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Lu P, Gong X, Gu X, Jiang S, Cao Y, Sun C, Du J, Lei X, Lee SK. Mortality and extrauterine growth restriction of necrotizing enterocolitis in very preterm infants with heart disease: a multi-center cohort study. Eur J Pediatr 2024; 183:3579-3588. [PMID: 38822834 DOI: 10.1007/s00431-024-05599-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 06/03/2024]
Abstract
Congenital heart disease (CHD) and patent ductus arteriosus (PDA) are risk factors of necrotizing enterocolitis (NEC) in infants. However, it is unclear whether the prognosis of NEC is different between very preterm infants (VPIs) with and without heart diseases. This was an observational cohort study that enrolled VPIs (born between 24+0 and 31+6 weeks) admitted to 79 tertiary neonatal intensive care units (NICU) in the Chinese Neonatal Network (CHNN) between 2019 and 2021. The exposure was CHD or isolated PDA, and VPIs with NEC were divided into three groups: complicated with CHD, with isolated PDA, and without heart diseases. The primary outcomes were NEC-related adverse outcomes (death or extrauterine growth restriction (EUGR)). Logistic regression models were used to adjust potential confounders and calculate the odds ratios (ORs) and 95% confidential intervals (CIs) for each outcome. A total of 1335 VPIs with NEC were enrolled in this study, including 65 VPIs with CHD and 406 VPIs with isolated PDA. The VPIs with heart diseases had smaller gestational ages and lower body weights at birth, more antenatal steroids use, and requiring inotrope prior to the onset of NEC. While suffering from NEC, there was no significant increased risks in NEC-related death in VPIs with either CHD (adjusted OR [aOR]: 1.10; 95% CI: 0.41-2.50) or isolated PDA (aOR: 1.25; 95% CI 0.82-1.87), and increased risks in EUGR were identified in either survival VPIs with CHD (aOR: 2.35; 95% CI: 1.31-4.20) or isolated PDA (aOR: 1.53; 95% CI: 1.16-2.01) in survivors. The composite outcome (death or EUGR) was also more often observed in VPIs with either CHD (aOR: 2.07; 95% confidence interval [CI]: 1.20-3.60) or isolated PDA (aOR: 1.51; 95% CI: 1.17-1.94) than that without heart diseases. VPIs with either CHD or isolated PDA were associated with significantly prolonged duration of fasting, extended time to achieve full enteral feeding, and longer ventilation duration and hospitalization duration. Similar characteristics were also seen in VPIs with isolated PDA, with the exception that VPIs with CHD are more likely to undergo surgical intervention and maintain a prolonged fast after NEC. Conclusion: In VPIs with NEC, CHD and isolated PDA are associated with an increased risk in worse outcomes. We recommend that VPIs with cardiac NEC be managed with aggressive treatment and nutrition strategies to prevent EUGR. What is Known: • CHD and PDA are risk factors for NEC in infants, which can lead to adverse outcomes such as death and EUGR. • NEC in infants with heart disease differs clinically from that in infants without heart disease and should be recognized as a separate disease process. What is New: • CHD and isolated PDA are associated with increased risks of EUGR in VPIs with NEC. • Risk factors associated with VPIs with cardiac NEC suggested these patients should be managed with aggressive treatment and nutrition strategies to adverse outcomes.
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MESH Headings
- Humans
- Enterocolitis, Necrotizing/epidemiology
- Enterocolitis, Necrotizing/mortality
- Enterocolitis, Necrotizing/complications
- Infant, Newborn
- Male
- Female
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/mortality
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/epidemiology
- Ductus Arteriosus, Patent/complications
- Ductus Arteriosus, Patent/epidemiology
- Cohort Studies
- Risk Factors
- Intensive Care Units, Neonatal/statistics & numerical data
- China/epidemiology
- Infant, Premature
- Retrospective Studies
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Affiliation(s)
- Pei Lu
- Department of Neonatology, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Xiaohui Gong
- Department of Neonatology, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Putuo District, Shanghai, 200062, China.
