Intraventricular Hemorrhage in Very Preterm Infants: A Comprehensive Review

Early skin-to-skin contact and the risk of intraventricular haemorrhage and sepsis in preterm infants

AIM

This study aimed to investigate the risks of intraventricular haemorrhage (IVH) or sepsis in extremely and very preterm infants exposed to early skin-to-skin contact (SSC).

METHODS

Data from the Swedish Neonatal Quality Register from 2015 to 2021 were extracted to compare the proportions of infants exposed and not exposed to SSC on day 0 and/or 1 in life that developed IVH or sepsis.

RESULTS

A total of 2514 infants, 1005 extremely preterm and 1509 very preterm, were included. This amounted to 69% of all extremely and very preterm infants born during the study period. The proportion of infants with IVH exposed and not exposed to early SSC was 11% and 27%, an adjusted odds ratio (aOR) of 0.67 (95%CI 0.52-0.86, p = 0.002). The proportion of infants with sepsis exposed and not exposed to early SSC was 16% and 30%, an aOR of 0.94 (95%CI 0.75-1.2, p = 0.60). For extremely preterm infants, the proportion with sepsis when exposed and not exposed to early SSC was 29% and 44%, an aOR of 0.65 (95%CI 0.46-0.92, p = 0.015).

CONCLUSION

In the current setting, the risk of IVH or sepsis is not increased when an extremely or very preterm infant is exposed to early SSC.

Delivery Mode and Neurological Complications in Very Low Birth Weight Infants

OBJECTIVE

 The risk of intraventricular hemorrhage (IVH) and periventricular leukomalacia is associated with low birth weight and gestational age. Caesarean section (CS) may reduce the risk of IVH, although it has been a matter of debate. The aim of this study was to evaluate the influence of the mode of delivery (MOD) on the development of IVH and cystic periventricular leukomalacia (cPVL).

STUDY DESIGN

 We analyzed an initial cohort of 11,023 very low birth weight (VLBW) infants born between January 2010 and December 2019. Infants with major malformations and gestational age <23 weeks and ≥32 weeks were excluded. A final cohort of 8,251 newborns was analyzed. Data was collected from Portuguese National very low birth weight registry. Cases were classified as vaginal delivery (VD) or CS. Outcome was assessed in univariate and logistic regression analyses.

RESULTS

 The median gestational age was 29 weeks (IQR 3.3) and the median weight was 1,100 g (IQR 555). The prevalence of IVH was significantly higher in the VD group versus the CS group, across all grading levels:1,144 newborns had grade I IVH (16% VD vs. 14% CS, p <0.01), 706 had grade II IVH (12% VD vs. 7.6% CS, p <0.01), and 777 had grade III IVH (14% VD vs. 7.9% CS, p <0.01). Post-hemorrhagic ventricular dilatation occurred in 457 newborns (8.3% VD vs. 4.6% CS, p <0.01) and 456 newborns had periventricular hemorrhagic infarction (8.4% VD vs. 4.5% CS, p <0.01). There was no association between MOD and cPVL. After applying a logistic regression analysis, including known risk factors for IVH and cPVL, VD was independently associated with an increased risk of IVH (odds ratio [OR] 1.600[1.423-1.799], p <0.001) and its complications (OR 1.440[1.195-1.735], p <0.001). MOD was not associated with an increased risk of cPVL.

CONCLUSION

 Our study suggests that CS is associated with a reduced risk of IVH and its complications in preterm VLBW infants < 32 weeks of gestational age. A CS should be considered in this group of infants to prevent the development of IVH and its complications.

KEY POINTS

· IVH and cPVL are risk factors for neurological disabilities.. · CS may decrease the risk of IVH in preterms <32 weeks GA.. · There is no association between the MOD and cPVL..

Prognosis of remaining fetus in twin pregnancy after demise of one fetus according to its location

BACKGROUND

To investigate the prognosis of the remaining fetus in twin pregnancy after experiencing one fetal demise in the first trimester according to the location of the demised fetus.

METHODS

This was a retrospective study of twin pregnancies with one fetal demise after the first trimester (14 weeks of gestation) delivered between September 2004 and September 2022. The study population was divided into two groups based on the location of the demised fetus as determined by the last recorded ultrasonography results: Group 1 included twin pregnancies where the presenting fetus was demised (n = 36) and Group 2 included twin pregnancies where the non-presenting fetus was demised (n = 44). The obstetric and neonatal outcomes were also reviewed.

RESULTS

A total of 80 pregnant women were included. The median gestational age for the diagnosis of fetal demise was 24.1 weeks. The gestational age of the demised fetus was not different between Groups 1 and 2; however, the gestational age of the remaining fetus at delivery was significantly earlier in Group 1 than it was in Group 2 (33.8 vs. 37.3 weeks, P = .004). The rate of preterm birth before 28 weeks was almost five times higher in Group 1 than in Group 2 (22.2% vs. 4.5%, P = .037). Regression analysis demonstrated significant differences between Groups 1 and 2. Respiratory distress syndrome, bronchopulmonary dysplasia, patent ductus arteriosus, retinopathy of prematurity, and jaundice were more common in Group 1 than in Group 2; however, the association was not significant after adjusting for gestational age at delivery.

