Neonatal Risk Factors for Treatment-Demanding Retinopathy of Prematurity: A Danish National Study

Fetal haemoglobin and oxygen requirement in preterm infants: an observational study

OBJECTIVE

To investigate the relationship between the fraction of fetal haemoglobin (HbF(%)) and oxygen requirement as determined by the fraction of inspired oxygen (FiO2) and alveolar-arterial gradient (A-a gradient). Increased alveolar exposure to oxygen may explain the association between decreased HbF(%) and the development of bronchopulmonary dysplasia (BPD).

DESIGN

Longitudinal, retrospective, observational study.

SETTING

Tertiary-level neonatal intensive care unit, referral centre for southern Sweden.

PATIENTS

Four hundred forty very preterm infants born before gestational week 30, 2009-2015.

INTERVENTION

Regular clinical practice.

MAIN OUTCOME MEASURES

The FiO2 and A-a gradient were determined at the time-point of 10 015 arterial blood gas analyses obtained during postnatal days 1-7. The relationship between HbF(%) and FiO2 and A-a gradient and the modifying influence of other factors affecting haemoglobin oxygen affinity were evaluated.

RESULTS

We found a significant relationship between a low fraction of HbF and an increase in FiO2 and A-a gradient, respectively. These relationships remained significant after adjusting for pH, pCO2, postnatal age, gestational age and sex.

CONCLUSION

These high-resolution data show that decreased HbF(%) during the first postnatal week is associated with increased FiO2 and A-a gradient in very preterm infants. Increased alveolar exposure to oxygen and resulting oxidative stress may, at least partly, explain the previously reported associations between decreased HbF, blood transfusions and the development of BPD in preterm infants.

Incidence, Risk Factors and Development of Retinopathy of Prematurity in Mid-Preterm and Late-Preterm Infants

PURPOSE

To evaluate the incidence, risk factors, and development of retinopathy of prematurity (ROP) in midpreterm and late-preterm infants born at 32 to 36 6/7 weeks of gestational age.

METHODS

The ophthalmic examination findings and risk factors of 5,477 preterm infants who underwent ophthalmological examination were evaluated retrospectively. The rates of any stage and severe ROP (requiring treatment) development and treatment options were recorded. The risk factors were analyzed by using logistic regression analysis.

RESULTS

A total of 5,477 infants were included in the study, of whom 2,715 (49.57%) were mid-preterm and 2,762 (50.43%) were late-preterm. The rates of any stage and severe ROP were 8.2% (n = 223) and 0.6% (n = 15) in mid-preterm infants, respectively. In late-preterm infants, the rate of any stage ROP was 2.1% (n = 59), and no severe ROP was detected. There was no significant difference in mean birth weight in mid-preterm infants between infants with any stage ROP and severe ROP (P = .104). Of the 15 infants (0.3%) who required treatment, 14 (0.2%) infants had laser photocoagulation, 1 (0.01%) had intravitreal bevacizumab, and 2 (0.03%) had additional therapy (laser photocoagulation and intravitreal bevacizumab). In logistic regression analysis, a significant association was found between treatment requirement and transport from an external center (P < .001, ß = 0.04).

CONCLUSIONS

Although ROP development rates decrease as birth weight and gestational age increase, late-preterm infants should be examined for ROP at least once, especially those born in low-income countries because ROP development can still be observed. [J Pediatr Ophthalmol Strabismus. 2024;61(5):351-357.].

Prediction models for retinopathy of prematurity occurrence based on artificial neural network

INTRODUCTION

Early prediction and timely treatment are essential for minimizing the risk of visual loss or blindness of retinopathy of prematurity, emphasizing the importance of ROP screening in clinical routine.

OBJECTIVE

To establish predictive models for ROP occurrence based on the risk factors using artificial neural network.

METHODS

A cohort of 591 infants was recruited in this retrospective study. The association between ROP and perinatal factors was analyzed by univariate analysis and multivariable logistic regression. We developed predictive models for ROP screening using back propagation neural network, which was further optimized by applying genetic algorithm method. To assess the predictive performance of the models, the areas under the curve, sensitivity, specificity, negative predictive value, positive predictive value and accuracy were used to show the performances of the prediction models.

RESULTS

ROP of any stage was found in 193 (32.7%) infants. Twelve risk factors of ROP were selected. Based on these factors, predictive models were built using BP neural network and genetic algorithm-back propagation (GA-BP) neural network. The areas under the curve for prediction models were 0.857, and 0.908 in test, respectively.

CONCLUSIONS

We developed predictive models for ROP using artificial neural network. GA-BP neural network exhibited superior predictive ability for ROP when dealing with its non-linear clinical data.

Comparison of Glutathione Nanoparticles, CoEnzyme Q10, and Fish Oil for Prevention of Oxygen-Induced Retinopathy in Neonatal Rats

Notch ligands and receptors are important for cell specification and angiogenesis, but their role in oxygen-induced retinopathy (OIR) is not well studied. Delta-like ligand (DLL)-4/Notch inhibits angiogenesis, while Jagged-1/Notch promotes angiogenesis. We tested the hypothesis that early supplementation with antioxidants and/or fish oil curtails severe OIR by inducing DLL-4/Notch and reducing Jagged-1/Notch. Newborn rats were exposed to brief intermittent hypoxia (IH) during hyperoxia, during which they received daily oral supplements of (1) fish oil, (2) coenzyme Q10 (CoQ10) in olive oil (OO), (3) glutathione nanoparticles (nGSH), (4) fish oil + CoQ10, or (5) OO (controls) from birth (P0) to P14. At P14, the pups were placed in room air (RA) until P21, with no further treatment. Oxidative stress, apoptosis, ocular histopathology, and Notch signaling were assessed. Neonatal IH resulted in severe retinal damage consistent with retinopathy of prematurity (ROP). Retinal damage was associated with induced oxidative stress and Jagged-1/Notch signaling, as well as reduced DLL-4/Notch signaling. All treatments reversed these outcomes, but nGSH produced the most beneficial outcomes. Severe OIR promoted the induction of Jagged-1/Notch and curtailed DLL-4/Notch, which was an effect that could be reversed with nGSH supplementation. These findings may indicate a potential alternate pathway for ROP treatment and/or prevention.

Genome-wide association identifies novel ROP risk loci in a multiethnic cohort

We conducted a genome-wide association study (GWAS) in a multiethnic cohort of 920 at-risk infants for retinopathy of prematurity (ROP), a major cause of childhood blindness, identifying 1 locus at genome-wide significance level (p < 5×10-8) and 9 with significance of p < 5×10-6 for ROP ≥ stage 3. The most significant locus, rs2058019, reached genome-wide significance within the full multiethnic cohort (p = 4.96×10-9); Hispanic and European Ancestry infants driving the association. The lead single nucleotide polymorphism (SNP) falls in an intronic region within the Glioma-associated oncogene family zinc finger 3 (GLI3) gene. Relevance for GLI3 and other top-associated genes to human ocular disease was substantiated through in-silico extension analyses, genetic risk score analysis and expression profiling in human donor eye tissues. Thus, we identify a novel locus at GLI3 with relevance to retinal biology, supporting genetic susceptibilities for ROP risk with possible variability by race and ethnicity.

Epidemiology, risk factors, clinical presentation and complications of late-onset neonatal sepsis among preterm neonates in Cyprus: a prospective case-control study

BACKGROUND

Late-onset neonatal sepsis (LOS) is common in preterm neonates, with increasing incidence in recent years. In the present study, we examined the epidemiology, clinical presentation, and complications of LOS in Cyprus and quantified possible risk factors for the development of this condition.

METHODS

The study subjects were preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of Archbishop Makarios III Hospital, the only neonatal tertiary centre in Cyprus. A prospective, case-control study was designed, and carried out between April 2017-October 2018. Depending on blood culture results, preterm neonates were classified as "Confirmed LOS": positive blood culture - microorganism isolated and LOS symptoms, "Unconfirmed LOS": negative blood culture and LOS symptoms, and "Controls" group: negative blood culture and absence of LOS symptoms. Comparisons between the 3 groups were performed and the associations between demographic, clinical and treatment characteristics with the likelihood of LOS were assessed using univariate and multivariate logistic regression.

RESULTS

A total of 350 preterm neonates were included in the study and the incidence of LOS was 41.1%. 79 (22.6%) and 65 (18.6%) neonates were classified as "Confirmed LOS", and "unconfirmed LOS" cases respectively while 206 (58.9%) served as controls. The rate of confirmed LOS ranged from 12.2% in moderate to late preterm neonates to 78.6% in extremely preterm neonates. In the multivariate model, we demonstrated an independent association between LOS and duration of hospitalization (OR: 1.06, 95%CI: 1.01-1.10), duration of ventilation (OR: 1.23, 95%CI: 1.07-1.43) and necrotising enterocolitis (OR: 3.41, 95%CI: 1.13-10.25).

