Optimizing care and outcome for late-preterm (near-term) infants: a summary of the workshop sponsored by the National Institute of Child Health and Human Development

Machine learning risk stratification for high-risk infant follow-up of term and late preterm infants

BACKGROUND

Term and late preterm infants are not routinely referred to high-risk infant follow-up programs at neonatal intensive care unit (NICU) discharge. We aimed to identify NICU factors associated with abnormal developmental screening and develop a risk-stratification model using machine learning for high-risk infant follow-up enrollment.

METHODS

We performed a retrospective cohort study identifying abnormal developmental screening prior to 6 years of age in infants born ≥34 weeks gestation admitted to a level IV NICU. Five machine learning models using NICU predictors were developed by classification and regression tree (CART), random forest, gradient boosting TreeNet, multivariate adaptive regression splines (MARS), and regularized logistic regression analysis. Performance metrics included sensitivity, specificity, accuracy, precision, and area under the receiver operating curve (AUC).

RESULTS

Within this cohort, 87% (1183/1355) received developmental screening, and 47% had abnormal results. Common NICU predictors across all models were oral (PO) feeding, follow-up appointments, and medications prescribed at NICU discharge. Each model resulted in an AUC > 0.7, specificity >70%, and sensitivity >60%.

CONCLUSION

Stratification of developmental risk in term and late preterm infants is possible utilizing machine learning. Applying machine learning algorithms allows for targeted expansion of high-risk infant follow-up criteria.

IMPACT

This study addresses the gap in knowledge of developmental outcomes of infants ≥34 weeks gestation requiring neonatal intensive care. Machine learning methodology can be used to stratify early childhood developmental risk for these term and late preterm infants. Applying the classification and regression tree (CART) algorithm described in the study allows for targeted expansion of high-risk infant follow-up enrollment to include those term and late preterm infants who may benefit most.

Early cognitive assessment in premature infants: the discriminatory value of eye-tracking vs. Bayley Scales

Introduction

The testing of visuocognitive development in preterm infants shows strong interactions between perinatal characteristics and cognition, learning and overall neurodevelopment evolution. The assessment of anticipatory gaze data of object-location bindings via eye-tracking can predict the neurodevelopment of preterm infants at the age of 3 years; little is known, however, about the early cognitive function and its assessment methods during the first year of life.

Methods

The current study presents data from a novel assessment tool, a Delayed Match Retrieval (DMR) paradigm via eye-tracking was used to measure visual working memory (VWM) and attention skills. The eye-tracking task that was designed to measure infants' ability to actively localize objects and to make online predictions of object-location bindings. 63 infants participated in the study, 39 preterm infants and 24 healthy full term infants - at a corrected age of 8-9 months for premature infants and similar chronological age for full term infants. Infants were also administered the Bayley Scales of Infant and Toddler Development.

Results

The analysis of the Bayley scores showed no significant difference between the two groups while the eye-tracking data showed a significant group effect on all measurements. Moreover, preterm infants' VWM performance was significantly lower than full term's. Birth weight affected the gaze time on all Areas Of Interest (AOIs), overall VWM performance and the scores at the Cognitive Bayley subscale. Furthermore, preterm infants with fetal growth restriction (FGR) showed significant performance effects in the eye-tracking measurements but not on their Bayley scores verifying the high discriminatory value of the eye gaze data.

Conclusion

Visual working memory and attention as measured via eye-tracking is a non-intrusive, painless, short duration procedure (approx. 4-min) was found to be a significant tool for identifying prematurity and FGR effects on the development of cognition during the first year of life. Bayley Scales alone may not pick up these deficits. Identifying tools for early neurodevelopmental assessments and cognitive function is important in order to enable earlier support and intervention in the vulnerable group of premature infants, given the associations between foundational executive functional skills and later cognitive and academic ability.

Respiratory distress syndrome is associated with increased morbidity and mortality in late preterm births

BACKGROUND

Respiratory distress syndrome is strongly associated with prematurity, including late preterm births. Respiratory distress syndrome has been shown to be associated with certain neonatal morbidities and mortality, but these associations are not well described among late preterm births.

OBJECTIVE

We sought to determine the association between respiratory distress syndrome and adverse neonatal outcomes among late preterm (34-36 weeks) born singleton neonates.

STUDY DESIGN

This is a retrospective cohort study using California's linked vital statistics and patient discharge data (2008-2019). We included singleton, nonanomalous births with a gestational age of 34-36 weeks. Outcomes of interest were interventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, neonatal sepsis, length of hospital stay, neonatal death, and infant death. Chi-square and multivariable Poisson regression analyses were used to examine the association of respiratory distress syndrome with outcomes at each gestational age. Adjusted risk ratio and 95% confidence interval values were estimated.

RESULTS

A total of 242,827 births were included, of which 11,312 (4.7%) had respiratory distress syndrome. We found that among neonates with respiratory distress syndrome, necrotizing enterocolitis was higher at 35 weeks (adjusted risk ratio, 3.97 [95% confidence interval, 1.88-8.41]) and 36 weeks (adjusted risk ratio, 4.53 [95% confidence interval, 1.45-14.13]). Intraventricular hemorrhage, retinopathy of prematurity, neonatal sepsis, and length of hospital stay were significantly higher at 34-36 weeks of gestation in neonates with respiratory distress syndrome. Neonatal death was significantly higher among neonates with respiratory distress syndrome at 35 weeks (adjusted risk ratio, 3.04 [95% confidence interval, 1.58-5.85]) and 36 weeks (adjusted risk ratio, 3.25; 95% confidence interval, 1.59-6.68). In addition, infant death was significantly higher at 35 weeks (adjusted risk ratio, 2.27 [95% confidence interval, 1.43-3.61]) and 36 weeks (adjusted risk ratio, 2.60 [95% confidence interval, 1.58-4.28]).

CONCLUSION

We found that respiratory distress syndrome was associated with intraventricular hemorrhage, retinopathy of prematurity, and sepsis at 34-36 weeks of gestation, whereas respiratory distress syndrome was associated with neonatal death, infant death, and necrotizing enterocolitis at 35 and 36 weeks. Clinicians should keep these outcomes in mind when making decisions about delivery timing, the potential benefits of antenatal steroids in pregnancies in the late preterm period, and the management of respiratory distress syndrome in late preterm neonates.

Antenatal Late Preterm Steroids: The Evolution of the ALPS Trial

The Antenatal Late Preterm Steroids (ALPS) trial was designed to address respiratory morbidity common in infants born late preterm. The study was published in April, 2016 and, shortly thereafter, changed clinical practice in obstetrics in the United States. The following chapter describes the ALPS trial study design in detail, including the background leading to the trial, the study outcomes, and the initial findings of the long-term follow-up study. The ALPS story would not be complete without Elizabeth Thom, PhD, who died before her time. Her brilliance largely contributed to the design of the ALPS trial.

Long-Term Neurodevelopmental Outcomes in Children with Gastroschisis: A Review of the Literature

This study aimed to investigate and present a review of the literature on long-term neurodevelopmental outcomes in children with gastroschisis. Gastroschisis is the most common abdominal wall defect. Children with gastroschisis are at high risk for premature birth, intestinal failure, sepsis, and repeated anesthesia exposure, which collectively increase the risk for adverse long-term neurodevelopmental outcomes. The existing literature on neurodevelopmental outcomes is limited in number, quality, and generalizability, creating a gap in clinical knowledge and care. Five internet databases were searched by a professional research librarian: Ovid MEDLINE, Scopus, Web of Science, PsycINFO, and Cochrane Library. Included articles were (1) published in English, (2) included postneonatal hospital discharge neurodevelopmental outcomes of children with gastroschisis, and (3) included patients under the age of 18 years. No date parameters were applied. The paucity of literature on long-term neurodevelopmental outcomes in gastroschisis children has left large gaps in the body of knowledge on post-hospital care of such children. In this review, 37 articles were found evaluating neurodevelopmental outcomes in gastroschisis and, while conclusions were contradictory, the literature broadly indicated the potential for neurodevelopmental deficits in the gastroschisis pediatric population. A significant limitation of this review was the heterogeneous samples included in available literature, which confounded the ability to determine cognitive risk of gastroschisis independent of other abdominal wall defects. Findings of this review demonstrate potential risk for neurodevelopmental deficits in the pediatric gastroschisis population exist, yet additional research is needed to definitively predict the significance, type, onset, and trajectory of neurodevelopmental impairment in this population. The significant gaps in long-term outcomes data have elucidated the need for prospective, longitudinal investigation of various cognitive domains in homogenous gastroschisis populations to properly evaluate prevalence of neurodevelopmental deficits and guide recommendations for long-term clinical care. KEY POINTS: · Limited literature exists regarding long-term neurodevelopmental outcomes in gastroschisis.. · There is some evidence to suggest worse cognitive behavioral outcomes in gastroschisis over time.. · Developmental surveillance, screening, and evaluation may be beneficial for gastroschisis patients..

The frequency-following response in late preterm neonates: a pilot study

Introduction

Infants born very early preterm are at high risk of language delays. However, less is known about the consequences of late prematurity. Hence, the aim of the present study is to characterize the neural encoding of speech sounds in late preterm neonates in comparison with those born at term.

