Association between early postnatal weight loss and death or BPD in small and appropriate for gestational age extremely low-birth-weight infants

Association of fluid overload with patent ductus arteriosus during the first postnatal day

BACKGROUND

Evidence examining the association of over-hydration during early life with hemodynamically significant patent ductus arteriosus (hsPDA) and other morbidities is limited. Our aim was to evaluate the association of fluid overload during the first postnatal day with hsPDA and common neonatal morbidities such as bronchopulmonary dysplasia in preterm infants.

METHODS

A retrospective cohort study was conducted enrolling infants ≤30 weeks' gestation and ≤1500 grams' birth weight, admitted to a tertiary Neonatal Unit. We calculated the fluid balance, and we estimated the incidence of infants with fluid overload ≥5% during the first postnatal day, evaluating any possible correlation with hsPDA.

RESULTS

One hundred three infants of 27.3±1.6 weeks' gestation and 1009±225 grams' birth weight were enrolled, of whom 32 (31%) were diagnosed with HsPDA. Fluid overload during the first postnatal day was recorded in 42 infants (41%). Infants with fluid overload were diagnosed with hsPDA in 48%, compared to 20% of infants without fluid overload (P=0.004). No differences were recorded in the development of bronchopulmonary dysplasia or survival. Fluid overload of ≥5% was significantly correlated with hsPDA (r=0.37, P=0.003) and had an independent contribution to the risk of hsPDA (OR=1.17, 95% CI: 1.05-1.58), irrespective of other perinatal factors.

CONCLUSIONS

In preterm infants, fluid overload ≥5% is significantly associated with hsPDA; therefore, fluid management during the first postnatal day should be closely regulated.

Correlation between early postnatal body weight changes and lung ultrasound scores as predictors of bronchopulmonary dysplasia in preterm infants: A secondary analysis of a prospective study

Recent research links early weight changes (EWC) with bronchopulmonary dysplasia (BPD) in preterm neonates, while lung ultrasound score (LUS) has shown promise in predicting BPD. We aimed to explore the correlation between LUS and EWC as markers of extravascular lung edema and to investigate the correlation between LUS and EWC in preterm infants with respiratory distress syndrome regarding future BPD development. This secondary analysis of a prospective study involved infants ≤ 28 weeks gestation. Enrolled infants underwent lung ultrasound assessment on postnatal days 3, 7 and 14, measuring LUS. EWC was computed on the same time points. Infants were classified as either having BPD or not. Descriptive statistics, correlation coefficient, and area under the receiver operating characteristic (AUROC) curve analysis were utilized. Of 132 infants, 70 (53%) had BPD. Univariate analysis revealed statistically significant differences in LUS and EWC at days 3, 7, and 14 between BPD and no-BPD groups (p < 0.001). A statistically significant but weak positive correlation existed between LUS and EWC (r0.37, r0.29, r0.24, and p < 0.01) at postnatal days 3, 7, and 14, respectively. AUROC analysis indicated LUS having superior predictive capacity for the need for invasive mechanical ventilation at day 14 as well as the later BPD development compared to EWC (p < 0.0001).

CONCLUSION

In a cohort of extreme preterm infants, our study revealed a positive yet weak correlation between LUS and EWC, suggesting that EWC was not the major contributing to the evolving chronic lung disease.

WHAT IS KNOWN

• Recent evidence links Early Weight-Changes with bronchopulmonary dysplasia in preterm neonates. • Lung ultrasound score has shown promise in early prediction of the subsequent development of bronchopulmonary dysplasia in preterm infants. No studies have examined the correlation between Early Weight-Changes and Lung ultrasound score in preterm infants during first 2 weeks after birth.

WHAT IS NEW

• Our study demonstrated a positive and statistically significant correlation between early LUS and EWC, indicating their potential role as early predictors for the subsequent development of BPD in extreme preterm infants. • The weak correlation between the two parameters may stem from the possible restricted influence of EWC, given that it may not be the primary factor contributing to the evolving chronic lung disease.

Risk factors and epidemiology of spontaneous intestinal perforation among infants born at 22-24 weeks' gestational age

OBJECTIVE

To describe the epidemiology, risk factors, and timing of spontaneous intestinal perforation (SIP) among infants born at 22-24 weeks' gestational age (GA).

STUDY DESIGN

Observational cohort study among infants born at 22-24 weeks' GA in 446 neonatal intensive care units.

RESULTS

We identified 9712 infants, of whom 379 (3.9%) developed SIP. SIP incidence increased with decreasing GA (P < 0.001). Antenatal magnesium (odds ratio (OR) 1.42; 95% confidence interval (CI), 1.09-1.85), antenatal indomethacin (OR 1.40; 95% CI, 1.06-1.85), postnatal indomethacin (OR 1.61; 95% CI, 1.23-2.11), and postnatal hydrocortisone exposure (OR 2.02; 95% CI 1.50-2.73) were associated with SIP. Infants who lost 15-20% (OR 1.77; 95% CI, 1.28-2.44) or >20% (OR 2.04; 95% CI, 1.46-2.85) of birth weight had higher odds of SIP than infants with weight loss <10%.