CONCLUSIONS

When the presenting fetus is demised in a twin pregnancy, the remaining fetus tends to be delivered earlier than when the non-presenting fetus is demised.

Bleeding Scoring Systems in Neonates: A Systematic Review

We conducted a systematic review aiming to summarize the data on the current hemorrhage prediction models and evaluate their potential for generalized application in the neonatal population. The electronic databases PubMed and Scopus were searched, up to September 20, 2023, for studies that focused on development and/or validation of a prediction model for bleeding risk in neonates, and described the process of model building. Nineteen studies fulfilled the inclusion criteria for the present review. Eighteen bleeding risk prediction models in the neonatal population were identified, four of which were internally validated, one temporally and one externally validated. The existing prediction models for neonatal hemorrhage are mostly based on clinical variables and do not take into account the clinical course and hemostatic profile of the neonates. Most studies aimed at predicting the risk of intraventricular hemorrhage (IVH) reflecting the fact that IVH is the most frequent and serious bleeding complication in preterm neonates. A justification for the study sample size for developing the prediction model was given only by one study. Prediction and stratification of risk of hemorrhage in neonates is yet to be optimized. To this end, qualitative standards for model development need to be further improved. The assessment of the risk of bleeding incorporating platelet count, coagulation parameters, and a set of relevant clinical variables is crucial. Large, rigorous, collaborative cohort studies are warranted to develop a robust prediction model to inform the need for transfusion, which is a fundamental step towards personalized transfusion therapy in neonates.

Long-term outcomes of very low birth weight infants with intraventricular hemorrhage: a nationwide population study from 2011 to 2019

BACKGROUND

Advancements in neonatal care have increased preterm infant survival but paradoxically raised intraventricular hemorrhage (IVH) rates. This study explores IVH prevalence and long-term outcomes of very low birth weight (VLBW) infants in Korea over a decade.

METHODS

Using Korean National Health Insurance data (NHIS, 2010-2019), we identified 3372 VLBW infants with IVH among 4,129,808 live births. Health-related claims data, encompassing diagnostic codes, diagnostic test costs, and administered procedures were sourced from the NHIS database. The results of the developmental assessments  are categorized into four groups based on standard deviation (SD) scores. Neonatal characteristics and complications were compared among the groups. Logistic regression models were employed to identify significant changes in the incidence of complications and to calculate odds ratios with corresponding 95% confidence intervals for each risk factor associated with mortality and morbidity in IVH. Long-term growth and development were compared between the two groups (years 2010-2013 and 2014-2017).

RESULTS

IVH prevalence was 12% in VLBW and 16% in extremely low birth weight (ELBW) infants. Over the past decade, IVH rates increased significantly in ELBW infants (P = 0.0113), while mortality decreased (P = 0.0225). Major improvements in certain neurodevelopmental outcomes and reductions in early morbidities have been observed among VLBW infants with IVH. Ten percent of the population received surgical treatments such as external ventricular drainage (EVD) or a ventriculoperitoneal (VP) shunt, with the choice of treatment methods remaining consistent over time. The IVH with surgical intervention group exhibited higher incidences of delayed development, cerebral palsy, seizure disorder, and growth failure (height, weight, and head circumference) up to 72 months of age (P < 0.0001). Surgical treatments were also significantly associated with abnormal developmental screening test results.

CONCLUSIONS

The neurodevelopmental outcomes of infants with IVH, especially those subjected to surgical treatments, continue to be a matter of concern. It is imperative to prioritize specialized care for patients receiving surgical treatments and closely monitor their growth and development after discharge to improve developmental prognosis. Supplementary file2 (MP4 77987 kb).

Mitochondrial ferritin upregulation reduced oxidative stress and blood-brain-barrier disruption by maintaining cellular iron homeostasis in a neonatal rat model of germinal matrix hemorrhage

Germinal matrix hemorrhage (GMH) is a devasting neurological disease in premature newborns. After GMH, brain iron overload associated with hemoglobin degradation contributed to oxidative stress, causing disruption of the already vulnerable blood-brain barrier (BBB). Mitochondrial ferritin (FTMT), a novel mitochondrial outer membrane protein, is crucial in maintaining cellular iron homeostasis. We aimed to investigate the effect of FTMT upregulation on oxidative stress and BBB disruption associated with brain iron overload in rats. A total of 222 Sprague-Dawley neonatal rat pups (7 days old) were used to establish a collagenase-induced GMH model and an iron-overload model of intracerebral FeCl2 injection. Deferiprone was administered via gastric lavage 1 h after GMH and given daily until euthanasia. FTMT CRISPR Knockout and adenovirus (Ad)-FTMT were administered intracerebroventricularly 48 h before GMH and FeCl2 injection, respectively. Neurobehavioral tests, immunofluorescence, Western blot, Malondialdehyde measurement, and brain water content were performed to evaluate neurobehavior deficits, oxidative stress, and BBB disruption, respectively. The results demonstrated that brain expressions of iron exporter Ferroportin (FPN) and antioxidant glutathione peroxidase 4 (GPX4) as well as BBB tight junction proteins including Claudin-5 and Zona Occulta (ZO)-1 were found to be decreased at 72 h after GMH. FTMT agonist Deferiprone attenuated oxidative stress and preserved BBB tight junction proteins after GMH. These effects were partially reversed by FTMT CRISPR Knockout. Iron overload by FeCl2 injection resulted in oxidative stress and BBB disruption, which were improved by Ad-FTMT mediated FTMT overexpression. Collectively, FTMT upregulation is neuroprotective against brain injury associated with iron overload. Deferiprone reduced oxidative stress and BBB disruption by maintaining cellular iron homeostasis partially by the upregulating of FTMT after GMH. Deferiprone may be an effective treatment for patients with GMH.

