.7 vs 49.71 hour; P≤.001).

CONCLUSION

Regardless of the indication for late preterm antenatal corticosteroid administration, the likelihood of delivery between 2 and 7 days later was low. Nevertheless, our data suggested that delivery within the desired time interval of antenatal corticosteroid administration is more common in women at risk of medically indicated late preterm birth compared with those at risk of spontaneous late preterm birth.

Time interval from late preterm antenatal corticosteroid administration to delivery and the impact on neonatal outcomes

BACKGROUND

Although administration of antenatal corticosteroids has been shown to decrease neonatal respiratory morbidity when given to women at risk for late preterm birth, the time interval from antenatal corticosteroid administration to delivery that is associated with the greatest neonatal benefit remains unknown.

OBJECTIVE

This study aimed to evaluate whether the time interval from administration of late preterm antenatal corticosteroids to delivery is associated with a change in the likelihood of transient tachypnea of the newborn, respiratory distress syndrome, and hypoglycemia.

STUDY DESIGN

This was a retrospective cohort study of all singleton neonates who were exposed to 1 or 2 doses of antenatal corticosteroids in the late preterm period (34+0 to 36+6 weeks' gestation) within a large healthcare system between November 2017 and March 2020. Neonates exposed to antenatal corticosteroids before 34 weeks' gestation and those with major fetal structural malformations and chromosomal disorders were excluded. Cases were stratified into the following groups based on the time interval from the first dose of antenatal corticosteroid administration to delivery: <2 days, 2 to 7 days, and >7 days. The primary outcome of transient tachypnea of the newborn was compared among the 3 groups. Secondary outcomes included respiratory distress syndrome and hypoglycemia. A multivariable logistic regression was performed to evaluate the association between the time interval and neonatal outcomes while adjusting for potential confounders. For each outcome, delivery within 2 to 7 days from the first dose of betamethasone administration was defined as the reference group. Data were presented as adjusted odds ratios with 95% confidence intervals, and statistical significance was defined as P < .05.

RESULTS

The study cohort comprised 1248 neonates. Of those, 649 (52%) were exposed to 1 dose of antenatal corticosteroids. There were statistically significant differences in the maternal characteristics such as nulliparity, pregnancies complicated by hypertensive disorders and fetal growth restriction, gestational age at antenatal corticosteroid administration, gestational age at delivery, and mode of delivery among the 3 groups. There was a significantly increased risk for transient tachypnea of the newborn (adjusted odds ratio, 4.81; 95% confidence interval, 1.72-12.92) and respiratory distress syndrome (adjusted odds ratio, 9.86; 95% confidence interval, 1.15-84.24) associated with delivery <2 days of antenatal corticosteroid administration. The risk for hypoglycemia was highest in the delivery <2 days group (adjusted odds ratio, 3.44; 95% confidence interval, 2.10-5.63) and decreased as the time interval from antenatal corticosteroid administration to delivery increased (adjusted odds ratio, 0.32; 95% confidence interval, 0.20-0.51 for delivery >7 days).

CONCLUSION

Adverse neonatal outcomes such as transient tachypnea of the newborn, respiratory distress syndrome, and hypoglycemia are more common when late preterm birth occurs <2 days after antenatal corticosteroid administration when compared with birth 2 to 7 days after administration. In addition, delivery >7 days after antenatal corticosteroid administration is associated with a decreased risk for hypoglycemia. Understanding the impact of antenatal corticosteroid timing on neonatal outcomes is essential in caring for patients at risk for late preterm birth.

Early term delivery is associated with increased neonatal respiratory morbidity

BACKGROUND

The recent increase in early term birth rates represents a growing challenge to public health given the association between early term birth and neonatal morbidities. We compared the risk of respiratory morbidity between early term and full-term infants.

METHODS

This retrospective cohort population study included infants born at 37-41 weeks' gestation in a single tertiary care university hospital between 2014 and 2016. Newborns were categorized as early term (37-38 weeks) and full term (39-41 weeks). The primary outcome was respiratory morbidity.

RESULTS

Of the 4,894 babies born at 37-41 weeks gestational age, 31% (n = 1,521) were early term births. The rate of cesarean deliveries, which were often elective, was higher for early term than for full-term newborns (P = 0.001). Compared with full-term newborns, early term newborns, had significantly higher risks of respiratory morbidity (13.2 % vs 6.3 %; odds ratio [OR], 2.28, P = 0.001), respiratory distress syndrome (0.5 % vs 0 %, P = 0.001), transient tachypnea of the newborn (11.2 % vs 4.6 %; OR, 2.72, P = 0.001), continuous positive airway pressure use (9.7 % vs 3.7 %; OR, 2.82, P = 0.001), and ventilation support (1.4% vs 0.4%; OR, 4.11, P = 0.001).

CONCLUSIONS

The elevated frequency of respiratory morbidity in early term infants emphasizes the importance of early term birth interventions. More than half of the early term births were elective cesarean sections; interventions should therefore focus on reducing elective cesarean procedures at the time of first birth.

