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

Analysis of MRI brain biometrics in fetuses monitored for intra uterine growth restriction and their prognostic value: Results of a prospective multicenter study

OBJECTIVE

Show a prognostic value of brain changes in fetuses with intra uterine growth restriction (IUGR) on early neonatal outcome.

STUDY DESIGN

We prospectively recruited pregnant women whose fetuses presented fetal weight < 5th centile. A brain MRI was performed between 28 and 32 weeks of gestation (WG). Several brain biometrics were measured (as fronto-occipital diameter (FOD) and transverse cerebellar diameter (TCD)). Neonatal prognosis was evaluated according to a composite criterion.

RESULTS

Of the 78 patients included, 62 had a fetal brain MRI. The mean centile value of FOD was lower in the unfavorable outcome group (n = 9) compared to the favorable outcome group (n = 53) (24.5 ± 16.8 vs. 8.6 ± 13.2, p = 0.004). The ROC curve for predicting risk of unfavorable neonatal outcome based on FOD presented an area under the curve of 0.81 (95 % CI, [0.63---0.99]) and a threshold determined at the 3rd centile was associated with sensitivity of 0.78 and a specificity of 0.89. In multivariate analysis, a FOD less than the 3rd centile was significantly associated with an unfavorable neonatal risk. There also was a reduction in TCD (25.5 ± 21.5 vs. 10.4 ± 10.4, p = 0.03) in the unfavorable neonatal outcome group.

CONCLUSION

We found an association between a reduction in FOD and TCD in fetal MRIs conducted between 28 and 32 WG in fetuses monitored for IUGR with an unfavorable neonatal outcome. Our results suggest that these biometric changes could constitute markers of poor neonatal prognosis.

Birth weight and head circumference discordance and outcome in preterms: results from the EPIPAGE-2 cohort

OBJECTIVE

To determine whether the relative measurement of birth weight (BW) and head circumference (HC) in preterm infants is associated with neurological outcomes.

METHODS

The EPIPAGE-2 Study included 3473 infants born before 32 weeks' gestation, classified based on their Z-score of BW and HC on the Fenton curves as concordant (≤1 SD apart) or discordant (>1 SD difference). We defined four mutually exclusive categories: discordant smaller BW (sBW) with BW-1SD and concordant small measurement (CsM) with BW and HC concordant and both ≤-1SD. Neurological outcomes at 5.5 years were evaluated with standard tests.

RESULTS

2592 (74.8%) preterm neonates were categorised as CM, 258 (7.4%) CsM, 378 (10.9%) sHC and 239 (6.9%) sBW. Compared with the CM children, those born with CsM had significantly higher risks of cognitive deficiency (adjusted OR (aOR) 1.3, 95% CI (1.0 to 2.0)), developmental coordination disorders (aOR 2.6 (1.5 to 4.4)) and need for special school services (aOR 2.3 (1.5 to 3.7)). Those born with sBW had significantly lower risk of cognitive deficiency (aOR 0.6 (0.4 to 0.9)) and the sHC group significantly higher risk of developmental coordination disorders (aOR 1.8 (1.0 to 3.2)).

CONCLUSIONS

The relative discordance of these preterm infants' BW and HC was associated with their neurological outcomes. It merits further exploration as an indirect indicator of development.

TRIAL REGISTRATION NUMBER

NCT03078439.

Comparison of birth outcomes of mothers covered by Medicaid versus those privately insured when accounting for social determinants of health

OBJECTIVES

To determine the association between maternal health insurance type and birth outcomes [prematurity, small for gestational age (SGA), Term/Appropriate for gestational age NICU admission (Term/AGA-NICU) & composite birth outcomes (CBO)] accounting for social determinants of health.

DESIGN/METHODS

A cross-sectional study of maternal surveys and birth certificate data of singleton live births in NY born to mothers with Medicaid (M) or Private Insurance (PI).

RESULTS

1015 mothers [M = 631, PI = 384) included. Individual birth outcomes did not differ between groups. Adjusting for social, demographic and clinical covariates, M mothers had similar odds of preterm birth, SGA, Term/AGA-NICU admission and CBO compared to PI.

CONCLUSIONS

M mothers were as likely as PI mothers to deliver a preterm, SGA or a Term/AGA-NICU infant after controlling for social determinants of health. Despite more social adversity among enrollees, our study suggests NY Medicaid recipients have similar birth outcomes to privately insured, socially advantaged women.

Use of E-Cigarettes and Cigarettes During Late Pregnancy Among Adolescents

Importance

Pregnant adolescents sometimes use cigarettes; however, little is known about e-cigarette use among pregnant adolescents, a population with increased health vulnerability.

Objective

To examine yearly trends, sociodemographic and pregnancy-related determinants, and the association with small-for-gestational-age (SGA) birth of e-cigarette and/or cigarette use during late pregnancy among adolescents.

Design, Setting, and Participants

This cohort study used existing data from the 2016-2021 Pregnancy Risk Assessment Monitoring System on 10 428 US adolescents aged 10 to 19 years who had a singleton birth with complete data on e-cigarette or cigarette use and SGA birth.

Exposure

Adolescents reported e-cigarette and cigarette use during the last 3 months of pregnancy.

Main Outcomes and Measures

SGA birth (birth weight below the 10th percentile for the same sex and gestational duration) was determined from birth certificates. Multivariable logistic regression was used to compare the odds of SGA birth across pregnant adolescents who exclusively used e-cigarettes, exclusively used cigarettes, used e-cigarettes and cigarettes, or did not use either.

Results

Of the 10 428 pregnant adolescents, 72.7% were aged 18 or 19 years; 58.9% self-identified as White and 23.3% as Black; and 69.8% were non-Hispanic. The weighted prevalence of exclusive e-cigarette use during late pregnancy increased from 0.8% in 2016 to 4.1% in 2021, while the prevalence of exclusive cigarette use decreased from 9.2% in 2017 to 3.2% in 2021. The prevalence of dual use fluctuated, ranging from 0.6% to 1.6%. White pregnant adolescents were more likely than those who self-identified as another race and ethnicity to use e-cigarettes (2.7% vs 1.0% for American Indian or Alaska Native adolescents, 0.8% for Asian or other race adolescents, 0.6% for Black adolescents, and 0.7% for multiracial adolescents). Compared with those who did not use either product, adolescents who exclusively used e-cigarettes (16.8% vs 12.9%; confounder-adjusted odds ratio [AOR], 1.68 [95% CI, 0.89-3.18]) or who used cigarettes and e-cigarettes (17.6% vs 12.9%; AOR, 1.68 [95% CI, 0.79-3.53]) had no statistically significant difference in risk of SGA birth. However, adolescents who exclusively used cigarettes had a more than 2-fold higher risk of SGA birth (24.6% vs 12.9%; AOR, 2.51 [95% CI, 1.79-3.52]).

Conclusions and Relevance

This cohort study suggests that pregnant adolescents increasingly used e-cigarettes, with the highest use among White adolescents. Results from this analysis found that, unlike cigarette use, e-cigarette use during late pregnancy was not statistically significantly associated with an increased risk of SGA birth among adolescents. Due to the uncertainty of this nonsignificant association, future research could benefit from a larger sample size.

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.

Neighborhood Socioeconomic Disadvantage and Abnormal Birth Weight

OBJECTIVE

To examine whether exposure to community or neighborhood socioeconomic disadvantage as measured by the ADI (Area Deprivation Index) is associated with risk of abnormal birth weight among nulliparous individuals with singleton gestations.

