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Speier RL, Cotten CM, Benjamin DK, Lewis K, Keeler K, Kidimbu G, Roberts W, Clark RH, Zimmerman KO, Stark A, Greenberg RG. Late-Onset Sepsis Evaluation and Empiric Therapy in Extremely Low Gestational Age Newborns. J Pediatric Infect Dis Soc 2023; 12:S37-S43. [PMID: 38146858 DOI: 10.1093/jpids/piad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/12/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Little is known about late-onset sepsis (LOS) evaluations in extremely low gestational age newborns (ELGANs). We describe frequencies of LOS evaluation in ELGANs, infant characteristics, and empiric therapy choices during evaluations. METHODS Cohort study of infants 22-28 weeks gestational age (GA) discharged from 243 centers from 2009 to 2018, excluding infants with congenital anomalies, discharged or deceased prior to postnatal day (PND) 2, or admitted after PND 2. A new LOS evaluation was defined as the first blood culture obtained between PND 3 and 90, or one obtained ≥1 day following a negative culture and ≥10 days from prior positive cultures. We determined numbers of evaluations and percentage positive by GA, center, and over time. We described characteristics associated with positive evaluations, infants with LOS, and empiric antimicrobials. We calculated descriptive and comparative statistics using Wilcoxon rank sum, Fisher's exact, or Pearson chi-square tests, as appropriate. RESULTS Of 47,187 included infants, 67% had ≥1 LOS evaluation and 21% of evaluated infants had ≥1 LOS (culture positive) episode; 1.6 evaluations occurred per infant and 10% were positive. The percentage of infants evaluated and positive for LOS was higher at earlier GA. LOS was associated with inotrope support (15% vs. 9%; p < .001) and invasive mechanical ventilation (66% vs. 51%; p < .001). Infants with positive cultures were more likely than infants with negative cultures to receive empiric antimicrobials during the LOS evaluation (95% vs. 73%; p < .001). CONCLUSIONS Among ELGANs, earlier GA and postnatal age were associated with LOS evaluation and positive cultures. Most infants undergoing evaluation were started on empiric antimicrobials.
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Affiliation(s)
| | | | - Daniel K Benjamin
- Department of Medicine, Duke University School of Medicine
- Duke Clinical Research Institute, Durham, NC, USA
| | - Kelsey Lewis
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Reese H Clark
- Pediatrix Center for Research, Education, Quality, and Safety, Sunrise, FL, USA
| | - Kanecia O Zimmerman
- Department of Medicine, Duke University School of Medicine
- Duke Clinical Research Institute, Durham, NC, USA
| | - Ashley Stark
- Department of Medicine, Duke University School of Medicine
| | - Rachel G Greenberg
- Department of Medicine, Duke University School of Medicine
- Duke Clinical Research Institute, Durham, NC, USA
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Bulka CM, Eaves LA, Gardner AJ, Parsons PJ, Galusha AL, Roell KR, Smeester L, O’Shea TM, Fry RC. Prenatal exposure to multiple metallic and metalloid trace elements and the risk of bacterial sepsis in extremely low gestational age newborns: A prospective cohort study. FRONTIERS IN EPIDEMIOLOGY 2022; 2:958389. [PMID: 36405975 PMCID: PMC9674331 DOI: 10.3389/fepid.2022.958389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Prenatal exposures to metallic and metalloid trace elements have been linked to altered immune function in animal studies, but few epidemiologic studies have investigated immunological effects in humans. We evaluated the risk of bacterial sepsis (an extreme immune response to bacterial infection) in relation to prenatal metal/metalloid exposures, individually and jointly, within a US-based cohort of infants born extremely preterm. METHODS We analyzed data from 269 participants in the US-based ELGAN cohort, which enrolled infants delivered at <28 weeks' gestation (2002-2004). Concentrations of 8 trace elements-including 4 non-essential and 4 essential-were measured using inductively coupled plasma tandem mass spectrometry in umbilical cord tissue, reflecting in utero fetal exposures. The infants were followed from birth to postnatal day 28 with bacterial blood culture results reported weekly to detect sepsis. Discrete-time hazard and quantile g-computation models were fit to estimate associations for individual trace elements and their mixtures with sepsis incidence. RESULTS Approximately 30% of the extremely preterm infants developed sepsis during the follow-up period (median follow-up: 2 weeks). After adjustment for potential confounders, no trace element was individually associated with sepsis risk. However, there was some evidence of a non-monotonic relationship for cadmium, with hazard ratios (HRs) for the second, third, and fourth (highest) quartiles being 1.13 (95% CI: 0.51-2.54), 1.94 (95% CI: 0.87-4.32), and 1.88 (95% CI: 0.90-3.93), respectively. The HRs for a quartile increase in concentrations of all 8 elements, all 4 non-essential elements, and all 4 essential elements were 0.92 (95% CI: 0.68-1.25), 1.19 (95% CI: 0.92-1.55), and 0.77 (95% CI: 0.57-1.06). Cadmium had the greatest positive contribution whereas arsenic, copper, and selenium had the greatest negative contributions to the mixture associations. CONCLUSIONS We found some evidence that greater prenatal exposure to cadmium was associated with an increased the risk of bacterial sepsis in extremely preterm infants. However, this risk was counteracted by a combination of arsenic, copper, and selenium. Future studies are needed to confirm these findings and to evaluate the potential for nutritional interventions to prevent sepsis in high-risk infants.
