Neonatal morbidity and mortality of late-preterm babies

Morbidities and rehospitalizations during the first year of life in moderate and late preterm infants: more similarities than differences?

BACKGROUND

The aim was to compare neonatal morbidities in moderate and late preterm infants and to analyze rates and causes for rehospitalizations during the first year of life.

METHODS

Prospective follow-up of a group of moderate and late preterm infants at a tertiary care hospital.

RESULTS

The study population comprised 215 infants (58% males; 60% singletons; 99 moderate and 116 late preterm infants) with a median gestational age of 34 weeks and birth weight of 2100 grams; 20% of them were small for gestational age. Moderate preterm infants more often had a diagnosis of mild respiratory distress syndrome (26% vs. 13%, P<0.01) and feeding problems with longer need for nasogastric tube feeding (median 9.5 vs. 4.2 days, P<0.01) and parenteral nutrition (3.5 vs. 2.7 days, P<0.01), and longer duration of stay at either NICU (10.6 vs. 3.7 days; P<0.01) or hospital (13 vs. 11 days; P<0.01). Fifty-two infants (24.3%) were hospitalized at 67 occasions without differences regarding readmission rates and causes between groups. Median age at readmission was 3 months, median stay 4 days. The most common diagnosis was respiratory illness (43.3%).

CONCLUSIONS

Moderate preterm infants had more neonatal morbidities diagnosed, but the same rehospitalization rates than late preterm infants.

Effectiveness and safety of atosiban versus conventional treatment in the management of preterm labor

OBJECTIVE

To compare the efficacy of atosiban with conventional treatment of the threatened preterm labor.

MATERIALS AND METHODS

All the data of pregnant women with threatened preterm labor from January 1 to December 31, 2017, who received atosiban were collected. Pregnant women with conventional treatment (including β-agonists, indomethacin, magnesium sulphate and calcium channel blockers, alone or in combination) were used as control.

RESULTS

The proportion of women not requiring an alternative tocolytic treatment within 48 h and remaining undelivered was significantly higher in atosiban treatment group (89.3%; n = 25/28) compared with conventional treatment (24.2%; n = 8/33) (P < 0.0001). For therapy efficacy, there was also no significant difference between atosiban groups and conventional treatment groups in the low gestational ages. However, for the high gestational ages, atosiban treatment group showed higher efficacy (84%; n = 21/25 vs. 37.5%; n = 3/8) (P < 0.05). Moreover, a significantly higher proportion of women in the atosiban treated group (89.3%; n = 25/28) was observed compared with the conventional treatment groups (51.5%; n = 17/33) who did not receive an alternative tocolytic within 48 h (P < 0.01). Maternal and fetal safety was significantly superior with atosiban treatment.

CONCLUSIONS

Our results support that atosiban would represent an advance over current tocolytic therapy especially for the high gestational ages.

Controversies in the management of twin pregnancy

Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts at standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

[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.

The assessment of phagocytic and bactericidal activity of platelets and plasma bactericidal activity in late preterm newborns*

Background

The aim of the study was to compare the phagocytic and bactericidal properties of blood platelets and the plasma bactericidal activity in 66 late preterm (LPN) and 74 full-term newborns (FTN).

Materials/Methods

Blood samples were collected from the umbilical artery. Bacteria of the Staphylococcus aureus ATCC 6538P were used for the tests.

Results

Platelet counts in LPN vs FTN were the following: 225 vs 258.5 (×103/μL), p = 0.003. The percentage of phagocytic platelets was the following: Me = 1.1 in LTN vs Me = 1.1 in FTN. The phagocytic index was the following: Me = 1 for both LPN and FTN. The phagocytic properties of platelets increased as the birth weight increased. The bactericidal activity of platelets was the following: Me = 0; (average = 0.7) in LPN vs Me = 0; (average = 0.8) in FTN. The median plasma bactericidal activity in LPN was 41.6 vs 43.8, in FTN, p = 0.027. The bactericidal capacity of plasma increased with increasing fetal age and birth weight of newborns. sP-selectin was: 63.9 ng/ml in LPN vs 71 ng/ml in FTN, p = 0.026. IL-6 in LPN was 3.6 vs 3.9 (pg/ml) in FTN, p = 0.02.

