Management and outcomes of very low birth weight

Diuresis-led volume replacement strategy in extremely low birth weight infants

AIM

In extremely low birth weight infants, fluid overload has been associated with bronchopulmonary dysplasia and death. Excessive weight loss may increase the risk of meconium obstruction and intestinal perforation. As these infants display oliguria followed by polyuria, we embarked on a diuresis-led volume replacement strategy as of January 2020.

METHODS

This single-centre analysis presents data of infants <1000 g birth weight surviving for more than 3 days admitted 2017-2019 (n = 217, daily volume increase) versus 2020-2022 (n = 2022, diuresis-led volume replacement).

RESULTS

The second cohort had lower gestational age (median [interquartile range]: 253/7 [243/7-264/7] vs. 263/7 [251/7-282/7] weeks), less antenatal steroids (58% vs. 69%), more indomethacin (66% vs. 47%) and higher initial diuresis (5.6 [4.9-6.8] vs. 4.8 [4.2-5.5] mL/kg/h) but did not differ by relative weight loss at Day 7 of life. Employing binary logistic regression with gestational age, antenatal steroids and indomethacin as covariates, the cohorts did not differ by rates of patent ductus arteriosus, abdominal surgery or severe retinopathy of prematurity, while there were significant declines in sepsis (from 32% to 19%), bronchopulmonary dysplasia (from 26% to 23%) and mortality (from 13% to 7%).

CONCLUSION

Diuresis-led volume replacement appears to be safe and maybe beneficial.

Effect of probiotic administration to breastfeeding mothers with very low birthweight neonates on some neonatal and maternal outcomes: study protocol for a randomised, double-blind, placebo-controlled trial

INTRODUCTION

Premature birth and very low birth weight (VLBW) are leading causes of neonatal mortality. Almost all premature infants experience hyperbilirubinaemia. Administering probiotics to breastfeeding mothers may positively affect infant outcomes. This trial aims to investigate whether probiotic supplementation for mothers with VLBW infants affects total serum bilirubin levels and postpartum depression scores (primary outcomes), as well as some other neonatal and maternal outcomes (secondary outcomes).

METHODS AND ANALYSIS

This is a randomised, double-blind, placebo-controlled superiority trial with two parallel arms. Participants, caregivers and outcome assessors will be blinded. A total of 122 breastfeeding mothers of neonates with a birth weight of 1000-1500 g, along with their infants within 48 hours of birth, will be assigned to either the probiotic or placebo group in a 1:1 ratio through block randomisation, stratified by singleton and twin births. The intervention will involve oral administration of probiotics containing Lactobacillus paracasei 431 and Bifidobacterium lactis BB-12, or an indistinguishable placebo, for 42-45 days. Outcomes will be assessed through daily observations, laboratory assessments and the Edinburgh Postpartum Depression Scale. Adverse events will also be documented. Modified intention-to-treat analyses will be employed for the primary and secondary outcomes, excluding participants lost to follow-up from all postintervention assessments.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Medical University of Tabriz Ethics Committee (IR.TBZMED.REC.1401.735). Findings will be disseminated through publication in a peer-reviewed journal and presentations at relevant conferences.

TRIAL REGISTRATION NUMBER

IRCT20100414003706N42.

Efficient administration of a combination of nifedipine and sildenafil citrate versus only nifedipine on clinical outcomes in women with threatened preterm labor: a systematic review and meta-analysis

BACKGROUND

Preterm labor (PTL) is a common and serious pregnancy disorder that can cause long-term neurological issues in the infant. There are conflicting studies concerning whether sildenafil citrate (SC) reduces preterm labor complications. Therefore, the meta-analysis aimed to examine the clinical outcomes in women with threatened PTL who received nifedipine plus SC therapy versus only nifedipine.

METHODS

For the original articles, six databases were searched using relevant keywords without restriction on time or language until January 13, 2024. The Cochrane risk-of-bias tool for randomized trials (RoB) and the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS) were both used to assess the risk of bias in randomized and non-randomized studies, and GRADE determined the quality of our evidence. Meta-analysis of all data was carried out using Review Manager (RevMan) version 5.1.

RESULTS

Seven studies with mixed quality were included in the meta-analysis. The study found that combining nifedipine and SC resulted in more prolongation of pregnancy (MD = 6.99, 95% CI: 5.32, 8.65, p < 0.00001), a lower rate of delivery in the 1st to 3rd days after hospitalization (RR = 0.62, 95% CI: 0.50, 0.76, p < 0.00001), a higher birth weight (252.48 g vs. nifedipine alone, p = 0.02), and the risk ratio of admission to the neonatal intensive care unit (NICU) was significantly lower (RR = 0.62, 95% CI: 0.50, 0.76, p < 0.00001) compared to nifidepine alone. The evidence was high for prolongation of pregnancy, delivery rate 24-72 h after admission, and NICU admission, but low for newborn birth weight.

CONCLUSIONS

Given the effectiveness of SC plus nifedipine in increased prolongation of pregnancy and birth weight, lower delivery in the 1st to 3rd days after hospitalization, and NICU admission, Gynecologists and obstetricians are suggested to consider this strategy for PTL management, although additional article rigor is required to improve the quality of the evidence.

Prenatal use of indomethacin for preterm labor and renal function among very low birth weight infants

BACKGROUND

Indomethacin is administered as a tocolytic agent for threatening preterm labor <28weeks of gestation. Only a few, not conclusive, studies have investigated its nephrotoxicity in very low birth weight (VLBW) infants. We investigated whether indomethacin increases the incidence of acute kidney injury (AKI) among VLBW infants.

METHODS

This is a retrospective study including all VLBW infants born at our center between January 1, 2005, and December 31, 2013. Indomethacin was administered to women with preterm labor and intact membranes. Neonatal AKI was defined according to KDIGO classification. Univariate analyses were performed comparing VLBW infants exposed to and not exposed to indomethacin. In the multivariable model, the association of indomethacin and AKI was adjusted for patent ductus arteriosus, use of nephrotoxic medications, birth weight, and gestational age.

RESULTS

Five hundred seventy-five VLBW infants were included, 49 (8.5%) of whom were exposed to indomethacin in utero. The univariate analysis showed that infants exposed to indomethacin had lower birth weight, lower gestational age, and higher incidence of AKI than infants not exposed. The multivariable model adjusted for confounding factors confirmed an increased risk of AKI in relation to gestational age at birth <27 weeks, but not to indomethacin.

CONCLUSIONS

Our data suggest that extreme prematurity, but not the use of indomethacin, is associated with AKI.

Challenges in Using Progestin to Prevent Singleton Preterm Births: Current Knowledge and Clinical Advice

Preterm birth is the leading cause of infant morbidity and mortality in children younger than 5 years old and accounts for approximately 35% of newborn deaths worldwide. The use of progestogen therapy for prevention of preterm birth has been one of the most controversial topics in modern obstetrics. Progestogens can be classified as natural or synthetic. Progesterone is a natural progestogen while progestins such as 17-alpha-hydroxyprogesterone caproate (17OHP-C) are synthetic steroid hormones. Evidence supporting the use of progestogens varies by formulation and populations studied. After more than a decade, the US Food and Drug Administration has withdrawn accelerated approval of 17OHP-C for the prevention of recurrent preterm birth in pregnant individuals with a singleton gestation. With this decision, there is no current FDA-approved treatment for prevention of spontaneous preterm birth. In this review, we provide a historical context behind the rise and fall of 17OHP-C clinical application, highlight the challenges behind the data supporting progestogen use, and offer suggestions on how to make an impact on preterm birth moving forward.

Impact of a family-centred clinical care programme on short-term outcomes of very low-birth weight infants

AIM

We evaluated the effects of a family-centred clinical care pathway and case management programme on short-term clinical outcome in a cohort of very low-birth weight (VLBW) infants.

METHODS

The programme, named NeoPAss, was developed at the Department of Neonatology Children's hospital Passau in 2013. Short-term outcomes of infants were compared to matched controls from the Bavarian neonatology surveillance database before (n = 111; 2008-2012) and after implementation (n = 170; 2014-2017).

RESULTS

After implementation the rate of late-onset sepsis was significantly lower (2.5% vs. 10.7%, p = 0.005) and the length of stay was significantly shorter (VLBW 28 to 31 weeks' gestational age (GA) 47.5 vs. 53.1 days, p = 0.047; <28 weeks' GA 79.4 vs. 91.9 days, p = 0.007) in the intervention group compared to controls. Infants were discharged with significantly lower weight (mean 2351 vs. 2539 g, p = 0.013). There was no statistically significant difference in the rate of intraventricular haemorrhage (3.7% vs. 8.2%), necrotizing enterocolitis (0.6% vs. 1.9%) and bronchopulmonary dysplasia (0% vs. 6.9%).

CONCLUSION

Our data confirm that of other studies demonstrating a beneficial effect of family-centred care programmes and provides evidence that structured parental involvement is not associated with increased risk of infection in a VLBW cohort.

Lung Volume Head Ratio: A Potential Parameter for Prediction of Respiratory Distress in Newborn

OBJECTIVE

This study aimed to evaluate the role of fetal lung biometry profile including fetal lung volume head ratio (LVHR) in predicting the occurrence of respiratory distress (RD) in early preterm newborn.