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Affiliation(s)
- Catherine M. Bulka
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren A. Eaves
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amaree J. Gardner
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Patrick J. Parsons
- Division of Environmental Health Sciences, Wadsworth Center, New York State Department of Health, Albany, NY, United States
- Department of Environmental Health Sciences, School of Public Health, University at Albany, Rensselaer, NY, United States
| | - Aubrey L. Galusha
- Division of Environmental Health Sciences, Wadsworth Center, New York State Department of Health, Albany, NY, United States
- Department of Environmental Health Sciences, School of Public Health, University at Albany, Rensselaer, NY, United States
| | - Kyle R. Roell
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa Smeester
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - T. Michael O’Shea
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Rebecca C. Fry
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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LEVITON A, ALLRED EN, FICHOROVA RN, VANDERVEEN DK, O’SHEA TM, KUBAN K, DAMMANN O. Early Postnatal IGF-1 and IGFBP-1 Blood Levels in Extremely Preterm Infants: Relationships with Indicators of Placental Insufficiency and with Systemic Inflammation. Am J Perinatol 2019; 36:1442-1452. [PMID: 30685870 PMCID: PMC7252600 DOI: 10.1055/s-0038-1677472] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate to what extent indicators of placenta insufficiency are associated with low concentrations of insulin-like growth factor 1 (IGF-1) and IGF-1-binding protein-1 (IGFBP-1) in neonatal blood, and to what extent the concentrations of these growth factors are associated with concentrations of proteins with inflammatory, neurotrophic, or angiogenic properties. STUDY DESIGN Using multiplex immunoassays, we measured the concentrations of IGF-1 and IGFBP-1, as well as 25 other proteins in blood spots collected weekly from ≥ 880 infants born before the 28th week of gestation, and sought correlates of concentrations in the top and bottom quartiles for gestational age and day the specimen was collected. RESULTS Medically indicated delivery and severe fetal growth restriction (sFGR) were associated with low concentrations of IGF-1 on the first postnatal day and with high concentrations of IGFBP-1 on almost all days. Elevated concentrations of IGF-1 and IGFBP-1 were accompanied by elevated concentrations of many other proteins with inflammatory, neurotrophic, or angiogenic properties. CONCLUSION Disorders associated with impaired placenta implantation and sFGR appear to account for a relative paucity of IGF-1 on the first postnatal day. Elevated concentrations of IGF-1 and especially IGFBP-1 were associated with same-day elevated concentrations of inflammatory, neurotrophic, and angiogenic proteins.
