Early predictors of hypertension in prematurely born adolescents

Continuous versus intermittent bolus infusion of calcium in preterm infants receiving total parenteral nutrition: a randomized blind clinical trial

BACKGROUND

Premature neonates need adequate nutritional support to provide sufficient essential nutrients for optimal growth. Calcium (Ca) is one of the important nutrients in parental nutrition support of premature infants. This study aimed to compare the effect of continuous and intermittent bolus infusion of Ca on the incidence of metabolic bone disease (MBD) in preterm infants.

METHODS

This randomized double-blind clinical trial was conducted on ninety preterm infants in the NICU of Al-Zahra Hospital in Tabriz, Iran. The preterm infants were randomly allocated to either a continuous infusion group (received 4-5 ml/kg/day of Ca gluconate 10% by PN solution in a 24-h period) or an intermittent bolus administration group (received 1-2 ml/kg/day Ca gluconate 10% three to four times per day). Serial serum levels of Ca, phosphorous, alkaline phosphatase (ALP), vitamin D and parathyroid hormone (PTH) were assessed on the 7th day, 30th day and 45th day of life.

RESULTS

A total of 78 infants completed the study. The serum ALP level on the 45th day after birth was 753.28 ± 304.59 IU/L and 988.2 ± 341.3 IU/L in the continuous infusion and intermittent bolus administration groups, respectively (P < 0.05). MBD in preterm infants with ALP levels above 900 IU/L on the 45th day of life was significantly lower in the continuous infusion group than in the intermittent bolus administration group (p < 0.05). The mean serum levels of calcium, phosphorus, vitamin D and PTH in 45-day-old infants were not significantly different between the two groups.

CONCLUSION

The MBD in preterm infants who received continuous infusion of Ca was lower than that in preterm infants who received intermittent bolus administration of Ca.

TRIAL REGISTRATION

The Iranian Registry of Clinical Trials ( http://www.irct.ir ) with the identification No. IRCT20210913052466N1.

Birth weight and subclinical cardiovascular and renal damage in a population-based study (the STANISLAS cohort study)

OBJECTIVE

Although preterm-born and low-birth-weight individuals have an increased risk of cardiovascular diseases in adulthood, little is known regarding early cardiovascular and renal damage (CVRD) or hypertension in adulthood. Our study investigated the association of birth weight with early CVRD markers as well as the heritability of birth weight in an initially healthy family-based cohort.

METHODS

This study was based on 1028 individuals from the familial longitudinal STANISLAS cohort (399 parents/629 children) initiated in 1993-1995, with a fourth examination conducted in 2011-2016. Analyses performed at the fourth visit included pulse-wave velocity, central pressure, ambulatory blood pressure, hypertension status, diastolic dysfunction/distensibility, left ventricular mass indexed (LVMI), carotid intima-media thickness and kidney damage. The family structure of the cohort allowed birth weight heritability estimation.

RESULTS

Mean (±SD) birth weight was 3.3 ± 0.6 kg. Heritability was moderate (42-44%). At the fourth visit, individuals were 37 years old (32.0-57.0), 56% were women and 13% had antihypertensive treatment. Birth weight was strongly and negatively associated with hypertension [odds ratio (OR) 95% confidence interval (CI) 0.61 (0.45-0.84)]. A nonlinear association was found with LVMI, participants with a birth weight greater than 3 kg having a higher LVMI. A positive association ( β 95% CI 5.09 (1.8-8.38)] was also observed between birth weight and distensibility for adults with normal BMI. No associations were found with other CVRD.

CONCLUSION

In this middle-aged population, birth weight was strongly and negatively associated with hypertension, and positively associated with distensibility in adults with normal BMI and with LVMI for higher birth weights. No associations were found with other CVRD markers.

Persistent high blood pressure and renal dysfunction in preterm infants during childhood

BACKGROUND

Infants born very preterm (≤32 weeks gestational age, GA) and very-low birth weight (≤1500 g; PT-VLBW) demonstrate high systolic blood pressure (SBP), renal dysfunction, and obesity at 6 months-3 years and in early adulthood. Their parallel measurement and progression during childhood is unclear.

METHODS

We reenrolled 62/120 patients originally seen at 1-3 years at 10-13 years and remeasured anthropometric indices, SBP, and serum creatinine (Cr) and cystatin C (cysC) to determine estimated glomerular filtration rate (eGFR). We selected Term-matched Controls at 10-13 years from the 2015-2016 NHANES database at a ratio of 2 Controls:1 Case (124:62).

RESULTS

Reenrolled patients were predominantly Hispanic, birth weight 1073 ± 251 g, and GA at birth 28 ± 2 weeks. At 10-13 years, 45% were classified overweight/obese, 48% had SBP ≥ 90th centile (77% considered hypertensive), and 34% had low eGFR (<90 mL min^-1 [1.73 m²]^-1). Notably, 57% of reenrolled PT-VLBW Cases had low eGFR_cysC at both 1-3 and 10-13 years, P < 0.03. Compared to Controls, Cases had four times the adjusted odds for having an elevated SBP and low eGFR_Cr despite similar proportions with overweight/obesity among Cases and Controls.

CONCLUSIONS

PT-VLBW infants seen at 1-3 years exhibit obesity, elevated SBP, and low eGFR in infancy and 10-13 years. Although the small sample size may limit conclusions, pediatricians should consider serial evaluations of PT-VLBW throughout childhood.

IMPACT

The association between preterm birth and elevated blood pressure, renal dysfunction, and obesity in young adults begins as early as 1 year and persists at 10-13 years of age. This is the first study reporting serial measurements of blood pressure, renal function, and obesity from infancy to preadolescence in children born very preterm. Fifty-seven percent of preterm 1-3 year olds have persistent low estimated glomerular filtration rate associated with hypertension at 10-13 years. Clinicians should consider serial evaluations of blood pressure, renal function, and obesity throughout infancy and childhood in all preterm births.

The critical importance of follow-up to school age: Contributions of the NICHD Neonatal Research Network

Follow-up studies are essential for understanding outcomes and informing the care of infants with high risk for medical and developmental consequences because of extreme prematurity or perinatal illness. Studies that extend to school age often identify sequelae that go unrecognized in neonatal or short-term follow-up studies. Many critical neurocognitive, behavioral, functional, and health outcomes are best assessed beginning at school age. The Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN) has performed comprehensive school age evaluations of several key trial cohorts. This manuscript summarizes the important contributions of school age follow-up studies in the NRN, both historically and in ongoing research. We describe in detail the clinical questions that have been answered by the completed studies and new questions about the outcomes of high-risk infants that must be addressed by ongoing and future studies.