New insights and potential biomarkers for intraventricular hemorrhage in extremely premature infant, case-control study

BACKGROUND

Despite advancements in neonatal care, germinal matrix-intraventricular hemorrhage impacts 20% of very preterm infants, exacerbating their neurological prognosis. Understanding its complex, multifactorial pathophysiology and rapid onset remains challenging. This study aims to link specific cord blood biomolecules at birth with post-natal germinal matrix-intraventricular hemorrhage onset.

METHODS

A monocentric, prospective case-control study was conducted at Rouen University Hospital from 2015 to 2020. Premature newborns ( < 30 gestational age) were included and cord blood was sampled in the delivery room. A retrospective matching procedure was held in 2021 to select samples for proteomic and metabolomic analysis of 370 biomolecules.

RESULTS

26 patients with germinal matrix-intraventricular hemorrhage cases and 60 controls were included. Clinical differences were minimal, except for higher invasive ventilation rates in the germinal matrix-intraventricular hemorrhage group. Germinal matrix-intraventricular hemorrhage newborns exhibited lower phosphatidylcholine levels and elevated levels of four proteins: BOC cell adhesion-associated protein, placental growth factor, Leukocyte-associated immunoglobulin-like receptor 2, and tumor necrosis factor-related apoptosis-inducing ligand receptor 2.

CONCLUSION

This study identifies biomolecules that may be linked to subsequent germinal matrix-intraventricular hemorrhage, suggesting heightened vascular disruption risk as an independent factor. These results need further validation but could serve as early germinal matrix-intraventricular hemorrhage risk biomarkers for future evaluations.

IMPACT

Decrease in certain phosphatidylcholines and increase in four proteins in cord blood at birth may be linked to subsequent germinal matrix-intraventricular hemorrhage in premature newborns. The four proteins are BOC cell adhesion-associated protein, placental growth factor, leukocyte-associated immunoglobulin-like receptor 2, and TNF-related apoptosis-inducing ligand receptor 2. This biological imprint could point toward higher vascular disruption risk as an independent risk factor for this complication and with further validations, could be used for better stratification of premature newborns at birth.

Detection and analysis of plasma lncRNA, miRNA and mRNA profile in preterm birth with intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is a cause of morbidity and mortality in preterm infants and is strongly associated with adverse neurological outcomes. The incidence of severe IVH (grade 3 or 4) has persisted despite the overall decline in IVH. IVH has been attributed to changes in cerebral blood flow to the immature germinal matrix microvasculature. The cascade of adverse events following IVH includes inflammation, white matter injury, and delayed oligodendrial maturation. In this study, we aimed to identify long non-coding RNA (lncRNA), microRNA (miRNA), and messenger RNA (mRNA) expression in the peripheral blood of preterm infants with IVH compared to normal controls, resulting in the finding of novel biomarkers for IVH. We conducted transcriptome sequencing and small RNA sequencing for identifying differential expression of RNA in preterm infants with IVH. We identified differentially expressed 47 lncRNAs, 95 miRNAs, and 1,370 mRNAs in preterm infants with IVH compared to normal control. Particularly, lncRNA H19 exhibited significantly high expression in preterm infants with IVH. The functional analysis revealed that differentially expressed RNAs in preterm infants with IVH were associated with ferroptosis, heme metabolism, and immune response such as lymphocyte activation and interferon response. In conclusion, these results demonstrate the potential of lncRNA, miRNA, mRNA as possible diagnostic and prognostic biomarkers for IVH.

Neurodevelopmental Outcomes of Extremely Preterm Infants Fed Donor Milk or Preterm Infant Formula: A Randomized Clinical Trial

Importance

Maternal milk feeding of extremely preterm infants during the birth hospitalization has been associated with better neurodevelopmental outcomes compared with preterm formula. For infants receiving no or minimal maternal milk, it is unknown whether donor human milk conveys similar neurodevelopmental advantages vs preterm formula.

Objective

To determine if nutrient-fortified, pasteurized donor human milk improves neurodevelopmental outcomes at 22 to 26 months' corrected age compared with preterm infant formula among extremely preterm infants who received minimal maternal milk.

Design, Setting, and Participants

Double-blind, randomized clinical trial conducted at 15 US academic medical centers within the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants younger than 29 weeks 0 days' gestation or with a birth weight of less than 1000 g were enrolled between September 2012 and March 2019.

Intervention

Preterm formula or donor human milk feeding from randomization to 120 days of age, death, or hospital discharge.

Main Outcomes and Measures

The primary outcome was the Bayley Scales of Infant and Toddler Development (BSID) cognitive score measured at 22 to 26 months' corrected age; a score of 54 (score range, 54-155; a score of ≥85 indicates no neurodevelopmental delay) was assigned to infants who died between randomization and 22 to 26 months' corrected age. The 24 secondary outcomes included BSID language and motor scores, in-hospital growth, necrotizing enterocolitis, and death.