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Affiliation(s)
- Alan LEVITON
- Departments of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Elizabeth N. ALLRED
- Departments of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Raina N. FICHOROVA
- Departments of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Deborah K. VANDERVEEN
- Departments of Ophthalmology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - T. Michael O’SHEA
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Karl KUBAN
- Division of Neurology, Department of Pediatrics, Boston Medical Center and Boston University, Boston, MA, USA
| | - Olaf DAMMANN
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA,Perinatal Neuropidemiology Unit, Hannover Medical School, Hannover, Germany
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Yanni D, Korzeniewski SJ, Allred EN, Fichorova RN, O'Shea TM, Kuban K, Dammann O, Leviton A. Both antenatal and postnatal inflammation contribute information about the risk of brain damage in extremely preterm newborns. Pediatr Res 2017; 82:691-696. [PMID: 28549057 PMCID: PMC5599336 DOI: 10.1038/pr.2017.128] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/15/2017] [Indexed: 12/02/2022]
Abstract
BackgroundPreterm newborns exposed to intrauterine inflammation are at an increased risk of neurodevelopmental disorders. We hypothesized that adverse outcomes are more strongly associated with a combination of antenatal and postnatal inflammation than with either of them alone.MethodsWe defined antenatal inflammation as histologic inflammation in the placenta. We measured the concentrations of seven inflammation-related proteins in blood obtained on postnatal days 1, 7, and 14 from 763 infants born before 28 weeks of gestation. We defined postnatal inflammation as a protein concentration in the highest quartile on at least 2 days. We used logistic regression models to evaluate the contribution of antenatal and postnatal inflammation to the risk of neurodevelopmental disorders.ResultsThe risk of white matter damage was increased when placental inflammation was followed by sustained elevation of C-reactive protein or ICAM-1. We found the same for spastic cerebral palsy when placental inflammation was followed by elevation of TNF-α or IL-8. The presence of both placental inflammation and elevated levels of IL-6, TNF-α, or ICAM-1 was associated with an increased risk for microcephaly.ConclusionCompared with a single hit, two inflammatory hits are associated with stronger risk for abnormal cranial ultrasound, spastic cerebral palsy, and microcephaly at 2 years.
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Affiliation(s)
- Diana Yanni
- Division of Newborn Medicine, Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
| | - Steven J. Korzeniewski
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Elizabeth N. Allred
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Raina N. Fichorova
- Departments of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - T. Michael O'Shea
- Department of Pediatrics, University of North Carolina, Chapel Hill North Carolina
| | - Karl Kuban
- Departments of Pediatrics and Neurology, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Olaf Dammann
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Alan Leviton
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Joseph RM, Korzeniewski SJ, Allred EN, O'Shea TM, Heeren T, Frazier JA, Ware J, Hirtz D, Leviton A, Kuban K. Extremely low gestational age and very low birthweight for gestational age are risk factors for autism spectrum disorder in a large cohort study of 10-year-old children born at 23-27 weeks' gestation. Am J Obstet Gynecol 2017; 216:304.e1-304.e16. [PMID: 27847193 PMCID: PMC5334372 DOI: 10.1016/j.ajog.2016.11.1009] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 10/21/2016] [Accepted: 11/06/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND No prospective cohort study of high-risk children has used rigorous exposure assessment and optimal diagnostic procedures to examine the perinatal antecedents of autism spectrum disorder separately among those with and without cognitive impairment. OBJECTIVE We sought to identify perinatal factors associated with increased risk for autism spectrum disorder with and without intellectual disability (intelligence quotient <70) in children born extremely preterm. STUDY DESIGN This prospective multicenter (14 institutions in 5 states) birth cohort study included children born at 23-27 weeks' gestation in 2002 through 2004 who were evaluated for autism spectrum disorder and intellectual disability at age 10 years. Pregnancy information was obtained from medical records and by structured maternal interview. Cervical-vaginal "infection" refers to maternal report of bacterial infection (n = 4), bacterial vaginosis (n = 30), yeast infection (n = 62), mixed infection (n = 4), or other/unspecified infection (n = 43; eg, chlamydia, trichomonas, or herpes). We do not know the extent to which infection per se was confirmed by microbial colonization. We use the terms "fetal growth restriction" and "small for gestational age" interchangeably in light of the ongoing challenge to discern pathologically from constitutionally small newborns. Severe fetal growth restriction was defined as a birthweight Z-score for gestational age at delivery <-2 (ie, ≥2 SD below the median birthweight in a referent sample that excluded pregnancies delivered for preeclampsia or fetal indications). Participants were classified into 4 groups based on whether or