The Combined Effect of Birth Weight and Lifestyle on Clustered Cardio-Metabolic Risk Factors in Children and Adolescents: A National School-Based Cross-Sectional Survey

Background: Due to the adverse effects of cardio-metabolic risk factors (CMRFs) in children and adolescents on their current and later life health, and the growing evidence that birth weight and lifestyle have on CMRFs, we aimed to estimate the combined effect of birth weight and lifestyle on clustered CMRFs in children and adolescents. Methods: We enrolled 11,509 participants aged 7–18 years old in a national school-based cross-sectional study in seven provinces in China in 2013. Information on CMRFs was collected through anthropometric measurements and blood sample testing. Information on birth weight, lifestyle and other basic information were investigated through children and adolescents’ as well as parents’ questionnaires. The generalized linear mixed model was applied to estimate the odd ratio (OR) and 95% confidence interval (95% CI) for the associations between CMRFs, clustered CMRFs and birth weight, lifestyle, and the combinations of birth weight and lifestyle. Results: Overall, the prevalence of clustered CMRFs was 3.6% in children and adolescents aged 7–18 years, higher in boys (4.4%) than girls (2.9%). The combination of LBW/ideal lifestyle (OR = 2.00, 95% CI: 1.07–3.72) was associated with higher risk of clustered CMRFs, as well as in adolescents aged 13–18 years and in boys. The combination of HBW/poor lifestyle (OR = 1.74, 95% CI: 1.13–2.68) was related to elevated risk of clustered CMRFs, especially in children aged 7–12 years. Conclusions: CMRFs in Chinese children and adolescents is concerning, ideal lifestyle could weaken the association of birth weight with clustered CMRFs, especially in younger age, indicating that programs to prevent abnormal birth weight or poor lifestyle or both among children and adolescents may reduce CMRFs in China.

Very preterm birth results in later lower platelet activation markers

BACKGROUND

Premature birth entails an adverse cardiovascular risk profile, but the underlying mechanisms are insufficiently understood. Here, we employed an unbiased cardiovascular proteomics approach to profile former very preterm-born preschoolers.

METHODS

This observational study investigated differences in plasma concentrations of 79 proteins, including putative cardiovascular biomarkers between very preterm- and term-born children on average 5.5 years old (53.1% male) using multiple-reaction monitoring mass spectrometry.

RESULTS

Very preterm-born (n = 38; median gestational age 29.6 weeks) compared to term-born (n = 26; 40.2 weeks) children featured lower plasma concentrations of platelet factor 4 (PLF4; -61.6%, P < 0.0001), platelet basic protein (CXCL7; -57.8%, P < 0.0001), and hemoglobin subunit beta (-48.3%, P < 0.0001). Results remained virtually unchanged when adjusting for complete blood count parameters, including platelet count. Conversely, whole blood hemoglobin was higher (+7.62%, P < 0.0001) in preterm-born children.

CONCLUSIONS

Very preterm birth was associated with decreased markers of platelet activation among preschoolers. These findings are consistent with reduced platelet reactivity persisting from very preterm birth to a preschool age.

IMPACT

Former very preterm-born preschoolers featured reduced levels of platelet activation markers. While lower platelet reactivity in very preterm-born compared to term-born infants in the first days of life was established, it was unknown when, if at all, reactivity normalizes. The current study suggests that platelet hyporeactivity due to very preterm birth persists at least up to a preschool age. "Immaturity of the hemostatic system" may be a persistent sequel of preterm birth, but larger studies are needed to investigate its potential clinical implications.

Adrenal Steroid Metabolism and Blood Pressure in 5- to 7-Year-Old Children Born Preterm as Compared to Peers Born at Term

Background: Previous studies indicated preterm birth to be a risk factor for hypertension in adolescence and adulthood. However, studies in children investigating the underlying mechanisms are scarce. Objective: We hypothesized children born preterm to have higher excretion of cortisol and/or androgen metabolites per day concomitantly with higher blood pressure as compared to peers born at term. We thus aimed to compare urinary steroid profiles and blood pressure between 5- to 7-year-old children born preterm and peers born at term. Furthermore, aldosterone precursor excretion per day was compared between both groups. Methods: Blood pressure was measured in 236 children (preterms n = 116; gestational age 29.8 ± 2.6 (30; 24-33) weeks [mean ± standard deviation (median; range)]) using an automatic oscillometric device. Urinary steroid profiles were determined in 24-h urine samples (preterms n = 109; terms n = 113) using gas chromatographic-mass spectrometric analysis. To assess excretion of cortisol and androgen metabolites per day, major cortisol and androgen metabolites were summed, respectively. To assess aldosterone excretion per day tetrahydrocorticosterone, 5α-tetrahydrocorticosterone, and tetrahydro-11-deydrocorticosterone were summed. Results: Multiple regression analyses showed prematurity to be associated with systolic but not with diastolic blood pressure. When adjusted for potential confounders (prematurity, gender, age at day of examination, being born small for gestational age, breastfeeding, accelerated weight gain during infancy, family history of cardiovascular disease, parental hypertension, and body mass index) prematurity was shown to be associated with an increase in systolic blood pressure by 2.87 mmHg (95% confidence interval 0.48-5.27; p = 0.02). Cortisol, androgen metabolite, and aldosterone precursor excretion per day were not higher in individuals born preterm. In contrast to our hypothesis, multiple regression analysis showed prematurity to independently decrease cortisol and aldosterone precursor excretion per day (p < 0.001 and 0.04, respectively). Conclusion: This study provides further evidence for systolic blood pressure to be higher after preterm birth as early as at the age of 5 to 7 years. However, this seems not to be explained by elevated excretion of cortisol and/or androgen metabolites.

Cardiovascular risk factors in those born preterm - systematic review and meta-analysis

Emerging evidence demonstrates a link between preterm birth (PTB) and later life cardiovascular disease (CVD). We conducted a systematic review and meta-analysis to compare conventional CVD risk factors between those born preterm and at term. PubMed, CINAHL, SCOPUS, and EMBASE databases were searched. The review protocol is registered in PROSPERO (CRD42018095005). CVD risk factors including systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index, lipid profile, blood glucose, and fasting insulin among those born preterm (<37 weeks' gestation) were compared with those born at term (≥37 weeks' gestation). Subgroup analyses based on gender, age, gestational at birth (<32 weeks' gestation and <28 weeks' gestation), and PTB associated with small for gestational age or average for gestational age were also performed. Fifty-six studies provided data on 308,987 individuals. Being born preterm was associated with 3.26 mmHg (95% confidence interval [CI] 2.08 to 4.44) higher mean SBP and 1.32 mmHg (95% CI: 0.61 to 2.04) higher mean DBP compared to being born at term. Subgroup analyses demonstrated that SBP was higher among (a) preterm compared to term groups from early adolescence until adulthood; (b) females born preterm but not among males born preterm compared to term controls; and (c) those born at <32 weeks or <28 weeks compared to term. Our meta-analyses demonstrate higher SBP and DBP among those born preterm compared to term. The difference in SBP is evident from early adolescence until adulthood.

Comparison of Blood Pressure and Kidney Markers between Adolescent Former Preterm Infants and Term Controls

BACKGROUND

Preterm infants are at an increased risk of developing hypertension and chronic kidney disease later in life. No recommendations exist for blood pressure (BP) and renal follow up for these patients.

AIM

To compare BP and serum and urinary kidney markers between preterm-born adolescents and term-born controls.

METHODS

BP measurements in 51 preterm-born (≤32 weeks gestational age) and 82 term-born adolescents at the age of 10-15 years were conducted. Stepwise regression analysis explored the association between BP and participant characteristics. Kidney markers measured in the serum and urine were creatinine, neutrophil gelatinase-associated lipocalin (NGAL), and uromodulin. Kidney markers measured in the serum were cystatin C, beta-2 microglobulin, and beta trace protein.