CONCLUSIONS

The present study highlights the epidemiology of LOS in preterm neonates in Cyprus and its association with the duration of ventilation and hospitalization as well as with necrotizing enterocolitis. Establishment of protocols for the prevention of nosocomial infections during hospitalization in the NICUs and mechanical ventilation of preterm neonates is recommended.

Erythrocyte transfusions are associated with retinopathy of prematurity in extremely low gestational age newborns

AIM

Retinopathy of prematurity (ROP) is a major morbidity in preterm infants causing visual impairment including blindness. Prevention and timely treatment are critical. We investigated the potential role of red blood cell (RBC) transfusions as risk factor for ROP development.

METHODS

Retrospective cohort study of data from 68 tertiary level neonatal intensive care units in Germany. Preterm infants born at 22 + 0 to 28 + 6 weeks of gestation between January 2009 and December 2021 were enrolled.

RESULTS

We included n = 12 565 infants. Prevalence of any ROP was 49.2% with most infants being diagnosed with stage 1 (21.5%) and 2 disease (17.2%). ROP stage 3 was present in 10.2%, stage 4 in 0.3%, and ROP requiring treatment in 6.6%. Infants with ROP had significantly more frequently a history of RBC transfusions. Adjusting for confounders, RBC transfusions were associated with increased odds of ROP (OR 1.4, p < 0.001), ROP progression (OR 2.1, p < 0.01) and ROP requiring treatment (OR 3.6, p < 0.001). Restrictive transfusion approaches correlated with decreased (OR 0.7, p < 0.001), liberal regimes with increased odds (OR 1.2, p = 0.001).

CONCLUSION

The present study confirmed an association of RBC transfusions and ROP. Our findings emphasise the need for anaemia prevention and critical re-evaluation of transfusion practices in preterm infants.

Near-Infrared Spectroscopy to Guide and Understand Effects of Red Blood Cell Transfusion

This review is a summary of available evidence regarding the use of near-infrared spectroscopy (NIRS) to help better guide and understand the effects of red blood cell (RBC) transfusion in neonatal patients. We review recent literature demonstrating the changes that take place in regional tissue oxygen saturation (rSO2) resulting from RBC transfusion. We also discuss in detail if any correlation exists between rSO2 and hemoglobin values in neonates. Finally, we review studies that have evaluated the use of NIRS as a transfusion guide during neonatal intensive care.

Association between fetal growth-restriction and retinopathy of prematurity using a unique identical twin model

BACKGROUND

Research in singletons identified fetal growth restriction (FGR) as a risk factor for retinopathy of prematurity (ROP), but is generally subject to confounding by genetic, obstetric, and maternal factors. We investigated the effect of FGR on ROP in growth-discordant identical twins, thereby controlling for confounding factors.

METHODS

All data of monochorionic (MC) twin pairs with a birth weight discordance ≥20% born in our center between 2010 and 2021 were retrospectively reviewed for the presence of ROP. Potential risk factors for ROP were analyzed. Outcomes were compared between the smaller and larger twin.

RESULTS

We included 88 MC twin pairs with growth discordance. In 34% (30/88), both neonates were at risk of ROP. Prevalence of ROP was higher among the smaller twin compared to the larger twin, 30% (9/30) versus 13% (4/30), respectively (OR 2.8, 95% CI: 1.2-6.6). The smaller twin had a longer duration of mechanical ventilation (8 (1-20) versus 2 (1-4) days) and received their first red blood cell transfusion at an earlier postmenstrual age (29.6 (28.1-31.6) versus 30.4 (29.7-32.6) weeks).

CONCLUSIONS

In this identical twin model, FGR is associated with almost tripled odds of ROP development, suggesting that both unfavorable antenatal growth conditions and adverse neonatal outcomes affect postnatal retinal vascular proliferation.

IMPACT

Fetal growth restriction in growth-discordant identical twins is associated with almost tripled odds of developing retinopathy of prematurity in the smaller twin. Since these twins do not only differ in birth weight but also duration of mechanical ventilation and timing of the first red blood cell transfusion, both unfavorable antenatal growth conditions and adverse neonatal outcomes can affect postnatal retinal vascular proliferation. More attention for preventing retinopathy of prematurity is needed in those with fetal growth restriction who received prolonged duration of mechanical ventilation, oxygen supplementation, or a first red blood cell transfusion <32 weeks postmenstrual age.

Placental Inflammation Significantly Correlates with Reduced Risk for Retinopathy of Prematurity

Retinopathy of prematurity (ROP), a blinding condition affecting preterm infants, is an interruption of retinal vascular maturation that is incomplete when born preterm. Although ROP demonstrates delayed onset following preterm birth, representing a window for therapeutic intervention, there are no curative or preventative measures available for this condition. The in utero environment, including placental function, is increasingly recognized for contributions to preterm infant disease risk. The current study identified a protective association between acute placental inflammation and preterm infant ROP development using logistic regression, with the most significant association found for infants without gestational exposure to maternal preeclampsia and those with earlier preterm birth. Expression analysis of proteins with described ROP risk associations demonstrated significantly decreased placental high temperature requirement A serine peptidase-1 (HTRA-1) and fatty acid binding protein 4 protein expression in infants with acute placental inflammation compared with those without. Within the postnatal peripheral circulation, HTRA-1 and vascular endothelial growth factor-A demonstrated inverse longitudinal trends for infants born in the presence of, compared with absence of, acute placental inflammation. An agnostic approach, including whole transcriptome and differential methylation placental analysis, further identify novel mediators and pathways that may underly protection. Taken together, these data build on emerging literature showing a protective association between acute placental inflammation and ROP development and identify novel mechanisms that may inform postnatal risk associations in preterm infants.

Incidence and Risk Factors for Retinopathy of Prematurity in a Tertiary Hospital in China

Purpose

To investigate the incidence and risk factors for the retinopathy of prematurity (ROP) in the neonatal intensive care unit (NICU) of Obstetrics and Gynecology Hospital of Affiliated to Nanjing Medical University, China.

Methods

This retrospective case-control study included 611 preterm infants with birth weight (BW)<1500 grams admitted to the Department of Neonatology, Obstetrics and Gynecology Hospital of Affiliated to Nanjing Medical University between January 2019 and December 2022. The incidence and risk factors for any stage and severe ROP were analyzed.

Results

Within 611 infants, 245(40.1%) developed ROP; 160(26.2%) infants were stage 1, 54(8.8%) were stage 2, and 31(5.1%) were stage 3, no stage 4 and 5. Among them, 22(3.6%) infants needed treatment. Multivariate analysis showed a higher gestational age (GA) was protective, whereas twin birth and moderate-to-severe BPD increased the hazard of any stage ROP; higher BW and male gender were significant risk factors for severe ROP.

Conclusion

Compared to other tertiary hospitals, the incidence of any stage ROP in our NICU was higher, but the rate of ROP needed treatment was lower. A higher GA was protective, whereas twin birth and moderate-to-severe BPD increased the hazard of any stage ROP; higher BW was protective, whereas male gender were risk factors for the development of severe ROP.

A Prospective Analysis of the Retinopathy of Prematurity Correlated with the Inflammatory Status of the Extremely Premature and Very Premature Neonates

Retinopathy of Prematurity (ROP) is a major cause of blindness in premature infants. This study aimed to evaluate the association between inflammatory markers and ROP development in extremely premature and very premature neonates and identify potential inflammatory biomarkers for ROP risk prediction. This prospective study was conducted from January 2021 to January 2023 in two clinical hospitals associated with the "Victor Babes" University of Medicine and Pharmacy Timisoara. The study population comprised neonates with a gestational age of less than 32 weeks. Various inflammatory markers, including total white blood cell count, polymorphonuclear leukocytes, C-reactive protein, interleukin-6, and lactate dehydrogenase, were analyzed from blood samples collected at birth and three days postnatally. ROP was diagnosed and classified following the International Classification of Retinopathy of Prematurity. The study included 48 neonates, 12 Extremely Premature Infants (EPI), and 36 Very Premature Infants (VPI). The EPI group had significantly higher mean interleukin-6 and lactate dehydrogenase levels at birth and three days postnatally than the VPI group. C-reactive protein levels at three days were significantly higher in the VPI group. Umbilical cord inflammation and ROP severity were found to have a statistically significant positive correlation. Half of the EPIs had moderate to severe ROP, significantly more than in the VPI group. The duration of oxygen supplementation, mechanical ventilation, Continuous Positive Airway Pressure (CPAP), gestational age less than 28 weeks, and umbilical cord inflammation at or above stage 3 were significant risk factors for developing ROP stage 2 or above. Elevated CRP and IL-6 were also significantly associated with an increased risk of developing ROP stage 2 or above, highlighting their potential as biomarkers for ROP risk prediction. This study suggests a significant association between inflammatory markers and ROP development in extremely premature and very premature neonates. These findings could contribute to the identification of potential inflammatory biomarkers for ROP risk prediction, improving early diagnosis and intervention strategies for this condition.