Conclusion

Late preterm newborns have lower defensive capacity against infection than full-term newborns, due to lower platelets count, lower plasma bactericidal activity and lower sP-selectin concentration, which cooperates with neutrophils, monocytes in fighting against infection. All newborns had similar phagocytic and bactericidal properties of platelets.

Factors Associated With Late Prematurity in the University Hospital of Valle Cali, Colombia During 2013-2014

Introduction: The birth rate of late premature babies has been increasing in recent years, composing now 75% of all premature births. This growing trend can be explained by different demographic transformations such as an increase in the demand for infertility treatments, older maternal age and the higher incidence of multiple pregnancies, cesarean sections, and labor induction. These premature babies contribute 30% to the global neonatal mortality rate. Objective: To identify the factors associated with late prematurity at the Hospital Universitario del Valle during the years 2013-2014. Methodology: Case and control design, 424 patients, 212 cases and 212 controls participated. Cases were defined as newborns with gestational age between 34 and 36 weeks and 6 days old. For the analysis, logistic regression models were developed and association forces (OR) were determined. Results: A univariate analysis shows that the proportion of teenage pregnant women corresponds to 22.64%. Bivariate analysis shows the maternal morbidity due to hypertensive disorders was 1.6 times higher (95% CI 1.06-2.63), the obstetric alterations in 2.9 times (CI of 95% 1.56-5.44), late preterm infants require more oxygen support 3.26 times (95% CI 1.76-6.03). After adjusting the model, it was found that late premature infants have a 3-fold probability of requiring some resuscitation maneuver (ORa 3.23 95% CI 2.09-4.99), birth is higher by cesarean section by 4.17 times (ORa 4.17 IC 95% 2.50-6.98), maternal morbidity was higher in 1.37 times (ORa 1.37 95% CI 1.14-1.65). The morbidity of the newborn was greater, close to the statistical significance for late premature infants in 1.26 times (ORa 1.26 95% CI 0.97-1.64). Conclusions: Late premature births in this study show a higher probability of developing morbidity, have a greater opportunity to be born by cesarean section, are products of mothers with morbidity (specifically hypertensive disorders), and require further resuscitation with a need of early obstetric intervention.

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.

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.

Feeding the Late and Moderately Preterm Infant: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

Nutritional guidelines and requirements for late or moderately preterm (LMPT) infants are notably absent, although they represent the largest population of preterm infants. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (CoN) performed a review of the literature with the aim to provide guidance on how to feed infants born LMPT, and identify gaps in the literature and research priorities.Only limited data from controlled trials are available. Late preterm infants have unique, often unrecognized, vulnerabilities that predispose them to high rates of nutritionally related morbidity and hospital readmissions. They frequently have feeding difficulties that delay hospital discharge, and poorer rates of breastfeeding initiation and duration compared with term infants. This review also identified that moderately preterm infants frequently exhibit postnatal growth restriction.The ESPGHAN CoN strongly endorses breast milk as the preferred method of feeding LMPT infants and also emphasizes that mothers of LMPT infants should receive qualified, extended lactation support, and frequent follow-up. Individualized feeding plans should be promoted. Hospital discharge should be delayed until LMPT infants have a safe discharge plan that takes into account local situation and resources.In the LMPT population, the need for active nutritional support increases with lower gestational ages. There may be a role for enhanced nutritional support including the use of human milk fortifier, enriched formula, parenteral nutrition, and/or additional supplements, depending on factors, such as gestational age, birth weight, and significant comorbidities. Further research is needed to assess the benefits (improved nutrient intakes) versus risks (interruption of breast-feeding) of providing nutrient-enrichment to the LMPT infant.