RESULTS

Systolic BP was significantly higher in preterm boys compared with term boys, but not in girls, and low birth weight was associated with higher BP in boys. In the preterm group, maternal hypertension/preeclampsia and adolescent height were associated with higher systolic BP. Serum creatinine and NGAL were significantly higher in the preterm group.

CONCLUSIONS

Our study confirms an inverse sex-dependant relationship between birth weight and BP at adolescent age. The higher serum creatinine and NGAL in the preterm group may indicate that premature birth affects kidney function in the long term.

Integration of an interpretable machine learning algorithm to identify early life risk factors of childhood obesity among preterm infants: a prospective birth cohort

BACKGROUND

The early life risk factors of childhood obesity among preterm infants are unclear and little is known about the influence of the feeding practices. We aimed to identify early life risk factors for childhood overweight/obesity among preterm infants and to determine feeding practices that could modify the identified risk factors.

METHODS

A total of 338,413 mother-child pairs were enrolled in the Jiaxing Birth Cohort (1999 to 2013), and 2125 eligible singleton preterm born children were included for analyses. We obtained data on health examination, anthropometric measurement, lifestyle, and dietary habits of each participant at their visits to clinics. An interpretable machine learning-based analytic framework was used to identify early life predictors for childhood overweight/obesity, and Poisson regression was used to examine the associations between feeding practices and the identified leading predictor.

RESULTS

Of the eligible 2125 preterm infants (863 [40.6%] girls), 274 (12.9%) developed overweight/obesity at age 4-7 years. We summarized early life variables into 25 features and identified two most important features as predictors for childhood overweight/obesity: trajectory of infant BMI (body mass index) Z-score change during the first year of corrected age and maternal BMI at enrollment. According to the impacts of different BMI Z-score trajectories on the outcome, we classified this feature into the favored and unfavored trajectories. Compared with early introduction of solid foods (≤ 3 months of corrected age), introducing solid foods after 6 months of corrected age was significantly associated with 11% lower risk (risk ratio, 0.89; 95% CI, 0.82 to 0.97) of being in the unfavored trajectory.

CONCLUSIONS

The trajectory of BMI Z-score change within the first year of life is the most important predictor for childhood overweight/obesity among preterm infants. Introducing solid foods after 6 months of corrected age is a recommended feeding practice for mitigating the risk of being in the unfavored trajectory.

Segmental infantile hemangioma and concomitant hypertension in three African American neonates

We present three African American infants with segmental, ulcerated infantile hemangiomas and concomitant, persistent hypertension. When treated with beta-blocker therapy, the hemangiomas decreased in size and the ulcerations resolved, but there was no impact on the elevated blood pressure in one of our patients. We failed to identify any associations between infantile hemangioma and hypertension in the literature.

Clinical consequences of developmental programming of low nephron number

Nephron number in humans varies up to 13-fold, likely reflecting the impact of multiple factors on kidney development, including inherited body size and ethnicity, as well as maternal health and nutrition, fetal exposure to gestational diabetes or preeclampsia and other environmental factors, which may potentially be modifiable. Such conditions predispose to low or high offspring birth weight, growth restriction or preterm birth, which have all been associated with increased risks of higher blood pressures and/or kidney dysfunction in later life. Low birth weight, preterm birth, and intrauterine growth restriction are associated with reduced nephron numbers. Humans with hypertension and chronic kidney disease tend to have fewer nephrons than their counterparts with normal blood pressures or kidney function. A developmentally programmed reduction in nephron number therefore enhances an individual's susceptibility to hypertension and kidney disease in later life. A low nephron number at birth may not lead to kidney dysfunction alone except when severe, but in the face of superimposed acute or chronic kidney injury, a kidney endowed with fewer nephrons may be less able to adapt, and overt kidney disease may develop. Given that millions of babies are born either too small, too big or too soon each year, the population impact of altered renal programming is likely to be significant. Many gestational exposures are modifiable, therefore urgent attention is required to implement public health measures to optimize maternal, fetal, and child health, to prevent or mitigate the consequences of developmental programming, to improve the health future generations.

Extremely Low Birth Weight Predisposes to Impaired Renal Health: A Pooled Analysis

BACKGROUND

A number of studies examined the association between preterm delivery and kidney size and function later in life. However, the number of cases in published cohort studies is low. This study was aimed at performing a multicenter collaboration to pool data to obtain more accurate results to quantify the extent of renal impairment in former extremely low birth weight (ELBW; <1,000 g) children.

METHODOLOGY

We performed a subject-level meta-analysis to pool data from Cracow (64 cases/34 controls) and Leuven (93 cases/87 controls). We assessed and analyzed cystatin C, estimated glomerular filtration rate (eGFR), ultrasound kidney length, and blood pressure (BP) in 11-year-old ELBW children compared with controls born at term. The prevalence of hypertension (HT) and prehypertension (preHT) in both groups was also analyzed.

RESULTS

The study group comprised 157 former ELBW children (gestational age 23-33 weeks and birth weight 430-1,000 g) and 123 children born at term. Former ELBW children had lower mean eGFR (100.62 ± 16.53 vs. 111.89 ± 15.26 mL/min/1.73 m2; p < 0.001), smaller absolute kidney length (8.56 ± 0.78 vs. 9.008 ± 0.73 cm; <0.001), and higher systolic (111.8 ± 9.8 vs. 107.2 ± 9.07 mm Hg; p = 0.01) and diastolic (68.6 ± 6.8 vs. 66.3 ± 7.7 mm Hg; p = 0.03) BP. Smaller renal size in former ELBW children was positively associated with lower birth weight, shorter gestational age, and severity of perinatal complications (intraventricular hemorrhage, length of stay, mechanical ventilation, and oxygen therapy).

CONCLUSION

ELBW is associated with lower eGFR and a high frequency of preHT and HT.

Prevalence of metabolic syndrome-like in the follow-up of very low birth weight preterm infants and associated factors

OBJECTIVE

To assess the prevalence of metabolic syndrome-like symptoms in a population of preterm infants with very low birth weight (<1500g) at 2 years of corrected age and identify the occurrence of associated risk factors.

METHODS

Cross-sectional study during a five-year period, including preterm infants born with very low birth weight evaluated at 2 years of corrected age. Metabolic syndrome-like symptoms was defined by the presence of three or more of these criteria: abdominal circumference≥90th percentile, fasting blood glucose≥100mg/dL, triglycerides≥110mg/dL, HDL cholesterol≤40mg/dL, and blood pressure≥90th percentile.

RESULTS

A total of 214 preterm infants with birth weight<1500g were evaluated. The prevalence of metabolic syndrome-like symptoms at 2 years of corrected age was 15.1%. Arterial hypertension was present in 57.5%, HDL≤40mg/dL in 29.2%, hypertriglyceridemia in 22.6%, and abdominal circumference above the 90th percentile in 18.8%. Only 3.7% had hyperglycemia. The presence of periventricular leukomalacia was an independent risk factor for arterial hypertension at this age (OR 2.34, 95% CI: 0.079-0.69, p=0.008). Overweight and obesity at 2 years of corrected age were independently associated with metabolic syndrome-like symptoms (OR 2.75, 95% CI: 1.19-6.36, p=0.018).

CONCLUSION

Metabolic syndrome-like symptoms can be observed in very low birth weight preterm infants as early as 2 years of corrected age. Overweight and early-onset obesity are significant risk factors for metabolic syndrome-like symptoms, which deserves appropriate intervention for this high-risk population.