Factors affecting infant mortality in the general population: evidence from the 2016 Ethiopian demographic and health survey (EDHS); a multilevel analysis

Background

Infant mortality is one of the leading public health problems globally; the problem is even more staggering in low-income countries. In Ethiopia seven in ten child deaths occurred during infancy in 2016. Even though the problem is devastating, updated information about the major determinants of infant mortality which is done on a countrywide representative sample is lacking. Therefore, this study was aimed to identify factors affecting infant mortality among the general population of Ethiopia, 2016.

Methods

A Community-based cross-sectional study was conducted in all regions of Ethiopia from January 18 to June 27, 2016. A total of 10,641 live births were included in the analysis. Data were analyzed and reported with both descriptive and analytic statistics. Bivariable and multivariable multilevel logistic regression models were fitted by accounting correlation of individuals within a cluster. Adjusted odds ratio (AOR) with 95% confidence interval was reported to show the strength of the association and its significance.

Results

A total of 10,641 live-births from the Ethiopian demographic and health survey (EDHS) data were included in the analysis. Being male infant (AOR = 1.51; 1.25, 1.82), Multiple birth (AOR = 5.49; 95% CI, 3.88–7.78), Preterm (AOR = 8.47; 95% CI 5.71, 12.57), rural residents (AOR = 1.76; 95% CI; 1.16, 2.67), from Somali region (AOR = 2.07; 1.29, 3.33), Harari (AOR = 2.14; 1.22, 3.75) and Diredawa (AOR = 1.91; 1.04, 3.51) were found to be statistically significantly associated with infant mortality.

Conclusion

The study has assessed the determinants of infant mortality based on EDHS data. Sex of the child, multiple births, prematurity, and residence were notably associated with infant mortality. The risk of infant mortality has also shown differences across different regions. Since infant mortality is still major public health problem interventions shall be done giving more attention to infants who were delivered multiple and who are preterm.

Preterm birth, low birthweight, and small for gestational age among women with preeclampsia: Does maternal age matter?

OBJECTIVES

To better understand the effects of maternal age on birth outcomes among preeclampsia (PE) patients, we examined the rates of preterm birth, low birthweight, and small for gestational age (SGA) among different age groups and explored whether maternal age was associated with those adverse outcomes.

STUDY DESIGN

This is a multicenter retrospective study. Data from 1128 PE patients, including 580 with early onset PE and 548 with late onset PE, were analyzed.

MAIN OUTCOME MEASURES

Maternal age was categorized into three groups: <25, 25-34, and ≥35 years. The outcome variables were preterm birth (<37 weeks; subgroups: <28 weeks, 28-33 weeks, and 34-36 weeks), low birthweight (<2500 g; subgroups: <1500 g and <1000 g), and SGA. Logistic regression was used to analyze the associations between maternal age groups and outcomes.

RESULTS

In early onset PE, compared with maternal age 25-34 years, maternal age ≥35 years was associated with elevated risk for preterm delivery before 28 weeks, and maternal age <25 years was associated with elevated risk for low birthweight and SGA. When the analysis was restricted to women who underwent cesarean section, elevated risks for preterm birth and/or low birthweight were observed for women younger than 25 years in both early and late onset PE.

CONCLUSIONS

Among women with PE, maternal age <25 years could add risk to preterm birth and/or low birthweight. For women with early onset PE, maternal age ≥35 years is a risk factor for preterm delivery before 28 weeks.

Intervención en un niño con autismo mediante el juego

Introducción. El autismo es una alteración en el neurodesarrollo en la que se compromete el desarrollo comunicativo, emocional y simbólico del niño, así como la capacidad de establecer relaciones con el adulto y los objetos.Objetivo. Identificar el impacto del juego en el desarrollo comunicativo, emocional y simbólico de un niño con autismo de 3 años y 6 meses.Materiales y métodos. Se hizo una entrevista a los padres del niño y una observación a este en el contexto educativo y clínico. Se aplicó una evaluación del desarrollo infantil antes y después de realizar una intervención en la que se empleó el método experimental formativo propuesto por Vigotsky. La investigación fue de carácter cualitativo de tipo descriptivo. La intervención se diseñó considerando las necesidades de desarrollo psicológico del niño en lo que se refiere a la actividad rectora de juego.Resultados. El juego es un medio efectivo que contribuye con el desarrollo de habilidades comunicativas, emocionales y simbólicas en casos de autismo.Conclusión. La intervención clínica desde la aproximación psicológica histórico-cultural y la teoría de la actividad tiene impacto positivo en el desarrollo psicológico del niño, se propone de manera intencional y promueve el desarrollo de habilidades de corregulación social que facilitan la interacción comunicativa en casos de autismo.

Current Practices and Attitudes Regarding Use of Inhaled Nitric Oxide in the NICU: Results From a Survey of Members of the National Association of Neonatal Nurse Practitioners

Background:

Excessive supplemental oxygen exposure in the neonatal intensive care unit (NICU) can be associated with oxygen-related toxicities, which can lead to negative clinical consequences. Use of inhaled nitric oxide (iNO) can be a successful strategy for avoiding hyperoxia in the NICU. iNO selectively produces pulmonary vasodilation and has been shown to improve oxygenation parameters across the spectrum of disease severity, from mild to very severe, in neonates with hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn.