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Siyuan Jiang
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
- Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
- Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Chengjun Sun
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Juan Du
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Xiaoping Lei
- Division of Neonatology, Department of Pediatrics, the Affiliated Hospital, Southwest Medical University, 8 Kangcheng Road, Luzhou, Sichuan, China.
| | - Shoo K Lee
- Maternal-Infant Care Research Centre, Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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2
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Palomino-Fernández L, Pastor-Villaescusa B, Velasco I, Rico MDLC, Roa J, Gil Á, Gil-Campos M. Metabolic and Low-Grade Inflammation Risk in Young Adults with a History of Extrauterine Growth Restriction. Nutrients 2024; 16:1608. [PMID: 38892541 PMCID: PMC11174372 DOI: 10.3390/nu16111608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Children with a history of extrauterine growth restriction (EUGR), later at prepubertal age, exhibit an increased metabolic risk including risen insulin resistance and low-grade inflammation. However, the progression of such metabolic changes after puberty and the lasting health implications have not yet been investigated. The objective of this study was to ascertain whether young adults with a history of EUGR faced increased vulnerability to metabolic disorders. A study was conducted comparing a group of adults with a history of EUGR with a healthy reference group. A total of 110 young adults (36 from the EUGR group and 74 from the control group) were included. Anthropometric variables, blood pressure (BP), general biochemical parameters, plasma inflammatory biomarkers, and adipokines were assessed. Compared to the reference group, the EUGR group had a shorter height and body weight with higher lean mass and waist circumference, as well as a greater percentage of individuals with high BP. In addition, EUGR patients had higher values of insulin, HOMA-IR, nerve growth factor, and leptin, and lower levels of adiponectin and resistin. The present study suggests that young adults with a history of EUGR present increased metabolic risk factors therefore, clinical follow-up should be considered.
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Affiliation(s)
- Laura Palomino-Fernández
- Metabolism and Investigation Unit, Reina Sofia University Hospital, Maimonides Institute of Biomedicine Research of Cordoba (IMIBIC), University of Cordoba, 14004 Cordoba, Spain; (L.P.-F.); (B.P.-V.); (M.G.-C.)
| | - Belén Pastor-Villaescusa
- Metabolism and Investigation Unit, Reina Sofia University Hospital, Maimonides Institute of Biomedicine Research of Cordoba (IMIBIC), University of Cordoba, 14004 Cordoba, Spain; (L.P.-F.); (B.P.-V.); (M.G.-C.)
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), RD21/0012/0008, Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
| | - Inmaculada Velasco
- Department of Cell Biology, Physiology and Immunology, Reina Sofia University Hospital, Maimonides Institute of Biomedicine Research of Cordoba (IMIBIC), University of Cordoba, 14004 Cordoba, Spain;
| | - María de la Cruz Rico
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, “José Mataix Verdú” Institute of Nutrition and Food Technology (INYTA), University of Granada, 18016 Granada, Spain; (M.d.l.C.R.); (Á.G.)
- Center of Biomedical Research, Instituto de Investigación Biosanitaria (IBS.Granada), University of Granada, 18016 Granada, Spain
| | - Juan Roa
- Department of Cell Biology, Physiology and Immunology, Reina Sofia University Hospital, Maimonides Institute of Biomedicine Research of Cordoba (IMIBIC), University of Cordoba, 14004 Cordoba, Spain;
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
| | - Ángel Gil
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, “José Mataix Verdú” Institute of Nutrition and Food Technology (INYTA), University of Granada, 18016 Granada, Spain; (M.d.l.C.R.); (Á.G.)
- Center of Biomedical Research, Instituto de Investigación Biosanitaria (IBS.Granada), University of Granada, 18016 Granada, Spain
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
| | - Mercedes Gil-Campos
- Metabolism and Investigation Unit, Reina Sofia University Hospital, Maimonides Institute of Biomedicine Research of Cordoba (IMIBIC), University of Cordoba, 14004 Cordoba, Spain; (L.P.-F.); (B.P.-V.); (M.G.-C.)
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain
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Kakatsaki I, Papanikolaou S, Roumeliotaki T, Anagnostatou NH, Lygerou I, Hatzidaki E. The Prevalence of Small for Gestational Age and Extrauterine Growth Restriction among Extremely and Very Preterm Neonates, Using Different Growth Curves, and Its Association with Clinical and Nutritional Factors. Nutrients 2023; 15:3290. [PMID: 37571226 PMCID: PMC10420820 DOI: 10.3390/nu15153290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
Monitoring the growth of neonates in the Neonatal Intensive Care Unit (NICU) using growth charts constitutes an essential part of preterm infant care. Preterm infants are at increased risk for extrauterine growth restriction (EUGR) due to increased energy needs and clinical complications. This retrospective study compares the prevalence of small for gestational age (SGA) at birth and EUGR at discharge in extremely and very preterm neonates hospitalized in the NICU of a tertiary hospital in Greece, using different growth curves, and it examines the associated nutritional and clinical factors. Fenton2013 and INTERGROWTH-21st growth curves were used to calculate z-scores of birth weight (BW) and weight, length, and head circumference at discharge. The study includes 462 newborns with a mean BW of 1341.5 g and mean GA of 29.6 weeks. At birth, 6.3% of neonates were classified as SGA based on Fenton2013 curves compared to 9.3% with INTERGROWTH-21st growth curves. At discharge, 45.9% of neonates were characterized as having EUGR based on the Fenton2013 weight curves and 29.2% were characterized based οn INTERGROWTH-21st curves. Nutritional factors such as the day of initiation, attainment of full enteral feeding, and the duration of parenteral nutrition were associated with EUGR by both curves. The prevalence of SGA and EUGR neonates differs between the two growth references. This shows that further evaluation of these charts is needed to determine the most appropriate way to monitor infant growth.
