Population based study on the outcome of small for gestational age newborns

Current Status and Associated Factors of Post-Hemorrhagic Hydrocephalus in Infants of 22 to 28 Weeks Gestation With Severe Intraventricular Hemorrhage in Korea: A Nationwide Cohort Study

BACKGROUND

Post-hemorrhagic hydrocephalus (PHH), a common complication of severe intraventricular hemorrhage (IVH) in very low birth weight (BW) infants, is associated with significant morbidity and poor neurological outcomes. The objective of this study was to assess the current status of PHH and analyze the risk factors associated with the necessity of treatment for PHH in infants born between 22 and 28 weeks of gestation, specifically those with severe IVH (grade 3 or 4).

METHODS

The analysis was conducted on 1,097 infants who were born between 22-28 gestational weeks and diagnosed with severe IVH, using data from the Korean Neonatal Network. We observed that the prevalence of PHH requiring treatment was 46.3% in infants with severe IVH.

RESULTS

Higher rates of mortality, transfer during admission, cerebral palsy, and ventriculoperitoneal shunt after discharge were higher in infants with PHH than in those without PHH. PHH in severe IVH was associated with a higher rate of pulmonary hemorrhage, seizures, and IVH grade 4 in the entire cohort. In addition, it was associated with a lower rate of small for gestational age and chorioamnionitis. In the subgroup analysis, high BW, outborn status, pulmonary hemorrhage, seizure, sepsis, and IVH grade 4 were associated with a higher incidence of PHH between 22 and 25 gestational weeks (GW). In infants born between 26 and 28 GW, a higher incidence of PHH was associated with seizures and IVH grade 4.

CONCLUSION

It is necessary to maintain meticulous monitoring and neurological intervention for infants with PHH not only during admission but also after discharge. In addition, identifying the clinical factors that increase the likelihood of developing PHH from severe IVH is crucial.

Association of small-for-gestational-age status with mortality and morbidity in very preterm Chinese infants

BACKGROUND

Very preterm infants born small for gestational age (SGA) are at risk for short- and long-term excess mortality and morbidity resulting from immaturity and deficient intrauterine growth. However, previous findings are inconclusive, and there is a paucity of contemporary data in Chinese population.

OBJECTIVES

To evaluate the excess risks of mortality and morbidity independently associated with SGA birth in very preterm (before 32 weeks of gestation) Chinese infants.

MATERIALS AND METHODS

The study population included all very preterm infants admitted to the neonatal intensive care units (NICUs) in our hospital and our medical treatment partner hospitals during a 6-year period. The SGA group consisted of 615 SGA infants, and 1230 appropriate-for-gestation-age (AGA) infants were matched with GA and sex as controls at a ratio of 2:1. The associations between SGA birth and outcomes (in-hospital mortality and morbidity) were evaluated by using multivariate logistic regression analysis after adjustment for potential confounders. The CRIBII score was used to indicate admission illness severity, acting as a covariate in the multivariate analysis.

RESULTS

The SGA group was associated with increased risks of mortality [odds ratio (OR) 2.12; 95% CI: 1.27-3.54] and BPD [OR 1.95; 95% CI: 1.58-2.41] compared to the AGA group. No significant incidences of respiratory distress syndrome (RDS), severe retinopathy of prematurity (sROP), severe intraventricular hemorrhage (sIVH), and necrotizing enterocolitis (NEC) were observed in the SGA group. Further GA-stratified subgroup analysis showed SGA status exhibited certain patterns of effects on mortality and morbidity in different GA ranges.

CONCLUSIONS

SGA status is associated with excess risks of neonatal mortality and BPD in very preterm infants, but the increased risks of mortality and morbidity are not homogeneous in different GA ranges. The contemporary data can help inform perinatal care decision-making and family counseling, particularly for very preterm SGA neonates.

Similar adverse outcome rates with high or low oxygen saturation targets in an area with low background mortality

Background

Randomized controlled trials have indicated reduced mortality rates in very preterm infants assigned to high compared to low oxygen saturation (SpO2) target levels, accompanied by higher rates of retinopathy of prematurity and bronchopulmonary dysplasia. However, the benefit-to-harm ratio may depend on the local background mortality risk. We therefore aimed to quantify the risk-benefit ratios of different SpO2 target ranges in 10 tertiary newborn intensive care units (NICUs) in East Germany.

Methods

In a retrospective multicenter study, 1,399 infants born between 2008 and 2012 at a gestational age between 24 0/7 and 27 6/7 weeks and with a birthweight below 1,250 g were grouped according to the hospital's target SpO2 range [high oxygen saturation group (HOSG) above 90%], low oxygen saturation group (LOSG) below 90%] and the compliance of units with their target SpO2 range. The association between neonatal morbidities, neurodevelopmental outcomes, selected treatment strategies, and target SpO2 ranges was calculated using chi-squared and Mann Whitney U tests.

Results

Nine of the ten participating NICUs met their SpO2 target ranges. Five units were considered as HOSG, and five units were considered as LOSG. Necrotizing enterocolitis and intraventricular hemorrhage grade ≥ 2 occurred significantly more frequently in the HOSG than in the LOSG (8.4% vs. 5.1%, p = 0.02; and 26.6% vs. 17.7%, p < 0.001). No significant differences in the mortality rate and the rate of retinopathy of prematurity were found.

Conclusion

In our patient population, a lower SpO2 target range was not associated with increased safety risks in extremely preterm infants. We cannot be sure that our outcome differences are associated with differences in oxygen saturations due to the retrospective study design and the differences in site practices.

The impact of small-for-gestational-age Status on the outcomes in very-Low-birth-weight (VLBW) premature infants: a prospective cohort study in Taiwan

Background

The impact of small-for-gestational-age (SGA) on very-low-birth-weight (VLBW) premature infants remains inconclusive. This study aimed to assess the effects of being born SGA status on the short-term and long-term outcomes in VLBW preterm infants.

Methods

We conducted a population-based, prospective cohort study on VLBW preterm infants born in Taiwan between 2012 and 2017. Sociodemographic, neonatal, growth and neurological data at 2 years of corrected age were collected. A total of 4243 VLBW infants born at 24 through 32 completed weeks' gestation participated in this study, of whom 1,005 had SGA status defined as a birth weight <10th percentile of gestation, and 3,238 did not (the non-SGA group).We compared the risks of short-term outcomes (neonatal mortality and morbidities), long-term outcomes (growth status, including weight, height, and head circumference <10th percentile, and neurodevelopmental impairments at 2 years of age). Subgroup analysis was performed by stratification of gestation age (GA): GA 24-26, 27-29 and 30-32 weeks.

Results

In the analysis of short-term outcomes, the SGA group had an increased risk of neonatal mortality [adjusted odds ratio (OR) = 2.66, 2.99, and 2.19, respectively] in all GA subgroups in comparison with the non-SGA group (p < 0.05). The SGA group had a significantly increased risk of bronchopulmonary dysplasia in GA 27-29 and 30-32 weeks (adjusted OR = 2.11 and 1.86, respectively). We also found that there was an increased risk of severe retinopathy of prematurity in GA 24-26 and 27-29 weeks in the SGA group compared with the non-SGA group (adjusted OR = 1.68 and 1.59, respectively).In the analysis of long-term outcomes, the SGA group had a significantly increased risk of NDI throughout all GA subgroups (adjusted = 1.94, 1.33, and 1.35, respectively) in comparison with the non-SGA group. The SGA groups also had an increased risk of growth status <10th percentile at 2 years of age (p < 0.05).