Results

Of 1965 eligible infants, 483 were randomized (239 in the donor milk group and 244 in the preterm formula group); the median gestational age was 26 weeks (IQR, 25-27 weeks), the median birth weight was 840 g (IQR, 676-986 g), and 52% were female. The birthing parent's race was self-reported as Black for 52% (247/478), White for 43% (206/478), and other for 5% (25/478). There were 54 infants who died prior to follow-up; 88% (376/429) of survivors were assessed at 22 to 26 months' corrected age. The adjusted mean BSID cognitive score was 80.7 (SD, 17.4) for the donor milk group vs 81.1 (SD, 16.7) for the preterm formula group (adjusted mean difference, -0.77 [95% CI, -3.93 to 2.39], which was not significant); the adjusted mean BSID language and motor scores also did not differ. Mortality (death prior to follow-up) was 13% (29/231) in the donor milk group vs 11% (25/233) in the preterm formula group (adjusted risk difference, -1% [95% CI, -4% to 2%]). Necrotizing enterocolitis occurred in 4.2% of infants (10/239) in the donor milk group vs 9.0% of infants (22/244) in the preterm formula group (adjusted risk difference, -5% [95% CI, -9% to -2%]). Weight gain was slower in the donor milk group (22.3 g/kg/d [95% CI, 21.3 to 23.3 g/kg/d]) compared with the preterm formula group (24.6 g/kg/d [95% CI, 23.6 to 25.6 g/kg/d]).

Conclusions and Relevance

Among extremely preterm neonates fed minimal maternal milk, neurodevelopmental outcomes at 22 to 26 months' corrected age did not differ between infants fed donor milk or preterm formula.

Trial Registration

ClinicalTrials.gov Identifier: NCT01534481.

Severe Intraventricular Hemorrhage is Associated with Lung Injury in Preterm Infants on Mechanical Ventilation

Background

The aim of this study was to better understand the relationship between intraventricular hemorrhage and the risk of development of early lung disease in extremely low birth weight infants. We hypothesize that infants with severe intraventricular hemorrhage have higher respiratory severity scores than infants with mild/no intraventricular hemorrhage within the first 7 days of life.

Methods

This was a single center retrospective study conducted on subjects born between 01/01/2018 and 06/30/2021 at the University of Kentucky Children's Hospital NICU. We enrolled preterm infants with gestational age of less than 30 weeks and birth weight of less than 1000 grams who were placed on mechanical ventilation on admission.

Results

We found a clinically significant increasing trend of respiratory severity scores within the first week of life in the group of infants with severe intraventricular hemorrhage.

Conclusion

This study is first to show that severe intraventricular hemorrhage is associated with higher respiratory severity scores predicting early lung injury in the extremely low birth weight infants placed on a mechanical ventilator within the first 7 days of life.

A Review of the Occurrence of Intraventricular Hemorrhage in Preterm Newborns and its Future Neurodevelopmental Consequences

Intraventricular hemorrhage (IVH) is a type of bleeding that occurs through the germinal matrix and comes through the ependymal cells into the ventricular cavity. It is mostly seen in preterm neonates but can also be seen sometimes in term neonates. Various factors predispose to preterm delivery; it can be spontaneous or medically induced. Spontaneous IVH occurs in cases of intrauterine infections in the mother, and it can be induced in cases of medical emergencies such as preeclampsia and eclampsia. The brain of a preterm newborn is not fully developed as it does not have pericytes and proteins, so it can bleed very quickly, which can cause IVH. Also, the vessels supplying the germinal matrix are immature and highly vascularized. IVH has four grades based on findings detected on cranial ultrasound and MRI. Management includes medical and surgical management; medical management includes phenobarbitone used for seizures and prophylaxis. Surgical management includes drainage, irrigation, and fibrinolytic therapy (DRIFT), and neuro-endoscopic lavage. IVH causes various short-term and long-term neurodevelopmental consequences. Long-term complications include cerebral palsy and intellectual disability, which hamper the life of the child. It mainly presents with seizures, flaccidity, decerebrate posture, etc. Various preventive measures can be taken to tackle IVH in newborns. First of all, preterm delivery should be avoided, and intrauterine infections in mothers should be treated. The administration of corticosteroids should be done for all preterm deliveries as it helps in the maturation of organs. The administration of magnesium sulfate should be done as it is neuroprotective and reduces cerebral palsy in the future. Delayed cord clamping is to be done to reduce recurrent blood transfusions and decrease the risk of IVH. This article explains the pathogenesis, management, prevention, and future outcomes of IVH.

Risk factors in the development of retinopathy of prematurity: A 10-year retrospective study

OBJECTIVE

To evaluate Retinopathy of Prematurity (ROP) rate and risk factors in a large cohort of preterm newborns.

METHODS

Single center retrospective study. All preterm inborn hospitalized at the Neonatal Intensive Care Unit of the Policlinico of Catania from January 1, 2009 till December 31, 2018, were included. ROP stage and location, treatments required, maternal and infant risk factors were evaluated.