Postnatal nutritional intakes and hyperglycemia as determinants of blood pressure at 6.5 years of age in children born extremely preterm

BACKGROUND

Adverse developmental programming by early-life exposures might account for higher blood pressure (BP) in children born extremely preterm. We assessed associations between nutrition, growth and hyperglycemia early in infancy, and BP at 6.5 years of age in children born extremely preterm.

METHODS

Data regarding perinatal exposures including nutrition, growth and glycemia status were collected from the Extremely Preterm Infants in Sweden Study (EXPRESS), a population-based cohort including infants born <27 gestational weeks during 2004-2007. BP measurements were performed at 6.5 years of age in a sub-cohort of 171 children (35% of the surviving children).

RESULTS

Higher mean daily protein intake (+1 g/kg/day) during postnatal weeks 1-8 was associated with 0.40 (±0.18) SD higher diastolic BP. Higher mean daily carbohydrate intake (+1 g/kg/day) during the same period was associated with 0.18 (±0.05) and 0.14 (±0.04) SD higher systolic and diastolic BP, respectively. No associations were found between infant growth (weight, length) and later BP. Hyperglycemia and its duration during postnatal weeks 1-4 were associated primarily with higher diastolic BP z-scores.

CONCLUSIONS

These findings emphasize the importance of modifiable early-life exposures, such as nutrition and hyperglycemia, in determining long-term outcomes in children born extremely preterm.

Correlates of elevated blood pressure in healthy children: a systematic review

The prevalence of hypertension in children is increasing globally. Addressing this will require a robust understanding of associated risk factors. To this end, we conducted a systematic review to identify correlates of elevated blood pressure (BP) in children. Literature searches were conducted using pre-defined search terms from three academic databases. The abstract and full text of identified studies were screened for eligibility by two independent reviewers. A total of 100 studies were included in this systematic review. An assessment tool was first used to assess study quality; a narrative synthesis was then performed. We found a broad range of physiological, social and behavioural factors associated with elevated BP in children. The most common correlate observed was adiposity, suggesting that childhood obesity may be implicated in the increased prevalence of hypertension observed in children. However, the broad range of other factors identified underscores the multi-factorial aetiology of hypertension. Data from a broad range of studies showed that the correlates of hypertension in children are multi-factorial. Therefore, approaches aimed at preventing hypertension must in turn be multi-factorial to ensure that the burden of hypertension in childhood is addressed.

What Are We Measuring as Outcome? Looking Beyond Neurodevelopmental Impairment

Outcomes of neonatal intensive care unit (NICU) graduates have been categorized by rates of neurodevelopmental impairment at 2 years old. Although useful as metrics for research, these early childhood assessments may underestimate or overestimate later functional capabilities. Often overlooked are less severe but more prevalent neurobehavioral dysfunctions seen later in childhood, and chronic health concerns that may impact the child's quality of life (QoL). Comprehensive NICU follow-up should include measures of less severe cognitive/learning delays, physical/mental well-being, and the promotion of resilience in children and families. Studies are needed to identify QoL measures that will optimize children's assessments and outcomes.

Extreme Preterm Infant Rates of Overweight and Obesity at School Age in the SUPPORT Neuroimaging and Neurodevelopmental Outcomes Cohort

OBJECTIVE

To identify rates of overweight (body mass index [BMI] ≥85th percentile) and obesity (BMI ≥95th percentile) at 6-7 years of age and associated risk factors among extremely preterm infants born at <28 weeks of gestation.

STUDY DESIGN

Anthropometrics, blood pressure, and active and sedentary activity levels were prospectively assessed. Three groups were compared, those with a BMI ≥85th percentile (overweight or obese for age, height, and sex) and ≥95th percentile (obese) vs <85th percentile. Multiple regression analyses estimated the relative risks of BMI ≥85th percentile and ≥95th percentile associated with perinatal and early childhood factors.

RESULTS

Of 388 children, 22% had a BMI of ≥85th percentile and 10% were obese. Children with obesity and overweight compared with normal weight children had higher body fat (subscapular skinfold and triceps skinfold >85th percentile), central fat (waist circumference >90th percentile), spent more time in sedentary activity (20.5 vs 18.2 vs 16.7 hours/week), and had either systolic and/or diastolic hypertension (24% vs 26% vs 14%), respectively. Postdischarge weight gain velocities from 36 weeks postmenstrual age to 18 months, and 18 months to 6-7 years were independently associated with a BMI of ≥85th percentile, whereas weight gain velocity from 18 months to 6-7 years was associated with obesity.

CONCLUSIONS

One in 5 former extremely preterm infants is overweight or obese and has central obesity at early school age. Postdischarge weight gain velocities were associated with overweight and obesity. These findings suggest the obesity epidemic is spreading to the most extremely preterm infants.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00063063 and NCT0000.

High Blood Pressure at Early School Age Among Extreme Preterms

BACKGROUND AND OBJECTIVES

Former preterm infants are at increased risk of hypertension with increasing age. Our objective was to identify rates of high blood pressure (BP) (≥90th percentile) and hypertension (BP ≥95th percentile) and associated risk factors among extreme preterm (EPT) infants at 6 to 7 years of age.

METHODS

Assessment included BP and anthropometrics. Comparisons were made by BP ≥90th versus <90th percentile. Regressions were run to identify relative risk (RR) of factors associated with BP ≥90th percentile.

RESULTS

Among 379 EPT infants, 20.6% had systolic high BP, 10.8% systolic hypertension, 21.4% diastolic high BP, and 11.4% diastolic hypertension. Children with systolic high BP had higher rates of BMI, triceps skinfolds >85th percentile, and waist circumference >90th percentile. In regression analyses, weight gain velocity from 18 months to school age (RR = 1.36), and maternal gestational diabetes (MGD) (RR = 2.04) predicted systolic and either systolic and/or diastolic high BP (RR = 1.27 and RR = 1.67). Among children with BMI <85th percentile, 17% had systolic and 19% had diastolic high BP. Regression analysis for normal weight children indicated public insurance (RR = 2.46) and MGD (RR = 2.16) predicted systolic high BP, and MGD (RR = 2.08) predicted either systolic or diastolic high BP.

CONCLUSIONS

Both overweight and normal weight EPT children are at risk for high BP and hypertension. Public insurance, MGD, and weight gain velocity are risk factors. Findings of high BP among EPT children at early school age are worrisome and indicate a need for close follow-up.

Incidence of neonatal hypertension from a large multicenter study [Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates-AWAKEN]

BACKGROUND

Hypertension occurs in up to 3% of neonates admitted to the Neonatal Intensive Care Unit (NICU), and is a potentially under-recognized condition. The aim of this study was to examine the incidence of documented and undiagnosed hypertension from the 24-center Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) database, and to assess risk factors for hypertension according to gestational age.

METHODS

Diagnosed hypertension was documented if an infant had a discharge diagnosis of hypertension and/or discharged on antihypertensive medications. Undiagnosed hypertension was defined when infants did not have a diagnosis of hypertension, but >50% of the lowest mean, diastolic and systolic blood pressure recordings were >95^th percentile for gestational age.

