Trends in outcomes for very preterm infants in the southern region of Sweden over a 10-year period

Enhancing the estimation of PaCO2 from etCO2 during ventilation through non-invasive parameters in the ovine model

BACKGROUND

In mechanically ventilated neonates, the arterial partial pressure of CO 2 ( PaCO 2 ) is an important indicator for the adequacy of ventilation settings. Determining the PaCO 2 is commonly done using invasive blood gas analyses, which constitute risks for neonates and are typically only available infrequently. An accurate, reliable, and continuous estimation of PaCO 2 is of high interest for medical staff, giving the possibility of a closer monitoring and faster reactions to changes. We aim to present a non-invasive estimation method for PaCO 2 in neonates on the basis of end-tidal CO 2 ( etCO 2 ) with inclusion of different physiological and ventilation parameters. The estimation method should be more accurate than an estimation by unaltered etCO 2 measurements with regard to the mean absolute error and the standard deviation.

METHODS

Secondary data from 51 preterm lambs are used, due to its high comparability to preterm human data. We utilize robust linear regression on 863 PaCO 2 measurements below or equal to 75 mmHg from the first day of life. etCO 2 along with a set of ventilation settings and measurements as well as vital parameters are included in the regression. Included independent variables are chosen iteratively by highest Pearson correlation to the remaining estimation deviation.

RESULTS

The evaluation is carried out on 12 additional neonatal lambs with 246 PaCO 2 measurements below or equal to 75 mmHg from the first two days of life. The estimation method shows a mean absolute error of 3.80 mmHg with a 4.92 mmHg standard deviation of differences and a standard error of 0.31 mmHg in comparison to measured PaCO 2 by blood gas analysis.

CONCLUSIONS

The estimation of PaCO 2 by the proposed equation is less biased than unaltered etCO 2 . The usage of this method in clinical practice or in applications like the automation of ventilation needs further investigation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of Papile versus Laterality-Based Al-Abdi System to Predict Neurodevelopmental Impairment in Extreme Preterm Infants after Severe Germinal Matrix Hemorrhage-Intraventricular Hemorrhage: A Retrospective Comparative Observational Study

BACKGROUND AND PURPOSE

The traditional Papile classification system for severe germinal matrix hemorrhage-intraventricular hemorrhage is limited in objectivity and interrater variability for accurate prediction of neurodevelopmental impairment in extremely preterm infants. Many extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage are still offered "redirection of care" in spite of the recent evidence suggesting that many of these infants can have normal outcomes. Therefore, it is important to consider the laterality and extent of brain hemisphere involvement while classifying severe germinal matrix hemorrhage-intraventricular hemorrhage to predict neurodevelopmental impairment. The aim of the present study was to compare the Al-Abdi system with the Papile system for their accuracy in predicting neurodevelopmental impairment in extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage.

MATERIALS AND METHODS

This is a retrospective study of extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage admitted to a tertiary neonatal intensive care unit (2006-2016). Cranial sonograms were independently re-reviewed by 2 radiologists as per the Al-Abdi system. The prognostic statistical indices for both systems to predict neurodevelopmental impairment were calculated.

RESULTS

A total of 91 infants with severe germinal matrix hemorrhage-intraventricular hemorrhage survived, and 83 (median gestational age, 26.3 weeks; and median birth weight, 890 g) completed developmental assessment. The receiver operating characteristic areas under the curve to predict neurodevelopmental impairment by the Papile versus Al-Abdi systems were 0.702 versus 0.723, respectively (P = .474). Corresponding Al-Abdi cutoff scores of 19, 20, 21, and 22 demonstrated increased specificity (76.36%-85.45%) and correct classification (69.88%-72.29%) to predict moderate-to-severe neurodevelopmental impairment.

CONCLUSIONS

The Al-Abdi system is comparable with the Papile system for predicting neurodevelopmental impairment for extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage, with higher Al-Abdi scores being more specific. This finding may prove useful for neonatal health care providers and parents in their decision regarding "continuation of care." Future multicentric studies are warranted to ascertain the validity of individual Al-Abdi scores.

Retinopathy of Prematurity: Advances in the Screening and Treatment of Retinopathy of Prematurity Using a Single Center Approach

PURPOSE

To focus on the longitudinal evaluation of high-risk infants for the development of retinopathy of prematurity (ROP) at a single tertiary neonatal intensive care unit (NICU), and to evaluate evolving demographics of ROP and the transition of treatment-warranted disease.

DESIGN

Retrospective cohort study.

METHODS

A consecutive retrospective review was performed of all infants screened for ROP between 1990 and 2019 at the Jackson Memorial Hospital neonatal intensive care unit. All inborn infants meeting a birth criteria of <32 weeks' gestational age (GA) or a birthweight (BW) of 1500 g were included. Longitudinal demographic, diagnostic, and treatment data were reported.

RESULTS

Between January 1, 1990, and June 20, 2019, a total of 25,567 examinations were performed and 7436 patients were included. Longitudinal trends over 3 decades demonstrated a decreasing incidence of ROP (P < .05). Although the mean BW and GA increased over 3 decades, patients with ROP demonstrated lower BW and GA over time (P < .05). The prevalence of micro-premature infants (as defined by BW <750 g) continues to rise over time. Micro-preemies demonstrated increasing severity of zone and stage grading, plus disease, and propensity to require treatment (P < .05). The rate of progression of ROP to stage 4 and 5 disease has decreased over time, and there has been an associated increased adoption of intravitreal bevacizumab as primary and salvage therapy.