Early childhood health and morbidity, including respiratory function in late preterm and early term births

Late preterm (LP) and early term (ET) infants have generally been considered in the same way as their healthy full term (FT) counterparts. It is only in the last decade that an increased risk of later poor health in children born LP has been recognised; evidence for health outcomes following ET birth is still emerging. However, reports are largely consistent in highlighting an increased risk, which lessens approaching FT but is measurable and persists into adolescence and beyond. The most thoroughly explored area to date is respiratory morbidity. This article reviews the body of available evidence for effects of LP birth on pulmonary function and ongoing morbidity, and other areas where an increased risk of health problems has been identified in this population. Implications for delivery of health care are considered and areas for further research are highlighted.

Outcomes of Implementation of a NICU-Based Late Preterm Infant Feeding Guideline

BACKGROUND AND OBJECTIVES

Late preterm (LPT) infants are at risk for feeding difficulties. Our objectives were to reduce the use of intravenous (IV) fluids and increase breastfeeding at discharge among LPT infants admitted to our NICU.

METHODS

We implemented a feeding guideline and evaluated its effect using a pre-post design. We examined rates of our main outcomes, IV fluid use, and any or exclusive breastfeeding at discharge, as well as several secondary outcomes, including hypoglycemia (glucose <50 mg/dL) at >8 hours of life, by using χ² and t tests. We excluded infants that were <2000 g, admitted to the NICU at >8 hours of life, or needed IV fluids at ≤8 hours of life for a medical reason. We used multivariable logistic regression to examine odds ratios and 95% confidence intervals of our main outcomes.

RESULTS

Fifty percent of infants were eligible. Of those eligible, 18 of 52 (35%) vs 14 of 65 (22%) received IV fluids at >8 hours of life (P = .06). In the 24 hours before discharge, 35 of 52 (75%) vs 46 of 65 (78%) received any breast milk (P = .67), and 10 of 52 (30%) vs 10 of 65 (21%) received exclusive breast milk (P = .43). More infants had hypoglycemia in the posttime period (16 of 65 [25%]) compared with the pretime period (3 of 52 [6%]; P = .01).

CONCLUSIONS

After implementation of a LPT feeding guideline in our NICU that defined specific expected feeding volumes, we did not find changes in IV fluid use or breastfeeding.

Do mothers sound good? A systematic review of the effects of maternal voice exposure on preterm infants' development

Preterm infants are hospitalized in the Neonatal Intensive Care Unit (NICU) and are precociously separated from their mothers. Although developmental care interventions are meant to facilitate mother-infant bonding, physical contact is not always possible. Maternal voice exposure has been proposed as a way to foster maternal closeness and support postnatal bonding. Here we present a systematic review on maternal voice effects on preterm infants' development. Literature search occurred on 4 databases (PubMed, Scopus, Web of Science and CINAHL). Preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines have been adopted and standardized quality appraisal has been carried on. Wide differences emerged in infants' characteristics and maternal voice exposure methods. Inconsistency emerged for physiological outcomes (e.g., heart rate variability, oxygen saturation, number of critical alarm events), whereas a robust pattern of findings emerged for feeding behaviors, as well as cognitive and neurobehavioral development. Maternal voice appears to be a non-noxious intervention, which is consistent with developmental care and which can be embedded in developmental care strategies.

Parental Perception of Risk Associated With Their Premature Infant

BACKGROUND

Preterm birth has been linked to increased parental stress, depression, and anxiety. Although the rate of neonatal morbidity and mortality decreases with increasing gestational age, recent research has revealed that there is no threshold age for risk or parental concern.

PURPOSE

This study examines parental concern about medical and developmental outcomes of their premature infant.

METHODS

Parents of 60 premature infants were surveyed in a follow-up clinic regarding their level of concern about 11 morbidities and their child's gestation-adjusted age; these were compared with the infant's inpatient chart. "Concern scores" were tallied and compared across gestational age groups and knowledge of gestation-adjusted age using Chi-square tests of independence.

FINDINGS

Many parents reported concerns about morbidities that were unsupported by their child's diagnoses. Across parents of extremely, very, and moderate-late preterm children, the mean concern scores were 13.9, 15.7, and 19.7, respectively. Overall, 62% of parents incorrectly reported the gestation-adjusted age of their child. Parents who were correct were significantly more likely to correctly anticipate abnormal developmental patterns (70%) and growth patterns (65%) than those who were incorrect (33% and 31%, respectively).