STUDY DESIGN

Prospective analytical cohort study was done to evaluate the clinical value of fetal sonographic measures, such as the total lung area (TLA), total lung volume (TLV), TLA head ratio (TLHR), LVHR, in pregnant women between 30 to 34 weeks' gestation who were expected to deliver within the next 72 hours. The cases with RD were compared with controls who had normal outcome.

RESULT

A total of 30 (27.4%) out of 110 patients, who underwent early preterm delivery, with RD rest 80 (72.6%) were controls. The TLA was 694.1 ± 373.1 mm2 in cases whereas 1,149.0 ± 506 0.7 mm2 in controls with significant difference between the two groups (p < 0.001). Similarly the lung volume (p < 0.001) and the LVHR were significantly less (p < 0.001) in cases compared with controls. The TLV was a better parameter (sensitivity, 73.7% and specificity, 86.4%) compared with TLA (sensitivity, 68.4% and specificity, 81.5%). Among the lung head ratios, LVHR had the best sensitivity of 95.5%, specificity: 80.3%, positive predictive value (PPV): 58.3%, and negative predictive value (NPV): 97.0% at the cut-off of 46.5.

CONCLUSION

RD was observed in nearly one-third of the preterm infants born between 30 and 34 weeks of gestation and could be predicted accurately in over 9 out of 10 cases using the novel parameter TLVR.

KEY POINTS

· Preterm newborn.. · Fetal lung volume.. · Respiratory distress..

The relationship between COVID-19 vaccination status in pregnancy and birthweight

BACKGROUND

Despite findings that maternal COVID-19 infection in pregnancy is associated with low birthweight (weight of ≤2500 g), previous studies demonstrate no difference in low birthweight risk between COVID-19 vaccinated and unvaccinated pregnant persons. Few studies, however, have examined the association between unvaccinated, incomplete vaccination, and complete vaccination on low birthweight, and they have been limited by small sample sizes and lack of adjustment for covariates.

OBJECTIVE

We sought to address key limitations of prior work and evaluate this association between unvaccinated, incomplete, and complete COVID-19 vaccination status in pregnancy and low birthweight. We predicted a protective association of vaccination on low birthweight that varies by number of doses received.

STUDY DESIGN

We performed a population-based retrospective study using the Vizient clinical database, which included data from 192 hospitals in the United States. Our sample included pregnant persons who delivered between January 2021 and April 2022 at hospitals that reported maternal vaccination data and birthweight at delivery. Pregnant persons were categorized into 3 groups as follows: unvaccinated; incompletely vaccinated (1 dose of Pfizer or Moderna); or completely vaccinated (1 dose of Johnson & Johnson or ≥2 doses of Moderna or Pfizer). Demographics and outcomes were analyzed using standard statistical tests. We performed multivariable logistic regression to account for potential confounders between vaccination status and low birthweight in the original cohort. Propensity score matching was used to reduce bias related to the likelihood of vaccination, and the multivariable logistic regression model was then applied to the propensity score-matched cohort. Stratification analysis was performed for gestational age and race and ethnicity.

RESULTS

Of the 377,995 participants, 31,155 (8.2%) had low birthweight, and these participants were more likely to be unvaccinated than those without low birthweight (98.8% vs 98.5%, P<.001). Incompletely vaccinated pregnant persons were 13% less likely to have low birthweight neonates compared to unvaccinated persons (odds ratio, 0.87; 95% confidence interval, 0.73-1.04), and completely vaccinated persons were 21% less likely to have low birthweight neonates (odds ratio, 0.79; 95% confidence interval, 0.79-0.89). After controlling for maternal age, race or ethnicity, hypertension, pregestational diabetes, lupus, tobacco use, multifetal gestation, obesity, use of assisted reproductive technology, and maternal or neonatal COVID-19 infections in the original cohort, these associations remained significant for only complete vaccination (adjusted odds ratio, 0.80; 95% confidence interval, 0.70-0.91) and not incomplete vaccination (adjusted odds ratio, 0.87; 95% confidence interval, 0.71-1.04). In the propensity score-matched cohort, pregnant persons who were completely vaccinated against COVID-19 were 22% less likely to have low birthweight neonates compared to unvaccinated and incompletely vaccinated individuals (adjusted odds ratio, 0.78; 95% confidence interval, 0.76-0.79).

CONCLUSION

Pregnant persons who were completely vaccinated against COVID-19 were less likely to have low birthweight neonates compared to unvaccinated and incompletely vaccinated individuals. This novel association was observed among a large population after adjusting for confounders of low birthweight and factors influencing the likelihood of receiving the COVID-19 vaccine.

Serum Zinc Levels in Preterm Newborns and its Relation with Retinopathy of Prematurity

Background

With the increased survival of preterm babies, retinopathy of prematurity (ROP) has become the leading cause of preventable childhood blindness. It is caused by oxidative damage to the immature retina and zinc may help in the prevention of ROP owing to its antioxidant properties.

Objective

To measure serum zinc levels in preterm neonates and study its association with the development of ROP.

Methods

A total of 360 preterm neonates of gestational age between 28 completed weeks to <37 weeks were included in this observational cross-sectional study. Serum zinc levels of the neonates aging <24 hours of life were measured at the time of admission in NICU by spectrophotometry. Taking the reference range of serum zinc levels between 70 to 150 mcg/dL babies were arbitrarily divided into 2 groups (<70 and >70 mcg/dL). ROP screening was done at appropriate postnatal age by indirect ophthalmoscopy. The results were analyzed by the SPSS software version.

Results

The mean serum zinc level was 114.99±54.47 mcg/dL. The overall prevalence of ROP was 26%; of which, 10% of neonates had severe ROP (≥stage 3). A significant association was found between gestational age and birth weight with ROP. Oxygen supplementation, respiratory distress syndrome, surfactant use, antibiotic use >7 days, and low serum zinc levels (<70 mcg/dL) were significant risk factors on univariate analysis and after multivariate analysis, gestational age, surfactant use, and low serum zinc levels (<70 mcg/dL) came out to be independent risk factors for ROP.

Conclusion

There was a statistically significant association of low serum zinc levels with the development of ROP and it was independent of other risk factors associated with ROP.

Profile of Hospital Admissions Due to Preterm Labor and Delivery in England

OBJECTIVES

Preterm labor and delivery are associated with various short- and long-term complications in neonates and infants. This research aimed to look at the trends in preterm labor and birth-related hospitalizations in England.

MATERIAL AND METHODS

The Hospital Episode Statistics database was used to extract hospital admission data for the ecological study of preterm labor and delivery between April 2012 and April 2020 in England.

RESULTS

The overall admission rates decreased by 26.2%, from 14,210 in 2012 (CI: 99.18-102.49) to 10,490 in 2020 (CI: 73.02-75.87) per 100,000 individuals. Hospitalizations were frequently caused by spontaneous labor with preterm delivery, spontaneous labor without delivery, and preterm delivery without spontaneous labor (68.9%, 20.6%, and 9.6%, respectively). The rate of hospital admission due to preterm delivery without spontaneous labor, preterm labor without delivery, preterm spontaneous labor with preterm delivery, and preterm spontaneous labor with term delivery decreased by 32.0%, 26.9%, 24.4%, and 14.7%, respectively. Women aged 25-29 years accounted for most hospital admissions.

CONCLUSION

Preterm labor and delivery-related hospital admissions rates have significantly decreased over the past decade. Women in the reproductive age range of 25-34 years were more prone to hospital admission followed by preterm labor due to various reasons.

Outcomes and predictors of functioning, mental health, and health-related quality of life in adults born with very low birth weight: a prospective longitudinal cohort study

Background

Very low birth weight (VLBW: ≤1500 g) is associated with multiple short and long-term complications. This study aimed to examine outcomes and predictors of functioning, mental health, and health-related quality of life in adults born with VLBW.

Methods

In this prospective longitudinal cohort study, 67 VLBW and 102 control participants were assessed using the Adult Self-Report of the Achenbach System of Empirically Based Assessment and Global Assessment of Functioning at 26 years, and the Hospital Anxiety and Depression Scale and Short Form-36 at 28 years of age. Associations between perinatal and childhood predictors and adult functioning were assessed using linear regression.

Results

Compared with controls, the VLBW group had lower mean raw scores on the Function and Symptom subscales of the Global Assessment of Functioning at 26 years, a higher sum score of symptoms of anxiety and depression due to more depressive symptoms, and poorer mental health-related quality of life at 28 years. The mean group differences ranged from 0.42 to 0.99 SD. Within the VLBW group, lower birth weight and gestational age, a higher number of days with respiratory support and poorer motor function at 14 years were associated with a higher sum score of symptoms of anxiety and depression at 28 years. Days with respiratory support and motor function at 14 years were also predictive of Global Assessment of Functioning scores at 26 years, and mental health-related quality of life at 28 years. Poorer motor and cognitive function at five years were associated with poorer physical health-related quality of life at 28 years. Parental socioeconomic status was related to mental and physical health-related quality of life.

Conclusion

In this study, VLBW adults reported poorer functioning and mental health-related quality of life, and more depressive symptoms than their term born peers. Days with respiratory support and adolescent motor function predicted most of the adult outcomes. This study explicates perinatal and developmental markers during childhood and adolescence which can be target points for interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03676-6.

Active Treatment of Infants Born at 22-25 Weeks of Gestation in California, 2011-2018

OBJECTIVE

To determine the rate and trend of active treatment in a population-based cohort of infants born at 22-25 weeks of gestation and to examine factors associated with active treatment.