CONCLUSIONS

Antenatal magnesium exposure, antenatal indomethacin exposure, postnatal hydrocortisone exposure, postnatal indomethacin exposure, and weight loss ≥15% were associated with SIP.

A Systematic Review: Is Early Fluid Restriction in Preterm Neonates Going to Prevent Bronchopulmonary Dysplasia?

Preterm birth causes constant challenges, with bronchopulmonary dysplasia (BPD) being a major concern. Immediately after birth, it takes time to establish feeding between the mother and the premature baby. During this time, the telological shifting of fluid from extracellular space to intracellular space will help the baby; this transition should be smooth. Both normal physiologic changes and pathophysiologic events are capable of disrupting this delicate fluid shifting that occurs in very low-birth-weight infants during the first week of life. The immaturity of the renal system and evaporative losses complicate this process. This lack of fluid displacement can be associated with an increased amount of water in the lungs and reduced lung compliance. This can lead to the need for more ventilatory support and a higher oxygen requirement, which, in turn, leads to lung damage. The fluid restriction is also associated with complications such as severe dehydration, intracranial hemorrhage, and bilirubin toxicity. However, the administration of large amounts of fluid and salt is associated with an increased incidence of patent ductus arteriosus, BPD, necrotizing enterocolitis, and intraventricular hemorrhage. There were studies conducted in both the pre-surfactant and surfactant eras that were inconclusive regarding fluid restriction in BPD. We only included very recent studies. This systematic review attempts to summarize the current evidence, focusing on the efficacy and safety of early fluid management in preterm infants. This reduces the risk of BPD and improves outcomes for premature infants. As we know, intact survival is very important. Our review supported the early fluid restriction.

Early Fluid and Nutritional Management of Extremely Preterm Newborns During the Fetal-To-Neonatal Transition

During the fetal-to-neonatal transitional period, extremely preterm newborns undergo significant intrabody fluid shifts and resulting weight loss due to increased insensible fluid losses due to immature skin, kidneys, among other factors. These ongoing physiologic changes make fluid and nutritional management complex in the neonatal-to-fetal transitional time period for extremely premature newborns. However, limited literature exists to guide optimal practices for providers caring for this population. Here, we review the evidence on optimal fluid and nutritional management during the fetal-to-neonatal transition of extremely preterm newborns.

Neonatal fluid overload-ignorance is no longer bliss

Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload.

Increasing Sodium Variability in the First 96 Hours after Birth is Associated with Adverse In-Hospital Outcomes of Preterm Newborns

Background

Neonatal intraventricular hemorrhage prevention bundles for preterm infants commonly defer daily weighing for the first 72 h, with reweighing occurring on day 4. Clinicians rely on maintaining stable sodium values as a proxy of fluid status to inform fluid management decisions over the first 96 h after birth. Yet, there exists a paucity of research evaluating whether serum sodium or osmolality are appropriate proxies for weight loss and whether increasing variability in sodium or osmolality during this early transitional period is associated with adverse in-hospital outcomes.

Objectives

To evaluate whether serum sodium or osmolality change in the first 96 h after birth was associated with percent weight change from birth weight, and to assess potential associations between serum sodium and osmolality variability with in-hospital outcomes.

Methods

This retrospective, cross-sectional study included neonates born at ≤30 gestational weeks or ≤1250 g. We evaluated associations between serum sodium coefficient of variation (CoV), osmolality CoV, and maximal weight loss percentage in the first 96 h after birth with in-hospital neonatal outcomes.

Results

Among 205 infants, serum sodium and osmolality were poorly correlated with percent weight change in individual 24-h increments (R2 = 0.01-0.14). For every 1% increase in sodium CoV, there was an associated 2-fold increased odds of surgical necrotizing enterocolitis and 2-fold increased odds of in-hospital mortality (odds ratio, 2.07; 95% CI: 1.02, 4.54; odds ratio, 1.95; 95% CI: 1.10, 3.64, respectively). Sodium CoV was more strongly associated with outcomes than absolute sodium maximal change.

Conclusions

In the first 96 h, serum sodium and osmolality are poor proxies for assessing percent weight change. Increasing variability of serum sodium is associated with later development of surgical necrotizing enterocolitis and all-cause in-hospital mortality. Prospective research is needed to evaluate whether reducing sodium variability in the first 96 h after birth, as assessed by CoV, improves newborn health outcomes.

Fluid and electrolyte management in preterm infants with patent ductus arteriosus

Optimal fluid management of preterm babies with suspected or confirmed diagnosis of patent ductus arteriosus (PDA) is frequently challenging for neonatal care physician because of paucity of clinical trials. There is wide variation in practice across neonatal units, resulting in significant impact on outcomes in Extremely Low Birth Weight (ELBW) babies with hemodynamically significant PDA. A delicate balance is required in fluid management to reduce mortality and morbidity in this population. The purpose of this review is to lay out the current understanding about fluid and electrolyte management in ELBW babies with hemodynamically significant PDA and highlight areas for future research.