CONCLUSIONS

Understanding the evolution of ROP infants and treatment over time is critical in identifying high-risk infants and in reducing the incidence of severe-stage ROP. Micro-prematurity is one of the significant risk factors for treatment-warranted ROP that continues to increase as neonatal care improves. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Developing eHealth in neonatal care to enhance parents' self-management

BACKGROUND

Discharge from a neonatal care unit is often experienced as a vulnerable time for parents. By communicating through digital technology, it may be possible to improve the support for parents and thereby make the transition from hospital to home less stressful.

AIM

To develop an eHealth device supporting the transition from hospital to home for parents with a preterm-born child in Sweden using participatory design.

METHOD

Employing a framework of complex interventions in health care using participatory design. Parents of preterm-born infants and professionals at a neonatal department identified specific technical requirements for an eHealth device to be developed in the context of neonatal care and neonatal home care. The prospective end-users - parents and professionals - were continuously involved in the process of designing solution prototypes through meetings, verbal and written feedback, and interviews. The interviews were analysed using thematic analysis.

RESULTS

Technical development was carried out with the perspectives of professionals and parents in mind, resulting in an eHealth application for computer tablets. The findings from the interviews with the parents and professionals revealed three categories: The tablets felt secure, easy to use and sometimes replaced visits to hospital and at home.

CONCLUSION

The use of participatory design to develop an eHealth device to support a safe transition from hospital to home can benefit parents, the child, the family, and professionals in neonatal care.

Risk Identification of Bronchopulmonary Dysplasia in Premature Infants Based on Machine Learning

Bronchopulmonary dysplasia (BPD) is one of the most common complications in premature infants. This disease is caused by long-time use of supplemental oxygen, which seriously affects the lung function of the child and imposes a heavy burden on the family and society. This research aims to adopt the method of ensemble learning in machine learning, combining the Boruta algorithm and the random forest algorithm to determine the predictors of premature infants with BPD and establish a predictive model to help clinicians to conduct an optimal treatment plan. Data were collected from clinical records of 996 premature infants treated in the neonatology department of Liuzhou Maternal and Child Health Hospital in Western China. In this study, premature infants with congenital anomaly, premature infants who died, and premature infants with incomplete data before the diagnosis of BPD were excluded from the data set. After exclusion, we included 648 premature infants in the study. The Boruta algorithm and 10-fold cross-validation were used for feature selection in this study. Six variables were finally selected from the 26 variables, and the random forest model was established. The area under the curve (AUC) of the model was as high as 0.929 with excellent predictive performance. The use of machine learning methods can help clinicians predict the disease so as to formulate the best treatment plan.

Respiratory Support of the Preterm Neonate: Lessons About Ventilation-Induced Brain Injury From Large Animal Models

Many preterm neonates require mechanical ventilation which increases the risk of cerebral inflammation and white matter injury in the immature brain. In this review, we discuss the links between ventilation and brain injury with a focus on the immediate period after birth, incorporating respiratory support in the delivery room and subsequent mechanical ventilation in the neonatal intensive care unit. This review collates insight from large animal models in which acute injurious ventilation and prolonged periods of ventilation have been used to create clinically relevant brain injury patterns. These models are valuable resources in investigating the pathophysiology of ventilation-induced brain injury and have important translational implications. We discuss the challenges of reconciling lung and brain maturation in commonly used large animal models. A comprehensive understanding of ventilation-induced brain injury is necessary to guide the way we care for preterm neonates, with the goal to improve their neurodevelopmental outcomes.

Short-term outcomes of extremely preterm infants at discharge: a multicenter study from Guangdong province during 2008-2017

BACKGROUND

An increasing number of extremely preterm (EP) infants have survived worldwide. However, few data have been reported from China. This study was designed to investigate the short-term outcomes of EP infants at discharge in Guangdong province.

METHODS

A total of 2051 EP infants discharged from 26 neonatal intensive care units during 2008-2017 were enrolled. The data from 2008 to 2012 were collected retrospectively, and from 2013 to 2017 were collected prospectively. Their hospitalization records were reviewed.

RESULTS

During 2008-2017, the mean gestational age (GA) was 26.68 ± 1.00 weeks and the mean birth weight (BW) was 935 ± 179 g. The overall survival rate at discharge was 52.5%. There were 321 infants (15.7%) died despite active treatment, and 654 infants (31.9%) died after medical care withdrawal. The survival rates increased with advancing GA and BW (p < 0.001). The annual survival rate improved from 36.2% in 2008 to 59.3% in 2017 (p < 0.001). EP infants discharged from hospitals in Guangzhou and Shenzhen cities had a higher survival rate than in others (p < 0.001). The survival rate of EP infants discharged from general hospitals was lower than in specialist hospitals (p < 0.001). The major complications were neonatal respiratory distress syndrome, 88.0% (1804 of 2051), bronchopulmonary dysplasia, 32.3% (374 of 1158), retinopathy of prematurity (any grade), 45.1% (504 of 1117), necrotizing enterocolitis (any stage), 10.1% (160 of 1588), intraventricular hemorrhages (any grade), 37.4% (535 of 1431), and blood culture-positive nosocomial sepsis, 15.7% (250 of 1588). The multivariate logistic regression analysis indicated that improved survival of EP infants was associated with discharged from specialist hospitals, hospitals located in high-level economic development region, increasing gestational age, increasing birth weight, antenatal steroids use and a history of premature rupture of membranes. However, twins or multiple births, Apgar ≤7 at 5 min, cervical incompetence, and decision to withdraw care were associated with decreased survival.