STUDY DESIGN

This observational study evaluated 8247 infants born at 22-25 weeks of gestation at hospitals in the California Perinatal Quality Care Collaborative between 2011 and 2018. Multivariable logistic regression was used to relate maternal demographic and prenatal factors, fetal characteristics, and hospital level of care to the primary outcome of active treatment.

RESULTS

Active treatment was provided to 6657 infants. The rate at 22 weeks was 19.4% and increased with each advancing week, and was significantly higher for infants born between days 4 and 6 at 22 or 23 weeks of gestation compared with those born between days 0 and 3 (26.2% and 78.3%, respectively, vs 14.1% and 65.9%, respectively; P < .001). The rate of active treatment at 23 weeks increased from 2011 to 2018 (from 64.9% to 83.4%; P < .0001) but did not change significantly at 22 weeks. Factors associated with increased odds of active treatment included maternal Hispanic ethnicity and Black race, preterm premature rupture of membranes, obstetrical bleeding, antenatal steroids, and cesarean delivery. Factors associated with decreased odds included lower gestational age and small for gestational age birth weight.

CONCLUSIONS

In California, active treatment rates at 23 weeks of gestation increased between 2011 and 2018, but rates at 22 weeks did not. At 22 and 23 weeks, rates increased during the latter part of the week. Several maternal and infant factors were associated with the likelihood of active treatment.

Long-term neurodevelopmental outcome in preterm infants with intraventricular haemorrhage

BACKGROUND

Intraventricular haemorrhage (IVH) is one of the key risks for long-term neurodevelopmental issues. There remains controversy over the impact low-grade IVH has on the long-term outcome of premature infants. This study describes the long-term neurodevelopmental impact of Grade I and II IVH in former preterm infants in the early school years.

METHODS

This is a retrospective cohort analysis from one tertiary neonatal intensive care unit (NICU) in Australia including all infants born at <30 weeks' gestation and admitted to the NICU between 2006 and 2013 with complete ultrasound reports and follow-up results. Results of standardised tests for neurodevelopmental outcomes at 5 and 8 years were compared between infants who suffered mild IVH and infants who had normal head ultrasounds.

RESULTS

During the study period, 491 infants <30 weeks gestation were admitted; 275 patients had full follow-up data available. We found no significant difference in examined outcomes at 5- and 8-year follow-up.

CONCLUSION

Mild IVH does not affect cognitive, motor and academic outcomes at school age.

Osteopathic Manipulative Treatment Decreases Hospital Stay and Healthcare Cost in the Neonatal Intensive Care Unit

Osteopathic manipulative treatment (OMT) is used in both inpatient and outpatient settings. Evidence suggests that OMT can reduce both patients' recovery time and the financial cost of their acute medical treatment and rehabilitation. Multiple studies from neonatal intensive care units (NICUs) are presented in this article that demonstrate infants treated with OMT recover faster, are discharged earlier, and have lower healthcare costs than their non-OMT-treated counterparts. Data clearly show that adjunctive OMT facilitates feeding coordination in newborns, such as latching, suckling, swallowing, and breathing, and increases long-term weight gain and maintenance, which reduces hospital length of stay (LOS). Osteopathic techniques, such as soft tissue manipulation, balanced ligamentous tension, myofascial release, and osteopathic cranial manipulation (OCM), can reduce regurgitation, vomiting, milky bilious, or bloody discharge and decrease the need for constipation treatment. OMT can also be effective in reducing the complications of pneumonia in premature babies. Studies show the use of OCM and lymphatic pump technique (LPT) reduces the occurrence of both aspiration and environmentally acquired pneumonia, resulting in significantly lower morbidity and mortality in infants. Based on published findings, it is determined that OMT is clinically effective, cost efficient, a less invasive alternative to surgery, and a less toxic choice to pharmacologic drugs. Therefore, routine incorporation of OMT in the NICU can be of great benefit in infants with multiple disorders. Future OMT research should aim to initiate clinical trial designs that include randomized controlled trials with larger cohorts of infants admitted to the NICU. Furthermore, a streamlined and concerted effort to elucidate the underlying molecular mechanisms associated with the beneficial effects of OMT will aid in understanding the significant value of incorporating OMT into optimal patient care.

A Neurologist's Guide to Neonatal Neurodevelopmental Assessments and Preterm Brain Injury

Despite advances in medical care and improved survival of extremely preterm infants, rates of neurodevelopmental impairment remain high. Outcomes are significantly improved with early intervention, but infants must be appropriately identified to facilitate services. Neuroimaging provides important information regarding neurodevelopmental outcomes but prognosticating and communicating risk remains challenging. Standardized neonatal neurodevelopmental assessments provide supplemental information to aid in the identification of high-risk infants and counseling for their families.

Antioxidants: Role the in prevention and treatment of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is one of the major causes of chronic respiratory diseases among infants. Both pharmacological and nonpharmacological approaches have been proposed for its management. Since oxidative stress is known to play a pivotal role in the pathogenesis of BPD, it is reasonable to consider the potential of antioxidant strategies in the prevention and treatment of this condition. Indeed, antioxidants can prevent or inhibit substrate oxidation. Some studies have evaluated the efficacy of the exogenous administration of vitamins and micronutrients in reducing the propagation of free radicals through their scavenging capacity. Nonetheless, encouraging preclinical results did not translate into effective preventive and/or therapeutic interventions. This narrative review evaluates the current evidence about the antioxidants that are potentially useful for preventing and treating BPD and explores the most relevant issues affecting their implementation in clinical practice, as well as their associated evidence gaps and research limitations.

Causes of Neonatal Acute Renal Injury during Critical Illnesses

The aim of the study was to assess acute kidney injury (AKI) and its contributing risk factors among neonates to reduce morbidity and mortality. The study included 310 neonates who were admitted to the neonatal intensive care unit (NICU). Serum creatinine (SCr) was elevated at admission, after 48 h, and before discharge or death. AKI was defined by either an acute rise in SCr of at least 0.3 mg/dL within 48 h or an increasing or persistently high level of SCr >1.5 mg/dL after 48-72 h of life. The patients who developed AKI were studied regarding the most common risk factors and outcomes. The prevalence of AKI in these neonates was 11.9%. Nephrotoxic drugs were the highest risk factor among patients with AKI, but this was not statistically significant different from patients without AKI. Perinatal asphyxia (59.5%), respiratory distress syndrome (48.6%), shock (43.2%), prematurity (40.5%), and sepsis (37.8%) were the main risk factors of AKI following the nephrotoxic drugs (64.9%). The mortality rate for cases with AKI was 62.1%, with a statistically significant difference from non-AKI neonates. The death rate was higher among neonates born before 36 weeks' gestation. There was no statistical difference between oliguric and non-oliguric neonates with AKI regarding the outcome. The overall incidence of AKI in sick neonates admitted to the NICU was 11.9%. Nephrotoxic drugs, perinatal asphyxia, shock, and prematurity were the main risk factors for developing AKI.

Exceeding expectations after perinatal risks for poor development: associations in term- and preterm-born preschoolers

OBJECTIVE

To define parenting/social characteristics associated with better-than-expected cognitive and motor outcomes in preschoolers at similar perinatal biological risk-level including various gestational ages at birth (GA) and perinatal complications.

STUDY DESIGN

Prospective cohort study (n = 87) of children at four years, median GA 29 weeks (IQR 26, 38). Assessments included Differential Ability Scales, Movement Assessment Battery, parenting styles, and social risk scores. Perinatal risk factors were weighted based on regression models for each outcome; individual calculated risk scores became predictors to extract standardized residuals from the mean (>1 SD above mean = better-than-expected). Mixed-effect regressions examined associations between positive adaptation and parenting/social factors.

RESULT

Perinatal risk scores explained 21-53% outcome variability. Children across all GA displayed positive adaptation. Children of parents with higher authoritarian scores had higher odds of better-than-expected outcomes (OR 1.17, p = 0.0002).

CONCLUSION

Parental structure may promote positive adaptation at preschool age in children with perinatal risk factors for poor development, including extreme prematurity.

Short information: Bacterial meningitis in very low birthweight infants in Korea from 2013-2016

BACKGROUND

Neonatal bacterial meningitis (BM) has an incidence of 0.2-0.4 per 1,000 births and a mortality rate of 20-25%. Data from the Korean Neonatal Network (KNN) were evaluated to study the incidence, mortality, and risk factors associated with BM in very-low-birthweight (VLBW; <1,500 g) infants.

METHODS

We analyzed KNN data from 2013-2016 collected from 70 neonatal units.

RESULTS

The incidence of BM in VLBW infants was 40 out of 8,263 (0.5%). The 40 infants with BM had a mean gestational age of 27.1 ± 2.0 weeks and a mean birthweight of 1,036.8 ± 220.0 g. Mean age at diagnosis was 51.5 ± 38.3 days (range, 1-171). Infants with BM were divided into two groups: Group 1 (onset age ≤ 28 days) and Group 2 (onset age > 28 days). Coagulase-negative Staphylococcus (CONS) was the most common pathogen underlying meningitis in 11 of 40 cases (28%). BM co-occurred with bacteremia in 14 of 40) of cases (35%); bacteremia was significantly more common in Group 1 than Group 2 (P < 0.05). Seizure and intraventricular hemorrhage (≥grade 3) were significantly more prevalent in Group 2 than Group 1 (P < 0.05). The mortality rate of infants with BM was 4 out of 40 (10%), which was significantly lower than that of VLBW infants without BM (1,152/8,223, [14%]; P < 0.05).

