Developmental Outcomes of Late Preterm Infants From Infancy to Kindergarten

Growth and respiratory status at 3 years of age after moderate preterm, late preterm and early term births: the Japan Environment and Children's Study

OBJECTIVE

To assess the association between gestational age at birth and the risk of growth failure and respiratory symptoms at 3 years of age.

DESIGN

Cohort study using the Japan Environment and Children's Study database.

PATIENTS

A total of 86 158 singleton infants born without physical abnormalities at 32-41 weeks of gestation were enrolled between January 2011 and March 2014.

MAIN OUTCOME MEASURES

Growth failure (weight <10th percentile and height <10th percentile) and respiratory symptoms (asthma and wheezing) at 3 years of age.

METHODS

Logistic regression analysis was used to evaluate the risk of growth failure and respiratory symptoms in the moderately preterm, late preterm and early term groups compared with the full-term group after adjusting for socioeconomic and perinatal factors. Multiple imputation was used to reduce the attrition bias related to missing data.

RESULTS

The respective adjusted ORs (95% CI) of growth failure and respiratory symptoms for the moderate preterm, late preterm and early term groups compared with the full-term group were as follows: weight <10th percentile, 2.29 (1.48-3.54), 1.43 (1.24-1.71) and 1.20 (1.12-1.28); height <10th percentile, 2.34 (1.59-3.45), 1.42 (1.25-1.60) and 1.15 (1.09-1.22); asthma, 1.63 (1.06-2.50), 1.21 (1.04-1.41) and 1.16 (1.09-1.23); and wheezing, 1.39 (1.02-1.90), 1.37 (1.25-1.51) and 1.11 (1.06-1.17).

CONCLUSION

Moderate preterm, late preterm and early term births were associated with a higher risk of growth failure and respiratory symptoms at 3 years of age than full-term births, with an inverse dose-response pattern.

[Being born moderately premature: a risky developmental trajectory]

Babies born prematurely are frequently prone to developmental disorders, which are all the more severe in babies of low gestational age. However, medium prematurity also generates its own set of difficulties, including sensory, motor, cognitive, behavioral, relational and emotional disorders. It is essential to gain a better understanding of the developmental trajectory of these children and its various ups and downs, in order to support their development as early as possible.

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.

Neurodevelopmental outcomes at age 3 years after moderate preterm, late preterm and early term birth: the Japan Environment and Children's Study

OBJECTIVE

To assess the association between gestational age classification at birth and the risk of neurodevelopmental impairments at age 3 years.

DESIGN

Cohort study using the Japan Environment and Children's Study database.

PATIENTS

A total of 86 138 singleton children born without physical abnormalities at 32-41 weeks of gestation enrolled between January 2011 and March 2014.

MAIN OUTCOME MEASURES

Neurodevelopmental impairment, evaluated using the Ages and Stages Questionnaire (third edition).

METHODS

Logistic regression analysis was used to evaluate the risk of neurodevelopmental impairment in moderate preterm, late preterm and early term children compared with term children after adjusting for socioeconomic and perinatal factors.

RESULTS

The respective adjusted ORs (95% CIs) of incidence of scores below the cut-off value (<-2.0 SD) at age 3 years for moderate preterm, late preterm and early term births, compared with full-term births, were as follows: communication, 2.40 (1.54 to 3.73), 1.43 (1.19 to 1.72) and 1.11 (1.01 to 1.21); gross motor, 2.55 (1.69 to 3.85), 1.62 (1.36 to 1.93) and 1.20 (1.10 to 1.30); fine motor, 1.93 (1.34 to 2.78), 1.55 (1.35 to 1.77) and 1.08 (1.01 to 1.15); problem solving, 1.80 (1.22 to 2.68), 1.36 (1.19 to 1.56) and 1.07 (1.00 to 1.14) and personal-social, 2.09 (1.29 to 3.40), 1.32 (1.07 to 1.63) and 1.00 (0.91 to 1.11).

CONCLUSION

Moderate preterm, late preterm and early term births were associated with developmental impairment at age 3 years compared with full-term births, with increasing prematurity. Careful follow-up of non-full-term children by paediatricians and other healthcare providers is necessary for early detection of neurodevelopmental impairment and implementation of available intervention.

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

Collapse

Grants

• K08 HD078506 NICHD NIH HHS

Collapse

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

Collapse

[Preeclampsia: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure≥140mmHg and/or diastolic blood pressure≥90mmHg) and proteinuria≥0.3g/24h or a Proteinuria/Creatininuria ratio≥30mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100-160mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159mmHg or diastolic blood pressure is measured between 90 and 109mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate).

CONCLUSION

The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.

Risk of Developmental Disorders in Children Born at 32 to 38 Weeks' Gestation: A Meta-Analysis

CONTEXT

Very preterm birth (<32 weeks) is associated with increased risk of developmental disorders. Emerging evidence suggests children born 32 to 38 weeks might also be at risk.

OBJECTIVES

To determine the relative risk and prevalence of being diagnosed with, or screening positive for, developmental disorders in children born moderately preterm, late preterm, and early term compared with term (≥37 weeks) or full term (39-40/41 weeks).

DATA SOURCES

Medline, Embase, Psychinfo, Cumulative Index of Nursing, and Allied Health Literature.

STUDY SELECTION

Reported ≥1 developmental disorder, provided estimates for children born 32 to 38 weeks.

DATA EXTRACTION

A single reviewer extracted data; a 20% sample was second checked. Data were pooled using random-effects meta-analyses.

RESULTS

Seventy six studies were included. Compared with term born children, there was increased risk of most developmental disorders, particularly in the moderately preterm group, but also in late preterm and early term groups: the relative risk of cerebral palsy was, for 32 to 33 weeks: 14.1 (95% confidence intervals [CI]: 12.3-16.0), 34 to 36 weeks: 3.52 (95% CI: 3.16-3.92) and 37 to 38 weeks: 1.44 (95% CI: 1.32-1.58).

LIMITATIONS

Studies assessed children at different ages using varied criteria. The majority were from economically developed countries. All were published in English. Data were variably sparse; subgroup comparisons were sometimes based on single studies.

CONCLUSIONS

Children born moderately preterm are at increased risk of being diagnosed with or screening positive for developmental disorders compared with term born children. This association is also demonstrated in late preterm and early term groups but effect sizes are smaller.

Encouraging Our NICU to "Read-a-Latte": Leveraging a Read-a-Thon to Launch a Quality Improvement Initiative

BACKGROUND

Preterm infants have known impairments in language development relative to infants born at full term, and the language-poor environment of the neonatal intensive care unit (NICU) is a contributing factor. Adapting outpatient literacy programs for the NICU is a potential evidence-based intervention to encourage adult speech exposure to infants through reading sessions during NICU hospitalization.

PURPOSE

To evaluate implementation of a 10-day NICU Read-a-Thon and potential barriers and facilitators of a year-round program aimed at increasing reading sessions for NICU patients.

METHODS

We established an implementation team to execute a Read-a-Thon and evaluated its impact utilizing quantitative and qualitative approaches. Quantitative methodology was used to report number of donated books and infant reading sessions. Qualitative methodology inclusive of interviews, surveys, and source document reviews was used to evaluate the Read-a-Thon.

RESULTS

We received approximately 1300 donated books and logged 663 reading sessions over the 10-day Read-a-Thon. Qualitative evaluation of the Read-a-Thon identified 6 main themes: motivation, emotional response to the program, benefits and outcomes, barriers, facilitators, and future of literacy promotion in our NICU. Our evaluation informed specific aims for improvement (eg, maintaining book accessibility) for a quality improvement initiative to sustain a year-round reading program.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal units can leverage Read-a-Thons as small tests of change to evaluate barriers, facilitators, and change processes needed to implement reading programs. Process maps of book inventory and conducting a 5 W's, 2 H's (who, what, when, where, why, how, how much) assessment can aid in program planning.