Methods

The speech-evoked frequency-following response (FFR) was recorded to a consonant-vowel stimulus /da/ in 36 neonates in three different groups: 12 preterm neonates [mean gestational age (GA) 36.05 weeks], 12 "early term neonates" (mean GA 38.3 weeks), and "late term neonates" (mean GA 41.01 weeks).

Results

From the FFR recordings, a delayed neural response and a weaker stimulus F0 encoding in premature neonates compared to neonates born at term was observed. No differences in the response time onset nor in stimulus F0 encoding were observed between the two groups of neonates born at term. No differences between the three groups were observed in the neural encoding of the stimulus temporal fine structure.

Discussion

These results highlight alterations in the neural encoding of speech sounds related to prematurity, which were present for the stimulus F0 but not for its temporal fine structure.

Listening Preference for Child-Directed Speech Versus Time-Reversed Speech in Moderate-Preterm Infants Compared to Full-Term Infants

PURPOSE

The purpose of the present study was to examine whether there is a listening preference for child-directed speech (CDS) over backward speech in moderate-preterm infants (MPIs).

METHOD

Eighteen MPIs of gestational age of 32.0 weeks (range: 32-34.06 weeks), chronological age of 8.09 months, and maturation age of 6.48 months served as the experimental group. The two control groups consisted of a total of 36 infants-20 full-term infants matched for chronological age and 16 full-term infants matched for maturation age. The infants were tested using the central fixation procedure and were presented with 16 trials of CDS and backward speech. A follow-up was conducted 5 years after the initial experiment using a developmental and a five-item parent questionnaire.

RESULTS

MPIs did not demonstrate a preference for CDS over backward speech, whereas both control groups demonstrated a listening preference for CDS over backward speech. MPIs showed a delayed use of first words and word combinations and lower scores on the five-item questionnaire compared to term infants. Twelve MPIs (67%) did not demonstrate a preference for CDS over backward speech. Four of them (33%) were later diagnosed with neurodevelopmental disorders.

CONCLUSIONS

The lack of preference for CDS over backward speech in the MPIs group suggests delayed developmental pattern of speech processing compared to full-term peers. Delays in neurological maturation as well as listening experience in an unregulated environment outside the uterus during a sensitive period of brain development may affect the recognition of phonological and prosodic patterns that support listening preference for speech over backward speech.

Neonatal Intensive Care Unit Resource Use for Infants at 22 Weeks' Gestation in the US, 2008-2021

Importance

During the past decade, clinical guidance about the provision of intensive care for infants born at 22 weeks' gestation has changed. The impact of these changes on neonatal intensive care unit (NICU) resource utilization is unknown.

Objective

To characterize recent trends in NICU resource utilization for infants born at 22 weeks' gestation compared with other extremely preterm infants (≤28 weeks' gestation) and other NICU-admitted infants.

Design, Setting, and Participants

This is a serial cross-sectional study of 137 continuously participating NICUs in 29 US states from January 1, 2008, through December 31, 2021. Participants included infants admitted to the NICU. Data analysis was performed from October 2022 to August 2023.

Exposures

Year and gestational age at birth.

Main Outcomes and Measures

Measures of resource utilization included NICU admissions, NICU bed-days, and ventilator-days.

Results

Of 825 112 infants admitted from 2008 to 2021, 60 944 were extremely preterm and 872 (466 [53.4%] male; 18 [2.1%] Asian; 318 [36.5%] Black non-Hispanic; 218 [25.0%] Hispanic; 232 [26.6%] White non-Hispanic; 86 [9.8%] other or unknown) were born at 22 weeks' gestation. NICU admissions at 22 weeks' gestation increased by 388%, from 5.7 per 1000 extremely preterm admissions in 2008 to 2009 to 27.8 per 1000 extremely preterm admissions in 2020 to 2021. The number of NICU admissions remained stable before the publication of updated clinical guidance in 2014 to 2016 and substantially increased thereafter. During the study period, bed-days for infants born at 22 weeks increased by 732%, from 2.5 per 1000 to 20.8 per 1000 extremely preterm NICU bed-days; ventilator-days increased by 946%, from 5.0 per 1000 to 52.3 per 1000 extremely preterm ventilator-days. The proportion of NICUs admitting infants born at 22 weeks increased from 22.6% to 45.3%. Increases in NICU resource utilization during the period were also observed for infants born at less than 22 and at 23 weeks but not for other gestational ages. In 2020 to 2021, infants born at less than or equal to 23 weeks' gestation comprised 1 in 117 NICU admissions, 1 in 34 of all NICU bed-days, and 1 in 6 of all ventilator-days.

Conclusions and Relevance

In this serial cross-sectional study of 137 US NICUs from 2008 to 2021, an increasing share of resources in US NICUs was allocated to infants born at 22 weeks' gestation, corresponding with changes in national clinical guidance.

Developmental trajectories of late preterm infants and predictors of academic performance

BACKGROUND

The trajectories of late preterm development from infancy to kindergarten reading and math, and predictors of academic resilience and risk are unknown.

METHODS

Sample included 1200 late preterm infants (LPIs) from the Early Childhood Longitudinal Study, Birth Cohort. Objective measurements of development at 9 and 24 months (Bayley-SFR) and reading and math academic achievement at preschool and kindergarten were standardized; trajectories of late preterm development from 9 months to kindergarten reading and math were identified using latent class growth analysis. Multinomial logistic regression [aOR, 95% CI] identified predictors of academic resilience and risk.

RESULTS

Four trajectory groups were observed for reading and three for math. More optimal trajectories (in reading and math) and academic resilience were associated with experiencing sensitive parenting and preschool attendance. Suboptimal (at-risk) trajectories (in reading or math) and an increased odds of academic risk were associated with

CONCLUSIONS

LPI trajectories varied from infancy to kindergarten. More sensitive parenting and preschool attendance predicted academic resilience, and should be encouraged. Select risk factors (prenatal smoking, twin/multiple gestation, male sex,

IMPACT

Late preterm infants (LPIs) have developmental risks compared to full terms. LPI trajectories of early reading and math varied from infancy to kindergarten. We identified predictors of academic resilience and risk, which can help inform anticipatory guidance provided to LPIs prior to kindergarten. Promotive factors (sensitive parenting and preschool enrollment) predicted academic resilience. Select maternal and neonatal characteristics ( Collapse

Key Words Collapse

MESH Headings

• Infant
• Humans
• Male
• Infant, Newborn
• Child, Preschool
• Infant, Premature
• Longitudinal Studies
• Child Development
• Academic Success
• Parenting

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Grants

• K08 HD078506 NICHD NIH HHS

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Affiliation(s)

Prachi E Shah Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA.
Julie Poehlmann Department of Human Development and Family Studies, University of Wisconsin, Madison, WI, USA
Heidi M Weeks Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
Maria Spinelli Department of Neurosciences, Imaging and Clinical Sciences, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
Blair Richards Michigan Institute for Clinical & Health Research (MICHR), University of Michigan, Ann Arbor, MI, USA
Joohee Suh Research Foundation for Mental Hygiene, New York, NY, USA
Niko Kaciroti Department of Biostatistics, School of Public of Health, University of Michigan, Ann Arbor, MI, USA

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Noninvasive Neurally Adjusted Ventilation versus Nasal Continuous or Intermittent Positive Airway Pressure for Preterm Infants: A Systematic Review and Meta-Analysis

The noninvasive neurally adjusted ventilatory assist (NIV-NAVA) is a newly developed noninvasive ventilation technique with promising clinical and ventilatory outcomes for preterm infants. This systematic review and meta-analysis aimed to investigate whether NIV-NAVA has better clinical and ventilatory outcomes than nasal continuous airway pressure (NCPAP) or noninvasive positive pressure ventilation (NIPP) on premature infants. MEDLINE, Embase, and CENTRAL were searched, and randomized controlled trials (RCTs) that compared NIV-NAVA with NCPAP or NIPP for preterm infants (gestational age: <37 weeks) were included. We evaluated the following outcomes in the neonatal intensive care unit: the desaturation rate, failure of noninvasive modality requiring intubation when received as the primary mode or the need for re-intubation after extubation from mechanical ventilation in the secondary mode (weaning), length of stay, and fraction of inspired oxygen. The mean difference and risk ratio were used to represent continuous and dichotomous outcomes, respectively. We included nine RCTs involving 339 preterm infants overall. NIV-NAVA showed similar clinical and ventilatory outcomes to NCPAP or NIPP, except for the maximum diaphragmatic electrical activity. The rate of failure of the noninvasive modality was not statistically different between NIV-NAVA and NCPAP. The pooled estimates for the maximum electrical activity were significantly reduced in NIV-NAVA compared with those in NIPP. The findings suggest that NIV-NAVA may be as safe and effective as NCPAP and NIPP for preterm neonates, particularly those who may not tolerate these alternative noninvasive methods. However, further trials are recommended for greater evidence.

The diagnostic value of pulmonary near-infrared spectroscopy in the early distinction of neonatal pneumonia from transient tachypnea of the newborn

AIM

Pulmonary near-infrared spectroscopy (NIRS) is a new and promising tool for diagnosis of neonatal respiratory diseases (RD). The study aimed to determine the role of pulmonary regional oxygen saturation (pRSO2 ) values obtained by NIRS in the early distinction of neonatal pneumonia (NP) from transient tachypnea of the newborn (TTN).