CONCLUSIONS

Our study revealed the short-term outcomes of EP infants at discharge in China. The overall survival rate was lower than the developed countries, and medical care withdrawal was a serious problem. Nonetheless, improvements in care and outcomes have been made annually.

Trends in outcomes of very preterm infants in Romania: A tale of three cities

BACKGROUND

Although survival of preterm infants has improved, prematurity remains the second most frequent cause of death before 5 years of age in Romania. Data on the changing mortality of Romanian preterm infants born before 29 weeks of gestation have not been available.

METHODS

Outcomes of infants of gestational age 25-28 weeks born in 2007-2010 (n = 247) were compared with those born in 2011-2014 (n = 235). Data were analyzed from three tertiary neonatal intensive care centers. Mortality rates and major morbidities were compared between these two epochs.

RESULTS

Infants in the later epoch were more likely to have been born by cesarean section and had higher 1 and 5 min Apgar scores. Mortality rate decreased significantly with increasing gestational age at birth. Between the two epochs, the in-hospital mortality rate decreased from 65.6% to 29.4% (P < 0.001); death in the first 48 h decreased from 30.0% to 8.5% (P < 0.001); and prevalence of severe intraventricular hemorrhage decreased from 52.2% to 11.9% (P < 0.001). There were significant increases in the rates of necrotizing enterocolitis and bronchopulmonary dysplasia among survivors but no change in the rate of retinopathy of prematurity. The rate of antenatal corticosteroid use did not change and was only 47% in the more recent epoch (2011-2014).

CONCLUSIONS

Overall mortality is decreasing, and infants admitted in the later epoch had substantially different rates of mortality and several serious morbidities. The low rate of antenatal corticosteroid use provides an opportunity for further reductions in mortality and morbidity among very preterm infants born in Romania.

Increased levels of phthalates in very low birth weight infants with septicemia and bronchopulmonary dysplasia

Very low birth weight infants (VLBW; birth weight<1500g) are exposed to potentially harmful phthalates from medical devices during their hospital stay. We measured urinary phthalate concentrations among hospitalized VLBW infants participating in a nutritional study. Possible associations between different phthalates and birth weight (BW), septicemia and bronchopulmonary dysplasia (BPD) were evaluated. Forty-six VLBW infants were enrolled in this randomized controlled nutritional study. The intervention group (n=24) received increased quantities of energy, protein, fat, essential fatty acids and vitamin A, as compared to the control group (n=22). The concentrations of 12 urinary phthalate metabolites were measured, using high-performance liquid chromatography coupled to tandem mass spectrometry, at 3 time points during the first 5weeks of life. During this study, the levels of di (2-ethylhexyl) phthalate (DEHP) metabolites decreased, whereas an increasing trend was seen regarding metabolites of di-iso-nonyl phthalate (DiNP). Significantly higher levels of phthalate metabolites were seen in infants with lower BW and those diagnosed with late onset septicemia or BPD. A significant positive correlation between the duration of respiratory support and DEHP metabolites was observed (p≤0.01) at 2.9weeks of age. Birth weight was negatively associated with urinary phthalate metabolite concentrations. Infants with lower BW and those diagnosed with septicemia or BPD experienced prolonged exposure from medical equipment containing phthalates, with subsequent higher levels of phthalate metabolites detected. Clinical Trial Registration no.: NCT01103219.

Maternal and perinatal outcomes of pregnancies delivered at 23 weeks' gestation

OBJECTIVE

To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation.

METHODS

This prospective cohort study included women in the Canadian Perinatal Network who were admitted to one of 16 Canadian tertiary perinatal units between August 1, 2005, and March 31, 2011, and who delivered at 23+0 to 23+6 weeks' gestation. Women were included in the network if they were admitted with spontaneous preterm labour with contractions, a short cervix without contractions, prolapsing membranes with membranes at or beyond the external os or a dilated cervix, preterm premature rupture of membranes, intrauterine growth restriction, gestational hypertension, or antepartum hemorrhage. Maternal outcomes included Caesarean section, placental abruption, and serious complication. Perinatal outcomes were mortality and serious morbidity.

RESULTS

A total of 248 women and 287 infants were included in the study. The rate of Caesarean section was 10.5% (26/248) and 40.3% of women (100/248) had a serious complication, the most common being chorioamnionitis (38.6%), followed by blood transfusion (4.5%). Of infants with known outcomes, perinatal mortality was 89.9% (223/248) (stillbirth 23.3% [67/287] and neonatal death 62.9% [156/248]). Of live born neonates with known outcomes (n = 181), 38.1% (69/181) were admitted to NICU. Of those admitted to NICU, neonatal death occurred in 63.8% (44/69). Among survivors at discharge, the rate of severe brain injury was 44.0% (11/25), of retinopathy of prematurity 58.3% (14/24), and of any serious neonatal morbidity 100% (25/25). Two subgroup analyses were performed: in one, antepartum stillbirths were excluded, and in the other only centres that indicated they offered fetal monitoring at 23 weeks' gestation were included and antepartum stillbirths were excluded. In each of these, perinatal outcomes similar to the overall group were found.