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Affiliation(s)
- Ioanna Kakatsaki
- Neonatal Intensive Care Unit, Department of Neonatology, University General Hospital of Heraklion, 71500 Crete, Greece; (I.K.); (S.P.); (N.H.A.); (I.L.)
| | - Styliani Papanikolaou
- Neonatal Intensive Care Unit, Department of Neonatology, University General Hospital of Heraklion, 71500 Crete, Greece; (I.K.); (S.P.); (N.H.A.); (I.L.)
| | - Theano Roumeliotaki
- Clinic of Preventive Medicine and Nutrition, Division of Social Medicine, School of Medicine, University of Crete, 70013 Crete, Greece;
| | - Nicolina Hilda Anagnostatou
- Neonatal Intensive Care Unit, Department of Neonatology, University General Hospital of Heraklion, 71500 Crete, Greece; (I.K.); (S.P.); (N.H.A.); (I.L.)
- Neonatology, School of Medicine, University of Crete, 70013 Crete, Greece
| | - Ioanna Lygerou
- Neonatal Intensive Care Unit, Department of Neonatology, University General Hospital of Heraklion, 71500 Crete, Greece; (I.K.); (S.P.); (N.H.A.); (I.L.)
| | - Eleftheria Hatzidaki
- Neonatal Intensive Care Unit, Department of Neonatology, University General Hospital of Heraklion, 71500 Crete, Greece; (I.K.); (S.P.); (N.H.A.); (I.L.)
- Neonatology, School of Medicine, University of Crete, 70013 Crete, Greece
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4
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Gounaris AK, Sokou R, Gounari EA, Panagiotounakou P, Grivea IN. Extrauterine Growth Restriction and Optimal Growth of Very Preterm Neonates: State of the Art. Nutrients 2023; 15:3231. [PMID: 37513649 PMCID: PMC10384682 DOI: 10.3390/nu15143231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Over the last few decades, there has been an ongoing debate over both the optimal feeding mode for very premature neonates (VPN) as well as what their optimal growth should be. Despite the American Academy of Pediatric declaring since 1997 that the growth of VPN should follow the trajectory of intrauterine fetal growth, differences of opinion persist, feeding policies keep changing, and the growth and development of VPN remains extremely variable not only between countries, but even between neighboring neonatal units. Even the appropriate terminology to express poor postnatal growth (extrauterine growth restriction (EGR) and postnatal growth failure (PGF)) remains a subject of ongoing discussion. A number of recent publications have shown that by implementing breast milk fortification and closely following growth and adjusting nutrition accordingly, as per the consensus guidelines of the major Neonatal Societies, we could achieve growth that closely follows birth centiles. A recent position paper from EPSGAN recommending targeted nutritional support to cover the energy and protein deficits sustained by VPN during periods of critical illness further strengthens the above findings. Conclusion: We can promote better growth of VPN by ensuring a stable administration of sufficient calories and protein, especially in the first 2 weeks of life, implementing breast milk fortification, covering energy and protein deficits due to critical illness, and increasing feeding volumes as per the latest guidelines. The adoption of universal protocol for nutrition and growth of VPN is essential and will enable better monitoring of long-term outcomes for this population.