METHODS

This prospective, observational, double-blind study was conducted in neonatal intensive care unit (NICU) between 2020 and 2021. Late preterm and term newborns hospitalized in the NICU due to the diagnosis of TTN and NP were included. Cerebral RSO2 and pRSO2 values were measured during the 1st, 24th, 48th, and 72nd hours of hospitalization, using NIRS.

RESULTS

Of the eligible 40 infants, 65% (n: 26) were diagnosed as TTN and 35% (n: 16) as NP. The pRSO2 values were significantly higher in the TTN group than the NP group for both apexes (75.3 ± 8.7 vs. 69 ± 5.4, p: .018, respectively) and lateral lung (77.8 ± 6 vs. 72.7 ± 6.2, p: .016, respectively) in the 1st hour of hospitalization. There were significant differences in pRSO2 apex and pRSO2 lateral values between the 1st and 24th hours of hospitalization and the 24th and 48th hours in the NP group (p2 : .001 for both). The optimal pRSO2 apex cut-off value was >72% to predict the diagnosis of NP with a sensitivity of 78.6% and a specificity of 69.2%.

CONCLUSION

Pulmonary NIRS may be considered as a feasible and promising diagnostic tool in late preterm and term infants with RD. It may also be helpful for the early differentiation of NP from TTN and the courses of these diseases.

Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: Pregnancy outcomes

INTRODUCTION

The standard procedure in cervical cancer is radical hysterectomy and pelvic lymphadenectomy (PLND). Because of the increasing age of women bearing children, fertility has become a major challenge. We present pregnancy results after less radical fertility-sparing surgery in women with IA1, LVSI positive, IA2 and IB1 (<2 cm, infiltration less than half of the cervical stroma).

MATERIALS AND METHOD

All women (n = 91) underwent laparoscopic sentinel lymph node mapping with frozen section followed by PLND and "selective parametrectomy" (removal of afferent lymphatic channels from the paracervix) if sentinel nodes (SLN) are negative. If lymph nodes were verified negative by definitive histopathology, patients were treated by simple trachelectomy (IB1) or large cone (IA1/IA2) biopsy 1 week after primary surgery.

RESULTS

From 1999 to 2018, 91 women were enrolled in the study (median age 29.1 years, range 21-40). Fertility was spared in 76 (83.5%) women; 13 (17.1%) women did not plan future pregnancy and 63 (82.9%) had pregnancy desires. Fifty-four of 63 women conceived (pregnancy rate 85.7%) and 48 of 63 delivered 58 babies (delivery rate 76.2%). Thirty-nine women delivered in term (67.2%): 13 women between 32 and 36 + 6 weeks of pregnancy, 3 between 28 and 31 + 6 weeks and 3 between 24 and 27 + 6 weeks. Only one woman still plans pregnancy. One woman is currently pregnant.

CONCLUSION

The goal of fertility-sparing surgery is to produce good oncological results and promising pregnancy outcomes. Pregnancy results after less radical fertility-sparing procedures show promise (pregnancy rate 82.9% and delivery rate 76.2%).

Predictors of adverse short-term outcomes in late preterm infants

BACKGROUND

Infants born between 34 weeks and 36 weeks and 6 days of gestation are defined as late preterm infants (LPIs), and they account for approximately 74% of all premature births. Preterm birth (PB) remains the leading cause of infant mortality and morbidity worldwide.

AIM

To analyse short-term morbidity and mortality and identify predictors of adverse outcomes in late preterm infants.

PATIENTS AND METHODS

In this retrospective study, we evaluated adverse short-term outcomes of LPIs admitted to the Intensive Care Unit (ICU), Clinic for Children's Diseases, University Clinical Center Tuzla, between 01.01.2020 and 31.12.2022. The analysed data included sex, gestational age, parity, birth weight, Apgar score (i.e., assessment of vitality at birth in the first and fifth minutes after birth), and length of hospitalization in NICU, as well as short-term outcome data. Maternal risk factors we observed were: age of mother, parity, maternal morbidity during pregnancy, complications and treatment during pregnancy. LPIs with major anatomic malformations were excluded from the study. Logistic regression analysis was used to identify risk factors for neonatal morbidity among LPIs.

RESULTS

We analysed data from 154 late preterm newborns, most of whom were male (60%), delivered by caesarean Sect. (68.2%) and from nulliparous mothers (63.6%). Respiratory complications were the most common outcome among all subgroups, followed by CNS morbidity, infections and jaundice requiring phototherapy. The rate of almost all of the complications in the late-preterm group decreased as gestational age increased from 34 to 36 weeks. Birth weight (OR: 1,2; 95% CI: 0,9 - 2,3; p = 0,0313) and male sex (OR: 2,5; 95% CI: 1,1-5,4; p = 0,0204) were significantly and independently associated with an increased risk for respiratory morbidity, and gestational weeks and male sex were associated with infectious morbidity. None of the risk factors analysed herein were predictors of CNS morbidity in LPIs.

CONCLUSION

A younger gestational age at birth is associated with a greater risk of short-term complications among LPIs, thus highlighting the need for increased knowledge about the epidemiology of these late preterm births. Understanding the risks of late preterm birth is critical to optimizing clinical decision-making, enhancing the cost-effectiveness of endeavours to delay delivery during the late preterm period, and reducing neonatal morbidity.

At-Risk Newborns: Overlooked in Expansion From Essential Newborn Care to Small and Sick Newborn Care in Low- and Middle-Income Countries

We propose adding the category of “at-risk” newborns for babies who are at increased risk of morbidity and/or mortality but do not require special or intensive care or monitoring to promote a 3-tiered newborn care approach in hospitals.

Patterns of volatile organic compounds in excrements of preterm neonates

BACKGROUND

As neonates are susceptible for many diseases, establishing noninvasive diagnostic methods is desirable. We hypothesized that volatile organic compounds (VOCs) could be successfully measured in diaper samples.

METHODS

We performed a feasibility study to investigate whether ambient air-independent headspace measurements of the VOC profiles of diapers from premature infants can be conducted using ion mobility spectrometer coupled with multi-capillary columns (B & S Analytik GmbH).

RESULTS

We analysed 39 diapers filled with stool (n = 10) or urine (n = 20) respectively, using empty diapers as a control (n = 9). A total of 158 different VOCs were identified, and we classified the content of the diapers (urine or stool) according to their VOC profiles with a significance level of p < 0.05.

CONCLUSIONS

We have developed a novel method to study headspace VOC profiles of biosamples using ion mobility spectrometry coupled with multi-capillary columns. Using this method, we have characterized the VOC profiles of stool and urine of preterm neonates. Future studies are warranted to characterize specific VOC profiles in infections and other diseases of the preterm neonate, thus establishing quick and noninvasive diagnostics in the routine care of the highly vulnerable preterm and term neonates.

Prematurity-associated wheeze: current knowledge and opportunities for further investigation

Prematurity-associated wheeze is a common complication of preterm birth, with significant impact on the health and healthcare utilization of former preterm infants. This wheezing phenotype remains poorly understood and difficult to predict. This review will discuss the current state of the literature on prematurity-associated wheeze. We will discuss etiology and pathophysiology, and offer two conceptual models for the pathogenesis of this complex condition. This review will also identify current methods of ascertainment, and discuss the strengths and limitations of each. We will explore research-backed approaches to prevention and management, and finally suggest both pre-clinical and clinical avenues for investigation. An in-depth understanding of prematurity-associated wheeze will aid clinicians in its diagnosis and management, and inspire scientists to pursue much-needed further study into causes and prevention of this common and impactful condition. IMPACT: There is no recent, concise review on the current state of research on prematurity-associated wheeze, which is a rapidly evolving area of study. This article highlights causal models of wheeze, methods of ascertainment, management strategies for the clinician, and opportunities for further research for the physician scientist.

The effects of betamethasone on the amplitude integrated EEG of infants born at 34- or 35-weeks gestation

OBJECTIVE

Assess if maternal betamethasone administration at 34-35 weeks accelerated neonatal amplitude integrated EEG (aEEG) maturation.

STUDY DESIGN

Nested, observational cohort in 7 centers participating in the Antenatal Late Preterm Steroid randomized trial. Up to 2 aEEGs were obtained in neonates born from 34⁰-35⁶ weeks gestation before 72 h (aEEG 1) and at 5-7 days (aEEG 2) if hospitalized. Personnel and aEEG central readers were masked to the intervention. The primary outcome was maturation reflected by cycle frequency; secondary outcomes were border voltage, span, and discontinuity.

RESULTS

58 neonates were enrolled (betamethasone, 28, placebo, 30). On aEEG 1, cycle frequency did not differ, but betamethasone exposed infants had a greater lower border voltage and a broader span. On aEEG 2, both groups displayed increases in lower border voltage.

CONCLUSIONS

Betamethasone associated changes in lower border voltage support accelerated electrical activity. Further investigation is needed to understand the broader span.