CONCLUSION

Pregnant women delivering at 23 weeks' gestation are at risk of morbidity. Their infants have high rates of serious morbidity and mortality. Further research is needed to identify strategies and forms of management that not only increase perinatal survival but also reduce morbidities in these extremely low gestational age infants and reduce maternal morbidity.

Neonatal outcome of extremely preterm Asian infants ⩽28 weeks over a decade in the new millennium

OBJECTIVE

To evaluate predischarge neonatal mortality and morbidity and associated risk factors in extremely preterm Asian infants ⩽28 weeks, over a decade, so as to facilitate formulation of perinatal guidelines and counseling.

STUDY DESIGN

Cohort study of 887 liveborn extremely preterm neonates between 2000 and 2009 at KKH, the centralized perinatal center in Singapore. Outcome measures were predischarge mortality, presence of one or more major neonatal morbidities and the composite outcome of mortality or neonatal morbidity.

RESULT

Overall survival to discharge was 709/887 (80%) and was significantly higher with increasing gestational age (GA) (19% at 23 weeks to 93% at 28 weeks, P<0.001). Survival remained unchanged between 78 and 86% during the decade with no significant secular trend. Overall incidence of major morbidities were bronchopulmonary dysplasia (29%), late onset sepsis (23%), severe retinopathy of prematurity (21%), Grade 3 to 4 intraventricular hemorrhage (12%) and necrotizing enterocolitis ⩾Bells' stage II/focal intestinal perforation (9%). Composite morbidity was seen in 465/835 (56%) neonatal intensive-care unit admissions, decreased with increasing GA (P<0.001; odds ratio 0.65 (95% confidence interval 0.56 to 0.75) and was independently predicted by birth weight, Clinical Risk Index for Babies-revised version II score, male gender, presence of patent ductus arteriosus and airleaks.

CONCLUSION

Although there was no significant trend in neonatal survival or composite morbidity over the decade, improved survival and morbidity were seen with increasing GA.

Population-based trends in mortality and neonatal morbidities among singleton, very preterm, very low birth weight infants over 16 years

BACKGROUND

Improved survival of singleton very preterm, very low birth weight (VPTVLBW) infants has been associated with increasing rates of severe neonatal morbidities.

AIM

To assess changes in mortality and neonatal morbidities among singleton VPT-VLBW infants.

STUDY DESIGN

Population-based observational study of data collected by the Israel Neonatal Network.

SUBJECTS

10,705 singleton VPT-VLBW infants born at 24-32 gestational weeks in 1995-2010.

OUTCOME MEASURES

Mortality and major neonatal morbidities over 3 time periods: 1995-2000, 2001-2005, and 2006-2010. Major neurological morbidities comprised intraventricular hemorrhage grades 3-4, periventricular leukomalacia and retinopathy of prematurity grades 3-4.

RESULTS

The mortality rate decreased over time from 20.2% to 13.8% for all birth weight and gestational age groups. Compared to the 1995-2000 period, the adjusted odds ratios (aORs) (95% confidence intervals,) for mortality in 2001-2005 and 2006-2010 were 0.78 (0.67-0.90) and 0.72 (0.62-0.84), respectively. The combined outcomes of death or major neurological morbidities, aOR 0.74 (0.65-0.84) and death or major neurological morbidities and/or bronchopulmonary dysplasia aOR 0.85 (0.75-0.96) decreased significantly between the first and last periods. A significant improvement in mortality rates and survival without one or more major neonatal morbidity was observed for all birth weight and gestational age groups. Among 8,886 surviving infants the rates of major neurological morbidities decreased from 16.4% to 12.8%, aOR 0.80 (0.68-0.95).

CONCLUSION

The improving survival of singleton VTP-VLBW infants was not associated with a concomitant increase in the risk for major neonatal neurological morbidities among surviving infants. Bronchopulmonary dysplasia, however, remained a significant burden. This analysis emphasizes the need to direct efforts towards the prevention and treatment of adverse respiratory sequelae.

The effects of dexamethasone on post-asphyxial cerebral oxygenation in the preterm fetal sheep

Exposure to clinical doses of the glucocorticoid dexamethasone increases brain activity and causes seizures in normoxic preterm fetal sheep without causing brain injury. In contrast, the same treatment after asphyxia increased brain injury. We hypothesised that increased injury was in part mediated by a mismatch between oxygen demand and oxygen supply. In preterm fetal sheep at 0.7 gestation we measured cerebral oxygenation using near-infrared spectroscopy, electroencephalographic (EEG) activity, and carotid blood flow (CaBF) from 24 h before until 72 h after asphyxia induced by 25 min of umbilical cord occlusion. Ewes received dexamethasone intramuscularly (12 mg 3 ml(-1)) or saline 15 min after the end of asphyxia. Fetuses were studied for 3 days after occlusion. During the first 6 h of recovery after asphyxia, dexamethasone treatment was associated with a significantly greater fall in CaBF (P < 0.05), increased carotid vascular resistance (P < 0.001) and a greater fall in cerebral oxygenation as measured by the difference between oxygenated and deoxygenated haemoglobin (delta haemoglobin; P < 0.05). EEG activity was similarly suppressed in both groups. From 6 to 10 h onward, dexamethasone treatment was associated with a return of CaBF to saline control levels, increased EEG power (P < 0.005), greater epileptiform transient activity (P < 0.001), increased oxidised cytochrome oxidase (P < 0.05) and an attenuated increase in [delta haemoglobin] (P < 0.05). In conclusion, dexamethasone treatment after asphyxia is associated with greater hypoperfusion in the critical latent phase, leading to impaired intracerebral oxygenation that may exacerbate neural injury after asphyxia.