Purpose:

An online survey was conducted among members of the National Association of Neonatal Nurse Practitioners to gain insight into the level of understanding and knowledge among neonatal nurse practitioners (NNPs) about optimizing supplemental oxygen exposure and the use of iNO in the NICU setting.

Results:

Of 937 NNP respondents, 51% reported that their healthcare team typically waits until the fraction of inspired oxygen level is 0.9 or more before adding iNO in patients not responding to oxygen ventilation alone. Among respondents with 1 or more iNO-treated patients per month, only 35% reported they know the oxygenation index level at which iNO should be initiated. Less than 20% of NNPs reported perceived benefits associated with early initiation of iNO for preventing progression to use of extracorporeal membrane oxygenation or reducing the length of hospital stay, and about one-third of respondents reported they believe early iNO use minimizes hyperoxia.

Implications for Practice:

More education is needed for NNPs regarding the negative effects of oxidative stress in neonates.

Implications for Research:

Additional clinical trials investigating the most beneficial strategies for avoiding neonatal hyperoxia are warranted.

Surfactant Protein A and B Gene Polymorphisms and Risk of Respiratory Distress Syndrome in Late-Preterm Neonates

Background and Objectives

Newborns delivered late-preterm (between 34^0/7 and 36^6/7 weeks of gestation) are at increased risk of respiratory distress syndrome (RDS). Polymorphisms within the surfactant protein (SP) A and B gene have been shown to predispose to RDS in preterm neonates. The aim of this study was to investigate whether specific SP-A and/or SP-B genetic variants are also associated with RDS in infants born late-preterm.

Methods

This prospective cross-sectional study included 56 late-preterm infants with and 60 without RDS. Specific SP-A1/SP-A2 haplotypes and SP-B Ile131Thr polymorphic alleles were determined in blood specimens using polymerase-chain-reaction and DNA sequencing.

Results

The SP-A1 6A⁴ and the SP-A2 1A⁵ haplotypes were significantly overrepresented in newborns with RDS compared to controls (OR 2.86, 95%CI 1.20–6.83 and OR 4.68, 95%CI 1.28–17.1, respectively). The distribution of the SP-B Ile131Thr genotypes was similar between the two late-preterm groups. Overall, the SP-A1 6A⁴ or/and SP-A2 1A⁵ haplotype was present in 20 newborns with RDS (35.7%), resulting in a 4.2-fold (1.60–11.0) higher probability of RDS in carriers. Multivariable regression analysis revealed that the effect of SP-A1 6A⁴ and SP-A2 1A⁵ haplotypes was preserved when adjusting for known risk or protective factors, such as male gender, smaller gestational age, smaller weight, complications of pregnancy, and administration of antenatal corticosteroids.

Conclusions

Specific SP-A genetic variants may influence the susceptibility to RDS in late-preterm infants, independently of the effect of other perinatal factors.

Macro preemies: no thresholds for risks or concerns

PURPOSE OF REVIEW

To provide an overview of the literature regarding medical and developmental risks for moderate to late preterm infants (32-36 weeks gestation), with particular attention to the pediatrician's role in care during both inpatient and outpatient periods.

RECENT FINDINGS

Although the risks of medical issues and developmental delays decrease with increasing gestational age, research suggests that infants born after 32 weeks' gestation often exhibit significant morbidities associated with prematurity. These infants, often referred to as 'macro preemies', have been found to be at a greater risk for medical complications secondary to immature organ systems including impairments in temperature regulation, respiratory functioning, feeding coordination, bilirubin excretion, glucose control, and infection susceptibility. Recent studies of macro preemies also suggest a higher incidence of significant deficits noted in gross and fine motor skills, speech and communication, and learning and behavior compared to their full-term counterparts. Without careful attention from birth, macro preemie infants could be susceptible to both medical issues and developmental delays.

SUMMARY

Physicians should be aware of the research regarding increased medical and developmental risks for all infants born before term in order to provide their patients with comprehensive medical and neurodevelopmental follow-up care.

The effects of vitamin C supplementation on pre-eclampsia in Mulago Hospital, Kampala, Uganda: a randomized placebo controlled clinical trial

Background

Oxidative stress plays a role in the pathogenesis of pre-eclampsia. Supplementing women with antioxidants during pregnancy may reduce oxidative stress and thereby prevent or delay the onset pre-eclampsia. The objective of this study was to evaluate the effect of supplementing vitamin C in pregnancy on the incidence of pre-eclampsia, at Mulago hospital, Kampala, Uganda.

Methods

This was a (parallel, balanced randomization, 1:1) placebo randomized controlled trial conducted at Mulago hospital, Department of Obstetrics and Gynecology. Participants included in this study were pregnant women aged 15-42 years, who lived 15 km or less from the hospital with gestational ages between 12-22 weeks. The women were randomized to take 1000mg of vitamin C (as ascorbic acid) or a placebo daily until they delivered. The primary outcome was pre-eclamsia. Secondary outcomes were: severe pre-eclampsia, gestational hypertension, preterm delivery, low birth weight and still birth delivery. Participants were 932 pregnant women randomized into one of the two treatment arms in a ratio of 1:1. The participants, the care providers and those assessing the outcomes were blinded to the study allocation.