METHODS

This was a secondary analysis from the prospective cohort NuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be). Participant addresses at cohort enrollment between 6 and 13 weeks of gestation were geocoded at the Census tract level and linked to the 2015 ADI. The ADI, which incorporates the domains of income, education, employment, and housing quality into a composite national ranking of neighborhood socioeconomic disadvantage, was categorized by quartiles (quartile 1, least disadvantaged, reference; quartile 4, most disadvantaged). Outcomes were large for gestational age (LGA; birth weight at or above the 90th percentile) and small for gestational age (SGA; birth weight below the 10th percentile) compared with appropriate for gestational age (AGA; birth weight 10th-90th percentile) as determined with the 2017 U.S. natality reference data, standardized for fetal sex. Multinomial logistic regression models were adjusted for potential confounding variables.

RESULTS

Of 8,983 assessed deliveries in the analytic population, 12.7% (n=1,143) were SGA, 8.2% (n=738) were LGA, and 79.1% (n=7,102) were AGA. Pregnant individuals living in the highest ADI quartile (quartile 4, 17.8%) had an increased odds of delivering an SGA neonate compared with those in the lowest referent quartile (quartile 1, 12.4%) (adjusted odds ratio [aOR] 1.32, 95% CI 1.09-1.55). Pregnant individuals living in higher ADI quartiles (quartile 2, 10.3%; quartile 3, 10.7%; quartile 4, 9.2%) had an increased odds of delivering an LGA neonate compared with those in the lowest referent quartile (quartile 1, 8.2%) (aOR: quartile 2, 1.40, 95% CI 1.19-1.61; quartile 3, 1.35, 95% CI 1.09-1.61; quartile 4, 1.47, 95% CI 1.20-1.74).

CONCLUSION

Neonates of nulliparous pregnant individuals living in U.S. neighborhoods with higher area deprivation were more likely to have abnormal birth weights at both extremes.

Maternal occupational exposure to selected organic and chlorinated solvents and delivery of small-for-gestational age or preterm infants

BACKGROUND

Potential reproductive effects of organic solvent exposure during pregnancy remain unclear. We investigated the association between maternal occupational exposure during pregnancy to six chlorinated solvents, three aromatic solvents, and Stoddard solvent, and delivery of preterm infants or those born small-for-gestational age (SGA).

METHODS

In this case-control study of SGA and preterm birth (PTB) nested within the National Birth Defects Prevention Study (NBDPS) from 1997 to 2011, we analyzed data from 7504 singleton live births without major birth defects and their mothers. Self-reported information on jobs held in the periconceptional period was assessed for solvent exposure. Unconditional logistic regression was used to estimate the association between maternal occupational exposure (any, none) during early pregnancy to organic solvents and PTB and SGA. Linear regression was used to examine changes in mean birthweight potentially associated with maternal occupational solvent exposure.

RESULTS

Maternal occupational exposure to any organic solvents overall was not associated with an increased odds of PTB (adjusted odds ratio [aOR] = 0.94; 95% confidence interval [CI] 0.67-1.33) or SGA (aOR = 0.93; 95% CI 0.65-1.34). Point estimates increased modestly for higher estimated exposure versus lower, but confidence intervals were wide and not statistically significant. Maternal exposure to solvents was not associated with a statistically significant change in term birthweight among infants.

CONCLUSIONS

Occupational exposure to organic solvents at the frequency and intensity levels found in a population-based sample of pregnant workers was not associated with PTB or SGA; however, we cannot rule out any effects among pregnant workers with uncommonly high exposure to organic solvents.

Documentation and prevalence of prenatal and neonatal outcomes in a cohort of individuals with KBG syndrome

Ankyrin Repeat Domain 11 (ANKRD11) gene mutations are associated with KBG syndrome, a developmental disability that affects multiple organ systems. The function of ANKRD11 in human growth and development is not clear, but gene knockout or mutation are lethal in mice embryos and/or pups. In addition, it plays a vital role in chromatin regulation and transcription. Individuals with KBG syndrome are often misdiagnosed or remain undiagnosed until later in life. This is largely due to KBG syndrome's varying and nonspecific phenotypes as well as a lack of accessible genetic testing and prenatal screening. This study documents perinatal outcomes for individuals with KBG syndrome. We obtained data from 42 individuals through videoconferences, medical records, and emails. 45.2% of our cohort was born by C-section, 33.3% had a congenital heart defect, 23.8% were born prematurely, 23.8% were admitted to the NICU, 14.3% were small for gestational age, and 14.3% of the families had a history of miscarriage. These rates were higher in our cohort compared to the overall population, including non-Hispanic and Hispanic populations. Other reports included feeding difficulties (21.4%), neonatal jaundice (14.3%), decreased fetal movement (7.1%), and pleural effusions in utero (4.7%). Comprehensive perinatal studies about KBG syndrome and updated documentation of its phenotypes are important in ensuring prompt diagnosis and can facilitate correct management.

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.

Cardiorespiratory Monitoring Data to Predict Respiratory Outcomes in Extremely Preterm Infants

Rationale: Immature control of breathing is associated with apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants. However, it is not clear if such events independently predict worse respiratory outcome. Objectives: To determine if analysis of cardiorespiratory monitoring data can predict unfavorable respiratory outcomes at 40 weeks postmenstrual age (PMA) and other outcomes, such as bronchopulmonary dysplasia at 36 weeks PMA. Methods: The Prematurity-related Ventilatory Control (Pre-Vent) study was an observational multicenter prospective cohort study including infants born at <29 weeks of gestation with continuous cardiorespiratory monitoring. The primary outcome was either "favorable" (alive and previously discharged or inpatient and off respiratory medications/O2/support at 40 wk PMA) or "unfavorable" (either deceased or inpatient/previously discharged on respiratory medications/O2/support at 40 wk PMA). Measurements and Main Results: A total of 717 infants were evaluated (median birth weight, 850 g; gestation, 26.4 wk), 53.7% of whom had a favorable outcome and 46.3% of whom had an unfavorable outcome. Physiologic data predicted unfavorable outcome, with accuracy improving with advancing age (area under the curve, 0.79 at Day 7, 0.85 at Day 28 and 32 wk PMA). The physiologic variable that contributed most to prediction was intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <90%. Models with clinical data alone or combining physiologic and clinical data also had good accuracy, with areas under the curve of 0.84-0.85 at Days 7 and 14 and 0.86-0.88 at Day 28 and 32 weeks PMA. Intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <80% was the major physiologic predictor of severe bronchopulmonary dysplasia and death or mechanical ventilation at 40 weeks PMA. Conclusions: Physiologic data are independently associated with unfavorable respiratory outcome in extremely preterm infants.

Regional references vs. international standards for assessing weight and length by gestational age in Lithuanian neonates

Introduction

There is no global consensus as to which standards are the most appropriate for the assessment of birth weight and length. The study aimed to compare the applicability of regional and global standards to the Lithuanian newborn population by sex and gestational age, based on the prevalence of small or large for gestational age (SGA/LGA).

Materials and Methods

Analysis was performed on neonatal length and weight data obtained from the Lithuanian Medical Birth Register from 1995 to 2015 (618,235 newborns of 24-42 gestational weeks). Their distributions by gestation and sex were estimated using generalized additive models for location, scale, and shape (GAMLSS), and the results were compared with the INTERGROWTH-21st (IG-21) standard to evaluate the prevalence of SGA/LGA (10th/90th centile) at different gestational ages.