Offspring school performance at age 12 after induction of labor vs non-intervention at term: A linked cohort study

INTRODUCTION

The incidence of induction of labor, for both medical reasons and as an elective procedure, has been rising and a further increase in induction of labor following the ARRIVE trial may be expected. The effects of induction of labor at term on childhood neurodevelopment, however, are not well studied. We aimed to study the influence of elective induction of labor for each week of gestation separately from 37 to 42 weeks on offspring school performance at 12 years of age after uncomplicated pregnancies.

MATERIAL AND METHODS

We performed a population-based study among 226 684 liveborn children from uncomplicated singleton pregnancies, born from 37⁺⁰ to 42⁺⁰  weeks of gestation in cephalic presentation in 2003-2008 (no hypertensive disorders, diabetes or birthweight ≤p5) in the Netherlands. Children with congenital anomalies, of non-white mothers and born after planned cesarean section were excluded. Birth records were linked with national data on school achievement. We compared, using a fetus-at-risk approach and per week of gestation, school performance score and secondary school level at age 12 in those born after induction of labor to those born after non-intervention, ie spontaneous onset of labor in the same week plus all those born at later gestations. Education scores were standardized to a mean of 0 and a standard deviation of 1 and adjusted in the regression analyses.

RESULTS

For each gestational age up to 41 weeks, induction of labor was associated with decreased school performance scores compared with non-intervention (at 37 weeks -0.05 SD, 95% confidence interval [CI] -0.10 to -0.01 SD; adjusted for confounding factors). After induction of labor, fewer children reached higher secondary school level (at 38 weeks 48% vs 54%; adjusted odds ratio [aOR] 0.88, 95% CI 0.82-0.94).

CONCLUSIONS

In women with uncomplicated pregnancies at term, consistently, at every week of gestation from 37 to 41 weeks, induction of labor is associated with lower offspring school performance at age 12 and lower secondary school level compared with non-intervention, although residual confounding may remain. These long-term effects of induction of labor should be incorporated in counseling and decision making.

Late preterm delivery has a distinctive second-stage duration and characteristics

BACKGROUND

Late preterm neonates born between 34.0 and 36.6 weeks' gestation are at increased risk for short- and long-term morbidity and mortality when compared with their term counterparts. Currently, no separate labor curve is available for late preterm births, and this group's optimal duration of the second stage of labor has never been defined separately.

OBJECTIVE

This study aimed to compare the second stage duration between late preterm and term births.

STUDY DESIGN

This was a retrospective study from May 2014 until May 2021. Eligible were women with a singleton pregnancy, vertex presentation, spontaneous or induced onset of labor, and those who delivered vaginally beyond 34.0 weeks of gestation. The primary outcome of our study was to compare and characterize the second stage of labor duration between late preterm and term births.

RESULTS

We analyzed 962 late preterm and 9476 term vaginal deliveries. Women who delivered during the late preterm period were more likely to be multiparous (52.4% vs 45.2%; P<.001) and fewer required oxytocin during labor (41.2% vs 54.4%; P<.001) or used epidural analgesia (75.2% vs 83.6%; P<.001). The overall mean duration of the second stage of labor was significantly shorter in the late preterm period than at term (1.08±1.09 hours vs 1.49±1.22 hours; P<.001). This was even more pronounced for nulliparous women (1.05±1.00 hours vs 2.10±1.17 hours; P<.001). Among multiparous women, epidural use significantly affected the duration of the second stage of labor, and the second stage was relatively longer during the late preterm period than at term in this subgroup (1.16 vs 0.5 hours; P<.001). Using a multivariate Cox regression, variables such as maternal age (hazard ratio, 1.02; 95% confidence interval, 1.01-1.04), parity (hazard ratio, 4.11; 95% confidence interval, 3.65-4.63), preterm birth (hazard ratio, 2.08; 95% confidence interval, 1.4-3.10), and birthweight at delivery (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30) shortened the second stage, whereas induction of labor (hazard ratio, 0.75; 95% confidence interval, 0.66-0.86) and epidural use (hazard ratio, 0.68; 95% confidence interval, 0.64-0.86) extended its total duration. Regardless of parity, lower rates of operative vaginal deliveries were observed in the late preterm period than at term (3.7% vs 15.5%; P<.001). This period was also associated with lower rates of third- and fourth-degree perineal lacerations (0.2% vs 2.2%; P<.001) but higher rates of chorioamnionitis (1.7% vs 0.1%; P<.001), Apgar score at 5 minutes <7 (1.0% vs 0.2%; P<.001), and admission to the neonatal intensive care unit (19.3% vs 1.0%; P<.001).

CONCLUSION

Women who delivered vaginally during the late preterm period had a distinctive second-stage duration. Primarily, it was shown to be significantly shorter for nulliparous and multiparous women. Future studies should further clarify the optimal duration of this stage in relation to neonatal outcomes at such a vulnerable period.

Growth of late preterm infants fed nutrient-enriched formula to 120 days corrected age-A randomized controlled trial

Objectives

We aimed to compare the effects of nutrient-enriched formula with standard term formula on rate of body weight gain of late preterm infants appropriately grown for gestational age.

Study design

A multi-center, randomized, controlled trial. Late preterm infants (34-37 weeks' gestation), with weight appropriate for gestational age (AGA), were randomized to nutrient enriched formula (NEF) with increased calories (22 kcal/30 ml) from protein, added bovine milk fat globule membrane, vitamin D and butyrate or standard term formula 20 kcal/30 ml (STF). Breastfed term infants were enrolled as an observational reference group (BFR). Primary outcome was rate of body weight gain from enrollment to 120 days corrected age (d/CA). Planned sample size was 100 infants per group. Secondary outcomes included body composition, weight, head circumference and length gain, and medically confirmed adverse events to 365 d/CA.

Results

The trial was terminated early due to recruitment challenges and sample size was substantially reduced. 40 infants were randomized to NEF (n = 22) and STF (n = 18). 39 infants were enrolled in the BFR group. At 120 d/CA there was no evidence of a difference in weight gain between randomized groups (mean difference 1.77 g/day, 95% CI, -1.63 to 5.18, P = 0.31). Secondary outcomes showed a significant reduction in risk of infectious illness in the NEF group at 120 d/CA [relative risk 0.37 (95% CI, 0.16-0.85), P = 0.02].

Conclusion

We saw no difference in rate of body weight gain between AGA late preterm infants fed NEF compared to STF. Results should be interpreted with caution due to small sample size.

Clinical Trial Registration

The Australia New Zealand Clinical Trials Registry (ACTRN 12618000092291). "mailto:maria.makrides@sahmri.com" maria.makrides@sahmri.com.

Cranial Ultrasound Abnormalities in Small for Gestational Age or Growth-Restricted Infants Born over 32 Weeks Gestation: A Systematic Review and Meta-Analysis

AIM

To perform a systematic review and meta-analysis of existing literature to evaluate the incidence of cranial ultrasound abnormalities (CUAs) amongst moderate to late preterm (MLPT) and term infants, affected by fetal growth restriction (FGR) or those classified as small for gestational age (SGA).

METHODS

A systematic review methodology was performed, and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement was utilised. Descriptive and observational studies reporting cranial ultrasound outcomes on FGR/SGA MLPT and term infants were included. Primary outcomes reported was incidence of CUAs in MLPT and term infants affected by FGR or SGA, with secondary outcomes including brain structure development and growth, and cerebral artery Dopplers. A random-effects model meta-analysis was performed. Risk of Bias was assessed using the Newcastle-Ottawa scale for case-control and cohort studies, and Joanna Briggs Institute Critical Appraisal Checklist for studies reporting prevalence data. GRADE was used to assess for certainty of evidence.