Postnatal maximal weight loss, fluid administration, and outcomes in extremely preterm newborns

OBJECTIVE

Evaluate maximal weight loss (MWL) and total fluid administration (TFA) association in first week after birth with outcomes among extremely preterm (EP) newborns.

STUDY DESIGN

We performed a retrospective analysis of the Preterm Erythropoietin Neuroprotection Trial evaluating first-week MWL, TFA, and association with in-hospital outcomes.

RESULTS

Among n = 883 included EP neonates, n = 842 survived ≥ 7 days and were included in outcome analyses. MWL between 5% to 15% was associated with decreased odds of necrotizing enterocolitis compared to MWL > 15% (OR 0.49, 95% CI 0.25-0.98). Average TFA > 150 mL/kg birthweight/day was associated with increased odds of necrotizing enterocolitis (OR 3.22, 95% CI 1.40-7.42) and patent ductus arteriosus requiring surgery (OR 2.14, 95% CI 1.10-4.15).

CONCLUSION

MWL between 5% to 15% is a potentially optimal window of MWL. Increasing average TFA in the first week is associated with adverse neonatal outcomes. Prospective studies evaluating MWL and TFA and relationship to outcomes in EP neonates are needed.

CLINICAL TRIAL REGISTRATION

This study is a secondary analysis of pre-existing data from the PENUT Trial Registration: NCT01378273, https://clinicaltrials.gov/ct2/show/NCT01378273 .

Commentary on "compatibility of rapid enteral feeding advances and noninvasive ventilation in preterm infants-an observational study"

Nutritional support is essential in the critical care of the very preterm infant, however, the study of the potential role of nutrition in the multifactorial pathogenesis of bronchopulmonary dysplasia (BPD) is limited. Achievement of full enteral feeding faster has not been shown to be harmful and may be of benefit in extremely preterm infants. This commentary discusses the studied risk and potential benefits of more rapid enteral feeding advancement in extremely preterm infants.

Association of Weight Changes by Three Days after Birth and Mortality and/or Severe Neurological Injury in Preterm Infants < 29 Weeks Gestational Age: A Multicenter Cohort Study

OBJECTIVE

This study aimed to determine the range of weight loss, at 3 days postnatal age, associated with the lowest risk of mortality/short-term morbidity in preterm infants <29 weeks gestational age (GA).

STUDY DESIGN

This multicenter retrospective cohort study employed data from the Canadian Neonatal Network database. The primary outcome was a composite of mortality and/or severe neurological injury. Multivariable quadratic and linear regression models which adjusted for potential confounders were built.

RESULTS

A total of 9275 preterm infants (median GA 26, IQR 25, 28 weeks) were included. The optimal weight change range at day three, after adjustment for potential confounders for the primary outcomes, was -15 to -8.9%.

CONCLUSIONS

There is a 'U'-shaped relationship between weight change from birth to day three and mortality and/or severe neurological injury. Interventional studies, which target weight loss within the range found in this study and evaluate the impact on neonatal outcomes, are needed to corroborate our findings.

Fluid management considerations in extremely preterm infants born at 22-24 weeks of gestation

Emerging data regarding the encouraging outcomes of extremely preterm infants from centers taking active approaches to the care of these infants have prompted dialogue regarding optimal medical management. Among the multitude of decisions providers make in caring for extremely premature infants is the prescribing of parenteral fluids. Surprisingly, there are limited data to guide evidenced-based approaches to fluid and electrolyte management in this population. Immaturity of renal function and skin barriers contribute to the impaired capacity of the preterm infant to maintain salt and water homeostasis. This perspective paper highlights developmental physiological properties of the kidney and skin, which the provider needs to understand to provide parenteral fluid therapy. Additionally, we provide recommendations for initial fluid and electrolyte management of the preterm infant based on novel data as well as the published literature.

The association between duration of postnatal weight loss and neurodevelopment outcomes in very low birth weight infants

BACKGROUND

Premature births account for around 11% of the world's live births. With the improvements in survival that have been achieved in recent years, the neurological outcomes of these infants have attracted greater attention. The aim of this study was to evaluate the association between postnatal weight loss and neurodevelopment outcomes of very low birth weight premature infants.

METHODS

This was a prospective cohort study that was conducted in a tertiary referral center. Premature infants of birth weight less than 1500 g born between October 2015 and January 2017 were enrolled. Perinatal-demographic characteristics, medical interventions, and nutrition records were collected. The Bayley III tests performed by licensed child psychiatrists at corrected ages 6, 12, and 24 months old were adopted as outcome measurements.

RESULTS

In total, 52 infants were enrolled. The mean birth weight was 1071 g and the mean gestational age was 29.0 weeks. According to the univariate analysis, the duration of postnatal weight loss had a significantly negative impact on motor outcomes at 12 and 24 months old. The negative impact remained robust after adjusting for confounding factors by multiple linear regression models. The effect of repeated measurement was further considered by generalized estimating equation (GEE) models. GEE models also demonstrated a negative association between the duration of body weight loss and motor scores.