Results

The difference in median length at term between the local reference and IG-21 was 3 cm-4 cm, while median weight at term differed by 200 g. The Lithuanian median weight at term was higher than in IG-21 by a full centile channel width, while the median length at term was higher by two channel widths. Based on the regional reference, the prevalence rates of SGA/LGA were 9.7%/10.1% for boys and 10.1%/9.9% for girls, close to the nominal 10%. Conversely, based on IG-21, the prevalence of SGA in boys/girls was less than half (4.1%/4.4%), while the prevalence of LGA was double (20.7%/19.1%).

Discussion

Regional population-based neonatal references represent Lithuanian neonatal weight and length much more accurately than the global standard IG-21 which provides the prevalence rates for SGA/LGA that differ from the true values by a factor of two.

Pregnancy-related hemodynamic biomarkers in relation to trimester-specific maternal per - and polyfluoroalkyl substances exposures and adverse birth outcomes

The fate of environmental chemicals in maternal and fetal tissues might be affected by pregnancy-related hemodynamic changes that occur across gestation. Specifically, hemodilution and renal function are hypothesized to confound associations between per- and polyfluoroalkyl substances (PFAS) exposure measures in late pregnancy with gestational length and fetal growth. We sought to analyze two pregnancy-related hemodynamic biomarkers, creatinine and estimated glomerular filtration rate (eGFR), as confounders of the trimester-specific relationships between maternal serum PFAS concentrations and adverse birth outcomes. Participants were enrolled in the Atlanta African American Maternal-Child Cohort between 2014 and 2020. Biospecimens were collected at up to two timepoints, which were categorized into the 1st trimester (N = 278; 11 mean weeks gestation), 2nd trimester (N = 162; 24 mean weeks gestation), and 3rd trimester (N = 110; 29 mean weeks gestation). We quantified six PFAS in serum, creatinine in serum and urine, and eGFR using the Cockroft-Gault equation. Multivariable regression models estimated the associations between single PFAS and their sum with gestational age at delivery (weeks), preterm birth (PTB, <37 gestational weeks), birthweight z-scores, and small for gestational age (SGA). Primary models were adjusted for sociodemographics. We additionally adjusted for serum creatinine, urinary creatinine, or eGFR in the confounding assessments. An interquartile range increase in perfluorooctanoic acid (PFOA) produced a non-significant reduction in birthweight z-score during the 1st and 2nd trimesters (β = -0.01 g [95% CI = -0.14, 0.12] and β = -0.07 g [95% CI = -0.19, 0.06], respectively) whereas the relationship was significant and positive during the 3rd trimester (β = 0.15 g; 95% CI = 0.01, 0.29). Trimester-specific effects were similar for the other PFAS and adverse birth outcomes, which persisted after adjusting for creatinine or eGFR. The relationships between prenatal PFAS exposure and adverse birth outcomes were not strongly confounded by renal function or hemodilution. However, 3rd trimester samples consistently exhibited different effects than those collected during the 1st and 2nd trimesters.

A prediction nomogram for moderate-to-severe bronchopulmonary dysplasia in preterm infants < 32 weeks of gestation: A multicenter retrospective study

Background

Moderate-to-severe bronchopulmonary dysplasia (msBPD) is a serious complication in preterm infants. We aimed to develop a dynamic nomogram for early prediction of msBPD using perinatal factors in preterm infants born at <32 weeks' gestation.

Methods

This multicenter retrospective study conducted at three hospitals in China between January 2017 and December 2021 included data on preterm infants with gestational age (GA) < 32 weeks. All infants were randomly divided into training and validation cohorts (3:1 ratio). Variables were selected by Lasso regression. Multivariate logistic regression was used to build a dynamic nomogram to predict msBPD. The discrimination was verified by receiver operating characteristic curves. Hosmer-Lemeshow test and decision curve analysis (DCA) were used for evaluating calibration and clinical applicability.

Results

A total of 2,067 preterm infants. GA, Apgar 5-min score, small for gestational age (SGA), early onset sepsis, and duration of invasive ventilation were predictors for msBPD by Lasso regression. The area under the curve was 0.894 (95% CI 0.869-0.919) and 0.893 (95% CI 0.855-0.931) in training and validation cohorts. The Hosmer-Lemeshow test calculated P value of 0.059 showing a good fit of the nomogram. The DCA demonstrated significantly clinical benefit of the model in both cohorts. A dynamic nomogram predicting msBPD by perinatal days within postnatal day 7 is available at https://sdxxbxzz.shinyapps.io/BPDpredict/.

Conclusion

We assessed the perinatal predictors of msBPD in preterm infants with GA < 32 weeks and built a dynamic nomogram for early risk prediction, providing clinicians a visual tool for early identification of msBPD.

Diagnostic Tests in the Prediction of Neonatal Outcome in Early Placental Fetal Growth Restriction

Background and Objectives: Monitoring pregnancies with fetal growth restriction (FGR) presents a challenge, especially concerning the time of delivery in cases of early preterm pregnancies below 32 weeks. The aim of our study was to compare different diagnostic parameters in growth-restricted preterm neonates with and without morbidity/mortality and to determine sensitivity and specificity of diagnostic parameters for monitoring preterm pregnancies with early preterm fetal growth restriction below 32 weeks. Materials and Methods: Our clinical study evaluated 120 cases of early preterm deliveries, with gestational age ≤ 32 + 0 weeks, with prenatally diagnosed placental FGR. All the patients were divided into three groups of 40 cases each based on neonatal condition,: I-Neonates with morbidity/mortality (NMM); II-Neonates without morbidity with acidosis/asphyxia (NAA); III-Neonates without neonatal morbidity/acidosis/asphyxia (NWMAA). Results: Amniotic fluid index (AFI) was lower in NMM, while NWMAA had higher biophysical profile scores (BPS). UA PI was lower in NWMAA. NWMAA had higher MCA PI and CPR and fewer cases with CPR <5th percentile. NMM had higher DV PI, and more often had ductus venosus (DV) PI > 95th‱ or absent/reversed A wave, and pulsatile blood flow in umbilical vein (UV). The incidence of pathological fetal heart rate monitoring (FHRM) was higher in NMM and NAA, although the difference was not statistically significant. ROC calculated by defining a bad outcome as NMM and a good outcome as NAA and NWMAA showed the best sensitivity in DV PIi. ROC calculated by defined bad outcome in NMM and NAA and good outcome in NWMAA showed the best sensitivity in MCA PI. Conclusions: In early fetal growth restriction normal cerebral blood flow strongly predicts good outcomes, while pathological venous blood flow is associated with bad outcomes. In fetal growth restriction before 32 weeks, individualized expectant management remains the best option for the optimal timing of delivery.

Characteristics of Gut Microbiota in Small for Gestational Age Infants with Very Low Birth Weight

Small for gestational age (SGA) birth is associated with high rates of mortality and morbidity in preterm infants. The aim of this preliminary observational study was to investigate the difference in gut microbiota between SGA and appropriate for gestational age (AGA) preterm infants with very low birth weight (VLBW). We included 20 VLBW preterm infants (SGA, n = 10; AGA, n = 10) in this study. Stool samples were collected on days 7, 14, and 30 after birth. We performed 16S ribosomal DNA sequencing to compare microbiota composition between both groups. The SGA group exhibited a lower abundance of Klebsiella on day 14 (SGA, 0.57%; AGA, 7.42%; p = 0.037). On day 30, the SGA group exhibited a lower abundance of Klebsiella (SGA 3.76% vs. AGA 16.05%; p = 0.07) and Enterobacter (SGA 5.09% vs. AGA 27.25%; p = 0.011) than the AGA group. Beta diversity demonstrated a separation of the bacterial community structure between both groups on day 30 (p = 0.019). The present study revealed that a distinct gut microbiota profile gradually develops in SGA preterm infants with VLBW during the early days of life. The role of changes in gut microbiota structure warrants further investigation.