Results

Of the 932 women recruited; 466 were randomized to the vitamin and 466 to the placebo group. Recruitment of participants was from November 2011 to June 2012 and follow up was up to January 2013. Outcome data was available 415 women in the vitamin group and 418 women in the placebo group.

There were no differences in vitamin and placebo groups in the incidence of pre-eclampsia (3.1% versus 4.1%; RR 0.77; 95% CI: 0.37-1.56), severe pre-eclampsia (1.2% versus 1.0%; RR 1.25; 95% CI: 0.34-4.65), gestational hypertension(7.7% versus 11.5%; RR 0.67; 95% CI: 0.43-1.03), preterm delivery (11.3% versus 12.2%; RR 0.92; 95% CI: 0.63-1.34), low birth weight (11.1% versus 10.3%; RR 1.07; 95% CI: 0.72-1.59) and still birth delivery (4.6% versus 4.5%; RR 1.01; 95% CI: 0.54-1.87).

Conclusions

Supplementation with vitamin C did not reduce the incidence of pre-eclampsia nor did it reduce the adverse maternal or neonatal outcomes. We do not recommend the use of vitamin C in pregnancy to prevent pre-eclampsia.

Trial registration

This study was registered at the Pan African Clinical Trial Registry, PACTR201210000418271 on 25^th October 2012.

Urinary Hypoxanthine as a Measure of Increased ATP Utilization in Late Preterm Infants

OBJECTIVE

To examine the effect of neonatal morbidity on ATP breakdown in late preterm infants.

STUDY DESIGN

Urinary hypoxanthine concentration, a marker of ATP breakdown, was measured from 82 late preterm infants on days of life (DOL) 3 to 6 using high-performance liquid chromatography. Infants were grouped according to the following diagnoses: poor nippling alone (n = 8), poor nippling plus hyperbilirubinemia (n = 21), poor nippling plus early respiratory disease (n = 26), and respiratory disease alone (n = 27).

RESULTS

Neonates with respiratory disease alone had significantly higher urinary hypoxanthine over DOL 3 to 6 when compared with neonates with poor nippling (P = .020), poor nippling plus hyperbilirubinemia (P < .001), and poor nippling plus early respiratory disease (P = .017). Neonates with poor nippling who received respiratory support for 2 to 3 days had significantly higher hypoxanthine compared with infants who received respiratory support for 1 day (P = .017) or no days (P = .007).

CONCLUSIONS

These findings suggest that respiratory disorders significantly increase ATP degradation in late premature infants.

Early neonatal morbidities and associated modifiable and non-modifiable risk factors in a cohort of infants born at 34-35 weeks of gestation

OBJECTIVE

To ascertain the most common early morbidities in a cohort of infants born at 34-35 weeks gestation and to identify the risk factors associated with these morbidities.

METHODS

Retrospective analysis of data collected prospectively for all 235 infants born at 34-35 weeks of gestation during an eight-month period at a single tertiary medical center. Study group infants (SG) were compared with 470 term infants (TI), matched both for gender and for mode of delivery.

RESULTS

Jaundice requiring phototherapy (32%), respiratory disease (19.1%) and cyanotic episodes (15.7%) were the most frequent early morbidities, followed by hypoglycemia, temperature instability and feeding intolerance. The risk of having a complication was 13.3-times higher in the SG compared with the TI group (95% CI 8.9-19.6, p < 0.001). Modifiable interventions associated with these morbidities were antenatal steroids, MgSO4 and mode of delivery. Non-modifiable factors were maternal age, parity, twins and gender.

CONCLUSIONS

Jaundice requiring phototherapy, respiratory disease and cyanotic episodes are the most frequent early morbidities among infants born at 34-35 weeks. Medically modifiable factors were found to be associated with the above morbidities. Whether specific recommendations for the care of these infants will affect early morbidities needs to be studied in controlled prospective studies.

Adverse neonatal outcomes in women with pre-eclampsia in Mulago Hospital, Kampala, Uganda: a cross-sectional study

INTRODUCTION

Pre-eclampsia, which is more prevalent in resource-limited settings, contributes significantly to maternal, fetal and neonatal morbidity and mortality. However, the factors associated with these adverse outcomes are poorly understood in low resource settings. In this paper we examine the risk factors for adverse neonatal outcomes among women with pre-eclampsia at Mulago Hospital in Kampala, Uganda.

METHODS

Pre-eclampsia, which is more prevalent in resource-limited settings, contributes significantly to maternal, fetal and neonatal morbidity and mortality. However, the factors associated with these adverse outcomes are poorly understood in low resource settings. In this paper we examine the risk factors for adverse neonatal outcomes among women with pre-eclampsia at Mulago Hospital in Kampala, Uganda.