Validity of foetal Doppler indices in predicting postnatal respiratory distress syndrome: a prospective study

Background

Respiratory distress syndrome (RDS) is a potentially fatal condition of neonate occurring due to alveolar surfactant deficiency causing inefficient gaseous exchange and leading to hampered respiratory function. Purpose of our study is to investigate the role of Doppler indices in antenatal prediction of clinical Respiratory Distress Syndrome (RDS) in late preterm and early term foetuses using Main pulmonary artery (MPA) Doppler indices. The current study was conducted on 342 pregnant women between 34 and 39 weeks of gestational age, who came for routine third trimester ultrasound examination. The standard foetal biometric parameters, gestational age and estimated foetal weight were first obtained. The MPA Doppler indices like pulsatility index (PI), resistivity index (RI), peak systolic velocity (PSV), systolic/diastolic ratio and acceleration time/ejection time (At/Et) were recorded and correlated with the postnatal development of RDS.

Results

Of the 342 foetuses, neonatal RDS was diagnosed in 47 foetuses. Foetuses diagnosed with RDS had statistically higher PI and RI values, whereas At/Et ratio and PSV were lower. At/Et ratio, PI and RI, PSV showed significant correlation with gestational age and the most statistically significant correlation was found with At/Et ratio. A cut-off value of 0.2865 (sensitivity 89.45%, specificity 94.79%) and 0.3155 (sensitivity 93.22%, specificity 96.78%) correlated strongly with development of RDS in late preterm foetuses and early term infants.

Conclusion

Foetal MPA indices like PSV, RI, PI and especially Foetal At/Et ratio is a promising non-invasive tool which helps in identifying foetuses at risk and may be very useful to plan delivery in complicated pregnancies and also for better post-natal care of the neonate.

Short-term neonatal and long-term infant outcome of late-preterm twins: nationwide population-based study

OBJECTIVES

To evaluate the short- and long-term outcome of late-preterm compared with term birth in twin pregnancy.

METHODS

This retrospective observational cohort study included all women who had a twin delivery between 1 January 2007 and 31 December 2010 recorded in the claims database of the Korea National Health Insurance, with at least one follow-up recorded in the database of the National Health Screening Program for Infants and Children. Outcomes were analyzed at the pregnancy level, with adverse outcome being defined as an adverse outcome in one or both twins, identified by a diagnosis according to the International Classification of Diseases 10^th Revision. The primary short-term outcome was composite morbidity, which included any of the following: transient tachypnea, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage and bronchopulmonary dysplasia. Long-term adverse outcome included any neurological or neurodevelopmental outcome, defined by prespecified neurological and developmental diagnoses; these were assessed by following up all neonates until the end of 2018, by which time they were 8-11 years of age. Outcomes were compared between twins delivered late preterm (34 + 0 to 36 + 6 weeks) and those delivered at term (≥ 37 weeks).

RESULTS

Among 17 189 women who delivered twins at ≥ 34 weeks of gestation during the study period, 5032 (29.27%) women delivered in the late-preterm period. On multivariate analysis, compared with the twins delivered at term, the late-preterm twins had an increased risk for the primary short-term outcome of composite morbidity (adjusted odds ratio (aOR), 2.09; 95% CI, 1.90-2.30), including transient tachypnea (aOR, 1.85; 95% CI, 1.64-2.09), respiratory distress syndrome (aOR, 2.31; 95% CI, 2.04-2.62), necrotizing enterocolitis (aOR, 2.10; 95% CI, 1.20-3.69) and intraventricular hemorrhage (aOR, 2.13; 95% CI, 1.46-3.11). For the long-term outcome, the late-preterm twins also had an increased risk for any neurological or neurodevelopmental outcome (adjusted hazard ratio, 1.14; 95% CI, 1.07-1.21).

CONCLUSIONS

Twins delivered in the late-preterm period have an increased risk for short- and long-term morbidity compared with twins delivered at term. These results should be considered when determining the timing of delivery in uncomplicated twin pregnancy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Management of Preterm Premature Rupture of Membranes in the Late Preterm Period

Importance

For patients who present with prelabor rupture of membrane (PROM) in the late preterm period (34 to 36 6/7 weeks), management remains unclear due to lack of consensus. However, recent guidelines have suggested that shared decision-making may be used and expectant management can be considered up to 37 0/7 weeks.

Objective

In this article, we review the contemporary studies comparing the risks and benefits of immediate delivery versus expectant management for patients with late preterm prelabor rupture of membranes (PPROM).

Evidence Acquisition

Original research articles, review articles, and guidelines on management of late PPROM.

Results

Three randomized clinical trials and 2 meta-analyses comparing expectant management and immediate delivery outcomes in late PPROM showed no significant difference in neonatal sepsis rates between groups. Expectant management increased the likelihood that pregnancies reached term while decreasing the rate of cesarean delivery. However, data suggest an increased risk of antepartum hemorrhage among patients in the expectant management groups, as well as higher rates of histologic chorioamnionitis.

Conclusions and Relevance

We recommend that clinicians offer expectant management as an alternative to immediate delivery in the setting of late PPROM through a shared decision-making process that clearly outlines the risks and benefits.

Child mortality of twins and singletons among late preterm and term birth: a study of national linked birth and under-five mortality data of Korea

Twins involve a higher risk of perinatal complications compared to singletons. We compared the risk of under five mortality between twins and singletons among late preterm and term births. The national birth data of South Korea pertaining to the years 2010-2014 linked with the mortality record of children aged under 5 years in 2010-2019 was analyzed. The final study population was 2,199,632 singletons and 62,351 twins. We conducted a survival analysis of under-five mortality with adjustment for neonatal and familial factors. Overall under-five mortality rates during the study period were 3.6 and 2.0 for twins and singletons, respectively. Although the unadjusted overall under-five mortality was higher in twins (hazard ratio [HR] = 1.80, 95% confidence interval [CI]: 1.57, 2.06, overall risk), twin birth was associated with comparable or lower risk (HR = 0.70, 95% CI: 0.58, 0.85, overall; 0.70, 95% CI: 0.56, 0.87, excluding neonatal mortality; 0.59, 95% CI: 0.40, 0.86, excluding infant mortality) after controlling for both neonatal and familial factors. Twins born at a gestational age of 34-35 weeks showed a generally lower risk of under-five mortality than their singleton counterparts, regardless of model specification.Conclusion: Among late preterm and term birth, under-5-year mortalities for twins were lower than singleton births when adjusted for neonatal and familial risk factors. This highlights the differential implication of gestational age at birth between twin and singleton in the child mortality.

Education Outcomes of Children Born Late Preterm: A Retrospective Whole-Population Cohort Study

BACKGROUND

Early life exposures can have an impact on a child's developmental trajectory and children born late preterm (34-36 weeks gestational age) are increasingly recognized to have health and developmental setbacks that extend into childhood.

OBJECTIVES

The purpose of this study was to assess whether late preterm birth was associated with poorer developmental and educational outcomes in the early childhood period, after controlling for health and social factors.

METHODS

We conducted a retrospective cohort study using administrative databases housed at the Manitoba Centre for Health Policy, including all children born late preterm (34-36 weeks gestational age (GA)) and at full-term (39-41 weeks GA) between 2000 and 2005 in urban Manitoba (N = 28,100). Logistic regression was used to examine the association between gestational age (GA) and outcomes, after adjusting for covariates.

RESULTS

Adjusted analyses demonstrated that children born late preterm had a higher prevalence of attention deficit hyperactivity disorder (ADHD) (aOR = 1.25, 95% CI [1.03, 1.51]), were more likely to be vulnerable in the language and cognitive (aOR = 1.29, 95% CI [1.06, 1.57]), communication and general knowledge (aOR = 1.24, 95% CI [1.01, 1.53]), and physical health and well-being (aOR = 1.27, 95% CI [1.04, 1.53]) domains of development at kindergarten, and were more likely to repeat kindergarten or grade 1 (aOR = 1.52, 95% CI [1.03, 2.25]) compared to children born at term. They did not differ in receipt of special education funding, in social maturity or emotional development at kindergarten, and in reading and numeracy assessments in the third grade.

CONCLUSIONS

Given that the late preterm population makes up 75% of the preterm population, their poorer outcomes have implications at the population level. This study underscores the importance of recognizing the developmental vulnerability of this population and adequately accounting for the social differences between children born late preterm and at term.

Birth Weight and Childhood Psychopathology in the ABCD Cohort: Association is Strongest for Attention Problems and is Moderated by Sex

Many studies have shown low birth weight is associated with psychopathology later in life, particularly attention-deficit/hyperactivity disorder (ADHD). The association is well-replicated, independent from a variety of potential familial confounds, and follows a dose-response curve (decreasing birth weight linked with increasing odds of disorder). However, the specificity of the association to attention problems is called into question by the extent of comorbidity in ADHD, and recent findings that the association is stronger for autism than ADHD. We test the relative dose-response strength of birth weight on multiple aspects of behavior to explore specificity of the effect to attention problems. We also test recent suggestions that the association between birth weight and attention problems is driven by males. Our sample consisted of 9,076 children aged 9-10 from the United States (Adolescent Brain Cognitive Development study). Outcomes included 9 problem-scales and the total problems scale from the Child Behavior Checklist (CBCL). Attention problems were the most strongly associated with birth weight after controlling for gestational age, potential familial confounds, and multiple testing, supporting the outcome-specificity of this association. Contrary to recent registry-based findings, an association between birth weight and an autism scale was not observed. Sex moderated the effect of birth weight on total problems, attention problems and aggressive behavior such that these inverse associations were strongly driven by males. Our findings have strong implications for sex-specific prediction and etiological models of childhood psychopathology.