Fetal growth restriction and neonatal-pediatric lung diseases: Vascular mechanistic links and therapeutic directions

Bronchopulmonary dysplasia (BPD) is the most common respiratory sequela of prematurity, and infants born with fetal growth restriction (FGR) are disproportionately represented in BPD statistics, as factors which affect somatic growth may also affect pulmonary growth. Effects of in-utero hypoxia underlying FGR on lung parenchymal architecture predisposing to BPD are well documented, but the pulmonary vascular constructs are not well appreciated. Disruption of angiogenesis during critical periods of lung growth impairs alveolarization, contributing to BPD pathogenesis. Pulmonary artery thickness/stiffness has been noted in FGR in the initial postnatal weeks, and also in well-grown infants with established BPD. The lack of waveform cushioning by the major arteries exposes the pulmonary resistance vessels to higher pulsatile stress, thereby accelerating microvascular disease. Reactive oxygen species, increased sympathetic activity and endothelial dysfunction are common mediators in FGR and BPD; each putative targets for prevention and/or therapeutics using interleukin (IL)-1 receptor antagonist (IL-1Ra), melatonin or inhibition of renin-angiotensin-aldosterone system. While BPD is the archetypal respiratory disease of infancy, effects of FGR on pulmonary function are long-term, extending well into childhood. This narrative links FGR in very/extremely preterm infants with BPD through the vascular affliction as a mechanistic and potentially, therapeutic pathway. Our objectives were to depict the burden of disease for FGR and BPD amongst preterm infants, portray vascular involvement in the placenta in FGR and BPD cohorts, provide high resolution vascular ultrasound information in both cohorts with a view to address therapeutic relevance, and lastly, link this information with paediatric age-group lung diseases.

Reduced Birth Weight and Exposure to Per- and Polyfluoroalkyl Substances: A Review of Possible Underlying Mechanisms Using the AOP-HelpFinder

Prenatal exposure to per- and polyfluorinated substances (PFAS) may impair fetal growth. Our knowledge of the underlying mechanisms is incomplete. We used the Adverse Outcome Pathway (AOP)-helpFinder tool to search PubMed for studies published until March 2021 that examined PFAS exposure in relation to birth weight, oxidative stress, hormones/hormone receptors, or growth signaling pathways. Of these 1880 articles, 106 experimental studies remained after abstract screening. One clear finding is that PFAS are associated with oxidative stress in in vivo animal studies and in vitro studies. It appears that PFAS-induced reactive-oxygen species (ROS) generation triggers increased peroxisome proliferator-activated receptor (PPAR)γ expression and activation of growth signaling pathways, leading to hyperdifferentiation of pre-adipocytes. Fewer proliferating pre-adipocytes result in lower adipose tissue weight and in this way may reduce birth weight. PFAS may also impair fetal growth through endocrine effects. Estrogenic effects have been noted in in vivo and in vitro studies. Overall, data suggest thyroid-damaging effects of PFAS affecting thyroid hormones, thyroid hormone gene expression, and histology that are associated in animal studies with decreased body and organ weight. The effects of PFAS on the complex relationships between oxidative stress, endocrine system function, adipogenesis, and fetal growth should be further explored.

Intention to Breastfeed and Paternal Influence on Pregnant Mothers Exclusively Using Marijuana Compared with Other Substances

Objective: To determine intention to breastfeed (ITBF) rates among mothers exclusively using marijuana (eMJ) compared with electronic cigarettes (eEcig), tobacco products (eTob), or multisubstances (MS), nonusers (NU), and the influence of paternal presence and paternal substance use. Study Design: Cross-sectional study of parental survey responses merged with electronic birth certificates. Accounting for clinical and social determinants of health, analyses of ITBF included (1) all mothers, (2) single mothers, and (3) mothers with fathers. Results: Among all mothers (n = 1,073), eMJ, eTob, and MS users had lower odds of ITBF compared with NU. Only eMJ users had lower odds of ITBF for those without paternal presence. However, in those mothers with a paternal presence, odds of ITBF were similar to NU for eMJ, eTob, and MS users when accounting for paternal factors, including paternal substance use. Conclusion: Women exclusively using MJ have lower ITBF compared with NU. However, paternal presence mitigated this effect, independent of parental MJ use. The presence of fathers may represent a unique predictor for increased ITBF in MJ using mothers.

Machine learning-based risk factor analysis of adverse birth outcomes in very low birth weight infants

This study aimed to analyze major predictors of adverse birth outcomes in very low birth weight (VLBW) infants including particulate matter concentration (PM₁₀), using machine learning and the national prospective cohort. Data consisted of 10,423 VLBW infants from the Korean Neonatal Network database during January 2013-December 2017. Five adverse birth outcomes were considered as the dependent variables, i.e., gestational age less than 28 weeks, gestational age less than 26 weeks, birth weight less than 1000 g, birth weight less than 750 g and small-for-gestational age. Thirty-three predictors were included and the artificial neural network, the decision tree, the logistic regression, the Naïve Bayes, the random forest and the support vector machine were used for predicting the dependent variables. Among the six prediction models, the random forest had the best performance (accuracy 0.79, area under the receiver-operating-characteristic curve 0.72). According to the random forest variable importance, major predictors of adverse birth outcomes were maternal age (0.2131), birth-month (0.0767), PM₁₀ month (0.0656), sex (0.0428), number of fetuses (0.0424), primipara (0.0395), maternal education (0.0352), pregnancy-induced hypertension (0.0347), chorioamnionitis (0.0336) and antenatal steroid (0.0318). In conclusion, adverse birth outcomes had strong associations with PM₁₀ month as well as maternal and fetal factors.

Comparison of Fenton, INTERGROWTH-21st, and Population-Based Growth Charts in Predicting Outcomes of Very Preterm Small-for-Gestational-Age Neonates

Growth chart aids in management by identifying at-risk neonates with abnormal growth. In this retrospective analysis of 1067 neonates of 26-31 wk gestational age, the utility of 3 growth charts (local population-based, Fenton-2013, and INTERGROWTH-21^st) was studied in identifying very preterm neonates at risk of developing complications secondary to intrauterine growth retardation (hypoglycemia, mortality, and BPD at 36 wk). The proportion of neonates classified as small for gestational age was 9% (n = 96) with Fernandez chart, 16.7% (n = 178) with Fenton-2013 chart, and 24.8% (n = 265) with INTERGROWTH-21^st charts. The INTERGROWTH-21^st charts were more sensitive in identifying neonates developing complications, followed by Fenton-2013 and population-based charts. The population-based charts were more specific, accurate, and precise in differentiating neonates developing complications from those who did not, followed by Fenton-2013 and INTERGROWTH-21^st charts. For the outcomes studied, INTERGROWTH-21^st charts had reasonable tradeoff between sensitivity and (34%-50%) and specificity (76%-77%).