RESULTS

Medical records of 898 preterms were retrospectively examined (mean gestational age 32.9 ± 2.3 weeks). Of them 149 (16.6 %) developed bilateral ROP (92 stage 1, 44 stage 2 and 13 stage 3); 66 (7.3 %) received bilateral laser treatment. Six eyes of three patients affected by zone I ROP 1, with plus persistence 15 days after an optimal laser treatment, also received intravitreal ranibizumab injection. Risk factors for ROP development were gestational age (GA) (p < 0.001), birthweight (p < 0.001), assisted ventilation duration (p < 0.001), multiple birth (p = 0.003), erythropoietin (EPO) administration (p = 0.005) and persistence of tunica vasculosa lentis. The decision-tree analysis showed gestational age as the most significant predictive factor (P < 0.001); secondary predictive factors were EPO administration (p = 0.001) in newborns 29-31 weeks GA and birthweight lower than 2090 g (p < 0.001) in 32-34 weeks GA; in this latter group patent ductus arteriosus (PDA) was a tertiary predictive factor (p = 0.043).

CONCLUSIONS

In our study ROP incidence was 16,6 %; 7.3 % of the patients required laser treatment. Besides well-known factors, such as GA and birthweight, other factors like duration of assisted ventilation, EPO, multiple births, PDA, tunica vasculosa lentis persistence should be considered to tailor ophthalmic evaluation and follow-up.

Quality of Life at a 10-Year Follow-Up of Children Born Preterm with Post-Hemorrhagic Ventricular Dilatation: A Cohort Study

BACKGROUND

Post-haemorrhagic ventricular dilatation (PHVD) is commonly seen in extremely preterm babies, carries significant morbidity, and may cause neonatal mortality. There is a lack of literature on the subsequent health-related quality of life (HRQoL) in childhood. The aim of this work was to assess the quality of life of preterm babies after PHVD at 10 years of age using two validated questionnaires.

METHODS

Children with PHVD were assessed as part of the 10-year follow-up of the drainage, irrigation, and fibrinolytic therapy trial. The HRQoL outcome was measured using parent-reported EQ-5D-5L and HUI-3 questionnaires. Both questionnaires produce a summary score anchored at 1 (best health) and 0 (equivalent to death).

RESULTS

Median scores at follow-up were 0.65 (IQR 0.36-0.84; n = 44) for the EQ-5D-5L and 0.52 (IQR 0.22-0.87; n = 51) for the HUI-3. Similar proportions had a score below 0.2 (HRQoL [20%], HUI-3 [21%]), while 20% had a HRQoL score above 0.80 compared to 34% using HUI-3. The most severe problems from the EQ-5D-5L were reported in the self-care, mobility, and activity domains, while the HUI-3 reported worse problems in ambulation, cognition, and dexterity domains. Infants with worse (grade 4) intraventricular haemorrhage had poorer HRQoL than those with grade 3 bleeds.

CONCLUSION

Children who survive to 10 years of age after PHVD have on average lower HRQoL than their peers. However, the reported range is wide, with a quarter of the children having scores above 0.87 (similar to population norms), while a fifth have very low HRQol scores. Impact was not uniform across domains, with mobility/ambulation a concern across both measures.

Navigating the Complexities of Intraventricular Hemorrhage in Preterm Infants: An Updated Review

Intraventricular hemorrhage (IVH) is a type of bleeding that occurs in the ventricular cavity of the brain. In this comprehensive study, we provide a summary of the pathogenesis, diagnosis, and treatment of intraventricular hemorrhage in premature infants. Preterm babies are at high risk of developing IVH because their germinal matrix is not fully developed, making their blood vessels more prone to rupture. However, that is not necessarily the case in all preterm babies as the inherent structure of the germinal matrix makes it more susceptible to hemorrhage. Incidences of IVH are discussed based on recent data which states that around 12,000 premature infants in the United States experience IVH each year. Although grades I and II make up the majority of IVH cases and are frequently asymptomatic, IVH remains a significant issue for premature infants in neonatal intensive care facilities worldwide. Grades I and II have been linked to mutations in the type IV procollagen gene, COL4A1, as well as prothrombin G20210A and factor V Leiden mutations. Intraventricular hemorrhage can be detected using brain imaging in the first seven to 14 days following delivery. This review also shines a light on reliable methods for identifying IVH in premature newborns like cranial ultrasound and magnetic resonance imaging along with the treatment of IVH which is primarily supportive and involves the management of intracranial pressure, the correction of coagulation abnormalities, and the prevention of seizures.

Brain Biometry Reveals Impaired Brain Growth in Preterm Neonates with Intraventricular Hemorrhage

INTRODUCTION

Preterm birth and cerebral hemorrhage have adverse effects on brain development. Alterations in regional brain size on magnetic resonance imaging (MRI) can be assessed using 2D biometrical analysis, an easily applicable technique showing good correlation with 3D brain volumes.

METHODS

This retrospective study included 74 preterm neonates with intraventricular hemorrhage (IVH) born <32+0 weeks of gestation between 2011 and 2019. Cerebral MRI was performed at term-equivalent age, and 2D measurement techniques were used for biometrical analysis and compared to normative data of two control groups. Finally, the correlation and association of brain parameters and patterns of impaired brain growth and outcome at 2 and 3 years of age were evaluated.