Long-term outcome for the tiniest or most immature babies: survival rates

This article focuses on the survival rates of the most immature babies considered viable from around the world. It discusses the various factors in terms of definition, inclusion criteria and policy which can result in marked differences in the apparent rates of delivery (all births), live birth, admission to neonatal intensive care and ultimately survival seen between otherwise similar countries, different regions of the same country, and even adjacent hospitals. Such variation in approach can result in major differences in reported survival and consequentially have large effects on apparent rates of adverse long-term outcome.

Lung function and respiratory health at school age in ventilated very low birth weight infants

OBJECTIVE

To investigate respiratory health and lung function in school-aged children without broncho-pulmonary dysplasia (BPD), who were very low birth weight (VLBWi) and randomized at birth to high frequency oscillatory ventilation (HFOV) or volume guarantee (VG) ventilation for severe respiratory distress syndrome (RDS).

METHODS

In this observational study, 7-y-old ex-preterm infants with severe RDS, randomly assigned at birth to receive assisted/control ventilation + VG (Vt = 5 mL/kg, PEEP = 5 cmH2O)(VG group; mean GA 27 ± 2 wk; mean BW 1086 ± 158 g) or HFOV (HFOV group; mean GA: 27 ± 2; mean BW: 1090 ± 139 g) (both groups were ventilated with Drager Babylog 8000 plus) were recalled. Neonatal clinical data and outcome were known. Actual outcomes were investigated with an interview; lung function was measured by whole-body plethysmography.

RESULTS

Twenty five children were studied (VG group, n = 13 vs. HFOV group, n = 12). There were no differences in anthropometric data, drugs (steroids/bronchodilators and antibiotics) or hospital readmission for respiratory disorders. Compliance to the test was adequate. The authors found a similar obstructive deficit (elevated values: airway resistance (RAW), residual volume (RV), total lung capacity (TLC) with near-normal spirometry) in both groups suggesting a persistent airflow limitation even in absence of BPD.

CONCLUSIONS

VLBW infants even in absence of BPD, need long term respiratory follow-up, because they frequently show an impairment of lung function, independent from initial respiratory support, even if at birth the choice is a lung protective approach (e.g., HFOV or VG ventilation).

Nationwide inventory of risk factors for retinopathy of prematurity in the Netherlands

OBJECTIVES

To study the incidence and risk factors for retinopathy of prematurity (ROP) in the Netherlands.

STUDY DESIGN

Prospective, approximating population-based study that included infants with gestational age (GA) <32 weeks and/or birth weight (BW) <1500 g born in 2009. Pediatricians and ophthalmologists of all hospitals involved in care for premature infants reported data that were matched with the national perinatal database for risk factor analysis.

RESULTS

Of 1380 infants, median GA 29.8 weeks (IQR 28.1-31.1) and median BW 1260 g (IQR 1020-1500), ROP developed in 21.9%. Logistic regression identified GA and BW as risk factors for ROP (P < .001). After adjustment for GA and BW, additional risk factors were inhaled nitric oxide (iNO; OR 2.6, 95% CI 1.1-6.2, P = .03), stay at a neonatal intensive care unit >28 days (OR 1.6, 95% CI 1.1-2.6, P = .03), and artificial ventilation >7 days (OR 1.6, 95% CI 1.1-2.5, P = .02). Prenatal glucocorticoids (OR 0.6, 95% CI 0.4-0.8, P < .001) and female sex (OR 0.7, 95% CI 0.5-0.99, P = .04) showed a lesser incidence of ROP. iNO remained significant after correction for all significant factors (OR 2.6, 95% CI 1.1-6.2, P = .03).

CONCLUSION

In addition to established risk factors (GA, BW, stay at a neonatal intensive care unit >28 days, and artificial ventilation >7 days), treatment with iNO as risk factor for ROP is a novel finding.

Clinical prediction models for bronchopulmonary dysplasia: a systematic review and external validation study

Background

Bronchopulmonary dysplasia (BPD) is a common complication of preterm birth. Very different models using clinical parameters at an early postnatal age to predict BPD have been developed with little extensive quantitative validation. The objective of this study is to review and validate clinical prediction models for BPD.

Methods

We searched the main electronic databases and abstracts from annual meetings. The STROBE instrument was used to assess the methodological quality. External validation of the retrieved models was performed using an individual patient dataset of 3229 patients at risk for BPD. Receiver operating characteristic curves were used to assess discrimination for each model by calculating the area under the curve (AUC). Calibration was assessed for the best discriminating models by visually comparing predicted and observed BPD probabilities.

Results

We identified 26 clinical prediction models for BPD. Although the STROBE instrument judged the quality from moderate to excellent, only four models utilised external validation and none presented calibration of the predictive value. For 19 prediction models with variables matched to our dataset, the AUCs ranged from 0.50 to 0.76 for the outcome BPD. Only two of the five best discriminating models showed good calibration.