Temporal trends and adverse perinatal outcomes of twin pregnancies at differing gestational ages: an observational study from China between 2012–2020

Background

With the development of assisted reproductive technology, the twinning rate in China has been increasing. However, little is known about twinning from 2014 onwards. In addition, previous studies analysing optimal gestational times have rarely considered maternal health conditions. Therefore, whether maternal health conditions affect the optimal gestational time remains unclear.

Methods

Data of women delivered between January 2012 and December 2020 were collected through China’s National Maternal Near Miss Surveillance System. Interrupted time series analysis was used to determine the rates of twinning, stillbirth, smaller than gestational age (SGA), and low Apgar scores (< 4) among twins in China. To estimate the risk of each adverse perinatal outcome for separate gestational weeks, a multivariate generalised linear model was used. Infants born at 37 weeks of gestational age or foetuses staying in utero were used as reference separately. The analyses were adjusted for the sampling distribution of the population and the cluster effect at the hospital and individual levels were considered.

Results

There were 442,268 infants enrolled in this study, and the adjusted rates for twinning, stillbirth, SGA, and low Apgar scores were 3.10%, 1.75%, 7.70%, and 0.79%, respectively. From 2012 to 2020, the twinning rate showed an increasing trend. Adverse perinatal outcomes, including stillbirth, SGA, and low Apgar scores showed a decreasing trend. A gestational age between 34 and 36 weeks decreased most for rate of stillbirth (average changing rate -9.72%, 95% confidence interval [CI] -11.41% to -8.00%); and a gestational age of between 37 and 38 weeks decreased most for rates of SGA (average changing rate -4.64%, 95% CI -5.42% to -3.85%) and low Apgar scores (average changing rate -17.61%, 95% CI -21.73% to -13.26%). No significant difference in changes in twinning rate or changes of each perinatal outcome was observed during periods of different fertility policies. Infants born at 37 weeks of gestation had a decreased risk of stillbirth, SGA, and low Apgar scores. Maternal antepartum or medical complications increased the risk of SGA and low Apgar scores in different gestational weeks.

Conclusion

China’s twinning rate showed an increasing trend, while adverse perinatal outcomes decreased from 2012 to 2020. Fertility policy changes have had little effect on the twinning rate or the rate of adverse perinatal outcomes such as stillbirth, SGA, or low Apgar scores. The optimal gestational age for twins was 37 weeks. Women pregnant with twins and with antepartum or medical complications should be cautious due to an increased risk of SGA and low Apgar scores.

The impact of prematurity and associated comorbidities on clinical outcomes in neonates with congenital heart disease

Prematurity is a common risk factor in children, affecting approximately 10% of live births, globally. It is more common in children with critical congenital heart disease (CCHD) and carries important implications in this group of patients. While outcomes have been improving over the years, even late preterm birth is associated with worse outcomes in children born with critical congenital heart disease compared to those without. Infants with both prematurity and CCHD are at particularly high risk for important comorbidities, including: necrotizing enterocolitis, intraventricular hemorrhage, white matter injury, neurodevelopmental anomalies and retinopathy of prematurity. Lesion-specific intensive care management of these infants, interventional and peri-operative management specifically tailored to their needs, and multidisciplinary care all have the potential to improve outcomes in this challenging group.

Neonatal Sequential Organ Failure Assessment (nSOFA) Score within 72 Hours after Birth Reliably Predicts Mortality and Serious Morbidity in Very Preterm Infants

The aim of this study was to assess the applicability of the neonatal sequential organ failure assessment score (nSOFA) within 72 h after delivery as a predictor for mortality and adverse outcome in very preterm neonates. Inborn neonates <32 weeks of gestation were evaluated. The nSOFA scores were calculated from medical records in the first 72 h after birth and the peak value was used for analysis. Death or composite morbidity at hospital discharge defined the adverse outcome. Composite morbidity consisted of chronic lung disease, intraventricular haemorrhage ≥grade III, periventricular leukomalacia and necrotizing enterocolitis. Among 423 enrolled infants (median birth weight 1070 g, median gestational age 29 weeks), 27 died and 91 developed composite morbidity. Death or composite morbidity was associated with organ dysfunction as assessed by nSOFA, systemic inflammatory response, and low birthweight. The score >2 was associated with OR 2.5 (CI 1.39−4.64, p = 0.002) for the adverse outcome. Area under the curve of ROC was 0.795 (95% CI = 0.763−0.827). The use of nSOFA seems to be reasonable for predicting mortality and morbidity in very preterm infants. It constitutes a suitable basis to measure the severity of organ dysfunction regardless of the cause.

Predictive role of Doppler indices of cerebral-placental-uterine ratio and umbilico-cerebral ratio for late-onset fetal growth restriction: a prospective cohort study

Predicting late-onset foetal growth restriction (FGR) has proven to be rather challenging. In this study, we propose a new parameter, cerebral-placental-uterine (CPU) ratio and umbilico-cerebral (UC) ratio for this matter. Results of this study which included a total of 227 nulliparous women showed that an increase in CPU ratio (OR = 0.45; 95% CI: 0.23-0.88; p=.020) was associated with lower odds of foetal weight above the 10th percentile at birth. CPU ratio measured at 35-37 weeks of gestation had an AUC of 0.78 (95% CI: 0.58, 0.98), sensitivity of 0.62 (95% CI: 0.24, 0.91) and specificity of 0.90 (95% CI: 0.79, 0.96) for prediction of late-onset FGR, which showed higher accuracy than UC ratio. As some cases of the late-onset FGR are not diagnosed by foetal biometry, it is important to find Doppler parameters that can help us predict these cases and CPU ratio may help physicians in detection of high-risk foetuses that will benefit from earlier intervention. Impact StatementWhat is already known on this subject? Late-onset foetal growth restriction (FGR) defined by an FGR diagnosis after 32 weeks of gestational age, can lead to short- and long-term morbidities and early diagnosis is the key to prevent these complications.What do the results of this study add? Results showed that each unit increase in numeric variables including CP ratio (OR = 0.29, p=.006), and CPU ratio (OR = 0.40, p=.006) was associated with lower odds of the foetal weight above the 10th percentile in the second ultrasound at 35-37 weeks. In other words, CPU ratio can prove to be useful marker in prediction of late-onset FGR.What are the implications of these findings for clinical practice and/or further research? Our prospective cohort study confirms the added value of low CPU ratio, with higher predictive accuracy than UC ratio, in predicting late-onset FGR. Detection of late FGR remains poor, but it is important to prevent stillbirth so further studies on the role of CPU ratio in predicting FGR and perinatal outcomes are needed.

Risk factors that affect the degree of bronchopulmonary dysplasia in very preterm infants: a 5-year retrospective study

Background

Bronchopulmonary dysplasia (BPD) is one of the most common adverse consequence of premature delivery and the most common chronic lung disease in infants. BPD is associated with long-term lung diseases and neurodevelopmental disorders that can persist into the adulthood. The adverse consequences caused by severe BPD are more serious. However, there were few studies on the risk factors for severe BPD.

Methods

This is a retrospective study of preterm infants born less than 32-week gestational age (GA) and diagnosed with BPD.