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Affiliation(s)
- Antonios K Gounaris
- Neonatal Clinic-NICU, University Hospital of Larissa, 413 34 Larissa, Greece
| | - Rozeta Sokou
- Neonatal Clinic-NICU, Nikea General Hospital "Agios Panteleimon", 184 54 Piraeus, Greece
| | | | | | - Ioanna N Grivea
- Neonatal Clinic-NICU, University Hospital of Larissa, 413 34 Larissa, Greece
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5
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Perrin T, Pradat P, Larcade J, Masclef-Imbert M, Pastor-Diez B, Picaud JC. Postnatal growth and body composition in extremely low birth weight infants fed with individually adjusted fortified human milk: a cohort study. Eur J Pediatr 2023; 182:1143-1154. [PMID: 36598567 PMCID: PMC10023649 DOI: 10.1007/s00431-022-04775-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/05/2023]
Abstract
This cohort study aimed to evaluate the impact of an individualised nutritional care approach combining standardised fortification with adjustable fortification on postnatal growth and body composition in extremely low birth weight (ELBW) infants. We included ELBW infants admitted to a neonatal intensive care unit and still hospitalised at 35 weeks postmenstrual age (PMA). The fortification of human milk was standardised (multicomponent fortifier) between 70 mL/kg/day and full enteral feeding, and then individualised using adjustable fortification. When weight gain was below 20 g/kg/day, protein or energy was added when serum urea was below or above 3.5 mmol/L, respectively. Postnatal growth failure (PNGF) was defined as being small for gestational age at discharge and/or when the Z-score loss between birth and discharge was higher than 1. Body composition was assessed between 35 and 41 weeks of PMA. Among the 310 ELBW infants included, the gestational age of birth was 26.7 ± 1.8 weeks, and the birth weight was 800 ± 128 g. The mean Z-score difference between birth and discharge was moderately negative for the weight (-0.32), more strongly negative for length (-1.21), and almost nil for head circumference (+ 0.03). Only 27% of infants presented PNGF. At discharge, fat mass was 19.8 ± 3.6%. Multivariable analysis showed that the proportion of preterm formula received and gestational age at birth were independently associated with the percentage of fat mass. Conclusion: The individualised nutritional care approach applied herein prevented postnatal weight loss in most infants, limited length growth deficit, and supported excellent head circumference growth. What is Known: • At least half of extremely low birth weight infants are small for gestational age at discharge and postnatal growth deficit has been associated with impaired neurocognitive and renal development. • Human milk is the main milk used in neonatology and, although fortification of human milk is a standard of care, there is no consensus regarding the optimal fortification strategy to be adopted. What is New: • Using an approach combining standardised fortification followed by individualised adjustable fortification limited postnatal growth deficit for body weight and head circumference. Postnatal growth failure is not a fatality in extremely low birth weight infants. • Each additional gestational age week at birth resulted in a decrease in fat mass percentage at discharge, which was higher than in foetuses of the same gestational age, likely representing a necessary adaptation to extra-uterine life.
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Affiliation(s)
- Tania Perrin
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Pierre Pradat
- Centre de Recherche Clinique, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, Lyon, 69004, France
| | - Julie Larcade
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Marion Masclef-Imbert
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Blandine Pastor-Diez
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Jean-Charles Picaud
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France.
- Laboratoire CarMen, INSERM, INRA, Université Claude Bernard Lyon1, Pierre-Bénite, Lyon, 69310, France.
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González-García L, Mantecón-Fernández L, Suárez-Rodríguez M, Arias-Llorente R, Lareu-Vidal S, Ibáñez-Fernández A, Caunedo-Jiménez M, González-López C, Fernández-Morán E, Fernández-Colomer B, Solís-Sánchez G. Postnatal Growth Faltering: Growth and Height Improvement at Two Years in Children with Very Low Birth Weight between 2002-2017. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121800. [PMID: 36553245 PMCID: PMC9777192 DOI: 10.3390/children9121800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022]
Abstract
The prevalence of postnatal growth faltering (PGF) in preterm infants with very low birth weight (VLBW) (<1500 g) is a universal problem. Growth improvement is expected as neonatal care is optimized. Objectives: To determine if there has been a decrease in the prevalence of PGF and an improvement in height at 2 years in appropriate for gestational age VLBW children in the last two decades. Methods: Clinical descriptive retrospective analysis of neonatal somatometry at birth and at two-year corrected age in VLBW preterm infants. Small for gestational age were excluded. Two cohorts (2002−2006, n = 112; and 2013−2017, n = 92) were compared. Results. In the second five-year period, a decrease in prevalence of PGF was observed (36.6% vs. 22.8%, p = 0.033), an increase in growth rate in the first 28 days (5.22 (4.35−6.09) g/kg/day vs. 11.38 (10.61−12.15) g/kg/day, p < 0.0001) and an increase in height standard deviation (SD) at 2 years (−1.12 (−1.35−−0.91) vs. −0.74 (−0.99−−0.49) p = 0.023). Probability of short stature at 2 years was directly related to daily weight gain in the first 28 days. Conclusions: when comparing two five-year periods in the last two decades, growth in VLBW preterm infants has improved, both during neonatal period and at two years of age.