RESULTS

Predictors of adverse neonatal outcomes were: preterm delivery (OR 5.97, 95% CI: 2.97-12.7) and severe pre-eclampsia (OR 5.17, 95% CI: 2.36-11.3).

CONCLUSION

Predictors of adverse neonatal outcomes among women with pre-eclampsia were preterm delivery and severe pre-eclampsia. Health workers need to identify women at risk, offer them counseling and, refer them if necessary to a hospital where they can be managed successfully. This may in turn reduce the neonatal morbidity and mortality associated with pre-eclampsia.

Respiratory disorders in moderately preterm, late preterm, and early term infants

Even when it is just a few weeks before term gestation, early birth has consequences, resulting in higher morbidity and mortality. Respiratory issues related to moderate prematurity include delayed neonatal transition to air breathing, respiratory distress resulting from delayed fluid clearance (transient tachypnea of the newborn), surfactant deficiency (respiratory distress syndrome), and pulmonary hypertension. Management approaches emphasize appropriate respiratory support to facilitate respiratory transition and minimize iatrogenic injury. Studies are needed to determine the impact of respiratory distress coupled with mild-moderate prematurity on long-term outcome.

Physiologic underpinnings for clinical problems in moderately preterm and late preterm infants

This article highlights some of the important developmental characteristics that underpin common problems seen in moderate and late preterm infants. Preterm birth is associated with an increased prevalence of clinical problems caused by functional immaturities in a wide variety of organ systems, acquired problems, and problems associated with inadequate monitoring and/or follow-up plans. There are variations in the degree of maturation among infants of similar gestational ages because the developmental process is nonlinear. Therefore, different organ systems mature at rates and trajectories that are specific to their functions. A better understanding of these principles can help guide optimal treatment strategies.

Life satisfaction and preterm birth among urban black women: findings from the Baltimore preterm birth study

PURPOSE

Preterm birth (PTB) is a major problem in the United States, and black women have greater risk of PTB than white women. The etiology of PTB and the racial disparity in preterm outcomes are poorly understood. Diminished life satisfaction is associated with adult health, but there are no studies of life satisfaction and PTB. In the research reported in this article, the relationship between life satisfaction and PTB among black women was studied.

METHODS

Women were enrolled in this prospective study at the time of the first visit to 5 prenatal clinics in Baltimore. Life satisfaction was assessed at the time of the first prenatal visit. Data on PTB were obtained from medical records.

RESULTS

The final sample consisted of 922 women. Among women who were somewhat or not at all satisfied with their lives, 16% had preterm births, whereas among women who were very satisfied with their lives, 10.7% had preterm births (unadjusted odds ratio = 1.6; 95% CI 1.1-2.4). The adjusted odds ratio was 1.6 (95% CI 1.00-2.5).

CONCLUSIONS

Women who reported being somewhat or not at all satisfied with their lives had a greater risk of PTB than women who reported being very satisfied with their lives.

NEONATAL OUTCOMES FOLLOWING LATE PRETERM BIRTH

It is well recognised that birth before 32 weeks of gestation is associated with substantial neonatal morbidity and mortality and these risks have been extensively reported. The focus of perinatal research for many years has therefore been very preterm and extremely preterm delivery, since the likelihood and severity of adverse neonatal outcomes are highest within this group. In contrast, until recently, more mature preterm infants have been understudied and indeed, almost ignored by researchers.

Health outcomes in infancy and childhood of moderate and late preterm infants

There has been a long-held belief that outcomes for babies born at moderate and late preterm gestations do not differ substantially from those of infants born at full term. This has recently been challenged by studies highlighting an increased risk of adverse neonatal outcomes, and of poorer cognitive, behavioural and educational outcomes in this population. Data about the effects of birth at moderate and late preterm gestations on later health outcomes are limited, but emerging evidence suggests that ongoing physical health may also be worse in those born just a few weeks before full term. This review summarises the available evidence, considers the factors influencing health outcomes and discusses the implications for the planning and provision of children's health care services.

Neonatal morbidity in singleton late preterm infants compared with full-term infants

AIM

The aim of this study was to test the hypothesis that singleton late preterm infants (34 0/7 to 36 6/7 weeks of gestation) compared with full-term infants have a higher incidence of short-term morbidity and stay longer in hospital.

METHODS

In this retrospective, multicentre study, electronic data of children born at five hospitals in Switzerland were recorded. Short-term outcome of late preterm infants was compared with a control group of full-term infants (39 0/7 to 40 6/7 weeks of gestation). Multiple gestations, pregnancies complicated by foetal malformations, maternal consumption of illicit drugs and infants with incomplete documentation were excluded. The results were corrected for gender imbalance.

RESULTS

Data from 530 late preterm and 1686 full-term infants were analysed. Compared with full-term infants, late preterm infants had a significant higher morbidity: respiratory distress (34.7% vs. 4.6%), hyperbilirubinaemia (47.7% vs. 3.4%), hypoglycaemia (14.3% vs. 0.6%), hypothermia (2.5% vs. 0.6%) and duration of hospitalization (mean, 9.9 days vs. 5.2 days). The risk to develop at least one complication was 7.6 (95% CI: 6.2-9.6) times higher among late preterm infants (70.8%) than among full-term infants (9.3%).