Retinopathy of prematurity: risk stratification by gestational age

OBJECTIVE

To identify gestational age (GA) specific risk factors for severe ROP (sROP).

STUDY DESIGN

Single-center cohort stratified by GA into <24 weeks, 24-26 weeks and ≥27 weeks.

RESULTS

132/1106 (11.9%) developed sROP. Time to full feeds was the only risk factor [HR 1.003 (1.001-1.006), p = 0.04] for infants<24 weeks GA. For infants 24-26 weeks GA, a higher GA was protective [HR 0.66 (0.51-0.85), p < 0.01], whereas steroids for bronchopulmonary dysplasia (BPD) [HR 2.21 (1.28-3.26), p < 0.01], patent ductus arteriosus (PDA) ligation [HR 1.99 (1.25-3.11), p < 0.01] and use of nitric oxide [HR 1.96 (1.11-3.30), p = 0.01] increased the hazard of sROP. Increasing birthweight was protective [HR 0.70 (0.54-0.89), p < 0.01] in infants ≥27 weeks GA. Cumulative hazard of sROP reached 1.0 by fifteen weeks for <24 weeks GA, 0.4 by twenty weeks for 24-26 weeks GA, and 0.05 by twenty weeks after birth for ≥27 weeks GA.

CONCLUSIONS

Risk factors, cumulative hazard, and time to sROP vary by GA.

The effect of sex on retinopathy of prematurity severity among premature mixed-sex multiple gestation infants

This retrospective study of 68 premature infants examined whether there was a difference between male and female mixed-sex multiple gestation infants with regard to stage of retinopathy of prematurity (ROP) developed or need for ROP treatment. We found that among mixed-sex twin infants there was no statistically significant difference between sexes in most severe ROP stage developed or need for ROP treatment, but males were treated at an earlier postmenstrual age (PMA) than females, despite females having a lower mean birthweight and slower mean growth velocity compared to males.

Intraocular pressure effect of intravitreal conbercept injection for retinopathy of prematurity

Purpose: Intravitreal injection of conbercept (IVC) is a novel anti-vascular endothelial growth factor (anti-VEGF) treatment for retinopathy of prematurity (ROP). This study aimed to assess the intraocular pressure (IOP) effect of IVC. Methods: All IVC surgeries were performed in the Department of Ophthalmology, Guangdong Women and Children Hospital, from January 2021 to May 2021. In this study, 30 eyes of 15 infants who received intravitreal injections of conbercept at a dose of 0.25 mg/0.025 mL were included. The IOP of all participants was measured prior to administering the injection and subsequently at 2 min, 1 h, 1 day, and 1 week thereafter. Results: We included 30 eyes (10 boys and 5 girls) with ROP. For the male group, the mean birth weight, mean gestational age at birth, and the mean time of postmenstrual age (PMA) at IVC treatment were 1,174.0 ± 446.0 g, 28.4 ± 3.0 weeks, and 37.1 ± 1.6 weeks, respectively; for the female group, they were 1,108 ± 285.5 g, 28.2 ± 2.5 weeks, and 36.8 ± 2.1 weeks, respectively. For the male group, the IOP at baseline, 2 min, 1 h, 1 day, and 1 week after IVC were 12.4 ± 1.5 mmHg, 49.0 ± 3.1 mmHg, 26.3 ± 2.5 mmHg, 13.4 ± 2.2 mmHg, and 11.6 ± 1.7 mmHg, respectively; for the female group, they were 10.7 ± 2.0 mmHg, 47.3 ± 3.2 mmHg, 26.4 ± 3.2 mmHg, 10.7 ± 1.8 mmHg, and 10.2 ± 1.8 mmHg, respectively. In both groups, the IOP immediately (2 min) after the operation was significantly higher than that at any other time point (p < 0.01). IOP values returned to the preoperative baseline level on the first day after surgery, with no significant difference compared with that before injection (p > 0.05). IOP continued to be maintained at the preoperative baseline level on the first week after surgery, with no significant difference compared with that before surgery (p > 0.05). Conclusion: Infants with ROP who received IVC experienced a sharp increase in the IOP immediately after injection, which decreased to below 30 mmHg after 1 h and maintain that level for 1 week or longer.

Modifiable Risk Factors and Preventative Strategies for Severe Retinopathy of Prematurity

Severe ROP is characterized by the development of retinal fibrovascular proliferation that may progress to retinal detachment. The purpose of this report is to review five of the most common and well-studied perinatal and neonatal modifiable risk factors for the development of severe ROP. Hyperoxemia, hypoxia, and associated prolonged respiratory support are linked to the development of severe ROP. While there is a well-established association between clinical maternal chorioamnionitis and severe ROP, there is greater variability between histologic chorioamnionitis and severe ROP. Neonatal sepsis, including both bacterial and fungal subtypes, are independent predictors of severe ROP in preterm infants. Although there is limited evidence related to platelet transfusions, the risk of severe ROP increases with the number and volume of red blood cell transfusions. Poor postnatal weight gain within the first six weeks of life is also strongly tied to the development of severe ROP. We also discuss preventative strategies that may reduce the risk of severe ROP. Limited evidence-based studies exist regarding the protective effects of caffeine, human milk, and vitamins A and E.

PRENATAL MATERNAL CHARACTERISTICS ASSOCIATED WITH RETINOPATHY OF PREMATURITY

PURPOSE

Determine whether prenatal maternal characteristics such as sociodemographic characteristics, comorbidities, or pregnancy complications affect retinopathy of prematurity (ROP) development.

METHODS

Medical records of 236 mother-infant dyads from our institution were reviewed, only including dyads in which infants were born at 30 weeks gestational age or earlier. The primary outcome measure was the risk of ROP (defined Stage 1 or greater in either eye) and its association with prenatal maternal variables.

RESULTS

Maternal Medicaid insurance, smoking during pregnancy, and chorioamnionitis were associated with an increased risk of ROP. For Medicaid insurance and chorioamnionitis, these risks were not appreciably altered by adjustment for potential confounders.

CONCLUSION

These results suggest that several prenatal maternal factors may independently affect the risk of ROP in preterm infants. Validation of our findings could aid in the identification of infants at high risk for ROP based on prenatal clinical features.

Impact of Early Hemoglobin Levels on Neurodevelopment Outcomes of Two-Year-Olds in Very Preterm Children

OBJECTIVE

To evaluate, in very preterm infants, the hemoglobin (Hb) levels during the first 24 h and the neurodevelopment outcomes at 24 months of corrected age.

DESIGN, SETTING, AND PATIENTS

We conducted a secondary analysis of the French national prospective and population-based cohort EPIPAGE-2. The eligible study participants were live-born singletons who were born before 32 weeks of gestational age, with early Hb levels who were admitted to the neonatal intensive care unit.

MAIN OUTCOME MEASURES

The early Hb levels for an outcome survival at 24 months of corrected age without neurodevelopmental impairment were measured. The secondary outcomes were survival at discharge and without severe neonatal morbidity.

RESULTS

Of the 2158 singletons of <32 weeks with mean early Hb levels of 15.4 (±2.4) g/dL, 1490 of the infants (69%) had a follow-up at two years of age. An early Hb of 15.2 g/dL is the minimum receiving operating characteristic curve at the 24 months risk-free level, but the area under the curve at 0.54 (close to 50%) indicates that this rate was not informative. In logistic regression, no association was found between early Hb levels and outcomes at two years of age (aOR 0.966; 95% CI [0.775-1.204]; p = 0.758) but rather there was a correlation found with severe morbidity (aOR 1.322; 95% CI [1.003-1.743]; p = 0.048). A risk stratification tree showed that male newborns of >26 weeks with Hb of <15.5 g/dL (n = 703) were associated with a poor outcome at 24 months (OR 1.9; CI: [1.5-2.4] p < 0.01).

CONCLUSIONS

Early low Hb levels are associated with major neonatal morbidities in VP singletons, but not with neurodevelopment outcomes at two years of age, except in male infants of >26 Weeks GA.

Preterm Assessment at Birth and Its Association With the Development of Retinopathy of Prematurity (ROP): A Tertiary Care Center Experience

BACKGROUND

Prematurity is a leading cause of neonatal morbidity and mortality and is associated with insufficient development of multiple body structures, including neurovascular and retinal tissues. Retinopathy of prematurity (ROP) is an abnormal vaso proliferation of the neonatal retina that results from an arrest in the normal development of the retinal nerve and blood supply. Incidence has been increasing due to advancements in intensive care and survival of preterm neonates, as well as improvements in screening methods for ROP.