RESULTS

Out of a total of 2085 studies identified through the search, seventeen were deemed to be relevant and included. Nine studies assessed CUAs in MLPT FGR/SGA infants, seven studies assessed CUAs in late preterm and term FGR/SGA infants, and one study assessed CUAs in both MLPT and term FGR/SGA infants. The incidence of CUAs in MLPT, and late preterm to term FGR/SGA infants ranged from 0.4 to 33% and 0 to 70%, respectively. A meta-analysis of 7 studies involving 168,136 infants showed an increased risk of any CUA in FGR infants compared to appropriate for gestational age (AGA) infants (RR 1.96, [95% CI 1.26-3.04], I² = 68%). The certainty of evidence was very low due to non-randomised studies, methodological limitations, and heterogeneity. Another meta-analysis looking at 4 studies with 167,060 infants showed an increased risk of intraventricular haemorrhage in FGR/SGA infants compared to AGA infants (RR 2.40, [95% CI 2.03-2.84], I² = 0%). This was also of low certainty.

CONCLUSIONS

The incidence of CUAs in MLPT and term growth-restricted infants varied widely between studies. Findings from the meta-analyses suggest the risk of CUAs and IVH may indeed be increased in these FGR/SGA infants when compared with infants not affected by FGR, however the evidence is of low to very low certainty. Further specific cohort studies are needed to fully evaluate the benefits and prognostic value of cranial ultrasonography to ascertain the need for, and timing of a cranial ultrasound screening protocol in this infant population, along with follow-up studies to ascertain the significance of CUAs identified.

Multiomic Analyses of Nascent Preterm Infant Microbiomes Differentiation Suggest Opportunities for Targeted Intervention

The first week after birth is a critical time for the establishment of microbial communities for infants. Preterm infants face unique environmental impacts on their newly acquired microbiomes, including increased incidence of cesarean section delivery and exposure to antibiotics as well as delayed enteral feeding and reduced human interaction during their intensive care unit stay. Using contextualized paired metabolomics and 16S sequencing data, the development of the gut, skin, and oral microbiomes of infants is profiled daily for the first week after birth, and it is found that the skin microbiome appears robust to early life perturbation, while direct exposure of infants to antibiotics, rather than presumed maternal transmission, delays microbiome development and prevents the early differentiation based on body site regardless of delivery mode. Metabolomic analyses identify the development of all gut metabolomes of preterm infants toward full-term infant profiles, but a significant increase of primary bile acid metabolism only in the non-antibiotic treated vaginally birthed late preterm infants. This study provides a framework for future multi-omic, multibody site analyses on these high-risk preterm infant populations and suggests opportunities for monitoring and intervention, with infant antibiotic exposure as the primary driver of delays in microbiome development.

Impact of early term and late preterm birth on infants' neurodevelopment: evidence from a cohort study in Wuhan, China

Background

The incidences of early term and late preterm birth have increased worldwide during recent years. However, there is a lack of prospective study about the influence of early term and late preterm birth on infants’ neurodevelopment, especially at the early stage. Therefore, we conducted this cohort study to investigate the impact of early term and late preterm birth on infants’ neurodevelopment within 6 months.

Methods

This cohort study was conducted in Wuhan, China, between October 2012 and September 2013. A total of 4243 singleton infants born within 34-41 weeks of gestation at Wuhan Children’s Hospital were included. The Gesell Developmental Scale (GDS) was utilized to evaluate the neurodevelopment of infants.

Results

Among the 4243 included participants, 155 (3.65%) were late preterm infants, 1288 (30.36%) were early term infants, and 2800 (65.99%) were full term infants. After adjusted for potential confounders, significant negative relationship was shown between late preterm birth and development quotient (DQ) in all domains of neurodevelopment: gross motor (β = − 17.42, 95% CI: − 21.15 to − 13.69), fine motor (β = − 23.61, 95% CI: − 28.52 to − 18.69), adaptability (β = − 10.10, 95% CI: − 13.82 to − 6.38), language (β = − 6.28, 95% CI: − 9.82 to − 2.74) and social behavior (β = − 5.99, 95% CI: − 9.59 to − 2.39). There was a significant negative trend for early term birth in DQ of fine motor (β = − 2.01, 95% CI: − 3.93 to − 0.09). Late preterm infants had a significantly elevated risk of neurodevelopmental delay in domains of gross motor (adjusted OR = 3.82, 95% CI: 2.67 to 5.46), fine motor (adjusted OR = 3.51, 95% CI: 2.47 to 5.01), and adaptability (adjusted OR = 1.60, 95% CI: 1.12 to 2.29), whereas early term birth was significantly associated with neurodevelopmental delay of fine motor (adjusted OR = 1.22, 95% CI: 1.05 to 1.42).

Conclusions

This study suggested that late preterm birth mainly elevated the risk of neurodevelopmental delay of gross motor, fine motor, and adaptability, whereas early term birth was associated with the developmental delay of fine motor within 6 months. Further research is needed to determine the effectiveness and necessity of the interventions at the early stage for early term and late preterm infants who had suspected neurodevelopmental delay.

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.

Household unmet basic needs in the first 1000 days and preterm birth status

OBJECTIVE

To examine the relationship of individual and composite number of unmet basic needs (housing, energy, food, and healthcare hardships) in the past year with preterm birth status among children aged 0-24 months.

STUDY DESIGN

We examined cross-sectional 2011-18 data of 17,926 families with children aged 0-24 months. We examined children born <31 weeks', 31-33 weeks', and 34-36 weeks' gestation versus term (≥37 weeks) using multivariable multinomial logistic regression.

RESULTS

At least 1 unmet basic need occurred among ≥60% of families with preterm children, compared to 56% of families with term children (p = 0.007). Compared to term, children born ≤30 weeks' had increased odds of healthcare hardships (aOR 1.28 [1.04, 1.56]) and children born 34-36 weeks' had increased odds of 1 (aOR 1.19 [1.05, 1.35]) and ≥2 unmet needs (aOR 1.15 [1.01, 1.31]).

CONCLUSION

Unmet basic needs were more common among families with preterm, compared to term children.

Association between early-term birth and delayed neurodevelopment at the age of 2 years: results from a cohort study in China

A growing body of evidence indicates that early-term births (37-38 weeks of gestational age) have an increased risk of short-term and long-term complications. Here, we sought to explore the association between early-term births and the risk of delayed neurodevelopment at age 2 years. Pregnant women and their live singleton birth were recruited from a single tertiary hospital between October 2013 and February 2017. Mental and Psychomotor Development Indexes (MDI and PDI) were assessed using the Bayley Scales of Infant Development (BSID). Delayed neurodevelopment was defined as scores of PDI or MDI less than -1SD relative to the mean score of the study population. In total, 1678 full-term infants and 727 early-term infants were assessed when they were 2 years old. After adjustment for potential confounders, early-term birth was related to 43% increased odds of neurodevelopmental delay in the PDI domain as compared with full-term birth (OR: 1.43; 95% CI: 1.12, 1.82). The observed associations were more prominent among those infants born by cesarean (OR: 1.44; 95% CI: 1.03, 2.00) and among males (OR: 1.66; 95% CI: 1.20, 2.28). No statistical difference in the MDI domain was found between early-term and full-term births.Conclusions: Our findings suggest that early-term birth was associated with increased odds of delayed neurodevelopment in the PDI domain as measured by BSID assessments at age 2 years. Health professionals should be aware of the influence of early-term birth on the risk of delayed neurodevelopment. What is Known: • Evidence indicates that early-term births have an increased risk of short-term and long-term complications. • The association between early-term births and delayed neurodevelopment at their early childhood has not been widely studied. What is New: • Early-term birth was associated with increased odds of delayed neurodevelopment in PDI domain as measured by BSID assessments at age 2 years. • The observed associations were more prominent among infants born by cesarean section and among male infants.