Conclusions

External validation demonstrates that, except for two promising models, most existing clinical prediction models are poor to moderate predictors for BPD. To improve the predictive accuracy and identify preterm infants for future intervention studies aiming to reduce the risk of BPD, additional variables are required. Subsequently, that model should be externally validated using a proper impact analysis before its clinical implementation.

Retinopathy of prematurity

The immature retinas of preterm neonates are susceptible to insults that disrupt neurovascular growth, leading to retinopathy of prematurity. Suppression of growth factors due to hyperoxia and loss of the maternal-fetal interaction result in an arrest of retinal vascularisation (phase 1). Subsequently, the increasingly metabolically active, yet poorly vascularised, retina becomes hypoxic, stimulating growth factor-induced vasoproliferation (phase 2), which can cause retinal detachment. In very premature infants, controlled oxygen administration reduces but does not eliminate retinopathy of prematurity. Identification and control of factors that contribute to development of retinopathy of prematurity is essential to prevent progression to severe sight-threatening disease and to limit comorbidities with which the disease shares modifiable risk factors. Strategies to prevent retinopathy of prematurity will depend on optimisation of oxygen saturation, nutrition, and normalisation of concentrations of essential factors such as insulin-like growth factor 1 and ω-3 polyunsaturated fatty acids, as well as curbing of the effects of infection and inflammation to promote normal growth and limit suppression of neurovascular development.

Counselling and management for anticipated extremely preterm birth

Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.

Obstetric and neonatal care practices for infants 501 to 1500 g from 2000 to 2009

OBJECTIVE

To identify changes in clinical practices for infants with birth weights of 501 to 1500 g born from 2000 to 2009.

METHODS

We used prospectively collected registry data for 355,806 infants born from 2000 to 2009 and cared for at 669 North American hospitals in the Vermont Oxford Network. Main outcome measures included obstetric and neonatal practices, including cesarean delivery, antenatal steroids, delivery room interventions, respiratory practices, neuroimaging, retinal exams, and feeding at discharge.

RESULTS

Significant changes in many obstetric, delivery room, and neonatal practices occurred from 2000 to 2009. Use of surfactant treatment in the delivery room increased overall (adjusted difference [AD] 17.0%; 95% confidence interval [CI] 16.4% to 17.6%), as did less-invasive methods of respiratory support, such as nasal continuous positive airway pressure (AD 9.9%; 95% CI 9.1% to 10.6%). Use of any ventilation (AD -7.5%; 95% CI -8.0% to -6.9%) and steroids for chronic lung disease (AD -15.3%; 95% CI -15.8% to -14.8%) decreased significantly overall. Most of the changes in respiratory care were observed within each of 4 birth weight strata (501-750 g, 751-1000 g, 1001-1250 g, 1251-1500 g).

CONCLUSIONS

Many obstetric and neonatal care practices used in the management of infants 501 to 1500 g changed between 2000 and 2009. In particular, less-invasive approaches to respiratory support increased.

Epidemiology and trends of necrotizing enterocolitis in Sweden: 1987-2009

OBJECTIVE

To investigate temporal, seasonal, and geographic variations in the incidence of necrotizing enterocolitis (NEC) and its relation to early infant survival in the Swedish population and in subgroups based on gestational age, birth weight, and gender.

METHODS

In the Swedish birth cohort of 1987 through 2009 all children with a diagnosis of NEC were identified in the National Patient Register, the Swedish Medical Birth Register, and the National Cause of Death Register. NEC incidence, early mortality, and seasonality were analyzed with descriptive statistics, Poisson regression, and auto regression.

RESULTS

The overall incidence of NEC was 3.4 in 10,000 live births, higher in boys than in girls (incidence rate ratio 1.22, 95% confidence interval 1.06-1.40, P = .005), with a peak in November and a trough in May, and increased with an average of ~5% a year during the study period. In most subgroups, except the most immature, an initial decrease was followed by a steady increase. Seven-day mortality decreased strongly in all subgroups over the entire study period (annual incidence rate ratio 0.96, 95% confidence interval 0.95-0.96, P < .001). This was especially marked in the most premature and low birth weight infants.

CONCLUSIONS

After an initial decrease, the incidence of NEC has increased in Sweden during the last decades. An association with the concurrent dramatically improved early survival seems likely.

Borderline Viability—Neonatal Outcomes of Infants in Singapore over a Period of 18 Years (1990 – 2007)