Conclusions

SGA VLBW premature infants had higher risks of neonatal death, growth status <10th percentile, and NDI at 2 years of corrected age compared with the non- SGA premature infants. Prenatal surveillance, postnatal attention, and long- term follow-up are warranted to improve the outcomes of VLBW SGA premature infants.

Neonatal mortality in small for gestational age infants based on reference local newborn curve at secondary and tertiary hospitals in Indonesia

BACKGROUND

Small for gestational (SGA) infants during the neonatal period have risks of mortality and sequelae for survival. Two - third of neonatal mortality occurs in the first weeks of life. Prevalence of SGA depends on the newbon curve used. Objectives of the study were to know the conditions that posed the risk of early neonatal and neonatal mortality, to identify preterm/full-term and SGA/appropriate gestational age (AGA) infants with cumulative mortality incident (CMI), to compare 5- year-period of early and neonatal mortality, and to investigate CMI on neonatal mortality of four categories during 5-year-period.

METHODS

A retrospective cohort study on all live births, during 1998-2017, was conducted in Sleman and Sardjito hospitals, Yogyakarta, Indonesia. Based on the reference local curve, the eligible subjects were categorized into SGA and AGA infants. The analyses were based on preterm/full-term and SGA/AGA, thus resulting in 4 categories: preterm-SGA, preterm-AGA, full-term-SGA and full-term-AGA. Analysis was made with Unadjusted Hazard Ratio (HR) by Simple Cox Regression and Adjusted HR was calculated by Multiple Cox Regression, survival analysis to calculate CMI, and analysis mortality for 5-year period ( 1998-2002, 2003-2007, 2008-2012, 2013-2017).

RESULT

There were 35,649 live births eligible for the study. Respiratory distress was the highest risk with HR 9,46, followed by asphyxia with HR 5,08, mother's death with HR 227, extra-health facility with HR 1,97, symmetrical SGA with HR 1,97, preterm-AGA with HR 1,75, low birth weight (LBW) with HR 1,64, primary health facility with HR 1,33, and boys with HR 1,16 consecutively. Early neonatal mortality in 4 categories by survival analysis revealed the highest CMI in preterm SGA. Similar result was found in neonatal mortality. Analysis of 5-year period unveiled the highest CMI during 1998-2002. The highest CMI based on the four categories, however, was found in preterm-SGA.

CONCLUSION

Respiratory distress posed the highest HR in early and neonatal mortality. Survival analysis showing the highest CMI on early and neonatal mortality was identified in preterm-SGA. The 5 - year - period of neonatal mortality showed the highest CMI during 1998-2002 period, whereas based on 4 SGA categories, preterm-SGA demonstrated the highest CMI.

Respiratory distress in small for gestational age infants based on local newborn curve prior to hospital discharge

BACKGROUND

Respiratory distress in newborns, which may lead to risks of morbidity and death, is one of the reasons for a referral to the more advanced health facilities. Respiratory distress analysis in small for gestational age (SGA) infants remains controversial. SGA infants are a big problem for and burden the low-medium income countries. Frequentness of SGA infants varies, depending on birth weight curve used.

OBJECTIVE

To identify the risks, complications, death induced by respiratory distress in SGA infants prior to hospital discharge.

METHODS

A retrospective cohort study was conducted on live- born infants at Sardjito Hospital. Singleton and gestational age 26-42 weeks were the inclusion criteria. The exclusion criteria included major congenital anomaly, chromosomal abnormalities, out-born infants admitted >24 h, discharge against medical advice, and incomplete data. The samples were categorized into appropriate gestational age (AGA) and SGA by a local newborn curve. The samples were also classified as full-term (FT)-AGA, preterm (PT)-AGA, FT-SGA, and PT-SGA. Odds ratio (OR) was based on entire respiratory distress. Complications of respiratory distress analyzed were length of hospital stay, administration of oxygen, Continuous Positive Airway Pressure (CPAP), and ventilator. Reverse Kaplan-Meier and Cumulative Mortality Incidence (CMI) were used to analyze respiratory distress-induced mortality. Stata 13 was used to analyze the data.

RESULTS

There were 12,490 infants eligible for the study, consisting of 9,396 FT-AGA infants, 2,003 PT-AGA infants, 771 FT-SGA infants, and 320 PT-SGA infants. Nine hundred and thirty-two infants developed respiratory distress. Multiple logistic regression analysis revealed highest risk of respiratory distress in PT-SGA infants with OR 5.84 (4.28-7.99). The highest respiratory distress complications were found in PT- SGA with significant difference on length of hospital stay and IRR 2.62 (2.09-3.27). In addition, the highest use of mechanical ventilator was found in PT-SGA with significant difference. CPAP use was the highest in PT-AGA infants. There was no significant difference in oxygen administration among the groups. Respiratory distress-induced mortality analysis found the highest CMI in PT-SGA infants.

CONCLUSION

PT-SGA had the highest risk of respiratory distress with complications of length of hospital stay, and ventilator use. Mortality analysis discovered the highest CMI in PT-SGA infants. We should therefore be alert when dealing with PT-SGA infants.

Being Small for Gestational Age does not Change Short-Term Outcomes for Extremely Low Birth Weight Babies at Townsville University Hospital

Aim To determine whether being small for gestational age (SGA) is associated with increased mortality and short-term morbidity for extremely low birth weight (ELBW) babies at Townsville University Hospital (TUH).

Methods All babies with a birth weight of <1,000 g born at TUH between January 1, 2010 and January 1, 2021 were included. Data from the neonatal unit's NeoDATA database were used to compare mortality and short-term morbidity outcomes for babies categorized as SGA (birth weight <10th centile) or not. Statistical analyses were used to determine associations between being SGA and survival to discharge, intubation for mechanical ventilation, duration of respiratory support, chronic neonatal lung disease (CNLD), home oxygen, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), sepsis, time to full enteral feeds, and duration of admission.

Results Of 461 ELBW babies, 62 (13.4%) were SGA. The SGA babies were significantly smaller at 714 (580–850) versus 810 (700–885) g (p < 0.001) and of advanced gestational age at 28.6 (26.6–30.2) versus 25.4 (24.4–26.6) weeks (p < 0.001). No significant difference in mortality existed, with 85% of SGA babies and 84% of others surviving. On univariate analysis, being SGA was associated with significant reductions in intubation for mechanical ventilation (p < 0.001), duration of respiratory support (p < 0.001), intraventricular hemorrhage (p = 0.002), NEC (p = 0.037), and admission duration (p = 0.038). After controlling for confounding factors, no outcomes were independently associated with being SGA. Logistic regression found survival was associated with birth weight (p = 0.030), gestational age (p = 0.007), and antenatal corticosteroids (p = 0.008).

Conclusions Being SGA is not an independent predictor of mortality nor adverse short-term morbidity for ELBW babies.

Risk Factors for Periventricular Leukomalacia in Preterm Infants: A Systematic Review, Meta-analysis, and GRADE-Based Assessment of Certainty of Evidence

BACKGROUND

We analyzed the certainty of evidence (CoE) for risk factors of periventricular leukomalacia (PVL) in preterm neonates, a common morbidity of prematurity.