CONCLUSION

The duration of postnatal weight loss might have a negative influence on long-term motor development in premature infants. Further studies of nutrition status and motor development are needed to elucidate the precise underlying mechanism.

Advances in Neonatal Acute Kidney Injury

In this state-of-the-art review, we highlight the major advances over the last 5 years in neonatal acute kidney injury (AKI). Large multicenter studies reveal that neonatal AKI is common and independently associated with increased morbidity and mortality. The natural course of neonatal AKI, along with the risk factors, mitigation strategies, and the role of AKI on short- and long-term outcomes, is becoming clearer. Specific progress has been made in identifying potential preventive strategies for AKI, such as the use of caffeine in premature neonates, theophylline in neonates with hypoxic-ischemic encephalopathy, and nephrotoxic medication monitoring programs. New evidence highlights the importance of the kidney in "crosstalk" between other organs and how AKI likely plays a critical role in other organ development and injury, such as intraventricular hemorrhage and lung disease. New technology has resulted in advancement in prevention and improvements in the current management in neonates with severe AKI. With specific continuous renal replacement therapy machines designed for neonates, this therapy is now available and is being used with increasing frequency in NICUs. Moving forward, biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, and other new technologies, such as monitoring of renal tissue oxygenation and nephron counting, will likely play an increased role in identification of AKI and those most vulnerable for chronic kidney disease. Future research needs to be focused on determining the optimal follow-up strategy for neonates with a history of AKI to detect chronic kidney disease.

Fluid Balance in the Critically Ill Child Section: "How Bad Is Fluid in Neonates?"

Fluid overload (FO) in neonates is understudied, and its management requires nuanced care and an understanding of the complexity of neonatal fluid dynamics. Recent studies suggest neonates are susceptible to developing FO, and neonatal fluid balance is impacted by multiple factors including functional renal immaturity in the newborn period, physiologic postnatal diuresis and weight loss, and pathologies that require fluid administration. FO also has a deleterious impact on other organ systems, particularly the lung, and appears to impact survival. However, assessing fluid balance in the postnatal period can be challenging, particularly in extremely low birth weight infants (ELBWs), given the confounding role of maternal serum creatinine (Scr), physiologic weight changes, insensible losses that can be difficult to quantify, and difficulty in obtaining accurate intake and output measurements given mixed diaper output. Although significant FO may be an indication for kidney replacement therapy (KRT) in older children and adults, KRT may not be technically feasible in the smallest infants and much remains to be learned about optimal KRT utilization in neonates. This article, though not a meta-analysis or systematic review, presents a comprehensive review of the current evidence describing the effects of FO on outcomes in neonates and highlights areas where additional research is needed.

Individualized fluid management in extremely preterm neonates to ensure adequate diuresis without increasing complications

OBJECTIVE

Decrease the incidence of inadequate diuresis (ID, loss of <6% of birth weight) in extremely preterm neonates (EPT, <28 weeks of gestation at birth) during the first week of life by 50% in 1 year.

STUDY DESIGN

Quality improvement project in a level IV neonatal intensive care unit. A fluid management protocol was implemented, including the use of a fluid guide sheet and closer monitoring of hydration parameters. Seventy-nine baseline EPT neonates were compared to 83 post intervention. The incidence of ID was tracked monthly, along with prespecified morbidities and complications. Statistical data analyses also compared the pre- and post-intervention periods.

RESULTS

Fluid volumes in the first week were decreased (p < 0.001). ID decreased from 43 to 29% (p = 0.061). Tracked morbidities and complications were not statistically different.

CONCLUSION

Intentional and individualized adjustment of fluids led to decreased ID without increased hypernatremia and dehydration, or a change in tracked morbidities.

The association of early postnatal weight loss with outcome in extremely low birth weight infants

BACKGROUND

To compare outcomes of extremely low birth weight (ELBW) infants having different weight losses in the first 3 days of life.

METHODS

One hundred and twenty six ELBW infants were evaluated retrospectively for weight loss percentages on the third day of life compared to their birth weight. We examined the weight loss on the third day of life compared to the birth weight for the ELBW infants and tested its association with mortality and morbidities. The mortality was subgrouped as overall mortality and mortality in the first 7 days of life. The morbidities were patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). BPD was defined as need for supplemental oxygen at 36 weeks' postconceptional age. We grouped the infants into four quartiles according to weight loss percentage on the third day of life: Group 1 (Quartile 1), infants with weight loss of 0-3% of birth weight; Group 2 (Quartile 2); infants with weight loss of 3.1-7.5%, Group 3 (Quartile 3), infants with weight loss of 7.51-12%; and Group 4 (Quartile 4), infants with weight loss of more than 12%. The mortality and morbidities were analyzed according to these groups and other risk factors.

RESULTS

Overall mortality and mortality in the first 7 days of life were significantly higher in Groups 1 (36% and 27%) and 4 (43% and 24%), compared to Groups 2 (10% and 10%) and 3 (18% and 9%), respectively.

CONCLUSION

Weight loss less than 3% and more than 12% was significantly associated with an increase in mortality. There was a positive correlation between weight loss on the third day of life and IVH.