CONCLUSION

Singleton late preterm infants show considerably higher rate of medical complications and prolonged hospital stay compared with matched full-term infants and therefore need more medical and financial resources.

Late preterm birth: preventable prematurity?

Prematurity is one of the leading causes of infant morbidity and mortality globally. Over the years, however, advances in medicine and technology have enhanced the ability to care for babies at very early gestations. There has also been a shift in the distribution of births away from term/post-term gestations and toward earlier gestational ages. These changes have added to the burden of premature births. The focus of this article is to present both sides of the story, one that highlights the many problems and morbidities faced by this subgroup of premature infants and the other that justifies their early delivery.

Controversy: antenatal steroids

There is no controversy that women at risk of preterm delivery before 32 to 34 weeks' gestational age should be treated with antenatal steroids. Three recent meta-analyses by the Cochrane Collaboration on the benefits of antenatal steroids, the choice of steroid and dosing, and repeat doses of corticosteroids comprehensively summarize the available clinical information to about 2007. However, there are many unanswered questions about which steroid and dose to use and about their use in selected populations. This review focuses on those areas of uncertainty.

Maternal preeclampsia and neonatal outcomes

Preeclampsia is a multiorgan, heterogeneous disorder of pregnancy associated with significant maternal and neonatal morbidity and mortality. Optimal strategies in the care of the women with preeclampsia have not been fully elucidated, leaving physicians with incomplete data to guide their clinical decision making. Because preeclampsia is a progressive disorder, in some circumstances, delivery is needed to halt the progression to the benefit of the mother and fetus. However, the need for premature delivery has adverse effects on important neonatal outcomes not limited to the most premature infants. Late-preterm infants account for approximately two thirds of all preterm deliveries and are at significant risk for morbidity and mortality. Reviewed is the current literature in the diagnosis and obstetrical management of preeclampsia, the outcomes of late-preterm infants, and potential strategies to optimize fetal outcomes in pregnancies complicated by preeclampsia.

Prediction of respiratory failure in late-preterm infants with respiratory distress at birth

The aim of this study was to evaluate indices of respiratory failure in terms of their ability to predict respiratory impairment and need for ventilatory support in late-preterm neonates with respiratory distress. Arterial blood gas data during the first 12 postnatal hours or until intubation were recorded in 155 neonates with gestational age 34(0/7)-36(6/7) weeks admitted in the NICU with respiratory distress between January 2006 and June 2008. Alveolar-arterial oxygen tension difference (A-aDO(2)), arterial to alveolar oxygen tension ratio (a/A ratio), and partial arterial oxygen tension to inspired oxygen fraction ratio (PaO(2)/FiO(2)) were calculated. Considering the worst single value of each parameter, receiver operating characteristic curve analyses and area under the curve (AUC) comparisons were used to evaluate their predictive performance. Fifty-five neonates (35.5%) required mechanical ventilation. The predictive performances of the maximum A-aDO(2) (AUC 0.97), minimum a/A ratio (AUC 0.95), and minimum PaO(2)/FiO(2) (AUC 0.95) were similar. The A-aDO(2) at a threshold of >200 mmHg proved to be more effective than the other parameters, having excellent positive and negative likelihood ratios of 24.5 and 0.02, respectively. This threshold was achieved by 98.25% of the neonates who developed respiratory failure at a median of 3 h before the ventilatory support to be definitely decided. Composite indices, such as A-aDO(2), a/A ratio, and PaO(2)/FiO(2), can reasonably predict respiratory failure in late-preterm neonates with respiratory distress, allowing for closer monitoring, early medical intervention, or transfer to a level III neonatal unit.

Determinants of morbidity in late preterm infants

OBJECTIVE

To assess the effect of selected maternal medical conditions and complications of pregnancy on the risk for morbidity among late preterm neonates.

DESIGN

Prospective cohort study.

MATERIAL AND METHODS

A total of 548 late preterm neonates (34(0/7) to 36(6/7)weeks' gestation) delivered from August 2006 to July 2009, were included. Information regarding demographics, gestational age, mode of delivery, maternal age and parity, pre-existing medical conditions and complications of pregnancy were obtained and associated with neonatal morbidity, both independently and as joint exposures. Newborn morbidity was defined by combining specific diagnoses, length of hospital stay, and transfer to the Neonatal Intensive Care Unit.

RESULTS

Overall, 165 (30.1%) of the late preterm infants suffered from morbidity. The morbidity rates were 16.8% at 36 weeks' gestation, and then approximately doubled from 38.2% at 35 weeks to 59.7% at 34 weeks. The joint effect of gestational age (OR 8.43 for 34 weeks and 3.60 for 35 weeks' gestation), small for gestational age (SGA) (OR 4.18), multiple gestation (OR 3.68) and lack of antenatal steroid administration (OR 4.03), was greater than the independent effect of each of these factors, and greater than additive. Emergency caesarean section (OR 1.43) and antepartum haemorrhage (OR 3.07) were also associated with a significant impact on neonatal morbidity.