Does antenatal corticosteroid therapy improve neonatal outcomes in late preterm birth?

BACKGROUND

Infants who are born at 34°^/7 to 36^6/7weeks of gestation (late preterm) are at greater risk for respiratory and other neonatal morbidities. The objective of this study was to examine the effects of the administration of antenatal corticosteroids (ACS) to women at risk for late preterm delivery on the incidence of neonatal outcomes.

METHOD

This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34°^/7 and 36^6/7weeks. Neonatal outcomes were compared between mothers who received ACS and those who did not. The primary outcome was the rate of composite respiratory morbidity defined as the need for treatment within 72 h of life (continuous positive airway pressure or high flow nasal cannula for least 2 h or supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least four continuous hours or mechanical ventilation).

RESULTS

During the 3-year study period, 595 subjects were included in this study, comprising 234 subjects that received ACS and 361 that did not. Administration of ACS significantly reduced the rates of composite respiratory morbidity (aOR 0.63 95% CI 0.40-0.99), the use of CPAP or HFNC for at least 2 h (aOR 0.57 95% CI 0.35-0.94), and transient tachypnea of the newborn (aOR 0.48 95% CI 0.28-0.82). Neonatal hypoglycemia was more significantly increased in the ACS group compared with controls (aOR 1.64 95% CI 1.04-2.59). We found no significant between-group differences in the rate of respiratory distress syndrome, surfactant use, need for resuscitation, jaundice requiring phototherapy, admission to neonatal intensive care or special care nursery, and duration of hospitalization.

CONCLUSION

Administration of ACS during the late preterm period decreased neonatal respiratory complications, however, increased the rate of hypoglycemia.

The use of immature granulocyte and other complete blood count parameters in the diagnosis of transient tachypnea of the newborn

Background

Although Transient tachypnea of the newborn (TTN) is one of the most common causes of respiratory distress in the newborn period, there is no laboratory parameter used to diagnose it. Immatur granulocyte (IG) measurement is accepted as a useful indicator that can be used in early detection of many infectious conditions, especially neonatal sepsis. In this study, it was aimed to determine if IG and other complete blood count (CBC) parameters could be used as laboratory findings supporting TTN diagnosis.

Materials and methods

This study, which was retrospectively planned, was conducted in the neonatal intensive care unit (NICU) a public hospital between January 1, 2019 and January 31, 2021. Randomly selected 50 infants, hospitalized with the diagnosis of TTN, constituted the patient group of the study. 50 infants hospitalized with the diagnosis of hyperbilirubinemia and did not have any additional problems accepted as the control group. IG and other CBC parameters of infants in the patient and control groups were compared in the study.

Results

There was no significant difference between the patient and control groups in terms of demographic data and types of delivery (p > 0.05). The rate of delivery by elective cesarean section (C/S) was significantly higher than the rate of normal spontaneous vaginal (NSV) delivery in the patient group (p < 0.001). The IG number and percentage, WBC (white blood cell) count, RDW (red cell distribution width), number and percentage of NRBC (nucleated red blood cell), neutrophil and lymphocyte ratio, count and percentage of basophil and PLR (platelet/lymphocyte ratio) of the patient group was significantly higher than the control group (p < 0.05).

Conclusion

According to the findings obtained in the study, it was concluded that IG and other CBC parameters may be used to support clinical and imaging findings to diagnose transient tachypnea of the newborn.

•

There was no significant difference between the patient and control groups in terms of demographic data and types of delivery.

•

The rate of elective cesarean section (C/S) was significantly higher than normal spontaneous vaginal (NSV) delivery in the patient group.

•

The IG number and percentage, WBC count, RDW, number and percentage of NRBC, neutrophil and lymphocyte ratio, count and percentage of basophil and PLR of the patient group was significantly higher than the control group.

•

IG and other CBC parameters can be useful to support clinical and imaging findings to diagnose TTN.

Comparison of neonatal outcomes with and without the administration of betamethasone in late preterm births

OBJECTIVE

To evaluate the effects of antenatal steroid administration on neonatal outcomes in late preterm births.

METHODS

Demographic and neonatal data from women who gave birth between May 2018 and March 2021 at 34⁺⁰ -36⁺⁶  weeks of gestation were screened from the information system of the hospital. The patients were assigned to two groups: those who were and those who were not given steroids. All parameters were compared between the two groups.

RESULTS

The 1-minute (9 versus 8) and 5-minute (10 versus 9) Apgar scores, need for a neonatal intensive care unit (NICU) stay (23.7% versus 27.8%), length of stay (Day) in the NICU (1.97 ± 0.24 versus 2.45 ± 0.16), rate of transient tachypnea of the newborn (3.3% versus 7.8%), respiratory distress syndrome (2.5% versus 5.2%), need for mechanical ventilation (1.2% versus 3.8%), and neonatal sepsis (1% versus 2.6%) were lower in the group that received betamethasone compared with the group that did not; the differences between the two groups were statistically significant.

CONCLUSION

Based on the results of the present study, we believe that antenatal steroid administration would be beneficial before late preterm births occurring between 34⁺⁰ and 36⁺⁶  weeks of pregnancy, considering the significant reduction in various respiratory complications, especially in respiratory distress syndrome and the need for an NICU stay.

Long-Term Neurodevelopmental Outcomes after Moderate and Late Preterm Birth: A Systematic Review

OBJECTIVE

To systematically review and perform meta-analyses on the long-term neurodevelopmental outcomes of adults born moderate and late preterm (MLPT) in relation to cognitive functioning and psychiatric disorders.

STUDY DESIGN

A search was conducted to identify any studies that involved prematurity in adulthood. From these studies, reports that included a group of MLPT adults and included description of cognitive and/or mental health domains (including specific long-term outcomes) were selected.

RESULTS

In total, 155 publications were identified, but only 16 papers met the inclusion criteria. A small effect size (g = 0.38) was found in MLPT to demonstrate poorer intellectual performance compared with those born at term. Moreover, MLPT adults exhibited greater odds for any psychiatric (OR 1.14), substance use (OR 1.16), mood (OR 1.06), and psychotic disorders (OR 1.40).

CONCLUSIONS

Despite inconsistency due to the methodologic differences between the selected studies, MLPT showed minor long-term effects into adulthood. However, more studies are needed, because prematurity seems to confer some vulnerability to biological and environmental factors that enhance susceptibility to adverse neurodevelopment outcomes.

Prenatal prediction of respiratory distress syndrome by multimodality approach using 3D lung ultrasound, lung-to-liver intensity ratio tissue histogram and pulmonary artery Doppler assessment of fetal lung maturity

OBJECTIVE

Studying the correlation of different lung parameters, using three-dimensional ultrasound (3D US) with fetal lung maturity (FLM) to predict the development of neonatal respiratory distress syndrome (RDS).

METHODS

Three-dimensional ultrasound was done to record the fetal lung volume (FLV), fetal lung-to-liver intensity ratio (FLLIR) and the main pulmonary artery (MPA) blood flow parameters; pulsatility index (PI), resistive index (RI) and acceleration time-to-ejection time ratio (At/Et), to 218 women between 32 and 40 weeks gestational age within 24 h from labor.

RESULTS

Of 218 fetuses examined, final analysis was done for 143 fetuses. Thirty eight (26.5%) were diagnosed with RDS. The MPA PI and RI were significantly higher in fetuses diagnosed with RDS compared with those without (2.51 ± 0.33 and 0.90 ± 0.03 cm/s versus 1.96 ± 0.20 and 0.84 ± 0.01 cm/s; p value < 0.001 and <0.001 respectively). MPA At/Et was significantly lower (0.24 ± 0.04 vs 0.35 ± 0.04; p value < 0.001). FLLIR was significantly lower (1.04 ± 0.07 vs 1.18 ± 0.11; p value < 0.001), and the mean FLV was significantly smaller (28.23 ± 5.63, vs 38.87 ± 4.68 cm³; p value < 0.001).

CONCLUSION

Main pulmonary artery (PI, RI, At/Et ratio), FLIIR, and mean FLV can be used as reliable predictors of neonatal RDS.

ADVANCES IN KNOWLEDGE

3D ultrasound VOCAL technique, ultrasound tissue histogram and pulmonary artery Doppler are reliable tools for prenatal prediction of fetal lung maturity.

Two-port, exteriorized uterus, fetoscopic meningomyelocele closure has fewer adverse neonatal outcomes than open hysterotomy closure

BACKGROUND

In utero closure of meningomyelocele using an open hysterotomy approach is associated with preterm delivery and adverse neonatal outcomes.

OBJECTIVE

This study compared the neonatal outcomes in in utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach vs the conventional open hysterotomy approach.

STUDY DESIGN

This retrospective cohort study included all consecutive patients who underwent in utero meningomyelocele closure using open hysterotomy (n=44) or a 2-port, exteriorized uterus, fetoscopic approach (n=46) at a single institution between 2012 and 2020. The 2-port, exteriorized uterus, fetoscopic closure was composed of the following 3 layers: a bovine collagen patch, a myofascial layer, and a skin. The frequency of respiratory distress syndrome and a composite of other adverse neonatal outcomes, including retinopathy of prematurity, periventricular leukomalacia, and perinatal death, were compared between the study groups. Regression analyses were performed to determine any association between the fetoscopic closure and adverse neonatal outcomes, adjusted for several confounders, including gestational age of <37 weeks at delivery.