CONCLUSIONS

The incidence of BM in VLBW infants was high, but the mortality rate was low. CONS was the most common pathogen of BM in VLBW infants.

Ventilatory control instability as a predictor of persistent periodic breathing in preterm infants

BACKGROUND

Periodic breathing (PB) is common in preterm infants. We aimed to characterize the contribution of ventilatory control instability to the presence and persistence of PB longitudinally.

METHODS

Infants born between 28 and 32 weeks of gestation were studied using daytime polysomnography at: 32-36 weeks postmenstrual age (PMA) (N = 32), 36-40 weeks PMA (N = 20), 3 months corrected age (CA) (N = 18) and 6 months CA (N = 19). Loop gain, a measure of sensitivity of the ventilatory control system, was estimated by fitting a mathematical model to ventilatory patterns associated with spontaneous sighs.

RESULTS

The time spent in PB decreased from 32-36 weeks PMA to 6 months CA (P = 0.005). Across all studies, studies with PB (N = 62) were associated with higher loop gain compared to those without PB (N = 23) (estimated marginal mean ± SEM: 0.445 ± 0.01 vs 0.388 ± 0.02; P = 0.020). A threshold of loop gain >0.415 (measured at 32-36 weeks PMA) provided a sensitivity of 86% and a specificity of 75% to detect the presence of PB at 6 months CA.

CONCLUSIONS

The course of PB in preterm infants is related to changes in loop gain. Higher loop gain at 32-36 weeks PMA was associated with a greater risk of persistent PB at 6 months CA.

IMPACT

The developmental trajectory of periodic breathing and its relationship to ventilatory control instability is currently unclear. Unstable ventilatory control is a determinant of periodic breathing in preterm infants up to 6 months corrected age. Infants who display greater ventilatory control instability at 32-36 weeks postmenstrual age may be at increased risk of persistent periodic breathing at 6 months corrected age. Assessment of ventilatory control stability may assist in the early identification of infants at risk of persistent periodic breathing and its potential adverse effects.

Premature Infants have no Higher Risk of Atopy and Respiratory Functions Compared to Control at 4-6 Years of Age

AIMS

This study aimed to evaluate the respiratory functions and atopy conditions of preterm infants treated with aminophylline or caffeine for apnea in NICU in early childhood.

MATERIALS AND METHODS

This is a retrospective cohort study. In this study, 27 patients aged 4 to 6 years hospitalized in NICU for prematurity and 26 healthy children were included. The subjects were evaluated for fx5, phadiatope, total IgE levels, skin tests, and respiratory function tests.

RESULTS

There was no statistically significant difference among groups in terms of fx5, phadiatope, total IgE levels, and skin test results. Moreover, no statistically significant difference was found among the groups in terms of FVC, FEV₁, FEV₁/ FVC, PEF, MEF₇₅, MEF₅₀, MEF₂₅, and MEF_25-75 values in respiratory function tests. Preterm neonates with bronchopulmonary dysplasia (BPD) had higher FEV₁ values compared to ones without BPD (p=0.02).

CONCLUSION

Preterm infants treated with aminophylline or caffeine did not have a higher risk of atopy and had similar respiratory function tests compared to healthy infants at 4-6 years old. However, FEV₁ values were higher in infants with BPD. These results suggested that respiratory functions could be affected in the long-term follow-up of premature infants with BPD.

Lack of Enteral Feeding Associated with Mortality in Prematurity and Necrotizing Enterocolitis

BACKGROUND

Necrotizing Enterocolitis (NEC) remains a significant cause of morbidity and mortality. Recently, there has been an increased recognition of the importance of intestinal immunity and the associations with antibiotics and enteral feeds in the pathophysiology of NEC. The primary purpose of this study is to examine the association of enteral feeds on the survival of premature neonates with NEC.

MATERIAL AND METHODS

A retrospective review using the Vermont Oxford Network for a Level IV NICU from January 1, 2013 through December 31, 2019 was performed. All neonates had a gestational age between 22 to 29 weeks, weighed at least 300 grams (n = 653), had a reported enteral feed status and were treated for NEC (n = 43). Data analysis utilized two-tailed t-tests for NEC and infection rates then Fisher's exact tests for survival status.

RESULTS

The incidence of NEC in the population was 6.6% (43/653). Of the 43 neonates treated for NEC, 27 were enterally fed, while the other 16 were not. All 27 neonates with NEC that were able to achieve enteral feeds survived and had an infection rate of 22.2%. Meanwhile, all 16 neonates with NEC that were unable to achieve enteral feeds died and had an infection rate of 62.5%.

CONCLUSIONS

There is a significant association between enteral feeds and NEC, survival, and infection rates in premature neonates. These findings support the importance of intestinal immunity and the microbiota in NEC. Given the limitations of the retrospective review, the profound survival advantage with enteral feeds reinforces the need for further study.

Sustained peripheral immune hyper-reactivity (SPIHR): an enduring biomarker of altered inflammatory responses in adult rats after perinatal brain injury

Background

Chorioamnionitis (CHORIO) is a principal risk factor for preterm birth and is the most common pathological abnormality found in the placentae of preterm infants. CHORIO has a multitude of effects on the maternal–placental–fetal axis including profound inflammation. Cumulatively, these changes trigger injury in the developing immune and central nervous systems, thereby increasing susceptibility to chronic sequelae later in life. Despite this and reports of neural–immune changes in children with cerebral palsy, the extent and chronicity of the peripheral immune and neuroinflammatory changes secondary to CHORIO has not been fully characterized.

Methods

We examined the persistence and time course of peripheral immune hyper-reactivity in an established and translational model of perinatal brain injury (PBI) secondary to CHORIO. Pregnant Sprague–Dawley rats underwent laparotomy on embryonic day 18 (E18, preterm equivalent). Uterine arteries were occluded for 60 min, followed by intra-amniotic injection of lipopolysaccharide (LPS). Serum and peripheral blood mononuclear cells (PBMCs) were collected at young adult (postnatal day P60) and middle-aged equivalents (P120). Serum and PBMCs secretome chemokines and cytokines were assayed using multiplex electrochemiluminescent immunoassay. Multiparameter flow cytometry was performed to interrogate immune cell populations.

Results

Serum levels of interleukin-1β (IL-1β), IL-5, IL-6, C–X–C Motif Chemokine Ligand 1 (CXCL1), tumor necrosis factor-α (TNF-α), and C–C motif chemokine ligand 2/monocyte chemoattractant protein-1 (CCL2/MCP-1) were significantly higher in CHORIO animals compared to sham controls at P60. Notably, CHORIO PBMCs were primed. Specifically, they were hyper-reactive and secreted more inflammatory mediators both at baseline and when stimulated in vitro. While serum levels of cytokines normalized by P120, PBMCs remained primed, and hyper-reactive with a robust pro-inflammatory secretome concomitant with a persistent change in multiple T cell populations in CHORIO animals.

Conclusions

The data indicate that an in utero inflammatory insult leads to neural–immune changes that persist through adulthood, thereby conferring vulnerability to brain and immune system injury throughout the lifespan. This unique molecular and cellular immune signature including sustained peripheral immune hyper-reactivity (SPIHR) and immune cell priming may be a viable biomarker of altered inflammatory responses following in utero insults and advances our understanding of the neuroinflammatory cascade that leads to perinatal brain injury and later neurodevelopmental disorders, including cerebral palsy.

Evaluation of the Mortality and Morbidity of Premature Infants During a Five-Year Period in the Neonatal Intensive Care Unit

Background Premature birth is the most important cause of perinatal mortality and morbidity. This study aimed to evaluate mortality and morbidity in premature infants over a five-year period at a university hospital providing tertiary intensive care health services. Methodology All premature infants born alive at ≤37 gestational weeks and hospitalized in neonatal intensive care units were included in the study. Data such as maternal and perinatal characteristics, characteristics of the newborn, respiratory and related problems, neonatal morbidities, and causes of death were retrieved retrospectively from file records. Results A total of 1,780 patients (53.7% male and 46.3% female) were included in the study. High-risk pregnancy was present in 55% of women. Respiratory distress syndrome (RDS) developed in 50.4% of the patients, intracranial hemorrhage in 8.4%, and necrotizing enterocolitis in 5.6%. Mortality was observed in 20.9% of the patients. The most frequent cause of death was RDS and related complications (11.8%), and 66.4% of mortality occurred during the early neonatal period, that is, the first 24 hours of life. Conclusions High-risk pregnancies were significantly associated with neonatal morbidity and mortality. Therefore, the management of maternal health factors should be the priority for controlling neonatal mortality.

Cognitive and Behavioral Outcomes of School-aged Children Born Extremely Preterm: a Korean Single-center Study with Long-term Follow-up

BACKGROUND

School-aged children born very preterm have been suggested to have worse cognitive and behavioral outcomes than children born full-term. Executive function (EF) is a higher level of cognitive function related to academic achievement. The present study aimed to evaluate the cognitive (including EF) and behavioral outcomes of Korean children born extremely preterm (EP) and to analyze any biological or socioeconomic risk factors for poor cognitive outcomes in this population.