IMPLICATIONS FOR RESEARCH

Future research should focus on whether NICU graduate parental stress levels are directly linked to the severity of their child's condition, and how physicians can help decrease NICU graduate parental stress.

IMPLICATIONS FOR PRACTICE

Parental anxiety regarding all gestational age neonatal intensive care unit infant outcomes can be decreased by a thorough explanation of gestation-adjusted age and a discussion of expected prematurity-related issues.

Health Services Use by Late Preterm and Term Infants From Infancy to Adulthood: A Meta-analysis

CONTEXT

Late-preterm infants born at 34 to 36 weeks' gestation have increased risks of various health problems. Health service utilization (HSU) of late-preterm infants has not been systematically summarized before.

OBJECTIVES

To summarize the published literature on short- and long-term HSU by late-preterm infants versus term infants from infancy to adulthood after initial discharge from the hospital.

DATA SOURCES

We searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO.

STUDY SELECTION

Cohort and case-control studies that compared HSU (admissions, emergency department visits, etc) between late-preterm infants and term infants were included.

DATA EXTRACTION

Data extracted included study design, setting, population, HSU, covariates, and effect estimates.

RESULTS

Fifty-two articles were included (50 cohort and 2 case-control studies). Meta-analyses with random effect models that used the inverse-variance method found that late-preterm infants had higher chances of all-cause admissions than term infants during all the time periods. The magnitude of the differences decreased with age from the neonatal period through adolescence, with adjusted odds ratios from 2.34 (95% confidence intervals 1.19-4.61) to 1.09 (1.05-1.13) and adjusted incidence rate ratios from 2.62 (2.52-2.72) to 1.14 (1.11-1.18). Late-preterm infants had higher rates of various cause-specific HSU than term infants for jaundice, infection, respiratory problems, asthma, and neurologic and/or mental health problems during certain periods, including adulthood.

LIMITATIONS

Considerable heterogeneity existed and was partially explained by the variations in the adjustment for multiple births and gestational age ranges of the term infants.

CONCLUSIONS

Late-preterm infants had higher risks for all-cause admissions as well as for various cause-specific HSU during the neonatal period through adolescence.

Gender Differences in Respiratory Morbidity and Mortality of Preterm Neonates

For the past century, researchers have underscored the "disadvantage" observed in respiratory morbidity and mortality of male newborns. In this contemporary review, we examine gender differences in preterm infant respiratory morbidity and mortality specifically appraising differences in the very low birth weight (VLBW) population as well as the late preterm (LPT) population. In the era of postnatal surfactant and antenatal corticosteroids, the gender gap in neonatal outcomes has not narrowed. Structural, physiologic, and hormonal sex differences may be at the root of this disparity. Further exploration into the origin of gender differences in respiratory morbidity and neonatal mortality will shape future therapies. These therapies may need to be gender specific to close the gender gap.

The influence of birth weight amongst 33-35 weeks gestational age (wGA) infants on the risk of respiratory syncytial virus (RSV) hospitalisation: a pooled analysis

OBJECTIVE

To investigate the association between birth weight and respiratory syncytial virus (RSV) hospitalisation during the first year of life in 33°-35⁶ weeks' gestational age (wGA) infants.

STUDY DESIGN

Pooled analysis of data (n = 1218) from Spain, Germany, France and Italy.

RESULT

RSV hospitalised infants overall had a significantly higher birth weight than non-hospitalised infants (2.24 versus 2.14 kg; p < 0.001) for both males (2.25 versus 2.18 kg; p = 0.049) and females (2.22 versus 2.11 kg, p = 0.007). The effect was significant only in 34 wGA infants (33 wGA: hospitalised 1.95 kg versus non-hospitalised 1.95 kg, p = 0.976; 34 wGA: 2.26 versus 2.14 kg, p = 0.007; 35 wGA: 2.37 versus 2.29 kg, p = 0.070), particularly female 34 wGA infants (female: 2.24 versus 2.08 kg, p = 0.019; male: 2.27 versus 2.20, p = 0.191). Birth weight was shown to be an independent risk factor for RSV hospitalisation.