CONCLUSION

Inappropriate weight loss in ELBW infants is associated with increased mortality and IVH. Appropriate weight loss can improve outcomes in this population.

Somatic growth and the risks of bronchopulmonary dysplasia and pulmonary hypertension: connecting epidemiology and physiology 1

In the premature infant, poor growth in utero (fetal growth restriction) and in the first weeks of life (postnatal growth restriction) are associated with increased risk for bronchopulmonary dysplasia and pulmonary hypertension. In this review, we summarize the epidemiologic data supporting these associations, present a novel rodent model of postnatal growth restriction, and review 5 promising mechanisms by which poor nutrition may affect the developing lung. These observations support the hypothesis that nutritional and (or) pharmacologic interventions early in life may be able to decrease risk of the pulmonary complications of extreme prematurity.

[Treatment and prognosis of pulmonary hemorrhage in preterm infants during 2007-2016]

OBJECTIVE

To study the treatment and prognosis of pulmonary hemorrhage in preterm infants.

METHODS

A total of 106 preterm infants diagnosed with pulmonary hemorrhage, who were hospitalized in the neonatal ward of Peking University Third Hospital between 2007 and 2016, were enrolled. These patients were divided into 2007-2011 group (34 cases) and 2012-2016 group (72 cases) according to the time of hospitalization, divided into conventional-frequency ventilation group (43 cases) and high-frequency oscillatory ventilation (HFOV) group (63 cases) according to the respiratory support method used after the development of pulmonary hemorrhage, and divided into non-operation group (34 cases) and operation group (14 cases) according to whether PDA ligation was performed for the unclosed PDA before pulmonary hemorrhage. The general data, treatment, and prognosis were compared between different groups.

RESULTS

Compared with the 2007-2011 group, the 2012-2016 group had higher rates of HFOV and PDA ligation (P&lt;0.05), a lower mortality rate during hospitalization (P&lt;0.05), a longer length of hospital stay (P&lt;0.05), and higher incidence rates of intracranial hemorrhage and bronchopulmonary dysplasia (P&lt;0.05). Compared with the conventional-frequency ventilation group, the HFOV group had a lower mortality rate during hospitalization (P&lt;0.05), a longer length of hospital stay (P&lt;0.05), and higher incidence rates of intracranial hemorrhage and bronchopulmonary dysplasia (P&lt;0.05). Compared with the non-operation group, the operation group had a lower mortality rate during hospitalization (P&lt;0.05), a longer length of hospital stay (P&lt;0.05), and higher incidence rates of intracranial hemorrhage and bronchopulmonary dysplasia (P&lt;0.05).

CONCLUSIONS

The application of HFOV and PDA ligation can improve the survival rate of preterm infants with pulmonary hemorrhage, but the incidence of intracranial hemorrhage and bronchopulmonary dysplasia is also increased.

Postnatal Transitional Weight Loss and Adverse Outcomes in Extremely Premature Neonates

The early postnatal weight loss (EPWL) is highly variable in the extremely low birth weight infants (birth weight <1000 g, ELBW). It is reported to be unassociated with adverse outcomes within a range of 3-21% of birth weight. Its wide range might have contributed to this lack of association. The aim of our paper is to study the effects of maximum EPWL, graded as low, medium and large on clinical outcomes in ELBW infants. In a retrospective cohort observational study EPWL was measured as maximum weight loss from birth weight (MWL) in ELBW infants and grouped as low (5-12%) moderate (18.1-12%) and high (18-25%). The clinical course and complications of infants were compared between the groups. Gestational age (GA) was highest and surfactant administration, peak inspiratory pressure requirement, fluid intake, urinary output, oxygen dependent days and the number of oxygen dependent infants at age 28 days were lower in the low MWL compared to the high MWL group. However, all these significant P-values declined after controlling for GA. Diabetes mellitus and pregnancy associated hypertension were not noted in mothers in high MWL group, whereas 38% of mothers in low MWL group suffered from the latter (P=0.05). Maximum postnatal transitional weight loss, assessed in the range of low, moderate and high, is not associated with adverse outcomes independent of gestational age in ELBW infants. Maternal hypertension decreases EPWL in them.

A new approach to estimating weight change and its reference intervals during the first 96 hours of life

AIM

We aimed to apply a novel model to estimate weight change and its reference intervals during the first 96 h of life and the time of weight nadir.

METHODS

This study involved 1288 full-term singletons, from the Generation XXI birth cohort. Recruitment occurred between 2005 and 2006 in all five public units providing obstetrical and neonatal care in Porto, Portugal. Birthweight was abstracted from clinical records, and the subsequent newborn anthropometrics were obtained by trained examiners. Longitudinal models to estimate postnatal weight were tested and the weight ratio was calculated as the weight during 96 h of life divided by birthweight.

RESULTS

The chosen model was (weight(t)~ 3241.442 + (-9.378) × t + 0.119 × t(2) + 0.000 × t(3) + b0i + b1i × t, where t represented the newborn infant's age in hours and bi represented the random coefficients. The curve inflection point (nadir) was achieved at 52.3 h of life, corresponding to a loss of 218 g and a weight ratio of 0.933. We estimated that at six, 12, 24 and 36 h of life the mean weight ratio and 10th-90th percentiles were 0.978 (0.968-0.988), 0.968 (0.953-0.983), 0.951 (0.928-0.974) and 0.939 (0.909-0.969), respectively.