RESULTS

The fetoscopic closure was associated with a lower rate of respiratory distress syndrome than the open hysterotomy closure (11.5% [5 of 45] vs 29.5% [13 of 44]; P=.037). The proportion of neonates with a composite of other adverse neonatal outcomes in the fetoscopic group was half of that observed patients in the open hysterotomy group; however, this difference did not reach statistical significance (4.3% [2 of 46] vs 9.1% [4 of 44]; P=.429). Here, regression analysis has demonstrated that fetoscopic meningomyelocele closure was associated with a lower risk of respiratory distress syndrome (adjusted odds ratio, 0.23; 95% confidence interval, 0.06-0.84; P=.026) than open hysterotomy closure.

CONCLUSION

In utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach was associated with a lower risk of respiratory distress syndrome than the conventional open hysterotomy meningomyelocele closure.

Early-term deliveries and long-term pediatric ophthalmic morbidity of the offspring. Int J Gynaecol Obstet 2021;157:640-646. [PMID: 34383310 DOI: 10.1002/ijgo.13875]

OBJECTIVE

To examine whether early-term delivery impacts on the long-term ophthalmic health of offspring.

METHODS

A retrospective population-based cohort study was conducted, including all singleton deliveries (1991-2014) occurring at a tertiary medical center. Gestational age was divided into: early prematurity, late prematurity, and early, full, late, and post term. Hospitalizations of offspring up to 18 years of age involving ophthalmic morbidity were evaluated. Survival curves compared cumulative hospitalizations and regression models controlled for confounders.

RESULTS

During the study period, 243 363 deliveries met the inclusion criteria. Ophthalmic-related hospitalization rates were lower among early-term born children (1.0%) as compared with early- (2.2%) and late-preterm (1.3%) born children, but higher than those in full- (0.9%), late- (0.8%), and post-term (0.8%) born offspring (P < 0.001). The survival curve demonstrated significantly different hospitalization rates in the different gestational ages (P < 0.001). The regression demonstrated an independent risk for ophthalmic morbidity among early-term born offspring (adjusted hazard ratio 1.14, confidence interval 1.03-1.27, P = 0.009), whereas late- and post-term deliveries were associated with a lower risk (adjusted hazard ratio 0.83 and 0.74, respectively) as compared with full-term deliveries.

CONCLUSION

The risk for long-term ophthalmic-related hospitalizations of offspring gradually declines as gestational age advances.

Antenatal dexamethasone use and respiratory distress in late preterm infants: results from first Vietnamese matched cohort study

Background

Respiratory distress syndrome (RDS) is one of the leading causes of early neonatal morbidity and mortality in late preterm infants (LPIs) worldwide. This matched cohort study aimed to assess how the antenatal dexamethasone use affect the respiratory distress (RD) proportion in preterm newborns between 34 0/7 weeks and 36 6/7 weeks of gestation.

Methods

This was a prospective cohort study on 78 women with singleton pregnancy who were in threatened preterm birth and had not received prior dexamethasone, who were admitted between 34 0/7 weeks and 36 6/7 weeks at Hue University of Medicine and Pharmacy Hospital from June 2018 to May 2020. The matched control group without dexamethasone use included 78 pregnant women diagnosed with threatened late preterm births who were at similar gestational ages and estimated fetal weights as the treatment group. The treatment group received 6 mg intramuscular dexamethasone every 12 h for a total of 4 doses or until delivery. Primary outcome was the rate of neonatal RD. Secondary neonatal outcomes included the need for respiratory support, neonatal intensive care unit (NICU) admission, hypoglycemia, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. Statistical analyses were performed by using SPSS software, version 26.0.

Results

The proportion of RD in LPI was significantly lower in the treatment group than in the matched control group (10.3% vs. 23.1%, respectively), adjusted Odds Ratio [aOR] 0.29; 95% confidence interval [CI] 0.10 – 0.83 and p = 0.021. Neonatal hypoglycemia was more common in the dexamethasone group than in the matched group (25.6% vs. 12.8%, respectively; aOR, 2.59; 95% CI, 1.06 – 6.33; p = 0.037). There were no significant between-groups differences in the incidence of respiratory support, NICU admission or length of hospital stay.

Conclusions

Administration of antenatal dexamethasone to women at risk for late preterm birth could help to lower the proportion of respiratory distress in late preterm infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04019-6.

Gestational Age at Term and Educational Outcomes at Age Nine

OBJECTIVES

To estimate associations between gestational age (GA) and teacher-reported academic outcomes at age 9 years among children born at term (37-41 weeks).

METHODS

A secondary data analysis of 1405 children participating in a national US birth cohort study was conducted. At age 9 years, students were evaluated by their teachers in the areas of mathematics, science and social studies, and language and literacy. Unadjusted and adjusted logistic regression models of associations between GA and teacher-reported academic outcomes were estimated and neonatal morbidities were explored as potential pathways.

RESULTS

A continuous measure of GA in weeks was significantly associated with above-average rankings in all areas. The associations were similar across outcomes (eg, mathematics [odds ratio (OR): 1.13; confidence interval (CI): 1.02-1.25], science and social studies [OR: 1.13; CI: 1.01-1.26], and language and literacy [OR: 1.16; CI: 1.05-1.28]) in a model that adjusted for child sex, maternal characteristics, and obstetric risk factors and delivery complications. Other specifications indicate a positive association between late term (41 weeks) and mathematics and a negative association between early term (37-38 weeks) and language and literacy, compared with term (39-40). The associations did not appear to operate through neonatal morbidity.

CONCLUSIONS

The findings highlight the importance of GA, even at term. Whereas current guidelines suggest waiting until at least 39 weeks to deliver when possible, our findings add to a small group of studies suggesting that GA through 41 weeks is associated with improvements in some educational outcomes.

Early Transient Hypoglycemia and Test Performance in At-Risk Newborns

OBJECTIVE

 This study aimed to evaluate if early (within the first 3 hours after birth) transient neonatal hypoglycemia (TNH) is associated with poor academic performance in infants at-risk for hypoglycemia.

STUDY DESIGN

 This was a retrospective cohort study of at risk-infants (late preterm infants, small and large for gestational age infants, and infants of diabetic mothers [IDMs]) who were born in 1998 and 1999 at the University of Arkansas for Medical Sciences and had ≥1 recorded glucose concentration. The outcome measure was proficiency on 4th grade literacy and mathematics achievement tests. Three glucose concentration cutoffs for defining hypoglycemia (<35, <40, and <45 mg/dL) were investigated. Logistic regression models were developed to examine the association between early TNH and achievement test proficiency based on perinatal factors.

RESULTS

 Among 726 infants, 472 had one, 233 had two, and 21 had three risk factor(s). Early TNH (glucose concentration <35, <40, and <45 mg/dL) was observed in 6.3, 11.6, and 20.5% of the study cohort, respectively. Irrespective of the cutoff used, the frequency of early TNH (number of patients with early TNH in a risk category divided by the total number of patients in that category) was significantly greater among infants with multiple risk factors. After controlling for perinatal factors, early TNH (cutoffs <35 and <40 mg/dL) was significantly associated with decreased probability of proficiency in literacy but not mathematics. Despite that early TNH was more common in IDMs and infants with three risk factors, the category or number of risk factors did not impact academic proficiency.

CONCLUSION

 Early TNH (<35 and <40 mg/dL) was associated with lower adjusted probability of proficiency on 4th grade literacy achievement tests in at-risk infants. The impact of early TNH on academic performance was similar irrespective of category or number of risk factors.

KEY POINTS

· Transient hypoglycemia was associated with lower proficiency on 4th grade tests in at-risk infants.. · The category of risk factors among at-risk infants did not impact 4th grade academic proficiency.. · The number of risk factors among at-risk infants did not impact 4th grade academic proficiency..

Elevated methylation of the vault RNA2-1 promoter in maternal blood is associated with preterm birth

Background

Preterm birth, defined as parturition before 37 completed weeks of gestation, is associated with an increased risk of neonatal complications and death, as well as poor health and disease later in life. Epigenetics could contribute to the mechanism underlying preterm birth.

Results

Genome-wide DNA methylation analysis of whole blood cells from 10 women (5 term and 5 preterm deliveries) was performed using an Illumina Infinium HumanMethylation450 BeadChips array. We identified 1,581 differentially methylated CpG sites in promoter regions between term and preterm birth. Although the differences were not significant after correcting for multiple tests, seven CpGs on the genomically imprinted vault RNA2-1 (VTRNA2-1; also known as non-coding RNA, nc886 or miR-886) showed the largest differences (range: 26–39 %). Pyrosequencing verification was performed with blood samples from pregnant women recruited additionally (39 term and 43 preterm deliveries). In total, 28 (34.1 %) samples showed hypomethylation of the VTRNA2-1 promoter (< 13 % methylation), while 54 (65.9 %) samples showed elevated methylation levels between 30 and 60 %. Elevated methylation of VTRNA2-1 promoter was associated with an increased risk of preterm birth after adjusting for maternal age, season of delivery, parity and white blood cell count. The mRNA expression of VTRNA2-1 was 0.51-fold lower in women with preterm deliveries (n = 20) compared with women with term deliveries (n = 20).