Supporting Feeding of Late Preterm Infants in the Hospital: A Quality Improvement Project

BACKGROUND

Feeding difficulty is the most common cause of delayed hospital discharge and readmission of late preterm infants. Frequent and adequate feedings from birth are protective against dehydration, hypoglycemia, and jaundice. The National Perinatal Association's feeding guidelines provide the foundation for late preterm infant standards of care. Feeding at least every 3 hours promotes nutritional status and neurologic development. One feeding assessment every 12 hours during the hospital stay can ensure quality of infant feeding.

PROBLEM

At a large urban hospital, medical record reviews were completed to evaluate nursing care practices consistent with the hospital's late preterm infant care standard policy. Feeding frequency and nurse assessment of feeding effectiveness were far below acceptable targets. A quality improvement team was formed to address inconsistency with expected practice.

METHODS

The project included an investigation using the define, design, implement, and sustain method of quality improvement. Parent education, nurse education, and visual cues were developed to sustain enhanced nursing practice.

RESULTS

Late preterm infants who received feedings at least every 3 hours increased from 2.5% (1 of 40) to 27% (11 of 40); (M = 0.275, SD = 0.446), p = 0.001. Documented breastfeeding assessments increased from 2% (5 of 264) to 8% (10 of 126), p = 0.001. Documented bottle-feeding assessments increased from 15% (39 of 264) to 31% (53 of 172), p < 0.001. Intervention time was cut short due to reprioritization of efforts in response to the COVID-19 pandemic.

CONCLUSION

Interventions and implementation of this process improvement is easy to replicate through attainable and sustainable goals directed toward improved outcomes for late preterm infants.

Nutritional Management and Recommendation for Preterm Infants: A Narrative Review

Background: Preterm birth is defined as birth before 37 completed weeks of pregnancy. It is the most important predictor of adverse health and development infant outcomes that extend into the early childhood and beyond. It is also the leading cause of childhood mortality under 5 years of age worldwide and responsible for approximately one million neonatal deaths. It is also a significant contributor to childhood morbidities, with many survivors are facing an increased risk of lifelong disability and poor quality of life. Purpose: In this article, we aimed to describe features of preterm infants, what makes them different from term infants, and what to consider in nutritional management of preterm infants through a traditional narrative literature review. Discussion: Preterm infants are predisposed to more health complications than term infants with higher morbidity and mortality. This morbidity and mortality can be reduced through timely interventions for the mother and the preterm infant. Maternal interventions, such as health education and administration of micronutrient supplementation, are given before or during pregnancy and at delivery, whereas appropriate care for the preterm infants should be initiated immediately after birth, which include early breastfeeding and optimalization of weight gain. Conclusion: Essential care of the preterm infants and early aggressive nutrition should be provided to support rapid growth that is associated with improved neurodevelopmental outcomes. The goal is not only about survival but making sure that these preterm infants grow and develop without any residual morbidity.

Short-Term and Long-Term Educational Outcomes of Infants Born Moderately and Late Preterm

OBJECTIVE

To assess the relationship of moderate and late preterm birth (32^0/7-36^6/7 weeks) to long-term educational outcomes.

STUDY DESIGN

We hypothesized that moderate and late preterm birth would be associated with adverse outcomes in elementary school. To test this, we linked vital statistics patient discharge data from the Office of Statewide Health Planning and Development including birth outcomes, to the 2015-2016 school year administrative data of a large, urban school district (n = 72 316). We compared the relative risk of moderate and late preterm and term infants for later adverse neurocognitive and behavioral outcomes in kindergarten through the 12th grade.

RESULTS

After adjusting for socioeconomic status, compared with term birth, moderate and late preterm birth was associated with an increased risk of low performance in mathematics and English language arts, chronic absenteeism, and suspension. These risks emerged in kindergarten through grade 2 and remained in grades 3-5, but seemed to wash out in later grades, with the exception of suspension, which remained through grades 9-12.

CONCLUSIONS

Confirming our hypothesis, moderate and late preterm birth was associated with adverse educational outcomes in late elementary school, indicating that it is a significant risk factor that school districts could leverage when targeting early intervention. Future studies will need to test these relations in geographically and socioeconomically diverse school districts, include a wider variety of outcomes, and consider how early interventions moderate associations between birth outcomes and educational outcomes.

Executive Functions and Academic Outcomes of Low Birthweight Infants: A Prospective Longitudinal U.S. Cohort

OBJECTIVE

Executive functions such as working memory and cognitive flexibility are key to lifelong learning. Our hypothesis was that children born low birthweight (LBW), defined as weight < 2,500 g, would have lower cognitive outcomes than those born normal weight, and children with poor executive functioning would be at risk for poor academic outcomes.

STUDY DESIGN

We evaluated data from 12,656 children followed prospectively in the Early Childhood Longitudinal Study, Kindergarten Class 2010-2011, assessing outcomes from kindergarten, first grade, and second grade. Multivariable linear and logistic regressions were run evaluating the relationship between birthweight and cognitive outcomes, and the odds of infants with poor executive functioning having poor academic outcomes.

RESULTS

Compared with children with normal birthweight, those born LBW had lower mean z-scores for academic and directly assessed executive functions from kindergarten through second grade. LBW children were at an increased risk of scoring in the bottom 20% of children at all time points: second-grade reading odds ratio (OR) = 1.60 (95% confidence interval [CI:] 1.23-2.09), math OR = 1.49 (95% CI: 1.21-1.84), science OR = 1.41 (95% CI: 1.11-1.81), cognitive flexibility OR = 1.61 (95% CI: 1.27-2.02), and working memory OR = 1.40 (95% CI: 1.10-1.77).

CONCLUSION

LBW infants remain at risk of poor cognitive outcomes in second grade. Early difficulties with executive functioning can increase the risk of a child's academic performance years later.

Academic school readiness in children born very preterm and associated risk factors

BACKGROUND AND AIMS

Although the intelligence quotient (IQ) test is useful to assess general cognitive function, it may miss more specific and subtle deficits of learning, working memory, attention and executive function. This study aims to evaluate cognitive performance and academic school readiness (SR) concepts in preterm very low birth weight (PT/VLBW) children, compared to typically developing term controls and to evaluate factors affecting basic (SR) concepts in children with IQ>85.

METHODS

A prospective cohort study of 123 PT/VLBW survivors with birth weights ≤1250 g and 74 term controls born between 2007 and 2009 in Singapore were assessed for school readiness using Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III), Bracken School Readiness Assessment (BSRA-3) and Beery-Buktenica Developmental Test of Visual Motor Integration (VMI) at age 5.5 years. Social risk composite score (SRCS) was calculated based on ethnicity, parental education and family income and marital status. Uni- and multi-variable regressions were conducted to evaluate risk factors associated with poor academic SR in the entire cohort and in those with IQ >85.

RESULTS

Mean gestational age and birth weight of the 123 PT/VLBW children were 27.8 (2.3) weeks and 939 (194) grams while that of the 74 term controls were 38.8 (1.2) weeks and 3165 (402) grams. PT/VLBW survivors had statistically significant lower full composite scores on WPPSI-III (97.0 vs 114), BSRA-3 (98.5 vs 112.3) and VMI (107.2 vs 112.9) compared to controls. The differences remained significant in preterm and children with higher SRCS even after adjustment.

CONCLUSIONS

Prematurity and high social composite risk scores were risk factors affecting academic SR and this difference persisted in PT/VLBW children with normal cognitive scores with IQ >85.