OBJECTIVES

The objective is to assess the initial clinical and laboratory characteristics of preterm infants at the time of birth to identify population-specific risk factors for the development of ROP in a tertiary care center in western Saudi Arabia.

METHODS AND MATERIALS

This was a retrospective record review conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. The study included 37 patients diagnosed with ROP. Their ROP staging, complete blood count, appearance, pulse, grimace, activity and respiration (APGAR) score, and birth characteristics were all analyzed.

RESULTS

Thirty-seven neonates diagnosed with ROP and who met the study inclusion criteria were included. our results showed a female predominance of 51.4%, the mean age of the pregnancy was 27.18 ± 2.29 weeks, the mean birth weight was 0.8 ± 0.26, and 66.7% of our sample was delivered by the cesarean section. A significant association was found between the birth weight and the development of ROP in the right eye (p = 0.026); another significance was found between gestational age and the development of ROP in the same eye (p = 0.016).

CONCLUSIONS

A low birth weight and gestational age show a significant association with the development of ROP. Early identification and treatment of ROP are important to preserve a neonate's eyesight.

Practice Patterns and Outcomes of Intravitreal Anti-VEGF Injection for Retinopathy of Prematurity: An International Multicenter Study

PURPOSE

To report practice patterns of intravitreal injections of anti-VEGF for retinopathy of prematurity (ROP) and outcomes data with a focus on retreatments and complications.

DESIGN

Multicenter, international, retrospective, consecutive series.

SUBJECTS

Patients with ROP treated with anti-VEGF injections from 2007 to 2021.

METHODS

Twenfty-three sites (16 United States [US] and 7 non-US) participated. Data collected included demographics, birth characteristics, examination findings, and methods of injections. Comparisons between US and non-US sites were made.

MAIN OUTCOME MEASURES

Primary outcomes included number and types of retreatments as well as complications. Secondary outcomes included specifics of the injection protocols, including types of medication, doses, distance from limbus, use of antibiotics, and quadrants where injections were delivered.

RESULTS

A total of 1677 eyes of 918 patients (43% female, 57% male) were included. Mean gestational age was 25.7 weeks (range, 21.2-41.5 weeks), and mean birth weight was 787 g (range, 300-2700 g). Overall, a 30-gauge needle was most commonly used (51%), and the quadrant injected was most frequently the inferior-temporal (51.3%). The distance from the limbus ranged from 0.75 to 2 mm, with 1 mm being the most common (65%). Bevacizumab was the most common anti-VEGF (71.4%), with a dose of 0.625 mg in 64% of cases. Overall, 604 (36%) eyes required retreatment. Of those, 79.8% were retreated with laser alone, 10.6% with anti-VEGF injection alone, and 9.6% with combined laser and injection. Complications after anti-VEGF injections occurred in 15 (0.9%) eyes, and no cases of endophthalmitis were reported. Patients in the United States had lower birth weights and gestational ages (665.6 g and 24.5 weeks, respectively) compared with non-US patients (912.7 g and 26.9 weeks, respectively) (P < 0.0001). Retreatment with reinjection and laser was significantly more common in the US compared with the non-US group (8.5% vs. 4.7% [P = 0.0016] and 55% vs. 7.2% [P < 0.001], respectively). There was no difference in the incidence of complications between the 2 geographic subgroups.

CONCLUSIONS

Anti-VEGF injections for ROP were safe and well tolerated despite a variance in practice patterns. Infants with ROP receiving injections in the US tended to be younger and smaller, and they were treated earlier with more retreatments than non-US neonates with ROP.

[Risk factors for recurrence after intravitreal anti-vascular endothelial growth factor injection for retinopathy of prematurity]

OBJECTIVES

To investigate the efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection in the treatment of retinopathy of prematurity (ROP) and the risk factors for recurrence.

METHODS

A retrospective analysis was performed on the medical data of 159 infants with ROP who were born in the First Affiliated Hospital of Zhengzhou University and underwent anti-VEGF treatment from January 2016 to December 2021. According to the presence or absence of recurrence within the follow-up period after initial anti-VEGF treatment, they were divided into a recurrence group with 24 infants and a non-recurrence group with 135 infants. The medical data were compared between the two groups, and a multivariate logistic regression analysis was used to investigate the risk factors for the recurrence of ROP after anti-VEGF treatment.

RESULTS

After one-time anti-VEGF treatment, all 159 infants showed regression of plus disease. Recurrence was observed in 24 infants (15.1%) after anti-VEGF treatment, with a mean interval of (8.4±2.6) weeks from treatment to recurrence. The multivariate logistic regression analysis showed that preoperative fundus hemorrhage and prolonged total oxygen supply time were risk factors for the recurrence of ROP (P<0.05), while gestational hypertension was a protective factor (P<0.05).

CONCLUSIONS

Intravitreal anti-VEGF injection is effective for ROP. Preoperative fundus hemorrhage and long duration of oxygen therapy may increase the risk of ROP recurrence, and further studies are needed to investigate the influence of gestational hypertension on the recurrence of ROP.

Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making

This article presents current literature and scientific evidence on hemoglobin thresholds and physiologic parameters to guide decisions regarding perioperative erythrocyte transfusions in pediatric patients based on the most up-to-date studies and expert consensus recommendations.

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Every treasured drop! Blood transfusion requirements in very preterm neonates after implementation of blood conservation strategies: an observational analytical study

BACKGROUND

Certain morbidities are inevitable in preterm infants; the challenge lies in minimizing them. Anemia of prematurity is multifactorial. Therapy largely depends on adult red blood cell transfusions (RBCT); which inherently, are not without problems. Most literature in this respect are retrospective or evaluate individual stratagems to reduce RBCT.

METHODS

This observational analytical study was planned to compare need for RBCT, before and after institution of blood conservation strategies (BCS). All those ≤30 weeks gestation at birth during two-time epochs were included (Before BCS: retrospective; After BCS: prospective). BCS constituted of delayed cord clamping (DCC), strict sampling indications, micro-sampling with point-of-care testing (MS-POCT) and adherence to RBCT thresholds.

RESULTS

Of 45 enrolled neonates in each group, proportion of those requiring even 1 RBCT was significantly reduced after BCS [51.1% vs. 26.7%, p = 0.02, OR 0.35, 95%CI (0.14, 0.84)]. Calculated cumulative blood volume losses (35.3 ml vs. 21.9 ml) and loss per kilogram birth weight (35.3 ml/kg vs. 20.12 ml/kg) were significantly lower after BCS (p = 0.0036). Need for &gt;1 RBCT, mean lowest Hb, mean maximum-hemoglobin drop, need for arterial lines were reduced. Adherence to RBCT thresholds were acceptably good in both time epochs. However, the compliance to DCC was low in both groups, identifying one area of focus with scope for massive improvement.

CONCLUSIONS

Need for RBCT transfusions largely attributable to reduced blood losses for lab analysis were reduced after BCS. Installation of in-house MS-POCT seemed to be the pivotal factor. Units that care for very preterm infants must make attempts to procure MS-POCT equipment.

Screening and Risk Factors for Retinopathy of Prematurity in a Tertiary Care Hospital in Cairo, Egypt

Purpose

To evaluate the retinopathy of prematurity (ROP) prevalence, risk factors and screening outcome in a tertiary hospital in Cairo, Egypt.

Methods

A prospective observational study was done in Neonatal Intensive Care Unit in Ain Shams University Hospital. A total of 159 premature infants were screened for ROP based on the most inclusive criteria reported to date. Screening included premature infants with gestational age (GA) of ≤34 weeks or birth weight (BW) of ≤2000 grams, or GA >34 weeks or BW >2000 grams, with multiple co-morbidities. The prevalence of ROP, plus disease and their correlation with risk factors of interest were studied.

Results

The GA of the included infants ranged from 27 to 36 weeks, mean (SD) 31.87 (± 1.81) weeks. The BW ranged from 640 to 3900 grams, mean (SD) 1784.71 (± 560.30) grams. The prevalence of ROP more than stage 0 was 25.8% (41 infants), 7.3% of the cases (11 infants) showed plus disease and 6.3% (10 infants) showed severe ROP requiring treatment. Of those, 2 cases (20%) fell outside the British Guideline's criteria for Screening. There was a highly significant (p < 0.0001) correlation between ROP more than stage 0 and low GA, low BW, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular haemorrhage, and blood transfusion. No significant correlation was found between appearance of ROP more than stage 0 and gender (p = 0.911), patent ductus arteriosus (p =0.187), or sepsis (p =0.998).

Conclusion

ROP is a significant problem in the premature infants in Egypt. Extremely premature infants with lower BW are more prone to develop ROP. However, cases with higher GA and BW than mentioned in the British guidelines screening criteria especially with multiple comorbidities showed severe ROP requiring intervention, which implies the need to develop a screening guideline for the Egyptian population.