CONCLUSIONS

In 33-35 wGA infants, a higher birth weight appeared independently associated with an increased risk of RSV hospitalisation.

Macro preemies: no thresholds for risks or concerns

PURPOSE OF REVIEW

To provide an overview of the literature regarding medical and developmental risks for moderate to late preterm infants (32-36 weeks gestation), with particular attention to the pediatrician's role in care during both inpatient and outpatient periods.

RECENT FINDINGS

Although the risks of medical issues and developmental delays decrease with increasing gestational age, research suggests that infants born after 32 weeks' gestation often exhibit significant morbidities associated with prematurity. These infants, often referred to as 'macro preemies', have been found to be at a greater risk for medical complications secondary to immature organ systems including impairments in temperature regulation, respiratory functioning, feeding coordination, bilirubin excretion, glucose control, and infection susceptibility. Recent studies of macro preemies also suggest a higher incidence of significant deficits noted in gross and fine motor skills, speech and communication, and learning and behavior compared to their full-term counterparts. Without careful attention from birth, macro preemie infants could be susceptible to both medical issues and developmental delays.

SUMMARY

Physicians should be aware of the research regarding increased medical and developmental risks for all infants born before term in order to provide their patients with comprehensive medical and neurodevelopmental follow-up care.

Clinical factors affecting the timing of delivery in twin pregnancies

OBJECTIVE

To investigate clinical factors affecting the timing of delivery in twin pregnancies in order to minimize perinatal complications.

METHODS

A retrospective study involved 163 twin pregnancies delivered from January 2006 to September 2011 at Gachon University Gil Medical Center. These cases were divided into three groups based on the delivery timing: less than 32 weeks' gestation (group A), between 32 and 35+6 weeks' gestation (group B), and over 36 weeks' gestation (group C). Clinical factors including maternal age, parity, presence of premature uterine contraction, presence of premature rupture of membrane, white blood cell, high sensitive C-reactive protein level, cervical dilatation, maternal complication, chorionicity, twin specific complication, and perinatal complication were analyzed for each group.

RESULTS

In group B, the timing of delivery was postponed for 14 days or more from the time of admission, and there were fewer numbers of babies with low Apgar score at birth compared with other groups. The frequency of uterine contraction (P<0.001), presence of premature rupture of membranes (P=0.017), dilatation of cervix (P<0.001), increased white blood cell and high sensitive C-reactive protein levels (P=0.002, P<0.001) were important clinical factors during decision making process of delivery timing in twin pregnancies. Twin specific fetal conditions, such as twin-twin transfusion syndrome and discordant growth (over 25% or more) were shown more frequently in group A. However, there were no significant statistical differences among three groups (P=0.06, P=0.14).

CONCLUSION

Proper management for preventing premature contraction and inflammation can be essential in twin pregnancies until 32 weeks' gestation, and may decrease maternal and perinatal complications.

Early neonatal morbidities and associated modifiable and non-modifiable risk factors in a cohort of infants born at 34-35 weeks of gestation

OBJECTIVE

To ascertain the most common early morbidities in a cohort of infants born at 34-35 weeks gestation and to identify the risk factors associated with these morbidities.

METHODS

Retrospective analysis of data collected prospectively for all 235 infants born at 34-35 weeks of gestation during an eight-month period at a single tertiary medical center. Study group infants (SG) were compared with 470 term infants (TI), matched both for gender and for mode of delivery.

RESULTS

Jaundice requiring phototherapy (32%), respiratory disease (19.1%) and cyanotic episodes (15.7%) were the most frequent early morbidities, followed by hypoglycemia, temperature instability and feeding intolerance. The risk of having a complication was 13.3-times higher in the SG compared with the TI group (95% CI 8.9-19.6, p < 0.001). Modifiable interventions associated with these morbidities were antenatal steroids, MgSO4 and mode of delivery. Non-modifiable factors were maternal age, parity, twins and gender.