not they met rigorous diagnostic criteria for autism spectrum disorder and intellectual disability (autism spectrum disorder+/intellectual disability-, autism spectrum disorder+/intellectual disability+, autism spectrum disorder-/intellectual disability+, and autism spectrum disorder-/intellectual disability-). Temporally ordered multinomial logistic regression models were used to examine the information conveyed by perinatal factors about increased risk for autism spectrum disorder and/or intellectual disability (autism spectrum disorder+/intellectual disability-, autism spectrum disorder+/intellectual disability+, and autism spectrum disorder-/intellectual disability+). RESULTS In all, 889 of 966 (92%) children recruited were assessed at age 10 years, of whom 857 (96%) were assessed for autism spectrum disorder; of these, 840 (98%) children were assessed for intellectual disability. Autism spectrum disorder+/intellectual disability- was diagnosed in 3.2% (27/840), autism spectrum disorder+/intellectual disability+ in 3.8% (32/840), and autism spectrum disorder-/intellectual disability+ in 8.5% (71/840). Maternal report of presumed cervical-vaginal infection during pregnancy was associated with increased risk of autism spectrum disorder+/intellectual disability+ (odds ratio, 2.7; 95% confidence interval, 1.2-6.4). The lowest gestational age category (23-24 weeks) was associated with increased risk of autism spectrum disorder+/intellectual disability+ (odds ratio, 2.9; 95% confidence interval, 1.3-6.6) and autism spectrum disorder+/intellectual disability- (odds ratio, 4.4; 95% confidence interval, 1.7-11). Severe fetal growth restriction was strongly associated with increased risk for autism spectrum disorder+/intellectual disability- (odds ratio, 9.9; 95% confidence interval, 3.3-30), whereas peripartum maternal fever was uniquely associated with increased risk of autism spectrum disorder-/intellectual disability+ (odds ratio, 2.9; 95% confidence interval, 1.2-6.7). CONCLUSION Our study confirms that low gestational age is associated with increased risk for autism spectrum disorder irrespective of intellectual ability, whereas severe fetal growth restriction is strongly associated with autism spectrum disorder without intellectual disability. Maternal report of cervical-vaginal infection is associated with increased risk of autism spectrum disorder with intellectual disability, and peripartum maternal fever is associated with increased risk for intellectual disability without autism spectrum disorder.
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Affiliation(s)
- Robert M. Joseph
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Steven J. Korzeniewski
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Epidemiology & Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Elizabeth N. Allred
- Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - T. Michael O'Shea
- Department of Pediatrics, University of North Carolina, Chapel Hill NC, USA
| | - Tim Heeren
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Jean A. Frazier
- University of Massachusetts Memorial Health Care and University of Massachusetts Medical School, Worcester, MA, USA
| | - Janice Ware
- Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Deborah Hirtz
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
- The University of Vermont Medical Center, Burlington, VT, USA
| | - Alan Leviton
- Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Karl Kuban
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
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Maternal and Placental Risk Factors for Developing Necrotizing Enterocolitis in Very Preterm Infants. Pediatr Neonatol 2017; 58:57-62. [PMID: 27328638 DOI: 10.1016/j.pedneo.2016.01.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 12/07/2015] [Accepted: 01/08/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite the clinical relevance of necrotizing enterocolitis (NEC), it remains difficult to predict which preterm infants are more likely to develop NEC. Contrary to the neonatal risk factors for the development of NEC, little information is available regarding maternal (prenatal) risk factors. We aimed to identify maternal risk factors associated with the subsequent development of NEC in very preterm infants and to determine whether the placental inflammatory lesions were related to the NEC. METHODS This retrospective cohort study examined newborns born at < 32 weeks (n=354) between July 2003 and July 2014 at a university teaching hospital. Medical records of eligible newborns and their mothers were reviewed. Maternal blood white blood cell and differential counts were measured at admission and the placentas were examined histologically after delivery. The primary outcome measure was NEC Bell Stage≥IIa. Bivariate analyses and multivariate logistic regression were used for the statistical analyses. RESULTS NEC was diagnosed in 26 of 354 very preterm infants (7.3%), including 19 Stage II and seven Stage III infants. Multivariate regression analysis identified maternal neutrophil-to-lymphocyte ratio [odds ratio (OR)=1.08, p=0.002], multiparity (OR=3.41, p=0.013), and birth weight (OR=0.07 per kg increase, p=0.01), but not clinical and histological chorioamnionitis and funisitis as significant predictors of NEC. CONCLUSION Maternal neutrophil-to-lymphocyte ratio, parity, and birth weight can independently predict the risk of NEC in very preterm infants, whereas clinical and histological chorioamnionitis and funisitis are not predictive of NEC.