RESULTS

Interhemispheric distance (IHD), the 3rd ventricle, and lateral ventricles presented larger, in contrast, cerebral biparietal width (cBPW), fronto-occipital diameter (FOD), and the length of the corpus callosum were smaller in IVH patients compared to respective controls. The strongest correlations with outcome were observed for the parameters FOD, anteroposterior diameter of the vermis, transverse cerebellar diameter (tCD), corpus callosum, 3rd ventricle, and left ventricular index. Patients with the small FOD, small BPW, and increased IHD pattern reached overall lower outcome scores at follow-up.

DISCUSSION

Preterm neonates with IVH showed reduced total brain sizes and enlarged pericerebral spaces compared to neurologically healthy controls. Biometric analysis revealed that several 2D brain parameters as well as different patterns of impaired brain growth were associated with neurodevelopmental impairment in early childhood. These findings may support prediction of long-term outcome and parental counseling in patients with IVH.

The Effectiveness of interventions to prevent intraventricular haemorrhage in premature infants: A systematic review and network meta-analysis

BACKGROUND

Intraventricular haemorrhage (IVH) is a common problem in preterm infants, being a major cause of morbidity and mortality. Despite many randomised controlled trials comparing interventions to prevent IVH, the best prevention remains unclear. This study aims to review all the interventions which intended to reduce the incidence of IVH and compare them in a network meta-analysis.

METHODS

A search on MEDLINE, EMBASE, Emcare, and CENTRAL was performed. Randomised controlled trials which evaluated neonatal interventions with a primary aim to reduce incidence of IVH in preterm infants were eligible. A surface under a cumulative ranking curve (SUCRA) was produced to indicate the intervention's likelihood of being the most effective for preventing IVH.

RESULTS

40 studies were eligible, enrolling over 6760 infants. Twelve intervention groups were found, including delayed cord clamping, erythropoietin, ethamsylate, fresh frozen plasma, heparin, ibuprofen, indomethacin, magnesium, nursing interventions, sedation, tranexamic acid, and vitamin E. Vitamin E and indomethacin had the highest probability of being the best interventions to prevent IVH in premature infants, but interpretation of these results is difficult due to study limitations.

CONCLUSION

Despite the impact of IVH, we were unable to identify a clearly beneficial treatment to reduce its incidence. Interpretation of the network meta-analysis was limited due to differences within studied populations, wide range of therapies trialled, and underlying advances in neonatal care between units, and over time. Although vitamin E and indomethacin appear to be promising candidates, contemporaneous trials of these, or novel agents, enrolling the most at-risk infants is needed urgently.

The clinical burden of extremely preterm birth in a large medical records database in the United States: complications, medication use, and healthcare resource utilization

INTRODUCTION

Approximately 5% of global preterm births are extremely premature (EP), defined as occurring at less than 28 weeks gestational age. Advances in care have led to an increase in the survival of EP infants during the neonatal period. However, EP infants have a higher risk of developing complications such as bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). BPD and other respiratory morbidities are particularly prevalent among this population. To understand the healthcare resource utilization (HRU) of EP infants in the United States, the clinical and economic burden of extreme prematurity was examined in this retrospective study of data extracted from electronic medical records in the Kaiser Permanente Northern California (KPNC) health system.

METHODS

The analysis included data from EP infants live-born between January 1997 and December 2016, and focused on complications and HRU up to 3 years corrected age (CA), covering the period up to December 2018. Stillbirths, infants born at <22 weeks gestational age, and infants with major congenital malformations were excluded. Complications of interest (BPD, IVH, and ROP) and medication use were compared by age group (≤1 year, >1 year and ≤2 years, and >2 years and ≤3 years CA). Analysis of HRU included hospital readmissions, ambulatory visits, and emergency room (ER) visits.

RESULTS

A total of 2154 EP births (0.32% of total live births and 4.0% of preterm births that met the inclusion/exclusion criteria) were analyzed. The prevalence of EP birth showed a declining trend over time. ROP was the most commonly recorded complication during the birth hospitalization (37.1% any stage; 2.9% Stages 3 and 4). BPD was recorded in 34.3% of EP infants. IVH (any grade) was recorded in 22.7% of EP infants (6.4% Grades III and IV). A majority (78.7%) of EP infants were diagnosed with at least one respiratory condition during the first year CA, the most common being pneumonia (68.9%); the prevalence of respiratory conditions decreased over the second and third years CA. During the first 3 years CA, the most common medications prescribed to children born EP were inhaled bronchodilators (approximately 30% of children); at least 15% of children received systemic corticosteroids and inhaled steroids during this period. During the first 3 years CA, at least one hospital readmission was recorded for 16.4% of children born EP; 57.1% of these readmissions were related to respiratory conditions. At least one ER visit was recorded for 33.8% of children born EP, for which 53.1% were due to a respiratory condition. Ambulatory visits were recorded for 54.2% of EP children, for which 82.9% were due to a respiratory condition.

CONCLUSIONS

The short- and long-term clinical burden of EP birth was high. The onset of BPD, IVH, and ROP was common during the birth hospitalization for EP infants. Medication use, hospital readmission, and clinic visits (ER and ambulatory) occurred frequently in these children during the first 3 years CA, and were commonly due to respiratory conditions. Strategies prioritizing the reduction of risk and severity of respiratory conditions may alleviate the clinical burden of EP birth over the long term.