CONCLUSION

This model allows a more accurate estimate of newborn weight change and its reference intervals, and estimated the nadir at 52.3 h of life, corresponding to a weight ratio of 0.933.

Do early postnatal body weight changes contribute to neonatal morbidities in the extremely low birth weight infants

BACKGROUND

The implications of early postnatal body weight changes (Δbw) in the morbidities related to body fluid metabolism in sick preterm infants in not well investigated. The extremely low birth weight infants (ELBW, birth weight <1000 g) have the highest incidence of such morbidities among all neonates.

AIM

To determine the relationships between Δbw and neonatal morbidities associated with body fluid metabolism in the ELBW infants.

METHODS

In an observational study, the associations between daily weight changes from birth weight (DΔ bw) and oxygen dependence on postnatal day 28 (BPD28), patent ductus arteriosus (PDA), intraventricular-periventricular hemorrhage (IVH), antenatal steroid (ANS) and gestational age (GA) were evaluated. Maximum weight loss (MΔ bw) was correlated with GA, BPD28 and BPD36 (oxygen dependence on postmenstrual 36 weeks). Pearson's correlation co-efficient and multivariate logistic regressions were performed for analysis.

RESULTS

DΔ bw correlated inversely with GA on days 1-8 of life (p <  0.01 for all, 0.06 for DOL 2). DΔ bw was associated with a lower risk of BPD28 on days 6 (OR 0.87, 95% CI 0.76-1), 10 (OR 0.86, 95% CI 0.76-0.98) and 11 (OR 0.87, 95% CI 0.77-0.99); with PDA on days 8-11 (OR ranging between 0.89 to 0.92 for the 4 days, 95% CI 0.83 to 0.99) and with IVH on day 5 (OR 0.93, 95% CI 0.86-1) after controlling for GA. DΔ bw was not identified as risk factor for the tested morbidities. ANS decreased DΔ bw on days 4 (OR 0.88, 95% CI 0.78-1) and 10 (OR 0.9, 95% CI 0.84-1). MΔbw correlated directly with BPD28 (r = 0.3, p = 0.004), which declined after controlling for GA (r = 0.2, p = 0.2).

CONCLUSIONS

DΔ bw is protective for PDA, BPD28 and IVH, independent of gestational age, whereas, the effects of MΔ bw on BPD are governed by maturation in ELBW infants. ANS decreases DΔbw, which correlates inversely with GA during the first week of life.

Determinants of weight changes during the first 96 hours of life in full-term newborns

BACKGROUND

Newborn weight loss (NWL) in the first 3 days of life is around 6 percent of birthweight (BW). We aim to describe the determinants of an excessive and insufficient NWL in the first 96 hours of life.

METHODS

A sample of 1,288 full-term singletons without congenital abnormality belonging to Generation XXI birth cohort was selected. Newborns were recruited in 2005-2006 at all public units providing obstetrical and neonatal care in Porto, Portugal. Information was collected by face-to-face interview and additionally abstracted from clinical records. Anthropometrics were obtained by trained examiners and newborn weight change (NWC) was estimated as (weight-BW)/BW × 100. We categorized NWL as excessive (below 10th percentile of the sample distribution of NWC: ≤-9.4% of BW), normal (between 10th and 90th percentiles: -9.3 to -4.2%) and insufficient (above 90th percentile: ≥ -4.1%). Adjusted odds ratios (OR) and 95 percent confidence intervals (CI) were calculated using multinomial regression models.

RESULTS

Excessive NWL was positively associated with maternal age ≥40 years (OR = 3.32, 95%CI 1.19-9.25), maternal education (OR = 1.04, 95% CI 1.00-1.09), cesarean delivery (OR = 2.42, 95% CI 1.12-5.23), and phototherapy-treated jaundice (OR = 1.69, 95% CI 1.00-2.87). Insufficient NWL was positively associated with low BW (OR = 2.68, 95% CI 1.13-6.33), and formula/mixed feeding (OR = 1.74, 95% CI 1.13-2.66).

CONCLUSION

Excessive NWL was positively associated with maternal age and education, cesarean delivery, and phototherapy-treated jaundice. Insufficient NWL reflected child's feeding. As breastfed newborns did not lose weight excessively, but newborns with formula/mixed feeding had insufficient NWL, our study supports that breastfeeding provides excellent nutrition during this period.

Serial echocardiography in very preterm infants: a pilot randomized trial

AIM

To determine whether routine echocardiography increases diagnosis and treatment for patent ductus arteriosus (PDA) and whether randomized nondisclosure is a feasible strategy for studying PDA management.

METHODS

Two-centre, pilot randomized, controlled trial. 88 infants with birth weights ≤1250 grams and gestational ages ≤30 weeks were randomized to disclosure or nondisclosure of serial echocardiogram findings. Echocardiograms were performed at 3-5 and 7-10 days of life. The primary outcome was time to regain birth weight.