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Sisman J, Logan JW, Westra SJ, Allred EN, Leviton A. Lenticulostriate vasculopathy in extremely low gestational age newborns: Inter-rater variability of cranial ultrasound readings, antecedents and postnatal characteristics. JOURNAL OF PEDIATRIC NEUROLOGY 2014; 12:183-193. [PMID: 25798046 DOI: 10.3233/jpn-140661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although lenticulostriate vasculopathy (LSV) was first detected on a cranial ultrasound nearly 30 years ago, its clinical implications and significance remain unknown. The objective of this study was to evaluate the inter-rater reliability of cranial ultrasound readings of LSV, and to explore relationships with potential antecedents and developmental correlates in extremely low gestational age newborns. Of the 1506 infants enrolled during the years 2002-2004, 1450 had at least one set of ultrasound scans evaluated for LSV and 939 had all three sets. To evaluate the inter-rater agreement for identifying LSV, we compared readings from two independent radiologists on days 1-4, 5-14, and on or after day 15. We then evaluated the relationships between LSV and maternal, antenatal, and postnatal characteristics. Our results showed that kappa values were 0.18, 0.33, and 0.36 on days 1-4, days 5-14, and day 15 or greater. Infants who were identified as LSV positive by two readers had higher Score for Neonatal Acute Physiology-II (an illness severity indicator), higher rates of tracheal infection and bacteremia, lower partial pressure of arterial oxygen and pH levels on 2 of the first 3 postnatal days, and they were more likely to have a lower psycho-motor development index at age 2 years. Positive agreement on the presence of LSV was low, as was the kappa value, an index of inter-rater reliability. Infants with high illness severity scores and their correlates were at increased risk of developing LSV, while those who develop LSV appear to be at increased risk of motor dysfunction.
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Affiliation(s)
- Julide Sisman
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Wells Logan
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Nationwide Children's Hospital, Columbus, OH, USA ; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Ohio State University Medical Center, Columbus, OH, USA
| | - Sjirk J Westra
- Department of Radiology, Harvard Medical School, Boston, MA, USA ; Department of Radiology, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Elizabeth N Allred
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA ; Department of Neurology, Boston Children's Hospital, Boston, MA, USA ; Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Alan Leviton
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA ; Department of Neurology, Harvard Medical School, Boston, MA, USA
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O'Shea TM, Shah B, Allred EN, Fichorova RN, Kuban KCK, Dammann O, Leviton A. Inflammation-initiating illnesses, inflammation-related proteins, and cognitive impairment in extremely preterm infants. Brain Behav Immun 2013; 29:104-112. [PMID: 23295265 PMCID: PMC3582030 DOI: 10.1016/j.bbi.2012.12.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 12/17/2012] [Accepted: 12/19/2012] [Indexed: 12/11/2022] Open
Abstract
Neonatal inflammation is associated with perinatal brain damage. We evaluated to what extent elevated blood levels of inflammation-related proteins supplement information about the risk of impaired early cognitive function provided by inflammation-related illnesses. From 800 infants born before the 28th week of gestation, we collected blood spots on days 1, 7 and 14, for analysis of 25 inflammation-related proteins, and data about culture-positive bacteremia, necrotizing enterocolitis (Bell stage IIIb), and isolated perforation of the intestine, during the first two weeks, and whether they were ventilated on postnatal day 14. We considered a protein to be persistently or recurrently elevated if its concentration was in the top quartile (for gestational age and day blood was collected) on two separate days one week apart. We assessed the children at 2 years of age with the Bayley Mental Development Index (MDI). The combinations of NEC and ventilation on day 14, and of bacteremia and ventilation on day 14 consistently provided information about elevated risk of MDI <55, regardless of whether or not a variable for an elevated protein concentration was included in the model. A variable for a persistently or recurrently elevated concentration of each of the following proteins provided additional information about an increased risk of MDI <55: CRP, SAA, IL-6, TNF-alpha, IL-8, MIP-1beta, ICAM-1, E-SEL, and IGFBP-1. We conclude that elevated blood concentrations of inflammation-related proteins provide information about the risk of impaired cognitive function at age 2 years that supplements information provided by inflammation-associated illnesses.