The follow up of complex infants in an aerodigestive clinic

The current available literature evaluating pediatric multidisciplinary aerodigestive programs for the management of aerodigestive disorders in infants was reviewed. Multidisciplinary aerodigestive programs have emerged to provide coordinated and comprehensive care for the growing population of children with aerodigestive conditions, including complex airway, pulmonary, gastrointestinal, and feeding disorders, which are prevalent among infants discharged from the neonatal intensive care unit (NICU). The team approach central to aerodigestive clinics offers a comprehensive diagnostic workup and unified management plan through consolidated interdisciplinary clinics, combined endoscopic procedures, and regular team discussions, leading to improved resource utilization and health care outcomes. We review common conditions presenting in the NICU that benefit from the aerodigestive model of care, including esophageal atresia, prematurity, bronchopulmonary dysplasia with or without tracheostomy or ventilator dependence, and dysphagia.

How to survive a periviable birth baby with birth weight of 450g: A case report

RATIONALE

An increasing number of periviable birth newborns (PVBs) have emerged with concurrent growing high-risk pregnancy. To date, postnatal management of PVBs remains one of the most challenging issues and limited studies have been reported.

PATIENT CONCERNS

A female baby born at 230/7 weeks of gestation with birth weight of 450g.

DIAGNOSIS

PVB baby, respiratory distress syndrome (RDS), ventilator associated pneumonia (VAP), intraventricular hemorrhage (IVH), metabolic bone disease of prematurity (MBDP), transient hypothyroxinemia of prematurity (THOP), bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP).

INTERVENTIONS

Individualized treatment and intensive care, including neonatal resuscitation, effective respiratory and circulatory support, venous access and nutrition, prevention and treatment of infection, management of endocrine and metabolic problems, individualized nursing such as developmental supportive care, integrated oral motor interventions, skin care, family-integrated-care, etc were performed according to existing literature.

OUTCOMES

The baby was discharged home after 138 days of hospitalization with body weight of 2700 g, a full oral feed achieved, and without any requirement of respiratory support or oxygen supply. Now she is 38-month-old, with no significant long-term adverse sequelae.

LESSONS

Our case expands the experience and knowledges of individualized and intensive management of PVB babies in their early life days, which increase PVBs' survival and improves their prognosis.

Neuroprotection care bundle implementation is associated with improved long-term neurodevelopmental outcomes in extremely premature infants

OBJECTIVE

To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature.

STUDY DESIGN

An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation.

RESULTS

Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17-0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12-0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12-0.94; P = 0.039), any motor, language, or cognitive composite score &lt;70 (aOR, 0.48; 95% CI: 0.26-0.90; P = 0.021).

CONCLUSION

Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.

Hexoprenaline Compared with Atosiban as Tocolytic Treatment for Preterm Labor

Introduction Preterm birth is defined as a live birth before 37 weeks of gestation and is associated with increased neonatal morbidity and mortality. The aim of this study is to compare the efficacy of hexoprenaline and atosiban for short- and long-term tocolysis and their effects on neonatal and maternal outcomes.

Methods This retrospective cohort study included women with threatened preterm labor between 24 + 0 and 34 + 0 weeks of gestation without premature rupture of membranes. The tocolytic efficacy of hexoprenaline and atosiban was compared in women receiving one of the two medications for short- and long-term tocolysis. Continuous variables were compared using t-test or Mann–Whitney U test, as appropriate. Comparison of categorical variables between the two groups was done with χ ² test after Pearsonʼs and Fisherʼs exact test.

Results 761 women were enrolled in this study; 387 women received atosiban and 374 women received hexoprenaline as their primary tocolytic agent. Atosiban showed a higher efficacy as a primary tocolytic agent (p = 0.000) within 48 hours. As regards long-term tocolysis, there were no differences between the treatment groups (p = 0.466). Maternal side effects such as tachycardia (p = 0.018) or palpitations (p = 0.000) occurred more frequently after the administration of hexoprenaline, while there were no differences between the two drugs administered with regard to any other maternal or neonatal outcome parameter.

Conclusion Our retrospective study shows a significantly higher efficacy of atosiban in the first 48 hours, especially when administered at an early gestational age. There were no significant differences in terms of neonatal outcome but significantly more maternal adverse effects during the administration of hexoprenaline.

[Influence of umbilical cord milking versus delayed cord clamping on the early prognosis of preterm infants with a gestational age of <34 weeks: a Meta analysis]

OBJECTIVES

To study the influence of umbilical cord milking versus delayed cord clamping on the early prognosis of preterm infants with a gestational age of <34 weeks.

METHODS

PubMed, Web of Science, Embase, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, Wanfang Data, Weipu Database, and SinoMed were searched for randomized controlled trials on umbilical cord milking versus delayed cord clamping in preterm infants with a gestational age of <34 weeks published up to November 2021. According to the inclusion and exclusion criteria, two researchers independently performed literature screening, quality evaluation, and data extraction. Review Manger 5.4 was used for Meta analysis.

