Neurodevelopmental outcome of preterm very low birth weight infants admitted to an Italian tertiary center over an 11-year period

Assessment of maternal phthalate exposure in urine across three trimesters and at delivery (umbilical cord blood and placenta) and its influence on birth anthropometric measures

Phthalates, commonly used in plastic manufacturing, have been linked to adverse reproductive effects. Our research from the Saudi Early Autism and Environment Study (2019-2022), involving 672 participants, focused on the impacts of maternal phthalate exposure on birth anthropometric measures. We measured urinary phthalate metabolites in 390 maternal samples collected during each of the three trimesters of pregnancy and in cord serum and placental samples obtained at delivery. We employed various statistical methods to analyze our data. Intraclass correlation coefficients were used to assess the consistency of phthalate measurements, generalized estimating equations were used to explore temporal variations across the trimesters, and linear regression models, adjusted for significant confounders and Bonferroni correction, were used for each birth outcome. Exposure to six phthalates was consistently high across trimesters, with 82 %-100 % of samples containing significant levels of all metabolites, except for mono-benzyl phthalate. We found a 3.15 %-3.73 % reduction in birth weight (BWT), 1.39 %-1.69 % reduction in head circumference (HC), and 3.63 %-5.45 % reduction in placental weight (PWT) associated with a one-unit increase in certain urinary di(2-ethylhexyl) phthalate (DEHP) metabolites during the first trimester. In the second trimester, exposure to MEP, ∑7PAE, and ∑LMW correlated with a 3.15 %-4.5 % increase in the APGAR 5-min score and increases in PWT by 8.98 % for ∑7PAE and 9.09 % for ∑LMW. Our study also highlighted the maternal-to-fetal transfer of DEHP metabolites, indicating diverse impacts on birth outcomes and potential effects on developmental processes. Our study further confirmed the transfer of DEHP metabolites from mothers to fetuses, evidenced by variable rates in the placenta and cord serum, with an inverse relationship suggesting a passive transfer mechanism. Additionally, we observed distinct phthalate profiles across these matrices, adversely impacting birth outcomes. In serum, we noticed increases associated with DEHP metabolites, with birth gestational age rising by 1.01 % to 1.11 %, HC by 2.84 % to 3.67 %, and APGAR 5-min scores by 3.77 % to 3.87 %. Conversely, placental analysis revealed a different impact: BWT decreased by 3.54 % to 4.69 %, HC reductions ranged from 2.57 % to 4.69 %, and chest circumference decreased by 7.13 %. However, the cephalization index increased by 3.67 %-5.87 %. These results highlight the complex effects of phthalates on fetal development, indicating their potential influence on crucial developmental processes like sexual maturation and brain development.

Early Intervention Guided by the General Movements Examination at Term Corrected Age-Short Term Outcomes

BACKGROUND AND AIM

The early identification of the former premature neonates at risk of neurologic sequelae could lead to early intervention and a better prognosis. This pilot study aimed to investigate whether the General Movement patterns observed at term-equivalent age in former premature infants could serve as predictors for guiding early intervention and improving prognosis.

MATERIALS AND METHODS

In a population of 44 premature neonates (mean gestational age 33.59 weeks (+2.43 weeks)) examined at term-equivalent age, 10 neonates with a cramped-synchronized General Movements motor pattern were identified. These neonates were included in an early intervention program consisting of physiotherapy executed both by the therapist and by the parents at home. They were again examined at a corrected age of 12 weeks. The presence or absence of fidgety movements and the MOS-R (motor optimality score revised) was noted. The examinations were performed by certified specialists.

RESULTS

Normal fidgety movements and a MOS-R of 20-24 were presented in 9/10 of the former premature infants, with normal foot to foot contact present in 7/10, and normal hand to hand contact present in 5/10. The atypical patterns noted were side to side movements of the head in 5/10, a non-centered head in 9/10, asymmetric tonic neck reflex in 9/10 and jerky movements in 10/10. One patient presented with no fidgety movements and a MOS-R score of 9.

CONCLUSION

Early intervention in our group of patients allowed for an improvement in the neurologic status, demonstrated by the presence of fidgety movements. We suggest that early intervention should be indicated in all premature infants that present with a cramped-synchronized GM pattern during examination at term-equivalent age. However, due to the small sample size, the absence of statistical analysis and a control group, and the limited follow-up period, the conclusions must be approached with caution.

Impact of low birth weight on academic attainment during adolescence: A comprehensive retrospective cohort study using linked data

BACKGROUND

This study addresses a critical knowledge gap by exploring the intricate relationship between low birth weight (LBW) and the heightened risk of suboptimal academic achievement during adolescence through a comprehensive retrospective cohort design.