Understanding Racial Disparities of Preterm Birth Through the Placenta

The racial disparity associated with preterm birth is a public health concern in the United States. The placenta is the principal metabolic, respiratory, and endocrine organ of the fetus and a key route by which environmental exposures are transmitted from mother to offspring. Available at every delivery, it may serve as a marker of differences in prenatal exposures that manifest differently by race. Recently, we described differences in placental pathology between African-American and White preterm births: the prevalence of chronic inflammation was higher among African-American women's placentas compared with those of White women. Similarly, racial differences have been shown in placental malperfusion and placental weight. Social determinants such as poverty and stress from discrimination have been implicated in racial disparities in preterm birth. To date, however, the underlying biological mechanisms, whether through inflammatory, oxidative stress, or other pathways involving epigenetic programming, remain largely unknown. The placenta, complemented by maternal and umbilical cord blood biomarkers, may provide important information on the perinatal environment that explains the origins of racial disparities in preterm birth rates and subsequent health outcomes. This article reviews existing literature and current research gaps. Opportunities are discussed for future placental research that may reveal novel mechanisms leading to the development of new approaches in the prevention and management of preterm birth and its outcomes.

Longitudinal changes in attachment patterns of preterm infants born in a non-Western country

Unexpected early birth of an infant may affect the attachment formation of mother-child dyads. This longitudinal study aimed to explore mother-infant attachment patterns of very preterm (VPT) and preterm (PT) infants compared to their term-born peers in a non-Western country. Neurodevelopmental outcomes of infants, maternal anxiety and depressive symptoms, and sociodemographic features were evaluated to explore their effects on attachment. Eighteen VPT, 11 PT, 11 term infants and their mothers participated. Observations of attachment patterns and neurodevelopmental assessments were performed at 18 and 24 months of corrected age. This study identified a change in attachment patterns of VPT infants over time such that VPT infants tended to have less insecure attachment patterns with their mothers at the end of the infancy period. While motor and language development scores were associated with attachment patterns at 18 months, models predicting attachment patterns were no longer significant at 24 months. Therefore, change in VPT infants' developmental outcomes and attachment patterns over time suggests that preterm birth itself is not necessarily a risk factor for developing insecure attachment patterns; yet, developmental delays may account for insecure attachment patterns. It is suggested that efforts to promote developmental outcomes of preterm infants may improve mother-child attachment.

Predictive value of the Ages and Stages Questionnaire® for school performance and school intervention in late preterm- and term-born children

BACKGROUND

The new health supervision guidelines emphasize the importance of surveillance or a formal developmental screening test at 4 years, one of the most used tests is Ages & Stages Questionnaire. Nevertheless, there is still not enough evidence whether these tools will be useful to predict future school performance (SP).

OBJECTIVES

The objectives of this study were to evaluate the Ages & Stages Questionnaire 3rd edition 48-month interval (ASQ3-48) translated to Spanish for predicting the need for school intervention (SI) and poor SP at 8-9 years of age, in late preterm infants (LPIs) and term-born infants (Terms) and to compare the prevalence of SI and poor SP in the two groups.

METHODS

Data were collected from a cohort of 75 LPIs and 58 Terms assessed with ASQ3-48 and with a further assessment of academic results at 8-9 years, through a standardized school test of the Education Department of Catalonia. SI data were obtained through a parent report. Area under the curve (AUC), sensitivity, specificity and predictive values were calculated, and logistic regression analysis was used.

RESULTS

The prevalence of poor SP was 12.8%, without statistically significant differences between LPIs and Terms. LPIs had higher SI than Terms (29.3% vs. 10.3%, P = 0.001). AUC for poor SP was 0.73 and for receiving SI was 0.56 without differences between the two groups. The sensitivity of the ASQ3-48 for poor SP was 41%, for specificity 92%, and for receiving SI 14% and 89%, respectively. Poor SP was related to having positive screening in the ASQ3-48 (OR 6.5 [95% CI, 1.9-22.2]) while having received SI was related to late prematurity (OR 3.6 [95% CI, 1.3-9.6]).

CONCLUSIONS

The ASQ3-48 shows acceptable predictive properties for poor SP but not for receiving SI. No differences were found in SP between LPI and Term cohorts, but LPIs are likelier to require SI.

Cognitive and Learning Outcomes in Late Preterm Infants at School Age: A Systematic Review

Late preterm children born between 34^0/7 and 36^6/7 weeks’ gestation account for ≈70% of prematurely born infants. There is growing concern about this population at risk of mild neurodevelopmental problems, learning disabilities and lower academic performance. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, this paper analyzes recent published evidence from 16selected studies involving late preterm children and control group assessments at preschool and/or school age, mainly focusing on cognitive functioning, language learning and academic achievement. The review identifies the assessment tools used in these studies (standardized tests, parental questionnaires and laboratory tasks) and the areas being evaluated from preschool (age 3 years) to primary school levels. Results reveal the presence of mild difficulties, pointing to suboptimal outcomes in areas such as executive function, short term verbal memory, literacy skills, attention and processing speed. Some difficulties are transient, but others persist, possibly compromising academic achievement, as suggested by the few studies reporting on higher risk for poor school performance. Given the increasing number of late preterm children in our society the review highlights the need to implement screening strategies to facilitate early risk detection and minimize the negative effects of this morbidity in childhood.

Preterm prelabor rupture of membranes management in Switzerland: a national survey

OBJECTIVE

To gain an overview of the current management of patients with preterm prelabor rupture of membranes (PPROM) in Swiss maternity hospitals.

STUDY DESIGN

We conducted a survey among all maternity hospitals in Switzerland from January to December 2018, irrespective of their annual birth rate and level of complexity. The survey consisted of an 11-item questionnaire, which was developed to retrieve information relevant to different areas of PPROM management.

RESULTS

Of 64 questionnaires distributed by email, 36 (56.3%) centers responded to the survey. Up to 12 different antibiotic regimens were reported. Among these, 91.7% included a beta-lactam, with amoxicillin as the preferred agent (55.6%). Combined antibiotic schemes were used in 30.6% of hospitals. All centers considered the use of corticosteroids for fetal lung maturity if PPROM occurred before 34 weeks, although 36.1% would consider their use until 37 weeks' gestation in the presence of an increased risk of neonatal respiratory distress syndrome. Maternity hospitals who accept deliveries at any gestational age usually used magnesium sulfate as fetal neuroprotection when delivering babies <32 weeks, with the exception of two hospitals where it was either not used or only indicated if maternal preeclampsia was present. Concerning the time to delivery, 58.3% centers tended to wait until 37 weeks' gestation, while the others considered that it was not necessary to go beyond 34 weeks.

CONCLUSION

Our survey shows that the current management of PPROM in Switzerland appears to be mostly in line with international recommendations. However, some heterogeneity exists, thus reflecting a lack of international consensus across guidelines, together with the absence of national Swiss guidelines, and this needs to be addressed to ensure high quality care for all patients and neonates.

[Neuropsychological development of late preterm infants and early term infants at the age of 1 year: a follow-up study]

OBJECTIVE

To study the level of neuropsychological development in late preterm infants and early term infants at the age of 1 year.

METHODS

A total of 1 257 children with a corrected age of 1 year were enrolled as subjects. According to gestational age at birth, they were divided into an early preterm group (28-33+6 weeks), a late preterm group (34-36+6 weeks), an early term group (37-38+6 weeks), and a full-term group (39-41+6 weeks). Gesell Developmental Schedules were used to assess the neuropsychological development of the children, and the groups were compared in terms of neuropsychological development at the age of 1 year.

RESULTS

There were significant differences in the developmental quotients of the five functional areas (adaptability, gross motor, fine motor, language and social ability) between the four groups at the age of 1 year (P<0.05), and the full-term infants had the highest development quotients, followed by the early term infants, the late preterm infants, and the early preterm infants (P<0.05). The full-term infants had the lowest rate of developmental delay in each functional area, while the early preterm infants had the highest rate (P<0.05). Compared with the full-term infants, the early term infants had a higher risk of developmental delay in adaptability (OR=1.796, P<0.05), and the late preterm infants had a higher risk of developmental delay in adaptability (OR=2.651, P<0.05) and fine motor (OR=2.679, P<0.05), while the early preterm infants had a higher risk of developmental delay in adaptability (OR=4.069, P<0.05), fine motor (OR=3.710, P<0.05), and social ability (OR=3.515, P<0.05).