METHODS

Medline, CENTRAL, Embase, and CINAHL were searched. Cohort and case-control studies and randomised randomized controlled trials were included. Data extraction was performed in duplicate. A random random-effects meta-analysis was utilizedused. CoE was evaluated as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

One hundred eighty-six studies evaluating 95 risk factors for PVL were included. Of the 2,509,507 neonates assessed, 16,569 were diagnosed with PVL. Intraventricular hemorrhage [adjusted odds ratio: 3.22 (2.52-4.12)] had moderate CoE for its association with PVL. Other factors such as hypocarbia, chorioamnionitis, PPROM >48 hour, multifetal pregnancy reduction, antenatal indomethacin, lack of antenatal steroids, perinatal asphyxia, ventilation, shock/hypotension, patent ductus arteriosus requiring surgical ligation, late-onset circulatory collapse, sepsis, necrotizing enterocolitis, and neonatal surgery showed significant association with PVL after adjustment for confounders (CoE: very low to low). Amongst the risk factors associated with mother placental fetal (MPF) triad, there was paucity of literature related to genetic predisposition and defective placentation. Sensitivity analysis revealed that the strength of association between invasive ventilation and PVL decreased over time (P < 0.01), suggesting progress in ventilation strategies. Limited studies had evaluated diffuse PVL.

CONCLUSION

Despite decades of research, our findings indicate that the CoE is low to very low for most of the commonly attributed risk factors of PVL. Future studies should evaluate genetic predisposition and defective placentation in the MPF triad contributing to PVL. Studies evaluating exclusively diffuse PVL are warranted.

Neonatal outcome of small for gestational age infants born at 26-33 weeks' gestation in Chinese neonatal intensive care units

BACKGROUND

Rate and outcomes of small for gestational age (SGA) infants admitted to Chinese neonatal intensive care units (NICU) has been poorly demonstrated. We aimed to describe the rate and outcomes of SGA preterm infants in Chinese NICU, and to evaluate the association of SGA status with neonatal outcomes in different gestational age (GA) and birth weight percentile groups.

METHODS

This cohort study included all infants born at 26-33 weeks' gestation and admitted to 25 tertiary Chinese NICUs from April 2015 to May 2018. SGA was defined as a birthweight <10th percentile for GA based on the Chinese neonatal birth weight curve.

RESULTS

A total of 24,596 infants were included, and 1,867 (7.6%) infants were SGA. SGA infants had significantly higher rates of death or any major morbidity (29.8% vs. 20.5%), mortality (7.0% vs. 4.1%), bronchopulmonary dysplasia (BPD, 17.6% vs. 9.8%), necrotizing enterocolitis (NEC, 4.8% vs. 3.2%) and sepsis (7.3% vs. 4.8%) than non-SGA infants. SGA status was independently associated with increased risk of death or any major morbidity [adjusted odds ratio: 2.37 (2.08-2.71)] as well as increased risks of death, BPD, ROP, death or BPD, death or ROP, NEC and sepsis. The increased risks of adverse outcomes for SGA infants existed across GA groups. The risks of adverse outcomes were highest among infants with a birthweight <3rd percentile.

CONCLUSIONS

SGA contributes significantly to adverse neonatal outcomes. Specific attentions are warranted when caring for SGA preterm infants.

Temperature Monitoring Devices in Neonates

Introduction: Accurate temperature monitoring of neonates is vital due to the significant morbidities and mortality associated with neonatal hypothermia. Many studies have compared different thermometers in neonates, however, there is a lack of consensus regarding which of the currently available thermometers is most suitable for use in neonates. Objectives: The aim of this review was to identify and compare current methods available for temperature monitoring of neonates beyond the delivery room, including the accuracy, advantages and disadvantages of each. Methods: A recent search and narrative synthesis of relevant studies published between January 1, 1949 and May 5, 2021 on the OVID Medline, PubMed and Google Scholar databases. Results: A total of 160 papers were retrieved for narrative synthesis. The main methods available for temperature monitoring in neonates are human touch and mercury-in-glass, electronic, infrared tympanic and other infrared thermometers. Newer innovations that are also available include liquid crystal thermometers and the BEMPU TempWatch. This paper discusses the current evidence available regarding the utility of these devices, and identifies barriers to valid comparison of different thermometry methods. Conclusion: Many methods for temperature monitoring in neonates are currently available, each with their own advantages and disadvantages. However, the accuracies of different devices are hard to determine due to variable methodologies used in relevant studies and hence, further research that addresses these gaps is needed.

Short-term outcome of very low-birth-weight infants in a tertiary care hospital in Saudi Arabia over a decade

BACKGROUND

Knowledge on short-term outcomes of preterm infants is important for quality control. Our objective was to analyze the outcomes of very low birth weight infants admitted to our neonatal intensive care unit over a ten years' period and to compare the results with internationally published data.

METHODS

We analyzed the outcome measures for all live born infants with birth weight (BW) of 400-1500 grams and gestational age (GA) of 23-32 weeks born at King Faisal Specialist Hospital & Research Centre between 2006 and 2015. Results were compared to data from four international neonatal networks.

RESULTS

During the study period, we admitted 528 infants born at a gestational age of≥23 and≤32 weeks with a very low birth weight (VLBW) of 400-1500 grams. Mean (SD) GA was 28 (2.4) weeks and mean (SD) BW was 1007 (290) grams. A hundred and twenty-nine (24.4%) infants were small for gestational age and major congenital anomalies were present in 56 (10.6 %) infants. The rate of bronchopulmonary dysplasia (BPD) was 24.4 %, necrotizing enterocolitis (NEC) 9.1%, patent ductus arteriosus (PDA) 29.9%, severe intraventricular hemorrhage (IVH)10.8 %, periventricular leukomalacia (PVL) 5.7%, severe retinopathy of prematurity (ROP) 8%, and late-onset sepsis was 18.8%. The incidences of major neonatal outcomes such as CLD, NEC, severe IVH and severe ROP were comparable to the international cohorts.

CONCLUSION

In our population of preterm infants, survival rates and complications of prematurity were comparable to international data.

Effects of small for gestational age status on mortality and major morbidities in ≤750 g neonates

BACKGROUND

Controversy exists regarding the impact of small for gestational age (SGA = birth weight < 10th percentile) status on mortality and major morbidities.

AIM

To assess the effects of SGA on mortality and major morbidities in ≤750 gram (g) neonates.

STUDY DESIGN

Retrospective (01/2005-12/2017), single center study at a tertiary NICU.

SUBJECTS

SGA neonates ≤ 750 g.

OUTCOME

Effect of SGA status on mortality and major morbidities.

RESULTS

183 infants were enrolled. 103 (56.3%) were non-SGA (mean gestational age 25 + 1 weeks ± 9.9 days, mean birth weight 662.6 ± 75.2 g), and 80 (43.7%) SGA (mean gestational age 26 + 6 weeks ± 14.0 days, mean birth weight 543.9 ± 114.7 g). Mortality was 24.1% (non-SGA: 30/103 (29.1%), SGA: 14/80 (17.5%); p = 0.08). Univariable logistic regression analysis revealed a significant protective effect of SGA status on pneumothoraces (OR 0.28, 95%-CI [0.11-0.69]), IVH (≥3) (OR 0.38; 95%-CI [0.15-0.67]), and seizures (OR 0.09, 95%-CI [0.01-0.76]), but NEC (≥2a) occurred more frequently in SGA neonates (p = 0.024). Multiple logistic regression analysis found SGA status to negatively influence ROP (≥3) (OR 2.87, 95%-CI [1.14-7.23]) and need for home monitoring (OR 2.38, 95%-CI [1.05-5.41]). Other major morbidities (IVH, PVL, RDS, BPD, NEC, FIP, sepsis, hearing impairment) and mortality rates were not significantly affected, but distinct organ-specific patterns were seen.