Retinopathy of Prematurity: A Global Perspective and Recent Developments

Retinopathy of prematurity (ROP) is a significant cause of potentially preventable blindness in preterm infants worldwide. It is a disease caused by abnormal retinal vascularization that, if not detected and treated in a timely manner, can lead to retinal detachment and severe long term vision impairment. Neonatologists and pediatricians have an important role in the prevention, detection, and management of ROP. Geographic differences in the epidemiology of ROP have been seen globally over the last several decades because of regional differences in neonatal care. Our understanding of the pathophysiology, risk factors, prevention, screening, diagnosis, and treatment of ROP have also evolved over the years. New technological advances are now allowing for the incorporation of telemedicine and artificial intelligence in the management of ROP. In this comprehensive update, we provide a comprehensive review of pathophysiology, classification, diagnosis, global screening, and treatment of ROP. Key historical milestones as well as touching upon the very recent updates to the ROP classification system and technological advances in the field of artificial intelligence and ROP will also be discussed.

Long use of continuous positive airway pressure protects against the development of treatment-requiring retinopathy of prematurity

Although preterm infant mortality is low, the proportion of patients with treatment-requiring retinopathy of prematurity (TR-ROP) is high in Japan. Various multicenter studies have reported the risk factors for TR-ROP; however, no large-scale studies have been conducted in Japan. We retrospectively analyzed 13,645 infants born at < 28 weeks’ gestation (January 1, 2009–December 31, 2018), and registered in the Neonatal Research Network of Japan database. TR-ROP was defined as ROP requiring retinal laser photocoagulation and/or intravitreal anti-vasoendothelial growth factor drugs. Multivariable logistic regression analysis was performed to identify factors associated with TR-ROP development. The median gestational age of enrolled infants was 26 weeks (interquartile range [IQR], 24–27 weeks), median birth weight was 760 g (IQR, 620–918 g). Proportion of patients with TR-ROP was 30.3%. TR-ROP was significantly associated with birth at < 26 weeks’ gestational age (adjusted odds ratio [aOR] 1.54), blood transfusion (aOR 1.49), invasive ventilation ≥ 28 days (aOR 1.41), sepsis (aOR 1.29), birth weight < 750 g (aOR 1.28), intraventricular hemorrhage (aOR 1.33), delayed achievement of full enteral feeding > 14 days (aOR 1.28), and continuous positive airway pressure (CPAP) therapy ≥ 28 days (aOR 0.79). Supplemental oxygen ≥ 28 days was not associated with TR-ROP development. Lower gestational age at birth and birth weight, blood transfusion, prolonged invasive ventilation, sepsis, intraventricular hemorrhage, and delayed achievement of full enteral feeding were risk factors for TR-ROP, whereas CPAP use was protective against TR-ROP.

Retinopathy of prematurity: contribution of inflammatory and genetic factors

Retinopathy of prematurity (ROP) is a retinal vasoproliferative disorder that represents an important cause of childhood visual impairment and blindness. Although oxidative stress has long been implicated in ROP etiology, other prenatal and perinatal factors are also involved. This review focuses on current research involving inflammation and genetic factors in the pathogenesis of ROP. Increasing evidence suggests that perinatal inflammation or infection contributes to ROP pathogenesis. Cytokines and chemokines with a fundamental role in inflammatory responses and that significantly contributing to angiogenesis are analyzed. Microglia cells, the retinal-resident macrophages, are crucial for retinal homeostasis, however, under sustained pathological stimuli release exaggerated amounts of inflammatory mediators and can promote pathological neovascularization. Current modulation of angiogenic cytokines, such as treatment with antibodies to vascular endothelial growth factor (anti-VEGF), has shown efficacy in the treatment of ocular neovascularization; however, some patients are refractory to anti-VEGF agents, suggesting that other angiogenic or anti-angiogenic cytokines need to be identified. Much evidence suggests that genetic factors contribute to the phenotypic variability of ROP. Several studies have implicated the involvement of candidate genes from different signaling pathways in the development of ROP. However, a genetic component with a major impact on ROP has not yet been discovered. Most studies have limitations and did not replicate results. Future research involving bioinformatics, genomics, and proteomics may contribute to finding more genes associated with ROP and may allow discovering better solutions in the management and treatment of ROP.

Risk of Retinopathy of Prematurity in Preterm Births with Respiratory Distress Syndrome: A Population-Based Cohort Study in Taiwan

Background

Methods

Results

Conclusion

Quantification of Early Neonatal Oxygen Exposure as a Risk Factor for Retinopathy of Prematurity Requiring Treatment

Purpose

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness related to oxygen exposure in premature infants. Since oxygen monitoring protocols have reduced the incidence of treatment-requiring ROP (TR-ROP), it remains unclear whether oxygen exposure remains a relevant risk factor for incident TR-ROP and aggressive ROP (A-ROP), a severe, rapidly progressing form of ROP. The purpose of this proof-of-concept study was to use electronic health record (EHR) data to evaluate early oxygen exposure as a predictive variable for developing TR-ROP and A-ROP.

Design

Retrospective cohort study.

Participants

Two hundred forty-four infants screened for ROP at a single academic center.

Methods

For each infant, oxygen saturations and fraction of inspired oxygen (FiO₂) were extracted manually from the EHR until 31 weeks postmenstrual age (PMA). Cumulative minimum, maximum, and mean oxygen saturation and FiO₂ were calculated on a weekly basis. Random forest models were trained with 5-fold cross-validation using gestational age (GA) and cumulative minimum FiO₂ at 30 weeks PMA to identify infants who developed TR-ROP. Secondary receiver operating characteristic (ROC) curve analysis of infants with or without A-ROP was performed without cross-validation because of small numbers.

Main Outcome Measures

For each model, cross-validation performance for incident TR-ROP was assessed using area under the ROC curve (AUC) and area under the precision-recall curve (AUPRC) scores. For A-ROP, we calculated AUC and evaluated sensitivity and specificity at a high-sensitivity operating point.

Results

Of the 244 infants included, 33 developed TR-ROP, of which 5 developed A-ROP. For incident TR-ROP, random forest models trained on GA plus cumulative minimum FiO₂ (AUC = 0.93 ± 0.06; AUPRC = 0.76 ± 0.08) were not significantly better than models trained on GA alone (AUC = 0.92 ± 0.06 [P = 0.59]; AUPRC = 0.74 ± 0.12 [P = 0.32]). Models using oxygen alone showed an AUC of 0.80 ± 0.09. ROC analysis for A-ROP found an AUC of 0.92 (95% confidence interval, 0.87–0.96).

Conclusions

Oxygen exposure can be extracted from the EHR and quantified as a risk factor for incident TR-ROP and A-ROP. Extracting quantifiable clinical features from the EHR may be useful for building risk models for multiple diseases and evaluating the complex relationships among oxygen exposure, ROP, and other sequelae of prematurity.

Impact of early postnatal exposure of red blood cell transfusions on the severity of retinopathy of prematurity

BACKGROUND

Postnatal exposure to red blood cell transfusion (RBCT) in premature infants is an important risk factor for Retinopathy of Prematurity (ROP) progression. We hypothesized that higher number and earlier timing of RBCT are associated with worse ROP severity and result in laser treatment at an earlier postmenstrual age (PMA) in very low birth weight (≤1500 g, VLBW) infants.

METHODS

A retrospective medical record review of 631 VLBW infants over a 5-year period was performed. Demographic features and potential clinical risk factors including number of RBCT, ROP severity, and progression to laser treatment were collected to evaluate predictors of severe ROP. ANCOVA, pairwise post-hoc analyses, and multivariate regression were used to determine associations between frequency and timing of RBCT and ROP severity.

RESULTS

Of the 456 eligible infants, 61 developed severe ROP (13%). There was significant correlation between number of RBCTs and ROP severity, adjusted for gestational age and birthweight (Adjusted R2 = 0.53; p <  0.001). Compared to infants with No/Mild and Type 2 ROP, infants with Type 1 ROP received more RBCTs, with higher number of RBCTs per week during the first month of life (mean RBCT in ROP No/Mild 5.7±0.4 vs Type 2 16.3±1.8 vs Type 1 22.4±1.5, p = 0.042). Laser-treated infants received a higher number of RBCTs than non-treated infants (mean RBCT 22.3 vs. 6.5, p <  0.001) but no correlation was observed between number of RBCTs and PMA at time of laser treatment.

CONCLUSION

Higher number of RBCTs in early postnatal life of VLBW infants was associated with more severe ROP.