RESULTS

Of the 2162 neonates enrolled in the study, hypertension was documented in 1.8%. An additional 3.7% were defined as having undiagnosed hypertension. There was a significant correlation with neonatal hypertension and acute kidney injury (AKI). Additional risk factors for neonatal hypertension were hyperbilirubinaemia, Caucasian race, outborn, vaginal delivery, and congenital heart disease. Protective factors were small for gestational age, multiple gestations, and steroids for fetal maturation.

CONCLUSIONS

Neonatal hypertension may be an under-recognized condition. AKI and other risk factors predispose infants to hypertension.

Nonrandomised interventional study showed that early aggressive nutrition was effective in reducing postnatal growth restriction in preterm infants

AIM

This study evaluated whether an early aggressive nutrition (EAN) strategy could limit extrauterine growth restriction (EUGR) in a cohort of preterm infants.

METHODS

This prospective nonrandomised interventional study was carried out in the neonatal intensive care unit of an Italian hospital from January 2013 to December 2015. The prevalence of EUGR was assessed in 100 infants with a gestational age of ≤34 weeks, 50 after the introduction of an EAN regimen in October 2014 and 50 before.

RESULTS

The prevalence of EUGR at discharge was significantly lower after the introduction of EAN than before for weight (34% vs. 66%), head circumference (22% vs. 42%) and length at discharge (20% vs. 48%). The Z-scores for all measurements were significantly higher after the introduction of EAN. In the EAN group, weight velocity was significantly higher and maximum weight loss and negative changes in the Z-scores from birth to discharge for weight were lower than in the pre-intervention controls. In extremely low birthweight subjects, the weight Z-score and weight velocity were significantly higher in the EAN group than the control group.

CONCLUSION

The use of EAN at a very early age reduced EUGR and improved auxological outcomes in preterm infants.

Association among prematurity (<30 weeks' gestational age), blood pressure, urinary albumin, calcium, and phosphate in early childhood

BACKGROUND

There is a paucity of data on blood pressures (BP), urinary albumin, and mineral excretion in early childhood in contemporary cohorts of extremely low gestational age (GA) neonates. Our aim was to compare BPs and the urinary excretion of albumin, calcium, and phosphate in preterm and term-born cohorts in early childhood.

METHODS

This was a prospective observational study conducted at a single center, involving children <5 years age, born preterm (GA <30 weeks) or at term (≥37 weeks' GA). Urinary albumin (mg/L), calcium and phosphate levels indexed to creatinine (mg/dL), and BP were measured.

RESULTS

The median (IQR) follow-up age of our cohort (n = 106) was 30 (16-48) months. Preterm-born children (n = 55) had a significantly lower mean GA and birth weight and higher mean systolic, diastolic, and mean BPs, compared with term (n = 51) controls. A significantly higher proportion of preterm-born children weighed <10th centile and had systolic BP >95th centile at follow-up. Albumin and calcium excretion did not differ between the groups; median urine-phosphate creatinine ratios were higher in the preterm group. On logistic regression, lower GA and younger age at follow-up were significantly associated with an increased risk of systolic and diastolic BP above the 95th centile; male gender was associated with decreased risk of diastolic hypertension.

CONCLUSIONS

Even in early childhood, children born preterm had significantly elevated BP, compared with their term-born counterparts. Closer monitoring of BPs in this population may be warranted.

The Impact of Kidney Development on the Life Course: A Consensus Document for Action

Hypertension and chronic kidney disease (CKD) have a significant impact on global morbidity and mortality. The Low Birth Weight and Nephron Number Working Group has prepared a consensus document aimed to address the relatively neglected issue for the developmental programming of hypertension and CKD. It emerged from a workshop held on April 2, 2016, including eminent internationally recognized experts in the field of obstetrics, neonatology, and nephrology. Through multidisciplinary engagement, the goal of the workshop was to highlight the association between fetal and childhood development and an increased risk of adult diseases, focusing on hypertension and CKD, and to suggest possible practical solutions for the future. The recommendations for action of the consensus workshop are the results of combined clinical experience, shared research expertise, and a review of the literature. They highlight the need to act early to prevent CKD and other related noncommunicable diseases later in life by reducing low birth weight, small for gestational age, prematurity, and low nephron numbers at birth through coordinated interventions. Meeting the current unmet needs would help to define the most cost-effective strategies and to optimize interventions to limit or interrupt the developmental programming cycle of CKD later in life, especially in the poorest part of the world.

Long-term metabolic risk among children born premature or small for gestational age

Accumulating evidence suggests that both the intrauterine environment and growth during early life can influence the development of chronic noncommunicable diseases, such as type 2 diabetes mellitus and cardiovascular disease, in adulthood. Here, we review the available human data supporting increased metabolic risk among children born premature or small for gestational age; the adrenal and pubertal modifications that contribute to this risk; metabolic changes that occur during adolescence and early adulthood; and approaches to potentially modify or decrease risk of metabolic disease. The risks associated with delivery at term or preterm are compared for each period of life. Knowledge of these associations is fundamental for the paediatric community to develop preventive strategies early during postnatal life.

Cardiac Disease after Pregnancy: A Growing Problem

Pregnancy complications, such as hypertensive disorders or preterm delivery, identify families predisposed to cardiovascular problems at other times in life. Whether the pregnancy complication induces cardiac disease or whether the pregnancy stress unmasks an underlying predisposition remains unclear. However, improved survival following severe pregnancy complications for both the mother and, in particular, the offspring - who is often born preterm - has resulted in a growing cohort of individuals who carry this increased cardiovascular risk. Research to understand the underlying pathological mechanisms that link these conditions might ultimately lead to novel therapeutic or prevention strategies for both cardiovascular and pregnancy disease.

Changing definitions of long-term follow-up: Should "long term" be even longer?

There have been amazing changes in outcomes of preterm (PT) infants in the past decades. Whereas early studies reported only survival rates, Dr. Julius Hess published the first outcome study of PT infants in Chicago in 1953. Dr. Lubchenco then published the 10-year follow-up of premature infants born in 1947-1953 and identified a 68% handicap rate. As a result of these early studies, the importance of evaluating NICU graduates both for surveillance and as an outcome of trials was recognized. During the 1970s, there was a gradual expansion in the number of follow-up programs in the United States (US) with an increasing number of follow-up studies published. In the 1980s, the importance of multicenter clinical research networks was recognized and the NICHD Neonatal Research Network (NRN) was initiated in 1986. Follow-up protocols, definitions, and outcomes have evolved over the last 30 years and will be reviewed with a focus on NICHD NRN studies.

Hypertension in pediatric dentistry practice

The authors discuss the factors coexistent with hypertension both in children and youth, as well as the treatment methods and possible symptoms that might appear in the oral cavity. In the work, the authors emphasize that there is a need for cooperation between the general practitioner, a cardiologist and a dentist, so as to provide an early diagnosis and effective treatment, as well as to prevent complications with regard to hypertension itself and the drugs used in treatment. The discussion is based on a review of the most recent works in the field.