Results

A total of 250 preterm infants with a diagnosis of BPD and GA < 32 weeks were included (137 boys [54.8%] and 113 girls [45.2%]). The birth weight ranged from 700 g to 2010 g and the mean birth weight was 1318.52 g (255.45 g). The GA ranged from 25 weeks to 31 weeks and 6 days (mean, 30 weeks). The number of cases of mild, moderate and severe BPD were 39 (15.6%), 185 (74.0%) and 26 (10.4%), respectively. There were significant differences in the rate of small for gestational age (SGA), intrauterine asphyxia, pulmonary hemorrhage, neonatal respiratory distress syndrome (NRDS), circulatory failure, pulmonary hypertension, patent ductus arteriosus (PDA), pulmonary surfactant (PS), aminophylline, caffeine, glucocorticoids, tracheal intubation, diuretics, and parenteral nutrition length among the three groups (P < 0.05). The time of parenteral nutrition (aOR = 3.343, 95%CI: 2.198 ~ 5.085) and PDA (aOR =9.441, 95%CI: 1.186 ~ 75.128) were independent risk factors for severe BPD compared with mild BPD. PDA (aOR = 5.202, 95%CI: 1.803 ~ 15.010) and aminophylline (aOR = 6.179, 95%CI: 2.200 ~ 17.353) were independent risk factors for severe BPD, while caffeine (aOR = 0.260, 95%CI: 0.092 ~ 0.736) was the protective factor for severe BPD compared with moderate BPD. The time of parenteral nutrition (aOR = 2.972, 95%CI: 1.989 ~ 4.440) and caffeine (aOR = 4.525, 95%CI: 1.042 ~ 19.649) were independent risk factors for moderate BPD compared with mild BPD. Caffeine (aOR = 3.850, 95%CI: 1.358 ~ 10.916) was the independent risk factor for moderate BPD, while PDA (aOR = 0.192, 95%CI: 0.067 ~ 0.555) and aminophylline (aOR = 0.162, 95%CI: 0.058 ~ 0.455) were protective factors for moderate BPD compared with severe BPD. The time of parenteral nutrition (aOR = 0.337, 95%CI: 0.225 ~ 0.503) and caffeine (aOR = 0.221, 95%CI: 0.051 ~ 0.960) were protective factors for mild BPD compared with moderate BPD. The time of parenteral nutrition (aOR = 0.299, 95%CI: 0.197 ~ 0.455) and PDA (aOR = 0.106, 95%CI: 0.013 ~ 0.843) were protective factors for mild BPD compared with severe BPD.

Conclusion

The time of parenteral nutrition is the risk factor of moderate and severe BPD. PDA and aminophylline are risk factors for severe BPD. The role of caffeine in the severity of BPD is uncertain, and SGA is not related to the severity of BPD. Severe or moderate BPD can be avoided by shortening duration of parenteral nutrition, early treatment of PDA, reducing use of aminophylline and rational use of caffeine.

Trial registration

Retrospectively registered.

Propensity-Matched Comparison of Very Preterm Small- and Appropriate-for-Gestational-Age Neonates

OBJECTIVE

Comparison of mortality and major morbidities between very preterm (< 32 wk gestational age) small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA) neonates.

METHODS

A retrospective observational study of neonates born between 26-31 wk gestational age from January 2015 to December 2019 was done in level-3 neonatal intensive care unit of a high-risk perinatal center in South India.

RESULTS

Of the 1,178 very preterm neonates born in the study period, 909 were eligible for inclusion. After propensity score matching for gestational age, gender, and antenatal steroid use, 592 (444 AGA and 148 SGA) were included in the final analysis. SGA neonates had increased odds of necrotizing enterocolitis (NEC) ≥ stage 2A [adjusted odds ratio (aOR): 2.2; 95% CI: 1.15-4.21], abnormal composite outcome, i.e., any one of the mortality or major morbidities (aOR: 2.99; 95% CI: 1.96-4.57), hypoglycemia requiring intravenous fluids (aOR: 2.11; 95% CI: 1.05-4.23), and anemia requiring blood transfusions (aOR: 3.13; 95% CI: 1.98-4.93); and a trend towards increased odds of bronchopulmonary dysplasia (aOR: 1.9, 95% CI: 0.92-3.91). Mortality, intraventricular hemorrhage ≥ grade 2, periventricular leukomalacia ≥ grade 2, and retinopathy of prematurity requiring treatment were not different.

CONCLUSIONS

SGA neonates have higher odds of having NEC ≥ stage 2A, abnormal composite outcome, hypoglycemia, and anemia compared to appropriately grown neonates.

Impact of paternal presence and parental social-demographic characteristics on birth outcomes

OBJECTIVES

Maternal race, marital status, and social environment impact risk of preterm delivery and size for gestational age. Although some paternal characteristics such as age are associated with pregnancy outcomes, the influence of the paternal presence, race/ethnicity and adverse life events is not well known. The objective of the study was to assess birth outcomes in mothers with a paternal presence compared to those without during the post-partum period. The secondary aim was to determine whether paternal race is associated with birth outcomes.

METHODS

This was a cross-sectional study using parental surveys linked with birth certificate data from 2016 to 2018. Adverse birth composite outcomes (ABCO) including small for gestational age (SGA), prematurity or neonatal intensive care unit admission (NICU) were assessed.

RESULTS

A total of 695 parents were analyzed (239 single mothers and 228 mother-father pairs). Compared to mothers with a father present, mothers without a father present exhibited increased odds of ABCO, prematurity and NICU. Non-Hispanic Black fathers had increased odds of ABCO and NICU compared to Non-Hispanic Whites (NHW). Hispanic fathers had increased odds of NICU compared to NHW.

CONCLUSIONS

Paternal absence in the post-partum period and paternal race were both independently associated with ABCO and NICU. Assessment of paternal presence and paternal race in clinical practice may help identify opportunities for additional support necessary to optimize birth outcomes.

Temporal trends and risk of small for gestational age (SGA) infants among Asian American mothers by ethnicity

PURPOSE

To examine the temporal trends and risk of small for gestational age (SGA) phenotypes across Asian American ethnic groups.

METHODS

We conducted a population-based retrospective study using the 1992-2018 natality data files obtained from the National Vital Statistics System. Joinpoint regression modeling was employed to calculate the average annual percentage change in SGA birth rates among Asian American sub-groups and NH-White women. Logistic regression was utilized to compute the adjusted odds ratio and 95% confidence interval for the association between maternal race (Asian American sub-groups vs. NH-White) and SGA birth and its phenotypes.

RESULTS

We analyzed data on 2,821,798 Asian Americans and 62,174,875 NH-White US live-born infants. Overall, NH-Whites had the lowest SGA rates, while all the Asian ethnic groups had almost consistently higher rates during the 27-year period. Disparity in SGA births in the Asian subgroups was observed. Compared to NH-Whites, stratified analyses showed varying and significantly higher odds of any SGA in all Asian ethnic groups. Asian Indians had the highest odds [adjusted odds ratio (AOR) = 2.23, 95% confidence interval (CI) = 2.22-2.23] of any SGA compared to NH-Whites.

CONCLUSIONS

Our findings support the evidence that Asian Americans are not a homogenous group and highlight the need to disentangle these differences when conducting population health research and interventions among Asian Americans.