CONCLUSIONS

Jaundice requiring phototherapy, respiratory disease and cyanotic episodes are the most frequent early morbidities among infants born at 34-35 weeks. Medically modifiable factors were found to be associated with the above morbidities. Whether specific recommendations for the care of these infants will affect early morbidities needs to be studied in controlled prospective studies.

A national survey of admission practices for late preterm infants in England

Background

Infants born at 34⁺⁰ to 36⁺⁶ weeks gestation are defined as ‘late preterm’ infants. It is not clear whether these babies can be managed on the postnatal ward (PNW) or routinely need to be admitted to the neonatal unit after birth.

Aim

To conduct a national survey of admission practice for late preterm and low birth weight infants directly to the PNW after birth in England.

Methods

All neonatal units were identified from the Standardised Electronic Neonatal Database (SEND). Individual units were contacted and data collected on their admission practice.

Results

All 180 neonatal units in England responded. 49, 84 and 47 Units were Special Care Units (SCUs), Local Neonatal Units (LNUs) and Neonatal Intensive Care Units (NICUs) respectively. 161 units (89%) had written guidelines in relation to direct PNW admission for late preterm infants.

The mean gestational age of infants admitted directly to the PNW was significantly lower in LNUs compared to SCUs and NICUs compared to LNUs. Mean birth weight limit for direct PNW admission was significantly lower in NICUs compared to SCUs.

72 units had PNW nursery nurses. There was no significant difference in gestational age or birth weight limit for direct PNW admission in the presence of PNW nursery nurses.

Conclusions

Admission practices of late preterm infants directly to the PNW varies according to designation of neonatal unit in England. Further studies are needed to establish the factors influencing these differences.

Preterm birth trends in Greece, 1980-2008: a rising concern

OBJECTIVE

To identify preterm birth trends in Greece.

DESIGN

Retrospective epidemiological study.

SETTING

Women giving birth in Greece from 1980 to 2008.

POPULATION

Live births beyond the 24th gestational week.

METHODS

Data acquisition from the Hellenic Vital Statistics records. Statistical analysis of preterm birth rate among neonates estimated for each year.

MAIN OUTCOME MEASURES

Total number of births and preterm births, as well as rate of preterm birth by gestational week. Stillbirth rates by gestational age.

RESULTS

3 218 463 births occurred during the period under study, 151 594 (4.7%) of which were preterm. A steep rise in preterm births was noted during the final years of the study, reaching 9.6% in 2008. This was mainly due to the "late preterm" sub-group (34(+0) -36(+6) gestational weeks). The rates of stillbirth fell in a constant way regardless of the maturity index.

CONCLUSIONS

Although preterm birth etiology is multifactorial, the selective rise in the "late preterm" group possibly was due to an increase in medical reasons necessitating a preterm delivery, changes in obstetric practice, or both. Further studies are needed to estimate the precise effect of each contributing factor.

Effect of delayed intermittent ventricular drainage on ventriculomegaly and neurological deficits in experimental neonatal hydrocephalus

PURPOSE

Evidence-based guidelines do not indicate when ventricular reservoirs should be placed in children with neonatal hydrocephalus, and delayed intervention is common. We hypothesize that delayed ventricular drainage has adverse effects on structural development and functional outcomes.

METHODS

Using a well-established animal model of kaolin-induced obstructive hydrocephalus, we evaluated neurologic deficit after early (~1 week post-kaolin) or late (~2 weeks post-kaolin) placement of ventricular reservoirs which were tapped according to strict neurologic criteria.

RESULTS

Progressive ventriculomegaly was similar in early- and late-reservoir implantation groups. The average neurologic deficit scores (NDSs) over the experimental period were 0 (n=6), 2.74 (n=5), and 2.01 (n=3) for the control, early-, and late-reservoir groups, respectively. At reservoir placement, early-group animals displayed enlarged ventricles without neurologic deficits (mean NDS=0.17), while the late group displayed ventriculomegaly with clinical signs of hydrocephalus (mean NDS=3.13). The correlation between ventriculomegaly severity and NDS in the early group was strongly positive in the acute (before surgery to 3 weeks post-reservoir placement) (R(2)=0.65) and chronic (6 to 12 weeks post-reservoir placement) (R(2)=0.65) phases, while the late group was less correlated (acute R(2)=0.51; chronic R(2)=0.19).