Conclusions

VTRNA2-1 is a noncoding transcript to environmentally responsive epialleles. Our results suggest that elevated methylation of the VTRNA2-1 promoter may result in increased risk of PTB caused by the pro-inflammatory cytokines. Further studies are needed to confirm the association of VTRNA2-1 methylation with preterm birth in a large population, and to elucidate the underlying mechanism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12864-021-07865-y.

Effect of continuous positive airway pressure versus nasal cannula on late preterm and term infants with transient tachypnea of the newborn

OBJECTIVE

To compare continuous positive airway pressure (CPAP) with nasal cannula (NC) as primary noninvasive respiratory therapy in hypoxic infants for transient tachypnea of the newborn (TTN).

STUDY DESIGN

Retrospective cohort study of infants born at ≥34 weeks of gestation between January 1, 2015 and December 31, 2018.

RESULT

After adjusting for gestational age and birth weight, the maximum fractional inspired oxygen (FiO2) was significantly lower in the CPAP group with an incidence rate ratio (IRR) of 0.85 (95% CI: 0.76-0.96). Although nonsignificant, the CPAP group needed 32% fewer hours on oxygen with an IRR of 0.68 (95% CI: 0.38-1.22). The duration of respiratory support and the incidence of pneumothorax were similar between both groups.

CONCLUSION

Comparing CPAP with NC as initial noninvasive respiratory therapy for TTN, significantly lower maximum FiO2 was observed in the infants of CPAP group without increase in the incidence of pneumothorax.

Late preterm births: neonatal mortality and morbidity in twins vs. singletons

OBJECTIVE

To examine the outcomes of twins and singletons in the late preterm period.

MATERIALS AND METHODS

This is a retrospective cohort study of data obtained for 165,894 births in California who delivered between 34 + 0 and 36 + 6 weeks. The primary outcome was neonatal and infant mortality. The secondary outcomes included the following neonatal morbidities: respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), seizure, and sepsis. Univariate analysis was performed using chi-square test and multivariable logistic regression was used to adjust for potential confounders.

RESULTS

There were 143,891 singleton and 22,003 twin gestations included in the study. There was no difference in the primary outcome, neonatal and infant mortality between twins and singletons delivered at 34 and 36 weeks. After controlling for multiple potential confounders, significant differences in secondary outcomes of neonatal morbidity were identified. At 34 weeks, twins had significantly higher rates of IVH (aOR 2.47 (95%CI 1.08-5.64)), NEC (aOR 2.46 (95%CI 1.42-4.29)), RDS (aOR 1.60 (95%CI 1.45-1.77)), and sepsis (aOR 1.19 (95%CI 1.05-1.34)) compared to singletons. By 36 weeks, only an increased risk of RDS persisted among twins.

CONCLUSIONS

While there was no difference in mortality among twins and singletons in the late preterm period, twins may have significantly increased neonatal morbidity compared to singletons delivered between 34 + 0 and 36 + 6 weeks.

Growth Abnormalities as a Risk Factor of Adverse Neonatal Outcome in Hypertensive Pregnancies-A Single-Center Retrospective Cohort Study

(1) Background: Hypertensive disorders of pregnancy (HDP) include gestational hypertension (GH), chronic hypertension (CH), preeclampsia (PE), and preeclampsia superimposed on chronic hypertension (CH with PE). HDP is associated with several short and long-term perinatal and neonatal complications, such as newborn growth restriction and death. This study aimed to establish the association between HDP, newborn growth abnormalities, and neonatal outcome. (2) Methods: This is a single-center retrospective cohort study of 63651 singleton deliveries. (3) Results: Univariate analysis showed a significantly increased risk of intrauterine and neonatal death associated with maternal hypertension and growth disorders. There were differences between growth charts used, with the highest risk of stillbirth for SGA defined by the Intergrowth chart (OR 17.2) and neonatal death for newborn growth restriction (NGR) based on Intergrowth (OR 19.1). Multivariate analysis showed that NGR is a stronger risk factor of neonatal death than SGA only. (4) Conclusions: HDP is significantly associated with growth abnormalities and is an independent risk factor of adverse outcomes. The presence of newborn growth restriction is strongly associated with the risk of neonatal death. The choice of growth chart has a substantial effect on the percentage of diagnosis of SGA and NGR.

Race and neonatal respiratory morbidity in the late preterm period

BACKGROUND

Prematurity is one of the leading causes of perinatal morbidity and mortality. Some studies suggest that respiratory disease may differ by race in early preterm infants. However, the role of race in late preterm neonatal morbidity is not yet established.

OBJECTIVE

The objective of our study was to determine whether neonatal respiratory morbidity differs by race in neonates born late preterm.

STUDY DESIGN

This was a secondary analysis of a randomized trial of women at high risk for late preterm delivery (Antenatal Late Preterm Steroids). Our study was limited to women with nonanomalous, singleton gestations, delivering between 34+0 to 36+6 weeks. Women were categorized into 4 groups by race: Black, White, Asian, or other/mixed. The primary outcome was a neonatal composite of treatment in the first 72 hours (continuous positive airway pressure or high-flow nasal cannula >2 hours, oxygen >4 hours, extracorporeal membrane oxygenation or mechanical ventilation) or stillbirth or neonatal death before 72 hours. The secondary outcomes included severe respiratory morbidity (the primary outcome extending continuous positive airway pressure or high-flow nasal cannula to >12 continuous hours and oxygen to at least 24 continuous hours), respiratory distress syndrome, transient tachypnea of the newborn, apnea, neonatal intensive care unit admission, bronchopulmonary dysplasia, and surfactant administration. The primary and secondary outcomes were assessed in the active (steroid) and placebo groups separately. We fit a logistic regression model to adjust for confounders related to respiratory morbidity.

RESULTS

Of a total of 2331 included women, 26.9% (n=627) were Black/African American, 57.1% (n=1333) White, 3.56% (n=83) Asian, and 12.36% (n=288) were other/mixed. In the placebo group, the rate of the primary outcome was significantly higher in Whites (18.6%) and Asians (22.8%) compared with the African American/Black group (12.3%) (P=.03). Adjusting for confounders, the primary outcome was not significant between the groups. The primary predictor for respiratory morbidity was a prior pregnancy with neonatal respiratory morbidity. Findings were similar in the steroid group, but severe respiratory morbidity was less common in Black infants compared with White infants (adjusted odds ratio, 0.45; 95% confidence interval, 0.24-0.83). However, a prior pregnancy with neonatal respiratory complications was no longer associated with respiratory morbidity after receipt of betamethasone.

CONCLUSION

Late preterm respiratory morbidity was similar between racial groups. Although a history of pregnancy with previous neonatal respiratory disease is the strongest risk factor for recurrence, this risk factor is mitigated by the receipt of steroids.

Assessment of morbidity and mortality in newborns with late prematurity: experience of a reference maternity in the northeast of Brazil

BACKGROUND

Late preterm infants show high rates of adverse perinatal outcomes. The aim of this study is to assess the morbidity and mortality of newborns (NBs) with late preterm birth in a reference maternity hospital in northeastern Brazil.

METHODS

Retrospective cohort study from March 1 to July 15, 2017. A total of 204 NBs with gestational age between 34 and 36 weeks and six days were evaluated and compared to 205 full-term NBs (39 and 40 weeks and six days). Perinatal outcomes including neonatal morbidity were evaluated. The Student's t and ANOVA tests were used for normal variables, and the Wilcoxon, Mann-Whitney and Kruskal-Wallis tests for non-normal variables.

RESULTS

Late preterm infants showed significant higher rates of hypothermia, hypoglycemia, respiratory distress syndrome, jaundice in need of phototherapy (67.6%), admission to the neonatal intensive care unit (ICU), and difficulty breastfeeding compared to full-term NBs (p<0.001). Respiratory distress was the main indication for the admission of late preterm infants (p<0.001) to neonatal ICU. Late preterm infants had a longer hospital stay (6.9 vs. 3.7 days, p<0.001). There were three deaths in the group of late preterm NBs, and none in the group of term NBs.

CONCLUSIONS

Late preterm NBs presented higher rates of morbidity and mortality when compared to full-term NBs.