CONCLUSION

SGA had negative effects on the rate of severe ROP and the need for home monitoring, but other major morbidities as well as mortality rates were not significantly affected. In the future, it will be important to delineate underlying pathophysiological mechanisms that contribute to this pattern.

Comparison of neonatal outcomes of small for gestational age and appropriate for gestational age preterm infants born at 28-36 weeks of gestation: a multicentre study in Ethiopia

PURPOSE

The aim of this study was to assess morbidity and mortality pattern of small for gestational age (SGA) preterm infants in comparison to appropriate for gestational age (AGA) preterm infants of similar gestational age.

METHOD

We compared neonatal outcomes of 1336, 1:1 matched, singleton SGA and AGA preterm infants based on their gestational age using data from the study 'Causes of Illness and Death of Preterm Infants in Ethiopia (SIP)'. Data were analysed using SPSS V.23. ORs and 95% CIs and χ² tests were done, p value of <0.05 was considered statistically significant.

RESULT

The majority of the infants (1194, 89%) were moderate to late preterm (32-36 weeks of gestation), 763 (57%) were females. Male preterm infants had higher risk of being SGA than female infants (p<0.001). SGA infants had increased risk of hypoglycaemic (OR and 95% CI 1.6 (1.2 to 2.0), necrotising enterocolitis (NEC) 2.3 (1.2 to 4.1), polycythaemia 3.0 (1.6 to 5.4), late-onset neonatal sepsis (LOS) 3.6 (1.1 to 10.9)) and prolonged hospitalisation 2.9 (2.0 to 4.2). The rates of respiratory distress syndrome (RDS), apnoea and mortality were similar in the SGA and AGA groups.

CONCLUSION

Neonatal complications such as hypoglycaemic, NEC, LOS, polycythaemia and prolonged hospitalisation are more common in SGA infants, while rates of RDS and mortality are similar in SGA and AGA groups. Early recognition of SGA status, high index of suspicion and screening for complications associated and timely intervention to prevent complications need due consideration.

Adverse effects of small for gestational age differ by gestational week among very preterm infants

OBJECTIVE

To characterise the excess risk for death, grade 3-4 intraventricular haemorrhage (IVH), bronchopulmonary dysplasia (BPD) and stage 3-5 retinopathy of prematurity independently associated with birth small for gestational age (SGA) among very preterm infants, stratified by completed weeks of gestation.

METHODS

Retrospective cohort study using the Optum Neonatal Database. Study infants were born <32 weeks gestation without severe congenital anomalies. SGA was defined as a birth weight <10th percentile. The excess outcome risk independently associated with SGA birth among SGA babies was assessed using adjusted risk differences (aRDs).

RESULTS

Of 6708 infants sampled from 717 US hospitals, 743 (11.1%) were SGA. SGA compared with non-SGA infants experienced higher unadjusted rates of each study outcome except grade 3-4 IVH among survivors. The excess risk independently associated with SGA birth varied by outcome and gestational age. The highest aRD for death (0.27; 95% CI 0.13 to 0.40) occurred among infants born at 24 weeks gestation and declined as gestational age increased. In contrast, the peak aRDs for BPD among survivors (0.32; 95% CI 0.20 to 0.44) and the composites of death or BPD (0.35; 95% CI 0.24 to 0.46) and death or major morbidity (0.35; 95% CI 0.24 to 0.45) occurred at 27 weeks gestation. The risk-adjusted probability of dying or developing one or more of the evaluated morbidities among SGA infants was similar to that of non-SGA infants born approximately 2-3 weeks less mature.

CONCLUSION

The excess risk for neonatal morbidity and mortality associated with being born SGA varies by adverse outcome and gestational age.

Nutrition and Lung Growth

Experimental evidence from animal models and epidemiology studies has demonstrated that nutrition affects lung development and may have a lifelong impact on respiratory health. Chronic restriction of nutrients and/or oxygen during pregnancy causes structural changes in the airways and parenchyma that may result in abnormal lung function, which is tracked throughout life. Inadequate nutritional management in very premature infants hampers lung growth and may be a contributing factor in the pathogenesis of bronchopulmonary dysplasia. Recent evidence seems to indicate that infant and childhood malnutrition does not determine lung function impairment even in the presence of reduced lung size due to delayed body growth. This review will focus on the effects of malnutrition occurring at critical time periods such as pregnancy, early life, and childhood, on lung growth and long-term lung function.

Three-Dimensional Power Doppler Evaluation of Cerebral Vascular Blood Flow: A Novel Tool in the Assessment of Fetal Growth Restriction

OBJECTIVES

To determine whether fetuses with fetal growth restriction (FGR) are more likely to have abnormal cerebral vascular flow patterns compared to fetuses who are appropriate for gestational age (AGA) when quantified by using 3-dimensional (3D) power Doppler ultrasound.

METHODS

We conducted a prospective cohort study of singleton gestations presenting for growth ultrasound examination between 24 and 36 weeks' gestation. Patients with FGR (estimated fetal weight < 10th percentile) were enrolled and matched 1:1 for gestational age (±7 days) with AGA fetuses. A standardized 3D power Doppler image of the middle cerebral artery territory was obtained from each patient. The vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated by the Virtual Organ computer-aided analysis technique (GE Healthcare, Milwaukee, WI). These indices were compared between FGR and AGA fetuses and correlated with 2-dimensional Doppler parameters. Neonatal outcomes were also compared with respect to the 3D parameters.

RESULTS

Of 306 patients, there were 151 cases of FGR. There was no difference in the VI (6.0 versus 5.7; P = .65) or VFI (2.0 versus 1.8; P = .31) between the groups; however, the FI was significantly higher in FGR fetuses compared to AGA controls (33.9 versus 32.3; P = .009). There was a weak, but significant, negative correlation between the FI and both the middle cerebral artery pulsatility index (r = -0.34; P < .001) and cerebroplacental ratio (r = -0.29; P < .001). Within the FGR group, there was no difference in any of the 3D vascular indices with regard to neonatal outcomes.

CONCLUSIONS

Three-dimensional power Doppler measurement of cerebral blood flow, but not the vascularization pattern, is significantly altered in FGR. This measurement may play a future role in distinguishing pathologic FGR from constitutionally small growth.

Effects of swaddled and traditional tub bathing methods on crying and physiological responses of newborns

PURPOSE

The purpose of this study was to examine the effects of two bathing methods on crying duration and physiological measurements of newborns.

DESIGN AND METHODS

A randomized trial design was used in this study. The sample consisted of newborns (n = 80) who were admitted to neonatal intensive care unit of a university hospital located in a large city. The groups were determined as swaddled bathing (SB) (n = 40) and traditional tub bathing (TTB) (n = 40) by using random number table. All newborns were bathed 24 hours after the birth. Environmental variables were organised identically in both experimental and control groups. Duration of bathing was determined as maximum 5 min in both groups. Body temperature, heart rate (HR), and O₂ saturation values were evaluated before bath, just after the bath and at 10 min after the bath. The groups were compared in terms of all vital symptoms and duration of crying during bath. Pre-bath and post-bath stress levels between newborns in both groups were compared by using the Newborn Infant Pain Scale (NIPS).

RESULTS

When the newborns were compared based on groups, it was observed that there was no statistically significant difference between SB and TTB groups in terms of the gestational week, APGAR score, postnatal age, and body weight. Body temperatures of the newborns in SB group just after the bath and 10 minutes after the bath were significantly higher than those in TTB group. HR was higher in TTB group in the post-bath period. NIPS scores of the newborns in SB group after bath decreased at a statistically significant level, but the scores of the newborns in TTB group increased. The results of the study indicated that SB was effective in maintaining body temperature, SpO₂ level, and HR of newborns within normal limits and may decrease stress experienced during the bath.