METHODS

A total of 71 infants weighing < 1,000 g at birth or born before 30 weeks of gestation (EP group) who were admitted to the neonatal intensive care unit from 2008 to 2009 were included in this study and compared with 40 term-birth controls. The Korean Wechsler Intelligence Scale for Children-Fourth Edition, Advanced Test of Attention (ATA), Stroop test, Children's Color Trails Test (CCTT), and Wisconsin Card Sorting Test (WCST) were used. Additionally, the Korean Child Behavior Checklist (K-CBCL) and Korean ADHD Rating Scale (K-ARS) were completed. Perinatal and demographic data were collected and analyzed.

RESULTS

The mean full-scale intelligence quotient (FSIQ) score in the EP group was significantly lower than that of the term control group (89.1 ± 18.3 vs. 107.1 ± 12.7; P < 0.001). In the EP group, 26 (37%) children had an FSIQ score below 85, compared to only one child (3%) in the control group. Furthermore, the EP group showed significantly worse EF test results (ATA, Stroop test, CCTT, WCST). Except for the higher social immaturity subscore in the EP group, the K-CBCL and K-ARS scores were not different between the two groups. EP children who received laser treatment for retinopathy of prematurity (ROP) had an 8.8-fold increased risk of a low FSIQ score, and a 1-point increase in the discharge weight Z-score decreased the risk of a low FSIQ score by approximately half in this EP cohort.

CONCLUSION

This is the first Korean study to investigate the cognitive and behavioral outcomes of school-aged children born EP. In the study cohort, EP children exhibited significantly lower FSIQ scores and EF than their full-term peers, and 37% of them had cognitive problems. Nonetheless, except for social immaturity, the behavioral problems were not different in EP children. Severe ROP and low discharge weight Z-score were identified as independent risk factors for low FSIQ score after adjusting for birth weight.

Weight gain in the first week of life and its association with morbidity and mortality in extremely low birthweight (ELBW) infants

BACKGROUND

Weight gain in the first week of life is indicative of fluid excess in preterm neonates.

AIMS

To determine if morbidity and/or mortality of extremely low birthweight (ELBW) infants was lower in those who did not have excess weight gain in the first week of life, compared with those who did.

STUDY DESIGN

Retrospective cohort study.

SUBJECTS

ELBW infants born from 1st May 2014 - 31st May 2019.

EXCLUSIONS

major congenital abnormalities (including hydrops), died within the first 7 days, no recorded weight on day 6, 7 or 8.

OUTCOME MEASURES

We compared infants whose weight was greater than birthweight by day 7 and infants whose weight remained at, or below, birthweight by day 7.

RESULTS

There were 312 ELBW infants in the study population: 15 (5%) died before discharge from hospital. Holding birthweight and gestational age (GA) constant, the odds of death in neonates with day 7 weight >birthweight was about 3 times the odds of death in neonates with day 7 weight ≤birthweight (adjusted odds ratio 3.18, 95% confidence interval 0.66-15.26, p = 0.15). Neonates with day 7 weight >birthweight were more likely to have had a PDA that required treatment than those with day 7 weight ≤birthweight (65% versus 43% respectively; p <0.001).

CONCLUSIONS

ELBW infants who gain weight in the first week of postnatal life, have a greater risk of PDA requiring treatment and may have a higher risk of mortality than infants who lose weight in the first week of life.

Association of maternal prenatal selenium concentration and preterm birth: a multicountry meta-analysis

BACKGROUND

Selenium (Se), an essential trace mineral, has been implicated in preterm birth (PTB). We aimed to determine the association of maternal Se concentrations during pregnancy with PTB risk and gestational duration in a large number of samples collected from diverse populations.

METHODS

Gestational duration data and maternal plasma or serum samples of 9946 singleton live births were obtained from 17 geographically diverse study cohorts. Maternal Se concentrations were determined by inductively coupled plasma mass spectrometry analysis. The associations between maternal Se with PTB and gestational duration were analysed using logistic and linear regressions. The results were then combined using fixed-effect and random-effect meta-analysis.

FINDINGS

In all study samples, the Se concentrations followed a normal distribution with a mean of 93.8 ng/mL (SD: 28.5 ng/mL) but varied substantially across different sites. The fixed-effect meta-analysis across the 17 cohorts showed that Se was significantly associated with PTB and gestational duration with effect size estimates of an OR=0.95 (95% CI: 0.9 to 1.00) for PTB and 0.66 days (95% CI: 0.38 to 0.94) longer gestation per 15 ng/mL increase in Se concentration. However, there was a substantial heterogeneity among study cohorts and the random-effect meta-analysis did not achieve statistical significance. The largest effect sizes were observed in UK (Liverpool) cohort, and most significant associations were observed in samples from Malawi.

INTERPRETATION

While our study observed statistically significant associations between maternal Se concentration and PTB at some sites, this did not generalise across the entire cohort. Whether population-specific factors explain the heterogeneity of our findings warrants further investigation. Further evidence is needed to understand the biologic pathways, clinical efficacy and safety, before changes to antenatal nutritional recommendations for Se supplementation are considered.

Long-term Follow-up of Preterm Infants Having Been Colonized With Extended Spectrum Beta-lactamase-producing Enterobacterales Over the First 6 Years of Life

We performed a retrospective case-control cohort study following 146 preterm infants (≤32 weeks of gestation) who had been colonized with extended spectrum beta-lactamase producing Enterobacterales and compared them with 1:1 matched controls regarding rates of hospitalizations and outpatient visits because of infectious and gastrointestinal diseases and developmental impairment up to school age. Preterm infants with extended spectrum beta-lactamase producing Enterobacterales colonization did have neither higher rates of gastrointestinal or infectious diseases nor higher rates of developmental impairments up to the age of 6 years.

Neonatal Intensive Care Unit Admission Temperatures of Infants 1500 g or More: The Cold Truth

BACKGROUND

Smaller preterm infants often receive extra attention with implementation of additional thermoregulation interventions in the delivery room. Yet, these bundles of interventions have largely remained understudied in larger infants.

PURPOSE

The purpose of this study was to evaluate initial (or admission) temperatures of infants born weighing 1500 g or more with diagnoses requiring admission to the neonatal intensive care unit (NICU).

METHODS

Retrospective medical record review of 388 infants weighing 1500 g or more admitted to the NICU between January 2016 and June 2017.

RESULT

In total, 42.5% of infants weighing 1500 g or more were admitted hypothermic (<36.5°C), 54.4% with a normothermic temperature, and 2.8% were hyperthermic. Of those infants admitted hypothermic, 30.4% had an admission temperature ranging from 36°C to 36.4°C and 12.1% had an admission temperature of less than 36°C. When compared with infants weighing less than 1500 g, who were born at the same institution and received extra thermal support interventions, there was a statistically significant difference (P < .001) between admission temperatures where infants less than 1500 g were slightly warmer (36.8°C vs 36.5°C).

IMPLICATIONS FOR PRACTICE

Ongoing admission temperature monitoring of all infants requiring NICU admission regardless of birth weight or admission diagnosis is important if we are going to provide the best support to decrease mortality and morbidity for this high-risk population.

IMPLICATIONS FOR RESEARCH

While this study examined short-term outcomes, effects on long-term outcomes were not addressed. Findings could be used to design targeted interventions to support thermal regulation for all high-risk infants.

CONCLUSION

Neonates admitted to the NICU weighing 1500 g or more are at high risk for developing hypothermia, similar to smaller preterm infants.

Factors associated with extubation failure in very low birth weight infants: a cohort study in the northeast Brazil

OBJECTIVES

Identifying and understanding the main risk factors associated with extubation failure of very low birthweight (VLBW) infants in different populations can subsequently help in establishing better criteria while taking decision of extubation. The aim of the study was to identify factors associated with extubation failure in VLBW infants.

METHODS

A cohort study of VLBW infants who underwent their first extubation between April 2018 and December 2019 in a Neonatal Intensive Care Unit, Alagoas, Brazil, were included in this study. Extubation failure was defined as reintubation within seven days of extubation. Relative risks of predictive variables different between the extubation success group (ES) and extubation failure group (EF) were estimated with a robust Poisson regression model.

RESULTS

Out of the 112 infants included, 26 (23%) cases exhibited extubation failure. Extremely low birth weight (RR 2.55, 95% CI 1.07, 6.06), mechanical ventilation duration for first extubation greater than seven days (RR 2.66, 95% CI 1.10, 6.45), vaginal delivery (RR 2.07, 95% CI 1.03, 4.18) and maternal chorioamnionitis (RR 4.89, 95% CI 1.26-18.98) remained independently associated with extubation failure. EF had a significant greater need for respiratory support, longer oxygen therapy duration, more bronchopulmonary dysplasia (BPD) and longer length of hospital stay, even when adjusted for confounding variables.

CONCLUSIONS

Extremely low birth weight infants needing mechanical ventilation, wherein the duration for first extubation was longer than seven days, with vaginal delivery and maternal chorioamnionitis failed more frequently at the first attempt of extubation. And this failure increased the risk of BPD and the length of hospital stay.

Thrombocytopenia: is it a prognostic factor for development of post-hemorrhagic hydrocephalus in neonates?

PURPOSE

Post-hemorrhagic hydrocephalus (PHH) is a rare but serious complication among premature babies in the neonatal intensive care unit. The causes of PHH are still not entirely understood, and its prevention and treatment are controversial. We tried to analyze the risk factors for such complication in our cohort.