Incidence, Risk Factors, and Outcomes of Preterm and Early Term Births: A Population-Based Register Study

Preterm birth (PTB) and early term birth (ETB) are associated with high risks of perinatal mortality and morbidity. While extreme to very PTBs have been extensively studied, studies on infants born at later stages of pregnancy, particularly late PTBs and ETBs, are lacking. In this study, we aimed to assess the incidence, risk factors, and feto-maternal outcomes of PTB and ETB births in Qatar. We examined 15,865 singleton live births using 12-month retrospective registry data from the PEARL-Peristat Study. PTB and ETB incidence rates were 8.8% and 33.7%, respectively. PTB and ETB in-hospital mortality rates were 16.9% and 0.2%, respectively. Advanced maternal age, pre-gestational diabetes mellitus (PGDM), assisted pregnancies, and preterm history independently predicted both PTB and ETB, whereas chromosomal and congenital abnormalities were found to be independent predictors of PTB but not ETB. All groups of PTB and ETB were significantly associated with low birth weight (LBW), large for gestational age (LGA) births, caesarean delivery, and neonatal intensive care unit (NICU)/or death of neonate in labor room (LR)/operation theatre (OT). On the other hand, all or some groups of PTB were significantly associated with small for gestational age (SGA) births, Apgar < 7 at 1 and 5 min and in-hospital mortality. The findings of this study may serve as a basis for taking better clinical decisions with accurate assessment of risk factors, complications, and predictions of PTB and ETB.

Improved Survival of Periviable Infants after Alteration of the Threshold of Viability by the Neonatal Resuscitation Program 2015

Periviable infants (PIs) born at 22–25 weeks gestational age (wGA) have a variable survival rate (49.7–86.2%) among hospitals. One factor involved in this difference may be the definition of the threshold of viability. The American Academy of Pediatrics revised the neonatal resuscitation program in late 2015 (NRP 2015) and altered the threshold of viability from 23 to 22 wGA. The impact on the survival of PIs after the guideline alteration has seldom been discussed. Since 2016, the unit of this study has implemented the renewed guideline for PIs. We retrospectively reviewed and analyzed the survival and clinical variables of PIs before and after implementation of the guideline, which included a 10-year cohort in a single center in Taiwan. There were 168 PIs enrolled between 2010 and 2019 (Epoch-I, 2010–2015; Epoch-II, 2016–2019), after excluding those with congenital anomalies and parent-decided comfort care. Compared to those in Epoch-I, the PIs in Epoch-II had significantly higher odds ratios (2.602) (95% confidence interval: 1.170–5.789; p = 0.019) for survival. Younger gestational age, small size for gestational age, cesarean delivery, low blood pH at birth, and surfactant therapeutic treatment were found to be significant risk factors associated with the survival of PIs (p < 0.05 for each). The altered threshold of viability by NRP 2015 may impact the survival of PIs. However, long-term follow-up for surviving PI is required in the future.

Aberrant Hematopoiesis and Morbidity in Extremely Preterm Infants With Intrauterine Growth Restriction

Background and Objective: Intrauterine growth restriction (IUGR) poses additional challenges in extremely low gestational age newborns (ELGANs). We assessed disturbed hematopoiesis and morbidities associated with this disorder. Methods: This single-center retrospective case-control study compared perinatal hematological profiles, major morbidities, and mortality of 49 infants (gestational age <28 weeks, birth weight ≤ 3rd percentile, and compromised placental function) and 98 infants (birth weight >10th percentile) matched for gestational age, year, and sex. Results: IUGR-ELGANs had significantly elevated nucleated red blood cells and lower neutrophil and platelet counts at birth and on the third day of life. During the first week of life, IUGR-ELGANs received more red blood cell, platelet, and plasma transfusions and were more intensively treated with antibiotics. Rates of infections acquired during the first week (59.2 vs. 17.3%, p < 0.001), severe bronchopulmonary dysplasia or death (42.9 vs. 17.3%, p < 0.01), and mortality (36.7 vs. 7.1%, p < 0.001) were markedly elevated in IUGR-ELGANs, but not of hemorrhages or other morbidities. Conclusions: IUGR-ELGANs have high rates of acquired infections during the first week of life and display severe pulmonary morbidity leading to bronchopulmonary dysplasia or death. The high rate of transfusions observed in these infants warrants further scrutiny.

Cholestasis after very preterm birth was associated with adverse neonatal outcomes but no significant long-term liver disease: A population-based study

AIM

To describe outcome linked to neonatal cholestasis in a defined cohort of very preterm infants.

METHODS

Population-based retrospective case-control study of preterm infants, gestational age <30 weeks, surviving for 28 days, in Stockholm County. Cholestasis was defined as conjugated bilirubin ≥30 μmol/L exceeding 20% of total level at least twice and graded as high if exceeding 100 μmol/L. Cholestatic cases were matched on gestational week with two non-cholestatic controls.

RESULTS

The incidence rate of cholestasis was 37/250 (14.8%), with increasing rates in lower gestational weeks. Perinatal factors associated with cholestasis were pre-eclampsia and being born small for gestational age. Cholestatic infants had three times more bronchopulmonary dysplasia and eight times more retinopathy of prematurity. The mortality was 13.5% in cholestatic infants versus 2.7% in controls (P = .040). All deceased cholestatic infants had high-grade cholestasis. No surviving infants developed chronic liver disease by 10 years of age.

CONCLUSION

Cholestasis was common in very preterm infants and linked to disease severity and adverse outcome. Cholestasis may be an independent risk factor for bronchopulmonary dysplasia and retinopathy of prematurity and more severe cholestasis associated with increased mortality. Cholestasis was not associated with chronic liver disease later in childhood.

What is bronchopulmonary dysplasia and does caffeine prevent it?

Bronchopulmonary dysplasia (BPD) is among the most severe complications of very premature birth. Clinical and laboratory studies indicate that lung immaturity, inflammatory lung injury, and disordered lung repair are the primary mechanisms responsible for the development of BPD. Caffeine, initiated within the first 10 days after birth, is one of few drug therapies shown to significantly decrease the risk of BPD in very low birth weight infants. This benefit is likely derived, at least in part, from reduced exposure to positive airway pressure and supplemental oxygen with caffeine therapy. Additional cardiorespiratory benefits of caffeine that may contribute to the lower risk of BPD include less frequent treatment for a PDA, improved pulmonary mechanics, and direct effects on pulmonary inflammation, alveolarization, and angiogenesis. Routine administration of caffeine is indicated in the vast majority of very low birth weight infants. However, current preventative strategies including widespread use of caffeine do not avert BPD in all cases. As such, there is continued need for novel methods to further reduce the risk of BPD in very low birth weight infants.

Neurodevelopmental outcomes of very preterm and very-low-birthweight infants in a population-based clinical cohort with a definite perinatal treatment policy

BACKGROUND

With constant changes in neonatal care practices, recent information is valuable for healthcare providers and for parental counselling. The aim of the study was to describe the neurodevelopmental outcome in a cohort of very preterm (VPT)/very-low-birthweight (VLBW) infants at 2 years corrected age (CA).

MATERIAL AND METHODS

This is a population-based cohort study of all infants born with a GA <31 weeks and/or BW < 1500 g between 2014 and 2016 admitted to the Flemish (Belgium) neonatal intensive care units. Infants had routine clinical follow-up around 2 years CA. The diagnosis of cerebral palsy (CP), visual and hearing impairments were recorded. Motor, cognitive and language outcomes were assessed using the Bayley-III. Neurodevelopmental impairment (NDI) was classified as mild (<1 standard deviation [SD]) or moderate-severe (<2SD) based on the defined categories of motor, cognitive, hearing, and vision impairments.

RESULTS

Of the 1941 admissions, 92% survived to discharge and follow-up data were available for 1089 infants (61.1%). Overall, 19.3%, 18.9% and 41.8% of infants had a motor, cognitive and language delay, respectively. CP was diagnosed in 4.3% of the infants. Mild and moderate-to-severe NDI was observed in 25.2% and 10.9% of the infants, respectively. The number of infants with a normal outcome increased from nearly 40% in the category of GA<26 weeks to 70% for infants in the category of 30─31 weeks GA.