PRACTICE IMPLICATIONS

Swaddled bathing decreases behavioural stress symptoms such as crying, agitation, and pulling arms and legs back unintentionally and thus the infants feel relaxed. Swaddled bathing can be recommended because swaddled bathing method decreases behavioural stress symptoms in infants.

Epigenomics and human adaptation to high altitude

Over the past decade, major technological and analytical advancements have propelled efforts toward identifying the molecular mechanisms that govern human adaptation to high altitude. Despite remarkable progress with respect to the identification of adaptive genomic signals that are strongly associated with the "hypoxia-tolerant" physiological characteristics of high-altitude populations, many questions regarding the fundamental biological processes underlying human adaptation remain unanswered. Vital to address these enduring questions will be determining the role of epigenetic processes, or non-sequence-based features of the genome, that are not only critical for the regulation of transcriptional responses to hypoxia but heritable across generations. This review proposes that epigenomic processes are involved in shaping patterns of adaptation to high altitude by influencing adaptive potential and phenotypic variability under conditions of limited oxygen supply. Improved understanding of the interaction between genetic, epigenetic, and environmental factors holds great promise to provide deeper insight into the mechanisms underlying human adaptive potential, and clarify its implications for biomedical research.

Neonatal outcome of small for gestational age preterm infants

Small for gestational age (SGA) preterm neonates (birth weight < -2 SDS) are considered to have increased risk of bronchopulmonary dysplasia (BPD) compared to appropriate for GA (AGA) neonates. It is unclear if SGA infants have increased risk for respiratory distress syndrome (RDS) and mortality. We analyzed data from 515 neonates born <30 weeks GA, 98(19%) were SGA. SGA were compared to AGA by univariate analysis and logistic regression analysis (LRA). Significant variables at univariate analysis were IUGR (67 vs 7%, p = 0.000), chorioamnionitis (1 vs 13%, p = 0.017), pre-eclampsia (62 vs 18%, p = 0.000), surfactant retreatment (47 vs 25%, p = 0.000), BPD (32 vs 20%, p = 0.015), death (30 vs 12%, p = 0.000), SatO2/FiO2 on day 3 (376 vs 433, p = 0.013), and SatO2/FiO2 ratio on day 28 (400 vs 448, p = 0.000). LRA found the following associations: regarding mortality, a decreased Sat/FiO2 ratio on day 3 (OR 1.99, 95% CI 1.26-3.16, p = 0.003); regarding BPD, surfactant retreatment (3.70, 2.11-6.49, p = 0.000), being SGA (2.69, 1.36-5.36, p = 0.005), decreasing GA (1.05, 1.03-1.08, p = 0.000), decreasing SatO2/FiO2 ratio on day 3 (1.25, 1.11-1.40, p = 0.000); and regarding severe RDS, pre-eclampsia (2.68, 1.58-4.55, p = 0.000) and decreasing GA (1.06, 1.04-1.08, p = 0.000).

CONCLUSIONS

In our cohort of preterm infants, being SGA was significantly associated with BPD, but not with increased risk of mortality or RDS due to multiple pathophysiologic mechanisms. What is Known: • Small for gestational age preterm neonates are considered to have increased risk of bronchopulmonary dysplasia (BPD) compared to appropriate for GA neonates. • It is still unclear if SGA infants have increased risk for respiratory distress syndrome (RDS) and mortality. What is New: • In our cohort of 515 preterm infants (19% SGA), being SGA was significantly associated with BPD, but not with increased risk of mortality or RDS. • These results may be explained by the heterogeneity of mechanisms leading to SGA condition and by multiple mechanisms involving lung growth impairment and other factors.

Comparing very low birth weight versus very low gestation cohort methods for outcome analysis of high risk preterm infants

Background

Compared to very low gestational age (<32 weeks, VLGA) cohorts, very low birth weight (<1500 g; VLBW) cohorts are more prone to selection bias toward small-for-gestational age (SGA) infants, which may impact upon the validity of data for benchmarking purposes.

Method

Data from all VLGA or VLBW infants admitted in the 3 Networks between 2008 and 2011 were used. Two-thirds of each network cohort was randomly selected to develop prediction models for mortality and composite adverse outcome (CAO: mortality or cerebral injuries, chronic lung disease, severe retinopathy or necrotizing enterocolitis) and the remaining for internal validation. Areas under the ROC curves (AUC) of the models were compared.

Results

VLBW cohort (24,335 infants) had twice more SGA infants (20.4% vs. 9.3%) than the VLGA cohort (29,180 infants) and had a higher rate of CAO (36.5% vs. 32.6%). The two models had equal prediction power for mortality and CAO (AUC 0.83), and similarly for all other cross-cohort validations (AUC 0.81–0.85). Neither model performed well for the extremes of birth weight for gestation (<1500 g and ≥32 weeks, AUC 0.50–0.65; ≥1500 g and <32 weeks, AUC 0.60–0.62).

Conclusion

There was no difference in prediction power for adverse outcome between cohorting VLGA or VLBW despite substantial bias in SGA population. Either cohorting practises are suitable for international benchmarking.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0921-x) contains supplementary material, which is available to authorized users.

Effects of delivery room quality improvement on premature infant outcomes

OBJECTIVE

Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality.

STUDY DESIGN

This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group.

RESULTS

Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death.

CONCLUSION

Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.

Population-based risks of mortality and preterm morbidity by gestational age and birth weight

OBJECTIVE

The objective of this study is to examine the effect of small or large for gestational age (SGA/LGA) status on mortality and morbidity by gestational age.

STUDY DESIGN

Logistic binomial regression was used to calculate relative risks (RRs) and 95% confidence intervals for infant mortality and preterm morbidities for SGA or LGA compared with appropriately grown (AGA) deliveries stratified by gestational age group.

RESULTS

Compared with AGA infants of similar gestational age, SGA infants were at increased risk for infant mortality. Mortality risk was decreased for LGA infants born between 25 and 27 weeks (RR: 0.6) but increased for LGA infants born between 28 and 31 weeks (RR: 1.9). Risk of preterm morbidity was increased for SGA infants born between 28 and 38 weeks, but decreased for LGA infants born before 37 weeks.

CONCLUSION

This study demonstrates the importance of considering birth weight for gestational age when evaluating morbidity and mortality risks.

The effect of coverings, including plastic bags and wraps, on mortality and morbidity in preterm and full-term neonates

Neonatal hypothermia is an important risk factor for mortality and morbidity, and is common even in temperate climates. We conducted a systematic review to determine whether plastic coverings, used immediately following delivery, were effective in reducing the incidence of mortality, hypothermia and morbidity. A total of 26 studies (2271 preterm and 1003 term neonates) were included. Meta-analyses were conducted as appropriate. Plastic wraps were associated with a reduction in hypothermia in preterm (⩽29 weeks; risk ratio (RR)=0.57; 95% confidence interval (CI) 0.46 to 0.71) and term neonates (RR=0.76; 95% CI 0.60 to 0.96). No significant reduction in neonatal mortality or morbidity was found; however, the studies were underpowered for these outcomes. For neonates, especially preterm, plastic wraps combined with other environmental heat sources are effective in reducing hypothermia during stabilization and transfer within hospital. Further research is needed to quantify the effects on mortality or morbidity, and investigate the use of plastic coverings outside hospital settings or without additional heat sources.