METHODS

We reviewed our neonatology data bank and included all preterms below 28 weeks who were born in the period between 1999 and 2014 and suffered from an intraventricular hemorrhage (IVH). We reviewed gestational age, gender, birth weight, type of birth, IVH degree, comorbidities, therapy, complications, time to event, protein content of cerebrospinal fluid, and clinical follow-up.

RESULTS

We identified 180 patients, divided into two subgroups, "B1" with 37 cases (IVH + PHH) and "B2" with 143 cases (IVH - PHH). In group B1, the presence of IVH grades I, II, III, or IV was in 11%, 19%, and 70% respectively. Nineteen patients were treated with a ventricular access device (VAD) or external ventricular drain (EVD). A total of 20 shunts were implanted, with 11 revisions (55%). One patient suffered from thrombocytopenia. In subgroup B2, 51% showed IVH grade I, whereas severe IVH grades were only present in 22%. 25.9% suffered from thrombocytopenia. Thrombocytopenia was significantly higher in patients who did not develop PHH (p value: 0.002).

CONCLUSION

According to our results, thrombocytopenia could play a decisive role in avoiding development of PHH as a sequel of IVH. We recommend a randomized controlled trial to assess the possible efficacy of antiplatelet drugs in avoiding PHH in this vulnerable group.

Trends in Perinatal Practices and Neonatal Outcomes of Very Low Birth Weight Infants during a 16-year Period at NEOCOSUR Centers

OBJECTIVE

To describe trends in mortality, major morbidity, and perinatal care practices of very low birth weight infants born at NEOCOSUR Neonatal Network centers from January 1, 2001, through December 31, 2016.

STUDY DESIGN

A retrospective analysis of prospectively collected data from all inborn infants with a birthweight of 500-1500 g and 23-35 weeks of gestation.

RESULTS

We examined data for 13 987 very low birth weight infants with a mean birth weight of 1081 ± 281 g and a gestational age of 28.8 ± 2.9 weeks. Overall mortality was 26.8% without significant changes throughout the study period. Decreases in early onset sepsis from 6.3% to 2.8% (P <.001), late onset sepsis from 21.1% to 19.5% (P = .002), retinopathy of prematurity from 21.3% to 13.8% (P <.001), and hydrocephalus from 3.8% to 2.4% (P <.001), were observed. The incidence for bronchopulmonary dysplasia decreased from 17.3% to 16% (P = .043), incidence of severe intraventricular hemorrhage was 10.4%, necrotizing enterocolitis 11.1%, and periventricular leukomalacia 3.8%, and did not change over the study period. Administration of antenatal corticosteroids increased from 70.2% to 82.3% and cesarean delivery from 65.9% to 75.4% (P <.001). The use of conventional mechanical ventilation decreased from 67.7% to 63.9% (P <.001) and continuous positive airway pressure use increased from 41.3% to 64.3% (P <.001). Survival without major morbidity increased from 37.4% to 44.5% over the study period (P <.001).

CONCLUSIONS

Progress in perinatal and neonatal care at network centers was associated with an improvement in survival without major morbidity of very low birth weight infants during a 16-year period. However, overall mortality remained unchanged.

Unique features and emerging in vitro models of human placental development

Background

The placenta is an essential organ for the normal development of mammalian fetuses. Most of our knowledge on the molecular mechanisms of placental development has come from the analyses of mice, especially histopathological examination of knockout mice. Choriocarcinoma and immortalized cell lines have also been used for basic research on the human placenta. However, these cells are quite different from normal trophoblast cells.

Methods

In this review, we first provide an overview of mouse and human placental development with particular focus on the differences in the anatomy, transcription factor networks, and epigenetic characteristics between these species. Next, we discuss pregnancy complications associated with abnormal placentation. Finally, we introduce emerging in vitro models to study the human placenta, including human trophoblast stem (TS) cells, trophoblast and endometrium organoids, and artificial embryos.

Main findings

The placental structure and development differ greatly between humans and mice. The recent establishment of human TS cells and trophoblast and endometrial organoids enhances our understanding of the mechanisms underlying human placental development.

Conclusion

These in vitro models will greatly advance our understanding of human placental development and potentially contribute to the elucidation of the causes of infertility and other pregnancy complications.

Mannose-binding lectin gene polymorphism and its effect on short term outcomes in preterm infants

OBJECTIVE

Mannose-binding lectin, which belongs to the collectin family, is an acute-phase reactant that activates the complement system. This study aimed to investigate the effect of MBL2 gene polymorphism on short-term outcomes in preterm infants.

METHOD

Infants of <37 gestational weeks who were admitted to the neonatal intensive care unit during a two-year period were enrolled in this prospective study. The neonates were categorized into two groups according to their MBL2 genotypes. Normal MBL2 genotype was defined as MBL2 wild-type (AA genotype), whereas mutant MBL2 genotype was defined as MBL2 variant-type (AO/OO genotype). The relationship between MBL2 genotype and short-term morbidity and mortality was evaluated.

RESULTS

During the two-year study period, 116 preterm infants were enrolled in this study. In MBL2 variant-type, mannose-binding lectin levels were significantly lower and incidences of mannose-binding lectin deficiency (MBL level<700ng/mL) were higher (p<0.001). In this group, the prevalence of respiratory distress syndrome and mortality was significantly higher (p<0.001, p=0.03 respectively). In the MBL2 wild-type group, the prevalence of necrotizing enterocolitis (NEC) was higher (p=0.01). Logistic regression analyses revealed that MBL2 variant-type had a significant effect on respiratory distress syndrome development (odds ratio, 5.1; 95% confidence interval, 2.2-11.9; p<0.001).

CONCLUSIONS

MBL2 variant-type and mannose-binding lectin deficiency are important risk factors for respiratory distress syndrome development in preterm infants. Additionally, there is an association between MBL2 wild-type and NEC. Further studies on this subject are needed.

Planned conservative management of placenta increta and percreta with prophylactic transcatheter arterial embolization and leaving placenta in situ for women who desire fertility preservation

INTRODUCTION

The objective of our study was to demonstrate planned conservative management of placenta increta and percreta in a single tertiary center.

METHODS

From April 2005 to July 2019, patients with placenta increta and percreta were managed conservatively at the Kaohsiung Chang Gung Memorial Hospital in Taiwan. The severity of placenta invasion was diagnosed by magnetic resonance imaging (MRI). After delivery of the neonate, prophylactic transcatheter arterial embolization (TAE) was performed immediately. The placenta was left in situ and prophylactic antibiotics were administered during hospitalization. The patient profiles, outcomes, and complications were retrospectively reviewed.

RESULTS

Based on the MRI findings, twenty-one patients with placenta increta or percreta were included. With prophylactic TAE, the mean surgical blood loss was 854.7 ± 478.2 mL. The mean natural resorption time of residual placenta was 4.69 ± 1.65 months. Regarding maternal complications, 4 patients (19%) had delayed postpartum hemorrhage (PPH), 12 patients (57.1%) developed postpartum infections, 3 patients (14.3%) progressed to sepsis, 4 patients (19%) underwent surgical evacuation, and 4 patients (19%) underwent hysterectomy. No maternal mortality was reported. Main neonatal complications were prematurity and respiratory distress. Regarding fertility, 16 (76.1%) patients had return of menstruation, and one (4.7%) had a subsequent pregnancy resulting in a live birth.

DISCUSSION

Planned conservative management with prophylactic TAE and leaving placenta in situ is feasible and safe for women with placenta increta or percreta who desire fertility preservation. Delayed PPH and postpartum infection are common complications after conservative treatment.

Determinants of preterm infants’ deaths at the Neonatal Intensive Care Units in the Northeast Countryside in Brazil

Abstract Objectives: to assess preterm infants’ characteristics, health conditions and neonatal care effect on their death at the neonatal ICU. Methods: this was a non-concurrent cohort study, including preterm infants from three neonatal ICUs from January 1st to December 31st, 2016, followed during the neonatal period and deaths registered during the entire hospitalization. Multivariate analysis was performed using Poisson regression. Results: of the 181 preterm infants, 18.8% died during hospitalization. Associated with the outcome: a gestational age between 28 and 32 weeks (RR= 5.66; CI95%= 2.08-15.40), and less than 28 weeks (RR=9.24; CI95%=3.27-26.12), Apgar score of 5th minutes less than 7 (RR: 1.82; CI95%=1.08-3.08), use of invasive mechanical ventilation up to 3 days (RR= 4.44; CI95%= 1.66-11.87) and 4 days and more (RR=6.87; CI95%=2.58-18.27). Besides the late sepsis (RR: 3.72, CI95%=1.77-7.83), acute respiratory distress syndrome (RR=2.86, CI95%=1.49-5.46), pulmonary hemorrhage (RR=1.97; CI95%=1.40-2.77), and necrotizing enterocolitis (RR= 3.41; CI95%=1.70-6.83). Conclusions: the results suggest the importance of using strategies to improve care during childbirth, conditions for extremely premature infants, early weaning from a mechanical ventilation and prevention on nosocomial infection.

Effect of Cervical Cerclage on the Risk of Recurrent Preterm Birth after a Twin Spontaneous Preterm Birth

BACKGROUND

This study aimed to evaluate the effect of cervical cerclage on the recurrence risk for preterm birth in singleton pregnant women after a twin spontaneous preterm birth (sPTB).