CONCLUSIONS

The risk of neuropsychological developmental delay decreases with the increase in gestational age in children at the age of 1 year, with a dose-response effect. There are varying degrees of developmental delay in early term infants and late preterm infants, and health care follow-up for early term infants and late preterm infants should be taken seriously.

[Neuropsychological development of late preterm infants and early term infants at the age of 1 year: a follow-up study]

OBJECTIVE

To study the level of neuropsychological development in late preterm infants and early term infants at the age of 1 year.

METHODS

A total of 1 257 children with a corrected age of 1 year were enrolled as subjects. According to gestational age at birth, they were divided into an early preterm group (28-33⁺⁶ weeks), a late preterm group (34-36⁺⁶ weeks), an early term group (37-38⁺⁶ weeks), and a full-term group (39-41⁺⁶ weeks). Gesell Developmental Schedules were used to assess the neuropsychological development of the children, and the groups were compared in terms of neuropsychological development at the age of 1 year.

RESULTS

There were significant differences in the developmental quotients of the five functional areas (adaptability, gross motor, fine motor, language and social ability) between the four groups at the age of 1 year (P<0.05), and the full-term infants had the highest development quotients, followed by the early term infants, the late preterm infants, and the early preterm infants (P<0.05). The full-term infants had the lowest rate of developmental delay in each functional area, while the early preterm infants had the highest rate (P<0.05). Compared with the full-term infants, the early term infants had a higher risk of developmental delay in adaptability (OR=1.796, P<0.05), and the late preterm infants had a higher risk of developmental delay in adaptability (OR=2.651, P<0.05) and fine motor (OR=2.679, P<0.05), while the early preterm infants had a higher risk of developmental delay in adaptability (OR=4.069, P<0.05), fine motor (OR=3.710, P<0.05), and social ability (OR=3.515, P<0.05).

CONCLUSIONS

The risk of neuropsychological developmental delay decreases with the increase in gestational age in children at the age of 1 year, with a dose-response effect. There are varying degrees of developmental delay in early term infants and late preterm infants, and health care follow-up for early term infants and late preterm infants should be taken seriously.

Stability of developmental status and risk of impairment at 24 and 36 months in late preterm infants

BACKGROUND

Few studies investigated whether late preterm infants might have developmental delays in several domains in early life and how stable the lag in developmental status might be.

AIM

We aimed to examine the stability of potential delays across developmental domains at 24 and 36 months of age in late preterm (34°-36⁶ weeks) and term (≥37 weeks) children and whether the risk of delays remained high at 36 months.

STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURE

We conducted a prospective cohort analysis of the children of pregnant women participating in the Vitamin Antenatal Asthma Reduction Trial (VDAART). 652 children who were prospectively followed up and had parent-completed Ages Stages Questionnaires (ASQ-3) questionnaires at both 24 and 36 months were analyzed to assess their domain-specific developmental status.

RESULTS

6.61 % (42/635) of children had a late preterm birth. Developmental delays were stable between 24 and 36 months on all 5 domains for the children born preterm and on 4/5 domains for those born at term. The developmental domains with the status stability at 24 and 36 months in both late preterm and term children were the gross motor, communication, personal-social skills, and problem-solving. Late preterm children compared with term children remained at higher risk of delays at 36 months for gross motor, communication, and problem-solving skills (aOR = 4.54, 95 %CI: 1.81-10.79; aOR = 8.60, 95 %CI: 3.10-23.28 and aOR = 3.80, 95 %CI: 1.58-8.73, respectively).

CONCLUSION

Late preterm birth is associated with suboptimal development and stability in several domains at both 24 and 36 months and compared with term birth, requiring early monitoring and assessment of the developmental lag to avoid potential long-term implications.

Mother And late Preterm Lactation Study (MAPLeS): a randomised controlled trial testing the use of a breastfeeding meditation by mothers of late preterm infants on maternal psychological state, breast milk composition and volume, and infant behaviour and growth

Background

Late preterm infants suffer from more complications and are less likely to be breastfed compared to term infants and their mothers experience higher levels of stress than mothers with term infants. The physiological or hormonal responses that influence milk ejection, milk production, and/or maternal behaviour are possible mechanisms by which maternal distress could negatively influence breastfeeding success. Maternal mood might also affect infant behaviour (feeding, sleeping, and crying) through changes in milk volume and composition, and consequently breastfeeding success and infant growth. Previous research, using relaxation therapy in 64 Malaysian first-time mothers breastfeeding their full-term infants, demonstrated that the therapy was effective in reducing maternal stress and improving infant growth. We hypothesise that expected benefits are even greater in a more vulnerable population where additional breastfeeding support is especially needed, such as in mothers of late preterm infants.

Methods/design

This protocol describes our randomised controlled trial that tests whether a breastfeeding meditation audio reduces maternal stress in mothers of late preterm infants in London. Home visits will be conducted at 2–3 and 6–8 weeks post-delivery. Participants will be randomised to a control group or an intervention group, where mothers will be asked to listen to a meditation tape on a daily basis while breastfeeding. The main outcomes of the intervention will be maternal stress markers and infant weight Z-score. Potential mediators will be the secondary outcomes and include breast milk macronutrient and hormone levels (ghrelin, leptin, cortisol, and adiponectin), milk volume assessed by 48-h test-weighing, and maternal engagement with the infant. Infant behaviour, including crying and sleeping, and infant appetite will be evaluated. Data about other mediators such as maternal perception of milk supply and salivary oxytocin will be collected.

Discussion

We hypothesise that the use of the breastfeeding meditation will reduce maternal stress and consequently improve infant growth mediated by changes in milk composition and volume and maternal behaviour. This study will allow us to understand the mother–infant factors that influence breastfeeding in late preterm infants and potentially identify a method that could improve mother, infant, and breastfeeding outcomes.

Trial registration

ClinicalTrials.gov, NCT03791749. Registered 1 January 2019.

Delayed neonatal visual evoked potentials are associated to asymmetric growth pattern in twins

OBJECTIVES

To study the association between intrauterine growth and visual pathways maturation by neonatal visual evoked potentials (VEPs) in twins, in view of a possible prognostic role.

METHODS

Seventy-four twin neonates from 37 pregnancies were selected based on gestational age of more than 30 weeks and uneventful perinatal clinical course. Flash VEPs were recorded at the same postmenstrual age in each twin pair. The association between P2 latency and anthropometric variables at birth was analyzed by comparison within each twin pair and regarding each variable as ordered difference between the two twins.

RESULTS

Analysis of differences within each twin pair highlighted that inter-twin difference in P2 latency was significantly related to difference in ponderal index (PI) (p = 0.048). Expressing the difference in latency as a categorical binary variable, the correlation was significant for both difference in PI, (median difference = -0.36, 95% CI -0.54 to -0.14, p = 0.001) and difference in body mass index (BMI), (median difference = -1.06, 95% CI -1.74 to -0.29, p = 0.006).

CONCLUSIONS

Lower values of PI and BMI differences are associated to delayed VEP latency in twin pairs.

SIGNIFICANCE

VEP latency suggests reduced myelination of visual pathways when difference in growth pattern occurs in twins.

Improved Referral of Very Low Birthweight Infants to High-Risk Infant Follow-Up in California

OBJECTIVE

To examine changes in referral rates of very low birthweight (birthweight <1500 g) infants to high-risk infant follow-up in California and identify factors associated with referral before and after implementation of a statewide initiative in 2013 to address disparities in referral.