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Affiliation(s)
- T Michael O'Shea
- Division of Neonatology, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
| | - Bhavesh Shah
- Department of Pediatrics, Baystate Children's Hospital, Springfield, MA 01199, USA
| | - Elizabeth N Allred
- Department of Neurology, Children's Hospital Boston, and Harvard Medical School, Boston, MA 02115, USA
| | - Raina N Fichorova
- Laboratory of Genital Tract Biology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Karl C K Kuban
- Division of Pediatric Neurology, Department of Pediatrics, Boston University, Boston, MA 02118, USA
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA 02111, USA; Perinatal Epidemiology Unit, Hannover Medical School, 30623 Hannover, Germany
| | - Alan Leviton
- Department of Neurology, Children's Hospital Boston, and Harvard Medical School, Boston, MA 02115, USA
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Lee JW, McElrath T, Chen M, Wallace DK, Allred EN, Leviton A, Dammann O. Pregnancy disorders appear to modify the risk for retinopathy of prematurity associated with neonatal hyperoxemia and bacteremia. J Matern Fetal Neonatal Med 2013; 26:811-8. [PMID: 23297684 DOI: 10.3109/14767058.2013.764407] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To explore (1) whether extremely low gestational age newborns exposed to inflammation-associated pregnancy disorders differ in retinopathy of prematurity (ROP) risk from infants exposed to placenta dysfunction-associated disorders, and (2) whether ROP risk associated with postnatal hyperoxemia and bacteremia differs among infants exposed to these disorders. METHODS Pregnancy disorders resulting in preterm birth include inflammation-associated: preterm labor, prelabor premature rupture of membranes (pPROM), cervical insufficiency, and abruption and placenta dysfunction-associated: preeclampsia and fetal indication. The risk of severe ROP associated with pregnancy disorders was evaluated by multivariable analyses in strata defined by potential effect modifiers, postnatal hyperoxemia and bacteremia. RESULTS Compared to preterm labor, infants delivered after pPROM were at reduced risk of plus disease (Odds ratio = 0.4, 95% confidence interval: 0.2-0.8) and prethreshold/threshold ROP (0.5, 0.3-0.8). Infants delivered after abruption had reduced risk of zone I ROP (0.2, 0.1-0.8) and prethreshold/threshold ROP (0.3, 0.1-0.7). In stratified analyses, infants born after placenta dysfunction had higher risks of severe ROP associated with subsequent postnatal hyperoxemia and bacteremia than infants born after inflammation-associated pregnancy disorders. CONCLUSION Infants exposed to placenta dysfunction have an increased risk of severe ROP following postnatal hyperoxemia and bacteremia compared to infants exposed to inflammation-associated pregnancy disorders.
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Affiliation(s)
- Jennifer W Lee
- Division of Newborn Medicine, Floating Hospital for Children at Tufts Medical Center, Boston, MA 02111, USA .
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10
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Streimish I, Bizzarro M, Northrup V, Wang C, Renna S, Koval N, Li FY, Ehrenkranz R, Rinder HM, Bhandari V. Neutrophil CD64 as a diagnostic marker in neonatal sepsis. Pediatr Infect Dis J 2012; 31:777-81. [PMID: 22481422 PMCID: PMC3375383 DOI: 10.1097/inf.0b013e318256fb07] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We assessed neutrophil CD64 as a diagnostic marker for neonatal sepsis. For early-onset sepsis, the CD64 index with a cut-point value of 2.38 had sensitivity, specificity and negative predictive values of 100%, 68% and 100%, respectively. For late-onset sepsis, the respective values were 3.62, 75%, 77% and 96%. Neutrophil CD64 index can be incorporated as a valuable marker for excluding neonatal sepsis.
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Affiliation(s)
- Iris Streimish
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Matthew Bizzarro
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | | | - Chao Wang
- Division of Perinatal Medicine, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Sara Renna
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Nancy Koval
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Fang-Yong Li
- Yale Center for Analytical Sciences, New Haven, CT, USA
| | - Richard Ehrenkranz
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Henry M. Rinder
- Division of Perinatal Medicine, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Vineet Bhandari
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT,Address for correspondence: Vineet Bhandari, MD, DM, Yale University School of Medicine, Yale Child Health Research Center, Room Number: 219, P.O. Box 208081, 464 Congress Avenue, New Haven, CT 06520, Phone: 203-785-2613, Fax: 203-737-5872,
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11
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Mancini N, Poloniato A, Ghidoli N, Carletti S, Fomasi M, Barera G, Rovelli R, Cichero P, Burioni R, Clementi M. Potential role of the detection of enterobacterial DNA in blood for the management of neonatal necrotizing enterocolitis. J Med Microbiol 2012; 61:1465-1472. [PMID: 22700552 DOI: 10.1099/jmm.0.043067-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We present three cases of pre-term low-weight infants with suspected necrotizing enterocolitis (NEC) [one eventually recognized as a connatal cytomegalovirus (CMV) infection], microbiologically monitored using a molecular assay detecting bacterial and fungal DNA in blood. The detection of DNA from enteric pathogens in blood was interpreted as a sign of ongoing perforation, and represented a useful complement in the management of the presented cases. Moreover, these cases suggest the opportunity for larger future studies to assess the possible role of a molecular approach in the close monitoring of infants with suspected NEC or with other conditions at-risk for intestinal perforation.