METHODS

This multicenter retrospective cohort study included women who had a singleton pregnancy from January 2009 to December 2018 at 10 referral hospitals and a twin sPTB before the current pregnancy. We compared the cervical lengths during pregnancy and pregnancy outcomes, according to the placement of prophylactic or emergency cerclage. We evaluated the independent risk factors for sPTB (< 37 weeks of gestation) in a subsequent singleton pregnancy.

RESULTS

For the index singleton pregnancy, preterm birth occurred in seven (11.1%) of 63 women. There was no significant difference in the cervical lengths during pregnancy in women with and without cerclage. In a multivariate logistic regression analysis, the placement of emergency cerclage was an independent risk factor for subsequent singleton preterm birth (odds ratio [OR], 93.188; 95% confidence interval [CI], 1.633-5,316.628; P = 0.027); however, the placement of prophylactic cerclage (OR, 19.264; 95% CI, 0.915-405.786; P = 0.057) was not a factor. None of the women who received prophylactic cerclage delivered before 35 weeks' gestation in the index singleton pregnancy.

CONCLUSION

Cerclage did not lower the risk of preterm birth in a subsequent singleton pregnancy after a twin sPTB. However, emergency cerclage was an independent risk factor for preterm birth and there was no preterm birth before 35 weeks' gestation in the prophylactic cerclage group. Therefore, close monitoring of the cervical length and prophylactic cerclage might be considered in women who have experienced a twin sPTB at extreme gestation.

The impact of the Medicaid high-risk ob care management program in New York State

OBJECTIVES

To examine the effect of high-risk obstetrics (HROB) care management on infant health and Medicaid expenditures.

DATA SOURCES/STUDY SETTING

Medicaid administrative data and vital statistics from 2011 to 2013. In New York State, all Medicaid managed care plans provide HROB care management to their members.

STUDY DESIGN

We conducted a retrospective cohort study with a nonequivalent control group. Selection bias was addressed by using probit and OLS models with the Heckman correction and inverse probability weight with regression adjustment.

PRINCIPAL FINDINGS

While program enrollment was associated with poor infant health outcomes (low birthweight, very low birthweight, preterm delivery, and gestational age), correcting for sample selection substantially improved most of these outcomes. All infant health outcomes significantly improved as the number of weeks in the program increased. We found that a 1-week increase in program duration is associated with a 0.01 percentage point decrease in low birthweight and a 0.03 percentage point decrease in very low birthweight. Further, a 1-week increase in program duration decreases the probability of preterm delivery by 0.01 percentage points and increases gestational age by 0.14 days. Medicaid expenditures for maternity care and newborn delivery were not significantly or materially affected by program enrollment or program duration.

CONCLUSIONS

High-risk obstetrics care management appears to successfully identify individuals with high-risk pregnancies and improve health without substantially increasing medical expenses.

European Respiratory Society guideline on long-term management of children with bronchopulmonary dysplasia

This document provides recommendations for monitoring and treatment of children in whom bronchopulmonary dysplasia (BPD) has been established and who have been discharged from the hospital, or who were >36 weeks of postmenstrual age. The guideline was based on predefined Population, Intervention, Comparison and Outcomes (PICO) questions relevant for clinical care, a systematic review of the literature and assessment of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. After considering the balance of desirable (benefits) and undesirable (burden, adverse effects) consequences of the intervention, the certainty of the evidence, and values, the task force made conditional recommendations for monitoring and treatment of BPD based on very low to low quality of evidence. We suggest monitoring with lung imaging using ionising radiation in a subgroup only, for example severe BPD or recurrent hospitalisations, and monitoring with lung function in all children. We suggest to give individual advice to parents regarding daycare attendance. With regards to treatment, we suggest the use of bronchodilators in a subgroup only, for example asthma-like symptoms, or reversibility in lung function; no treatment with inhaled or systemic corticosteroids; natural weaning of diuretics by the relative decrease in dose with increasing weight gain if diuretics are started in the neonatal period; and treatment with supplemental oxygen with a saturation target range of 90-95%. A multidisciplinary approach for children with established severe BPD after the neonatal period into adulthood is preferable. These recommendations should be considered until new and urgently needed evidence becomes available.

Early neonatal outcomes of very-low-birth-weight infants in Turkey: A prospective multicenter study of the Turkish Neonatal Society

Objective

To investigate the early neonatal outcomes of very-low-birth-weight (VLBW) infants discharged home from neonatal intensive care units (NICUs) in Turkey.

Material and methods

A prospective cohort study was performed between April 1, 2016 and April 30, 2017. The study included VLBW infants admitted to level III NICUs. Perinatal and neonatal data of all infants born with a birth weight of ≤1500 g were collected for infants who survived.

Results

Data from 69 NICUs were obtained. The mean birth weight and gestational age were 1137±245 g and 29±2.4 weeks, respectively. During the study period, 78% of VLBW infants survived to discharge and 48% of survived infants had no major neonatal morbidity. VLBW infants who survived were evaluated in terms of major morbidities: bronchopulmonary dysplasia was detected in 23.7% of infants, necrotizing enterocolitis in 9.1%, blood culture proven late-onset sepsis (LOS) in 21.1%, blood culture negative LOS in 21.3%, severe intraventricular hemorrhage in 5.4% and severe retinopathy of prematurity in 11.1%. Hemodynamically significant patent ductus arteriosus was diagnosed in 24.8% of infants. Antenatal steroids were administered to 42.9% of mothers.

Conclusion

The present investigation is the first multicenter study to include epidemiological information on VLBW infants in Turkey. Morbidity rate in VLBW infants is a serious concern and higher than those in developed countries. Implementation of oxygen therapy with appropriate monitoring, better antenatal and neonatal care and control of sepsis may reduce the prevalence of neonatal morbidities. Therefore, monitoring standards of neonatal care and implementing quality improvement projects across the country are essential for improving neonatal outcomes in Turkish NICUs.

Influence of the Adequacy of the Prenatal Care Utilization Index on Small-For-Gestational-Age Infants and Preterm Births in the United States

Little is known about the associations of Adequacy of Prenatal Care Utilization (APNCU) index with small-for-gestational-age (SGA) infants and preterm births. This study investigated the association between the Adequacy of Prenatal Care Utilization (APNCU) index in relation to small-for-gestational-age (SGA) infants and preterm births. We used data from 212,050 pregnant women from the Pregnancy Risk Assessment Monitoring System (PRAMS) between 2004 and 2011. Multivariable logistic regression analyses were performed to examine the effect of the APNCU index on SGA infants and preterm births after controlling for maternal sociodemographic factors. Women who received adequate-plus prenatal care in reference to adequate prenatal care had increased odds for delivering SGA infants (adjusted odds ratio (AOR) = 1.08, 95% confidence interval (CI) = 1.03-1.15). Women with 9-11 prenatal care visits had increased odds of delivering SGA infants (AOR = 1.07, 95% CI = 1.02-1.14) compared to those with more than 12 visits. Among the four APNCU index categories, the highest rate of preterm births was observed in the adequate-plus group. Compared to those with adequate prenatal care, women who received adequate-plus prenatal care had increased odds of preterm birth (AOR = 1.69, 95% CI = 1.55-1.84). Compared to those with more than 12 visits, women with fewer than eight prenatal care visits had increased odds of preterm birth (AOR = 1.29, 95% CI = 1.13-1.48). In conclusion, women in the adequate-plus APNCU index category were more likely to deliver SGA infants and to have preterm births compared to those in the adequate APNCU index category. Women in the U.S. with high-risk pregnancies were prone to receiving adequate-plus prenatal care. Future prospective studies are warranted to investigate the influence of APNCU index in relation to pregnancy and birth outcomes.

Twin versus singleton pregnancy in women ≥ 45 years of age: comparison of maternal and neonatal outcomes

Objectives: The aim of the study is to compare the effect of very advanced maternal age (≥45 years) on maternal and neonatal outcomes of twin and singleton pregnancies.Materials and methods: This retrospective cohort study included women ≥ 45 years of age who gave birth to twins. Each was randomly matched to two women ≥ 45 years of age who gave birth to singletons within 7 days of the study subject. Data on maternal age, gravidity, parity, background medical information, body mass index at conception, number of fetuses, mode of conception (either spontaneous or assisted reproductive technology [ART]), mode of delivery, and gestational age at delivery were extracted from a real-time computerized database.Results: The data of 75 twin pregnancies of women aged ≥ 45 years were compared with those of 150 singleton pregnancies matched for maternal age. There were significantly more cases of hypertensive complications among the twin pregnancies compared to the singleton pregnancies (41.33 versus 14.00%, respectively, OR = 3.33, 95% CI = 2.26-8.30, p = .000) and more cases of preeclamptic toxemia (29.33 versus 12.00%, respectively, OR = 3.04, 95% CI = 1.51-6.13, p = .001). The duration of twin pregnancies was much shorter compared to singleton pregnancies, with a higher incidence of deliveries prior to 37 weeks' gestation (56.00 versus 8.00%, respectively, OR = 14.64, 95% CI = 6.94-30.85, p = .000), and deliveries prior to 34 weeks' gestation (22.67 versus 2.00%, respectively, OR = 14.36, 95% CI = 4.06-50.86, p = .000). More infants of twin pregnancies had a low birth weight (68.00 versus 10.00%, respectively, OR = 19.13, 95% CI = 10.14-36.06, p = .000), and many had a very low birth weight (10.67 versus 0.67%, respectively, OR = 17.79, 95% CI = 2.33-135.97, p = .000). The infants of twin pregnancies also included more cases of intubation (10.00 versus 0.00%, respectively, p = .000), more cases of hypoglycemia (12.67 versus 5.33%, respectively, OR = 2.57, 95% CI = 1.09-6.08, p = .026), and were admitted much more often to the neonatal intensive care unit (36.00 versus 8.00%, respectively, OR = 6.47, p = .00, CI = 3.29-12.74).Conclusions: Women ≥ 45 years of age with twin pregnancies and their neonates sustain more severe adverse outcome compared to matched pairs of singleton pregnancies. It is recommended that a single embryo transfer should be offered in preference to multiple embryos when those women are undergoing ART.