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Affiliation(s)
| | - Laura Mantecón-Fernández
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
- Instituto Investigación Sanitaria Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Marta Suárez-Rodríguez
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
- Instituto Investigación Sanitaria Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Rosa Arias-Llorente
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Sonia Lareu-Vidal
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | | | - María Caunedo-Jiménez
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Clara González-López
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Eva Fernández-Morán
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Belén Fernández-Colomer
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
- Instituto Investigación Sanitaria Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Gonzalo Solís-Sánchez
- Pediatrics Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
- Instituto Investigación Sanitaria Principado de Asturias, ISPA, 33011 Oviedo, Spain
- Medical Department, University of Oviedo, 33003 Oviedo, Spain
- Correspondence:
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7
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Lyu Y, Zhu D, Wang Y, Jiang S, Lee SK, Sun J, Li L, Cao Y. Current epidemiology and factors contributing to postnatal growth restriction in very preterm infants in China. Early Hum Dev 2022; 173:105663. [PMID: 36087460 DOI: 10.1016/j.earlhumdev.2022.105663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postnatal growth restriction (PGR) is common in very preterm infants (VPIs) and is associated with adverse short and long-term developmental outcomes. Postnatal growth status for VPIs in middle- or low-income countries remains unclear. AIMS To evaluate PGR in VPIs and identify maternal and neonatal factors, clinical practice, and major neonatal morbidities associated with PGR in China. STUDY DESIGN Prospective cohort study. SUBJECTS We included 6085 infants born at <32 weeks gestation who were admitted at 57 hospitals in the Chinese Neonatal Network in 2019. OUTCOME MEASURES Birth and discharge weights were converted to age-specific Z-scores. PGR was defined as a decrease in weight z-score from birth to discharge >2. RESULTS The overall incidence of PGR was 19.9 %. The mean (standard deviation [SD]) weight Z-score was 0.12 (0.78) at birth and decreased to -1.36 (0.98) at discharge. About 4.0 % of VPIs were small for gestational age (SGA) at birth and 25.5 % of SGA infants had PGR. The incidence of PGR increased with decreasing gestational age except in the SGA subgroup. Each 1-unit increase in birthweight Z-score was associated with a 1.49-fold increased risk for PGR. Late initiation of enteral feeds and late achievement of full enteral feeds were positively associated with PGR. The common morbidities that influenced PGR were necrotizing enterocolitis ≥ stage II, patent ductus arteriosus requiring medical or surgical treatment, sepsis, bronchopulmonary dysplasia, and respiratory distress syndrome requiring surfactants. CONCLUSION Nearly one fifth of VPIs were PGR, and one fourth of SGA had PGR, which warranted further study to investigate underlying causes by which to improve postnatal growth in very preterm infants in future.
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Affiliation(s)
- Yanyu Lyu
- Department of Neonatology, Children's Hospital of Capital Institute of Pediatrics, Beijing, China; Experiment Center, Capital Institute of Pediatrics, Beijing, China
| | - Dongzhe Zhu
- Department of Neonatology, Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Yanchen Wang
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Siyuan Jiang
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China; Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre, Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Jianhua Sun
- Division of Neonatology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Li
- Department of Neonatology, Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Yun Cao
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China; Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.
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8
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Lucaccioni L, Iughetti L, Berardi A, Predieri B. Challenges in the growth and development of newborns with extra-uterine growth restriction. Expert Rev Endocrinol Metab 2022; 17:415-423. [PMID: 35941822 DOI: 10.1080/17446651.2022.2110468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 08/03/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Extra-uterine growth restriction (EUGR) is a condition caused by the failure of very preterm infants to reach their potential growth during the NICU hospital stay. Despite enormous improvements in nutritional support and strategies, the growth pattern of preterm infants is still far from the one expected. AREAS COVERED This review focuses on what EUGR is, highlighting controversial aspects of this topic. EUGR is still missing a univocal definition, and the international debate is also open on what is the best growth chart to use. Moreover, professionals in NICU may not be trained on how to perform anthropometric measurements, increasing the risk of over- or underestimation, especially for length assessment. EUGR has recently been described as one of the main comorbidities in NICU, influencing growth, metabolism, and neurodevelopment later in life. EXPERT OPINION There is still much to investigate about what the best growth pattern in the NICU should be. What is known so far is that the majority of preterm neonates develop EUGR, and this leads to several short- and long-term consequences. It is imperative that neonatologists and pediatric endocrinologists work together, to modulate growth in the NICU.