CONCLUSIONS

The risk for morbidity among late preterm infants, changes with each passing week of gestation. This risk seems to be intensified, when other exposures such as SGA, multiple gestation, emergency caesarean section, lack of antenatal steroid administration and antepartum haemorrhage, are also present.

Efeitos do banho logo após o nascimento sobre as adaptações térmica e cardiorrespiratória do recém-nascido a termo

OBJETIVO: Determinar se o banho dado ao recém-nascido (RN) logo após o nascimento interfere na transição para a vida extrauterina, especialmente nas adaptações cardiorrespiratória e na termorregulação. MÉTODOS: Estudo retrospectivo realizado por meio de levantamento de prontuários de RN admitidos em maternidade de São Paulo, entre janeiro e março de 2006. Foram incluídos RN com boletim de Apgar >8 no quinto minuto de vida: peso de nascimento >2500g; idade gestacional >37 semanas e sem malformações congênitas, divididos em dois grupos: 'banho', banhados na sala de parto, e 'controle', banhados após a terceira hora de vida. Na admissão do RN na unidade neonatal, as seguintes variáveis foram analisadas: temperatura axilar, frequência cardíaca e respiratória, pressão arterial média e saturação de oxigênio. Analisou-se também o tipo de parto, o tempo decorrido entre o parto e a admissão no berçário e a taxa de aleitamento na sala de parto. RESULTADOS: Incluíram-se 194 RN, 98 no grupo banho e 96 no grupo controle. Em ambos os grupos, a temperatura corpórea na admissão era similar (36,6±0,4 e 36,6±0,3ºC; p=0,68); frequência cardíaca (143±13 e 146±14 bpm; p=0,26) e respiratória (51±6 e 51±9 mov/min; p=0,90), pressão arterial média (44±6 e 47±9 mmHg; p=0,13) e saturação de oxigênio (98±2 e98±3%; p=0,99) foram semelhantes. A taxa de aleitamento materno (91 e 57%; p<0.001) e o tempo em sala de parto (95±21 e 79±29 minutos, p<0,001) foram significativamente maiores no grupo banho. CONCLUSÕES: Neste estudo retrospectivo, o banho na sala de parto em RN a termo e saudáveis não interferiu na adaptação cardiorrespiratória e na temperatura à admissão na unidade neonatal.

Prenatal corticosteroid prophylaxis for women delivering at late preterm gestation

OBJECTIVE

We studied patterns of prenatal corticosteroid use, respiratory distress syndrome, and associated mortality rates to assess the congruence between knowledge and clinical practice related to such prophylaxis.

METHODS

We used data on all live births in the United States (for the years 1989-1991, 1995-1997, and 2002-2004) and Nova Scotia, Canada (for the years 1988-2007). Gestational age-specific temporal trends in infant deaths resulting from respiratory distress syndrome were quantified in the United States, and gestational age-specific temporal trends in corticosteroid use and morbidity (respiratory distress syndrome and intraventricular hemorrhage) were quantified in Nova Scotia.

RESULTS

In the United States, infant deaths associated with respiratory distress syndrome decreased by 48% (95% confidence interval: 46%-50%) from 1989-1991 to 1995-1997 and then decreased by another 18% (95% confidence interval: 15%-22%) by 2002-2004. The latter mortality reduction was evident at 28 to 32 weeks but not 33 to 36 weeks of gestation. Corticosteroid use at 28 to 32 weeks was high in Nova Scotia and increased from 30.7% in 1988-1989 to 50.0% in 1996-1997 and to 52.9% in 2006-2007, whereas rates of use at 33 to 36 weeks were much lower (eg, 6.7%, 17.0%, and 15.7% at 34 weeks in the 3 periods). Increased corticosteroid use at 33 and 34 weeks was estimated to reduce respiratory distress syndrome substantially.

CONCLUSION

Addressing the knowledge-practice gap in corticosteroid use at 33 to 34 weeks should reduce infant morbidity and mortality rates.

So, he's a little premature...what's the big deal?

Health care providers have recently recognized that a large segment of the morbidity associated with preterm birth is disproportionately due to the late preterm infant (LPI). One explanation is that this population is the fastest-growing sector of all preterm births. This article describes the epidemiology and etiology of the LPI, and discusses why the LPI is at an increased risk for complications, such as thermal instability, hypoglycemia, feeding difficulties, respiratory distress, hyperbilirubinemia, and sepsis. The need for emergency department visits after hospital discharge and what is currently known regarding neurodevelopmental outcomes are also presented.

[Late preterm infants: A population at underestimated risk]

BACKGROUND AND OBJECTIVE

There has been a gradual rise in prematurity rates recent years, almost exclusively at the expense of the late preterm (34 to 36 weeks). This population, although with less risk than smaller preterm gestational age, has a morbidity rate significantly higher than term infants. However, there is some underestimation regarding developments in the short and long term. The aim of this study was to look at the incidence of prematurity in our institution and to analyze morbidity and mortality in late preterm compared with term infants

SUBJECTS AND METHODS

We performed a retrospective review of newborns in our Hospital from January 1992 until December 31, 2008. Late preterm group was defined as between 34(0/7) and 36(6/7) weeks gestation (N=2003) and term infants from 37 to 42 weeks gestation (N=32015). We formed 2 subgroups according two time periods (1992-1998 and 2000-2008). The morbidity and mortality for each of the groups and subgroups, and the morbidity from week 34 to 42, were analysed and compared.