NLRP7 is increased in human idiopathic fetal growth restriction and plays a critical role in trophoblast differentiation

Fetal growth restriction (FGR) the leading cause of perinatal mortality and morbidity is highly related to abnormal placental development, and placentas from FGR pregnancies are often characterized by increased inflammation. However, the mechanisms of FGR-associated inflammation are far from being understood. NLRP7, a member of a family of receptors involved in the innate immune responses, has been shown to be associated with gestational trophoblastic diseases. Here, we characterized the expression and the functional role of NLRP7 in the placenta and investigated its involvement in the pathogenesis of FGR. We used primary trophoblasts and placental explants that were collected during early pregnancy, and established trophoblast-derived cell lines, human placental villi, and serum samples from early pregnancy (n = 38) and from FGR (n = 40) and age-matched controls (n = 32). Our results show that NLRP7 (i) is predominantly expressed in the trophoblasts during the hypoxic period of placental development and its expression is upregulated by hypoxia and (ii) increases trophoblast proliferation ([³H]-thymidine) and controls the precocious differentiation of trophoblasts towards syncytium (syncytin 1 and 2 and β-hCG production and xCELLigence analysis) and towards invasive extravillous trophoblast (2D and 3D cultures). We have also demonstrated that NLRP7 inflammasome activation in trophoblast cells increases IL-1β, but not IL-18 secretion. In relation to the FGR, we demonstrated that major components of NLRP7 inflammasome machinery are increased and that IL-1β but not IL-18 circulating levels are increased in FGR. Altogether, our results identified NLRP7 as a critical placental factor and provided evidence for its deregulation in FGR. NLRP7 inflammasome is abundantly expressed by trophoblast cells. It is regulated by a key parameter of placental development, hypoxia. It controls trophoblast proliferation, migration, and invasion and exhibits anti-apoptotic role. NLRP7 machinery is deregulated in FGR pregnancies. KEY MESSAGES: NLRP7 inflammasome is abundantly expressed by trophoblast cells. It is regulated by a key parameter of placental development, hypoxia. It controls trophoblast proliferation, migration, and invasion and exhibits anti-apoptotic role. NLRP7 machinery is deregulated in FGR pregnancies.

Bronchopulmonary Dysplasia: An Update of Current Pharmacologic Therapies and New Approaches

Bronchopulmonary dysplasia (BPD) remains the most prevalent long-term morbidity of surviving extremely preterm infants and is associated with significant health care utilization in infancy and beyond. Recent advances in neonatal care have resulted in improved survival of extremely low birth weight (ELBW) infants; however, the incidence of BPD has not been substantially impacted by novel interventions in this vulnerable population. The multifactorial cause of BPD requires a multi-pronged approach for prevention and treatment. New approaches in assisted ventilation, optimal nutrition, and pharmacologic interventions are currently being evaluated. The focus of this review is the current state of the evidence for pharmacotherapy in BPD. Promising future approaches in need of further study will also be reviewed.

Dietary Arginine Supplementation Affects Intestinal Function by Enhancing Antioxidant Capacity of a Nitric Oxide-Independent Pathway in Low-Birth-Weight Piglets

Background

Low-birth-weight (LBW) neonates are susceptible to intestinal dysfunction. Furthermore, the antioxidant capacity of LBW neonates is significantly lower compared with that of normal-birth-weight (NBW) neonates both at birth and at weaning. In LBW neonates, dietary supplementation with arginine has shown beneficial effects on intestinal function.

Objective

The present study explored the potential mechanisms of arginine-induced protective effects against intestinal dysfunction in LBW piglets.

Methods

Forty 4-d-old LBW piglets [body weight (BW): 1.05 ± 0.04 kg] (Large White × Landrace) were assigned to 4 treatments and artificially fed a whole-milk powder- and whey protein concentrate-based diet (containing 0.65% arginine) either not supplemented with arginine (LBWC) or supplemented with 0.5%, 1.0%, or 1.5% l-arginine for 21 d. In addition, 10 NBW siblings (BW: 1.96 ± 0.03 kg) were selected and fed the basal diet. Growth performance, intestinal morphology, mRNA expression of tight junction protein, redox-sensitive genes and nitric oxide (NO) synthase, cytokines, and redox indexes were determined. Data were subjected to 1-factor ANOVA.

Results

LBW piglets exhibited poorer growth performance (29.9%), lower Claudin1 mRNA level (63.6%), lower antioxidant capacity (22.9 ∼ 24.3%), and higher jejunum interleukin 1 (IL-1) concentration (18.8%) compared with NBW piglets. Dietary supplementation with 0.5% and 1.0% l-arginine significantly enhanced daily BW gain of LBW piglets by 13.6% and 18.2%, respectively. Compared with LBWC, dietary supplementation with 1.0% l-arginine increased the serum insulin concentration (32.2%) and villus height in the jejunum (12.2%) and ileum (20.5%). In the jejunum, the mRNA levels for Claudin1 (105%) and glutathione peroxidase (36%) were higher, and the concentrations of IL-1 (31.7%) and tumor necrosis factor α (TNF-α) (30%) were lower in arginine-treated piglets than in the LBWC group. However, NO synthase activity and NO concentration in the jejunum of LBW piglets were not influenced by l-arginine supplementation.

Conclusion

The results suggested that supplementation with 1.0% l-arginine not only promoted growth performance and improved intestinal functions in LBW piglets but also improved intestinal barrier functions and enhanced antioxidant capacity by an NO-independent pathway.

Progesterone Antagonizes Dexamethasone-Regulated Surfactant Proteins In Vitro

Pregnant women at risk of preterm labor routinely receive glucocorticoids (GCs) and frequently also progesterone. Administration of GCs accelerates intrauterine surfactant synthesis and lung maturation, thereby reducing the incidence of neonatal respiratory distress syndrome; progesterone has the potential to prevent preterm birth. Little is known about possible interactions of GCs and progesterone. Our aim was to clarify whether progesterone can affect dexamethasone (DXM)-regulated expression of surfactant protein A (SP-A), SP-B, and SP-D in lung epithelial cells. H441 cells were exposed to DXM and progesterone and expression of SPs was analyzed by quantitative real-time polymerase chain reaction and immunoblotting. Although progesterone had no direct effect on the expression of SP-B, DXM-mediated induction was inhibited dose dependently on the transcriptional (64 µM [P < .0001], 32 µM [P = .0005], 16 µM [P = .0019]) and the translational level. Furthermore, progesterone inhibited stimulatory effects of other GCs as well. While exogenous tissue growth factor β1 (TGF-β1) inhibited DXM-induced SP-B expression (messenger RNA [mRNA]: P = .0014), progesterone itself did not influence TGF-β1 mRNA expression and/or TGF-β1/Smad signaling, demonstrating that TGF-β1 and/or Smad activation is not involved. The inhibitory effect of progesterone could be imitated by the GC and progesterone receptor (PR) antagonist RU-486, but not by the specific PR antagonist PF-02413873, indicating that progesterone acts as a competitive antagonist of DXM. The effect of progesterone on DXM-regulated genes was not specific for SP-B, as expression of SP-A and SP-D mRNAs was also antagonized. The present study highlights a new action of progesterone as a potential physiological inhibitor of GC-dependent SP expression in lung epithelial cells. The clinical relevance of this in vitro finding is currently unknown.

Plasma proteomics reveals gestational age-specific responses to mechanical ventilation and identifies the mechanistic pathways that initiate preterm lung injury

The preterm lung is particularly vulnerable to ventilator-induced lung injury (VILI) as a result of mechanical ventilation. However the developmental and pathological cellular mechanisms influencing the changing patterns of VILI have not been comprehensively delineated, preventing the advancement of targeted lung protective therapies. This study aimed to use SWATH-MS to comprehensively map the plasma proteome alterations associated with the initiation of VILI following 60 minutes of standardized mechanical ventilation from birth in three distinctly different developmental lung states; the extremely preterm, preterm and term lung using the ventilated lamb model. Across these gestations, 34 proteins were differentially altered in matched plasma samples taken at birth and 60 minutes. Multivariate analysis of the plasma proteomes confirmed a gestation-specific response to mechanical ventilation with 79% of differentially-expressed proteins altered in a single gestation group only. Six cellular and molecular functions and two physiological functions were uniquely enriched in either the extremely preterm or preterm group. Correlation analysis supported gestation-specific protein-function associations within each group. In identifying the gestation-specific proteome and functional responses to ventilation we provide the founding evidence required for the potential development of individualized respiratory support approaches tailored to both the developmental and pathological state of the lung.