CONCLUSIONS

Current practice favors delaying reservoir implantation until signs of elevated intracranial pressure and neurologic deficit appear. Our results demonstrate that animals in early and late groups undergo the same course of ventriculomegaly. The findings also show that tapping reservoirs in these neonatal hydrocephalic animals based on neurologic deficit does not halt progressive ventricular enlargement and that neurologic deficit correlates strongly with ventricular enlargement.

Late preterm birth: a review of medical and neuropsychological childhood outcomes

Late preterm (LP) birth (34 0/7 - 36 6/7 weeks' gestation) accounts for nearly three-fourths of all preterm births, making this population a sizeable public health concern. The immature fetal development associated with LP delivery increases the risk of mortality and short-term medical complications. Which combination of maternal, fetal, or neonatal risk factors may be most critical has only recently begun to be addressed, and whether LP birth's disruptive impact on brain development will exert adverse effects on neuropsychological functioning in childhood and adolescence has been understudied. Early data have shown a graded response, with LP children often functioning better than very preterm children but worse than term children, and with subtle intellectual and neuropsychological deficits in LP children compared with healthy children born at term gestational age. Further characterization of the neuropsychological profile is required and would be best accomplished through prospective longitudinal studies. Moreover, since moderate and LP births result in disparate medical and psychological outcomes, the common methodology of combining these participants into a single research cohort to assess risk and outcome should be reconsidered. The rapidly growing LP outcomes literature reinforces a critical principle: fetal development occurs along a dynamic maturational continuum from conception to birth, with each successive gestational day likely to improve overall outcome.

NEONATAL OUTCOMES FOLLOWING LATE PRETERM BIRTH

It is well recognised that birth before 32 weeks of gestation is associated with substantial neonatal morbidity and mortality and these risks have been extensively reported. The focus of perinatal research for many years has therefore been very preterm and extremely preterm delivery, since the likelihood and severity of adverse neonatal outcomes are highest within this group. In contrast, until recently, more mature preterm infants have been understudied and indeed, almost ignored by researchers.

Neonatal problems of late and moderate preterm infants

Late and moderate preterm infants account for >80% of premature births. These newborns experience considerable mortality and morbidity in comparison with full-term born infants. The purpose of this paper is to summarise the most common morbidities of late and moderate preterm infants in the neonatal period, their incidence, severity, risk factors and need for admission to the different levels of care. The recent findings on preventive strategies and management priorities for clinical care of these vulnerable babies are also reviewed.

Hypoglycemia in critically ill children

BACKGROUND

The practice of glycemic control with intravenous insulin in critically ill patients has brought clinical focus on understanding the effects of hypoglycemia, especially in children. Very little is published on the impact of hypoglycemia in this population. We aimed to review the existing literature on hypoglycemia in critically ill neonates and children.

METHODS

We performed a systematic review of the literature up to August 2011 using PubMed, Ovid MEDLINE and ISI Web of Science using the search terms "hypoglycemia or hypoglyc*" and "critical care or intensive care or critical illness". Articles were limited to "all child (0-18 years old)" and "English".

RESULTS

A total of 513 articles were identified and 132 were included for review. Hypoglycemia is a significant concern among pediatric and neonatal intensivists. Its definition is complicated by the use of a biochemical measure (i.e., blood glucose) for a pathophysiologic problem (i.e., neuroglycopenia). Based on associated outcomes, we suggest defining hypoglycemia as <40-45 mg/dl in neonates and <60-65 mg/dl in children. Below the suggested threshold values, hypoglycemia is associated with worse neurological outcomes, increased intensive care unit stay, and increased mortality. Disruptions in carbohydrate metabolism increase the risk of hypoglycemia incritically ill children. Prevention of hypoglycemia, especially in the setting of intravenous insulin use, will be best accomplished by the combination of accurate measuring techniques, frequent or continuous glucose monitoring, and computerized insulin titration protocols.