Blood Pressure in Young Adults Born at Very Low Birth Weight: Adults Born Preterm International Collaboration

Adults born preterm at very low birth weight (VLBW; <1500 g) have higher blood pressure than those born at term. It is not known whether all VLBW adults are at risk or whether higher blood pressure could be attributed to some of the specific conditions underlying or accompanying preterm birth. To identify possible risk or protective factors, we combined individual-level data from 9 cohorts that measured blood pressure in young adults born at VLBW or with a more stringent birth weight criterion. In the absence of major heterogeneity, we performed linear regression analysis in our pooled sample of 1571 adults born at VLBW and 777 controls. Adults born at VLBW had 3.4 mm Hg (95% confidence interval, 2.2-4.6) higher systolic and 2.1 mm Hg (95% confidence interval, 1.3-3.0) higher diastolic pressure, with adjustment for age, sex, and cohort. The difference in systolic pressure was present in men (1.8 mm Hg; 95% confidence interval, 0.1-3.5) but was stronger in women (4.7 mm Hg; 95% confidence interval, 3.2-6.3). Among the VLBW group, blood pressure was unrelated to gestational age, maternal smoking, multiple pregnancy, retinopathy of prematurity, or bronchopulmonary dysplasia. Blood pressure was higher than that of controls among VLBW adults unexposed to maternal preeclampsia. Among those exposed, it was even higher, especially if born appropriate for gestational age. In conclusion, although female sex and maternal preeclampsia are additional risk factors, the risk of higher blood pressure is not limited to any etiologic subgroup of VLBW adults, arguing for vigilance in early detection of high blood pressure in all these individuals.

Blood Pressure Profile in the 7th and 11th Year of Life in Children Born Prematurely

Background

Several research trials have analyzed the impact of prematurity on the prevalence of hypertension (HT). However, prospective long-term studies are lacking.

Objectives

The aim of this study was to evaluate the prevalence of HT at the age of 7 and 11 years in a regional cohort of preterm infants with a birth weight of ≤ 1000 g.

Patients and Methods

This study included 67 children with a birth weight of ≤ 1000 g who were born in Malopolska between September 2002 and August 2004. The control group consisted of 38 children born at term, matched for age. Each child underwent 24-h ambulatory blood pressure measurement (ABPM) twice, once at the age of 7 and again at 11 years. The presence of HT was estimated according to the mean arterial pressure (MAP) and a number of individual measurements.

Results

At aged 7 years, preterm infants had a significantly higher incidence of HT, defined on the basis of MAP (15% vs. 0%; P < 0.02) and on the percent of individual measurements (56% vs. 33%, P < 0.036). After taking into account the group of patients who received anti-HT treatment after the first part of the study, the incidence of HT at the age of 11 years based on MAP was 19% vs. 10%. Based on the individual measurements, it was 36.5% in the preterm infants vs. 24% in the control group. The differences were not statistically significant. At both time points, the preterm group had a higher mean heart rate (HR) than the control group.

Conclusions

Children born prematurely are predisposed to HT in later life, in addition to the persistence of an increased HR.

Retinopathy of prematurity: the need for prevention

More than 450,000 babies are born prematurely in the USA every year. The improved survival of even the most vulnerable low body weight preterm infants has, despite improving health outcomes, led to the resurgence in preterm complications including one of the major causes for blindness in children, retinopathy of prematurity (ROP). The current mainstay in ROP therapy is laser photocoagulation and the injection of vascular endothelial growth factor (VEGF) antibodies in the late stages of the disease after the onset of neovascularization. Both are proven options for ophthalmologists to treat the severe forms of late ROP. However, laser photocoagulation destroys major parts of the retina, and the injection of VEGF antibodies, although rather simple to administer, may cause a systemic suppression of normal vascularization, which has not been studied in sufficient depth. However, the use of neither VEGF antibody nor laser treatment prevents ROP, which should be the long-term goal. It should be possible to prevent ROP by more closely mimicking the intrauterine environment after preterm birth. Such preventive measures include preventing the toxic postbirth influences (eg, oxygen excess) as well as providing the missing intrauterine factors (eg, insulin growth factor 1) and are likely to also reduce other complications of premature birth as well as ROP. This review is meant to summarize the current knowledge on the prevention of ROP with a particular emphasize on the use of insulin growth factor 1 supplementation.

The effects of preterm birth and its antecedents on the cardiovascular system

INTRODUCTION

Preterm birth occurs in approximately 10% of all births worldwide. It prematurely exposes the developing cardiovascular system to the hemodynamic transition that occurs at birth and to the subsequent functional demands of life ex utero. This review describes the current knowledge of the effects of preterm birth, and some of its common antecedents (chorioamnionitis, intra-uterine growth restriction, and maternal antenatal corticosteroid administration), on the structure of the myocardium.

MATERIAL AND METHODS

A thorough literature search was conducted for articles relating to how preterm birth, and its antecedents, affect development of the heart. Given that sheep are an excellent model for the studies of cardiac development, this review has focused on experimental studies in sheep as well as clinical findings.

RESULTS

Our review of the literature demonstrates that individuals born preterm are at an increased risk of cardiovascular disease later in life, including increased mean arterial pressure, abnormally shaped and sub-optimally performing hearts and changes in the vasculature. The review highlights how antenatal corticosteroids, intra-uterine growth restriction, and exposure to chorioamnionitis also have the potential to impact cardiac growth in the preterm newborn.

CONCLUSIONS

Preterm birth and its common antecedents (antenatal corticosteroids, intra-uterine growth restriction, and chorioamnionitis) have the potential to adversely impact cardiac structure immediately following birth and in later life.

Preterm at birth is not associated with greater cardiovascular risk in adolescence

OBJECTIVE

To determine the effects of preterm birth and gender on subsequent cardiovascular risk factors among urban adolescents in a capital in the Brazilian northeast and to compare them with a group of adolescents term at birth.

METHODS

In a retrospective double cohort, data of birth weight were extracted from hospital registers of children born in a same day of birth, between 1992 and 2002. We classified the preterm as a unique group born before 37 weeks of gestation. A total of 134 adolescents, aged 10-20 years were found and investigated. We measured anthropometric and clinical data, blood lipid profile and glucose after overnight fasting.

RESULTS

Preterm subjects had less years of scholar education, especially between females (p = 0.01). Preterm females also had lower height (p = 0.00) and waist-hip circumference ratio (p = 0.01). Preterm males had lower cesarean delivery (p = 0.05) and greater family history of cardiovascular disease (p = 0.05). Although the differences on clinical or laboratorial measurements were small and non-significant for cardiovascular risk factors, systolic blood pressure (SBP) and diastolic blood pressure (DBP) tended to be higher in preterm groups, especially for females (SBP = 4.1 mmHg and DBP = 1.6 mmHg, p = 0.12 and p = 0.38, respectively).

CONCLUSION

Premature did not increase cardiovascular risk adolescents in this sample. The lower association between premature and poor health outcomes among adolescents in a low average socioeconomic status population from a capital in the Brazilian northeast corroborates previous findings in other countries.

Long-Term Outcomes of Pulmonary Hypertension in Preterm Infants with Bronchopulmonary Dysplasia

BACKGROUND

The long-term cardiovascular outcomes of pulmonary hypertension (PH) in preterm infants with bronchopulmonary dysplasia (BPD) are uncertain.

OBJECTIVES

The purpose of this study was to assess outcomes of PH in prematurely born children diagnosed with moderate to severe BPD.

METHODS

We retrospectively reviewed the medical records of patients born before 32 weeks of gestation and diagnosed with moderate to severe BPD from June 2004 to April 2008. Patients were recruited for a cross-sectional study from August to October 2014 and underwent echocardiography.