RESULTS

During the period studied, the prematurity rate increased from 3.9% to 9.8%, exclusively at the expense of the late preterm (79%). The rate of mortality in late preterm was 5 per thousand compared to 1.1 per thousand in the term (P <0.0001, OR 4.71, 95% CI 2.3-9.5). The incidence of admission to the Neonatal Unit, Cesarean rate, twin, respiratory disorders, need for respiratory support in the form of nasal CPAP or mechanical ventilation, incidence of apnea, jaundice requiring phototherapy, hypoglycaemia and need for parenteral nutrition were significantly higher (P<0.0001) in the late preterm group compared with term infants. The morbidity rate decreased significantly as gestational age increased, with the lowest value from 39 weeks.

CONCLUSIONS

Morbidity and mortality in late preterm infants is significantly higher than in term infants. The guidelines for these near term premature babies need to be reviewed, looking for possible causes of prematurity, and trying to reduce their impact, as well as developing a protocol for their care and close monitoring to minimize the associated morbidity. There should be long-term monitoring to find out the consequences on their psychomotor development. The obstetrics group should be made aware of the true risks of births in the near-term gestational ages.

Health issues of the late preterm infant

"Late preterm" birth is not such an unusual occurrence; in fact these infants were the first group of premature infants who pediatricians learned to treat, and did so with such remarkable success that physicians no longer consider them to be of high risk. So, why the sudden interest in this group? There is now enough evidence that this population is not as benign as previously thought. They have increased mortality when compared to term infants and are at increased risk for complications including transient tachypnea of newborn (TTN), respiratory distress syndrome (RDS), persistent pulmonary hypertension (PPHN), respiratory failure, temperature instability, jaundice, feeding difficulties and prolonged neonatal intensive care unit (NICU) stay. Evidence is currently emerging that late preterm infants make up a majority of preterm births, take up significant resources, have increased mortality/morbidity, and may even have long-term neurodevelopmental consequences secondary to their late prematurity.

Antenatal corticosteroid treatment: what's happened since Drs Liggins and Howie?

In 1972, Drs Liggins and Howie published a landmark article demonstrating that antenatal corticosteroids significantly reduced the frequency of respiratory distress syndrome and neonatal mortality. A single course of antenatal corticosteroids has become standard of care for pregnant women at risk for preterm birth. Recent studies have suggested weekly courses of antenatal corticosteroids result in improvement in the acute neonatal condition but have not supported long-term benefit. With greater understanding of the beneficial actions of corticosteroids on the fetal lung, the role for this therapy may expand. In addition to increased surfactant production and secretion, corticosteroids facilitate clearance of fetal lung fluid, as well as other maturational effects. Thus, antenatal corticosteroids may prove valuable in the late preterm period and before elective cesarean delivery at term.

Complications of the late preterm infant

One of the goals of Healthy People 2010 (set in 1998) was to reduce preterm birthrates from 11.6% to 7.6%. However, in 2004, the preterm birthrate of 12.5% was actually higher than the rate in 1998. Approximately 65% of this increase in prematurity rate is attributed to the increasing birthrate of the late preterm infant. Care of the late preterm infant is far more complicated than many hospital policies and clinical guidelines imply. It cannot be stressed enough to frontline clinicians that late preterm infants are not full-term infants. Their care should not be defined by the same policies and practices that govern term infants. The purpose of this article is to explore the complications that accompany late preterm birth. The following complications will be discussed: thermoregulation challenges, feeding difficulty, late neonatal sepsis, prolonged physiologic jaundice, hypoglycemia, possible neurodevelopmental differences, and respiratory problems.

Resuscitative procedures at birth in late preterm infants

OBJECTIVE

Evaluate the need for resuscitative procedures at birth, in late prematures.

STUDY DESIGN

This prospective cohort study enrolled all liveborn infants from 1 to 30 September 2003, with 34 to 41 weeks of gestation without congenital anomalies, born in 35 public hospitals of 20 Brazilian state capitals. Logistic regression analyzed variables associated with the need for bag and mask ventilation.

RESULT

Of the 10 774 infants studied, 1054 were late preterms and 485 required resuscitative measures. Of the 1054, 338 (32%) received only free-flow oxygen, 143 (14%) were bag and mask ventilated, 27 (3%) were intubated and 10/27 received chest compressions and/or medications. Bag and mask ventilation in late preterms was associated with twin gestation, maternal hypertension, nonvertex presentation, cesarean delivery and lower gestational age.

CONCLUSION

Improving control of maternal hypertension, prolonging gestation for 1 to 2 weeks and restricting operative deliveries could decrease the need of resuscitation of late preterms at birth.