METHODS

In this registry-based cohort study, meticulously linked health and curriculum-based test data for individuals born in New South Wales (NSW), Australia, between 2003 and 2005 were employed. Birth weight data were carefully sourced from the NSW perinatal data collection (PDC). The educational performance of offspring was thoroughly evaluated using the National Assessment Program for Literacy and Numeracy (NAPLAN) during grade 9, approximately at 14 years of age.

RESULTS

After rigorous adjustments for potential confounders, findings revealed a compelling narrative: LBW adolescents demonstrated an elevated susceptibility to not meeting national minimum standards across all domains, encompassing spelling [OR, 1.59 (95%CI 1.48-1.69)], writing [OR, 1.51 (95%CI 1.41-1.61)], reading [OR, 1.38 (95%CI 1.29-1.48)], and numeracy [OR, 1.52 (95%CI 1.40-1.63)]. Notably, LBW boys exhibited a more pronounced inclination towards diminished academic performance compared to their female counterparts.

CONCLUSIONS

This comprehensive retrospective cohort study, based on linked data, unequivocally establishes LBW as significantly associated with an increased vulnerability to substandard educational achievement during adolescence. Particularly robust effects were observed in females across all outcomes. Aimed at investigating whether LBW serves as a predictive factor for later academic difficulties, this study underscores the imperative for the adoption and fortification of preventative and early intervention strategies to curtail the prevalence of LBW-associated academic underachievement in later adolescence.

Neurodevelopmental Outcome and Neuroimaging of Very Low Birth Weight Infants from an Italian NICU Adopting the Family-Centered Care Model

BACKGROUND

Improvements in perinatal care have substantially decreased mortality rates among preterm infants, yet their neurodevelopmental outcomes and quality of life persist as a pertinent public health concern. Family-centered care has emerged as a holistic philosophy that promotes effective alliances among patients, families, and healthcare providers to improve the quality of care.

AIMS

This longitudinal prospective study aims to evaluate the neurodevelopmental outcomes and brain MRI findings in a cohort of preterm newborns admitted to a neonatal intensive care unit (NICU) adopting a family-centered care model.

METHODS

Very low birth weight (VLBW) infants admitted to the NICU of Modena between 2015 and 2020 were enrolled. Infants who underwent conventional brain magnetic resonance imaging (MRI) at term-equivalent age were included. Neurodevelopmental follow-up was performed until the age of 24 months by a multidisciplinary team using the Amiel-Tison neurological assessment and the Griffiths Mental Developmental Scales (GMDS-R). Neurodevelopmental outcomes were classified as major sequelae (cerebral palsy, DQ ≤ 70, severe sensory impairment), minor sequelae (minor neurological signs such as clumsiness or DQ between 71 and 85), and normal outcomes (no neurological signs and DQ > 85). Risk factors for severe outcomes were assessed.

RESULTS

In total, 49 of the 356 infants (13.8%) died before hospital discharge, and 2 were excluded because of congenital disorders. Of the remaining 305 infants, 222 (72.8%) completed the 24 month follow-up and were included in the study. Neurodevelopmental outcomes were classified as normal (n = 173, 77.9%), minor (n = 34, 15.3%), and major sequelae (n = 15, 6.8%). Among 221 infants undergoing brain MRI, 76 (34.4%) had major lesions (intraventricular hemorrhage, hemorrhagic parenchymal infarction, periventricular leukomalacia, and large cerebellar hemorrhage). In the multivariate regression model, the retinopathy of prematurity (OR 1.8; p value 0.016) and periventricular-intraventricular hemorrhage (OR 5.6; p value < 0.004) were associated with major sequelae.

CONCLUSIONS

We reported low rates of severe neurodevelopmental outcomes in VLBW infants born in an Italian NICU with FCC. Identifying the risk factors for severe outcomes can assist in tailoring and optimizing early interventions on an individual basis, both within the NICU and after discharge.

Developmental consequences of short apneas and periodic breathing in preterm infants

OBJECTIVE

We investigated the relationship between respiratory events experienced before and after hospital discharge and developmental outcomes at 6 months corrected age (CA).

STUDY DESIGN

Preterm infants born between 28-32 weeks gestational age (GA) were studied at 32-36 weeks postmenstrual age (PMA), 36-40 weeks PMA, 3- and 6-months CA. Percentage total sleep time (%TST) with respiratory events (isolated apneas, sequential apneas and periodic breathing (PB)) at each study was calculated. Stepwise multiple linear regressions determined significant predictors of developmental outcomes at 6 months.