RESULTS

Forty-two children were enrolled. Their mean gestational age and birth weight were 26.2 ± 1.7 weeks and 753.1 ± 172.5 g, respectively. Sixteen patients (38%) were diagnosed with PH at a mean age of 3.3 ± 1.6 months, and the PH improved after a median of 12.3 months (range 0.7-46.6). Cardiovascular function was reassessed at a mean age of 7.7 ± 0.9 years, at which time 1 patient was taking a medication for recurrent PH, and 12 (28.6%) patients exhibited elevated blood pressure. Conventional 2-dimensional and Doppler echocardiography indicated normal ventricular function in all children. However, right ventricular longitudinal strains were decreased in children with previous PH.

CONCLUSIONS

Subclinical ventricular dysfunction was detectable using sensitive echocardiographic techniques in children with previous BPD-associated PH. Long-term follow-up and meticulous cardiovascular function assessment are required in this population.

The Perinatal Origins of Cardiovascular Disease

In recent decades, with advances in neonatal intensive care, extremely premature infants are now surviving into adulthood. Epidemiologic data on the health of these ex-premature infants have begun to reveal a concerning motif-that is, prematurity, in and of itself, seems to be a risk factor for cardiovascular and metabolic disease in later adulthood. The mechanisms underlying this increased risk are unclear, but it is believed that both adverse fetal environment and postnatal exposures for a premature infant likely contribute to the developmental programming of disease by altering the normal trajectory of maturation and aging of multiple organ systems. This article specifically focuses on perinatal factors that may affect risk for cardiovascular disease.

Lactobacillus reuteri DSM 17938 as a Probiotic for Preterm Neonates: A Strain-Specific Systematic Review

INTRODUCTION

Prevention of necrotizing enterocolitis (NEC) while optimizing enteral nutrition (EN) is a priority in preterm neonates. Lactobacillus reuteri DSM 17938 (L reuteri) is known to improve gut motility. Previous systematic reviews have not adequately assessed the effects of L reuteri in improving feed tolerance in preterm neonates.

OBJECTIVE

To assess the effects of L reuteri in preterm neonates.

DESIGN

A systematic review of randomized controlled trials (RCTs) and non-RCTs of L reuteri was conducted. We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and CINAHL databases and proceedings of Pediatric Academic Society meetings in December 2014.

RESULTS

Six RCTs (n = 1778) and 2 non-RCTs (n = 665) were included. Meta-analysis of RCTs estimated that the time to full feeds (mean difference [MD], -1.34 days; 95% confidence interval [CI], -1.81 to -0.86; 2 RCTs), duration of hospitalization (-10.77 days; 95% CI, -13.67 to -7.86; 3 RCTs), and late-onset sepsis (LOS) (relative risk [RR], 0.66; 95% CI, 0.52 to 0.83; 4 RCTs) were reduced in the L reuteri group. Mortality (RR, 0.79; 95% CI, 0.57-1.09; 3 RCTs) and ≥ stage II NEC (RR, 0.69; 95% CI, 0.47-1.01; 3 RCTs) were reduced but statistically not significant. There were no adverse effects of supplementation. Both non-RCT studies showed significant improvement in the incidence of NEC with L reuteri supplementation.

CONCLUSIONS

Evidence from a limited number of studies suggests that L reuteri supplementation has the potential to reduce the risk of NEC and LOS while facilitating EN in preterm infants. Larger definitive RCTs are needed to confirm these findings.

Characteristics of systemic hypertension in preterm children

The prevalence of essential hypertension (EH) among preterm children is unknown. The authors evaluated consecutive children with a diagnosis of hypertension and prematurity (gestational age <37 weeks) in a tertiary pediatric hypertension clinic and identified 36 preterm hypertensive children. Among these preterm children, 23 were diagnosed in the neonatal intensive care unit (NICU; infantile) and 13 were diagnosed at an older age (childhood). When compared with patients with a childhood diagnosis, patients with an infantile diagnosis had a significantly lower gestational age, longer duration of hospitalization in the NICU, and a higher incidence of perinatal risk factors for hypertension. None with infantile diagnosis had EH, whereas 46% with childhood diagnosis had EH. Among premature children, systemic hypertension was either diagnosed in infancy or in childhood, with each age at diagnosis having unique risk factors and clinical course. Although 83% of preterm children had secondary hypertension, EH was diagnosed in 17% and was only seen in those diagnosed beyond infancy.

Components of the metabolic syndrome in early childhood in very-low-birth-weight infants

BACKGROUND/AIMS

Term small-for-gestational-age and preterm born infants have an increased prevalence of metabolic syndrome components already in childhood. Data in very-low-birth-weight (VLBW) children are limited. We investigated the prevalence of metabolic syndrome components in VLBW infants at 2 years of corrected age.

METHODS

We included 38 children, participating in the Neonatal Insulin Replacement Therapy in Europe (NIRTURE) trial, a randomized controlled trial of early insulin therapy in VLBW infants. Metabolic syndrome components were defined as: body mass index SDS >2; blood pressure (systolic and/or diastolic) ≥ 90th percentile; triglycerides ≥ 0.98 mmol/l; high-density lipoprotein (HDL) cholesterol ≤ 1.03 mmol/l; glucose ≥ 5.6 mmol/l.

RESULTS

Two children (5%) had three metabolic syndrome components, 13 children (34%) had two components, and 11 children (29%) one component. 63% had raised blood pressure (prevalence higher in boys), 32% low HDL, and 30% high triglycerides (prevalence lower in early insulin group). In children with body mass index SDS <0, insulin-treated children had higher HDL than children with standard care. Systolic blood pressure was correlated with growth between term and 2 years of corrected age.

CONCLUSIONS

VLBW infants already have a high prevalence of metabolic syndrome components at 2 years of corrected age. Early insulin treatment could have long-term benefits for some of these components.

Benefits of probiotics on enteral nutrition in preterm neonates: a systematic review

INTRODUCTION

The optimization of enteral nutrition is a priority in preterm neonates worldwide. Probiotics are known to improve gut maturity and function in preterm neonates. To our knowledge, previous systematic reviews have not adequately assessed the effects of probiotic supplementation on enteral nutrition in preterm neonates.

OBJECTIVE

We assessed the evidence on effects of probiotics on enteral nutrition in preterm neonates.

DESIGN

A systematic review of randomized controlled trials (RCTs) of probiotic supplementation in preterm (gestation <37 wk) or low-birth-weight (birth weight <2500 g) neonates was conducted. With the use of the Cochrane Neonatal Review Group strategy, we searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Cumulative Index of Nursing and Allied Health Literature databases and proceedings of Pediatric Academic Society meetings in April 2014.

RESULTS

A total of 25 RCTs (n = 5895) were included in the review. A meta-analysis (random-effects model) of data from 19 of 25 trials (n = 4527) estimated that the time to full enteral feeds was shorter in the probiotic group (mean difference: -1.54 d; 95% CI: -2.75, -0.32 d; P < 0.00001, I(2) = 93%). Other benefits included fewer episodes of feed intolerance, better weight gain and growth velocity, decreased transition time from orogastric to breast feeds, and increased postprandial mesenteric flow. There were no adverse effects of probiotic supplementation.

CONCLUSIONS

Probiotics reduced the time to full enteral feeds in preterm neonates. Additional research is necessary to assess the optimal dose, duration, and probiotic strain or strains used specifically for facilitating enteral nutrition in this population.