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Affiliation(s)
- Laura Lucaccioni
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Alberto Berardi
- Neonatology Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Barbara Predieri
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
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Ordóñez-Díaz MD, Gil-Campos M, Flores-Rojas K, Muñoz-Villanueva MC, Mesa MD, de la Torre-Aguilar MJ, Gil Á, Pérez-Navero JL. Impaired Antioxidant Defence Status Is Associated With Metabolic-Inflammatory Risk Factors in Preterm Children With Extrauterine Growth Restriction: The BIORICA Cohort Study. Front Nutr 2022; 8:793862. [PMID: 34993223 PMCID: PMC8724254 DOI: 10.3389/fnut.2021.793862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: An impaired antioxidant status has been described during foetal growth restriction (FGR). Similarly, the antioxidant defence system can be compromised in preterm children with extrauterine growth restriction (EUGR). The aim of this prospective study was to evaluate the antioxidant status in prepubertal children with a history of prematurity without FGR, with and without EUGR, compared to a healthy group. Methods: In total, 211 children were recruited and classified into three groups: 38 with a history of prematurity and EUGR; 50 with a history of prematurity and adequate extrauterine growth (AEUG); and 123 control children born at term. Catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx) and glutathione reductase (GR) activities were assessed in lysed erythrocytes with spectrophotometric methods. Plasma levels of the antioxidants α-tocopherol, retinol and β-carotene were determined through solvent extraction and ultra-high-pressure liquid chromatography coupled to mass spectrometry. Results: Children with the antecedent of EUGR and prematurity had lower CAT activity than the other two groups and lower GPx activity than the control children. Lower SOD, GPx and GR activities were observed in the AEUG group compared to the controls. However, higher concentrations of α-tocopherol and β-carotene were found in the EUGR group compared to the other groups; retinol levels were also higher in EUGR than in AEUG children. In EUGR and AEUG children, enzymatic antioxidant activities and plasma antioxidants were associated with metabolic syndrome components and pro-inflammatory biomarkers. Conclusions: This study reveals, for the first time, that the EUGR condition and prematurity appear to be linked to an impairment of the antioxidant defence status, which might condition an increased risk of adverse metabolic outcomes later in life.
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Affiliation(s)
- María Dolores Ordóñez-Díaz
- Unit of Neonatology, Department of Paediatrics, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia Hospital, University of Córdoba, Córdoba, Spain
| | - Mercedes Gil-Campos
- Unit of Metabolism and Paediatric Research, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain.,Biomedical Research Center-Pathophysiology of Obesity and Nutrition, Carlos III Health Institute, Madrid, Spain
| | - Katherine Flores-Rojas
- Unit of Metabolism and Paediatric Research, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain.,Biomedical Research Center-Pathophysiology of Obesity and Nutrition, Carlos III Health Institute, Madrid, Spain
| | | | - María Dolores Mesa
- Department of Biochemistry and Molecular Biology II, Center of Biomedical Research, Institute of Nutrition and Food Technology, University of Granada, Granada, Spain.,Granada Biosanitary Research Institute (ibs.Granada), Granada, Spain
| | - María José de la Torre-Aguilar
- Unit of Metabolism and Paediatric Research, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain
| | - Ángel Gil
- Biomedical Research Center-Pathophysiology of Obesity and Nutrition, Carlos III Health Institute, Madrid, Spain.,Department of Biochemistry and Molecular Biology II, Center of Biomedical Research, Institute of Nutrition and Food Technology, University of Granada, Granada, Spain.,Granada Biosanitary Research Institute (ibs.Granada), Granada, Spain
| | - Juan Luis Pérez-Navero
- Unit of Metabolism and Paediatric Research, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain.,Biomedical Research Center-Rare Diseases (CIBERER), Carlos III Health Institute, Madrid, Spain
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Growth of Very Preterm Infants in a Low-Resourced Rural Setting after Affiliation with a Human Milk Bank. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9010080. [PMID: 35053701 PMCID: PMC8774553 DOI: 10.3390/children9010080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/17/2021] [Accepted: 12/28/2021] [Indexed: 11/17/2022]
Abstract
The extrauterine growth restriction (EUGR) of very preterm infants has been associated with long-term complications and neurodevelopmental problems. EUGR has been reported at higher rates in low resource settings. There is limited research investigating how metropolitan human milk banks contribute to the growth outcomes of very preterm infants cared in rural areas. The setting of this study is located at a rural county in Taiwan and affiliated with the Taiwan Southern Human Milk Bank. Donor human milk was provided through a novel supplemental system. A renewal nutritional protocol was initiated as a quality improvement project after the affiliated program. This study aimed to compare the clinical morbidities and growth outcome at term equivalent age (TEA) of preterm infants less than 33 weeks of gestational age before (Epoch-I, July 2015–June 2018, n = 40) and after the new implementation (Epoch-II, July 2018–December 2020, n = 42). The Epoch-II group significantly increased in bodyweight z-score at TEA ((−0.02 ± 1.00) versus Epoch-I group (−0.84 ± 1.08), p = 0.002). In multivariate regression models, the statistical difference between two epochs in bodyweight z-score changes from birth to TEA was still noted. Modern human milk banks may facilitate the nutritional protocol renewal in rural areas and improve the growth outcomes of very preterm infants cared for. Establishing more distribution sites of milk banks should be encouraged.