RESULTS

100% of echocardiograms in the disclosure group were disclosed; 16% (echocardiogram #1) and 29% (echocardiogram #2) were disclosed in the nondisclosure group. There was a statistically nonsignificant decrease in drug therapy for PDA in the nondisclosure group (adjusted odds ratio [AOR] 0.56, 95% confidence interval [CI] 0.24-1.34). There was no difference in time to regain birth weight or in other important neonatal outcomes. However, infants in the nondisclosure group were more likely to demonstrate appropriate weight loss and then regain birth weight within 7-14 days (AOR 2.64, 95% CI 1.08-6.44).

CONCLUSION

Randomized nondisclosure of echocardiograms is a feasible strategy for evaluation of approaches to PDA management in very preterm infants. Avoidance of routine echocardiography may reduce drug therapy for PDA without adverse clinical effects.

Fluctuations in relative humidity provided to extremely low-birthweight infants (R1)

BACKGROUND

In extremely low-birthweight infants, the addition of relative humidity (RH) improves thermal stability, fluid and electrolyte balance. However, during routine care this microenvironment is frequently disturbed. The objective of this study was to determine the frequency, magnitude and direction of fluctuations in RH provided to extremely low-birthweight infants.

METHODS

All infants in our study had ambient temperature and RH continuously recorded for 48 h using a datalogger device (RH32S-C2). A clinically acceptable range for RH was defined as the set point ± 10%. A secondary analysis was performed to compare outcomes between infants that spent > 50% of the time out-of-range (OOR) or inside the range (IR). A P-value < 0.05 was significant.

RESULTS

A total of 20 infants were included. Important fluctuations were detected by the device with infants spending 40% and 14% of the time above and below the range, respectively. However, the RH set point did not differ from the mean levels measured over 48 h by the RH32S-C2 or the incubator. Infants in the OOR group spent significantly more time at values higher than the planned range when compared to IR infants.

CONCLUSION

Although significant fluctuations in RH above the desired range were detected in more than half of the infants, the average values were similar to the set points. Nevertheless, knowledge of these dynamic changes may help to optimize individualized care.

Risk factors for bronchopulmonary dysplasia in neonates born at ≤ 1500 g (1999-2009)

BACKGROUND

Advances in perinatal care have improved the survival rate for very low-birthweight (VLBW) infants in China. The incidence of bronchopulmonary dysplasia (BPD), however, has not been reduced. The objective of the present study was to identify the perinatal risk factors for BPD in neonates born at ≤ 1500 g.

METHODS

A retrospective analysis of data for neonates born at ≤ 1500 g between 1999 and 2009 in the neonatal intensive care unit (NICU) of Second Affiliated Hospital of Sun Yat-Sen University, Guangzhou city, China, was carried out.

RESULTS

Out of a total of 11,506 live births, 3538 infants were admitted to level II nursery and NICU (level III nursery). Among 149 preterm infants born at ≤ 1500 g, 77.8% survived until day 28, and the incidence of BPD was 48.3%. Logistic regression analysis showed that gestational age (GA) ≤ 30 weeks (odds ratio [OR], 9.507; 95% confidence intervals [95%CI]: 2.604-34.707), maternal chorioamnionitis (OR, 41.987; 95%CI: 6.048-291.492), ventilation-associated pneumonia (OR, 11.600; 95%CI: 2.847-47.268), and more than three blood transfusions (OR, 10.214; 95%CI: 2.191-47.623) were associated with the development of BPD.

CONCLUSION

Clinical evidence has been provided for possibly significant risk factors associated with BPD in neonates born at ≤ 1500 g, which can provide useful information for further research to improve survival of VLBW infants and decrease the incidence of BPD.

Acute lung injury in preterm newborn infants: mechanisms and management

Respiratory morbidity and mortality remain common in preterm infants. The immature preterm lung is especially prone to injury. This process often starts in-utero due to maternal chorioamnionitis, priming the lung for further injury in response to post-natal ventilation, oxygen and nosocomial infection. Pulmonary inflammation has been strongly implicated in the pathway leading to lung injury in this population of infants. Several therapeutic approaches have been attempted to prevent acute lung injury or to limit its progress. The mechanisms of acute lung injury in preterm infants; their clinical correlates and available therapeutic approaches are reviewed here.

Does parenteral nutrition influence electrolyte and fluid balance in preterm infants in the first days after birth?

Background

New national guidelines recommend more restricted fluid intake and early initiation of total parenteral nutrition (TPN) in very preterm infants. The aim was study the effect of these guidelines on serum sodium and potassium levels and fluid balance in the first three days after birth.

Methods

Two cohorts of infants <28 weeks gestational age, born at the Leiden University Medical Center in the Netherlands, were compared retrospectively before (2002–2004, late-TPN) and after (2006–2007, early-TPN) introduction of the new Dutch guideline. Outcome measures were serum sodium and potassium levels, diuresis, and changes in body weight in the first three postnatal days.