STUDY DESIGN

We included very low birthweight infants born 2010-2016 in the population-based California Perinatal Quality Care Collaborative who survived to discharge home. We used multivariable logistic regression to examine factors associated with referral and derive risk-adjusted referral rates by neonatal intensive care unit (NICU) and region.

RESULTS

Referral rate improved from 83.0% (preinitiative period) to 94.9% (postinitiative period); yielding an OR of 1.48 (95% CI, 1.26-1.72) for referral in the postinitiative period after adjustment for year. Referral rates improved the most (≥15%) for infants born at ≥33 weeks of gestation, with a birthweight of 1251-1500 g, and born in intermediate and lower volume NICUs. After the initiative, Hispanic ethnicity, small for gestational age status, congenital anomalies, and major morbidities were no longer associated with a decreased odds of referral. Lower birthweight, outborn status, and higher NICU volume were no longer associated with increased odds of referral. African American race was associated with lower odds of referral, and higher NICU level with a higher odds of referral during both time periods. Referral improved in many previously poor-performing NICUs and regions.

CONCLUSIONS

High-risk infant follow-up referral of very low birthweight infants improved substantially across all sociodemographic, perinatal, and clinical variables after the statewide initiative, although disparities remain. Our results demonstrate the benefit of a targeted initiative in California, which may be applicable to other quality collaboratives.

Autonomic signatures of late preterm, early term, and full term neonates during early postnatal life

BACKGROUND

Late preterm and early term births account for ~25% of live births. Infants born prior to term are at significantly higher risk for subsequent morbidity and mortality.

AIMS

Determine autonomic regulation differences in infants (35-40 weeks gestation) during sleep at birth and one-month after delivery.

STUDY DESIGN

Consecutive enrollment until at least 20 infants per group: 75 late preterm (35-36 weeks gestation), 110 early term (37-38 weeks), and 130 full term (39-40 weeks). Assess autonomic parameters 12-84 h after delivery and again at one month of life.

SUBJECTS

329 newborns met inclusion criteria.

EXCLUSIONS

maternal age < 18 years, major maternal medical problems, psychiatric medications, drug use, Apgar <8 at 5 min, medical complications requiring other than standard care, non-English or non-Spanish speaking.

OUTCOME MEASURES

Heart rate and two measures of heart rate variability in active and quiet sleep at birth and at one month of life.

RESULTS

Late preterm and early term newborns demonstrate immature patterns of autonomic regulation at birth. Heart rate decreased with gestational age in both sleep states whereas the standard deviation of R-R intervals and beat-to-beat variability in heart rate both increased with gestational age in both sleep states. One month after delivery, i.e. at term-equivalent age, late preterm infants continued to have higher heart rates than infants born full term; and their heart rate was also significantly higher when compared to that of full term newborns at birth, i.e. their autonomic signature did not "normalize" over the first four weeks of life. Early term infants, however, did not differ from full term infants when they reached a postmenstrual age of 44 weeks.

CONCLUSION

The specific patterns of immature autonomic regulation in late preterm and early term infants during early postnatal life may underlie their increased morbidity and mortality in infancy and later in development. Future studies should address how early autonomic measures might relate to adverse outcomes. Results suggest the need for autonomic nomograms at birth and at one month after delivery that are stratified by both gestational week and sleep state.

Late preterm: a new high risk group in neonatology

Late preterm infants are those infants born between 34 0/7 weeks through 36 6/7 week of gestation. These are physiologically less mature and have limited compensatory responses to the extrauterine environment compared with term infants. Despite their increased risk for morbidity and mortality, late preterm newborns are often cared in the well-baby nurseries of hospital after birth and are discharged from the hospital by 2-3 days of postnatal age. They are usually treated like developmentally mature term infants because many of them are of same birth weight and same size as term infants. There is a steady increase in the late preterm birth rate in last decade because of either maternal, fetal, or placental/uterine causes. There has been shift in the distribution of births from term and post-term toward earlier gestations. Although late preterm infants are the largest subgroup of preterm infants, there has been little research on this group until recently. This is mainly because of labeling them as "near-term". Such infants were being looked upon as "almost mature", and were thought as neonate requiring either no or minimal concern. In the obstetric and pediatric practice, late preterm infants are often considered functionally and developmentally mature and often managed by protocols developed for full-term infants. Thus, limited efforts are taken to prolong pregnancy in cases of preterm labor beyond 34 weeks, moreover after 34 weeks most centers do not administer antenatal prophylactic steroids. These practices are based on previous studies reporting neonatal mortality and morbidity in the late preterm period to be only slightly higher in comparison with term infants and whereas in the current scenario the difference is significant. Late preterm infants have 2-3-fold increased risk of morbidities such as hypothermia, hypoglycemia, delayed lung fluid clearance, respiratory distress, poor feeding, jaundice, sepsis, and readmission rates after initial hospital discharge. This leads to huge impact on the overall health care resources. In this review, we cover various aspects of these late preterm infants like etiology, immediate and long-term outcome.

A study on the neurodevelopment outcomes of late preterm infants

Background

The study is intended to fill the knowledge gap about the neuropsychology and neuromotor developmental outcomes, and identify the perinatal risk factors for late preterm infants (LPIs 34~36 weeks GA) born with uncomplicated vaginal birth at the age of 24 to 30 months.

Methods

The parents/guardians of 102 late preterm infants and 153 term infants, from 14 community health centers participated in this study. The Modified Checklist for Autism in Toddlers (M-CHAT) questionnaire, the Chinese version of Gesell Development Diagnosis Scale (GDDS), and the Sensory Integration Schedule (SIS), a neurological examination for motor disorders (MD) were carried out. Infants screening positive to the M-CHAT were referred to specialist autism clinics.

Results

Forty-six LPIs (45.1%) scored low in GDDS. Nine LPIs (8.8%) scored positive on M-Chat. 8.8% of LPIs (9 out of 102) were diagnosed MD (p <  0.05). Compared with their full-term peers, LPIs had statistically lower scores in GDDS and the Child Sensory Integration Checklist. LPIs who had positive results on M-CHAT showed unbalanced abilities in every part of GDDS. Risk factors of twin pregnancies, pregnancy induced hypertension and premature rupture of membranes had negative correlation with GDDS (all p <  0.05). Birth weight and gestational age were positively correlated with GDDS.

Conclusions

LPIs shall be given special attention as compared to normal deliveries, as they are at increased risk of neurodevelopment impairment, despite being born with no major problems. Some perinatal factors such as twin pregnancies, and pregnancy induced hypertension etc. have negative effects on their neurodevelopment. Regular neurodevelopmental follow- up and early intervention can benefit their long term outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1336-0) contains supplementary material, which is available to authorized users.

The profile of very preterm children on academic achievement. A cross-population comparison with children with specific learning disorders

BACKGROUND

Very preterm (VPT) children showed delays in reading, spelling and maths, but their academic achievement profile is not clearly understood.

AIMS

VPT children were compared with children with specific learning disorders (SLD) and typically developing (TD) children on academic achievement, considering cognitive and linguistic phenotypic markers. A learning profile analysis was also performed.

METHODS

We included 170 10-year old monolingual Italian-speaking children (37 VPT, 28 SLD, 105 TD) assessing cognitive, linguistic and academic skills.

RESULTS

On academic achievements VPT children fell behind TD peers in some reading (text speed, comprehension), spelling (non-word), and math (number knowledge, written calculations and problem-solving) tasks. SLD children underperformed in all academic tasks with respect to VPT and TD peers. Concerning cognitive and linguistic phenotypic markers, compared to TD peers, VPT children showed lower scores in verbal IQ and phonological fluency, SLD children in phonological processing and rapid automatized naming. VPT children showed a higher rate of at-risk performance in reading compared to TD group, but a minor percentage of impaired profiles and comorbidity among learning areas compared to SLD group.