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Ruzok T, Schmitz-Koep B, Menegaux A, Eves R, Daamen M, Boecker H, Rieger-Fackeldey E, Priller J, Zimmer C, Bartmann P, Wolke D, Sorg C, Hedderich DM. Lower hypothalamus subunit volumes link with impaired long-term body weight gain after preterm birth. Front Endocrinol (Lausanne) 2022; 13:1057566. [PMID: 36589836 PMCID: PMC9797519 DOI: 10.3389/fendo.2022.1057566] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Preterm birth is associated with an increased risk for impaired body weight gain. While it is known that in prematurity several somatic and environmental factors (e.g., endocrine factors, nutrition) modulate short- and long-term body weight gain, the contribution of potentially impaired body weight control in the brain remains elusive. We hypothesized that the structure of hypothalamic nuclei involved in body weight control is altered after preterm birth, with these alterations being associated with aberrant body weight development into adulthood. MATERIALS AND METHODS We assessed 101 very preterm (i.e., <32 weeks of gestational age) and/or very low birth weight (i.e., <1500g; VP/VLBW) and 110 full-term born (FT) adults of the population-based Bavarian Longitudinal Study with T1-weighted MRI, deep learning-based hypothalamus subunit segmentation, and multiple body weight assessments from birth into adulthood. RESULTS Volumes of the whole hypothalamus and hypothalamus subunits relevant for body weight control were reduced in VP/VLBW adults and associated with birth variables (i.e., gestational age and intensity of neonatal treatment), body weight (i.e., weight at birth and adulthood), and body weight trajectories (i.e., trajectory slopes and cluster/types such as long-term catch-up growth). Particularly, VP/VLBW subgroups, whose individuals showed catch-up growth and/or were small for gestational age, were mostly associated with volumes of distinct hypothalamus subunits such as lateral or infundibular/ventromedial hypothalamus. CONCLUSION Results demonstrate lower volumes of body weight control-related hypothalamus subunits after preterm birth that link with long-term body weight gain. Data suggest postnatal development of body weight -related hypothalamic nuclei in VP/VLBW individuals that corresponds with distinct body weight trajectories into adulthood.
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Affiliation(s)
- Tobias Ruzok
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- TUM-NIC, Technical University of Munich Neuroimaging Center, Munich, Germany
- *Correspondence: Tobias Ruzok,
| | - Benita Schmitz-Koep
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- TUM-NIC, Technical University of Munich Neuroimaging Center, Munich, Germany
| | - Aurore Menegaux
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- TUM-NIC, Technical University of Munich Neuroimaging Center, Munich, Germany
| | - Robert Eves
- Department of Psychology, University of Warwick, Coventry, United Kingdom
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Marcel Daamen
- Clinical Functional Imaging Group, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
- Department of Neonatology, University Hospital Bonn, Bonn, Germany
| | - Henning Boecker
- Clinical Functional Imaging Group, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Esther Rieger-Fackeldey
- Department of Neonatology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Josef Priller
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Neuropsychiatry, Charité - Universitätsmedizin Berlin and German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
- UK Dementia Research Institute, University of Edinburgh (UK DRI), Edinburgh, United Kingdom
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- TUM-NIC, Technical University of Munich Neuroimaging Center, Munich, Germany
| | - Peter Bartmann
- Department of Neonatology, University Hospital Bonn, Bonn, Germany
| | - Dieter Wolke
- Department of Psychology, University of Warwick, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Christian Sorg
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- TUM-NIC, Technical University of Munich Neuroimaging Center, Munich, Germany
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dennis M. Hedderich
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- TUM-NIC, Technical University of Munich Neuroimaging Center, Munich, Germany
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Gounaris A, Sokou R, Theodoraki M, Gounari E, Panagiotounakou P, Antonogeorgos G, Ioakeimidis G, Parastatidou S, Konstantinidi A, Grivea IN. "Aggressive" Feeding of Very Preterm Neonates and Body Mass Index at School Age. Nutrients 2021; 13:nu13061901. [PMID: 34205860 PMCID: PMC8227043 DOI: 10.3390/nu13061901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The effects of "aggressive" neonatal feeding policies of very preterm neonates (VPN) and the risk of metabolic syndrome later in life remain questionable. We aimed to evaluate the effect of our "aggressive" nutrition policies of VPN during hospitalisation on body mass index (BMI) at ages 2 and 8 years. MATERIALS AND METHODS Eighty four VPN, who received "aggressive" nutrition during hospitalisation in an effort to minimise postnatal growth restriction (PGR) (group A), and 62 term neonates, as controls (group B), were enrolled in the study. Group A was further divided in four subgroups depending on the type (A1: fortified expressed breast milk and preterm formula; A2: exclusively preterm formula) and quantity of milk received (A3: maximum feeds 180-210 mL/kg/day; A4: maximum feeds 210 and up to 260 mL/kg/day). BMI was calculated at ages 2 and 8 years and plotted on the centile charts. RESULTS There was no significant difference in BMI between groups A and B at 2 and 8 years, respectively, in both absolute BMI values and their centile chart distribution. There was no significant difference in BMI at 2 and 8 years either between subgroups A1 and A2 or between subgroups A3 and A4. CONCLUSIONS "Aggressive" and individualised feeding policy for VPN did not affect the BMI and obesity rates at ages of 2 and 8 years in our study population. The type and quantity of milk feeds had no impact on their BMI at school age. Further larger studies are needed to confirm our results.