Impact of intrauterine growth restriction on preterm lung disease

AIM

Intrauterine growth restriction (IUGR) is an important cause for prematurity and adversely influences prematurity-related morbidities. This study evaluates the impact of IUGR on respiratory outcomes in infants <32 weeks with IUGR and birthweight <10th centile (SGA) compared to matched appropriate for gestation (AGA) controls.

METHODS

The primary outcomes of this retrospective study are short-term pulmonary outcomes of chronic lung disease (CLD), CLD or death, and need for home oxygen at discharge. Subgroup analysis by gestation-based stratification (<28 and ≥28 <32 weeks) was decided a priori.

RESULTS

Total of 153 IUGR and 306 non-IUGR infants were enrolled. The rate of CLD (45% vs. 17%, p = 0.0001), death (16% vs. 4.6%, p = 0.0001), CLD or death (46% vs. 21.5%, p = 0.0001), home oxygen rates (13.7% vs. 6.5%, p = 0.01) and duration of respiratory support was significantly higher in the IUGR group. IUGR emerged as the strongest predictor of CLD (adjusted OR, 95%CI: (8.4 [2, 35]) and CLD or death (12.7 [3, 54]) across all gestation.

CONCLUSION

IUGR is a major risk factor for adverse short-term pulmonary outcomes as reflected by higher rates of CLD, CLD or death, and oxygen dependency at discharge in preterm infants.

The clinical use of corticosteroids in pregnancy

BACKGROUND

The use of antenatal steroid therapy is common in pregnancy. In early pregnancy, steroids may be used in women for the treatment of recurrent miscarriage or fetal abnormalities such as congenital adrenal hyperplasia. In mid-late pregnancy, the antenatal administration of corticosteroids to expectant mothers in anticipation of preterm birth is one of the most important advances in perinatal medicine; antenatal corticosteroids are now standard care for pregnancies at risk of premature delivery in high- and middle-income countries. The widespread uptake of this therapy is due to a compelling body of evidence demonstrating improved neonatal outcomes following antenatal corticosteroid exposure, stemming most notably from corticosteroid-driven maturation of fetal pulmonary function. As we approach the 50th anniversary of landmark work in this area by Liggins and Howie, it is apparent that much remains to be understood with regards to how we might best apply antenatal corticosteroid therapy to improve pregnancy outcomes at both early and mid to late gestation.

METHODS

Drawing on advances in laboratory science, pre-clinical and clinical studies, we performed a narrative review of the scientific literature to provide a timely update on the benefits, risks and uncertainties regarding antenatal corticosteroid use in pregnancy. Three, well-established therapeutic uses of antenatal steroids, namely recurrent miscarriage, congenital adrenal hyperplasia and preterm birth, were selected to frame the review.

RESULTS

Even the most well-established antenatal steroid therapies lack the comprehensive pharmacokinetic and dose-response data necessary to optimize dosing regimens. New insights into complex, tissue-specific corticosteroid signalling by genomic-dependent and independent mechanisms have not been used to inform corticosteroid treatment strategies. There is growing evidence that some fetal corticosteroid treatments are either ineffective, or may result in adverse outcomes, in addition to lasting epigenetic changes in a variety of homeostatic mechanisms. Nowhere is the need to better understand the intricacies of corticosteroid therapy better conveyed than in the findings of Althabe and colleagues who recently reported an increase in overall neonatal mortality and maternal morbidity in association with antenatal corticosteroid administration in low-resource settings.

CONCLUSIONS

New research to clarify the benefits and potential risks of antenatal corticosteroid therapy is urgently needed, especially with regard to corticosteroid use in low-resource environments. We conclude that there is both significant scope and an urgent need for further research-informed refinement to the use of antenatal corticosteroids in pregnancy.

Does fetal growth restriction lead to increased brain injury as detected by neonatal cranial ultrasound in premature infants?

AIM

Intra-uterine growth restriction (IUGR) is an important cause for prematurity as well as a significant risk factor for neurodevelopmental deficits. In this study, we aimed to examine the association between IUGR and early brain injury on neonatal cranial ultrasound in preterm infants.

METHODS

This retrospective cohort study examined the relationship between IUGR and neonatal cranial ultrasound findings in preterm infants <32 weeks gestation with IUGR, compared with gestation and year of birth-matched appropriately grown infants, in a tertiary level neonatal unit. Primary outcome was incidence and severity of intraventricular haemorrhage (IVH), periventricular leucomalacia (PVL) and hydrocephalus detected by cranial ultrasound in the neonatal period.

RESULTS

A total of 153 IUGR and 306 non-IUGR preterm infants <32 weeks were included. The rates of IVH (21.6% vs. 23.9%), severe IVH (3.9% vs. 4.6%), PVL (8.4% vs. 9.4%), cystic PVL (2.6% vs. 0%) and hydrocephalus (0.7% vs. 0.3%) were similar in the two groups. Composite outcome of death and severe brain injury (severe IVH, cystic PVL and hydrocephalus) was greater (20.2% vs. 9.1%, P = 0.001) in IUGR infants.

CONCLUSION

IUGR did not lead to increased neonatal brain injury on cranial ultrasound but was associated with increased mortality. Advanced neonatal neuroimaging techniques may be necessary to estimate risk and to provide prognostic information of adverse neurological outcomes in this vulnerable population.

Short- and Long-Term Outcomes in Very Low Birth Weight Infants with Admission Hypothermia

BACKGROUND

Neonatal hypothermia remains a common problem and is related to elevated morbidities and mortality. However, the long-term neurodevelopmental effects of admission hypothermia are still unknown. This study attempted to determine the short-term and long-term consequences of admission hypothermia in VLBW preterm infants.

STUDY DESIGN

This retrospective study measured the incidence and compared the outcomes of admission hypothermia in very low birth weight (VLBW) preterm infants in a tertiary-level neonatal intensive care unit. Infants were divided into the following groups: normothermia (36.5-37.5°C), mild hypothermia (36.0-36.4°C), moderate hypothermia (32.0-35.9°C), and severe hypothermia (< 32°C). We compared the distribution, demographic variables, short-term outcomes, and neurodevelopmental outcomes at 24 months of corrected age among groups.

RESULTS

We studied 341 infants: 79 with normothermia, 100 with mild hypothermia, 162 with moderate hypothermia, and 0 with severe hypothermia. Patients in the moderate hypothermia group had significantly lower gestational ages (28.1 wk vs. 29.7 wk, P < .02) and smaller birth weight (1004 g vs. 1187 g, P < .001) compared to patients in the normothermia group. Compared to normothermic infants, moderately hypothermic infants had significantly higher incidences of 1-min Apgar score < 7 (63.6% vs. 31.6%, P < .001), respiratory distress syndrome (RDS) (58.0% vs. 39.2%, P = .006), and mortality (18.5% vs. 5.1%, P = .005). Moderate hypothermia did not affect neurodevelopmental outcomes at 2 years' corrected age. Mild hypothermia had no effect on short-term or long-term outcomes.

CONCLUSIONS

Admission hypothermia was common in VLBW infants and correlated inversely with birth weight and gestational age. Although moderate hypothermia was associated with higher RDS and mortality rates, it may play a limited role among multifactorial causes of neurodevelopmental impairment.

The impact of small-for-gestational-age on neonatal outcome among very-low-birth-weight infants

BACKGROUND

This study aimed to evaluate the impact of small-for-gestational-age (SGA) on mortality and morbidity in very-low-birth-weight (VLBW) infants.