RESULT

%TST with respiratory events at term were significant predictors of language (R2 = 0.165, β = -0.416) and motor (R2 = 0.180, β = -0.485) composite scores of the Bayley Scales of Infant Development at 6 months, independent of GA, birth weight and sex.

CONCLUSIONS

In clinically stable very preterm infants at term equivalent age, time spent having respiratory events, was related to a reduction in language and motor outcomes at 6 months.

Risk Factors for Neurodevelopmental Impairment at 2- and 5-Years Corrected Age in Preterm Infants with Established Bronchopulmonary Dysplasia

INTRODUCTION

The objective of this study was to identify risk factors for neurodevelopmental impairment (NDI) at 2- and 5-years corrected age (CA) in a cohort of preterm infants with established bronchopulmonary dysplasia (BPD).

METHODS

This single-center retrospective cohort study included infants born between 2009 and 2016 at a gestational age (GA) <30 weeks with moderate or severe BPD at 36 weeks' postmenstrual age. Perinatal characteristics, (social) demographics, and comorbidities were collected from the electronic patient records. Odds ratios for NDI were calculated with univariate and multivariate logistic regression analyses adjusting for potential confounders.

RESULTS

Of the 602 eligible infants, 123 infants were diagnosed with BPD. NDI was present in 30.3% and 56.1% at 2- and 5-years CA, respectively. The only independent risk factors associated with NDI in the multivariate analyses were birthweight (adjusted odds ratio [aOR] 0.74, 95% CI 0.57-0.95; aOR 0.70, 95% CI 0.54-0.91, respectively), small for GA (SGA) (aOR 3.25, 95% CI 1.09-9.61; aOR 5.44, 95% CI 1.62-18.2, respectively) at both time points, and male gender at 5-years CA (OR 2.49, 95% CI 1.11-5.57).

CONCLUSION

Birthweight and SGA are independent risk factors for NDI at 2- and 5-years CA and male gender at 5-years CA in preterm infants with BPD. In contrast, well-known other risk factors for NDI in the general population of preterm infants, such as GA, maternal education, and neonatal comorbidities were not independently associated with NDI.

Sensory Modulation Abilities in Healthy Preterm-Born Children: An Observational Study Using the Sensory Processing and Self-Regulation Checklist (SPSRC)

This study aimed to investigate prematurity as a risk factor for sensory processing disorders, using the Italian Version of Sensory Processing and Self-Regulation Checklist (SPSRC-IT), based on a sample of healthy Italian children born preterm in comparison with a sample of typical full-term children. Two groups of caregivers of Italian healthy preschooler children were recruited. The first group comprised 37 caregivers of full-term children (FT), while the second group consisted of 37 caregivers of preterm children (PT) (gestational age < 37 weeks). Significant differences between the groups in several subsections and factors of the SPSRC-IT were found, specifically in the Physiological Conditions section, in the Gustatory and Olfactory Sense section, in the Vestibular Sense section, and in the Proprioceptive Sense section, with lower scores in the PT group. Moreover, children born at a lower gestational age or with lower weights had a higher risk of dysfunctions in processing gustatory and olfactory, vestibular, and proprioceptive stimuli. In conclusion, the SPSRC-IT suggested a potential link between prematurity and challenges in the development of sensory processing and self-regulation skills, especially in children with a very low birth weight and very low gestational age.

Exposure of preterm neonates receiving total parenteral nutrition to phthalates and its impact on neurodevelopment at the age of 2 months

This prospective study assessed the exposure to phthalates of preterm neonates who received total parenteral nutrition (TPN) during their stay in the neonatal intensive care unit (NICU) and the risk of neurodevelopment delays at the age of 2 months. Our study recruited 33 preterm neonates who required TPN upon NICU admission. Urine samples for analyzing phthalate metabolites were obtained at admission and then daily until the last day of receiving TPN. Phthalates in the daily TPN received by the preterm neonates were analyzed. The neurodevelopment of the neonates was assessed using the Ages and Stages Questionnaire Edition 3 (ASQ-3). Diethyl phthalate and butyl benzyl phthalate were found in all TPN samples, while 27% and 83% contained dibutyl phthalate and di-(2-ethylhexyl) phthalate (DEHP), respectively. Yet, the daily dose of each phthalate that our preterm neonates received from TPN was much lower than the recommended tolerable limit. Urinary levels of monobenzyl phthalate and four metabolites of DEHP [i.e., mono-(2-ethylhexyl) phthalate (MEHP), mono-(2-ethyl-5-hydroxyhexyl) phthalate, mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), and mono-(2-ethyl-5-carboxypentyl) phthalate (MECPP)] and the sum of four DEHP metabolites (∑₄DEHP) increased significantly in preterm neonates before discharge. However, these levels were not correlated with their phthalate parent compounds in TPN, suggesting other sources of exposure in the NICU. At 2 months, we found that urinary levels of mono-iso-butyl phthalate (MiBP), MECPP, MEHP, and ∑₄DEHP were inversely related to fine motor skills. After adjusting for head circumference, the inverse relationships remained significant, suggesting direct effects from phthalates. Given the extreme vulnerability of our population, it is critical to minimize exposure to phthalates during their NICU stay.