CONCLUSION

Studies on hypoglycemia in critically ill children have focused on spontaneous hypoglycemia. With the current practice of maintaining blood glucose within a narrow range with intravenous insulin, the risk factors and outcomes associated with insulin-induced hypoglycemia should be rigorously studied to prevent hypoglycemia and potentially improve outcomes of critically ill children.

A systematic review of severe morbidity in infants born late preterm

OBJECTIVE

Late-preterm infants (34 weeks 0/7 days-36 weeks 6/7 days' gestation) represent the largest proportion of singleton preterm births. A systematic review was performed to access the short- and/or long-term morbidity of late-preterm infants.

STUDY DESIGN

An electronic search was conducted for cohort studies published from January 2000 through July 2010.

RESULTS

We identified 22 studies studying 29,375,675 infants. Compared with infants born at term, infants born late preterm were more likely to suffer poorer short-term outcomes such as respiratory distress syndrome (relative risk [RR], 17.3), intraventricular hemorrhage (RR, 4.9), and death <28 days (RR, 5.9). Beyond the neonatal period, late-preterm infants were more likely to die in the first year (RR, 3.7) and to suffer from cerebral palsy (RR, 3.1).

CONCLUSION

Although the absolute incidence of neonatal mortality and morbidity in infants born late preterm is low, its incidence is significantly increased as compared with infants born at term.

Maternal and neonatal profile of late-preterm survivors in a poorly resourced country

OBJECTIVE

To determine maternal indicators and adverse perinatal outcomes among late-preterm infants during birth hospitalization in a low-income country.

METHODS

Cross-sectional study of late-preterm and term survivors in a tertiary maternity hospital in southwest Nigeria using multivariable logistic regression analysis and population attributable risk (PAR) percentage. Adjusted odds ratios (OR) and 95% confidence intervals (CI) of significant factors are stated.

RESULTS

Of 4176 infants enrolled, 731 (17.5%) were late preterm and 3445 (82.5%) were full-term. Late-preterm delivery was independently associated with mothers who were unmarried (OR: 1.71, CI: 1.06-2.75), lacked formal education (OR: 1.75, CI: 1.06-2.89), human immunodeficiency virus positive (OR: 1.61, CI: 1.17-2.20), with hypertensive disorders (OR: 3.07, CI: 2.32-4.08), antepartum hemorrhage (OR: 3.66, CI: 1.97-6.84), and were unlikely to have induced labor (OR: 0.010, CI: 0.01-0.69). Hypertensive disorders and antepartum hemorrhage had a combined PAR of 48.4%. Infants born late preterm were more likely to have low 5-min Apgar scores (OR: 1.70, CI: 1.01-2.83), sepsis (OR: 1.62, CI: 1.05-2.50), hyperbilirubinemia (OR: 1.56, CI: 1.05-2.33), admission into special care baby unit (OR: 1.85, CI: 1.38-2.48), and nonexclusive breast-feeding (OR: 1.49, CI: 1.49, CI: 1.18-1.89).

CONCLUSIONS

These findings suggest that late-preterm infants in low-resource settings are at risk of severe morbidity and suboptimal feeding. Education and close monitoring of high-risk mothers are warranted to prevent avoidable late-preterm delivery and facilitate the proactive management of unavoidable late-preterm births.

Atosiban in the Management of Preterm Labour

The purpose of this review was to look at the evidence available for the use of atosiban as a tocolytic in cases of threatened preterm labour. A Royal College of Obstetricians and Gynaecologists Green Top Guideline concluded that there was no clear evidence to show a benefit to tocolysis in reducing perinatal and neonatal morbidity and mortality. Using a systematic literature search, we summarise the evidence available on the use of atosiban for the prevention of preterm birth and compare it with other commonly used tocolytic agents in terms of efficacy, patient preference and drug safety. We conclude that although atosiban appears to be the tocolytic of choice, a clear benefit of using tocolysis in all cases of threatened preterm labour remains to be justified and clinical management should be tailored according to individual needs.