METHODS

We conducted a retrospective cohort study on VLBW infants registered at the Premature Baby Foundation of Taiwan between 2007 and 2011. All 21 neonatal departments in Taiwan participated in the data collection, and a total of 4636 VLBW infants were registered during the study period. The SGA group (n = 560) was selected from the database on the basis of birth weight below the 10(th) percentile for gestational age, whereas the appropriate-weight-for-gestational-age (AGA) group (n = 1120) included infants randomly selected via incidence density sampling with a 2:1 match for each SGA case. The association of SGA with individual outcome variables including mortality, respiratory distress syndrome, necrotizing enterocolitis, retinopathy of prematurity (ROP), intraventricular hemorrhage, periventricular leukomalacia, and bronchopulmonary dysplasia (BPD) was evaluated after adjustment for potential confounders.

RESULTS

The SGA group was associated with increased risks of mortality [odds ratio (OR) 1.89; 95% confidence interval (CI) 1.39‒2.58], severe ROP (OR 1.56; 95% CI 1.13-2.14), and BPD (OR 2.08; 95% CI 1.58-2.75) compared to the AGA group. Further subgroup analysis showed that SGA had significant effects on mortality in the VLBW infants with a gestational age of 24-29 weeks, as well as on BPD in those with a gestational age of 27-32 weeks. By contrast, the association of SGA with severe ROP was only significant in the VLBW infants with a gestational age of 27-29 weeks.

CONCLUSION

Our data provide evidence that SGA may be associated with increased risks of neonatal mortality, ROP, and BPD in VLBW infants.

New Japanese neonatal anthropometric charts for gestational age at birth

BACKGROUND

More than 10 years have passed since the previous Japanese neonatal growth charts were published, therefore the aim of this study was to develop an updated set of Japanese neonatal growth charts.

METHODS

We used data from the registry database of the Japan Society of Obstetrics and Gynecology from 2003 until 2005. A total of 150,471 singleton live births without stillbirth or severe congenital malformation were enrolled in the preliminary analysis. It was found that the distribution of the 10th centile charts based on these subjects was skewed toward lower birthweight for preterm infants, because of the significantly lower birthweight in the 10th centile in neonates delivered by cesarean section than those delivered vaginally. Therefore, the data of subjects delivered by cesarean section were also excluded.

RESULTS

Finally, 104,748 singleton vaginal births at 22-41 weeks of gestation were used to construct a new set of Japanese neonatal anthropometric charts. The birthweight chart is parity and sex specific. The differences between the Japanese fetal growth chart and the new neonatal birthweight chart were small.

CONCLUSION

The present new neonatal anthropometric charts may reveal unrestricted growth pattern mimicking fetal growth. Use of these charts may result in recognition of abnormal fetal growth and risk in preterm infants. Further studies are needed to evaluate the risk for adverse neonatal and long-term outcome among small-for-gestational-age infants using these neonatal charts.

Predictors of full enteral feeding achievement in very low birth weight infants

BACKGROUND

To elucidate the role of prenatal, neonatal and early postnatal variables in influencing the achievement of full enteral feeding (FEF) in very low birth weight (VLBW) infants and to determine whether neonatal intensive care units (NICUs) differ in this outcome.

METHODS

Population-based retrospective cohort study using data on 1,864 VLBW infants drawn from the "Emilia-Romagna Perinatal Network" Registry from 2004 to 2009. The outcome of interest was time to FEF achievement. Eleven prenatal, neonatal and early postnatal variables and the study NICUs were selected as potential predictors of time to FEF. Parametric survival analysis was used to model time to FEF as a function of the predictors. Marginal effects were used to obtain adjusted estimates of median time to FEF for specific subgroups of infants.

RESULTS

Lower gestational age, exclusive formula feeding, higher CRIB II score, maternal hypertension, cesarean delivery, SGA and PDA predicted delayed FEF. NICUs proved to be heterogeneous in terms of FEF achievement. Newborns with PDA had a 4.2 days longer predicted median time to FEF compared to those without PDA; newborns exclusively formula-fed had a 1.4 days longer time to FEF compared to those fed human milk.

CONCLUSIONS

The results of our study suggest that time to FEF is influenced by clinical variables and NICU-specific practices. Knowledge of the variables associated with delayed/earlier FEF achievement could help in improving specific aspects of routine clinical management of VLBW infants and to reduce practice variability.

Fetal growth restriction is worse than extreme prematurity for the developing lung

BACKGROUND

Perinatal lung growth is highly vulnerable to inflammation and intrauterine growth restriction (IUGR), two major risk factors for chronic lung disease (CLD) in preterm neonates. However, the balance between extremely low gestational age (ELGA) and IUGR in very preterm infants as risk factors for CLD and co-morbidities remains poorly explored.

OBJECTIVES

This single-center study aims to compare neonatal morbidity (including CLD) and mortality among ELGA infants with normal birth weight (ELGA-AGA), very preterm infants with IUGR <3rd percentile (VLGA-IUGR) and very preterm infants with a birth weight appropriate for gestational age (VLGA-AGA), matched with VLGA-IUGR infants.

METHODS

Selected characteristics of the perinatal and neonatal periods were recorded and retrospectively compared among the three groups. Infants with major congenital anomalies were excluded. The diagnosis of CLD was based on whether the infant was receiving supplemental oxygen and/or non-invasive ventilation at a postmenstrual age of 36 weeks.

RESULTS

We found that, despite a median difference of 3 weeks in gestational age at birth between VLGA-IUGR and ELGA-AGA infants, neonatal mortality was 35% higher in neonates who had experienced fetal growth restriction, and that VLGA- IUGR was five times more predictive of CLD than was ELGA-AGA. These differences persisted after adjustment for confounding factors such as antenatal steroids, gender and respiratory distress syndrome.

CONCLUSIONS

This study reports that VLGA-IUGR infants are at higher risk of neonatal mortality and CLD than both ELGA-AGA and VLGA-AGA infants.

[Intrauterine growth retardation and lung development]

Epidemiological studies have shown that intrauterine growth restriction is associated with increased respiratory morbidity in the neonatal period with an increased risk of bronchopulmonary dysplasia. Respiratory consequences of environmental intrauterine changes extend into childhood and adulthood with abnormal lung function tests. In animal models, changes in surfactant and alveolarization disorders vary from one study to another. Moreover, the molecular mechanisms involved are poorly understood. Fetal adaptations to intrauterine malnutrition result in permanent changes in lung structure, raising the question of lung "programming".

The early prediction of neonatal morbidity and mortality in singleton small for gestational age infants with a birthweight < 1,500 g

OBJECTIVE

Identify factors for discrimination of "high" and "low risk" small for gestational age infants.

STUDY DESIGN

Singleton infants born small for gestational age with a birthweight  <1,500 g between 1999 and 2007 were included. Maternal, placental, and infant related factors were analyzed with regard to mortality and morbidity. Patients who died or suffered from complications were defined "high risk" as opposed to "low risk". Parameters associated with "high risk" were identified and an equation established to predict the minimal expected probability to die or suffer from neonatal morbidity.

RESULTS

Around 231 patients showed a mortality rate of 12.6 %, respiratory distress syndrome in 35.5 %, necrotizing enterocolitis in 8.2 % and neurological morbidities in 6.5 %. Of these, 58.9 % survived without complications. The factors for discrimination of "high" and "low risk" were Z-score of birth weight, gestational age, and pH.

CONCLUSION

We facilitate prognostication by classifying small for gestational age preterms into "low" and "high risk".