Noninvasive ventilation for respiratory distress syndrome is a potential risk factor for retinopathy of prematurity : Single Slovenian tertiary center study

Retinopathy of prematurity (nROP) among extremely low gestational age newborns (ELGAN) in Slovenia has increased in recent years. At the same time mortality has further decreased and less invasive approaches for treatment of respiratory distress syndrome have been established. With the aim to study the possible association between the incidence of ROP and the duration of noninvasive ventilation, this retrospective study comprised ELGANs born during the first period (2010/2011), when invasive respiratory support was the prevalent method and in the second period (2015/2016), when noninvasive respiratory support was adopted. The results showed that the duration of noninvasive ventilation is a potential risk factor for ROP. Controlling for known risk factors for ROP and then adjusting for gestational age, number of transfusions and fraction of inspired oxygen (FiO₂), the odds of ROP were 1.22 times greater (95% confidence interval, CI 1.01-1.48) with every additional week of noninvasive ventilation (p = 0.03).

Risk Factors Associated with Retinopathy of Prematurity in Very and Extremely Preterm Infants

Background and Objectives: Retinopathy of prematurity (ROP) is the leading cause of blindness in preterm infants. We studied the relationship between different perinatal characteristics, i.e., sex; gestational age (GA); birth weight (BW); C-reactive protein (CRP) and lactate dehydrogenase (LDH) concentrations; ventilation, continuous positive airway pressure (CPAP), and surfactant administration; and the incidence of Stage 1–3 ROP. Materials and Methods: This study included 247 preterm infants with gestational age (GA) < 32 weeks that were successfully screened for ROP. Univariate and multivariate binary analyses were performed to find the most significant risk factors for ROP (Stage 1–3), while multivariate multinomial analysis was used to find the most significant risk factors for specific ROP stages, i.e., Stage 1, 2, and 3. Results: The incidence of ROP (Stage 1–3) was 66.40% (164 infants), while that of Stage 1, 2, and 3 ROP was 15.38% (38 infants), 27.53% (68 infants), and 23.48% (58 infants), respectively. Following univariate analysis, multiple perinatal characteristics, i.e., GA; BW; and ventilation, CPAP, and surfactant administration, were found to be statistically significant risk factors for ROP (p < 0.001). However, in a multivariate model using the same characteristics, only BW and ventilation were significant ROP predictors (p < 0.001 and p < 0.05, respectively). Multivariate multinomial analysis revealed that BW was only significantly correlated with Stage 2 and 3 ROP (p < 0.05 and p < 0.001, respectively), while ventilation was only significantly correlated with Stage 2 ROP (p < 0.05). Conclusions: The results indicate that GA; BW; and the use of ventilation, CPAP, and surfactant were all significant risk factors for ROP (Stage 1–3), but only BW and ventilation were significantly correlated with ROP and specific stages of the disease, namely Stage 2 and 3 ROP and Stage 2 ROP, respectively, in multivariate models.

Incidence and risk factors of retinopathy of prematurity in an Italian cohort of preterm infants

OBJECTIVE

Non-negligible differences in retinopathy of prematurity (ROP) and its risk factors between different neonatal intensive care units (NICUs) are reported. Our aim was to assess the incidence and risk factors for ROP development in a large cohort of very preterm infants who were assisted in two Italian NICUs.

METHODS

Preterm infants with gestational age between 23+ 0 and 29+ 6 weeks were stratified into subgroups of infants who developed ROP and those who did not; their clinical characteristics were compared with univariate and multivariable logistic regression analyses.

RESULTS

We studied a total of 178 infants of whom 67 (38%) developed ROP (stage 1: n = 12; stage 2: n = 41; stage 3: n = 14). Regression analysis demonstrated that maternal milk (OR 0.979, 95% Cl 0.961-0.998) decreased the risk of developing ROP, while intraventricular hemorrhage (IVH) (OR 2.055, 95% Cl 1.120-3.772) increased it. Moreover, maternal milk was found to decrease (OR 0.981, 95% Cl 0.964-0.997) the risk of ROP at discharge, while RBC transfusion increased it (OR 1.522, 95% Cl 1.208-1.916).

CONCLUSIONS

In our cohort the occurrence of ROP was similar to that previously reported. Strategies for promoting the use of mother's own milk, preventing IVH, and standardizing the approach to RBC transfusions could contribute to decreasing the risk of ROP in very preterm infants.

Incidence, Risk Factors and Screening Evaluation of Retinopathy of Prematurity in High Birthweight Infants: A Large Cohort Study in Turkey

Purpose: To report and evaluate the incidence and risk factors of retinopathy of prematurity (ROP) and to assess the sensitivity and specificity of Turkish national screening guideline (NSG) in heavier infants with a birth weight (BW) of >1500 g.Methods: The data of 1784 preterm infants with BW>1500 g, who were screened between 2009 and 2016 in a university hospital in Turkey, were analyzed retrospectively. The rates of any stage and severe (treatment-requiring) ROP incidence were investigated. The possible protective and risk factors were evaluated with univariate analyses and logistic regression analysis.Results: The rate of any stage ROP was 14.1% (n = 251). Severe ROP was observed in 11 infants (0.6%), and 2 of the infants (0.1%) had a gestational age (GA)>32 weeks, which fell outside of the NSG. In logistic regression analysis, BW, GA, O₂ therapy duration, and exchange transfusion were determined to be independent risk factors (respectively, p < .001, p < .001, P = .055, and P = .033). Furthermore, antenatal steroid therapy was determined to have a highly significant protective effect on ROP development (p < .001). The sensitivity of Turkish NSG in identifying severe ROP increased from 82% to 100% with the inclusion of risk factors in addition to GA and BW.Conclusion: This study shows the presence of severe ROP in mature and heavy infants in Turkey. The positive effect of antenatal steroid use and the negative impact of exchange transfusion have been demonstrated for ROP development in mature infants. Possible risk factors should be evaluated with GA and BW to avoid missing severe ROP.

Short-term outcomes of Jewish and Arab preterms: a population-based comparison

OBJECTIVE

To compare short-term outcomes of Arabs versus Jewish infants in Israel.

METHODS

We used the Israel national VLBW infant database to compare adjusted mortality and major morbidities rates of Arabs versus Jewish infants delivered between January 1995 and December 2016. Multivariable logistic regression analyses were performed to study the association of ethnicity with the odds for mortality and neonatal morbidities.

RESULTS

The study population comprised 22431 VLBW, very preterm (<32 weeks gestation) infants (27.7% Arabs and 72.3% Jewish) without congenital malformations. The Arab infants had significantly higher odds ratios for mortality, and most neonatal morbidities. Despite the significant decline in mortality over time in both ethnic groups, the difference in mortality rates remained unchanged over time.

CONCLUSIONS

We found significant ethic disparity that remained unchanged over time. Some of the disparities identified in this study may be amenable to improvement through proper policies and education.

Retinopathy of Prematurity and Assisted Reproductive Technology: Is There an Association?

Purpose

This study aimed to determine the incidence of retinopathy of prematurity (ROP) and to assess whether assisted reproductive technology (ART) is a risk factor for ROP independent of the generation of multiple births by determining the occurrence and severity of ROP and the need for treatment. We will also evaluate other risk factors associated with the development of ROP among preterm infants.

Patients and Methods

We conducted a retrospective chart review for all premature infants who were screened for ROP according to the screening guidelines of the American Academy of Ophthalmology and born at King Abdulaziz University Hospital from 2015 to 2019. In addition to ophthalmological results, data on gestational age (GA), birth weight (BW), type of pregnancy (singleton or multiple), type of conception (natural or ART), infantile factors, and maternal factors were recorded.

Results

A total of 229 preterm babies met our criteria. The mean GA at birth was 29.35 weeks. Notably, 175 neonates were conceived naturally and 54 were conceived by ART. Furthermore, 33 infants in the natural conception group were products of multiple pregnancies, as were 49 infants in the ART group. ROP was noted in 96 of 229 infants (41.92%). No significant difference was found in the occurrence of ROP between multiple neonates in the natural and ART groups. However, ART birth babies in general were significantly associated with the development of ROP (P=0.045). On multiple regression analysis, early GA, low BW, and extended oxygen therapy were the variables most significantly associated with ROP (P≤0.001).

Conclusion

In our sample, ART in multiple birth babies per se did not seem to be a risk factor for ROP. However, ART babies were more prone to develop ROP than natural conception birth babies, which seemed to be more severe.