Introduction: This study assesses the trends and predictors of mortality and morbidity in infants of gestational age (GA) <27 weeks from 1990 to 2007. Materials and Methods: This is a retrospective cross-sectional cohort study of infant deliveries between 1990 and 2007 in the largest perinatal centre in Singapore. This is a study of infants born at <27 weeks in 2 Epochs (Epoch 1 (E1):1990 to 1998, Epoch 2 (E2):1999 to 2007) using logistic regression models to identify factors associated with mortality and composite morbidity. The main outcomes that were measured were the trends and predictors of mortality and morbidity. Results: Four hundred and eight out of 615 (66.3%) live born infants at 22 to 26 weeks survived to discharge. Survival improved with increasing GA from 22% (13/59) at 23 weeks to 87% (192/221) at 26 weeks (P <0.01). Survival rates were not different between E1 and E2, (61.5% vs 68.8%). In logistic regression analysis, higher survival was independently associated with increasing GA and birthweight, while airleaks, severe intraventricular haemorrhage (IVH) and necrotizing enterocolitis (NEC) contributed to increased mortality. Rates of major neonatal morbidities were bronchopulmonary dysplasia(BPD) (45%), sepsis (35%), severe retinopathy of prematurity (ROP) (31%), severe IVH/ periventricular leucomalacie (PVL) (19%) and NEC (10%). Although composite morbidity comprising any of the above was not significantly different between the 2 Epochs (75% vs 73%) a decreasing trend was seen with increasing GA (P <0.001). Composite morbidity/mortality was significantly lower at 26 weeks (58%) compared to earlier gestations (P<0.001, OR 0.37, 95% CI, 0.28 to 0.48) and independently associated with decreasing GA and birth weight, male sex, hypotension, presence of patent ductus arteriosus (PDA) and airleaks. Conclusion: Increasing survival and decreasing composite morbidity was seen with each increasing week in gestation with marked improvement seen at 26 weeks. Current data enables perinatal care decisions and parental counselling. Key words: Composite Morbidity, Neonatal Mortality

Review Article: Health benefit of increased serum 25(OH)D levels from oral intake and ultraviolet-B irradiance in the Nordic countries

Aims: A low serum 25-hydroxyvitamin D [25(OH)D] level is a risk factor for many diseases, including musculoskeletal diseases, many types of cancer, cardiovascular diseases, diabetes mellitus, infectious diseases, autoimmune diseases, and brain diseases. This report estimates the reduction in mortality rates for the five Nordic countries for an increase in population mean serum 25-hydroxyvitamin D level to 105 nmol/L. Methods: Serum vitamin D dose—incidence/prognosis relationships can be developed with significant levels of reliability for most vitamin D-sensitive diseases on the basis of ecological, cross-sectional, and observational studies, randomized controlled trials, and meta-analysis of such studies. These dose—response relations are used to estimate the population-wide benefit of raising mean serum 25(OH)D concentration to 105 nmol/L for the five Nordic countries. Results: From this study, the reductions in mortality rates possible by raising population mean serum 25(OH)D levels to 105 nmol/L are: Denmark, 17% (estimated range,11%—24%); Finland, 24% (17%—32%); Iceland, 24% (17%—32%); Norway, 18% (11%—26%); and Sweden, 18% (8%—25%). Conclusions: Reaching these levels would require changes in health policies with respect to solar ultraviolet-B (UVB) irradiance, vitamin D fortification of food, availability of vitamin D and calcium supplements, and attitude toward use of UVB lamps. Adverse effects of oral vitamin D intake are limited, and those from UVB irradiance are minor compared with the benefits.

Respiratory outcomes and atopy in school-age children who were preterm at birth, with and without bronchopulmonary dysplasia

OBJECTIVE

To assess pulmonary function and the prevalence of atopy in school-age children who were very low birth weight as infants and to compare those who had bronchopulmonary dysplasia to those who did not.

METHOD

We studied 85 (39 male and 46 female) at a mean age of 84 (range, 62 to 107) months who were very low birth weight infants. Bronchopulmonary dysplasia was defined as oxygen dependency at 36 weeks gestational age. We excluded 8 patients (4 for cerebral palsy and 4 for no collaboration). Detailed perinatal and clinical data were collected. Lung function was evaluated using conventional spirometry. Atopy (assessed by the allergy skin-prick test) was considered when at least one positive skin test occurred in a panel of the most common environmental allergens in the local region. Comparisons between the bronchopulmonary dysplasia and no bronchopulmonary dysplasia groups were performed using the Mann-Whitney, x2 and Fisher's exact tests.

RESULTS

We compared the bronchopulmonary dysplasia (n = 13) and no bronchopulmonary dysplasia (n = 64) groups. Atopy was observed in 4 (30.8%) of the bronchopulmonary dysplasia patients and in 17 (26.6%) of the no bronchopulmonary dysplasia patients (p = 0.742). Two (15.4%) patients with bronchopulmonary dysplasia had a family history of atopy vs. 17 (26.6%) in the no bronchopulmonary dysplasia group (p = 0.5). Lung function tests showed airway obstruction in 2 (15.4%) of the bronchopulmonary dysplasia patients and in 10 (15.6%) of the no bronchopulmonary dysplasia patients (p = 1.0). Four (33.3%) of the bronchopulmonary dysplasia patients had small airway obstruction vs. 14 (22.2%) of the no bronchopulmonary dysplasia patients (p = 0.466).

CONCLUSION

Our data showed no significant differences in lung function between bronchopulmonary dysplasia and no bronchopulmonary dysplasia patients at school age and no evidence of an association between atopy and bronchopulmonary dysplasia.

Risk factors for bronchopulmonary dysplasia in five Portuguese neonatal intensive care units

The pathogenesis of bronchopulmonary dysplasia (BPD) is clearly multifactorial. Specific pathogenic risk factors are prematurity, respiratory distress, oxygen supplementation, mechanical ventilation (MV), inflammation, patent ductus arteriosus (PDA), etc.

AIM

To evaluate BPD prevalence and to identify risk factors for BPD in five Portuguese Neonatal Intensive Care Units in order to develop better practices the management of these newborns.