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Affiliation(s)
- Nicasio Mancini
- Laboratorio di Microbiologia e Virologia, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Antonella Poloniato
- U.O. di Neonatologia e Patologia Neonatale, Dipartimento di Pediatria, Ospedale San Raffaele, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Nadia Ghidoli
- Laboratorio di Microbiologia e Virologia, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Silvia Carletti
- Laboratorio di Microbiologia e Virologia, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Martina Fomasi
- U.O. di Neonatologia e Patologia Neonatale, Dipartimento di Pediatria, Ospedale San Raffaele, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Graziano Barera
- U.O. di Neonatologia e Patologia Neonatale, Dipartimento di Pediatria, Ospedale San Raffaele, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Rosanna Rovelli
- U.O. di Neonatologia e Patologia Neonatale, Dipartimento di Pediatria, Ospedale San Raffaele, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Paola Cichero
- Laboratorio di Microbiologia e Virologia, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Roberto Burioni
- Laboratorio di Microbiologia e Virologia, Università 'Vita-Salute' San Raffaele, Milano, Italy
| | - Massimo Clementi
- Laboratorio di Microbiologia e Virologia, Università 'Vita-Salute' San Raffaele, Milano, Italy
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12
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Leviton A, O'Shea TM, Bednarek FJ, Allred EN, Fichorova RN, Dammann O. Systemic responses of preterm newborns with presumed or documented bacteraemia. Acta Paediatr 2012; 101:355-9. [PMID: 22085230 DOI: 10.1111/j.1651-2227.2011.02527.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM To compare the frequency of elevated concentrations of inflammation-related proteins in the blood of infants born before the 28th week of gestation who had documented bacteraemia and those who had presumed (antibiotic-treated but culture-negative) bacteraemia to those who had neither. METHODS The subjects of this study are the 868 infants born at 14 institutions for whom information about protein measurements on at least two of the three protocol days (days 1, 7, and 14) was available and who did not have Bell stage 3 necrotizing enterocolitis or isolated bowel perforation, which were strongly associated with bacteraemia in this sample. RESULTS Newborns with presumed early (week 1) bacteraemia had elevated concentrations of only a few inflammation-related proteins, while those who had presumed late (weeks 2-4) bacteraemia did not have any elevations. In contrast, newborns who had documented early bacteraemia had a moderately strong signal, while those who had documented late bacteraemia had a stronger signal with more protein concentrations elevated on two separate occasions a week apart. CONCLUSIONS Culture-confirmed early and late bacteraemia are accompanied/followed by systemic inflammatory responses not seen with presumed early and late bacteraemia.
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Affiliation(s)
- Alan Leviton
- Department of Neurology, Children's Hospital Boston, and Harvard Medical School, Boston, MA 02215-5349, USA.
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13
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Abstract
INTRODUCTION Infection is a risk factor for adverse neurodevelopmental outcome in preterm newborns. Our objective was to characterize the association of postnatal infection with adverse microstructural and metabolic brain development in premature newborns. RESULTS In 34/117 newborns studied, clinical signs were accompanied by positive cultures whereas 17 had clinical signs of sepsis alone. White matter injury (WMI) was identified in 34 newborns. In multivariate regression models, infected newborns had brain imaging measures indicative of delayed brain development: lower N-acetylaspartate/choline, elevated average diffusivity (D(AV)), and decreased white matter fractional anisotropy. These widespread brain abnormalities were found in both newborns with positive-culture infection and in those with clinical infection. DISCUSSION These findings suggest that postnatal infection, even without a positive culture, is an important risk factor for widespread abnormalities in brain development. These abnormalities extend beyond brain injuries apparent with conventional magnetic resonance injury (MRI). METHODS 117 preterm newborns (24-32 wk gestation) were studied prospectively at a median of 32.0 and 40.3 wk ostmenstrual age with MRI (WMI, hemorrhage), magnetic resonance (MR) spectroscopy (metabolism), and diffusion tensor imaging (microstructure). Newborns were categorized as having "no infection," "clinical infection," or "positive-culture infection." We compared brain injuries as well as metabolic and microstructural development across these infection groups.