Long-term renal consequences of preterm birth

The normal development of the kidney may be affected by several factors, including abnormalities in placental function, resulting in fetal growth restriction, exposure to maternal disease states, including hypertension and diabetes, antenatal steroids, chorioamnionitis, and preterm delivery. After preterm birth, several further insults may occur that may influence nephrogenesis and renal health, including exposure to nephrotoxic medications, postnatal growth failure, and obesity after growth restriction. In this review article, common clinical neonatal scenarios are used to highlight these renal risk factors, and the animal and human evidence on which these risk factors are based are discussed.

Effect of postnatal maternal protein intake on prenatal programming of hypertension

This study examined whether postnatal maternal dietary protein deprivation during the time of nursing can program hypertension when the offspring are studied as adults. Rats were fed either a 6% or 20% protein diet during the second half of pregnancy and continued on the same diet while rats were nursing their pups. The neonates of all of the rats were cross-fostered to a different mother and studied as adults. Adult rats that had a normal prenatal environment but were reared by mothers fed a low-protein diet until weaning (20%-6%) were hypertensive, had a higher renal Na(+)-K(+)-2Cl(-) cotransporter (NKCC2) and Na(+)-Cl(-) cotransporter (NCC) protein abundance yet a comparable number of glomeruli, and had higher plasma renin and angiotensin II levels compared to control (20%-20%). Rats whose mothers were fed a 6% protein diet and cross-fostered to a different rat fed a 6% protein diet until weaning (6%-6%) were hypertensive, had elevated plasma renin and angiotensin II levels, and had a reduction in nephron number but had NKCC2 and NCC levels comparable to 20% to 20% offspring. The 6% to 20% had blood pressure and glomerular numbers comparable to 20% to 20% rats. The hypertension resulting from prenatal dietary protein deprivation can be normalized by improving the postnatal environment. Combined prenatal and postnatal maternal dietary protein deprivation and maternal dietary protein deprivation while nursing alone (20%-6%) results in hypertension, but the mechanism for the hypertension in these groups is different.

Long term cardiovascular consequences of chronic lung disease of prematurity

Pulmonary arterial (PA) hypertension in preterm infant is an important consequence of chronic lung disease of prematurity (CLD) arising mainly due to impaired alveolar development and dysregulated angiogenesis of the pulmonary circulation. Although PA pressure and resistance in these children normalise by school age, their pulmonary vasculature remains hyper-reactive to hypoxia until early childhood. Furthermore, there is evidence that systemic blood pressure in preterm born children with or without CLD is mildly increased at school age and in young adulthood when compared to term-born children. Arterial stiffness may be increased in CLD survivors due to increased smooth muscle tone of the pre-resistance and resistance vessels rather than the loss of elasticity in the large arteries. This review explores the long term effects of CLD on the pulmonary and systemic circulations along with their clinical correlates and therapeutic approaches.

Developmental programming of eNOS uncoupling and enhanced vascular oxidative stress in adult rats after transient neonatal oxygen exposure

The authors have previously shown that neonatal hyperoxic stress leads to high blood pressure, impaired endothelium-mediated vasodilatation, and increased vascular production of superoxide anion by NAD(P)H oxidase in adulthood. However, it is unknown whether changes in nitric oxide (NO) production and/or bioinactivation prevail and whether NO synthase (NOS) is also a source of superoxide. The purpose of this study was to evaluate whether adult animals exposed to neonatal hyperoxic stress have impaired vascular NO production associated with NOS uncoupling participating to vascular superoxide production and vascular dysfunction. In adult male rats exposed to 80% oxygen from day 3 to 10 of life (H, n = 6) versus room air controls (CTRL, n = 6), vascular (aorta) NO production is decreased at baseline (CTRL: 21 ± 1 vs. H: 16 ± 2 4,5-diaminofluorescein diacetate fluorescence intensity arbitrary units; P < 0.05) and after carbachol stimulation (acetylcholine analog; CTRL: 26 ± 2 vs. H: 18±2; P < 0.05). Pretreatment with L-arginine (CTRL: 32 ± 4 vs. H: 31 ± 5) and L-sepiapterine [analog of key NOS cofactor tetrahydro-L-biopterin (BH4)] (CTRL: 30 ± 3 vs. H: 29 ± 3) normalizes NO production after carbachol. L-Sepiapterine also normalizes impaired vasodilatation to carbachol. Vascular endothelial NO synthase (eNOS) immunostaining is reduced, whereas total eNOS protein expression is increased in H (CTRL: 0.76 ± 0.08 vs. H: 1.76± 0.21; P < 0.01). The significantly higher superoxide generation (CTRL: 20 ± 2 vs. H: 28 ± 3 hydroethidine fluorescence intensity arbitrary units; P < 0.05) is prevented by pretreatment with the eNOS inhibitor N-nitro-L-arginine methyl ester (CTRL: 21 ± 4 vs. H: 22 ± 4). Taken together, the current data indicate a role for eNOS uncoupling in enhanced vascular superoxide, impaired endothelium-mediated vasodilatation, and decreased NO production in adult animals with programmed elevated blood pressure after a brief neonatal oxygen exposure.

Standardised parenteral nutrition

Parenteral nutrition (PN) has become an integral part of clinical management of very low birth weight premature neonates. Traditionally different components of PN are prescribed individually considering requirements of an individual neonate (IPN). More recently, standardised PN formulations (SPN) for preterm neonates have been assessed and may have advantages including better provision of nutrients, less prescription and administration errors, decreased risk of infection, and cost savings. The recent introduction of triple-chamber bag that provides total nutrient admixture for neonates may have additional advantage of decreased risk of contamination and ease of administration.

Renal function and systolic blood pressure in very-low-birth-weight infants 1-3 years of age

BACKGROUND

Preterm very-low-birth-weight (PT-VLBW) infants are at risk of an elevated systolic blood pressure (SBP) in infancy and adulthood; however, the pathogenesis remains unclear. Altered renal development or function may be associated with increased SBP, but their contribution in PT-VLBW is unknown.

METHODS

We determined renal function and its relationship to SBP in three groups of PT-VLBW at 1, 2, and 3 years of age, using serum cystatin-C to calculate the estimated glomerular filtration rate (eGFR).

RESULTS

Cystatin-C levels decreased from 0.84 ± 0.2 (SD) within the 1-year group to 0.70 ± 0.1 mg/l (±SD; P < 0.001) at 3 years and were unrelated to gender, fetal growth, and neonatal indomethacin exposure. eGFR rose from 121 ± 59 in the 1-year group to 138 ± 21 ml/min · 1.73 m(2) (P < 0.001) at 3 years. At 1 year, cystatin-C levels decreased with increasing SBP (P < 0.007), and infants with SBP ≥ 90 th% had lower cystatin-C and higher eGFR (P < 0.05). At 3 years, infants with lower birth weight (P < 0.03) and gestational age (P = 0.06) had reduced eGFR.

CONCLUSIONS

Preterm very-low-birth-weight infants demonstrate increasing renal function with advancing age. An elevated SBP and eGFR at 1 year suggests dysfunctional renal autoregulation and hyperfiltration, which may alter subsequent renal function and contribute to the lower eGFR seen at 3 years in infants with the lowest birth weight and gestational age.