MATERIAL AND METHODS

256 very low birth weight infants with gestational age (GA) <30 weeks and/or birthweight (BW) <1250 g admitted in five Portuguese NICUs, between 2004 and 2006 were studied. A protocol was filled in based on clinical information registered in the hospital charts. BPD was defined as oxygen dependency at 36 weeks of postconceptional age.

RESULTS

BPD prevalence was 12.9% (33/256). BPD risk decreased 46% per GA week and of 39% per 100g BW. BPD risk was significantly higher among newborns with low BW (adj OR= 0.73, 95% CI=0.57- 0.95), severe hyaline membrane disease (adj OR= 9.85, 95% CI=1.05-92.35), and those with sepsis (adj OR=6.22, 95% CI=1.68-23.02), those with longer duration on ventilatory support (42 vs 3 days, respectively in BPD and no BPD patients, p <0.001) and longer duration of FiO2>0.30 (85 vs 5 days, respectively in BPD and no BPD patients, p <0.001).

COMMENTS

The most relevant risk factors were low birth weight, severe hyaline membrane disease, duration of respiratory support and oxygen therapy, and nosocomial sepsis. The implementation of potentially better practices to reduce lung injury in neonates must be addressed to improve practices to decrease these risk factors.

Follow-up of adolescents born extremely preterm: cognitive function and health at 18 years of age

AIM

To compare cognitive ability, school achievement and self-perceived health aspects in adolescents born extremely preterm and term born controls.

METHOD

Fifty-two, out of 61, extremely preterm born adolescents (mean age 18.4 years) and 54 matched controls (mean age 18.3 years) born at full term were investigated; intelligence quotient was measured with the Wechsler Adult Intelligence Scale; cognitive flexibility, i.e. a measure of visuomotor speed and attention, with the Trail Making Test; school achievement and choice of upper secondary programmes were reported. Health aspects were investigated in a semi structured interview.

RESULT

The adolescents born prematurely had significantly lower IQ than the controls, mean 93 (SD 15.4) vs 106 (12.5), p < 0.001; showed slower visuomotor speed; had lower grades from compulsory school (192.7 vs 234.8, p < 0.001); and chose to a greater extent practical upper secondary school programmes. There were no differences between the groups in health care consumption, prevalence of chronic disease, allergy or infectious diseases.

CONCLUSION

Poorer cognitive performance, in extremely preterm born individuals, seems to persist into late adolescence. Fewer prematurely born than control chose theoretical upper secondary school programmes. However, no difference was noted regarding self-perceived health aspects.

Risk factors for intestinal failure in infants with necrotizing enterocolitis: a Glaser Pediatric Research Network study

OBJECTIVE

To determine risk factors for intestinal failure (IF) in infants undergoing surgery for necrotizing enterocolitis (NEC).

STUDY DESIGN

Infants were enrolled in a multicenter prospective cohort study. IF was defined as the requirement for parenteral nutrition for >or= 90 days. Logistic regression was used to identify predictors of IF.

RESULTS

Among 473 patients enrolled, 129 had surgery and had adequate follow-up data, and of these patients, 54 (42%) developed IF. Of the 265 patients who did not require surgery, 6 (2%) developed IF (OR 31.1, 95% CI, 12.9 - 75.1, P < .001). Multivariate analysis identified the following risk factors for IF: use of parenteral antibiotics on the day of NEC diagnosis (OR = 16.61, P = .022); birth weight < 750 grams, (OR = 9.09, P < .001); requirement for mechanical ventilation on the day of NEC diagnosis (OR = 6.16, P = .009); exposure to enteral feeding before NEC diagnosis (OR=4.05, P = .048); and percentage of small bowel resected (OR = 1.85 per 10 percentage point greater resection, P = .031).

CONCLUSION

The incidence of IF among infants undergoing surgical treatment for NEC is high. Variables characteristic of severe NEC (low birth weight, antibiotic use, ventilator use, and greater extent of bowel resection) were associated with the development of IF.

Incidence of and risk factors for neonatal morbidity after active perinatal care: extremely preterm infants study in Sweden (EXPRESS)

AIMS

The aim of this study was to determine the incidence of neonatal morbidity in extremely preterm infants and to identify associated risk factors.

METHODS

Population based study of infants born before 27 gestational weeks and admitted for neonatal intensive care in Sweden during 2004-2007.

RESULTS

Of 638 admitted infants, 141 died. Among these, life support was withdrawn in 55 infants because of anticipation of poor long-term outcome. Of 497 surviving infants, 10% developed severe intraventricular haemorrhage (IVH), 5.7% cystic periventricular leucomalacia (cPVL), 41% septicaemia and 5.8% necrotizing enterocolitis (NEC); 61% had patent ductus arteriosus (PDA) and 34% developed retinopathy of prematurity (ROP) stage > or =3. Eighty-five per cent needed mechanical ventilation and 25% developed severe bronchopulmonary dysplasia (BPD). Forty-seven per cent survived to one year of age without any severe IVH, cPVL, severe ROP, severe BPD or NEC. Tocolysis increased and prolonged mechanical ventilation decreased the chances of survival without these morbidities. Maternal smoking and higher gestational duration were associated with lower risk of severe ROP, whereas PDA and poor growth increased this risk.

CONCLUSION

Half of the infants surviving extremely preterm birth suffered from severe neonatal morbidities. Studies on how to reduce these morbidities and on the long-term health of survivors are warranted.