Effects of perinatal testosterone on infant health, mother-infant interactions, and infant development

OBJECTIVE

Many researchers and health care providers have noticed male vulnerability in infant health, mother-infant interactions, and some infant cognitive development, especially among very low birth weight (VLBW) preterm infants. However, factors beyond gender that could explain these observed differences have not been clear. The purpose of this article is to review the literature on the subject and to introduce a conceptual framework relating these factors.

DISCUSSION

According to gender-difference theories, prenatal exposure to high levels of testosterone may influence infant health and mother-infant interactions by negatively affecting infant cognitive/motor/language development. We constructed a conceptual framework based on the associations among biological (perinatal testosterone), stress-related (perinatal and maternal cortisol), and developmental (infant cognitive/motor/language skills) factors. If research establishes these biological, environmental, and developmental associations in mother-VLBW preterm pairs, the results will highlight the importance of addressing gender differences in nursing research and encourage the development of nursing interventions designed to reduce stress among mothers of VLBW preterm infants, particularly male infants.

CONCLUSION

From a psychobiosocial perspective, combining biophysiological factors such as perinatal testosterone and cortisol with socioenvironmental factors such as the quality of mother-infant interactions and infant temperament may provide a broader view of gender differences in infant health and development.

Customised birthweight models: do they increase identification of at-risk infants?

AIM

The study aims to describe the cohort of women and babies who are classified as small-for-gestational age (SGA) at term by both an Australian customised birthweight model (CBM) and a commonly used population-based standard, and to investigate and compare the utility of these models in identifying babies at risk of experiencing adverse outcomes

METHODS

Routinely collected data on 54 890 singleton-term births at the Mater Mothers' Hospitals, Brisbane, with birthweight less than 4000 g between January 1997 and December 2008, was extracted. Each birth was classified as SGA (<10th centile) or not SGA by either and/or both methods: population-based standards (SGApop ) and CBM (SGAcust ). Babies classified as SGApop , SGAcust or SGAboth were compared with those not classified as SGA by both methods using relative risk and 95% confidence interval, and those only classified as SGAcust were compared with those only classified as SGApop . Maternal demographics, maternal risk factors for fetal growth restriction, pregnancy and labour complications and adverse neonatal outcomes are reported.

RESULTS

 A total of 4768 (8.7%) births were classified as SGApop , while 6479 (11.8%) were SGAcust of whom 4138 (63.9%) were also classified as SGApop . Maternal risk factors such as smoking and hypertension were statistically higher for the SGAcust group when compared with SGApop . For the majority of adverse neonatal outcomes, a trend was noted to increased identification using the CBM.

CONCLUSION

The CBM provides a modest improvement when compared to a population-based standard to identity term infants at birth who are at risk of adverse neonatal outcomes.

The CD95/CD95L pathway is involved in phagocytosis-induced cell death of monocytes and may account for sustained inflammation in neonates

BACKGROUND

The propensity for sustained inflammation after bacterial infection in neonates, resulting in inflammatory sequelae such as bronchopulmonary dysplasia and periventricular leucomalacia, is well known, but its molecular mechanisms remain elusive. Termination of inflammatory reactions physiologically occurs early after removal of bacteria by phagocytosis-induced cell death (PICD) of immune effector cells such as monocytes. PICD from cord blood monocytes (CBMOs) was shown to be reduced as compared with that of peripheral blood monocytes (PBMOs) from adult donors in vitro.

METHODS

PBMOs, CBMOs, and Fas (CD95)-deficient (lpr) mouse monocytes were analyzed in an in vitro infection model using green fluorescence protein-labeled Escherichia coli (E. coli-GFP). Phagocytosis and apoptosis were quantified by flow cytometry and CD95L secretion was quantified by enzyme-linked immunosorbent assay.

RESULTS

We demonstrate the involvement of the CD95/CD95 ligand pathway (CD95/CD95L) in PICD and provide evidence that diminished CD95L secretion by CBMOs may result in prolonged activation of neonatal immune effector cells.

CONCLUSION

These in vitro results offer for the first time a molecular mechanism accounting for sustained inflammation seen in neonates.

Association between soluble (Pro)renin receptor concentration in cord blood and small for gestational age birth: a cross-sectional study

Objective

The (pro)renin receptor [(P)RR] has been recognized as a multifunctional receptor. The purpose of this study was to assess the association between plasma soluble (P)RR [s(P)RR] concentration in human cord blood (i.e., neonatal blood at birth) and small for gestational age (SGA) birth.

Methods

Participants were women with a singleton pregnancy who delivered at the National Center for Child Health and Development between January 2010 and December 2011. Inclusion criteria were availability of maternal pre-pregnancy and paternal body mass index, and the absence of structural anomalies in neonates. s(P)RR concentration in cord blood was measured in 621 neonates. The 621 pairs of mothers and neonates were categorized into four groups based on quartiles of s(P)RR concentrations in cord blood. SGA was defined as a birth weight below the 10^th percentile for gestational age. Logistic regression analysis was performed to assess the association between cord plasma s(P)RR concentration (quartiles) and incidence of SGA births.

Results

Among 621 neonates, 55 (8.9%) were diagnosed as SGA (SGA group) and 566 (91.1%) were not (non-SGA group). Average s(P)RR concentration in cord blood was 66.1±12.6 ng/ml (mean±standard deviation). There were 155 pairs in the first plasma s(P)RR concentration quartile (Q1: <58.2 ng/ml), 153 pairs in the second quartile (Q2: 58.2–65.1 ng/ml), 157 pairs in the third quartile (Q3: 65.1–73.1 ng/ml) and 156 pairs in the fourth quartile (Q4: >73.1 ng/ml). The distribution of SGA births was 18 (11.6%) in Q1, 14 (9.2%) in Q2, 16 (10.2%) in Q3 and 7 (4.5%) in Q4, respectively. The odds ratio of SGA births was 0.24 (95% confidence interval: 0.08–0.71) for the fourth quartile compared to the first quartile in multivariate models. The P-value for trend was also significant (P = 0.020).

Conclusion

High s(P)RR concentration is associated with a lower SGA birth likelihood.

Associations between salivary testosterone and cortisol levels and neonatal health and growth outcomes

OBJECTIVES

Male vulnerability in health and growth outcomes has often been reported in very low birth weight (VLBW) preterm neonates. On the basis of gender-difference theories, possible associations were explored between the levels of postnatal salivary testosterone/cortisol and the outcomes of neonatal health/growth.

METHODS

This study used an exploratory and comparative research design. One-hundred-one mother-VLBW preterm neonate pairs were recruited from the neonatal intensive care unit (NICU) of a tertiary medical center in the Southeastern, US. Demographic information, health and growth variables of neonates, and pregnancy and labor variables of mothers were obtained from the medical record reviews and interviews of mothers. Saliva samples from each pair were collected between 9 and 60 days of age. The levels of testosterone and cortisol were determined by using an enzyme immunoassay methodology.

RESULTS

Linear regression analysis showed that neonatal health problems were positively associated with the levels of postnatal salivary testosterone and cortisol, while growth delays were positively associated with the levels of postnatal salivary testosterone after adjusting for the characteristics of neonates and mothers and day of saliva sampling. The salivary levels of testosterone and cortisol were higher in neonates than in mothers. A positive correlation between the levels of testosterone and cortisol was found in neonates and in mothers.

CONCLUSIONS

The level of postnatal salivary testosterone is a more reliable marker in assessing neonatal health and growth outcomes compared to salivary cortisol. Further research on both testosterone and cortisol measurements at various stages during the neonatal period may elucidate further these associations.