CONCLUSIONS AND IMPLICATIONS

The academic achievement profile of VPT children shows persistent delays, but it differs to that of SLD children, since delays are less widespread and severe, and differences were found in phenotypic markers and comorbidity. Follow-up programs and effective interventions are needed for VPT children.

Late Preterm Infants: Morbidities, Mortality, and Management Recommendations

Infants born between 34 weeks 0 days and 36 weeks 6 days of gestation are termed late preterm. This group accounts for the majority of premature births in the United States, with rates increasing in each of the last 3 years. This increase is significant given their large number: nearly 280,000 in 2016 alone. Late preterm infants place a significant burden on the health care and education systems because of their increased risk of morbidities and mortality compared with more mature infants. This increased risk persists past the newborn period, leading to the need for continued health monitoring throughout life.

Gastroschisis at school age: what do parents report?

Children with gastroschisis are at high risk of morbidity in early life, which could affect long-term outcomes. We determined parent-reported outcomes in school-aged children born in 2000-2012, using paper questionnaires. Parent-perceived child vulnerability and motor function were compared with the Dutch reference data; parent-rated data on cognition, health status, quality of life, and behavior were compared with those of controls matched for age, gender, and maternal education level. Of 77 eligible participants, 31 (40%) returned the questionnaires. Parent-reported motor function was normal in 23 (74%) children. Total scores on health status, quality of life, and behavior did not differ significantly from those of matched controls. Children with gastroschisis had lower scores on cognition (median (interquartile range); 109 (87-127)) than their matched controls (124 (113-140); p = 0.04). Neonatal intestinal failure and increased parent-perceived vulnerability were associated with lower scores on cognition (β - 25.66 (95% confidence interval - 49.41, - 1.91); - 2.76 (- 5.27, - 0.25), respectively).Conclusion: Parent-reported outcomes of school-aged children with gastroschisis were mainly reassuring. Clinicians and parents should be aware of the higher risk of cognitive problems, especially in those with neonatal intestinal failure or increased parent-perceived vulnerability. We recommend multidisciplinary follow-up at school age of children with gastroschisis and neonatal intestinal failure. What is Known: • Many infants with gastroschisis experience morbidity in early life. • Data on developmental outcomes and daily functioning in children with gastroschisis beyond the age of 5 years are scarce and conflicting. What is New: • Parents of school-aged children treated for gastroschisis report normal motor function, health status, quality of life, and behavior. • Children with gastroschisis, especially those with intestinal failure, may be at risk for cognitive problems at school age. Parents who reported their child as being more vulnerable also reported more cognitive problems at school age.

Neonatal Neuroprotection: Bringing Best Practice to the Bedside in the NICU

Preterm birth interrupts the precise process of fetal maturation, forcing critical neurologic growth to continue within the Neonatal Intensive Care Unit (NICU). Concern for the impact of the NICU experience on the developing brain led to a unit-based Quality Improvement (QI) project to promote best outcomes for our graduates. The objective was to implement a standard of care for neonatal neuroprotection in a large urban tertiary center. A multidisciplinary committee researched and developed the Neonatal Neuroprotective Best Practice Guidelines to identify optimal interventions, as well as provide physiologic rationales to reinforce importance of these practices. An educational initiative accompanied release of this document to support consistency in clinical practice and to stress the critical role that every caregiver played in a child's outcome. As the Best Practice Guidelines encompassed virtually all aspects of caregiving in the NICU, it was impractical to measure the impact of such a broad range of interventions in a methodical manner. The full effect of these interventions will not likely be evident until NICU graduates have grown into childhood and adolescence. These constraints limited the scope of this QI project to the practicalities of identifying neuroprotective best practice and bringing it to the bedside. When combined with evidence-based medical and nursing care, neuroprotective care represents the best means of facilitating normal development and minimizing disability for our NICU graduates.

Cognition and behaviour in children with congenital abdominal wall defects

AIM

To characterise neurodevelopment at age two years and cognition and behaviour at age five years in children born with abdominal wall defects (gastroschisis or exomphalos).

STUDY DESIGN

Participants were treated as neonates for gastroschisis or exomphalos and invited for routine clinical follow-up at ages two and five years. Thirty-nine two year-olds and 20 five year-olds with gastroschisis and 20 two year-olds and 10 five year-olds with exomphalos returned for age-appropriate assessments of development (two years) and intellectual functioning (IQ), executive function, and behavioural problems. Results were compared with normative data from the tests and published data from local term-born children.

RESULTS

For both gastroschisis and exomphalos two year-olds, neurodevelopment was in line with the test normative data, but below the level of local normative data for all domains (effect sizes from -0.4 to -1.4 standard deviations). At five years, children with gastroschisis performed similarly to the normative mean for IQ but had high rates of various executive functioning problems on parent report (18-41% compared with 7% expected from norms). There was also a tendency for increased frequency of internalising problems (33% compared with normative expectation of 16%). Five year-olds with exomphalos also performed similarly to the normative mean for IQ and had low rates of executive and behavioural problems.

CONCLUSIONS

Survivors of gastroschisis and exomphalos may be at risk of poor neurodevelopment in toddlerhood, depending on the reference group, and children with gastroschisis may be particularly at risk for executive functioning difficulties despite an IQ within normal limits.

Executive functioning in low birth weight children entering kindergarten

OBJECTIVES

Poor executive functioning is associated with life-long difficulty. Identification of children at risk for executive dysfunction is important for early intervention to improve neurodevelopmental outcomes.

STUDY DESIGN

This study is designed to examine relationships between birthweight and executive functioning in US children during kindergarten. Our hypothesis was that children with higher birthweights would have better executive function scores. We evaluated data from 17506 US children from the Early Childhood Longitudinal Study-Kindergarten 2011 cohort. Birthweight and gestational age were obtained by parental survey. Executive functions were directly assessed using the number reverse test and card sort test to measure working memory and cognitive flexibility, respectively. Teacher evaluations were used for additional executive functions. Data were analyzed using SAS to run all linear and logistical regressions.

RESULTS

For every kilogram of birthweight, scores of working memory increased by 1.47 (P<0.001) and cognitive flexibility increased by 0.28 (P<0.001) independent of gender, gestational age, parental education, and family income. Low birthweight infants were 1.5 times more likely to score in the bottom 20% of children on direct assessment OR=1.49 (CI 1.21-1.85) and OR=1.55 (CI 1.26-1.91).

CONCLUSIONS

Infants born low birthweight are at increased risk of poor executive functioning. As birthweight increases executive function scores improve, even among infants born normal weight. Further evaluation of this population including interventions and progression through school is needed.

The Effect of a Social-Emotional Intervention on the Development of Preterm Infants in Institutions

This study examined the effect of a social-emotional intervention implemented in one St. Petersburg (Russian Federation) institution (called a Baby Home, BH) on the general behavioral development of preterm children (gestational ages of 30-36 weeks) during their first two years of life. The intervention consisted of training caregivers and implementing structural changes to create a more family-like environment. The study included preterm (N = 56) and full-term (N = 93) children from one BH that implemented the intervention and from another BH with no intervention. Children were assessed at 3, 6, 9, 12, 18 and 24 months of age with the Battelle Development Inventory (LINC Associates, 1988). The results showed that the intervention positively influenced the general behavioral development of BH preterm children throughout their first two years of life compared to preterms from the no-intervention BH. Also, results indicated that the intervention effect was developmentally similar for preterm and for full-term children, but preterm children consistently scored lower than full-terms during their first two years living in the BH. In general, our research emphasizes the crucial role of warm, sensitive, and responsive interactions with a constant and emotionally available caregiver for healthy child development for both term and preterm children.