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Affiliation(s)
- Antonios Gounaris
- Neonatal Clinic-NICU, University General Hospital, 41222 Larissa, Greece;
- Correspondence: ; Tel.: +30-6944-887-522
| | - Rozeta Sokou
- Neonatal Clinic-NICU, General Hospital “Agios Panteleimon”, 18454 Piraeus, Greece; (R.S.); (M.T.); (P.P.); (G.A.); (G.I.); (S.P.); (A.K.)
| | - Martha Theodoraki
- Neonatal Clinic-NICU, General Hospital “Agios Panteleimon”, 18454 Piraeus, Greece; (R.S.); (M.T.); (P.P.); (G.A.); (G.I.); (S.P.); (A.K.)
| | - Eleni Gounari
- Royal Alexandra Children’s Hospital Brighton, Eastern Road, Brighton BN2 5BE, East Sussex, UK;
| | - Polytimi Panagiotounakou
- Neonatal Clinic-NICU, General Hospital “Agios Panteleimon”, 18454 Piraeus, Greece; (R.S.); (M.T.); (P.P.); (G.A.); (G.I.); (S.P.); (A.K.)
| | - George Antonogeorgos
- Neonatal Clinic-NICU, General Hospital “Agios Panteleimon”, 18454 Piraeus, Greece; (R.S.); (M.T.); (P.P.); (G.A.); (G.I.); (S.P.); (A.K.)
| | - Georgios Ioakeimidis
- Neonatal Clinic-NICU, General Hospital “Agios Panteleimon”, 18454 Piraeus, Greece; (R.S.); (M.T.); (P.P.); (G.A.); (G.I.); (S.P.); (A.K.)
| | - Stavroula Parastatidou
- Neonatal Clinic-NICU, General Hospital “Agios Panteleimon”, 18454 Piraeus, Greece; (R.S.); (M.T.); (P.P.); (G.A.); (G.I.); (S.P.); (A.K.)
| | - Aikaterini Konstantinidi
- Neonatal Clinic-NICU, General Hospital “Agios Panteleimon”, 18454 Piraeus, Greece; (R.S.); (M.T.); (P.P.); (G.A.); (G.I.); (S.P.); (A.K.)
| | - Ioanna N. Grivea
- Neonatal Clinic-NICU, University General Hospital, 41222 Larissa, Greece;
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Makker K, Ji Y, Hong X, Wang X. Antenatal and neonatal factors contributing to extra uterine growth failure (EUGR) among preterm infants in Boston Birth Cohort (BBC). J Perinatol 2021; 41:1025-1032. [PMID: 33589730 PMCID: PMC7883994 DOI: 10.1038/s41372-021-00948-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/16/2020] [Accepted: 01/20/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Identify antenatal and neonatal factors associated with primary outcome of EUGR. METHODS 1063 preterm infants from a subset of the BBC were included in this prospective cohort study. Regression analysis was carried out to evaluate associations of EUGR with antenatal factors and neonatal factors. RESULTS 6.1% of the infants had in-utero growth restriction (IUGR) at birth and 21.7% of infants had EUGR. The adjusted odds ratio for EUGR status were significant for birth weight (OR 0.99, p = 0.00, CI 0.99-0.99), for GA at birth (OR 4.58, p = 0.00, CI 3.25-6.44), for PDA (OR 2.9, p = 0.02, CI 1.17-7.1), for NEC (OR 5.14, p = 0.012, CI 1.44-18.3) and for day of life of reaching full feeds (OR 1.04, p = 0.001, CI 1.01-1.06). CONCLUSION This study highlights important factors associated with EUGR. Additional studies are needed to gain further insight.
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Affiliation(s)
- Kartikeya Makker
- Division of Neonatology Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Yuelong Ji
- grid.21107.350000 0001 2171 9311Center on the Early Life Origins of Disease, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Xiumei Hong
- grid.21107.350000 0001 2171 9311Center on the Early Life Origins of Disease, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Xiaobin Wang
- grid.21107.350000 0001 2171 9311Center on the Early Life Origins of Disease, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA ,grid.21107.350000 0001 2171 9311Division of General Pediatrics, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD USA
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