Results

In the first three postnatal days no differences between late-TPN (N = 70) and early-TPN cohort (N = 73) in mean (SD) serum sodium (141.1 (3.8) vs 141.0 (3.7) mmol/l) or potassium (4.3 (0.5) vs 4.3 (0.5) mmol/l) were found, but in the early-TPN cohort diuresis (4.5 (1.6) vs 3.2 (1.4) ml/kg/h) and loss of body weight were decreased (−6.0% (7.7) vs −0.8% (8.0)).

Conclusions

Initiation of TPN immediately after birth and restricted fluid intake in very preterm infants do not seem to influence serum sodium and potassium levels in first three postnatal days. Further research is needed to see if a decreased diuresis and loss of body weight in the first days is the result of a delayed postnatal adaptation or better energy balance.

Clinical determinants and utility of early postnatal maximum weight loss in fluid management of extremely low birth weight infants

BACKGROUND

The early postnatal physiological body weight loss process is poorly understood in preterm infants. It is complicated by clinical conditions which adversely affect the body fluid balance during 1st two weeks of life. A lack of physiological weight loss potentially could result in significant morbidities. Body weight is utilized in determining daily fluid volume intakes. Extremely low birth weight infants (birth weight<1000 g, ELBW) have the highest morbidity and mortality among all neonates.

AIM/OBJECTIVE

The objective was to evaluate the early postnatal weight changes and its clinical determinants in ELBW infants. We examined the maximum weight loss from birth weight (MWL) in ELBW infants and tested its association with clinical variables which could potentially implicate the body fluid balance during the first two weeks of life.

STUDY DESIGN

Prospectively entered data in the computerized radiology, biochemical and hematological records, and daily case notes were retrospectively extracted during a 3-year study period. The infants' and maternal demographic, clinical course and outcome variables relevant to body fluid balance during the first two weeks of life were correlated with MWL. Pearson's correlation coefficient and Pearson's partial correlation tests were utilized for data analysis.

RESULTS

Data are presented as mean+/-SD. MWL in the entire cohort (n=102) was 14.2+/-5.4%. Day of life of MWL was 5.5+/-2.1 and that of birth weight regained 14.5+/-4.2 days. MWL correlated negatively with gestational age, antenatal steroid receipt (ANS) and pregnancy associated hypertension and positively with total days on oxygen, fluid intake, urinary output and the day of life when birth weight was regained. All these correlations were lost after controlling for GA except for the day of life when birth weight was regained. MWL did not correlate with RDS or its severity, hypotension, PIE, IVH, PDA and length of stay. Over 91% infants had MWL within 3.1-25%. Male, Caucasian and ELBW infants unexposed to ANS tended to have weight loss in excess of 25%.

CONCLUSION

MWL is governed by maturation and is not affected by concurrent clinical factors including fluid intakes during the 1st two weeks of life in ELBW infants. MWL within the estimated range of 14.5+4.2% of birth weight does not promote morbidities. Male, Caucasian and ELBW infants unexposed to ANS are susceptible to excessively high weight losses in early postnatal period.

Fluid regimens in the first week of life may increase risk of patent ductus arteriosus in extremely low birth weight infants

BACKGROUND

High fluid volumes may increase neonatal morbidity. However, evidence supporting fluid restriction is inconclusive and restricting fluids may restrict caloric intake.

OBJECTIVE

To determine if higher fluid intake was associated with increased risk of patent ductus arteriosus (PDA) or bronchopulmonary dysplasia (BPD) in extremely low birth weight (ELBW) infants.

STUDY DESIGN

A total of 204 ELBW (<or=32 weeks, <or=1250 g) infant survivors were grouped into low-, intermediate- and high-fluid groups. chi2 analyzed proportions of subjects with and without morbidities across groups. Logistic regression quantified increased risk of PDA or BPD associated with fluid intake while controlling for confounders. Analysis of variance compared differences in caloric intake across groups.

RESULT

After controlling for gestational age, severity of illness and weight change, fluid intake on day 2 (odds ratio (OR) 1.014; confidence interval (CI) 1.001 to 1.028) and day 3 (OR 1.022; CI 1.004 to 1.040) was associated with increased risk of PDA.

CONCLUSION

High fluid intake (>170 ml kg(-1) day(-1)) in the first days of life is associated with increased risk of PDA.

Weight loss and bronchopulmonary dysplasia in very low birth weight infants

Our objective was to evaluate the extent of weight loss in very low birth weight (VLBW) preterm infants and to discover how weight loss and other variables correlate with bronchopulmonary dysplasia (BPD). We conducted an observational study of 387 VLBW preterms, gestational age (GA) < 33 weeks, in a single institution over a period of 5 years. The mean weight loss of AGA infants was significantly greater than that of SGA infants. In AGA infants, GA, z-score, weight loss, and male sex were found to correlate with BPD. After adjustments were made for GA and birth weight, each 10% loss of body weight increased the risk for developing BPD by a factor of 2.7. We concluded that excessive weight loss does not prevent BPD in VLBW preterms and presumably should be prevented. Controlled fluid restriction resulting in milder weight loss is probably the right choice.