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14
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Leviton A, Allred EN, Yamamoto H, Fichorova RN. Relationships among the concentrations of 25 inflammation-associated proteins during the first postnatal weeks in the blood of infants born before the 28th week of gestation. Cytokine 2011; 57:182-90. [PMID: 22133344 DOI: 10.1016/j.cyto.2011.11.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 10/14/2011] [Accepted: 11/01/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND Inflammation appears to be involved in processes leading to organ damage in preterm newborns, yet little is known about the relationships among elevated concentrations of inflammation-associated proteins in the blood of preterm newborns. METHODS In this exploratory study, we used an electrochemiluminescence method to measure 25 proteins in blood obtained on postnatal day 1 (range 1-3), day 7 (range 5-8), and day 14 (range 12-15) from 939 children born before the 28th week of gestation and evaluated to what extent those whose concentration of each protein was elevated (defined as in the highest quartile for gestational age and day the specimen was obtained) also had an elevated concentration of every other protein the same day or on a day 1 or 2 weeks later (p<.0001). RESULTS On each of the 3 days assessed, elevated concentrations of 17 proteins were associated with elevated concentrations of 15 or more of the other 24 proteins. VEGF, VEGF-R1, VEGF-R2 were among these proteins, while IGFBP-1 was associated with 13 other proteins on day 7. An elevated concentration of eight proteins on day 1 predicted an elevated concentration of 10 or more proteins on day 7, while an elevated concentration of only two proteins on day 7 were associated with elevated concentrations of 10 or more proteins on day-14. Few associations were seen between days 1 and 14. CONCLUSIONS/INFERENCES: Inflammation is a diffuse process in ELGANs, with elevated concentrations of cytokines, chemokines, adhesion molecules, matrix metalloproteinases, a growth factor and its receptors, as well as a growth factor binding protein associated with each other the same day, as well as on subsequent days.
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Affiliation(s)
- Alan Leviton
- Department of Neurology, Children's Hospital Boston and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115-5724, USA.
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15
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Persistence after birth of systemic inflammation associated with umbilical cord inflammation. J Reprod Immunol 2011; 90:235-43. [PMID: 21722967 DOI: 10.1016/j.jri.2011.03.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 03/16/2011] [Accepted: 03/22/2011] [Indexed: 12/20/2022]
Abstract
Intrauterine inflammation is followed by elevated concentrations of inflammation-related proteins in the newborn's blood. Many of these proteins have short half-lives. The persistence of this postnatal inflammation has not previously been investigated. In a sample of 834 infants born before the 28th week of gestation, 12% (103) had grade 1 or 2, and 17% (142) had grade 3, 4, or 5 umbilical cord inflammation. Concentrations of nine proteins previously shown to be associated with umbilical cord inflammation at birth were measured on the first postnatal day and at two weekly intervals after birth. We evaluated the hypothesis that children who had umbilical cord inflammation were no more likely than others to have elevated concentrations of inflammation-related proteins in postnatal blood. The concentrations of seven of the nine proteins [C-reactive protein (CRP), myeloperoxidase (MPO), IL1β, IL8, TNFα, intercellular adhesion molecule-1 (ICAM3), and matrix metalloproteinase (MMP9)] showed a tendency to be elevated on day 7 among infants with funisitis. Adjusting for gestational age, growth restriction, and three postnatal exposures (ventilation on day 7, presumed and definite early bacteremia, and Bell stage III necrotizing endocolitis) did not diminish the elevated odds ratios of concentrations in the top quartile (for gestational age and day the specimen was obtained) of MPO, IL1β, TNFα, IL8, ICAM3, and MMP9. The persistence of a relationship between umbilical cord inflammation and elevated blood concentrations of inflammation-related proteins on postnatal day 7 suggests the existence of phenomena that contribute to a reinforcement loop and thereby sustained systemic inflammation.
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16
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Affiliation(s)
- Andreas Ohlin
- Örebro University Hospital, Department of Paediatrics, Sweden.
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