RESULTS

A total of 11 articles were included in the analysis, with 1 621 preterm infants in total, among whom there were 809 infants in the umbilical cord milking group and 812 in the delayed cord clamping group. The Meta analysis showed that compared with delayed cord clamping, umbilical cord milking increased the mean blood pressure after birth (weighted mean difference=3.61, 95%CI: 0.73-6.50, P=0.01), but it also increased the incidence rate of severe intraventricular hemorrhage (RR=1.83, 95%CI: 1.08-3.09, P=0.02). There were no significant differences between the two groups in hemoglobin, hematocrit, blood transfusion rate, proportion of infants undergoing phototherapy, bilirubin peak, and incidence rates of complications such as periventricular leukomalacia and necrotizing enterocolitis (P>0.05).

CONCLUSIONS

Compared with delayed cord clamping, umbilical cord milking may increase the risk of severe intraventricular hemorrhage in preterm infants with a gestational age of <34 weeks; however, more high-quality large-sample randomized controlled trials are needed for further confirmation.

Cerebral Venous Sinus Thrombosis in Preterm Infants

BACKGROUND:

Neonatal cerebral venous sinus thrombosis (CVST) can lead to brain injury and neurodevelopmental impairments. Previous studies of neonatal CVST have focused on term infants, and studies of preterm infants are lacking. In this study, we examined the clinical and radiological features, treatment and outcome of CVST in preterm infants.

METHODS:

This was a retrospective, consecutive cohort study of preterm infants (gestational age <37 weeks) with radiologically confirmed CVST. All magnetic resonance imaging/MRV and CT/CTV scans were re-reviewed to study thrombus characteristics and pattern of brain injury. Outcome was assessed by the validated pediatric stroke outcome measure at the most recent clinic visit.

RESULTS:

Twenty-six preterm infants with CVST were studied. Of these, 65% were moderate-late preterm (32–37 weeks), 27% very preterm (28–32 weeks), and 8% extreme preterm (<28 weeks). Most (73%) were symptomatic at presentation with seizures or abnormal exam. Transverse (85%) and superior sagittal (42%) sinuses were common sites of thrombosis. Parenchymal brain injury was predominantly periventricular (35%) and deep white matter (31%) in location. Intraventricular hemorrhage occurred in 46%. Most infants (69%) were treated with anticoagulation. No treated infant (including eleven with pretreatment hemorrhage) had new or worsening post-treatment hemorrhage. Outcomes ranged from no deficits (50%), mild-moderate (25%), and severe (25%) impairment.

CONCLUSIONS:

In our sample of preterm infants with CVST, more than one-quarter were asymptomatic. White matter brain lesions predominated and one-half had neurological deficits at follow-up. Anticoagulation of preterm CVST in this small cohort appeared to be safe. Larger studies of preterm CVST are needed.

The Effect of Intraventricular Hemorrhage on Brain Development in Premature Infants: A Synthetic MRI Study

Objectives: Synthetic MRI can obtain multiple parameters in one scan, including T1 and T2 relaxation time, proton density (PD), brain volume, etc. This study aimed to investigate the parameter values T1 and T2 relaxation time, PD, and volume characteristics of intraventricular hemorrhage (IVH) newborn brain, and the ability of synthetic MRI parameters T1 and T2 relaxation time and PD to diagnose IVH.

Materials and methods: The study included 50 premature babies scanned with conventional and synthetic MRI. Premature infants were allocated to the case group (n = 15) and NON IVH (n = 35). The T1, T2, PD values, and brain volume were obtained by synthetic MRI. Then we assessed the impact of IVH on these parameters.

Results: In the posterior limbs of the internal capsule (PLIC), genu of the corpus callosum (GCC), central white matter (CWM), frontal white matter (FWM), and cerebellum (each p < 0.05), the T1 and T2 relaxation times of the IVH group were significantly prolonged. There were significant differences also in PD. The brain volume in many parts were also significantly reduced, which was best illustrated in gray matter (GM), cerebrospinal fluid and intracranial volume, and brain parenchymal fraction (BPF) (each p < 0.001, t = −5.232 to 4.596). The differential diagnosis ability of these quantitative values was found to be excellent in PLIC, CWM, and cerebellum (AUC 0.700–0.837, p < 0.05).

Conclusion: The quantitative parameters of synthetic MRI show well the brain tissue characteristic values and brain volume changes of IVH premature infants. T1 and T2 relaxation times and PD contribute to the diagnosis and evaluation of IVH.

Intraventricular haemorrhage and posthaemorrhagic ventricular dilatation: moving beyond CSF diversion

Advances in medical care have led to more premature babies surviving the neonatal period. In these babies, germinal matrix haemorrhage (GMH), intraventricular haemorrhage (IVH) and posthaemorrhagic ventricular dilatation (PHVD) are the most important determinants of long-term cognitive and developmental outcomes. In this review, we discuss current neurosurgical management of IVH and PHVD, including the importance of early diagnosis of PHVD, thresholds for intervention, options for early management through the use of temporising measures and subsequent definitive CSF diversion. We also discuss treatment options for the evolving paradigm to manage intraventricular blood and its breakdown products. We review the evidence for techniques such as drainage, irrigation, fibrinolytic therapy (DRIFT) and neuroendoscopic lavage in the context of optimising cognitive, neurodevelopmental and quality of life outcomes in these premature infants.