Maternal Prepregnancy Weight and Pregnancy Outcomes in Saudi Women: Subgroup Analysis from Riyadh Mother and Baby Cohort Study (RAHMA)

The objectives of this study were to estimate the prevalence of prepregnancy overweight/obesity and underweight among Saudi mothers and to determine the adverse pregnancy outcomes associated with them. Methods. This is a subgroup analysis from a Riyadh mother and baby cohort study. Participants were divided into four groups according to prepregnancy BMI. Participants with normal BMI were the reference group. Groups were compared in relation to pregnancy-related obstetric, as well as fetal and neonatal complications. A regression model was used to control for covariates, and adjusted odds ratios (AOR) with 95% Confidence Intervals (95% CI) were calculated. Results. A total of 7,029 women were included, 29.7% had normal BMI, 33.3% were overweight, 34.8% were obese, and 2.2% were underweight. Obesity was associated with increased odds of gestational diabetes (AOR 2.07, 95% CI 1.73-2.47), hypertensive events in pregnancy (AOR 2.33, 95% CI 1.19-3.91), induction of labour (IOL) (AOR 1.40, 95% CI, 1.19-1.65), failed IOL (AOR 2.13, 95% CI 1.40-3.25), and delivery by emergency caesarean section (CS) (AOR 1.67, 95% CI 1.39-2.01). Infants of obese women had increased odds of macrosomia (AOR 3.73, 95% CI 2.33-5.98). Overweight women had increased odds of CS delivery (AOR 1.25, 95% CI 1.03-1.5) and failed IOL (AOR 1.69, 95% CI 1.09-2.60). Underweight women had increased odds of delivering a low birth weight (LBW) infant (AOR 2.49, 95% CI, 1.58-3.92). Conclusion. The prevalence of prepregnancy overweight and obesity is very high in Saudi Arabia. Prepregnancy obesity is associated with GDM and hypertensive events inpregnancy, IOL, failed IOL, and CS delivery. Infants of obese mothers were at higher risk of macrosomia, while underweight women were at increased risk of delivering LBW infants.

[Perinatal conditions of late preterm twins versus early term twins]

OBJECTIVE

To study the perinatal complications of late preterm twins (LPTs) versus early term twins (ETTs).

METHODS

A retrospective analysis was performed for the complications of 246 LPTs, 496 ETTs, and their mothers. The risk factors for late preterm birth were analyzed. According to gestational age, the twins were divided into five groups: 34-34⁺⁶ weeks (n=44), 35-35⁺⁶ weeks (n=70), 36-36⁺⁶ weeks (n=132), 37-37⁺⁶ weeks (n=390), and 38-38⁺⁶ weeks (n=106). The perinatal complications were compared between groups.

RESULTS

Maternal hypertension, maternal thrombocytopenia, placenta previa, and premature rupture of membranes were independent risk factors for late preterm birth in twins (P < 0.05). The LPT group had higher incidence rates of respiratory diseases, feeding intolerance, and hypoglycemia than the ETT group (P < 0.05). The 34-34⁺⁶ weeks group had a higher incidence rate of neonatal asphyxia than the 37-37⁺⁶ weeks and 38-38⁺⁶ weeks groups; and had a higher incidence rate of septicemia than 36-36⁺⁶ weeks group (P < 0.0045). The 34-34⁺⁶ weeks and 35-35⁺⁶ weeks groups had higher incidence rates of neonatal respiratory distress syndrome, neonatal apnea, and anemia than the other three groups; and had higher incidence rates of neonatal pneumonia, hypoglycemia and septicemia than the 37-37⁺⁶ weeks and 38-38⁺⁶ weeks groups (P < 0.0045). The 35-35⁺⁶ weeks group had a higher incidence rate of feeding intolerance than the 36-36⁺⁶ weeks, 37-37⁺⁶ weeks, and 38-38⁺⁶ weeks groups (P < 0.0045). The 36-36⁺⁶ weeks group had a lower incidence rate of hypoglycemia than the 34-34⁺⁶ weeks group and a higher incidence rate of hypoglycemia than the 37-37⁺⁶ weeks group (P < 0.0045).

CONCLUSIONS

Compared with ETTs, LPTs have an increased incidence of perinatal complications. The incidence of perinatal complications is associated with gestational ages in the LPTs and ETTs.

Transcutaneous Bilirubin Levels and Risk of Significant Hyperbilirubinemia in Early-Term and Term Newborns

OBJECTIVE

To compare the course of the transcutaneous bilirubin (TcB) values of early-term newborns with those of term newborns in the first month of life and to investigate whether early-term newborns have an increased risk of significant hyperbilirubinemia requiring treatment.

DESIGN

A prospective, controlled cohort analysis.

SETTING

A tertiary level mother-child birth and health care center.

PARTICIPANTS

Four hundred early-term (37 0/7 to 38 6/7 weeks) and 320 term (39 0/7 to 41 6/7 weeks) newborns born during a 27-month period.

METHODS

A total of six TcB measurements in a longitudinal manner were made in early-term and term newborns: the first two at 6 and 48 hours after birth and the next four on routine examination days (Days 4, 7, 15, and 30). Demographic characteristics, values of daily TcB measurements, number of newborns with significant hyperbilirubinemia, and risk of jaundice requiring treatment were compared between the two groups.

RESULTS

All six TcB values were significantly greater in the early-term group than in the term group (p < .001 for each). Early-term newborns had a statistically significant increased risk of jaundice requiring treatment compared to term newborns (risk ratio = 1.91; 95% confidence interval [1.23-2.96]; p = .0046). Results of the repeated-measures analysis of variance and post hoc adjusted multiple comparison analysis showed that TcB levels increased to and peaked at 96 hours after birth and then gradually decreased to baseline (first measurement) levels at 30 days after birth in each group.

CONCLUSIONS

Early-term newborns should not be treated as full-term newborns because they have significantly higher TcB levels. These newborns should be closely monitored for pathologic jaundice because they have increased risk for significant hyperbilirubinemia requiring phototherapy.

Early-term elective Caesarean sections did not increase the risk of behavioural problems at six to eight years of age

AIM

Our aim was to explore the under-researched associations between an elective Caesarean section (C-section) at early-term or full-term gestation and behaviour at 6-8 years of age.

METHODS

We identified 1220 eligible children born by elective C-sections at Danish hospital from 2009 to 2011. Their mothers were randomised to elective C-sections at either 38+3 (early-term) or 39+3 (full-term) weeks of gestation. From December 2017 to August 2018, the parents completed the Strengths and Difficulties Questionnaire. The results were adjusted for maternal education, parity and the child's sex.

RESULTS

Of the 574 (45%) children followed up, 288 were delivered early-term and 286 were delivered full-term. The groups had similar baseline characteristics. There were no differences in the total difficulties score, subscale scores or the risk of being classified as having a possible or probable psychiatric disorder. Early-term boys had a lower risk of being classified as having a possible or probable psychiatric disorder and early-term girls had higher risk, but the results were not statistically significant.

CONCLUSION

We found no difference in behaviour at 6-8 years of age between children born by elective C-section at early- versus full-term gestation.

The relationship between umbilical cord blood vitamin A levels and late preterm infant morbidities: a prospective cohort study

The aim of this study is to explore the association between umbilical cord blood (UCB) vitamin A levels and late preterm infants morbidities. We conducted a prospective cohort study of 208 late-preterm infants(from 34 ⁰/₇ to 36 ⁶/₇ weeks gestational age) between January 1, 2014 and June 30, 2015. UCB specimens were collected shortly after birth, and vitamin A levels were determined by enzyme-linked immunosorbent assay. Prevalence of low UCB vitamin A level < 0.7 μmol/L was 37.5% in late preterm infants. In comparison to vaginal delivery, cesarean section was associated with UCB vitamin A level < 0.7 μmol/L (P < 0.001). Nevertheless, UCB vitamin A levels did not correlate with gestational age, birth weight, and gender. UCB vitamin A level < 0.7 μmol/L was not an independent risk factor for hospitalization, oxygen supplementation, hyperbilirubinemia, sepsis, and respiratory distress syndrome.Conclusions: Low umbilical cord blood vitamin A levels are common among late-preterm infants. Cesarean section delivery is associated with low umbilical cord blood vitamin A level. Low umbilical cord blood vitamin A levels at birth do not increase morbidity of late-preterm infants, including hyperbilirubinemia, sepsis, and respiratory distress syndrome. What is Known: • Late preterm infants have a higher morbidity and mortality rates when compared to term infants. • Low plasma vitamin A levels increase the risk of preterm infants' morbidity. What is New: • Late preterm infants commonly have low level of umbilical cord blood vitamin A. • Low umbilical cord blood vitamin A level at birth appears to be not associated with the morbidity of late-preterm infants. • Cesarean section is associated with low umbilical cord blood vitamin A level < 0.7 μmol/L compared with vaginal delivery.

Trends in Costs of Birth Hospitalization and Readmissions for Late Preterm Infants

Background: The objective is to study previously unexplored trends of birth hospitalization and readmission costs for late preterm infants (LPIs) in the United States between 2005 and 2016. Methods: We conducted a retrospective analysis of claims data to study healthcare costs of birth hospitalization and readmissions for LPIs compared to term infants (TIs) using a large private insurance database. We used a generalized linear regression model to study birth hospitalization and readmission costs. Results: A total of 2,123,143 infants were examined (93.2% TIs; 6.8% LPIs). The proportion of LPIs requiring readmission was 4.2% compared to 2.1% of TIs, (p < 0.001). The readmission rate for TIs decreased during the study period. LPIs had a higher mean cost of birth hospitalization (25,700 vs. 3300 USD; p < 0.001) and readmissions (25,800 vs. 14,300 USD; p < 0.001). For LPIs, birth hospitalization costs increased from 2007 to 2013, and decreased since 2014. Conversely, birth hospitalization costs of TIs steadily increased since 2005. The West region showed higher birth hospitalization costs for LPIs. Conclusions: LPIs continue to have a higher cost of birth hospitalization and readmission compared to TIs, but these costs have decreased since 2014. Standardization of birth hospitalization care for LPIs may reduce costs and improve quality of care and outcomes.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.