A Good Way to Reduce Screening for Retinopathy of Prematurity: Development of the ROP Model in a China Preterm Population

Importance: Retinopathy of prematurity (ROP) is a preventable cause of blindness in children. Without treatment, more than 45% of eyes may suffer permanent vision loss. Current ROP screening guidelines, which include a range of birth weights (BWs) and gestational ages (GAs), may require screening many low-risk preemies who might develop severe ROP. Method: All high-risk infants in the neonatal intensive care unit (NICU) of the First Affiliated Hospital of Zhengzhou University from 2017 to 2021 were included in this retrospective cohort study. Each of the 27 candidate risk factors was evaluated in univariate analysis and adjusted for known risk factors (i.e., GA and BW). The significant results were analyzed in a backward selection multivariate logistic regression model. Receiver operating characteristic (ROC) curves and a nomogram were drawn. Results: The study included 2,040 infants who underwent ROP screening. The weight gain rate [OR, 2.65; 95% confidence interval (CI), 1.49-1.21 ≤ 12 g/d vs. > 18 g/d; P = 0.001], blood transfusion (OR, 2.03; 95% CI, 1.14-3.64; P = 0.017), invasive mechanical ventilation (OR, 1.74; 95% CI, 1.15-2.66; P = 0.009) and N-terminal segment of pro-B-type natriuretic peptide (NT-proBNP) ≥ 25,000 ng/L (OR, 1.51; 95% CI, 1.00-2.28; P = 0.048) were four new statistically independent risk factors in addition to GA and BW. The area under the curve (AUC) of the final multivariate model was 0.90 (95% CI, 0.88-0.92; P < 0.001). Conclusions and Relevance: These findings add to our understanding of ROP screening because they include all eligible infants rather than only high-risk infants, as in previous studies. Under the control of BW and GA, low weight gain rate, increased number of blood transfusion, invasive mechanical ventilation and NT-proBNP ≥ 25,000 ng/L were "new" statistically independent risk factors for ROP. The ROP risk can be calculated manually or represented by a nomogram for clinical use.

Risk Factors for Retinopathy of Prematurity in the Netherlands: A Comparison of Two Cohorts

INTRODUCTION

Retinopathy of prematurity (ROP) remains an important cause for preventable blindness. Aside from gestational age (GA) and birth weight, risk factor assessment can be important for determination of infants at risk of (severe) ROP.

METHODS

Prospective, multivariable risk-analysis study (NEDROP-2) was conducted, including all infants born in 2017 in the Netherlands considered eligible for ROP screening by pediatricians. Ophthalmologists provided data of screened infants, which were combined with risk factors from the national perinatal database (Perined). Clinical data and potential risk factors were compared to the first national ROP inventory (NEDROP-1, 2009). During the second period, more strict risk factor-based screening inclusion criteria were applied.

RESULTS

Of 1,287 eligible infants, 933 (72.5%) were screened for ROP and matched with the Perined data. Any ROP was found in 264 infants (28.3% of screened population, 2009: 21.9%) and severe ROP (sROP) (stage ≥3) in 41 infants (4.4%, 2009: 2.1%). The risk for any ROP is decreased with a higher GA (odds ratio [OR] 0.59 and 95% confidence interval [CI] 0.54-0.66) and increased for small for GA (SGA) (1.73, 1.11-2.62), mechanical ventilation >7 days (2.13, 1.35-3.37) and postnatal corticosteroids (2.57, 1.44-4.66). For sROP, significant factors were GA (OR 0.37 and CI 0.27-0.50), SGA (OR 5.65 and CI 2.17-14.92), postnatal corticosteroids (OR 3.81 and CI 1.72-8.40), and perforated necrotizing enterocolitis (OR 7.55 and CI 2.29-24.48).

CONCLUSION

In the Netherlands, sROP was diagnosed more frequently since 2009. No new risk factors for ROP were determined in the present study, apart from those already included in the current screening guideline.

Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants

BACKGROUND

Limited data suggest that higher hemoglobin thresholds for red-cell transfusions may reduce the risk of cognitive delay among extremely-low-birth-weight infants with anemia.

METHODS

We performed an open, multicenter trial in which infants with a birth weight of 1000 g or less and a gestational age between 22 weeks 0 days and 28 weeks 6 days were randomly assigned within 48 hours after delivery to receive red-cell transfusions at higher or lower hemoglobin thresholds until 36 weeks of postmenstrual age or discharge, whichever occurred first. The primary outcome was a composite of death or neurodevelopmental impairment (cognitive delay, cerebral palsy, or hearing or vision loss) at 22 to 26 months of age, corrected for prematurity.

RESULTS

A total of 1824 infants (mean birth weight, 756 g; mean gestational age, 25.9 weeks) underwent randomization. There was a between-group difference of 1.9 g per deciliter (19 g per liter) in the pretransfusion mean hemoglobin levels throughout the treatment period. Primary outcome data were available for 1692 infants (92.8%). Of 845 infants in the higher-threshold group, 423 (50.1%) died or survived with neurodevelopmental impairment, as compared with 422 of 847 infants (49.8%) in the lower-threshold group (relative risk adjusted for birth-weight stratum and center, 1.00; 95% confidence interval [CI], 0.92 to 1.10; P = 0.93). At 2 years, the higher- and lower-threshold groups had similar incidences of death (16.2% and 15.0%, respectively) and neurodevelopmental impairment (39.6% and 40.3%, respectively). At discharge from the hospital, the incidences of survival without severe complications were 28.5% and 30.9%, respectively. Serious adverse events occurred in 22.7% and 21.7%, respectively.

CONCLUSIONS

In extremely-low-birth-weight infants, a higher hemoglobin threshold for red-cell transfusion did not improve survival without neurodevelopmental impairment at 22 to 26 months of age, corrected for prematurity. (Funded by the National Heart, Lung, and Blood Institute and others; TOP ClinicalTrials.gov number, NCT01702805.).

Retinopathy of prematurity in infants without fetal growth restriction is decreased with the progression of acute histologic chorioamnionitis: New observation as a protective factor against retinopathy of prematurity

INTRODUCTION

IGF-1 deficiency in prenatal period is known to be a definite pathophysiology of retinopathy of prematurity(ROP), which is more frequent in infants with fetal growth restriction(FGR). Of note, recent reports demonstrated intra-amniotic inflammation(IAI) closely linked to acute histologic chorioamnionitis(acute-HCA) is associated with a decrease in intact-form of IGFBP-1, ultimately rising the probability of an increase in IGF-1. Therefore, we hypothesized ROP in preterm-infants without FGR would be decreased with the progression of acute-HCA.

METHODS

The frequency of ROP was examined in 85 singleton preterm-infants(24.5weeks ≤ gestational-age[GA] at delivery<30weeks) due to either preterm-labor and intact-membranes(PTL) or preterm premature rupture of membranes(preterm-PROM) without FGR(birth-weight<5th percentile for GA). Patients were divided according to the progression of inflammation in extra-placental membranes(EPM) and the progression of inflammation in chorionic-vessel(CV) and umbilical-cord(UC).

RESULTS

1) ROP was present in 40%(34/85) of study-population; 2) Of note, there was a significant stepwise-decrease in ROP with the progression of inflammation in EPM(inflammation-free EPM vs. inflammation restricted to CD vs. amnionitis; 55.6%[15/27]vs.39.5%[17/43]vs.13.3%[2/15]) and the progression of inflammation in CV and UC(inflammation-free CV and UC vs. inflammation restricted to CV and umbilical vessels vs. inflammation in Wharton's jelly[WJ]; 49.2%[29/59]vs.25.0%[3/12]vs.14.3%[2/14])(each-for P < 0.05, Chi-square test and each-for P < 0.01, linear-by-linear association); 3) Multiple logistic-regression analysis demonstrated amnionitis(Odds-Ratio 0.120, 95%Confidence-Interval 0.022-0.654, P = 0.014) and inflammation in WJ(Odds-Ratio 0.124, 95%Confidence-Interval 0.022-0.694, P = 0.018) were independent protective-factors against ROP.

DISCUSSION

ROP in preterm-infants due to PTL or preterm-PROM without FGR is decreased with the progression of acute-HCA. This finding may be an evidence to suggest the progression of acute-HCA is closely associated with reducing the pathophysiology of ROP.

The Serine Protease HTRA-1 Is a Biomarker for ROP and Mediates Retinal Neovascularization

Retinopathy of prematurity (ROP) is a blinding aberrancy of retinal vascular maturation in preterm infants. Despite delayed onset after preterm birth, representing a window for therapeutic intervention, we cannot prevent or cure ROP blindness. A natural form of ROP protection exists in the setting of early-onset maternal preeclampsia, though is not well characterized. As ischemia is a central feature in both ROP and preeclampsia, we hypothesized that angiogenesis mediators may underlie this protection. To test our hypothesis we analyzed peripheral blood expression of candidate proteins with suggested roles in preeclamptic and ROP pathophysiology and with a proposed angiogenesis function (HTRA-1, IGF-1, TGFβ-1, and VEGF-A). Analysis in a discovery cohort of 40 maternal-infant pairs found that elevated HTRA-1 (high-temperature requirement-A serine peptidase-1) was significantly associated with increased risk of ROP and the absence of preeclampsia, thus fitting a model of preeclampsia-mediated ROP protection. We validated these findings and further demonstrated a dose-response between systemic infant HTRA-1 expression and risk for ROP development in a larger and more diverse validation cohort consisting of preterm infants recruited from two institutions. Functional analysis in the oxygen-induced retinopathy (OIR) murine model of ROP supported our systemic human findings at the local tissue level, demonstrating that HtrA-1 expression is elevated in both the neurosensory retina and retinal pigment epithelium by RT-PCR in the ROP disease state. Finally, transgenic mice over-expressing HtrA-1 demonstrate greater ROP disease severity in this model. Thus, HTRA-1 may underlie ROP protection in preeclampsia and represent an avenue for disease prevention, which does not currently exist.