Cognitive and motor development in preterm children from 6 to 36 months of age: Trajectories, risk factors and predictability

BACKGROUND

Although numerous studies have examined the development of preterm children born very low birth weight (VLBW, birth body weight < 1500 g), variations of developmental progress within individuals have rarely been explored. The aim of this research was to examine the cognitive and motor trajectories in preterm children born VLBW at early ages and to assess the risk factors and predictability of these trajectories.

METHOD

Five hundred and eighty preterm infants born VLBW from three cohort studies (2003 to 2014) were prospectively assessed their mental and motor development using the Bayley Scales at 6, 12, 24, and 36 months, and cognitive, motor and behavioral outcomes using the Movement Assessment Battery for Children and the Child Behavior Checklist for Ages 1.5-5 at 4 years of age.

RESULTS

Preterm children born VLBW manifested three cognitive patterns (stably normal [64.0 %], deteriorating [31.4 %], and persistently delayed [4.6 %]) and four motor patterns (above average [6.3 %], stably normal [60.0 %], deteriorating [28.5 %], and persistently delayed [5.2 %]) during 6-36 months. Low birth body weight, stage III-IV retinopathy of prematurity and low parental socio-economic status were associated with the deteriorating patterns; prolonged hospitalization and major brain damage were additionally associated with the persistently delayed patterns. Furthermore, the cognitive and motor deteriorating pattern was each predictive of cognitive and motor impairment at 4 years of age; whereas, the persistently delayed patterns were predictive of multiple impairments.

CONCLUSION AND IMPLICATIONS

Preterm children born VLBW display heterogeneous trajectories in early cognitive and motor development that predict subsequent developmental and behavioral outcomes.

Impact of children born with low birth weight on stunting and wasting in Sindh province of Pakistan: a propensity score matching approach

Low Birth Weight (LBW) is considered as a major public health issue and leading cause of neonatal death. Almost one in four newborns are reported as underweight in Pakistan. Children born with low birth weight are highly vulnerable to develop diseases and death and/or remain undernourished (i.e., stunted and wasted). This study determines the LBW newborns are more prone to develop stunting and wasting in province of Sindh, Pakistan. Moreover, regression-based estimation of the impact of LBW on the child health outcomes of under five years of age, may be prone to selection bias because of the nature of non-experimental data set, thus, propensity score matching methods are used in this study. Data for this study was used from Multiple Indicators Cluster Survey (MICS-2014). MICS is a two-stage, stratified cluster sampling household level data covering urban and rural areas and consists of 19,500 households from five administrative divisions and 28 districts of Sindh province of Pakistan. The total sample size of children less than five years of age after cleaning the data are 7781, of which 2095 are LBW having birth weight categorized as "smaller than average and very small" and 5686 are normal birth weight (NBW) having birth weight very large, larger than average, and average. This study employed propensity score matching (PSM) regression methods to understand whether the children born as low birth weight are more prone to stunting and wasting and/or both. In province of Sindh, moderate wasting children under five years were 21%, severe wasting 6% and both wasting and stunting 10%. The propensity score results are shown significant in all groups. Specifically, all four types of PSM methods confirm a significant difference in the potential outcome variables-meaning that a child born with LBW has a significant adverse effect on the potential child health outcome variables (stunting, wasting and both). Thus, the propensity score matching findings confirm a significant and adverse effect of LBW on potential health outcomes of under five children. Similarly, low birth weight children are significantly more likely to be moderately wasted (OR = 1.5, CI = 1.3-1.6) and severely wasted (OR = 1.6, CI = 1.3-2.0) and both (stunted and wasted, OR = 2.0, CI = 1.7-2.3) as compared to children with normal birth weight. Male children, if born with low birth weight, are significantly more likely to be moderately wasted (OR = 1.3, CI = 1.1-1.5) and both (wasted and stunted, OR = 1.3, CI = 1.1-1.5) than girls. This large data analysis finding proved that the LBW newborns are on higher risk to develop wasting and stunting in Pakistan.