CONCLUSION

At 2 years CA, 64% were free from NDI and 90% were free from moderate-to-severe NDI. However, a lower GA and BW are associated with higher rates of adverse neurodevelopmental outcomes at 2 years CA.

Association of small for gestational age with retinopathy of prematurity: a systematic review and meta-analysis

CONTEXT

The association between small for gestational age (SGA) and retinopathy of prematurity (ROP) is unclear.

OBJECTIVE

A systematic review and meta-analysis was conducted to evaluate the association between ROP and SGA in preterm infants <37 weeks' gestational age (GA) admitted to neonatal intensive care unit.

METHODS

Medline, PubMed, Web of Science and Cochrane Central databases were searched from inception through 15 January 2019. Studies reporting outcomes based on SGA as the primary exposure variable were included. Data were extracted independently by two coauthors. Modified Newcastle-Ottawa scale was used for risk of bias assessment.

RESULTS

Database search yielded 536 records (Medline=152, PubMed=171, Web of Science=144 and Cochrane Central=69). Twenty-one studies evaluating 190 946 infants were included. SGA was associated with significantly higher odds of any stage of ROP on unadjusted analysis (unadjusted OR (uOR) 1.55; 95% CI 1.22 to 1.98; 10 studies) but not on adjusted analysis (adjusted OR (aOR) 2.16; 95% CI 0.66 to 7.11; 3 studies). SGA was associated with significantly higher odds of severe ROP (aOR 1.92; 95% CI 1.57 to 2.34; nine studies). SGA was also significantly associated with higher odds of treated ROP (aOR 1.39; 95% CI 1.18 to 1.65; three studies). In subgroup analysis of infants <29 weeks' GA, SGA was significantly associated with increased odds of ROP (uOR 1.64; 95% CI 1.19 to 2.26; two studies), severe ROP (aOR 1.61; 95% CI 1.23 to 2.10; four studies) and treated ROP (aOR 1.37; 95% CI 1.16 to 1.62; two studies).

CONCLUSION

SGA was associated with increased odds of any stage of ROP, severe ROP and treated ROP in preterm infants. Neonatologists should incorporate SGA into the risk assessment during ROP evaluation and while providing counselling to the families of preterm SGA infants. ROP screening guidelines should look into the frequency of follow-up examination in SGA infants in aim to offer early detection and treatment.

Diet as a counteracting agent of the effect of some well-known risk factors for small for gestational age

OBJECTIVE

The aim of this study was to assess whether diet variables can neutralize the risk produced by three well-known risk factors for being small for gestational age: smoking, body mass index (BMI) ˂20 kg/m², and having a previous preterm/low birth weight (LBW) newborn.

METHODS

A matched case control study was conducted (518 cases and 518 controls of pregnant women) in Spain. We collected data on demographic characteristics, socioeconomic status, toxic habits, and diet. Dietary intake during pregnancy was assessed using a validated food frequency questionnaire, categorized into quintiles. Adjusted odds ratios (aORs) and their 95% confidence intervals (CI) were estimated by conditional regression logistic models.

RESULTS

Women who smoked during pregnancy had a 78% increased risk for having an SGA newborn (aOR, 1.78; 95% CI, 1.28-2.74). Lean women (BMI ˂ 20 kg/m² before pregnancy) augmented the risk 139% (aOR, 2.39; 95% CI, 1.68-3.40), and those with a previous SGA-LBW an increase of 160% (aOR, 2.60; 95% CI, 1.53-4.37). Smoking in women with a fruit intake of ≥421 g/d was not associated with a higher risk for SGA versus non-smoking women with the same fruit intake (aOR, 0.98; 95% CI, 0.41-2.33). A BMI <20 kg/m² with an intake of ≥33 g/d of legumes did not increase the risk for SGA versus women with a BMI ≥20 kg/m² with the same legume intake (aOR, 1.35; 95% CI, 0.54-3.37). Diet did not modify the risk by having a previous SGA-LBW newborn.

CONCLUSIONS

Smoking and leanness increased the SGA risk; nevertheless foods such as fruit, fish, and legumes, as well as intake of vitamins D and B₃ and ω-3 marine fatty acids, may "at" least partially counteract this increase.

Health, Physical Growth, and Neurodevelopmental Outcomes in Preterm Infants of Women With Hypertensive Disorders of Pregnancy

OBJECTIVE

To compare the health, physical growth, and developmental outcomes in preterm infants of women with and without hypertensive disorders of pregnancy (HDP).

DESIGN

Cross-sectional analysis of health outcomes; physical growth (head circumference, height, and weight) collected at birth and 2 months, corrected for prematurity; and cognitive, language, and motor skills of preterm infants of women with and without HDP.

SETTING

Four NICUs in the United States.

PARTICIPANTS

Women (n = 221) and their preterm infants who weighed less than 1,750 g were enrolled in a multicenter, randomized trial of two interventions administered by each infant's mother when the infant was no longer critically ill.

METHODS

Women and their preterm infants were categorized into groups with (n = 80) and without (control, n = 141) HDP. Data were extracted from infants' medical records, and the women completed questionnaires.

RESULTS

The infants of women with HDP were more likely to be small for gestational age than the infants of women without HDP (31.7% vs. 10.6%, p < .002). The proportion of infants with greater neurologic risk, patent ductus arteriosus, intraventricular hemorrhage, and days on a ventilator did not differ between the groups. Although mean infant height at 2 months was less in the HDP group than the control group, other growth and neurodevelopmental outcomes did not differ between the groups.

CONCLUSION

Among preterm infants admitted to NICUs, those born to women with HDP were more likely to be small for gestational age than those born to normotensive women. Additional research is needed to optimize care for infants born to women with HDP.

Accuracy of Brain Natriuretic Peptide for Diagnosing Pulmonary Hypertension in Severe Bronchopulmonary Dysplasia

BACKGROUND

Premature infants with severe bronchopulmonary dysplasia (sBPD) are at risk of pulmonary hypertension (PH). Serum brain natriuretic peptide (BNP) is used to predict disease severity in adult PH. Its diagnostic utility in sBPD-associated PH is unknown.

OBJECTIVE

The aim of this paper was to determine the accuracy of BNP, against echocardiogram (echo), to diagnose PH in infants born <32 weeks' gestation with sBPD.

METHODS

We conducted a retrospective cohort study of all infants with sBPD with an echo and BNP within a 24-h period, at ≥36 weeks postmenstrual age. PH was defined as: right ventricular pressure >½ systemic blood pressure estimated from tricuspid regurgitant jet or patent ductus arteriosus (PDA) velocity, bidirectional or right-to left-PDA, and/or flat/bowing ventricular septum at end-systole. Receiver-operating characteristic (ROC) curves were constructed to test the diagnostic accuracy of BNP.

RESULTS

Of 128 infants, 68 (53%) had echo evidence of PH. BNP was higher among the infants with PH (median [interquartile range]: 127 pg/mL [39-290] vs. 35 [20-76], p < 0.001). The area under the ROC curve for diagnosing PH using BNP was 0.74 (95% CI 0.66-0.83). At an optimal cutpoint of 130 pg/mL, BNP correctly classified the presence or absence of PH in 70% of the infants (specificity: 92, sensitivity: 50%).

CONCLUSIONS

BNP, relative to concurrent echo, demonstrated moderate accuracy for diagnosing PH in this cohort of preterm infants with sBPD. BNP may help rule in PH in this population but has low utility to rule out the disease.

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.