Inadequate laser coagulation is an important cause of treatment failure in Type 1 retinopathy of prematurity

PURPOSE OF THE STUDY

To examine the cause of treatment failures in Type 1 retinopathy of prematurity (ROP).

PATIENTS AND METHODS

The medical charts of all infants with disease persistence after laser treatment at Uppsala University Hospital, Sweden, during a 10-year period (2009-2019) were reviewed. RetCam photography and angiography were used to document the retinal appearance before and after retreatment.

RESULTS

Ten infants (18 eyes), of whom nine were referred from other hospitals, had persistence of Type 1 ROP in zone I or zone II despite previous laser treatment. Their mean gestational age was 24 weeks and their mean birth weight was 618 g. Seven eyes were diagnosed as stage 3 plus, eight eyes as stage 4A and three eyes as stage 4B. In eight infants (14 eyes), inadequate laser coagulation was suspected to be the cause for persistence of type 1 disease. Two infants (four eyes) were appreciated to have persistence of plus disease because of presence of zone I disease. For persistence of Type 1 ROP, five infants (seven eyes) were treated with vitrectomy, two infants (three eyes) with laser photocoagulation and anti-vascular endothelial growth factor (VEGF), two infants (four eyes) with anti-VEGF alone and finally two infants (four eyes) with laser photocoagulation alone. The anatomical outcome was good in 14 eyes and poor in four eyes (three infants).

CONCLUSIONS

Inadequate laser coagulation is an important cause of treatment failure of ROP Type 1. Another cause is laser coagulation in zone I. To minimize remaining visual disability, some kind of centralization of the ROP treatment is suggested.

Neonatal red blood cell transfusion

Transfusions are more common in premature infants with approximately 40% of low birth weight infants and up to 90% of extremely low birth weight infants requiring red blood cell transfusion. Although red blood cell transfusion can be life-saving in these preterm infants, it has been associated with higher rates of complications including necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity and possibly abnormal neurodevelopment. The main objective of this review is to assess current red blood cell transfusion practices in the neonatal intensive care unit, to summarize available neonatal transfusion guidelines published in different countries and to emphasize the wide variation in transfusion thresholds that exists for red blood cell transfusion. This review also addresses certain issues specific to red blood cell processing for the neonatal population including storage time, irradiation, cytomegalovirus (CMV) prevention strategies and patient blood management. Future research avenues are proposed to better define optimal transfusion practice in neonatal intensive care units.

Higher incidence of retinopathy of prematurity in extremely preterm infants associated with improved survival rates

AIM

This study assessed possible reasons for the increasing incidence of retinopathy of prematurity (ROP) since mid-2015 at our institution.

METHODS

Retrospective analysis of all preterm infants born July 2013 to June 2017 with a gestational age (GA) <29 completed weeks admitted to the neonatal intensive care unit at the University Hospital Zurich during the first 28 days of life. The primary outcome measures were severest ROP stage. Statistical analysis was performed using generalised additive models in R.

RESULTS

During the study period, survival increased in extremely preterm infants. Significant predictors for severest ROP stage were GA, days of mechanical ventilation and multiple gestation (P = .0322). A composite of severe comorbidities had no significant effect on severest ROP stage. GA was identified as the only significant risk factor the for severest ROP stage (P = .0045).

CONCLUSION

Increased survival rate of extremely preterm infants was associated with an increased incidence of ROP at our institution. Despite the increase, the incidence is still very low compared with other countries. No other additive factors were identified.

Effects of Liberal vs Restrictive Transfusion Thresholds on Survival and Neurocognitive Outcomes in Extremely Low-Birth-Weight Infants: The ETTNO Randomized Clinical Trial

IMPORTANCE

Red blood cell transfusions are commonly administered to infants weighing less than 1000 g at birth. Evidence-based transfusion thresholds have not been established. Previous studies have suggested higher rates of cognitive impairment with restrictive transfusion thresholds.

OBJECTIVE

To compare the effect of liberal vs restrictive red blood cell transfusion strategies on death or disability.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted in 36 level III/IV neonatal intensive care units in Europe among 1013 infants with birth weights of 400 g to 999 g at less than 72 hours after birth; enrollment took place between July 14, 2011, and November 14, 2014, and follow-up was completed by January 15, 2018.

INTERVENTIONS

Infants were randomly assigned to liberal (n = 492) or restrictive (n = 521) red blood cell transfusion thresholds based on infants' postnatal age and current health state.

MAIN OUTCOME AND MEASURES

The primary outcome, measured at 24 months of corrected age, was death or disability, defined as any of cognitive deficit, cerebral palsy, or severe visual or hearing impairment. Secondary outcome measures included individual components of the primary outcome, complications of prematurity, and growth.

RESULTS

Among 1013 patients randomized (median gestational age at birth, 26.3 [interquartile range {IQR}, 24.9-27.6] weeks; 509 [50.2%] females), 928 (91.6%) completed the trial. Among infants in the liberal vs restrictive transfusion thresholds groups, respectively, incidence of any transfusion was 400/492 (81.3%) vs 315/521 (60.5%); median volume transfused was 40 mL (IQR, 16-73 mL) vs 19 mL (IQR, 0-46 mL); and weekly mean hematocrit was 3 percentage points higher with liberal thresholds. Among infants in the liberal vs restrictive thresholds groups, the primary outcome occurred in 200/450 (44.4%) vs 205/478 (42.9%), respectively, for a difference of 1.6% (95% CI, -4.8% to 7.9%; P = .72). Death by 24 months occurred in 38/460 (8.3%) vs 44/491 (9.0%), for a difference of -0.7% (95% CI, -4.3% to 2.9%; P = .70), cognitive deficit was observed in 154/410 (37.6%) vs 148/430 (34.4%), for a difference of 3.2% (95% CI, -3.3% to 9.6%; P = .47), and cerebral palsy occurred in 18/419 (4.3%) vs 25/443 (5.6%), for a difference of -1.3% (95% CI, -4.2% to 1.5%; P = .37), in the liberal vs the restrictive thresholds groups, respectively. In the liberal vs restrictive thresholds groups, necrotizing enterocolitis requiring surgical intervention occurred in 20/492 (4.1%) vs 28/518 (5.4%); bronchopulmonary dysplasia occurred in 130/458 (28.4%) vs 126/485 (26.0%); and treatment for retinopathy of prematurity was required in 41/472 (8.7%) vs 38/492 (7.7%). Growth at follow-up was also not significantly different between groups.

CONCLUSIONS AND RELEVANCE

Among infants with birth weights of less than 1000 g, a strategy of liberal blood transfusions compared with restrictive transfusions did not reduce the likelihood of death or disability at 24 months of corrected age.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01393496.

Incidence and risk factors of retinopathy of prematurity in Korle-Bu Teaching Hospital: a baseline prospective study

OBJECTIVE

To determine the incidence of retinopathy of prematurity (ROP) and any associated risk factors among preterm infants at the Neonatal Intensive Care Unit (NICU) of Korle-Bu Teaching Hospital (KBTH).

DESIGN

Prospective study.

SETTING

Level 3 NICU of KBTH from June 2018 to February 2019.

PARTICIPANTS

Eligible infants with birth weight (BW) less than 2 kg or gestational age (GA) less than 37 weeks were examined at scheduled intervals until full maturity of their retina.

OUTCOME MEASURES

The primary outcome measure was cumulative incidence of ROP and secondary outcome measure was risk factors associated with ROP.

RESULTS

Of the 401 infants, 222 were females (55.4%), mean±SD GA was 32.3±2.4 weeks (median 32, IQR 31 to 34) and mean BW 1.6±0.4 kg (median 1.5, IQR 1.3 to 1.9). The cumulative incidence of ROP was 13.7% (95% CI: 10.5 to 17.5%), with 1.8% (seven infants) having type 1 ROP. Increased risk of ROP was observed in babies with supplemental oxygen exposure (p<0.001), BW less than 1.5 kg (p=0.019), confirmed neonatal sepsis (p=0.001), nasogastric tube feeding (p=0.03) and poor pupillary dilation (0.032). A reduced risk of ROP was observed in boys (p=0.004) and after delivery by caesarean section (p=0.019).

CONCLUSION

The rates of ROP at KBTH are comparable to other NICUs in sub-Saharan Africa. Birth weight less than 1.5 kg, confirmed neonatal sepsis, nasogastric tube feeding and poor pupil dilation were independently associated with increased incidence of ROP. ROP screening should be a part of the routine service for premature infants in Ghana.